Sage Journals: Discover world-class research

Abstract

Background:

Medical professionalism enhances doctor-patient relationships and advances patient-centric care. However, despite its pivotal role, the concept of medical professionalism remains diversely understood, taught and thus poorly assessed with Singapore lacking a linguistically sensitive, context specific and culturally appropriate assessment tool. A scoping review of assessments of professionalism in medicine was thus carried out to better guide its understanding.

Methods:

Arksey and O’Malley’s (2005) approach to scoping reviews was used to identify appropriate publications featured in four databases published between 1 January 1990 and 31 December 2018. Seven members of the research team employed thematic analysis to evaluate the selected articles.

Results:

3799 abstracts were identified, 138 full-text articles reviewed and 74 studies included. The two themes identified were the context-specific nature of assessments and competency-based stages in medical professionalism.

Conclusions:

Prevailing assessments of professionalism in medicine must contend with differences in setting, context and levels of professional development as these explicate variances found in existing assessment criteria and approaches. However, acknowledging the significance of context-specific competency-based stages in medical professionalism will allow the forwarding of guiding principles to aid the design of a culturally-sensitive and practical approach to assessing professionalism.

Keywords

Medicine professionalism medical school physicians medical professionalism assessment methods medical education

Background

Medical professionalism underpins the development of trusting doctor-patient relationships that help inform and guide the delivery of socioculturally sensitive, patient-centric care and enhance healthcare outcomes and overall patient satisfaction.^1-4 It forms the cornerstone of effective self-regulation and the promulgation of a transparent, accountable and evidence-based clinical practice.^1-3 Ensuring that medical professionalism is effectively practised is thus pivotal to the standing of the medical profession, the preservation of public trust and the provision of quality healthcare.^5-8

However, the perception of healthcare services as commodities subjected “to the forces of commercialisation and profit-making in the free-market economy”⁹ has seen the erosion of professional, moral and ethical values in medical practice. In addition to this scrupulous emphasis on productivity, the profession has struggled to “hold up against [the] prevailing philosophy of moral scepticism and relativism in the present post-modernist society”.⁹ Pervasive technological changes to the therapeutic relationship has also led to the blurring of professional boundaries between doctors and patients^10-12 and these issues have complicated oversight of appropriate professional behaviour in medicine.^11,13 These considerations underscore the need to better assess medical professionalism.^14-17

Defining medical professionalism

A consistent understanding of medical professionalism remains elusive in part due to the influence of practical and local sociocultural, legal, financial, educational and healthcare considerations.^3,18-30 This diversity is captured in Birden, et al’s³¹ comprehensive overview of key concepts in professionalism and in the definitions/domains of medical professionalism proffered by the Accreditation Council for Graduate Medical Education (ACGME)³² in the United States, the General Medical Council (GMC)³³ in the United Kingdom and the Canadian Medical Education Directives for Specialists (CanMEDS)³⁴ (Table 1).

Table 1.

Definition/domains of medical professionalism.

Healthcare regulatory organisations	Definitions/domains of medical professionalism
Accreditation Council for Graduate Medical Education (ACGME)	(a) Demonstrating professional conduct and accountability. (b) Demonstrating humanism and cultural proficiency. (c) Maintaining emotional, physical, and mental health. (d) Pursuing continual personal and professional growth.
General Medical Council (GMC)	The domains for professionalism include: (a) Knowledge, skills, and performance • Make the care of your patient your first concern. • Provide a good standard of practice and care. (b) Safety and quality • Take prompt action if you think that patient safety, dignity or comfort is being compromised. • Protect and promote the health of patients and the public. (c) Communication partnership and teamwork • Treat patients as individuals and respect their dignity. • Work in partnership with patients. • Work with colleagues in the ways that best serve patients’ interests. (d) Maintaining trust • Be honest and open and act with integrity. • Never discriminate unfairly against patients or colleagues. Never abuse your patients’ trust in you or the public’s trust in the profession.
Canadian Medical Education Directives for Specialists (CanMEDS)	As Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health. • Commitment to patients • Commitment to society • Commitment to the profession • Commitment to self

Recognising this diversity in concepts, the Ottawa Consensus Group meeting in 2018 acknowledged the need to explore “the perspectives of patients and the tensions of individual and institutional values in regard to professionalism” as opposed to “a standardised, single, and reductionist definition”.² This position underlines the need for context-specific, culturally appropriate and linguistically sensitive assessments.^1,2

The need for this review

The absence of such a context-specific, culturally appropriate and linguistically sensitive assessment tool within the Singapore setting inspired this scoping review. It is hoped that the insights proffered will guide design of a tool for the local context.

Methods

Building upon Li et al’s,³⁵ Wilkinson et al’s⁴ and Veloski et al’s³⁶ reviews, this scoping review explores the size and scope³⁷ of published data in peer-reviewed literature on tools used to assess medical professionalism.^38-43 Use of a scoping review also allows for the systematic extraction, synthesis and summarising of actionable and applicable information⁴⁴ in available literature^45,46 across a wide range of pedagogies, assessment contents and practice settings.^47-51 Levac et al’s⁵² adaptation of Arksey and O’Malley’s³⁸ framework for scoping reviews was used to map key concepts, sources and types of evidences available to guide future research.^39,53,54 Levac et al’s framework was also guided concurrently by the PRISMA-P 2015 checklist⁴⁵ and a 6-stage scoping review protocol was developed for this study.^38-42,52

Stage 1: Identifying the research question

The 11-member research team was guided by a team of local clinicians, educators and researchers from Yong Loo Lin School of Medicine at National University of Singapore (YLLSoM), Duke-NUS Medical School, the University of Liverpool and the National Cancer Centre Singapore (NCCS), and two librarians from the medical libraries at YLLSoM and NCCS (henceforth the expert team). The expert and research teams discussed prevailing issues, needs, and practices pertaining to assessment tools used in medical professionalism and determined the primary research question to be: ‘what tools are available to assess medical professionalism among medical students or physicians?’ The teams determined the secondary research questions to be: ‘what domains are assessed and what approaches are used to carry out these assessments?’ and ‘what existing frameworks are used to guide them?’ These questions were designed based on prevailing population, conceptual and contextual considerations⁵⁵ using a PICOS format (Table 2).

Table 2.

PICOS, inclusion and exclusion criteria.

PICOS	Inclusion criteria	Exclusion criteria
Population	• Undergraduate and postgraduate medical students, residents or doctors within the clinical, medical, research or academic settings	• Allied health specialties such as Pharmacy, Dietetics, Chiropractic, Midwifery, Podiatry, Speech Therapy, Occupational and Physiotherapy • Non-medical specialties such as Clinical and Translational Science, Alternative and Traditional Medicine, Veterinary, Dentistry
Intervention	• Curricular assessment tools on professionalism of medical students or doctors
Comparison	• Comparisons of the various assessment tools, including the assessment principles, modalities and criteria
Outcome	• Assessment principles, modalities, and criteria• Impact of assessment on those being assessed
Study design	• Articles in English or translated to English• All study designs including: ○ Mixed methods research, meta-analyses, systematic reviews, randomised controlled trials, cohort studies, case-control studies, cross-sectional studies, and descriptive papers• Year of Publication: 1 January 1990 to 31 December 2018• Databases: PubMed, ERIC, Google Scholar, Web of Science databases	• Grey Literature/electronic and print information not controlled by commercial publishing• Case reports and series, ideas, editorials, and perspectives

These collaborative consultations between the research and expert teams also took place at Stage 1, 2, 3 and 6 of the research process.

Stage 2: Identifying relevant studies

Guided by the expert team and prevailing definitions and descriptions of medical professionalism by ACGME, GMC and CanMEDS,^32,33,56 the research team developed their search strategy which may be found in Online Appendix A.

In keeping with Pham et al’s⁵⁴ approach to ensuring a viable and sustainable research process, the research team confined the searches to articles published between 1 January 1990 and 31 December 2018 on PubMed, ERIC, Web of Science and Google Scholar. All qualitative and quantitative research methodologies in peer-reviewed articles published in English or had English translations were included. The independent searches of the four databases were carried out between 13 February 2019 and 24 April 2019.

