Abstract

Introduction

Although there is not one single concept¹1. Park SY , Shon C , Kwon OY , Yoon TY , Kwon I . A qualitative thematic content analysis of medical students’ essays on professionalism . BMC Med Educ . 2017 ; 17 :79. doi: https://dx.doi.org/10.1186/s12909-017-0920-5 .
https://dx.doi.org/10.1186/s12909-017-09... , ²2. McLachlan JC , Finn G , Macnaughton J . The conscientiousness index: a novel tool to explore students’ professionalism . Acad Med . 2009 ; 84 ( 5 ): 559 - 65 . , professionalism can be defined as a group of attitudes, values, behaviors and interactions that act as the basis of the health professional’s contract with society³3. Sattar K , Roff S , Meo SA . Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism . BMC Med Educ . 2016 ; 16 : 285 . doi: https://dx.doi.org/10.1186/s12909-016-0807-x .
https://dx.doi.org/10.1186/s12909-016-08... . It represents a complex, dynamic and multi-dimensional construct that is difficult to define and encompasses multiple and varied concepts which, many times, are dissimilar. It also includes individual and behavioral factors that are learned throughout life and are influenced by sociocultural aspects¹1. Park SY , Shon C , Kwon OY , Yoon TY , Kwon I . A qualitative thematic content analysis of medical students’ essays on professionalism . BMC Med Educ . 2017 ; 17 :79. doi: https://dx.doi.org/10.1186/s12909-017-0920-5 .
https://dx.doi.org/10.1186/s12909-017-09... , ⁴4. Jauregui J , Gatewood MO , Ilgen JS , Schaninger C , Strote J . Emergency medicine resident perceptions of medical professionalism . West J Emerg Med . 2016 ; 17 ( 3 ): 355 - 61 . . Due to this, establishing an ideal model to teach and assess professional attitudes can be quite challenging¹1. Park SY , Shon C , Kwon OY , Yoon TY , Kwon I . A qualitative thematic content analysis of medical students’ essays on professionalism . BMC Med Educ . 2017 ; 17 :79. doi: https://dx.doi.org/10.1186/s12909-017-0920-5 .
https://dx.doi.org/10.1186/s12909-017-09... , ²2. McLachlan JC , Finn G , Macnaughton J . The conscientiousness index: a novel tool to explore students’ professionalism . Acad Med . 2009 ; 84 ( 5 ): 559 - 65 . . Likewise, conducting such an assessment among medical students, capturing lapses or inadequate attitudes, is not an easy task⁵5. Cendán JC , Castiglioni A , Jonhson TR , Eakins M , Verduin ML , Asmar A , et al . Quantitative and qualitative analysis of the impact of adoption of a mobile application for the assessment of professionalism in medical trainees . Acad Med . 2017 ; 92 ( 11 ): 31 - 42 . .

The most recent version of the National Curricular Guidelines (DCN) for the Medicine Program, published in 2014, does not cite the term professionalism. The competencies that must be developed by the medical student, cited in the DCN, are: humanism, ethics, sensitivity, confidentiality, sense of social responsibility, non-verbal communication, commitment, empathy, decision-making, reflection and communication, which encompass the need to develop attitudes characterized as professional.⁶6. Brasil . Ministério da Educação . Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina. Resolução nº 3 CNE/CES, de 20 de Junho de 2014 . Diário Oficial da União . 6 Jun 2014 .

Medicine embraces attributes that go beyond technical skills, such as humanism, integrity, accountability, altruism, teamwork, among others. Therefore, the doctor is expected to have developed non-cognitive skills, like communication, collaboration and self-improvement. Professional competency depends on the presence of all these characteristics⁷7. Huffmyer JL , Kirk SE . Professionalism: the “forgotten” core competency . Professionalism Anesthesiol . 2017 ; 125 ( 2 ): 378 - 9 . , ⁸8. Jaya WP , Rukmini E . Applying conscientiousness index: a tool to explore medical students’ professionalism in Indonesia . Int J Med Educ . 2018 ; 7 : 222 - 9 . .

