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Medical Education 2011: 45: 946–957
CONTEXT Training future doctors to develop an appropriate professional persona is an important goal of medical student education and residency training. Most medical education research paradigms on professionalism have focused largely on lapses (e.g. yelling as an example of communication failure) and tend to emphasise behaviour that should be avoided. The assumption is that, if left unchecked, students will see these negative behaviours exhibited by their role models and possibly emulate them, allowing the potential reinforcement of the inappropriate behaviours.
OBJECTIVES Identifying and characterising exemplary, or positive, behaviours can be similarly valuable to both medical students and residents as tangible examples of behaviours to strive towards. The goal of the present research was to determine and thematically define the exemplary professional actions that medical students observe in the intense and patient-focused environment of the operating room (OR).
METHODS Using qualitative methodology of content analysis and theme identification, we systematically documented the type of exemplary professional behaviours reported by medical students (n = 263) when observing health care teams on an anaesthesia rotation in the OR.
RESULTS The analysis generated a taxonomy of exemplary OR behaviour that included six overarching themes (e.g. teamwork), 15 sub-themes (e.g. collegial) and numerous exemplars (e.g. showed mutual respect). These themes and sub-themes were then conceptually ‘matched’– through the use of antonyms – to complement an existing framework focused on medical student reports of professional lapses witnessed during medical school.
CONCLUSIONS Year 3 medical students in the USA reported observing very positive, exemplary health care provider interactions that were diverse in focus. Themes were identified regarding the OR team members’ interactions with patients (calm, communication, comforting), with one another (teamwork, respect) and with the medical students (teaching). This classification of exemplary OR behaviour contributes to our understanding of how professional behaviour is viewed and potentially emulated by medical students on surgical rotations.
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The process by which doctors acquire the knowledge and skills to practise medicine is an ongoing research interest. It is one that is well represented in the medical education research literature,1 as well as in the field of expertise development.2 The means by which doctors learn the behaviours that define being a professional, however, have been more challenging to conceptualise, evaluate and implement.3–6
Medical students are expected to apply medical knowledge, learn hands-on procedural skills and acquire professional behaviour through an ‘apprenticeship model’ by shadowing and observing doctor role models throughout their medical school education. A unique setting for observing and training medical professionals is the operating room (OR). Non-technical skills, such as good communication skills, are important assets for surgeons and other OR team members because these skills help the team to avoid errors and to function efficiently.7 Conflict in the OR has been shown to adversely impact patient care.8 Moreover, in this environment, the elements of appropriate professional behaviour can often be marred by the fact that the time available for decision making is compressed, especially in trauma situations. Nevertheless, these OR interactions are considered as ‘learning moments’. Indeed, such informal role-modelling scenarios – in which OR team members function as role models with or without their comprehension of this fact – occur constantly.9
Workshops and seminars on appropriate professional behaviours are held regularly for medical students in order to supplement observational learning and training. However, in clinical settings, students often report observing behaviours by doctors that are not appropriate or that contradict behaviours that are emphasised during class.10 As a result, medical students may feel appropriate professional behaviour is unimportant, despite efforts to the contrary.11
Most research studies into professional behaviour in the past have focused largely on professional lapses (e.g. communication failure) and the development of formal conceptual frameworks for unprofessional behaviour in medicine.6,12 These studies have been based on the concept that ‘it is necessary to understand the professional challenges and dilemmas [the students] perceive in the clinical setting’5 in order to support their development of professionalism. A coding system for lapses in professional behaviour has been developed to identify action-oriented and contextual rather than theoretical situations.6 In this system, lapses in professional behaviour are well characterised; they include communication violations, role resistance, objectification of patients, ignoring patients, treating patients as vehicles for learning, denying accountability, subjecting patients to crossfire between members of the health care team and causing physical harm.6
More recently, medical education researchers have attempted to shed light on the effects of emphasising exemplary professional behaviour over professional lapses by observing and documenting expert behaviour in the field2 and by deliberate role-modelling.13,14 Medical professionalism as defined by the American Board of Internal Medicine15 includes altruism, honesty, respect for others and accountability, and applies to patient interactions as well as to interactions with fellow staff. Studies focused on exemplary professional behaviour16 have emphasised that it is important that doctors in training can recognise such behaviour if they are to emulate it.17,18
Exemplary professional behaviour has been documented in recent studies19 by analysing notable incidents of professional behaviours during patient interactions. In another approach, Maker and Donnelly20 noted that junior surgical residents have a high regard for senior residents who show good professional behaviour. Other studies have defined good professional behaviour through reports by senior residents, medical students, faculty members and other staff.21 These studies show that medical students, interns and residents are able to report and reflect on their own exemplary behaviour, as well as on that of others.