Stage 3: Selecting studies to be included in the review

The nine members of the research team independently screened the titles and abstracts by exporting and organising the articles using the Endnote software. This allowed for the removal of duplicate titles and the generation of a tentative list. Sandelowski and Barroso’s⁵⁷ ‘negotiated consensual validation’ approach was used to agree on the final list of articles to be reviewed and, later, the final list of full text articles to be scrutinised.

A summary of the PRISMA process may be found in Figure 1.

Figure 1.

PRISMA flow chart.

Stage 4: Data characterisation and analysis

Braun and Clarke’s⁵⁸ approach to thematic analysis was adopted to scrutinise articles with different goals and populations of medical students and doctors. It circumnavigates the context-specific and socioculturally influenced nature⁴² of medical professionalism^{1-3,31,35,58-60} and the wide range of research methodologies present among the included articles that prevent the use of statistical pooling and analysis.^58,61-66

The members of the research team independently reviewed and ‘actively’ read the included articles to find meanings and patterns in the data to construct ‘codes’ from the ‘surface’ meaning of the text.^58,67-69 The initial codes from ‘open coding’ were grouped into categories then into themes. The reviewers reconvened at online and face-to-face meetings to discuss their individual findings.

Stage 5: Collating, summarising, and reporting the results

A total of 3799 abstracts were identified from four databases, 138 full-text articles reviewed, and 74 full-text articles were analysed.

The narrative produced was guided by the Best Evidence Medical Education (BEME) Collaboration guide⁶⁴ and the STORIES (Structured approach to the Reporting In healthcare education of Evidence Synthesis) statement.⁷⁰

In addition, two reviewers carried out individual appraisals of quantitative studies using the Medical Education Research Study Quality Instrument (MERSQI)⁷¹ and the Consolidated Criteria for Reporting Qualitative Studies (COREQ)⁷² to evaluate the quality of qualitative and quantitative studies included in this review. They met face-to-face to reconcile any differences in their assessments and forwarded a consensus-based appraisal of the included studies. A summary of these quality assessments may be found Online Appendix B.

Stage 6: Consultations with expert team and key stakeholders

Whilst the findings were well-received by the expert team, several members stressed the need to consider the impact of the diverse assessment methods, approaches, goals, and populations in relation to the local educational, healthcare and linguistic setting. This is so as to facilitate development of a cohesive, longitudinal and holistic system of assessments with appropriate integration of individual assessment tools calibrated for various training stages within the Singaporean setting.

Results

For transparency and ease of review the themes are delineated in tables. The initial themes identified were attributes and assessment criteria for professionalism (Table 3a and b); tools, approaches and modalities used to assess professionalism (Table 4); and prevailing assessment frameworks established by healthcare regulatory organisations (Table 5).

Table 3a.

Attributes of professionalism.

General attitudes and behaviour• Confidence⁷³ • Innovation⁷⁴ • Collegiality⁷³ • Altruism^{21,24,29,75-77} • Self-motivation^78,79 • Commitment to lifelong learning^{4,73,75,77,78,80} • Commitment to profession^{23,73,75,81,82} • Upholding standards of excellence^21,29,76,83

Ethical attitudes and behaviour• Integrity^{21,24,29,30,73-77,83-87} • Equity²⁴ • Respect^{21,24,25,73,76-78,85,88-91} • Confidentiality^{75,77,83,84,87,88,91,92} • Trustworthiness^{21,23,29,30,93,73,77,78,80,81,84-87,94-97} • Responsibility^{21,28,75,82,83,88} • Accountability^{77,78,81,83,85,86,88,98-100} • Upholding justice and social responsibility^{21,75,78,80,89,92,95,100} • Upholding moral fiduciary relationship and duty^24,82

Patient care• Patient-centred approach^{78,89,90,95-97} • Empathy^{85,87,90-92,97,101} • Humanism^{73,80,82,102-104} • Compassion^{75,77,83,84,87,88,91,92} • Cultural sensitivity and proficiency^{29,73,77,80,82,91-93,97,102}

Table 3b.

Assessment criteria for professionalism.

Attitudes	• (Perceived) facilitators and barriers to professional and unprofessional behaviour^{25,85,100,105-107} • Awareness of exposure to unprofessional behaviour in the informal and hidden curriculum^{28-30,86,92,100,105,107-110} • Adopting a humanistic attitude towards medicine¹⁰ • Self-efficacy in acquiring professionalism skillsets and in interpersonal interactions and teamwork^{86,89,93,105,111,112} • Focusing on patient’s needs above self and empathising with and respecting patient’s dignity^{90,91,96,101,103,106}
Behaviours	Individual level• Balancing competing demands of research, clinical, personal and fellowship life⁹⁰ • Asking for help when needed⁸⁷ such as for mental and physical abuse⁸⁷ • Maintaining composure in difficult situations^87,104 • Establishing personal-professional lifestyle balance• Ensuring “protected time” for scholarly pursuits and spontaneously pursuing own area of interest^106,113 • Adhering to and role modelling ethical conduct and professionalism^{25,29,77-79,100} • Respecting and cooperating with authority^4,73,80 • Displaying lifelong learning and adaptability as well as taking initiatives, being punctual and attentive^{4,23,26,30,73,77-80,85,87,97,104,105} • Responding constructively to assessments and criticism^{23,30,73,75,77-79,87,91,92,93,97,99,104,114} Interpersonal level• Ensuring the following unprofessional behaviours are not performed• Acting compulsively³⁰ • Venting emotions against patients, family, and colleagues^90,96 • Using derogatory language^92,104 • Pushing the blame onto others¹¹² • Denigrating the medical profession³⁰ • Respecting and collaborating with fellow healthcare professionals^{30,78,90,97,104,111} • Participating proactively in team-based learning¹¹⁵ • Teaching and assisting peers, juniors and students^78,101,113 • Providing constructive feedback,^{25,74,89,92,97,100,101,111,115} accepting and soliciting feedback^{73,74,81,86,92,104,115} • Reporting dishonesty⁷⁸ • Avoiding abuse of power^78,92 • Respecting and collaborating with patients^{30,78,89,90,95,96,103,104,111} • Providing holistic care and showing interest in patient as a person^{73,80,82,102-104} • Sharing decision-making with patients and acknowledging and advocating for patient autonomy^91,92,97,103 • Communicating honestly^92,103 and empathetically^{92,101,103,104} • Respecting patient’s family^{30,78,89,90,95,104} • Managing conflicts of interest^78,95 Organisational and Societal Level• Involved in citizenship and professional engagement⁸⁵ • Treating underprivileged patients and improving access to medical care such as through joint and appropriate distribution and use of healthcare resources^{78,82,89,95,104,113} • Bringing positive influence to the work environment⁸⁷
Clinical skills and competencies	Interpersonal skills with fellow healthcare professionals• Communication,^30,83,92,104 leadership,^87,89,99 teamwork,^77,89,99 educational knowledge and competencies⁹⁴ Interpersonal skills with patients• Communicating well with patients^{25,26,73,74,80,84,85,88,89,91,92,94,96-98,104,105,112,116} such as appropriately breaking bad news,^93,112 and discerning appropriate language to use to ensure patient understands^85,96 Self-development skills• Coping against depression and burnout^23,81,87,90 • Self-directed learning,^{23,78,88,97-99,104,111,113} self-awareness and self-regulation^{30,73,75,83,92,93,104} • Reflectivity^4,104 • Time management¹⁰⁴ • Problem-solving and critical thinking⁹¹ Clinical skills• Risk assessment^{89,99,104,112,114} • Clinical decision-making^{82,89,94,96,97,99,104,114} and situational awareness in times of medical or ethical dilemma^{89,91,96,99,104,114} • Quality and error management^{23,30,73,75,77-79,87,91-93,97,99,104,114} Competencies in procedural medical skills,⁸⁹ providing continuity of care,^{87,89,104,114} medication prescription and counselling,^93,96,97,114 caring for the dying,⁹⁰ obtaining informed consent⁹³ and medical documentation¹¹²
Other measures	• Improvement in clinical¹¹⁷ and evidence-based practice⁷³ • Improvement in patient satisfaction and reduction in complaints¹¹⁸

Table 4.

