Teaching and Assessment of Professionalism in Health Professions Education

By Alam Sher Malik

Affiliations

1. Department of Paediatrics, International Medical School, Management and Science University, Shah Alam, Malaysia

doi: 10.29271/jcpsp.2025.12.1501

Professional principles and conduct are fundamental to medical practice, yet they remain one of the most difficult topics to teach and formally assess through conventional educational and evaluative methods. One of the many reasons for this persistent challenge is the absence of a universally agreed-upon definition of professionalism, which hinders rationality in both teaching and assessment. The influence of diverse cultural and religious beliefs, along with societal values, shapes the portrayal of professionalism as a regional concept rather than a universal construct. Furthermore, professionalism in the 21^st century demands fostering skills of self- directed and life-long learning in students, so they can effectively  deal  with  unforeseen  challenges  in  the  future.¹

Curriculum developers and other stakeholders need to adopt approaches that ensure the understanding, teaching, learning, and appreciation of professionalism becomes a central and unambiguous component of healthcare training. Teaching frameworks should reflect cultural values, traditions, societal norms, and  community  expectations  from  medical  professionals.²

For this purpose, based on a locally agreed definition of professionalism, curriculum developers need to identify clear intended learning outcomes, including personal qualities, values, attitudes, and behaviours, to guide academicians in selecting course content and aligning teaching/learning approaches with assessment methods. Although core values remain consistent, evolving societal norms should be considered when defining learning outcomes. Historical, cultural, religious, and philosophical views can enhance learners’ under- standing of the evolution of professionalism, from its origin in ancient Greece with the Hippocratic oath to the present era. Continuous professional and personal development is another important aspect that must be embedded in both teaching and assessment methods. Students must learn the required skills to develop their professional identity throughout their career as healthcare  providers.

The American College of Physicians and the European Federation of Internal Medicine published a Physician’s Charter,³ which provides a comprehensive framework for professionalism. The recommended professional attributes include: professional competence, honesty, patients’ confidentiality, appropriate relationships with patients, quality of care, fair utilisation of finite resources, scientific knowledge, trust, and professional responsibilities.

A report from the Royal College of Physicians underscores the significance of expertise and proficiency as vital components of professionalism—a notion not specifically highlighted previously. This report stresses the need to incorporate leadership, teamwork, training, and evaluative skills into medical curricula and training programmes, along with developing the ability to manage  healthcare  professions.³

Learning outcomes must be agreed upon by all stakeholders, including both learners and teachers. Without such consensus, the implementation of effective teaching and assessment processes is likely to face intractable challenges.

Three models have been recommended for teaching pro- fessionalism: experiential learning, reflection and reflective practice, and situated learning.¹ Kolb’s experiential learning cycle offers learning through concrete experience followed by abstract conceptualisation. Reflection, on the other hand, is a form of mental processing with a purpose and/or anticipated outcome.⁴ It has been argued that reflection-on-action is more effective than reflection-in-action in facilitating the integration of professionalism training into medical education.¹ Students openly and freely deliberating on simulated or actual case scenarios, vignettes based on professional or unprofessional behaviours, thought-provoking incidents, videos, or pictures in a small-group classroom setting under the supervision of an expert facilitator are examples of situated learning. The situated learning theory recommends the presentation of information in authentic contexts.⁵ This set-up may stimulate a healthy debate among participants, enabling students to explore professional issues from their own perspective in greater depth. This type of learning is context-specific, occurring through co-participation and shared cognition.¹ Students may also discuss a range of professional behaviours (both positive and negative) that they observe during their clerkship, without identifying the individuals involved. However, facilitators must be able to manage this relatively complex environment  with  the  skills  to  negotiate   interpersonal   skirmishes.

Training students in emotional intelligence helps them to improve their communication skills, teamwork, and empathy, along with academic performance,⁶ which are some of the important attributes of professionalism. Informal curriculum, such as extracurricular activities and social interactions, may significantly contribute to the development of professionalism. Therefore, this aspect must be considered when planning such events  and  gatherings.

