A strategy for the detection and evaluation of unprofessional behavior in medical students. University of California, San Francisco School of Medicine Clinical Clerkships Operation Committee.

The authors describe the first four years (1995-1998) in which the University of California, San Francisco School of Medicine operated an evaluation system to monitor students' professional behaviors longitudinally through their clinical rotations. The goals of this system are to help "turn around" students found to have behaved unprofessionally, to demonstrate the priority placed by the school on the attainment of professional behavior, and to give the school "muscle" to deal with issues of professionalism. A student whose professional skills are rated less than solid at the end of the clerkship receives a "physicianship report" of unprofessional behavior. If the student receives such a report from two or more clerkships, he or she is placed on academic probation that can lead to dismissal even if passing grades are attained in all rotations. Counseling services and mentoring by faculty are provided to such students to improve their professional behaviors. From 1995 to 1998, 29 reports of unprofessional behavior on the part of 24 students were submitted to the dean's office; five students received two reports. The clerkship that submitted the most reports was obstetrics-gynecology. The most common complaint for the five students who received two reports was a poor relationship with the health care team. Four of these students had their difficulties cited in their dean's letters and went on to residency; the fifth voluntarily withdrew from medical school. The authors describe the students' and faculty members' responses to the system, discus lessons learned, difficulties, and continuing issues, review future plans (e.g., the system will be expanded to the first two years of medical school), and reflect on dealing with issues of professionalism in medical school and the importance of a longitudinal (i.e., not course-by-course) approach to monitoring students' behaviors. The authors plan to compare the long-range performances of students identified by the evaluation system with those of their classmates.     

Viewpoint: learning professionalism: a view from the trenches.

The authors, medical students immersed in learning professionalism, observe that most of the professionalism literature misses the mark. Their views on professionalism education, although not the result of qualitative research, were gained from four years of conversations with students from a dozen medical schools, plus online student discussions, focus groups, and meetings with supervisors from five schools. The authors propose that the chief barrier to medical professionalism education is unprofessional conduct by medical educators, which is protected by an established hierarchy of academic authority. Students feel no such protection, and the current structure of professionalism education and evaluation does more to harm students' virtue, confidence, and ethics than is generally acknowledged. The authors maintain that deficiencies in the learning environment, combined with the subjective nature of professionalism evaluation, can leave students feeling persecuted, unfairly judged, and genuinely and tragically confused. They recommend that administrators, medical educators, residents, and students alike must show a personal commitment to the explicit professionalism curriculum and address the hidden curriculum openly and proactively. Educators must assure transparency in the academic process, treat students respectfully, and demonstrate their own professional and ethical behavior. Students overwhelmingly desire to become professional, proficient, and caring physicians. They seek professional instruction, good role models, and fair evaluation. Students struggle profoundly to understand the disconnect between the explicit professional values they are taught and the implicit values of the hidden curriculum. Evaluation of professionalism, when practiced in an often unprofessional learning environment, invites conflict and compromise by students that would otherwise tend naturally toward avowed professional virtues.     

Assessing how well three evaluation methods detect deficiencies in medical students' professionalism in two settings of an internal medicine clerkship.

PURPOSE: To compare the performances of three evaluation methods in detecting deficiencies of professionalism among third-year medical students during their ambulatory care and inpatient ward rotations of a core internal medicine clerkship. METHOD: From 1994 to 1997, 18 students at The Uniformed Services University of the Health Sciences failed to satisfactorily complete their core 12-week third-year internal medicine clerkship due to deficiencies in professionalism. Three evaluation methods had been used to assess all students' professionalism during the two rotations of their clerkship: standard checklists, written comments, and comments from formal evaluation sessions. Using qualitative methods and the information obtained by the three evaluation methods, the authors abstracted the record of each student concerning his or her clerkship behavior in terms of the six domains of professionalism used on the standard checklist. A detection index, which is the percentage of all instructors' less-than-acceptable ratings of a student across the six professionalism domains, was calculated for each evaluation method for each of the two clerkship settings. RESULTS: For each evaluation method, deficiencies in professionalism were twice as likely to be identified during the ward rotation as during the ambulatory care rotation (p < .002 for all). Formal evaluation session comments had the highest detection index in both clinical settings. Although the numbers of written and formal evaluation session comments per evaluator and per cited professionalism domain were similar, nearly a fourth of the instructors made identifying comments at the evaluation sessions only. CONCLUSION: In the clerkship studied, deficiencies in professionalism of such magnitude as to require remediation were more likely to be identified in the inpatient than in the ambulatory care setting. Of the three evaluation methods studied, the face-to-face, formal evaluation sessions significantly improved the detection of unprofessional behavior in both clerkship settings. Further efforts at such an interactive evaluation process with ambulatory care clerkship instructors may be essential for improving the identification of unprofessional behavior in that setting.     