The final objective of medical education is to form competent professionals who have technical and clinical knowledge and capacity, who are capable of renewing their learning throughout life, and who have an ethical and moral behavior⁹9. Tsou KI , Lin CS , Cho SL , Powis D , Bore M , Munro D , et al . Using personal qualities assessment to measure the moral orientation and personal qualities of medical students in a non-western culture . Eval Health Prof . 2014 ; 36 ( 2 ): 174 - 90 . . The art of providing care is a daily challenge that requires of the doctor a holistic view of the patient. This art must be taught and improved in a broad, universal, ethical and humanistic way during the doctor’s education¹⁰10. Benedetto MAC , Moreto G , Janaudis MA , Levites MR , Blasco PG . Educando as emoções para uma atuação ética: construindo o profissionalismo médico . Rev Bras Med . 2014 ; Esp : 15 - 24 . . Some changes undergone by Medicine throughout the years have caused the emergence of questionings about medical education and its forms of assessment and teaching inside universities¹1. Park SY , Shon C , Kwon OY , Yoon TY , Kwon I . A qualitative thematic content analysis of medical students’ essays on professionalism . BMC Med Educ . 2017 ; 17 :79. doi: https://dx.doi.org/10.1186/s12909-017-0920-5 .
https://dx.doi.org/10.1186/s12909-017-09... , ¹¹11. Brissette MD , Johnson KA , Raciti PM , McCloskey CB , Gratzinger DA , Conran RM , et al . Perceptions of unprofessional attitudes and behaviors implications for faculty role modeling and teaching professionalism during pathology residency . Arch Pathol Lab Med . 2017 ; 141 ( 10 ): 1394 - 401 . .

Students’ negative behavior during undergraduate education continues in professional life, influencing their conducts in their future career⁷7. Huffmyer JL , Kirk SE . Professionalism: the “forgotten” core competency . Professionalism Anesthesiol . 2017 ; 125 ( 2 ): 378 - 9 . . For this reason, there has been a great concern about the establishment of an ideal model for medical assessment focusing on interventions that aim at behavioral changes and enable new teaching models²2. McLachlan JC , Finn G , Macnaughton J . The conscientiousness index: a novel tool to explore students’ professionalism . Acad Med . 2009 ; 84 ( 5 ): 559 - 65 . .

In this process, it is necessary to raise the faculty’s awareness of their role as formative agents of behaviors and attitudes, and as influencers of good actions and changes in their students’ way of acting⁴4. Jauregui J , Gatewood MO , Ilgen JS , Schaninger C , Strote J . Emergency medicine resident perceptions of medical professionalism . West J Emerg Med . 2016 ; 17 ( 3 ): 355 - 61 . , ¹¹11. Brissette MD , Johnson KA , Raciti PM , McCloskey CB , Gratzinger DA , Conran RM , et al . Perceptions of unprofessional attitudes and behaviors implications for faculty role modeling and teaching professionalism during pathology residency . Arch Pathol Lab Med . 2017 ; 141 ( 10 ): 1394 - 401 . . In addition, it is important that the assessment and teaching processes enable students to reflect on the importance of displaying professional behaviors⁸8. Jaya WP , Rukmini E . Applying conscientiousness index: a tool to explore medical students’ professionalism in Indonesia . Int J Med Educ . 2018 ; 7 : 222 - 9 . .

Assessment strategies that include, simultaneously, knowledge, moral attitudes, values and behavior are very limited; therefore, new approaches are needed. Due to this, the search for a definition and for an adequate form of assessment of medical professionalism has originated assessment instruments¹²12. Goss BD , Ryan AT , Waring J , Judd T , Chiavaroli NG , O’ Brien RC , et al . The use of situational judgement tests in the teaching and assessment of professionalism . Acad Med . 2017 ; 92 : 780 - 4 . , ¹³13. Guillemin F , Bombardier C , Beaton D . Cross-cultural adaptation of healthrelated quality of life measures: literature review and proposed guidelines . J Clin Epidemiol . 1993 ; 46 ( 12 ): 1417 - 32 . .

Different models have been used to assess medical professionalism based on attributes called “domains”, which can be exemplified by altruism, honor, compassion, responsibility, teamwork, self-control, ethical principles, and clinical excellence. Each domain must be adequately defined and adapted to the local reality. Furthermore, it must have a meaning of its own in undergraduate education, so that it has efficacy and can guide teaching methods²2. McLachlan JC , Finn G , Macnaughton J . The conscientiousness index: a novel tool to explore students’ professionalism . Acad Med . 2009 ; 84 ( 5 ): 559 - 65 . .

In view of the fact that the concept of medical professionalism is not standardized and due to the importance of this theme for medical education, we developed this study in order to investigate definitions of medical professionalism present in the scientific literature and in what way this concept has been assessed among medical students. Thus, we propose, in this integrative review, to compile the information available in scientific productions about the definition of medical professionalism and its forms of assessment.

