Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching Professionalism in Undergraduate Medical Education. JAMA. 1999;282(9):830-832. doi:10.1001/jama.282.9.830
Author Affiliations: Association of American Medical Colleges, Washington, DC. Dr Swick is with the Department of Neurology, University of Kansas, Kansas City. He is currently a scholar in residence with the Association of American Medical Colleges.
Context There is a growing consensus among medical educators that to promote
the professional development of medical students, schools of medicine should
provide explicit learning experiences in professionalism.
Objective To determine whether and how schools of medicine were teaching professionalism
in the 1998-1999 academic year.
Design, Setting, and Participants A 2-stage survey was sent to 125 US medical schools in the fall of 1998.
A total of 116 (92.3%) responded to the first stage of the survey. The second
survey led to a qualitative analysis of curriculum materials submitted by
Main Outcome Measures Presence or absence of learning experiences (didactic or experiential)
in undergraduate medical curriculum explicitly intended to promote professionalism
in medical students, with curriculum evaluation based on 4 attributes commonly
recognized as essential to professionalism: subordination of one's self-interests,
adherence to high ethical and moral standards, response to societal needs,
and demonstration of evincible core humanistic values.
Results Of the 116 responding medical schools, 104 (89.7%) reported that they
offer some formal instruction related to professionalism. Fewer schools have
explicit methods for assessing professional behaviors (n=64 [55.2%]) or conduct
targeted faculty development programs (n=39 [33.6%]). Schools use diverse
strategies to promote professionalism, ranging from an isolated white-coat
ceremony or other orientation experience (n=71 [78.9%]) to an integrated sequence
of courses over multiple years of the curriculum (n=25 [27.8%]). Of the 41
schools that provided curriculum materials, 27 (65.9%) addressed subordinating
self-interests; 31 (75.6%), adhering to high ethical and moral standards;
17 (41.5%), responding to societal needs; and 22 (53.7%), evincing core humanistic
Conclusions Our results suggest that the teaching of professionalism in undergraduate
medical education varies widely. Although most medical schools in the United
States now address this important topic in some manner, the strategies used
to teach professionalism may not always be adequate.
There is a growing awareness, both within and outside the medical profession,
that the corporate transformation of the US health care system threatens to
undermine the professionalism of physicians.1
The rise of managed care and consumerism in medicine have led many to worry
about changes both in physicians' attitudes about their roles and responsibilities
and in the behaviors they demonstrate in the daily practice of medicine. Medical
educators have become concerned about an erosion of medical professionalism
because of the impact that the attitudes and behaviors of practicing physicians,
particularly clinical faculty, have on the professional development of medical
students and resident physicians.
Reflecting these concerns, the Section on Medical Schools of the American
Medical Association devoted its May 1998 meeting to an exploration of certain
aspects of professionalism, and in July 1998, the Association of American
Medical Colleges sponsored a colloquium of medical educators, ethicists, and
experts from law and philosophy who had written about professionalism. These
meetings contributed to the development of a consensus among medical educators
that medical schools should offer both didactic and experiential learning
experiences designed to promote the development of professionalism among medical
students and resident physicians. In response to this consensus, we conducted
a survey of US medical schools to determine whether they were teaching professionalism,
and if so, how. This article reports the results of that survey.
A 2-stage survey of US medical schools was conducted in the fall of
1998. In the first stage, a 1-page survey instrument was sent to the associate
dean responsible for the medical student education program at each school.
The survey instrument was intended to gain general information about a school's
activities related to the teaching of professionalism (questions 1-3 and 8, Table 1). Even though professionalism is
a complex concept encompassing a number of attitudes, values, and behaviors,
the survey instrument focused attention on only 4 attributes: (1) subordinating
one's self-interest to the interest of patients; (2) adhering to high ethical
and moral standards; (3) responding to societal needs; and (4) evincing core
humanistic values (eg, empathy, integrity, altruism, trustworthiness). The
authors selected these 4 attributes because they have often been recognized
as essential elements of professionalism2- 5
and because they were thought to be the attributes most likely to be addressed
formally by schools.