From traditional to patient-centered learning: curriculum change as an intervention for changing institutional culture and promoting professionalism in undergraduate medical education.

The authors reframe a curriculum change from a traditional lecture-based to an integrated patient-centered approach as an intervention for changing the culture and hidden curriculum of an institution in ways that promote professionalism. Within this context, the authors articulate some of the inherent process and relational factors brought about by these curricular changes that are essential elements of this intervention process. In 1998 the University of North Dakota School of Medicine and Health Sciences (UNDSMHS) introduced a new preclinical patient-centered learning (PCL) curriculum for first- and second-year medical students. Case-based, small-group learning forms the critical foundation of the PCL process, and an integrated basic and clinical science didactic component supports this process. At the student level, the case-based PCL process generates innovative opportunities for professionalism education from the explicitly articulated formal content that arises naturally from the cases, but more importantly from the implicit values inherent to the PCL small-group process itself--humanism, accountability, pursuit of excellence, and altruism. Further, the organizational changes necessary for the transformation to the PCL curriculum required process changes at student, faculty, and administrative levels that have resulted in a cultural shift toward relationship centeredness within the institution. The authors describe the evolution and structure of the PCL curriculum at UNDSMHS and how this curricular transformation has served as an intervention that promotes professionalism and institutional culture change through (1) processes at the student level that present new opportunities for professionalism education, and (2) processes at student, faculty, administrative, and institutional levels that have created an institutional culture that supports, models, and promotes relationship-centered professional values.     

Understanding social influence in medical education.

Many aspects of the medical education system lead trainees to a host of maladaptive reactions and behaviors, but far too little attention has been focused on the impact that interactions between teacher and learner can have on the development of professionalism. The authors discuss the concept of "social influence," a change of attitude, belief, or behavior resulting from the actions of another person in the context of the medical education setting. Using the example of a medical student who has not adequately completed his inpatient medicine requirements, they identify ten strategies of social influence that a medical educator might invoke to change the student's behavior and evaluate the benefits and drawbacks of these strategies. This overview can be used by faculty to explore new strategies of teaching and to reflect on their current teaching styles.     

A study of seat-taking in seminar classes: data analysis of three seminar classes in a women's university

The purpose of this study was to examine the conditions under which human territoriality (self/other boundary-regulation mechanism) appears in seat-taking behavior. Seat-taking in a social psychology seminar class of twelve students at a women's university was observed during the 1983, 1984 and 1985 academic years by female part-time lecturer (the author herself). At the beginning of each class, the lecturer drew the figure of the students' seating arrangement at a rectangular table, while calling each student's name. Questionnaires were also administered to the students at the end of the observation in the period 1983 and 1985 academic years. The results obtained were: 1) each student was more attached to one seating area and seating side than the others, 2) this fact reflected her seating preference to some extent, 3) no student monopolize the special seats to which she was most attached, 4) extra spaces were left between the lecturer's and the student's seat. The third finding was considered to be due to homogeneity of the student with respect to major, grade and sex and their temporal relationships within the seminar group. Also the fourth result was due to the status difference between the lecturer and the students, which led to the recognition that the seating places were mutually exclusive for both sides of them.     

The trouble with assessing students' professionalism: theoretical insights from sociocognitive psychology.