Methods

Aiming to synthesize the results of relevant and internationally recognized research, the method used was the integrative literature review. The integrative review is a very important tool in the area of health, as it synthesizes the knowledge that is available about a certain subject, improving the utilization of present evidence¹⁴14. Souza MT , Silva MD , Carvalho R . Revisão integrativa: o que é e como fazer . Einstein . 2010 ; 8 ( 1 Pt 1 ): 102 - 6 . .

The search was guided by the question: What is defined as medical professionalism in the scientific literature and how has it been assessed among medical students? The research was carried out in May 2018 by means of searches in the following electronic databases: EBSCOhost, Latin American & Caribbean Health Sciences Literature (LILACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE), via PubMed, in the period from 2013 to 2018. The descriptors used were obtained from Descritores em Ciências da Saúde (Health Sciences Descriptors - DeCS) or from Medical Subject Headings (MeSH). In English, they were: “Professionalism” (DeCS and MeSH), “Education, Medical” (DeCS), “Education, Medical, Undergraduate” (MeSH), “Internship and Residency” (DeCS and MeSH). The Boolean expression “AND” was used, always intersecting the first descriptor with one of the other three. In the MEDLINE database, the descriptors in English were used. In the other databases, the search was conducted with the descriptors in English and their correspondents in Portuguese. The research included observational studies (cohort, case-control and cross-sectional studies), indexed in the last five years in the selected databases, that answered the research question. Opinion articles, letters to editors, theses, dissertations and comments were excluded.

Overall, 85 articles were found, of which 13 were excluded due to duplicity with the use of the Mendeley platform. Of the 72 remaining articles, 35 were excluded because they did not answer the research question. Of the 37 articles selected through the reading of their abstracts, 8 were not fully available, 3 defined professionalism but did not cite its form of assessment, and 14 focused on forms of assessment in medical residency. The 12 articles that remained are presented in Table 1 , which summarizes the definition of professionalism, its assessment methods and the domains assessed in each published study. The flowchart of the selection of the articles that composed the integrative review can be found in Figure 1 . It was not necessary to obtain the approval of the research ethics committee (CEP) because this research does not involve human beings.

Results and discussion

After the analysis of the texts, three thematic axes emerged: a) Professionalism: a multidimensional and undefined construct; b) The teaching of medical professionalism; and c) Assessing professionalism: multiple assessment strategies.

Professionalism: a multidimensional and undefined construct

Historically, professionalism has been associated with its relation to the personality traits, values, attitudes, and beliefs that compose an individual. A possible definition of professionalism is based on developed qualities that make the activities performed by a certain person be recognized as professional. It includes humanism, altruism, empathy, respect and honesty¹⁵15. Kelly AM , Gruppen LD , Mullan MP . Teaching and assessing professionalism in radiology resident education . Acad Radiol . 2017 ; 24 ( 5 ): 563 - 73 . . Likewise, it has been defined as a group of attitudes, values, behaviors, and interactions that represent the health professional’s contract with society³3. Sattar K , Roff S , Meo SA . Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism . BMC Med Educ . 2016 ; 16 : 285 . doi: https://dx.doi.org/10.1186/s12909-016-0807-x .
https://dx.doi.org/10.1186/s12909-016-08... .

Throughout the years, Medicine and medical education have undergone modifications. The increment in the use of technologies and transformations in service provision forms have changed the relationship between doctor and patient, increasing the distance between them and enabling the emergence of unprofessional attitudes¹1. Park SY , Shon C , Kwon OY , Yoon TY , Kwon I . A qualitative thematic content analysis of medical students’ essays on professionalism . BMC Med Educ . 2017 ; 17 :79. doi: https://dx.doi.org/10.1186/s12909-017-0920-5 .
https://dx.doi.org/10.1186/s12909-017-09... , ¹¹11. Brissette MD , Johnson KA , Raciti PM , McCloskey CB , Gratzinger DA , Conran RM , et al . Perceptions of unprofessional attitudes and behaviors implications for faculty role modeling and teaching professionalism during pathology residency . Arch Pathol Lab Med . 2017 ; 141 ( 10 ): 1394 - 401 . .

Students are admitted to medical schools as laypeople, bringing behaviors they have learned throughout their lives. They have ideals that, many times, are lost during the undergraduate course. Their behavior must be shaped during education and this approach cannot be neglected when the student is admitted into university. The student’s transformation process into a doctor is modified every year and depends on the context in which they are inserted. Professionalism will have different definitions and will encompass different experiences and attitudes as a result of the student’s practice and experience¹⁶16. Randall VF , Foster CW , Olsen CH , Warwick AB , Fernandez KA , Crouch G . Defining medical professionalism across the years of training and experience at the uniformed services university of the health sciences . Mil Med . 2016 ; 181 ( 10 ): 1294 - 9 . .

