Ambiguity, Circularity, and Professionalism in Undergraduate Medical Education

Abstract

Introduction The notion of professionalism informs policy-making at all levels of medical practice, from national specialty organizations and licensing boards to hospital disciplinary committees. The creation of policies to promote professionalism, however, is made all the more complex in the context of undergraduate medical education, where the notion of professionalism not only acts to govern student’s behavior, but also to shape the professional identity of physicians-in-training. This challenge is evident in the ambiguity and conceptual circularity which can be found in the professionalism policies governing undergraduate medical education. We offer, here, a preliminary report on our current effort to descriptively characterize the breadth of this phenomenon. Study Objective Here, we report on data collected through the ongoing Insight Into Professionalism Initiative, which has sought to characterize the role of professionalism in undergraduate medical education as reflected in the institutional policies of all allopathic medical schools in the United States. Methods We utilize a qualitative approach, built on a Critical Policy Analysis framework, which has to date allowed for the assessment of policies from thirty medical schools. We define “professionalism policies” as those policies which (i) satisfy LCME Standard 3.5 or otherwise define professional characteristics or behaviors or (ii) are referenced by the policies described by (i). In cases where no particular policy satisfied these requirements, the entire medical student handbook from that institution was analyzed. We designate such policies as ambiguous when they (i) define professionalism circularly (i.e., using references to professionalism to define professionalism) or (ii) rely on undefined ideas of appropriateness, collegiality, reasonableness, suitability, or the standards of the medical profession. Results Of the thirty medical schools whose policies have been assessed to date, twenty-two (73%) have policies designated as ambiguous, and nineteen (63%) had multiple policies which were designated as ambiguous. Twenty-two policy sets (73%) used patently circular language. Seventeen policy sets (57%) referred to undefined ideas of appropriateness, and twelve (40%) referred to the standards of the medical profession. References to reasonableness, collegiality, and suitability were less common, with only four policy sets (13%), three policy sets (10%), and two policy sets (7%) respectively referencing these notions. Conclusion Professionalism has been explicitly identified by the LCME as a key competency for graduating medical students. Here, however, we have collected evidence that a primary modality for communicating professional expectations—namely, professionalism policies—are currently inadequate, and offer circular or otherwise ambiguous definitions of professionalism which cannot guide the professional development of students. While we cannot yet claim that this problem is universal among allopathic medical schools in the United States, there is cause for concern—and an important opportunity for medical educators and students to turn their attention to correcting it.