Tools, approaches and modalities used in the assessment of professionalism.

Assessment approaches and modalities
Tool	• Dreyfus and Dreyfus Level of Mastery¹⁰⁵ • Miller’s Performance Level^3,26,74,85 • Pangaro’s Performance Level⁸⁵ • REFLECT rubric¹¹⁹ • Kirkpatrick model¹¹⁸ • Entrustable Professional Activities^{21,23,29,74-76,79,84,87,89,93,94,96,98,105,119-121}
Setting	• Undergraduate medical school education^{18,20,24-26,28,74,80,83,85,96,98,104,106,107,109,111,115,117,119,120,122,123-127} • Graduate medical school education⁸⁸ • Postgraduate clinical training^{4,21-23,29,30,76-79,81,86,90,93-95,97,99,100,102,103,105,108,110,112-114,116,118,121,128} • Continuing professional development from medical school education to medical doctor training^{3,75,84,101,129,130}
Target population	• Medical Students^{18,20,24,25,28,83,85,96,98,104,106,107,109,111,115,117,119,120,122-127} • Residents^{4,23,29,30,77,79,81,86,87,89,93,100,102,103,108,110,112,114,116,121} • Medical Doctors^{21,22,76,78,82,94,95,97,99,100,113,118,128,131} • Clinical fellows⁹⁰ • Faculty staff or tutors^{75,92,100,101,105,123}
Methods	Mixed method• Questionnaire^{22,75,83,85,88,92,96,100,109,112,114,119,120,122,124,131} • Portfolio^4,122 Quantitative• Likert Scale Questionnaire^{22-24,28-30,76-78,83,85-88,90,92-94,96,97,99,101-107,109,110,111,112,116-122,124-127,129} • Frequency of behaviour scale^21,84 • Yes/No questionnaire^76,84 • Checklist^84,115,128 • Multiple-choice questions/responses^118,131 Open-ended• Interview^25,81,85 • Reflective Writing/Diary^85,100,119 • Focus group discussion^84,124 • Open-ended Questionnaire-Free Text and Essay^{22,83,85,88,92,96,97,109,114,120,124,131} • Comment card¹²²
Goals	• Formative^21,98,117 • Summative^93,95,104
Source	• Multi-modal^75,118,122 • Multi-source^{3,4,23,26,30,74,80-84,105,108,115,116,122,130} • Self-assessment^{20,21,24,25,28,76-79,83,85,88-90,97-100,106,109,111-117,119-121,126,127,131} • Peer-assessment^83,97 • Faculty-assessment^{29,86,87,93,95,100,104,107} • Patient-assessment^85,96,97,103 • Nurse-assessment^23,80,116

Table 5.

Assessment frameworks established by healthcare regulatory organisations.

Assessment frameworks
• Accreditation Council for Graduate Medical Education (United States)• American Board of Internal Medicine Medical Professionalism Framework• American Board of Medical Specialties• American College of Physician Professionalism Domains• Canadian Medical Education Directives for Specialists Roles for Family Medicine• European Federation for Internal Medicine’s Physician Charter for Medical Professionalism• General Medical Council Professionalism Capabilities Framework (United Kingdom)• Indian Medical Council Professional Conduct, Etiquette and EthicsInternational Classification of Primary Care Competency

Assessment frameworks

• Accreditation Council for Graduate Medical Education (United States)• American Board of Internal Medicine Medical Professionalism Framework• American Board of Medical Specialties• American College of Physician Professionalism Domains• Canadian Medical Education Directives for Specialists Roles for Family Medicine• European Federation for Internal Medicine’s Physician Charter for Medical Professionalism• General Medical Council Professionalism Capabilities Framework (United Kingdom)• Indian Medical Council Professional Conduct, Etiquette and EthicsInternational Classification of Primary Care Competency

Upon recommendation from the expert team, these three initial themes were reconfigured into two in this review^132-134 – the context-specific and competency-based nature of assessments. The competency-based nature of assessments correspond to various stages of a medical student’s or doctor’s training (henceforth competency-based stages).

Context-specific nature of professionalism assessments

Although many of the included articles adopted definitions of medical professionalism outlined by frameworks established by key healthcare regulatory organisations, their assessments were revealed to be significantly context specific. For example, whilst the ACGME definition was adopted by Hochberg et al⁹³ and Fontes et al²³ in surgical education, the former’s assessments focused on the prevailing surgical culture, the informal and hidden curriculum, and specific competencies practised in their specialty. The latter, however, focused on “exposure to professionalism and interpersonal and communication skills concepts”. In further contrast, Malakoff et al’s¹⁰⁸ assessments of internal medicine and transitional year residents revealed a heavier focus on participation in events such as grand rounds and sponsored conferences despite following the same ACGME definition guidelines.

Differences in settings, specialties, target populations and rationales also influenced assessments of professionalism. Further examples of the context-specific nature of assessments of professionalism are featured in Table 6.

Table 6.

Shared professionalism frameworks with variances in assessment context and domains.

Framework	Author, year	Setting	Rationale	Key domains assessed
				PCAC	HACP	MEPMH	PCPPG	Commitment to:
				PCAC	HACP	MEPMH	PCPPG	Patients	Society	Profession	Self
Accreditation Council for Graduate Medical Education (ACGME)	Chandler et al¹¹⁶	Postgraduate (PG), Paediatrics, Residents	To determine if non-faculty ratings of resident professionalism and interpersonal skills differ from faculty ratings through use of 360-degree evaluations suggested by ACGME	X
ACGME	Fontes et al²³	PG, Neuro surgery, Residents	To foster teaching and continuous evaluation of ACGME core competencies through findings from two interventions implemented on residents	X		X	X			X	X
ACGME	Gauger et al³⁰	PG, Surgery, Residents	To develop an instrument to measure specific aspects of professionalism in surgical residents	X
ACGME, American Board of Medical Specialties (ABMS), American Board of Internal Medicine (ABIM), Association of American Colleges (AAC)	Gillespie et al²⁹	PG, Various, Senior residents in emergency medicine, internal medicine, paediatrics, psychiatry and surgery	To assess perceptions of professional competence and professionalism in residents’ learning environment	X
ACGME	Hochberg et al⁹³	PG, Surgery, Residents	To assess whether professionalism has taken root in their surgical resident culture three years after implementing professionalism curriculum	X	X	X	X
ACGME	Malakoff et al¹⁰⁸	PG, Internal medicine, Medical students and transitional year residents	To objectively assess professionalism	X
ACGME	Picho et al⁷⁹	Undergraduate (UG)	To assess alumni perceptions of clinical practice preparedness using ACGME competencies	X
ACGME	Rawlings et al⁸⁷	PG, General surgery, Residents	To develop and evaluate narrative cases representing the five levels of the ACGME professionalism milestones	X
ACGME	Santosa et al¹²¹	PG, Psychiatry, Residents	To develop an ACGME-adapted instrument to assess professionalism in psychiatric residents	X
ACGME	Tanaka et al⁸¹	PG, Anaesthesiology, Residents	To define optimal professionalism feedback; develop, test, and implement a web-based feedback tool; and map the results to ACGME anaesthesiology milestones	X
ACGMEABMS	Williams et al¹⁰⁵	PG, Physicians at a large Midwestern regional healthcare provider and hospital system	To determine convergence of Miller’s framework with the ACGME/ABMS Core Competency framework	X
General Medical Council (GMC)	Campbell et al⁹⁷	PG, Non-training grade doctors, colleagues and patients	To investigate potential sources of systematic bias arising in the assessment of doctors’ professionalism	X			X	X		X	X
GMC	Johnston et al¹⁰⁹	UG, Medical students at Queen’s University, Belfast, United Kingdom	To assess professional attitudes at different curriculum stages and investigate the influence of the hidden curriculum using a novel tool based on GMC standards	X
GMC	Olsson et al⁹⁴	PG, Family Medicine, Residents	To assess the internal consistency of components in the Swedish adaptation of the GMC questionnaires and to determine aspects of good medical practice reflected in their latent variable structure	X	X
Canadian Medical Education Directives for Specialists (CanMEDS)	Al-Abdulrazzaq et al¹⁹	UG, Final year medical students at Kuwait University	To explore experiences and views of Kuwait students on professionalism					X	X	X
CanMEDS	Kalen et al¹²⁰	UG, Medical students at Karolinska Institutet, Sweden	To explore perceptions of specific learning activities and their relation to professional development as defined by CanMEDS			X	X
CanMEDS	Ortwein et al⁹⁹	PG, Anaesthesiology, Specialist and registrar	To evaluate the validity of a core competency catalogue based on CanMEDS and to ascertain differences in perceptions by specialists and registrars	X	X		X	X		X
CanMEDS	Peterkin et al¹¹⁹	UG, Third year medical students	To determine if using reflective writing in teaching roles delineated by CanMEDS increases students’ understanding of clinical roles	X
CanMEDS	Rademakers et al¹²⁷	UG, Sixth year medical students	To determine value of specific CanMEDS competencies as perceived by students	X
CanMEDS	Warren et al⁷⁵	PG, Canadian residency program directors in anaesthesiology, diagnostic radiology, general surgery, internal medicine, obstetrics and gynaecology, paediatrics and psychiatry	To understand the program directors’ perceptions of the CanMEDS Professional Role, and identify teaching and assessment methods employed				X
American Board of Internal Medicine (ABIM)	Askarian et al⁷⁶	UG, Medical students	To investigate perceptions of professional behaviour exhibited by peers	X
American Board of Internal Medicine (ABIM)	Blackall et al²⁴	UG, Medical students	To evaluate the development and factorial validity of an instrument used to measure attitudes toward professionalism in medical education among students, residents and faculty	X
ABIMAmerican College of Physicians (ACP)European Federation of Internal Medicine (EFIM)	Humphrey et al⁸⁴	UG, Preclinical and clinical students, and residents	To increase awareness of medical professionalism across institution and better understand changes in medical trainees’ professional behaviours as a result of learning environment	X	X	X	X
ABIM	Roberts et al¹²³	UG, Faculty	To determine unprofessional behaviours endemic in their institution and particular departments	X
ABIM	Tsai et al²⁰	UG, Seventh year medical students	To identify and understand structure of latent traits underlying concept of medical professionalism for Taiwanese students	X
Indian Medical Council (IMC)	Bahus Førde¹³⁵	UG, Medical students at a private medical school in Pondicherry, India	To evaluate awareness of the ethical code of conduct for medical practitioners	X