The academic literature on professionalism assessment in medical education is burgeoning, and its focus has primarily been on the assessment of professional behaviors. Consequently, the attitudinal elements of professionalism have largely been ignored in the literature. As a result, educators chiefly rely on professional behavior alone as the primary measure for professionalism without giving proper consideration to students' underlying attitudes. Using theoretical insights from sociocognitive psychology, this viewpoint article begins by discussing the relationship between attitudes and behaviors. It suggests that attitudes are poor predictors of behavior when external constraints, such as social pressure to behave in a particular way, are strong. It continues with a critical examination of the phenomenon of "faking it"--students faking professional behaviors to garner positive reactions from observers. This practice is contrasted with students who at times behave unprofessionally in response to social pressures or other contextual components, despite having professional attitudes. So, in using behavioral assessment alone, we may pass students with professional behaviors but unethical attitudes and fail students with unprofessional behaviors but ethical attitudes. Guided by a sociocognitive model of behavioral explanation, the article ends with some practical recommendations for coupling observation with conversation to assess students' professional behaviors and their attitudes more fairly.     

Do we need dissection in an integrated problem-based learning medical course? Perceptions of first- and second-year students

BACKGROUND: The introduction of a problem-based learning (PBL) curriculum at the School of Medicine of the University of Melbourne has necessitated a reduction in the number of lectures and limited the use of dissection in teaching anatomy. In the new curriculum, students learn the anatomy of different body systems using PBL tutorials, practical classes, pre-dissected specimens, computer-aided learning multimedia and a few dissection classes. The aims of this study are: (1) to assess the views of first- and second-year medical students on the importance of dissection in learning about the anatomy, (2) to assess if students' views have been affected by demographic variables such as gender, academic background and being a local or an international student, and (3) to assess which educational tools helped them most in learning the anatomy and whether dissection sessions have helped them in better understanding anatomy. METHODS: First- and second-year students enrolled in the medical course participated in this study. Students were asked to fill out a 5-point Likert scale questionnaire. Data was analysed using Mann-Whitney's U test, Wilcoxon's signed-ranks or the calculation of the Chi-square value. RESULTS: The response rates were 89% for both first- and second-year students. Compared to second-year students, first-year students perceived dissection to be important for deep understanding of anatomy (P < 0.001), making learning interesting (P < 0.001) and introducing them to emergency procedures (P < 0.001). Further, they preferred dissection over any other approach (P < 0.001). First-year students ranked dissection (44%), textbooks (23%), computer-aided learning (CAL), multimedia (10%), self-directed learning (6%) and lectures (5%) as the most valuable resources for learning anatomy, whereas second-year students found textbooks (38%), dissection (18%), pre-dissected specimens (11%), self-directed learning (9%), lectures (7%) and CAL programs (7%) as most useful. Neither of the groups showed a significant preference for pre-dissected specimens, CAL multimedia or lectures over dissection. CONCLUSIONS: Both first- and second-year students, regardless of their gender, academic background, or citizenship felt that the time devoted to dissection classes were not adequate. Students agreed that dissection deepened their understanding of anatomical structures, provided them with a three-dimensional perspective of structures and helped them recall what they learnt. Although their perception about the importance of dissection changed as they progressed in the course, good anatomy textbooks were perceived as an excellent resource for learning anatomy. Interestingly, innovations used in teaching anatomy, such as interactive multimedia resources, have not replaced students' perceptions about the importance of dissection.     

Using standardized patients to evaluate undergraduate medical students' proficiency in speaking English.

PURPOSE: To explore the use of standardized patients for evaluating medical student's proficiency in speaking English. METHOD: In 1995, using a language rating scale constructed by the authors, six standardized patients evaluated the English-language proficiencies of 127 second-year medical student undergraduates enrolled at the University of Adelaide, Australia, many of whom were from a non-English speaking background. RESULTS: An earlier standardized test (Screening Test for Adolescent Language) had identified approximately one third of the students as potentially experiencing difficulties in using English in their training. Students so identified were rated lower than were their peers by the standardized patients. CONCLUSION: The study proved useful both in identifying aspects of speech that can be reasonably rated by standardized patients and also in identifying students who might benefit from language interventions. Replication studies with the new instrument are required to further establish its reliability, validity, and generalizability across different student cohorts.     

