Medical education leaders have long advocated the importance of teaching professionalism to medical school students.

The Liaison Committee on Medical Education (LCME), the independent authority for accreditation of medical schools leading to an MD degree, requires it. 

No one disputes its importance. Unprofessional behavior in medical school is linked strongly with later disciplinary action, according to an often-quoted study. Researchers found that 95% of disciplinary actions from one state medical board over a 10-year period were for deficiencies in professionalism — and those disciplined physicians were more than twice as likely as a control group to have received negative comments about professionalism during medical school.

“Professionalism is an agreed upon set of behaviors we expect of all trainees and physicians and other staff,” said Matthew R. Carroll, MD, assistant professor of obstetrics and gynecology at Baylor College of Medicine, Houston, who published a report on promoting professionalism in medical education. Professionalism includes competence, honesty with patients, good quality of care, and the maintenance of trust, among other components.

The LCME requires professionalism instruction but does not dictate howto teach it.

“The faculty of the school, through its curriculum committee, decides how to approach all aspects of the medical education program as the LCME does not prescribe curricula content,” a LCME spokesperson told Medscape Medical News. 

Now, some medical school leaders are saying it’s time to discard the traditional rules-centric approach, saying that a heavy focus on disciplinary actions can be unfair, can target people unfairly and misses the point of how to help students develop professionalism. It’s time, they say, to move to a more comprehensive model that emphasizes more than correcting negative behavior.

Cultivating Competence and Character

Professionalism education does need to include rules that must be followed, said Marin Gillis, PhD, senior executive dean for faculty affairs and learning innovation at Roseman University College of Medicine, Las Vegas.

But what she calls the disciplinary or compliancy model can get ridiculous, be dismissed by students and others, and sometimes be unfair, she said. She recalled a medical student who said she was written up for not being on time — when she said she arrived at the exact time her supervisors arranged. To focus only on behaviors such as being late, not finishing paperwork on time, and similar actions, is only part of teaching professionalism, Gillis said.

“Traditionally, medical schools have focused on professionalism as breaches of behavior,” said Gillis, who is also a professor of bioethics, humanism, and policy. That’s not the whole picture. “You can’t tell a student he is being unprofessional if you don’t teach him what professional behavior is. If you are going to do citations for poor behavior, you should do citations for exemplary behavior,” Gillis said.

Being a medical professional isn’t just following ethical behavior, she said, “but all of the behaviors of being a good physician — that is, doing well at what a physician does, not just the ethical part.” It also means knowing clinical science, keeping up with medical literature and being an effective problem solver, among other attributes.

At Roseman, the curriculum is grounded in a concept called “professionalism as flourishing,” Gillis said. The approach to professionalism is built on a framework of virtues — a character-based model focused on adaptability, beneficence, compassion, conscientiousness, critical thinking, curiosity, discernment, excellence, fair-mindedness, humility, integrity, and respect.

Professionalism isn’t a single course or subject but is embedded into the entire curriculum, Gillis said. The concept is rooted in Aristotle’s idea that flourishing is a state, actively built with the cultivation and habituation of virtue.

The curriculum emphasizes the social contract model, which looks at physicians as a group with a public commitment to patient welfare and social justice, and the professional identity formation model, which looks at professionalism as developmental over time.

One example: While mandatory reporting (of suspected abuse or neglect) is a legal requirement, students are asked to discuss in class how to approach the conversation in a way that preserves trust and minimizes harm.

When discussing complex patients, students are urged to avoid terms such as “difficult patient.”

Professionalism: A Process

The word professionalism can turn people off, including students, said Deepthiman (Deepu) Gowda, MD, MPH, MS, assistant dean of Medical Education at the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California. “Sometimes people feel [the word ] professionalism can be tied to old-fashioned notions of who can be a doctor and who can’t. People sometimes think about it not encompassing the diversity of people who go into medicine.”

For all those reasons, he said, it’s preferable to focus on behaviors and attitudes that students need to develop. “When you think about behaviors, I think we can align on what are the professional behaviors that allow for best care to be given,” he said.

This is communicated through a course that began when the school opened in July 2020. Known as REACH, it includes reflection, education, assessment, coaching, and health and wellbeing, Gowda said. It continues all 4 years, mainly taught in week-long blocks, Gowda said.

“An important part of REACH is helping students understand professionalism as a process, not just a set of rules,” said Sharon Okonkwo-Holmes, MD, clinical assistant professor of clinical science at the university and a course director for REACH.

“Through coaching, reflective writing, small groups, assessment reviews, and well-being activities, students examine how they show responsibility, honesty, and good judgment in patient care and teamwork,” she said.

Coaching is an important part of the process, she said, and it’s different than traditional mentoring. In the program, students are encouraged to discover insights themselves rather than a coach providing the answers.

The coaches follow students all the way to graduation, Gowda said. Students meet one-on-one several times a year with the coach. “The coaches have access to their test results [from procedures], assessment data. They sit down together and assess together.” The point is to assess what could have been done better, to learn from mistakes.

The coaching helps students develop “what we call a growth mindset,” Gowda said. “This is such an important concept and ties in very much with professionalism.”

Student Feedback

“One of the most meaningful lessons I learned was the power of community and the value of listening to others’ lived experiences,” said Jenna Philippe, a student at Kaiser Permanente School of Medicine. “These experiences deepened my commitment to empathy and cultural humility, better preparing me to provide compassionate, patient-centered care to individuals from diverse backgrounds and in navigating the world around me.”

“A lesson that hit home with me through the REACH program was that here is no mold that we’re supposed to fit into for medicine to be great doctors,” said Jose Barrera, 32, of Pasadena, California, who is also a Kaiser Permanente School of Medicine student. “We create our own mold with our life experiences and perspectives, and it is by having those experiences that we will be able to connect better with patients to provide them with the best care that we can.”

The experts cited in this article had no relevant disclosures.