Abbreviations: PCAC, Professional Conduct and Accountability; HACP, Humanism and Cultural Proficiency; MEPMH, Maintaining Emotional, Physical and Mental Health; PCPAPG, Pursuing Continual Personal and Professional Growth.

Competency-based stages in professionalism assessment

The competency-based nature of assessments is evidenced by ten studies which put forth a stepwise approach to the assessment of professionalism knowledge and skills informed by the learner’s development.^{23,93,100-102,114,118,119,122,131}

In the initial stages, assessments focus on evaluating the understanding of concepts of professionalism as well as their key attributes and role in medical education. Next, perceptions and attitudes towards the roles and responsibilities of a professional are assessed. The final stage culminates in the sustained development and display of key professional attitudes and behaviours over time.^{23,93,100-102,114,118,119,122,131}

The presence of such progressive and longitudinal competency-based stages highlights the need for a safe and supportive environment as well as structured training processes.¹²⁵

Discussion

In highlighting available tools used to assess medical professionalism as well as pertinent domains to consider, this systematic scoping review successfully meets its primary and secondary research objectives. The context-specific nature of assessments is evident in the fact that prevailing tools or systems of assessments are based on regnant characterisations^{23,28,29,74,75,79,84,87,89,93,94,98,104,105,119-121} and prioritisation of specific professional attributes of medical professionalism.^{21,29,75,76,78,80,83,89,92,95,100}

However, despite these contextual differences, it is equally important to acknowledge that there are consistent features to most of them. These include use of a variety of modalities, sources of assessments, and focus on knowledge, attitudes, behaviours, skills, competencies and outcomes.^{3,4,23,26,30,74,75,80-84,105,108,115,116,118,122,130}

The findings further reinforce the notion that professionalism assessments should be competency-based, highlighting the need to carefully design their various stages. It is posited here that the stages of professionalism in the included articles correspond with the stages of Miller’s Pyramid (Table 7). In turn, assessments of professionalism are consistent with Kirkpatrick’s Model of Assessment (Table 8).^{23,93,118,122} Here, it is inferred that well-established milestones and competency levels are able to guide the learner’s progress as well as inform assessment processes.

Table 7.

Miller’s pyramid (reproduced from Moore et al¹³⁶).

Miller pyramid	Definition	Outcomes reported
Does	Demonstration of Professionalism in Everyday Clinical Practice	Likelihood of students to report physicians, nurses and fellow students¹²⁵
		Impact of faculty development process on faculty’s humanistic teaching^92,101
		Medical students’ professionalism,^91,111 manifest through behaviour and communication skills^80,83,104 • Self-assessment⁸³ • Peer-assessment⁸³ • Multi-source feedback¹¹⁵ • Assessed by Patients⁸⁵
		Physicians’ professionalism^{30,22,90,96,118,122} such as through behaviour^73,86 and/or demonstration of Core Competencies set out by ACGME^79,89,99 • Peer-assessment⁹⁷ This may also be carried out via evaluating the interpersonal and communication skills,^23,116 self-control⁷⁷ and empathy¹⁰²
		The professionalism curriculum as a cultural change agent⁹³
Shows how	Demonstration of Professionalism in a controlled setting such as in response to clinical vignettes and case scenarios	Likelihood of students to report physicians, nurses and fellow students for unprofessional behaviour¹²⁵
		Response to case scenarios of ethical issues^18,128 and unprofessional behaviour¹³¹
		Demonstration of professional behaviour using clinical vignettes¹²⁹ and standardised patients¹⁰³
Knows how/Understand	Being able to articulate understanding of professionalism	Faculty understanding of feedback delivery for professionalism competency pre- and post- faculty development program¹⁰⁰
Knows/Knowledge	State the definition of professionalism (but not necessarily demonstrate understanding and internalisation)	Perception and attitudes of professionalism^{24,25,84,88,109,117,130} and professional behaviour^21,76,109
		Change in attitudes towards professionalism after professionalism course^{25,109,114,117,119}
		Residents’ perceptions of their own professionalism and the professionalism of their learning environment²⁹

Table 8.

Kirkpatrick’s model of assessment.

Articles	Learning
Articles	Level 1 (participation)	Level 2a (attitudes and perception)	Level 2b (knowledge and skills)	Level 3 (behavioural change)	Level 4a (organisation practice)	Level 4b (patient benefits)
Aggarwal and Kheriaty¹²⁵	X	X
Akhund et al¹²⁶	X
Arnold et al¹⁰⁶
Arun Babu et al¹⁸			X
Asghari et al²¹		X
Askarian et al⁷⁶		X
Blackall et al²⁴		X
Branch et al¹⁰¹	X	X	X	X
Brauch et al¹⁰⁰	X	X	X
Bryan et al⁸³				X
Campbell et al⁹⁷				X
Chandler et al¹¹⁶				X
Cruess et al¹⁰⁴				X
Cuesta-Briand et al²⁵		X
Davis et al⁸⁵		X
Delport et al⁹¹				X
Domen et al¹³¹	X	X	X
Dyrbye et al²⁸
Elcin et al¹¹⁷		X
Emanuel⁸²
Emke et al¹¹⁵				X
Fontes et al²³	X	X	X	X
Gauger et al³⁰				X
Gillespie et al²⁹				X
Gisondi et al¹²⁸			X
Goldie³
Guraya et al²⁶
Haque et al⁸⁸		X	X
Hershberger et al⁷⁷			X
Hochberg et al⁹³	X	X	X	X	X
Hultman et al¹¹⁸	X	X	X	X	X
Humphrey et al⁸⁴		X		X
Iramaneerat⁹⁵
Johnston et al¹⁰⁹		X
Kalen et al¹²⁰	X
Kalet et al¹²²	X	X	X	X
Katic et al⁹⁶				X
Kesselheim et al⁹⁰				X
Mak-van der Vossen et al¹⁰⁷
Malakoff et al¹⁰⁸				X
Menna et al⁸⁰				X
Nagler et al²²		X		X
O’Sullivan, Toohey¹²⁹		X	X
Olsson et al⁹⁴				X
Ortwein et al⁹⁹				X
Pavon et al¹¹⁴	X	X	X
Peterkin et al¹¹⁹	X	X	X
Peterson et al⁸⁹				X
Picho et al⁷⁹				X
Rademakers et al¹²⁷		X
Raee et al¹¹¹				X
Rawlings et al⁸⁷
Roberts et al¹⁰²	X	X	X	X
Roberts et al¹²³
Sang et al¹¹³				X
Santen et al⁹⁸
Santosa et al¹²¹				X
Stockley, Forbes¹²⁴
Strowd et al⁷⁸		X
Sullivan et al¹¹⁰
Tanaka et al⁸¹
Taylor et al¹¹²			X
Todhunter et al⁹²			X	X
Tsai et al²⁰		X
van de Camp et al⁷³				X
Vora et al¹⁰³	X	X	X	X
Wilkinson et al⁴
Williams et al⁷⁴
Williams et al¹⁰⁵
Yazdankhah et al⁸⁶				X

