Learning about medicalprofessionalism – don’tforget emotion!Kirsty Foster, Northern Clinical School and Office of Postgraduate Medical Education,University of Sydney, New South Wales, Australia

BACKGROUND

‘Professionalism’ is a buzzword in medical educationright now. Public expecta-

tion is that the medical professionwill ensure high standards in itsmembers, not only in knowledgeand technical expertise, but alsoin integrity, compassion and eth-ical behaviour. In response, ‘pro-fessionalism’ has been introducedinto curricula both at undergrad-uate and postgraduate levels. Thispresents a challenge because thevalues, beliefs, culture, andbehaviours comprising medicalprofessionalism are complex anddynamic.1 In the real world ofmedical practice, students begin aprocess of socialisation into the

medical profession during whichthey learn about professionalismthrough experience and reflec-tion.2 The clinical environmentexposes medical students andtrainees to a ‘community of prac-tice’3 of experienced health pro-fessionals, into which theygradually become acculturated.Learning during this process islargely the result of a ‘hiddencurriculum’,4 which is unstruc-tured, uncontrolled and often atodds with the principles taught inthe classroom. Students and ju-nior doctors look to more seniorcolleagues for guidance, and thestrong influence of such rolemodels on them, especially inrelation to professionalism andprofessional behaviour, is well

recognised.5,6 However, these rolemodels may not always be exem-plary in their behaviour7, and theemotional aspect of these rela-tionships is relatively underem-phasised, both at undergraduateand postgraduate levels.8 Tradi-tionally, emotionality has beenregarded as antithetical withobjective assessment and man-agement of patients, resulting inthe relegation of the ‘art’ of med-icine in favour of the ‘science’.

My research explores the im-pact of clinician role models asclinical teachers on learningabout professionalism in theclinical setting. As a background,some key points from the profes-sionalism literature are outlined

Publicexpectation isthat the medicalprofession willensure highstandards in itsmembers

Professionalism

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in Box 1. The ultimate aim is toimprove the congruence betweenthe aspirations for professional-ism presented in the classroomand the real experience, which sostrongly influences the develop-ment of proto-professionals8.

METHOD

The participants in this qualita-tive study were senior clinicianscurrently involved in clinicalteaching or supervision. Semi-structured interviews captureddata on memorable learningexperiences, and an insight intohow participants felt their notionof professionalism, their ownprofessional identity and subse-quent professional behaviour hadbeen influenced.

Initial thematic coding basedon grounded theory identified theimportance of role models and thelearning environment. This sup-ported evidence from the litera-ture,9 and these aspects ofclinical training were further ex-plored in the narrative analysispresented briefly here.

RESULTS AND DISCUSSION

Twelve doctors, six men and sixwomen, from eight specialtieswere interviewed. The samplecomprised rural and city-baseddoctors with between 10 and40 years experience sincequalifying in medicine.

Every participant rememberedat least one clinical teacher whoseinfluence was formative in shapingtheir own professional identity.The memories were vivid, evenafter many years, and typicallyrelated to everyday occurrencesrather than major incidents ordifficult ethical dilemmas.

Those people who created astrong impact during training werepowerful characters, often verycharismatic. They held high statuswithin the medical hierarchy andhad the power to influence self-esteem, confidence, behaviour andeven career choice. Derek, de-scribes one such clinical teacher30 years after this contact.

And I still remember this tothis day. Professor TS, whowas one of those thespianprofessors of pathology,wore a bow tie, played aviolin, acted Shakespearewith great proficiency(laughs) ... pathology wasmy strongest preclinicalstudy and probably greatlyinfluenced by very goodteachers who had a greatsense of humour.

This brief excerpt, told withfondness, describes a teacher whodemonstrated skills and interestsoutside of medicine, and

respected students enough toshare his personal interests withthem. Derek acknowledges thatthis teacher contributed to hisown good performance in pathol-ogy. Linking a good sense ofhumour to good teaching sug-gests that TS created a relaxedenvironment conducive to learn-ing.

The balance of good and badexperiences referred to by Hiltonand Slotnick8 is evident too.These emotions endured for manyyears, testament to the powerfulimpact of the experience. Royrecalled an encounter with asurgeon supervisor when he was aresident 13 years earlier.

He was incredibly awful, youknow, I think his openingwords to me when I startedthe term were ‘‘Are yougoing to cry? The last threehave cried’’.

This experience had been trau-matic, producing strong feelings ofanger, which Roy had been unableto express at the time. Even after13 years, he wanted to go back and‘tell him to f#@% off ’.

Furthermore, Roy indicatedthat he felt that this experiencehad influenced the way he nowbehaves in his own seniorposition as a clinical supervisor.