The concept of professionalism is hard to define, as it involves multiple and varied concepts that, many times, are different. Its definition is complex, without a unitary characterization, and includes medical ethics, science and humanity¹⁷17. Kim S , Choi S . The medical professionalism of Korean physicians: present and future . BMC Med Ethics . 2015 ; 16 : 56 . doi: https://dx.doi.org/10.1186/s12910-015-0051-7 .
https://dx.doi.org/10.1186/s12910-015-00... . Due to the lack of one definition, it is difficult to teach it, and there may be differences between the concept given by the curriculum and what really occurs in practice¹⁵15. Kelly AM , Gruppen LD , Mullan MP . Teaching and assessing professionalism in radiology resident education . Acad Radiol . 2017 ; 24 ( 5 ): 563 - 73 . .

Professionalism is a fundamental aspect of medical practice and is directly related to culture. Due to this, curricular interventions inside the university must be adapted individually to meet the needs of students from each location, in their different social and cultural contexts¹1. Park SY , Shon C , Kwon OY , Yoon TY , Kwon I . A qualitative thematic content analysis of medical students’ essays on professionalism . BMC Med Educ . 2017 ; 17 :79. doi: https://dx.doi.org/10.1186/s12909-017-0920-5 .
https://dx.doi.org/10.1186/s12909-017-09... , ³3. Sattar K , Roff S , Meo SA . Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism . BMC Med Educ . 2016 ; 16 : 285 . doi: https://dx.doi.org/10.1186/s12909-016-0807-x .
https://dx.doi.org/10.1186/s12909-016-08... .

For the assessment of professionalism, attributes called “domains” have been created and subdivided into specific attributes, which facilitates analyses based on characteristics. Examples of domains are empathy, altruism, self-improvement, competency, punctuality, responsibility, respect, confidentiality, secrecy and fairness¹1. Park SY , Shon C , Kwon OY , Yoon TY , Kwon I . A qualitative thematic content analysis of medical students’ essays on professionalism . BMC Med Educ . 2017 ; 17 :79. doi: https://dx.doi.org/10.1186/s12909-017-0920-5 .
https://dx.doi.org/10.1186/s12909-017-09... , ⁴4. Jauregui J , Gatewood MO , Ilgen JS , Schaninger C , Strote J . Emergency medicine resident perceptions of medical professionalism . West J Emerg Med . 2016 ; 17 ( 3 ): 355 - 61 . , ¹⁰10. Benedetto MAC , Moreto G , Janaudis MA , Levites MR , Blasco PG . Educando as emoções para uma atuação ética: construindo o profissionalismo médico . Rev Bras Med . 2014 ; Esp : 15 - 24 . , ¹⁵15. Kelly AM , Gruppen LD , Mullan MP . Teaching and assessing professionalism in radiology resident education . Acad Radiol . 2017 ; 24 ( 5 ): 563 - 73 . . It should be emphasized that the process of teaching and assessing students must highlight the importance of displaying these behaviors⁸8. Jaya WP , Rukmini E . Applying conscientiousness index: a tool to explore medical students’ professionalism in Indonesia . Int J Med Educ . 2018 ; 7 : 222 - 9 . .

The way in which students understand the importance of ethical values in their profession influences their action as doctors in the future. The uncorrected mistake made in university tends to repeat itself after the education period and favors the receipt of disciplinary actions in the workplace¹⁵15. Kelly AM , Gruppen LD , Mullan MP . Teaching and assessing professionalism in radiology resident education . Acad Radiol . 2017 ; 24 ( 5 ): 563 - 73 . , ¹⁸18. Dong T , Kelly W , Hays M , Berman NB , Durning SJ . An investigation of professionalism reflected by student comments on formative virtual patient encounters . BMC Med Educ . 2017 ; 17 ( 1 ): 3 . doi: https://dx.doi.org/10.1186/s12909-016-0840-9 .
https://dx.doi.org/10.1186/s12909-016-08... , ¹⁹19. Ziring D , Danoff D , Grosseman S , Langer DMPA , Esposito AMS , Jan MK , et al . How do medical schools identify and remediate professionalism lapses in medical students? A study of U.S. and Canadian medical schools . Acad Med . 2015 ; 90 ( 7 ): 913 - 20 . . The student must be conscious of their mistake, and the mistake must be corrected when it occurs¹⁹19. Ziring D , Danoff D , Grosseman S , Langer DMPA , Esposito AMS , Jan MK , et al . How do medical schools identify and remediate professionalism lapses in medical students? A study of U.S. and Canadian medical schools . Acad Med . 2015 ; 90 ( 7 ): 913 - 20 . .