The stages of assessments also reveal the longitudinal nature of professional development and the need for longitudinal assessments. There are a number of considerations.

One, reliance upon pre-existing knowledge and skills foregrounds the need for effective assessments prior to commencement of professionalism training. Whilst it is crucial that standards and codes of conduct are consistently applied, personalised training and assessments are also paramount as learners may have different baseline abilities and often require different forms of support at different junctures to achieve their desired goals.

Two, longitudinal assessments must be sensitive not only to the personalised aspect of professional development but also the appropriate stage of their learning. Indeed, emphasis on regular assessments require acknowledgement of the learner’s prevailing contextual, linguistic and cultural sensitivity as well as local understanding of professionalism. These also underscore the importance of discerning appropriate tools to be employed at each stage, with the learner’s movement from didactic learning to independent display of practical knowledge and skills. This stage-wise consideration is important given that the data accrued at each developmental stage will guide subsequent teaching, assessments and remediation for the learner.

Three, most tools do not incorporate multisource data required to effectively appreciate the evolving, adaptive nature of a developing professional identity in an individual and their practice. As far as possible, tools should be specific to different stages of professionalism development or be sufficiently flexible to account for differences in the learner’s abilities and setting.

Four, clear and realistic milestones must be established at each competency-based stage. Remediation plans should be also made available and actively integrated to ensure that learners in need do not slip between the cracks and are offered targeted and timely support.

Five, given that assessments are largely dependent upon the supervisor, mentor, coach and/or tutor, assessors must be trained on which tool to use and how each tool is to be effectively used. To facilitate communication between assessors in different settings and acknowledging the longitudinal nature of professional development, a portfolio-based assessment method should be employed to streamline the assessment process.

Consequently, these aspects of assessing professionalism affirms the fact that medical professionalism cannot be restricted to a “standardised and reductionist” definition and assessment method.^2,31,137 Rather, these findings underline the need for a portfolio-based assessment program^4,122 where a mixture of generalised tools and context-specific ‘specialised’ assessment methods can be employed to assess competencies and milestones achieved. The portfolio must also consider the prevailing practice culture, availability of resources and receptivity of its implementation to ensure the sustainability of professionalism assessment.

A portfolio approach would also allow reflections on individual experiences and allow assessors to evaluate and provide feedback on these reviews of experiences and refinements in practice and thinking. An additional consideration is that learners can also provide their perspective of the assessments and may even provide their views of a particular assessment and challenge the appraisal. This introduces the need for assessments to overseen and reviewed by independent third parties who may offer a review of the overall progress of the learner or a review of a particular assessment.

Mapping these findings have generated much insight and a general guidance for the design of professionalism assessments is featured in Figure 2 where key principles corresponding to each competency-based stage is foregrounded.

Figure 2.

Competency-based stages of professionalism assessment.

Limitations

Whilst this review focused solely on medical professionalism assessments, the articles included explored broader concepts of professionalism. The limited scope of this review also saw the exclusion of closely associated concepts such as professional identity formation and ethics³¹ which may have hampered a holistic picture of assessment practices in medical professionalism.^2,31,137 Due to time, manpower and resource constraint, the exclusion of other health professional literature may have also led to the omission of key ideas potentially transferable to the field of medical education.

Moreover, as the included articles were restricted to those in English, majority of the accounts originated from North America and the European countries. Although the utilisation of similar internationally acclaimed and accredited professionalism frameworks may suggest universal similarities and agreement over the domains of medical professionalism, it is evident that clinical and educational committees evaluate and adapt their guidelines in tandem with local healthcare and educational contexts and cultures. As the findings may not be representative of professionalism assessment practices beyond these countries, this review is limited in guiding educators on assessment attributes and criteria that will overcome nuanced geographical and cultural boundaries.^{1-3,31,35,58-60}

Future directions to consider

Mapping of prevailing medical professionalism assessment practices highlight the following potential areas for future research and action:

Delineate a working definition of medical professionalism that acknowledges their longitudinal and competency-based nature and integrates local sociocultural and contextual factors

Establish consensus on a medical professionalism framework that incorporates universally agreeable codes of conduct whilst granting flexibility for geographical and cultural considerations and specialties

Develop principles to guide the design of professionalism assessments with more robust understanding of how various assessment methods, criteria, content, goals, and needs may be integrated with due consideration for prevailing resources, settings and target populations

Evaluate the significance of sociocultural and linguistic idiosyncrasies in the design of assessment tools

Carry out more detailed and context-specific systematic reviews to better determine unique factors influencing how professionalism could be best assessed in psychiatry and other medical and surgical specialities

Adequately train and support assessors to ensure efficacious use of assessment tools and transparently convey to learners on the specifics of what they will be assessed on and how they will be assessed

Consider the use of portfolios which will allow for longitudinal, multidimensional reviews and learner initiated commentaries and reflections – this would provide greater opportunities for personalised remediation and training, as well as more streamlined communications between assessors

Supplemental Material

Appendix_A_xyz4525182e020e7 – Supplemental material for Assessing Professionalism in Medicine – A Scoping Review of Assessment Tools from 1990 to 2018

Supplemental material, Appendix_A_xyz4525182e020e7 for Assessing Professionalism in Medicine – A Scoping Review of Assessment Tools from 1990 to 2018 by Kuang Teck Tay, Shea Ng, Jia Min Hee, Elisha Wan Ying Chia, Divya Vythilingam, Yun Ting Ong, Min Chiam, Annelissa Mien Chew Chin, Warren Fong, Limin Wijaya, Ying Pin Toh, Stephen Mason and Lalit Kumar Radha Krishna in Journal of Medical Education and Curricular Development

Supplemental Material

Appendix_B_xyz4525142640e2f – Supplemental material for Assessing Professionalism in Medicine – A Scoping Review of Assessment Tools from 1990 to 2018

Supplemental material, Appendix_B_xyz4525142640e2f for Assessing Professionalism in Medicine – A Scoping Review of Assessment Tools from 1990 to 2018 by Kuang Teck Tay, Shea Ng, Jia Min Hee, Elisha Wan Ying Chia, Divya Vythilingam, Yun Ting Ong, Min Chiam, Annelissa Mien Chew Chin, Warren Fong, Limin Wijaya, Ying Pin Toh, Stephen Mason and Lalit Kumar Radha Krishna in Journal of Medical Education and Curricular Development

Footnotes

Acknowledgements

The authors would like to dedicate this paper to the late Dr S Radha Krishna whose advice and ideas were integral to the success of this study. The authors would like to thank the anonymous reviewers whose advice and feedback greatly improved this manuscript.

Declaration of conflicting interests:

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding:

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: None. This work was carried out as part of the Palliative Medicine Initiative run by the Division of Supportive and Palliative Care at the National Cancer Centre Singapore.