Fewer studies have systematically defined the construct of exemplary professional behaviour. Such work is necessary, however, if we are to build it into the curriculum and develop instruments with which to evaluate it.22,23 Moreover, identifying and characterising exemplary behaviours can be valuable to both medical students and residents because they often do not accurately perceive their own behaviour as appropriate or inappropriate.24,25 This inability to self-assess is surprisingly common among young trainees.26 In addition, junior or novice team members often mimic the behavioural styles of their senior counterparts during high-tension situations in the OR.9 Emphasising exemplary behaviours during these situations should foster professionalism and train better doctors.
Using the perspective of medical students as a reference point, we extended this line of research to observe doctor behaviour in the OR. Anecdotal reports indicate that the OR environment can be harsh, demeaning and impersonal. Thus, exemplary professional behaviour is thought to be hard to find here. The goals of this study were: (i) to determine the type of exemplary professional behaviour medical students were observing in the OR, and (ii) to thematically document their analysis of the observed exemplary OR behaviours. These goals were achieved through qualitative methodologies that will be discussed in the next section. Documenting and analysing the various types of exemplary behaviour observed in the OR allows us to help students develop and apply appropriate professional behaviour throughout their careers. Our study shows that medical students see a wide range of exemplary professional behaviour demonstrated across the range of individuals who make up an OR team. The resulting framework is complementary to other models of medical students’ views of professionalism and adds to our understanding of how implicit learning of exemplary (i.e. good) behaviour occurs through informal role-modelling.
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Our results demonstrate that Year 3 medical students on an anaesthesia clerkship rotation in the OR were able to witness very good health care provider interactions that were diverse in focus. They were able to include in their reports interactions among patients, attending physicians, residents, medical students, nurses and the OR team as a whole. The themes identified referred to OR team members interacting with patients (calm, communication, comforting), with one another (teamwork, respect) and with the medical students (teaching). We were also able to show that these accounts are compatible with an existing framework of professional behaviour that was similarly derived from medical students through qualitative methodology (Table 3).
It is important to note that the students were not shy about making comments. They explicitly stated what they saw and why they thought it was exemplary behaviour. The comments did not mention the theories of professionalism nor its language (i.e. altruism, accountability, honesty, respect for others). Instead, student reports represented exemplary OR behaviour as a series of actions by the doctors involved.
The students saw the acts of calming and comforting patients, staying calm in difficult circumstances, and communicating well with patients as demonstrations of good behaviour compatible with their perception of the way a doctor should behave. Although the OR staff may have performed a particular operation many times, the procedure usually represented a first and very personal moment for the patient. From the reports offered in this study, we see that medical students appreciated the staff’s handling of this.
Teamwork among different services was seen as important in smoothing the OR experience for all involved. It is important that the medical students were able to identify teamwork as indicative of exemplary OR behaviour because it has future value as they move through medical school and into residency. For example, the hospital accrediting agency in the USA, The Joint Commission (TJC), has noted that patient safety is at risk from the disruptive behaviour of health care professionals and lack of teamwork.28 Because the medical students in this study witnessed this team-based behaviour from a positive, exemplary perspective, it may provide them with a more well-rounded understanding that smooth working teams are a critical element of patient care.
Respect for others included the understanding of patient sensibilities, but was noted more often in the respect demonstrated by health care professionals for one another. Students were able to understand that no single person was responsible for the good outcome of an operation. The medical students were aware that everyone involved had a role to play in the procedure and should be respected and appreciated for what they do.
Interestingly, we found that explicit teaching was a frequent characteristic of the exemplary behaviour noted by students. Because these observations were drawn from the perspective of students, this may not be unusual; today’s medical students pay a lot of money for their education and expect to have a steady stream of teaching and learning moments. The frequent mention of teaching in this study suggests that explicit teaching may not happen as often as students would like.