The teaching of medical professionalism

The teaching of professionalism is one of the great challenges faced by university teachers. Understanding that technical improvement must be allied to humanistic values and being committed to putting this into practice are extremely important to the success of learning, as it is not possible to have a competent doctor without the fusion of technical skills and humanization⁷7. Huffmyer JL , Kirk SE . Professionalism: the “forgotten” core competency . Professionalism Anesthesiol . 2017 ; 125 ( 2 ): 378 - 9 . , ¹²12. Goss BD , Ryan AT , Waring J , Judd T , Chiavaroli NG , O’ Brien RC , et al . The use of situational judgement tests in the teaching and assessment of professionalism . Acad Med . 2017 ; 92 : 780 - 4 . .

This teaching of a professional conduct encompasses many aspects and lasts from the beginning of education in the classroom until the first contact with the patient. In the great majority of medical schools, teaching focuses on technical education to the detriment of values such as humanization, respect, interpersonal relationship, and behavior¹⁰10. Benedetto MAC , Moreto G , Janaudis MA , Levites MR , Blasco PG . Educando as emoções para uma atuação ética: construindo o profissionalismo médico . Rev Bras Med . 2014 ; Esp : 15 - 24 . .

The teaching of professionalism is very important. Thus, the educator must be committed to providing orientation about behaviors and values during the student’s education. However, there is not a standard model for this process and each institution decides what will be used in it⁵5. Cendán JC , Castiglioni A , Jonhson TR , Eakins M , Verduin ML , Asmar A , et al . Quantitative and qualitative analysis of the impact of adoption of a mobile application for the assessment of professionalism in medical trainees . Acad Med . 2017 ; 92 ( 11 ): 31 - 42 . . This orientation does not refer exclusively to adequate technical education; it approaches values like moral and ethical standards, commitment to excellence, development of new skills and interest in new information, knowing how to deal with uncertainties, demonstration of empathy, compassion, honesty, integrity, altruism and care, loyalty and respect for patients and colleagues, and capacity to reflect on one’s own actions. Unfortunately, many of these values are not approached during academic education and ethical problems are not corrected during the university period¹⁰10. Benedetto MAC , Moreto G , Janaudis MA , Levites MR , Blasco PG . Educando as emoções para uma atuação ética: construindo o profissionalismo médico . Rev Bras Med . 2014 ; Esp : 15 - 24 . .

In view of all these factors, it is considered that the teaching of professionalism must be explicit in the undergraduate curriculum; however, this is still a gap in medical education³3. Sattar K , Roff S , Meo SA . Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism . BMC Med Educ . 2016 ; 16 : 285 . doi: https://dx.doi.org/10.1186/s12909-016-0807-x .
https://dx.doi.org/10.1186/s12909-016-08... , ²⁰20. Hochberg MS , Berman RS , Kalet AL , Zabar S , Gillespie C , Pachter HL . Professionalism training for surgical residents documenting the advantages of a professionalism curriculum . Ann Surg . 2016 ; 264 ( 3 ): 501 - 7 . . The domains of professionalism must be very clear to students, so that they understand what needs to be modified in their attitudes⁵5. Cendán JC , Castiglioni A , Jonhson TR , Eakins M , Verduin ML , Asmar A , et al . Quantitative and qualitative analysis of the impact of adoption of a mobile application for the assessment of professionalism in medical trainees . Acad Med . 2017 ; 92 ( 11 ): 31 - 42 . .

In the University of Montreal, Canada, a pilot study published in 2015 employed a Concordance of Judgement Learning Tool (CJLT) in 20 clinical cases about professionalism situations. The cases are judged by students and discussed with teachers²¹21. Foucault A , Dubé S , Fernandez N , Gagnon R , Charlin B . Learning medical professionalism with the online concordanceof-judgment learning tool (CJLT): a pilot study . Med Teach . 2015 ; 37 ( 10 ): 955 - 60 . .