Authors’ contributions

KTT, SN, JMH, EWYC, DY, YTO, AMCC, WF, LW, SM, YPT and LKRK were involved in the conception and design of this study, data acquisition, analysis and interpretation of data and writing of the publication. MC was involved in the analysis and interpretation of data and editing of the publication.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

ORCID iDs

Elisha Wan Ying Chia

Warren Fong

Stephen Mason

Lalit Kumar Radha Krishna

Supplemental material

Supplemental material for this article is available online.

References

Norcini

Anderson

Bollela

, et al. 2018 Consensus framework for good assessment. Med Teach. 2018;40:1102-1109.

Hodges

Paul

Ginsburg

; The Ottawa Consensus Group Members. Assessment of professionalism: from where have we come–to where are we going? An update from the Ottawa Consensus Group on the assessment of professionalism. Med Teach. 2019;41:249-255.

Goldie

Assessment of professionalism: a consolidation of current thinking. Med Teach. 2013;35:e952-e956.

Wilkinson

Wade

Knock

LD.

A blueprint to assess professionalism: results of a systematic review. Acad Med. 2009;84:551-558.

Pellegrino

. Medical professionalism: can it, should it survive? J Am Board Fam Pract. 2000;13:147-149.

Coulehan

Williams

PC.

Vanquishing virtue: the impact of medical education. Acad Med. 2001;76:598-605.

Coulehan

Today’s Professionalism: engaging the mind but not the heart. Acad Med. 2005;80:892-898.

Baek

HJ.

New medical professionalism. Int J Rheum Dis. 2012;19:316-325.

Chin

JJ.

Ethical sensitivity and the goals of medicine: resisting the tides of medical deprofessionalisation. Singapore Med J. 2001;42:582-585.

10.

Gabbard

Nadelson

Professional boundaries in the physician-patient relationship. JAMA. 1995;273:1445-1449.

11.

Chin

JJ.

Medical professionalism in the internet age. Ann Acad Med Singap. 2010;39:345-347.

12.

Thompson

Dawson

Ferdig

, et al. The intersection of online social networking with medical professionalism. J Gen Intern Med. 2008;23:954-957.

13.

Farnan

Paro

Higa

Edelson

Arora

VM.

The YouTube generation: implications for medical professionalism. Perspect Biol Med. 2008;51:517-524.

14.

Hensel

Dickey

NW.

Teaching professionalism: passing the torch. Acad Med. 1998;73:865-870.

15.

Chuan

Huxtable

Peart

Healthcare Ethics, Law and Professionalism: Essays on the Works of Alastair V. Campbell. New York, NY: Routledge; 2018.

16.

Hochberg

Seib

Berman

Kalet

Zabar

Pachter

HL.

Perspective: malpractice in an academic medical center: a frequently overlooked aspect of professionalism education. Acad Med. 2011;86:365-368.

17.

Zhao

Cajas-Monson

Ramamoorthy

Malpractice allegations: a reality check for resident physicians. Am J Surg. 2019;217:350-355.

18.

Arun Babu

Venkatesh

Sharmila

. Are tomorrow’s doctors aware of the code of medical ethics? Indian J Med Ethics. 2013;10:192-194.

19.

Al-Abdulrazzaq

Al-Fadhli

Arshad

Advanced medical students’ experiences and views on professionalism at Kuwait University. BMC Med Educ. 2014;14:150.

20.

Tsai

Lin

Harasym

Violato

Students’ perception on medical professionalism: the psychometric perspective. Med Teach. 2007;29:128-134.

21.

Asghari

Fard

Atabaki

Are we proper role models for students? Interns’ perception of faculty and residents’ professional behaviour. Postgrad Med J. 2011;87:519-523.

22.

Nagler

Andolsek

Rudd

Sloane

Musick

Basnight

The professionalism disconnect: do entering residents identify yet participate in unprofessional behaviors?

BMC Med Educ. 2014;14:60.

23.

Fontes

Selden

Byrne

RW.

Fostering and assessing professionalism and communication skills in neurosurgical education. J Surg Educ. 2014;71:e83-e89.

24.

Blackall

Melnick

Shoop

, et al. Professionalism in medical education: the development and validation of a survey instrument to assess attitudes toward professionalism. Med Teach. 2007;29:E58-E62.

25.

Cuesta-Briand

Auret

Johnson

Playford

‘A world of difference’: a qualitative study of medical students’ views on professionalism and the ‘good doctor’. BMC Med Educ. 2014;14:77.

26.

Guraya

Mahabbat

Fallatah

Al-Ahmadi

Alalawi

HH.

The desired concept maps and goal setting for assessing professionalism in medicine. J Clin Diagn Res. 2016;10:JE01.

27.

Byram

JN.

The Professionalization of Medical Students: A Longitudinal Analysis of Professional Identity Formation and Professionalism Perceptions in Second and Third Year Medical Students. Indiana University; 2017.

28.

Dyrbye

Massie

Eacker

, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304:1173-1180.

29.

Gillespie

Paik

Ark

Zabar

Kalet

Residents’ perceptions of their own professionalism and the professionalism of their learning environment. J Grad Med Educ. 2009;1:208-215.

30.

Gauger

Gruppen

Minter

Colletti

Stern

DT.

Initial use of a novel instrument to measure professionalism in surgical residents. Am J Surg. 2005;189:479-487.

31.

Birden

Glass

Wilson

Harrison

Usherwood

Nass

Defining professionalism in medical education: a systematic review. Med Teach. 2014;36:47-61.

32.

NEJM Knowledge+ Team. Exploring the ACGME core competencies: professionalism (Part 7 of 7). https://knowledgeplus.nejm.org/blog/acgme-core-competencies-professionalism/. Accessed July 14, 2017.

33.

General Medical Council. Professionalism in action. Good Medical Practice 2019; https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/professionalism-in-action. Accessed July 14, 2019.

34.

Cruess

Johnston

Cruess

RL.

“Profession”: a working definition for medical educators. Teach Learn Med. 2004;16:74-76.

35.

Ding

Zhang

Liu

Wen

Assessing medical professionalism: a systematic review of instruments and their measurement properties. PLoS ONE. 2017;12:e0177321.

36.

Veloski

Fields

Boex

Blank

LL.

Measuring professionalism: a review of studies with instruments reported in the literature between 1982 and 2002. Acad Med. 2005;80:366-370.

37.

Horsley

Tips for improving the writing and reporting quality of systematic, scoping, and narrative reviews. J Contin Educ Health Prof. 2019;39:54-57.

38.

Arksey

O’Malley

Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19-32.

39.

Grant

Booth

A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26:91-108.

40.

Lorenzetti

Powelson

SE.

A scoping review of mentoring programs for academic librarians. J Acad Librarian. 2015;41:186-196.

41.

Mays

Roberts

Popay

. Synthesising research evidence. In: Fulop

Allen

Clarke

Black

, eds. Studying the Organization and Delivery of Health Services: Research Methods. London: Routledge; 2001:194-220.

42.

Thomas

Menon

Boruff

Rodriguez

Ahmed

Applications of social constructivist learning theories in knowledge translation for healthcare professionals: a scoping review. Implement Sci Commun. 2014;9:54.

43.

Kwan

Png

Phang

, et al. A systematic review of the quality and utility of observer-based instruments for assessing medical professionalism. J Grad Med Educ. 2018;10:629-638.

44.

Du Mont

Macdonald

Kosa

Elliot

Spencer

Yaffe

. Development of a comprehensive hospital-based elder abuse intervention: an initial systematic scoping review. PLoS ONE. 2015;10:e0125105.

45.

Osama

Brindley

Majeed

, et al. Teaching the relationship between health and climate change: a systematic scoping review protocol. BMJ Open. 2018;8:e020330.

46.

O’Donovan

Kuhn

Sachs

Winters

Ongoing training of community health workers in low-income andmiddle-income countries: a systematic scoping review of the literature. BMJ Open. 2018;8:e021467.

47.

Chidwick

Faith

Godkin

Hardingham

Clinical education of ethicists: the role of a clinical ethics fellowship. BMC Med Ethics. 2004;5:6.

48.

Pape

Manning

. The educational ladder model for ethics committees: confidence and change flourishing through core competency development. HEC Forum. 2006;18:305-318.