The fact that moments of overt, explicit teaching were so notable for many of the medical students creates a conundrum for the mainstay of clerkship and residency education, namely: implicit teaching through role-modelling. Role-modelling is common in the medical environment and can be a powerful tool for learning. For example, when Park et al.29 interviewed surgical faculty staff and residents and asked them how they had learned professionalism, ‘learning by example’ was the most common method mentioned. Because much role-modelling is informal, it is important that medical students are made more aware that overt, didactic teaching is not the norm. In addition, teachers of medical students (in this case, the OR team) also need to be aware that, because of the implicit learning context of the OR, every one of their actions represents a ‘teaching moment’ during which some impressionable person may be ‘learning’.
To summarise, the resulting taxonomy of exemplary OR behaviour themes and sub-themes was ‘matched’ to that of an existing framework focused on medical student reports of general lapses of professionalism in medicine. As in the work on lapses in professional behaviour, it is important to note that the taxonomy represents medical student opinions of exemplary professional behaviour in the OR, which may only be an approximation of what would traditionally be defined as ‘professionalism’. Instead, our intent was to have medical students concentrate on identifying exemplary behaviours as they perceived them through the lens of the fast-paced, yet focused, environment of the OR. This allows for a more complete analysis of how professionalism is viewed and potentially emulated by medical students.
With reference to the focus on how to avoid professional lapses (e.g. ‘Don’t yell’), this study indicates that medical students do also see doctoring at its best and witness behaviour in which the solicitous care of the patient is placed first and foremost in the actions of practitioners. For the medical students, the relatively immediate discussions of these personal observations with faculty staff helped to reinforce the sense that these exemplary behaviours noted were worth emulating. Making this information known to the teachers of students may help in several ways. Firstly, it can show teachers that their exemplary behaviour is noted and appreciated. Secondly, this behaviour may then be reinforced and continued, to the betterment of patient care and the training of future doctors. Thirdly, by laying out a taxonomy of exemplary OR behaviour, we may be able to demonstrate to students as well as to faculty staff the type of behaviour they should aim for, rather than simply focusing on avoiding the classic lapses in professional behaviour.
Our study is limited because our sample involved only two year groups of medical students and their experiences at a single large, urban institution. It is also limited because it was conducted within only the anaesthesia rotation, which lasts only 1 week, whereas other rotations in the OR (such as surgery) are longer and may offer opportunities for more extended observation and the formation of a different perspective over time. As has been suggested in the context of self-assessment, at least eight encounters with the same individual are necessary to give reliable information and avoid memory bias.26
A further limitation is that students may have been somehow biased in their reporting because they were actually on an anaesthesia rotation and shared their experiences with the anaesthesia clerkship director directly. Yet, as the examples in Table 1 show, the patterns of perceived professional lapses displayed by attending physicians in particular seem to suggest otherwise; our medical students were not apprehensive about discussing attending physicians – in either exemplary terms or with regard to perceived professional lapses – with their anaesthesia clerkship director.
Finally, did explicit learning take place? This question is beyond the reach of the data we collected; however, each of the medical students’ observations included a statement about what the student perceived he or she had learned from the interaction and thus we can infer that teaching and learning occurred from the exercise of observations. The wish to emulate the observed behaviour was noted multiple times. Although this may not represent proof that learning occurred, it does at least indicate the potential that the observed exemplary behaviours will be remembered and practised.
Contributors: SEC conceptualised the study and research design, collected data, and collaborated on data analysis and interpretation, and the drafting of the article. CIC was responsible for data management and contributed to the interpretation of data, background research and the preparation of the manuscript. MJG oversaw the methodological process of the study and the management, analysis and interpretation of data, and contributed to the preparation of the manuscript. All authors collaborated on the critical revision of the manuscript and approved the final version for publication.
Acknowledgements: the authors acknowledge Hilary Schmidt for collaborating on the conceptualising of this study, Boyd Richards for comments on an earlier draft, Leslie Wright and Gingi Pica for data preparation and analysis, and the editing of earlier drafts, and two anonymous reviewers for their helpful comments. Mark Graham is now at Yale University in New Haven, Connecticut, USA.