合肥市男女高中生上网情况调查

目的 了解男女高中生上网行为的特点及其家庭、学校的影响因素.方法 采取系统分层随机抽样方法,选取合肥市3所不同类型的高中学校的993名学生为研究对象.实际有效问卷953份.自行设计的"高中学生背景调查表".结果 有上网经历的718人,男生428人,女生290人.无上网经历的235人.男生平均一次上网最长时间约8小时,近半年每周上网次数男生平均近4次,均是女生的两倍;男生的特点是多选择网吧,目的多是玩网络游戏,大多感到成绩下降,逃课的行为发生率高.结论 家庭、学校因素对高中学生的上网行为有影响;不恰当的网络使用对中学生的学业带来负面影响;性别因素可作为网络成瘾的重要影响因子进行研究.     

Can there be a single system for peer assessment of professionalism among medical students? A multi-institutional study.

PURPOSE: Peer assessment is a valuable source of information about medical students' professionalism. How best to facilitate peer assessment of students' professional behavior remains to be answered, however. This report extends previous research through a multi-institutional study of students' perspectives about system characteristics for peer assessment of professionalism. It examines whether students from different schools and year levels prefer different characteristics of peer assessment to assess each other candidly, or whether a single system can be designed. It then identifies the characteristics of the resulting preferred system(s). METHOD: At the beginning of academic year 2004-2005, students (1,661 of 2,115; 78%) in years one through four at four schools replied to a survey about which peer assessment characteristics - related to, for example, who receives the assessment, its anonymity, and timing - would prevent or encourage their participation. Multivariate analysis of variance was used to detect differences among institutions and students from each year level. RESULTS: Students across year levels and schools generally agreed about the characteristics of peer assessment. They prefer a system that is 100% anonymous, provides immediate feedback, focuses on both unprofessional and professional behaviors, and uses peer assessment formatively while rewarding exemplary behavior and addressing serious repetitive professional lapses. The system, they emphasize, must be embedded in a supportive environment. CONCLUSIONS: Students' agreement about peer-assessment characteristics suggests that one system can be created to meet the majority of students' preferences. Once implemented, the system should be monitored for student acceptability to maximize participation and to determine the formative and summative value of the process.     

The ecology of achievement among students diverse in ethnicity and ability

This longitudinal study uses an ecological framework to examine school and individual influences on academic achievement among African American and Latino students with and without disabilities who had recently transferred to more inclusive schools. The authors' ecological framework includes four domains: organizational policies and practices, school environment, student–school connections, and psychological symptoms. The authors tested a comprehensive model with 111 students from 16 schools over 3 years, as well as an organizational model with a smaller sample. Organizational policies and practices of inclusion and student–school connections of belonging each predicted higher academic achievement, and psychological symptoms of aggressive behavior predicted lower academic achievement across time. Their findings are consistent with and extend existing research through support of a comprehensive ecological model across time. Findings also yield significant implications for ecological theory and research in community psychology, school planning, intervention, and implementation of inclusive best practices for students with and without disabilities. © 2011 Wiley Periodicals, Inc.     

The advisory dean program: a personalized approach to academic and career advising for medical students.

Advising and mentoring programs for medical students vary in their official names, scope, and structures. Catalyzed by negative student feedback regarding career advising and a perceived disconnection between faculty and students, in academic year 2003-2004, Columbia University College of Physicians and Surgeons implemented its formal Advisory Dean (AD) Program and disbanded its former advising system that used faculty volunteers. The AD Program has become a key element for enhancing the students' professional development throughout their student training, focusing on topics including, but not limited to, career counseling, professionalism, humanism, and wellness resources. Advisory deans and the dean for student affairs, familiar with resources for academic development, student support, and extracurricular activities, operate at the nexus of the program, providing personalized mentoring and advising for each student. Fully supported by administration and faculty, the program has shown early success according to student feedback. Early feedback from the Class of 2006, who had been involved in our AD Program for three years, has been encouraging. Out of 152 students, 104 (68%) provided feedback, with 93 (89%) of the respondents reporting the AD Program as a valuable initiative. Expecting to further improve on this early positive response, the AD Program will continue to foster an environment conducive to a seamless transition from student to physician.     

Mentorship through advisory colleges.