49.

Pinkus

Aumann

Kuczewski

, et al. The Consortium Ethics Program: an approach to establishing a permanent regional ethics network. HEC Forum. 1995;7:13-32.

50.

Pinkus

RLB

. The consortium ethics program: continuing ethics education for community healthcare professionals. HEC Forum. 1999;11:233.

51.

May

The breadth of bioethics: core areas of bioethics education for hospital ethics committees. J Med Philos. 2001;26:101-118.

52.

Levac

Colquhoun

O’Brien

KK.

Scoping studies: advancing the methodology. Implement Sci. 2010;5:69.

53.

Daudt

van Mossel

Scott

SJ.

Enhancing the scoping study methodology: a large, inter-professional team’s experience with Arksey and O’Malley’s framework. BMC Med Res Methodol. 2013;13:48.

54.

Pham

Rajić

Greig

Sargeant

Papadopoulos

McEwen

SA.

A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Res Synth Methods. 2014;5:371-385.

55.

Peters

Godfrey

McInerney

Soares

Khalil

Parker

. The Joanna Briggs Institute reviewers’ manual 2015: methodology for JBI scoping reviews. 2015. http://joannabriggs.org/assets/docs/sumari/Reviewers-Manual_Methodology-for-JBI-Scoping-Reviews_2015_v1.pdf. Accessed April 29, 2019.

56.

Royal College of Physicians and Surgeons of Canada. CanMEDS role: professional. 2019. http://www.royalcollege.ca/rcsite/canmeds/framework/canmeds-role-professional-e. Accessed July 14, 2019.

57.

Sandelowski

Barroso

Handbook for Synthesizing Qualitative Research. New York, NY: Springer Publishing Company; 2006.

58.

Braun

Clarke

Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101.

59.

Patterson

Roberts

Hanson

, et al. 2018 Ottawa consensus statement: selection and recruitment to the healthcare professions. Med Teach. 2018;40:1091-1101.

60.

Van Der Vleuten

Schuwirth

LW.

Assessing professional competence: from methods to programmes. Med Educ. 2005;39:309-317.

61.

Gordon

Gibbs

STORIES statement: publication standards for healthcare education evidence synthesis. BMC Med. 2014;12:143.

62.

Haig

Dozier

BEME Guide no 3: systematic searching for evidence in medical education–part 1: sources of information. Med Teach. 2003;25:352-363.

63.

Schönrock-Adema

Heijne-Penninga

van Hell

Cohen-Schotanus

Necessary steps in factor analysis: enhancing validation studies of educational instruments. The PHEEM applied to clerks as an example. Med Teach. 2009;31:e226-e232.

64.

Haig

Dozier

BEME Guide no 3: systematic searching for evidence in medical education–part 2: constructing searches. Med Teach. 2003;25:463-484.

65.

Soemantri

Herrera

Riquelme

Measuring the educational environment in health professions studies: a systematic review. Med Teach. 2010;32:947-952.

66.

Riquelme

Herrera

Aranis

Oporto

Padilla

Psychometric analyses and internal consistency of the PHEEM questionnaire to measure the clinical learning environment in the clerkship of a Medical School in Chile. Med Teach. 2009;31:e221-e225.

67.

Boyatzis

RE.

Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA: Sage; 1998.

68.

Sawatsky

Parekh

Muula

Mbata

Bui

Cultural implications of mentoring in sub-Saharan Africa: a qualitative study. Med Educ. 2016;50:657-669.

69.

Voloch

K-A

Judd

Sakamoto

. An innovative mentoring program for Imi Ho’ola Post-Baccalaureate students at the University of Hawai’i John A. Burns School of Medicine. Hawaii Med J. 2007;66:102.

70.

Frei

Stamm

Buddeberg-Fischer

Mentoring programs for medical students–a review of the PubMed literature 2000-2008. BMC Med Educ. 2010;10:32.

71.

Reed

Beckman

Wright

Levine

Kern

Cook

DA.

Predictive validity evidence for medical education research study quality instrument scores: quality of submissions to JGIM’s Medical Education Special Issue. J Gen Intern Med. 2008;23:903-907.

72.

Tong

Sainsbury

Craig

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349-357.

73.

van de Camp

Vernooij-Dassen

Grol

Bottema

Professionalism in general practice: development of an instrument to assess professional behaviour in general practitioner trainees. Med Educ. 2006;40:43-50.

74.

Williams

Byrne

Welindt

Williams

MV.

Miller’s pyramid and core competency assessment: a study in relationship construct validity. J Contin Educ Health Prof. 2016;36:295-299.

75.

Warren

Allen

Bergin

, et al. Understanding, teaching and assessing the elements of the CanMEDS Professional Role: Canadian Program Directors’ views. Med Teach. 2014;36:390-402.

76.

Askarian

Ebrahimi Nia

Sadeghipur

Danaei

Momeni

Shiraz medical students’ perceptions of their colleagues’ professional behavior. J Adv Med Educ Prof. 2015;3:111-116.

77.

Hershberger

Zryd

Rodes

Stolfi

Professionalism: self-control matters. Med Teach. 2010;32:e36-e41.

78.

Strowd

Saylor

Salas

Thorpe

Cruz

Gamaldo

CE.

Speaking the same language: cross-sectional assessment of perceived contributors to professionalism across generations. Neurol Clin Pract. 2016;6:230-240.

79.

Picho

Gilliland

Artino

, et al. Assessing curriculum effectiveness: a survey of uniformed services university medical school graduates. Mil Med. 2015;180:113-128.

80.

Menna

Petty

Wheeler

Vang

Evaluation of medical student professionalism: a practical approach. Med Sci Educ. 2005;15:45-48.

81.

Tanaka

Bereknyei Merrell

Walker

, et al. Implementation of a needs-based, online feedback tool for anesthesia residents with subsequent mapping of the feedback to the ACGME milestones. Anesth Analg. 2017;124:627-635.

82.

Emanuel

LL.

A professional response to demands for accountability: practical recommendations regarding ethical aspects of patient care. Ann Intern Med. 1996;124:240-249.

83.

Bryan

Krych

Carmichael

Viggiano

Pawlina

Assessing professionalism in early medical education: experience with peer evaluation and self-evaluation in the gross anatomy course. Ann Acad Med Singap. 2005;34:486-491.

84.

Humphrey

Smith

Reddy

Scott

Madara

Arora

VM.

Promoting an environment of professionalism: the University of Chicago “Roadmap”. Acad Med. 2007;82:1098-1107.

85.

Davis

King

Wayne

Kalishman

SG.

Evaluating medical student communication/professionalism skills from a patient’s perspective. Front Neurol. 2012;3:98.

86.

Yazdankhah

Tayefeh Norooz

Ahmadi Amoli

, et al. Using 360-degree multi-source feedback to evaluate professionalism in surgery departments: an Iranian perspective. Med J Islam Repub Iran. 2015;29:284.

87.

Rawlings

Knox

ADC

Park

, et al. Development and evaluation of standardized narrative cases depicting the general surgery professionalism milestones. Acad Med. 2015;90:1109-1115.

88.

Haque

Zulkifli

Haque

, et al. Professionalism perspectives among medical students of a novel medical graduate school in Malaysia. Adv Med Educ Pract. 2016;7:407-422.

89.

Peterson

Rusticus

Wilson

Eva

Lovato

CY.

Readiness for residency: a survey to evaluate undergraduate medical education programs. Acad Med. 2015;90:S36-S42.

90.

Kesselheim

Agrawal

Bhatia

, et al. Measuring pediatric hematology-oncology fellows’ skills in humanism and professionalism: a novel assessment instrument. Pediatr Blood Cancer. 2017;64.

91.

Delport

Kruger

van Rooyen

Pickworth

Developing an outcomes-based charter to direct teaching and assessment of medical professionalism. Afr J Health Prof Educ. 2015;7:10-15.

92.

Todhunter

Cruess

Young

Steinert

Developing and piloting a form for student assessment of faculty professionalism. Adv Health Sci Educ. 2011;16:223-238.

93.

Hochberg

Berman

Kalet

Zabar

Gillespie

Pachter

HL.