It should be noted that the learning of professionalism is not instinctive and it is not adequate for it to be taught exclusively by modeling, as the student may have contact with negative attitudes only, which emphasizes the great importance of the faculty’s collaboration in this function⁷7. Huffmyer JL , Kirk SE . Professionalism: the “forgotten” core competency . Professionalism Anesthesiol . 2017 ; 125 ( 2 ): 378 - 9 . , ¹¹11. Brissette MD , Johnson KA , Raciti PM , McCloskey CB , Gratzinger DA , Conran RM , et al . Perceptions of unprofessional attitudes and behaviors implications for faculty role modeling and teaching professionalism during pathology residency . Arch Pathol Lab Med . 2017 ; 141 ( 10 ): 1394 - 401 . .

The lack of formative examples is a point that should be corrected in universities, as it is known that positive characteristics brought by students may be lost over the years through contact with inadequate behaviors, but, fortunately, can be improved through adequate training¹⁰10. Benedetto MAC , Moreto G , Janaudis MA , Levites MR , Blasco PG . Educando as emoções para uma atuação ética: construindo o profissionalismo médico . Rev Bras Med . 2014 ; Esp : 15 - 24 . .

We strengthen the importance of associating, with the disciplines of the undergraduate course, an informal curriculum involving the teaching of ethical conducts and professional attitudes in a longitudinal way. Students must be informed that this content is also part of their learning experience¹¹11. Brissette MD , Johnson KA , Raciti PM , McCloskey CB , Gratzinger DA , Conran RM , et al . Perceptions of unprofessional attitudes and behaviors implications for faculty role modeling and teaching professionalism during pathology residency . Arch Pathol Lab Med . 2017 ; 141 ( 10 ): 1394 - 401 . . If professionalism and ethics are not emphasized during medical education, students may infer that they are not important in their education¹⁵15. Kelly AM , Gruppen LD , Mullan MP . Teaching and assessing professionalism in radiology resident education . Acad Radiol . 2017 ; 24 ( 5 ): 563 - 73 . . Many researchers consider that the teaching of professionalism must be explicit in the formal undergraduate curriculum, being clear to students, so that they understand what needs to be modified in their attitudes³3. Sattar K , Roff S , Meo SA . Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism . BMC Med Educ . 2016 ; 16 : 285 . doi: https://dx.doi.org/10.1186/s12909-016-0807-x .
https://dx.doi.org/10.1186/s12909-016-08... , ²⁰20. Hochberg MS , Berman RS , Kalet AL , Zabar S , Gillespie C , Pachter HL . Professionalism training for surgical residents documenting the advantages of a professionalism curriculum . Ann Surg . 2016 ; 264 ( 3 ): 501 - 7 . .

Thus, we emphasize, once again, the faculty’s role in the teaching of professional behavior, viewing it as a key element for attitude changes. The learning of professionalism is also structured on models presented by the teachers-professionals who teach classes during the undergraduate course⁴4. Jauregui J , Gatewood MO , Ilgen JS , Schaninger C , Strote J . Emergency medicine resident perceptions of medical professionalism . West J Emerg Med . 2016 ; 17 ( 3 ): 355 - 61 . , ¹¹11. Brissette MD , Johnson KA , Raciti PM , McCloskey CB , Gratzinger DA , Conran RM , et al . Perceptions of unprofessional attitudes and behaviors implications for faculty role modeling and teaching professionalism during pathology residency . Arch Pathol Lab Med . 2017 ; 141 ( 10 ): 1394 - 401 . . An educational model in which the faculty is aware of their function is likely to successfully promote positive attitudes in students³3. Sattar K , Roff S , Meo SA . Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism . BMC Med Educ . 2016 ; 16 : 285 . doi: https://dx.doi.org/10.1186/s12909-016-0807-x .
https://dx.doi.org/10.1186/s12909-016-08... , ⁴4. Jauregui J , Gatewood MO , Ilgen JS , Schaninger C , Strote J . Emergency medicine resident perceptions of medical professionalism . West J Emerg Med . 2016 ; 17 ( 3 ): 355 - 61 . . It is important to understand that the student repeats, unconsciously, attitudes witnessed during the undergraduate course. Due to this, teachers’ development has great validity²2. McLachlan JC , Finn G , Macnaughton J . The conscientiousness index: a novel tool to explore students’ professionalism . Acad Med . 2009 ; 84 ( 5 ): 559 - 65 . .