The contribution of role models in promoting professionalism has been valued; however, with students coming from diverse cultural, social, and socio-economic backgrounds, this informal process may be complicated by differing beliefs about what constitutes professional and unprofessional in different contexts.²

The educational climate—including traditionally agreed but informal rules, routine behaviours, and formalities within the medical profession—is implicitly observed by learners. This is termed as a hidden curriculum. In certain circumstances, the hidden curriculum may be more impactful than the formal curriculum. Therefore, it is imperative that the elements contributing to the hidden curriculum are carefully studied and appropriately  dealt  with.

The hidden curriculum may promote the ‘‘the-boss-is-always- right’’ culture. The negative effects of the hidden curriculum on learning may include: loss of critical thinking, idealism, and ethical integrity.⁷ At worst, students may believe that they are more likely to be rewarded for imitating the unprofessional behaviour  of  their  teachers.⁸

In an uncontrolled environment, such as clerking patients in hospital wards, learners are likely to observe inconsistent and suboptimal professional behaviours. Opportunities should be provided for discussion, and guidance for reflecting on such incidents should be readily available. Students should know whom  to  consult  in  these  situations.

Digital professionalism is a relatively new area, and students need to be guided on protecting their personal information, avoiding inappropriate groups, and being mindful when sharing or watching photos and videos. They also need training on how to search for authentic scientific information and on the judicial use  of  artificial  intelligence  tools.⁹

Professionalism cannot be taught effectively by traditional lectures or by allocating a limited time for questions at the end of the session. To make the session exciting and rewarding, enough time needs to be allocated for reflection and open discussion.² To improve professionalism, teaching and assessment methods must be formal and categorically stressed in the curriculum. However, assessing professionalism is perhaps one of  the  most  challenging  tasks  in  medical  education.

Even after several reviews, no definitive method for assessing professionalism has been agreed upon. However, several shared approaches exist, such as Objective Structured Clinical Examinations (OSCEs), multisource assessments—including assessment by peers and direct observation by faculty— reporting of serious incidents, reflective writing, self-assessment, and the use  of  portfolios.¹⁰

Common elements that need to be assessed include life-long learning skills, altruism, honesty and integrity, maintaining confidentiality, improving the quality of care, maintaining appropriate relationships with patients and their caregivers, proper and judicial use of finite resources, respect for others, adherence to ethical and moral standards, managing conflicts of interest, honour, accountability, and professional responsi- bilities. These responsibilities include teamwork, leadership qualities, conflict prevention and management, and understanding one’s own professional limitations. These terms are difficult to translate into concrete, measurable outcomes. However, observing external professional behaviour may reflect internal attitudinal values.¹¹

The assessment of professional behaviour must be for both formative and summative purposes and should be valid, reliable, acceptable and feasible. The findings should be gathered longitudinally and analysed judiciously before making an overall judgement.

Assessment must be entrenched in the curriculum and in- corporated at progressively higher levels of complexity as learners advance through the training programmes. Several instruments have been developed to assess different aspects of professionalism from different angles. For example, a ques-tionnaire was developed to assess professionalism among surgical residents at the University of Michigan.¹² Based on the concept of the mini Clinical Evaluation Exercise (mini-CEX), a Professionalism Mini Evaluation Exercise (P-MEX) was created.¹³ The Professionalism Assessment Tool (PAT) was developed in the Pakistani context using Delphi techniques.¹⁴ Team-based assessment (TAB) includes professional conduct, communication skills, teamwork, and accessibility.¹⁵ The situational judgement test evaluates professional capability and perceives stu­dents’ expected behaviour in their future careers.¹⁶

Along with knowledge and skills, a strong commitment from the institution, leadership, and faculty is vital to successfully teach and assess professionalism.

COMPETING  INTEREST:
The  author  declared  no  conflict  of  interest.

AUTHOR’S  CONTRIBUTION:
ASM: Contributed to the conception, study design, data acquisition, analysis and interpretation, and approved the final version to be published.

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