Box 1. The nature of professionalism

• Professionalism is a dynamic entity depending on the social and cultural context of the doctor, and is not definedby a list of qualities and attributes1

• Attaining professionalism is a staged process during which the novice medical student ⁄ proto-professionalacquires the values, attitudes, interests, skills and knowledge of the medical profession, and moves towards expertstatus2

• Acquisition of professionalism requires an explicit cognitive component, reinforced and internalised throughexperiential learning2

• Professionalism arises from experience and reflection on experience and is a combination of phronesis (practicalwisdom), specialised knowledge and technical skills8

• Development of a professional identity is the result of simultaneous positive and negative influences on theproto-professional during undergraduate and postgraduate training8

• Emotional stress and harassment by supervising physicians can subvert the professional behaviours educators seekto encourage7

Semi-structuredinterviews

captured dataon memorable

learningexperiences

10 � Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 9–12

Well you can’t have that sortof really intense experiencewithout it affecting you. Icertainly try to be verysupportive of junior staff.

Gemma also vividly recalledthe intense feelings she had dur-ing her resident training, whichbegan in a paediatric ward almost20 years earlier.

I was very emotional. I usedto really care about mypatients, but in anemotional way. And Iremember one of the paedi-atricians saying ‘‘You’re tooemotional, you’re too emo-tional’’ ... obviously now Idon’t, I don’t have that, ... Idon’t have that emotionalthing, ... that had to besuppressed a little bit.

And later in the interviewGemma recalls:

I used to feel very upsetwhen they [children] usedto die, very upset and reallyupset. I used to cry and Iwas really upset. Even whenold people used to die I usedto cry, you know I was veryemotional, I wouldn’t dothat now, never.

Gemma learned that strongemotions are unacceptable in theculture of medicine, and that to beupset when someone dies isunprofessional. This was how sheinterpreted a brief comment from asenior colleague at an early stagein her career. It appears that herprogress towards phronesis8 wasinhibited by the lack of opportu-nity to discuss the issue at thetime. She gives insight into theimpact of her learning experienceon both her teaching of traineesand her own psyche,when she says:

… it’s less teaching thantrying to make them [train-ees] feel as though they’remaking the right decisions.And making them feel com-fortable and capable ofdoing it. Because a lot ofthem have those anxietiesabout not being able toperform and not being up toscratch and so because I’mthe master of knowing whatthat was like (laughs).

Most participants also recalledmedical teachers who had beensupportive in their relationshipwith students. Often apparentlysmall actions made a big impacton self-esteem, and in turn onprofessional identity develop-ment. Helen said of her professor

of medicine, when she was astudent 14 years previously:

He knew everyone, and thatmakes a real differencewhen a senior teacher knowsyou by name, and that is abig influence on you.

Lorna recalled the long-lastingmemory of the positive effect of afew seconds of feedback from aconsultant when she was anintern 15 years before interview:

He would draw you aside atGrand Rounds and say ‘‘Nicejob on such and such’’. Littlethings like that. Littlethings that I’m rememberingas I’m training my juniors.I remember how much it

Strong emotionsareunacceptable inthe culture ofmedicine

� Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 9–12 11

made me swell inside withpride.

In my data, feelings are cen-tral to memories of professional-ism-related learning experiencesfrom early clinical years. Evenafter many years emotions arerecalled with intensity. The per-sistence of strong memories formany years suggests that theemotional impact at the time wassubstantial, and that learningcame at some cost. Boud de-scribes ‘attending to feelings’ asan essential step in reflecting on,and hence learning from, experi-ence.10 In a busy clinical area thispresents a challenge, and may besimply forgotten. Feelings notattended to, Boud suggests, actas barriers to learning, and it isreasonable to assume this appliesto knowledge and skills as well asto professionalism.

Glicken and Merenstein arguethat medical educators must takeresponsibility for modelling pro-fessional values when teaching,as well as when interacting withpatients and colleagues.11 Fromthis study it seems that manyclinical teachers underestimatethe impact of their behaviourtowards students and trainees in aclinical setting. The examplesdiscussed in this paper suggest

positive outcomes even from poorrole-modelling, but this may notalways be the case.7 It is unlikelythat doctors who chose toemulate negative behaviour wouldagree to participate in a studyabout professionalism, and this isan important area for furtherwork.

CONCLUSIONS

The memories of professionalism-related learning experiences canbe long lasting. Strong emotionsand feelings elicited in proto-professionals are key componentsof the reflection on learningexperience that shapes profes-sional identity. Furthermore, thisstudy shows that both good andbad experiences as a studentinfluence future behaviour whenin a teaching and supervisoryrole. Clinical teachers need to beaware of the lasting and powerfuleffects of emotions evoked bytheir behaviour towards studentsand trainees.

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