The professionalism curriculum as a cultural change agent in surgical residency education. Am J Surg. 2012;203:14-20.

94.

Olsson

Wallentin

Toth-Pal

Ekblad

Bertilson

BC.

Psychometric analysis of the Swedish version of the General Medical Council’s multi source feedback questionnaires. Int J Med Educ. 2017;8:252-261.

95.

Iramaneerat

Instruction and assessment of professionalism for surgery residents. J Surg Educ. 2009;66:158-162.

96.

Katic

Budak

Ivankovic

, et al. Patients’ views on the professional behaviour of family physicians. Fam Pract. 2001;18:42-47.

97.

Campbell

Roberts

Wright

, et al. Factors associated with variability in the assessment of UK doctors’ professionalism: analysis of survey results. Br Med J. 2011;343.

98.

Santen

Peterson

Khandelwal

House

Manthey

Sozener

CB.

Medical student milestones in emergency medicine. Acad Emerg Med. 2014;21:905-911.

99.

Ortwein

Knigge

Rehberg

Hein

Spies

Validation of core competencies during residency training in anaesthesiology. Ger Med Sci. 2011;9:Doc23.

100.

Brauch

Goliath

Patterson

Sheers

Haller

A qualitative study of improving preceptor feedback delivery on professionalism to postgraduate year 1 residents through education, observation, and reflection. Ochsner J. 2013;13:322-326.

101.

Branch

Jr Frankel

Gracey

, et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med. 2009;84:117-125.

102.

Roberts

Cornell

Bostrom

, et al. Communication skills training for surgical residents: learning to relate to the needs of older adults. J Surg Educ. 2018;75:1180-1187.

103.

Vora

Lineberry

Dobiesz

VA.

Standardized patients to assess resident interpersonal communication skills and professional values milestones. West J Emerg Med. 2018;19:1019-1023.

104.

Cruess

McLlroy

Cruess

Ginsburg

Steinert

The professionalism mini-evaluation exercise: a preliminary investigation. Acad Med. 2006;81:S74-S78.

105.

Williams

Byrne

Williams

MV.

Dreyfus and Dreyfus and indicators of behavioral performance: a study of measurement convergence. J Contin Educ Health Prof. 2017;37:50-54.

106.

Arnold

Shue

Kalishman

, et al. Can there be a single system for peer assessment of professionalism among medical students? A multi-institutional study. Acad Med. 2007;82:578-586.

107.

Mak-van der Vossen

van Mook

Kors

, et al. Distinguishing three unprofessional behavior profiles of medical students using latent class analysis. Acad Med. 2016;91:1276-1283.

108.

Malakoff

Payne

Staton

Kolade

Panda

Accounting for professionalism: an innovative point system to assess resident professionalism. J Community Hosp Intern Med Perspect. 2014;4.

109.

Johnston

Cupples

McGlade

Steele

Medical students’ attitudes to professionalism: an opportunity for the GP tutor?

Educ Prim Care. 2011;22:321-327.

110.

Sullivan

Murano

Comes

Smith

Katz

. Emergency medicine directors’ perceptions on professionalism: a council of emergency medicine residency directors survey. Acad Emerg Med. 2011;18:S97-S103.

111.

Raee

Amini

Momen Nasab

Malek Pour

Jafari

MM.

Team-based assessment of professional behavior in medical students. J Adv Med Educ Prof. 2014;2:126-130.

112.

Taylor

Luterman

Richards

Gonzalez

Rodning

CB.

Application of the core competencies after unexpected patient death: consolation of the grieved. J Surg Educ. 2013;70:37-47.

113.

Sang

Hall

Huong

Giang le

Hinh

ND.

Validity and reliability of the Vietnamese Physician Professional Values Scale. Glob Public Health. 2015;10 Suppl 1:S131-S148.

114.

Pavon

Pinheiro

Buhr

GT.

Resident learning across the full range of core competencies through a transitions of care curriculum. Gerontol Geriatr Educ. 2018;39:144-159.

115.

Emke

Cheng

Chen

Tian

Dufault

A novel approach to assessing professionalism in preclinical medical students using multisource feedback through paired self- and peer evaluations. Teach Learn Med. 2017;29:402-410.

116.

Chandler

Henderson

Park

Byerley

Brown

Steiner

MJ.

Use of a 360-degree evaluation in the outpatient setting: the usefulness of nurse, faculty, patient/family, and resident self-evaluation. J Grad Med Educ. 2010;2:430-434.

117.

Elcin

Odabasi

Gokler

Sayek

Akova

Kiper

Developing and evaluating professionalism. Med Teach. 2006;28:36-39.

118.

Hultman

Halvorson

Kaye

, et al. Sometimes you can’t make it on your own: the impact of a professionalism curriculum on the attitudes, knowledge, and behaviors of an academic plastic surgery practice. J Surg Res. 2013;180:8-14.

119.

Peterkin

Roberts

Kavanagh

Havey

Narrative means to professional ends New strategies for teaching CanMEDS roles in Canadian medical schools. Can Fam Physician. 2012;58:E563-E569.

120.

Kalen

Lachmann

Varttinen

Moller

Bexelius

Ponzer

Medical students’ experiences of their own professional development during three clinical terms: a prospective follow-up study. BMC Med Educ. 2017;17.

121.

Santosa

Marchira

Sumarni

Rianto

BUD

Supriyanto

The association between anxiety and professionalism in residents of ENT specialist training program in the Faculty of Medicine, Gadjah Mada University, Indonesia. Res Dev. 2017;6:58-61.

122.

Kalet

Sanger

Chase

, et al. Promoting professionalism through an online professional development portfolio: successes, joys, and frustrations. Acad Med. 2007;82:1065-1072.

123.

Roberts

Dorsey

Wold

Unprofessional behavior by specialty: a qualitative analysis of six years of student perceptions of medical school faculty. Med Teach. 2014;36:621-625.

124.

Stockley

Forbes

Medical professionalism in the formal curriculum: 5th year medical students’ experiences. BMC Med Educ. 2014;14:259.

125.

Aggarwal

Kheriaty

Same behavior, different provider: American medical students’ attitudes toward reporting risky behaviors committed by doctors, nurses, and classmates. AJOB Empir Bioeth. 2018;9:12-18.

126.

Akhund

Shaikh

Ali

SA.

Attitudes of Pakistani and Pakistani heritage medical students regarding professionalism at a medical college in Karachi, Pakistan. BMC Res Notes. 2014;7:150.

127.

Rademakers

de Rooy

Ten Cate

OT.

Senior medical students’ appraisal of CanMEDS competencies. Med Educ. 2007;41:990-994.

128.

Gisondi

Smith-Coggins

Harter

Soltysik

Yarnold

PR.

Assessment of resident professionalism using high-fidelity simulation of ethical dilemmas. Acad Emerg Med. 2004;11:931-937.

129.

O’Sullivan

Toohey

SM.

Assessment of professionalism in undergraduate medical students. Med Teach. 2008;30:280-286.

130.

Rodriguez

Siegelman

Leone

Kessler

Assessing professionalism: summary of the working group on assessment of observable learner performance. Acad Emerg Med. 2012;19:1372-1378.

131.

Domen

Talbert

Johnson

, et al. Assessment and management of professionalism issues in pathology residency training: results from surveys and a workshop by the Graduate Medical Education Committee of the College of American Pathologists. Acad Pathol. 2015;2:2374289515592887.

132.

Hsieh

H-F

Shannon

SE.

Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277-1288.

133.

Mayring

Qualitative content analysis. A Compan Qual Res. 2004;1:159-176.

134.

Kondracki

Wellman

Amundson

DR.

Content analysis: review of methods and their applications in nutrition education. J Nutr Educ Behav. 2002;34:224-230.

135.

Bahus

Førde

Discussing end-of-life decisions in a clinical ethics committee: an interview study of Norwegian doctors’ experience. HEC Forum. 2016;28:261-272.

136.

MooreDE

Green

Gallis

HA.

Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. J Contin Educ Health Prof. 2009;29:1-15.

137.

Harden

Lilley

Best practice for assessment. Med Teach. 2018;40:1088-1090.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.09 MB

0.29 MB