OBJECTIVE: Medical students face pressures ranging from the need to create a social network to learning vast amounts of scientific material. Students often feel isolated in this system and lack mentorship. In order to counteract feelings of bureaucratic anonymity and isolation, the University of California San Francisco has created an advisory college to foster the professional and personal growth and well being of students. DESCRIPTION: UCSF has developed a formal structure to advise medical students. A selection committee, chaired by the associate dean of student affairs, appointed five faculty mentors to head advisory colleges. These five colleges serve as the advising and well-being infrastructure for the students. Mentors were chosen from a balanced range of clinical disciplines, both primary and specialty. The disciplines are obstetrics-gynecology, otolaryngology/head and neck surgery, medicine, pediatrics, and psychiatry. The mentors have demonstrated excellence in advising and counseling of students. Mentors meet individually at the beginning of the academic year with incoming first-year and second-year students. They then have bimonthly meetings with eight to ten students within each college throughout the academic year. Curricula for these group sessions include well-being discussions and coping techniques, sessions on the hidden and informal curriculum of professionalism, and discussions on career choices and strategies. For third-year students, advisory college meetings are scheduled during intersessions, which are weeklong courses that occur between the eight-week clerkship blocks. Mentors are available throughout the year to meet with students on an as-needed basis, and advisory colleges may hold group social activities. The dean's office supports each mentor with 20% salary and provides administrative support for the group college activities. DISCUSSION: Historically, UCSF students feel they receive an excellent education and appropriate job opportunities, but they do not feel they receive adequate advising and mentoring. This may have as its root cause the financial, clinical, and research pressures placed upon a faculty who are also responsible for mentoring residents and fellows. The advisory colleges begin by providing an infrastructure for developing a relationship for the student with a single faculty member. The advisory college system is incorporated into the academic schedule rather than relying on ad-hoc activities from well-meaning but inconsistently available faculty. In the early part of medical school, the advisory college relationship concentrates on assimilation into the new environment and provides the student with advice pertaining to mastering academic material. The college also serves as a sounding board for problems that can then be relayed to course directors to improve the educational experience. For students encountering academic difficulty, the college advisor can provide discreet advice about tutoring resources and can direct the student to a separately staffed Student Well-being Program. As time progresses, the mentors can direct students to key people in different fields of interest such as program directors and keep the students on track to make career decisions in a timely manner. The college system can help transform an anonymous medical school experience into a supportive, rich environment.     

Comparing students' feedback about clinical instruction with their performances

Validation of students' feedback as a measure of teaching effectiveness has been problematic for courses teaching clinical skills. This is true in part because establishing a valid and reliable method of assessing students' mastery of clinical skills has been a stumbling block. Reported here is the correlation of students' performances on an objective structured clinical examination (OSCE) with previously and independently collected feedback from students. In 1987-88, 190 second-year medical students at the University of Minnesota Medical School--Minneapolis spent one fourth of a second-year clinical skills course on neurology randomly assigned to one of four teaching sites--hospitals A, B, C, and D. Following their rotations, 180 of the students completed usable feedback forms. The students were consistently and significantly more positive about the teaching at hospital A. At the end of the year, all 190 students were tested using an OSCE having 20 stations, four of which presented neurologic problems. The students who had the neurology course at hospital A performed better on all four neurology problems, and differences were statistically significant for two of the problems. Feedback in this case accurately reflected a more effective teaching program.     

Viewpoint: professionalism and humanism beyond the academic health center.

Medical professionalism and humanism have long been integral to the practice of medicine, and they will continue to shape practice in the 21st century. In recent years, many advances have been made in understanding the nature of medical professionalism and in efforts to teach and assess professional values and behaviors. As more and more teaching of both medical students and residents occurs in settings outside of academic medical centers, it is critically important that community physicians demonstrate behaviors that resonate professionalism and humanism. As teachers, they must be committed to being role models for what physicians should be. Activities that are designed to promote and advance professionalism, then, must take place not only in academic settings but also in clinical practice sites that are beyond the academic health center. The author argues that professionalism and humanism share common values and that each can enrich the other. Because the cauldron of practice threatens to erode traditional values of professionalism, not only for individual physicians but also for the medical profession, practicing physicians must incorporate into practice settings activities that are explicitly designed to exemplify those values, not only with students and patients, but also within their communities. The author cites a number of examples of ways in which professionalism and humanism can be fostered by individual physicians as well as professional organizations.     

