Making an Impact: Professionalism Policy and Practice for Medical Students
Professionalism is taught formally within all UK medical schools, and informally during
students’ workplace learning experiences. Sometimes, however, classroom teaching is not
always translated into practice. Professionalism dilemmas are situations in which a person
participates in (or witnesses) something they believe to be unprofessional, unethical or
‘wrong’. Following a 5-year international programme of research with collaborators across
the UK and Australia investigating healthcare students’ professionalism dilemma situations,
Dr Lynn Monrouxe’s work is beginning to have a positive impact on professionalism policy
and practice across medical education in the UK.
Dr Monrouxe, Director of Medical Education Research, Institute of Medical Education and
her colleagues’ work has led to the understanding of a greater range of professionalism
dilemma situations than previously found: including how systemic cultural power dynamics
operating within the NHS impacts not only on students’ learning to become healthcare
practitioners but also on issues such as patient safety and dignity which sometimes become
compromised along the way. Furthermore, their work has provided a greater understanding
of how these difficult experiences affect tomorrows’ healthcare workers in terms of how
students develop their identities as patient-centred professionals and of the negative
emotional impact that witnessing and/or participating in unethical practice has on them.
Here are some common ‘professionalism dilemmas’ themes and brief illustrative examples
from the UK questionnaire study:
Patient care dilemmas relating to the actions of health care professionals (HCPs): Actions
by health care professionals that compromise patient dignity and patient safety (66.7%
[n=1,597] of all students and 81.4% [n=1,307] of clinical students reported experiencing
these).*
Example: ‘A doctor told a patient that he thought the patient was faking his pain and was
too fat to fit in the CT [computerised tomography] scanner anyway, so if he did insist on
being in pain they would have to take him to London Zoo and put him in the elephant
scanner’.
Patient care dilemmas around student action: Actions by students that compromise patient
dignity or patient safety (47.7% [n=1,142] of all students and 59.8% [n=960] of clinical
students reported experiencing these).
Example: ‘Being asked to clerk and examine a very ill man (who died later that day) for my
own education’.
Intimate examination: Students learning intimate examinations on patients without valid
patient consent (20.6% [n=331] of clinical students reported this for female patient with a
similar number for male patients).
Example: ‘Had gained consent to watch a vaginal examination of an elderly lady. I was
watching and consultant said: ‘‘[Name], put on a glove.’’ Once I had done [so] he instructed
me to feel the ring he had inserted into the vaginal entrance. After I ... started to ask for
consent, he cut me off saying, ‘‘You don’t mind if he feels do you, he’s just a doctor in
training and needs to know how it feels.’’ Was very much a statement rather than [a]
question’’.
*Monrouxe et al. (under revision) Professionalism dilemmas in UK medical students’ workplace learning environments: A questionnaire
exploring the influence of gender and frequency on moral distress. Acad Med; Rees et al. (in press) Narrative, emotion and action:
Analysing medical students’ written stories of ‘most memorable’ professionalism dilemmas. Med Educ.
As a result of this work, medical schools across the UK are now beginning to change (or
better enforce) ethical guidelines around students’ interactions with patients. For example,
Newcastle School of Medicine undertook independent work of their own year four and five
students and confirmed the scale of the problem at their school. Following this they
reviewed their regional consent policy, fed back their findings to Directors of Medical
Education and their Regional Senior Medical Advisory Group for further changes to be
made. Peninsula Medical School also made policy changes and have taken steps to
implement them.
“The new undergraduate curriculum in Cardiff will have professionalism as a clear vertical
theme throughout the five years,” said Professor Paul Kinnersley, Director of Teaching and
C21 Lead for Professionalism, Ethics and Personal Development, Institute of Medical
Education. “The lessons from Lynn Monrouxe's research will be at the foundation of
teaching, and students will have regular opportunities to share and discuss the dilemmas
they have come across,” he added. “This will support students to re-commit to the
professionalism values taught during formal learning. ”
Dr Monrouxe and her colleagues (notably Professor Charlotte Rees, University of Dundee,
Dr Ming-Jung Ho, National Taiwan University College of Medicine and Dr Madawa
Chandratilake, University of Kelaniya) have now begun to develop a similar programme of
work within a Chinese cultural setting and a South-east Asian cultural setting to facilitate
organizational cultural change internationally and to enhance a cultural awareness of the
differences in professionalism for medical trainees, educators, and providers who frequently
travel across cultural borders at home and abroad.
Picture by Jasmine Monrouxe Photography