Assessing professionalism: multiple assessment strategies

Based on the analysis of the articles, we noted different forms of assessment. There is not an ideal and universal model. Many times, they are used in a joint way, aiming at a more reliable and complete assessment. Strategies like the application of PROMOBES (Professional Mobile Monitoring of Behaviors) facilitated the capture of behavioral attitudes in real time, as it is a mobile application for cell phones. Students modeled themselves because they knew they were being observed all the time and, through instantaneous feedback, were stimulated to reflect and change their attitudes. Likewise, teachers became aware of the importance of observing conducts, and interested in intervening whenever necessary⁵5. Cendán JC , Castiglioni A , Jonhson TR , Eakins M , Verduin ML , Asmar A , et al . Quantitative and qualitative analysis of the impact of adoption of a mobile application for the assessment of professionalism in medical trainees . Acad Med . 2017 ; 92 ( 11 ): 31 - 42 . .

The Situational Judgement Test - SJT, in which students are assessed through simulated clinical scenarios and receive feedback, is a tool that enables the evaluation of various professionalism domains in a real way, measuring behavior, empathy, integrity, resilience, teamwork, and technical skills. The method also allows students to participate in the discussion of cases and to suggest new situations based on their personal experiences¹²12. Goss BD , Ryan AT , Waring J , Judd T , Chiavaroli NG , O’ Brien RC , et al . The use of situational judgement tests in the teaching and assessment of professionalism . Acad Med . 2017 ; 92 : 780 - 4 . .

In the United Kingdom, a study involving different health courses used two online questionnaires approaching ethical dilemmas and unprofessional attitudes experienced during the undergraduate course and concluded that the health professional’s education occurs in work environments where they frequently face dilemmas that result in distress²²22. Monrouxe LV , Rees CE , Dennis I , Wells SE . Professionalism dilemmas, moral distress and the healthcare student: insights from two online UK-wide questionnaire studies . BMJ Open . 2015 ; 5 : e007518 . doi: https://dx.doi.org/10.1136/bmjopen-2014-007518 .
https://dx.doi.org/10.1136/bmjopen-2014-... .

In a South Korean university, students enrolled in ethics wrote an anonymous text about an example of professionalism (or of nonprofessional behaviors) they had witnessed and, based on this, reflected on their own attitudes. Words like respect, responsibility and reliability predominated¹1. Park SY , Shon C , Kwon OY , Yoon TY , Kwon I . A qualitative thematic content analysis of medical students’ essays on professionalism . BMC Med Educ . 2017 ; 17 :79. doi: https://dx.doi.org/10.1186/s12909-017-0920-5 .
https://dx.doi.org/10.1186/s12909-017-09... .

In the United States, an institution used a tool called MedU, which assessed professionalism through comments written by students after assisting virtual patients. It was possible to capture negative and unprofessional behaviors during the simulation of clinical cases¹⁸18. Dong T , Kelly W , Hays M , Berman NB , Durning SJ . An investigation of professionalism reflected by student comments on formative virtual patient encounters . BMC Med Educ . 2017 ; 17 ( 1 ): 3 . doi: https://dx.doi.org/10.1186/s12909-016-0840-9 .
https://dx.doi.org/10.1186/s12909-016-08... .

The Dundee Polyprofessionalism Inventory was developed in the University of Dundee, United Kingdom, and has been validated in several countries. It lists different professionalism lapses and requests appropriate sanctions. A study carried out in Saudi Arabia with this instrument found a series of unprofessional behaviors and a large amount of students who considered a bad attitude as something natural, not amenable to correction. This revealed the need of an urgent intervention to help students understand these attitudes as something maleficent to their integrity and professional future³3. Sattar K , Roff S , Meo SA . Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism . BMC Med Educ . 2016 ; 16 : 285 . doi: https://dx.doi.org/10.1186/s12909-016-0807-x .
https://dx.doi.org/10.1186/s12909-016-08... .

The assessment through OSTEs (Objective Structured Teaching Encounter), or OST Exercise, promotes the inverse process. It shows cases, using a standardized student who presents various professionalism lapses, like missed hand hygiene, lack of attention to patient comfort, poor interpersonal communication, overuse of medical terminology, unprofessional attire, and assesses how students perceive and remediate these attitudes, complemented by feedback²³23. Tucker RC , Choby BA , Moore A , Parker RS , Zambeti BR , Naids S , et al . Speaking up: using OSTEs to understand how medical students address professionalism lapses . Med Educ Online . 2016 ; 21 ( 1 ): 32610 . doi: https://dx.doi.org/10.3402/meo.v21.32610 .
https://dx.doi.org/10.3402/meo.v21.32610... .