Influence of a computer database and problem exercises on students' knowledge of bacteriology.

This study compared the performances of students at the University of North Carolina at Chapel Hill School of Medicine who had access to sets of problem exercises and a computer database to support their learning of bacteriology with the performances of students at the University of Iowa College of Medicine who did not have such access. The study also examined the extent of a student's database use as a predictor of posttest performance. The students studied were randomly selected groups of 32-44 first-year students per year at each school; the study was conducted in three academic years (1988-1990) with some modifications in the intervention as the host environment evolved. The criterion measure was a posttest created from the same pool of problems used to generate the problem sets. The students at the intervention school scored significantly higher on the posttest in two of the three years, and overall. Also in two of the three years and overall, there was a significant relationship between the extent of a student's database use and his or her posttest score. Although the observed effects may have been due to other factors in this quasi-experimental design, the authors conclude that the use of problem sets and a computer database had a positive influence on the students' learning.     

Repetitive behaviors in CHARGE syndrome: differential diagnosis and treatment options

Twenty-nine students with CHARGE syndrome were evaluated using the Compulsive Behavior Checklist (CBC). Most of the students obtained a high score for repetitive behaviors, averaging 11.5 repetitive behaviors per student. Most students' repetitive behaviors significantly interfered with their daily routine. Thirty-four percent of the students responded to redirection with aggression toward themselves or others. Many of these behaviors do not respond well to traditional behavioral techniques. Through observation, definitions, and using functional analysis of behavior, repetitive behaviors were assigned to one of four categories. Each category has different treatment options. A case study of an adolescent girl with CHARGE syndrome who has profound deafness, colobomas, and moderate cognitive delay is presented. She displayed severe behavior challenges and significant medical issues. The course of treatment is outlined over 5 years. Behavior management, medical management, and psychiatric management were used in regulating her behavior, medical issues, and anxiety disorder. Close coordination between disciplines and excellent family involvement led to a very positive outcome. The student, now 19 years old, has made progress in her educational program and has been able to experience more community integration.     

Characteristics of medical students completing an honors program in pathology

The Honors Program in pathology at Jefferson Medical College provides a voluntary enrichment opportunity for students who have demonstrated a superior ability to cope with the pathology curriculum and who rank in the upper fifth of their class. This study was performed to determine whether honor students possess cognitive and psychosocial attributes that distinguish them from their classmates. Students from five academic years (entering classes 1991 to 1995) were divided into 3 groups: (1) those who completed the Honors Program (n = 85), (2) those in the top 20% of the class who were offered the option but chose not to participate in the Honors Program (n = 128), and (3) students who did not qualify for the program (n = 953). Comparisons between these three groups were made on the basis of selected measures of academic achievement retrieved from the Jefferson Longitudinal Study database and psychosocial data obtained from a questionnaire completed during the first-year orientation. Students who completed the Honors Program in pathology had scored higher on the physical science section of the Medical College Admission Test (MCAT) and had obtained higher first-year grade point averages than students in both of the other groups. Subsequently, they attained higher second-year grade point averages and scored higher on Step 1 and Step 2 of the United States Medical Licensing Examination (USMLE), compared with their peers in the other groups. There were no significant differences in psychosocial measures between honor students and the rest of the cohort (group 3). However, students in the top 20% of the class who declined the invitation to participate in the Honors Program (group 2) showed higher scores on the Taylor Manifest Anxiety Scale and the Eysenck Emotional Instability (Neuroticism) Scale than did their classmates. Despite these differences, students who completed the Honors Program (group 1) and eligible students who declined participation (group 2) selected similar pathways of postgraduate residency training: both groups preferred internal medicine to family practice, and both were more likely than the rest of the cohort to begin residency training at a top-ranked academic/research medical center. Voluntary participation in an Honors Program is a self-selection system that identifies students who are most likely to succeed academically at the highest levels. Residency selection committees may wish to pay dose attention to student involvement in similar programs, because this information may provide insights into student personality and general aptitude.