Feedback-associated modeling is cited as an efficient method, strengthening the importance of consciously teaching the domains of the professionalism construct⁷7. Huffmyer JL , Kirk SE . Professionalism: the “forgotten” core competency . Professionalism Anesthesiol . 2017 ; 125 ( 2 ): 378 - 9 . , ¹⁵15. Kelly AM , Gruppen LD , Mullan MP . Teaching and assessing professionalism in radiology resident education . Acad Radiol . 2017 ; 24 ( 5 ): 563 - 73 . . Other methods investigate what is understood by professionalism by sending e-mails to university teachers and students and requesting them to list the three most important characteristics of a professional¹⁶16. Randall VF , Foster CW , Olsen CH , Warwick AB , Fernandez KA , Crouch G . Defining medical professionalism across the years of training and experience at the uniformed services university of the health sciences . Mil Med . 2016 ; 181 ( 10 ): 1294 - 9 . .

At the New York University, the Professional Identity Essay is used as an instrument for reflection on issues related to professionalism and on the meaning of being a doctor, evaluated as the first stage of Professional Identity Formation²⁴24. Kalet A , Buckvar-Keltz L , Monson V , Harnik V , Hubbard S , Crowe R , et al . Professional identity formation in medical school: one measure reflect changes during pre-clerkship training . Amee MedEdPublish . 2018 ; 7 ( 1 ): 41 . doi: https://dx.doi.org/10.15694/mep.2018.0000041.1 .
https://dx.doi.org/10.15694/mep.2018.000... .

In 2015, when Hultman and Wagner assessed a large number of students, residents and doctors, they cited as efficient forms: modeling, personal experience and 360 degree peer evaluations, and classified as less efficient instruments: lectures, written tests, portfolios and journals²⁵25. Hultman CS , Wagner IJ . Professionalism in plastic surgery attitudes, knowledge, and behaviors in medical students compared to surgeons in training and practice-one, but not the same . Ann Plast Surg . 2015 ; 74 Suppl 4 : S247 - 54 . .

Assessment methods favor the identification of professional lapses, enabling the student to reflect, and this tends to generate behavioral changes⁵5. Cendán JC , Castiglioni A , Jonhson TR , Eakins M , Verduin ML , Asmar A , et al . Quantitative and qualitative analysis of the impact of adoption of a mobile application for the assessment of professionalism in medical trainees . Acad Med . 2017 ; 92 ( 11 ): 31 - 42 . . Examples of lapses are: being late for classes, obtaining illegal access to examination questions, legitimizing absences by false testimony, forging signatures, cheating in examinations, posting inappropriate material on social media, using drugs, drinking alcohol before medical visits, physically assaulting colleagues or employees, and falsifying or fabricating data in published works³3. Sattar K , Roff S , Meo SA . Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism . BMC Med Educ . 2016 ; 16 : 285 . doi: https://dx.doi.org/10.1186/s12909-016-0807-x .
https://dx.doi.org/10.1186/s12909-016-08... . It is necessary to develop methods that improve the teacher’s capacity to detect these signs and to remediate, as early as possible, negative attitudes¹⁸18. Dong T , Kelly W , Hays M , Berman NB , Durning SJ . An investigation of professionalism reflected by student comments on formative virtual patient encounters . BMC Med Educ . 2017 ; 17 ( 1 ): 3 . doi: https://dx.doi.org/10.1186/s12909-016-0840-9 .
https://dx.doi.org/10.1186/s12909-016-08... .

The problem posed by the assessment instruments is that it must be analyzed if what is assessed by them really corresponds to what is experienced and performed by students in practice²2. McLachlan JC , Finn G , Macnaughton J . The conscientiousness index: a novel tool to explore students’ professionalism . Acad Med . 2009 ; 84 ( 5 ): 559 - 65 . .

Thus, we found that the assessment by means of instruments, guided by domains, is the most frequent. In the reviewed studies, four universities used simulated scenarios or standardized patients, three employed online questionnaires, four highlighted the importance of feedback associated with other methods, and one used a cell phone application for instantaneous assessment. Modeling is highlighted and cited in almost all the texts. In two cases, the opinions of teachers and deans about professional attitude and correction of lapses were also evaluated, strengthening the great importance of modeling and of the training of professionals who act in student education in undergraduate courses.

Final remarks

The study showed that professionalism is still an undefined and dynamic concept, with variations in each institution, as there is not one single concept in the scientific literature. Professionalism is assessed, mostly, by the evaluation of domains that encompass various attitudes understood as professional. Different assessment strategies are used, mainly questionnaires, standardized patients and simulated clinical cases, feedback and modeling. We believe it is necessary to associate methods to achieve a better longitudinal assessment, adapted to the stage the student is at during the undergraduate course.

References

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