In the second stage, a more detailed survey instrument was sent to those
schools that reported on the first instrument that they did offer some formal
instruction in professionalism. The second survey instrument was designed
to determine when and in what format professionalism was taught, as well as
the specific goals and objectives of such curricular offerings (questions
4-7, Table 1). This instrument
was directed toward a specific contact person—most often a course or
program director—identified in the first survey. These individuals also
were asked to submit copies of curriculum materials used in courses related
Simple descriptive statistics (frequencies and percentages) were computed
for each survey question. In addition, curriculum materials, ranging from
brief outlines to multivolume syllabi, were reviewed by one of the authors
(H.M.S.) to determine when and how a school conveyed attributes of professionalism.
The reviewer used both a key word descriptive approach to ascertain if the
materials used explicit language related to 1 of the core attributes and a
more subjective approach to determine whether the presentation of certain
topics addressed 1 of the core attributes. An example of the key word approach
would be a discussion of specific ethical behaviors in a course on biomedical
ethics. An example of the subjective approach would be the reviewer's determination
of whether a presentation on access to care for the uninsured reflected a
physician's social responsibility, based on the reviewer's judgment of stated
course objectives or other materials.
Of the 125 US medical schools, 116 (92.3%) responded to the first stage
of the survey. The second survey instrument was sent to the 104 schools that
indicated that they did offer formal instruction on professionalism. Of those,
90 (86.5%) schools responded; 41 (75.9%) of the 54 schools that indicated
they had a course syllabus or similar materials submitted those materials
The results of the survey are summarized in Table 1. A total of 104 (89.7%) of the responding US medical schools
reported that they had some formal instruction related to professionalism.
Slightly more than half of the responding schools (64 [55.2%]) reported having
an explicit rigorous process to assess the students' professional behaviors,
while 39 (33.6%) had targeted faculty development programs.
The majority of schools (71 [78.9%]) that address professionalism do
so during orientation, often in a "white-coat ceremony" designed to symbolize
the matriculating students' induction into the medical profession6; a smaller majority of schools (54 [60%]) incorporate
professionalism as a component of multiple courses (question 4, Table 1). Fewer than a third of the schools (26 [28.9%]) reported
that they teach professionalism in a single course or as an integrated sequence
of courses (25 [27.8%]). Of the schools reporting that they taught professionalism,
56 (68.3%) had written goals or objectives, 52 (63.4%) provided course outlines
for students or faculty, and 54 (65.9%) used a syllabus or other written materials.
Schools appeared to recognize some inadequacies in their approach to
professionalism. The majority of the schools that responded to the first survey
instrument indicated that their efforts to teach professionalism would benefit
from examples of evaluation instruments (84.5%), faculty development materials
(81.9%), and formal teaching materials or model programs (76.7%).
The analysis of the curriculum materials provided by the 41 schools
revealed significant variation in the number of schools covering the 4 selected
attributes of professionalism in 1 or more of their courses. While about three
quarters of the schools covered the attribute "adhere to high ethical and
moral standards," fewer than half addressed the attribute "respond to societal
needs and reflect a social contract with the communities served" (Table 2). The data reported in Table 2 are derived from both the key word
and the more subjective approaches.
Most of the explicit teaching of professionalism occurred during the
first 2 years, whether in a single course or in multiple courses. Only 8 of
the 41 schools submitted materials related to explicit learning experiences
conducted in the last 2 years of the curriculum. The most common approach,
used by 20 of the 41 schools, was to incorporate various concepts of professionalism
into 1 or more courses that focused on a variety of topics in which professionalism
is addressed indirectly.
For many years, the acquisition of professional values and behaviors
occurred largely through an informal process of socialization that extended
from medical school through residency and fellowship training. As issues of
medical practice have become more complex and as students enter the study
of medicine from increasingly diverse social, cultural, and socioeconomic
backgrounds, schools of medicine have recognized that such an informal process
no longer suffices. While role modeling and experiential learning remain critically
important, many schools perceive the need also to offer explicit learning
activities that will inculcate in students and residents the knowledge, values,
attitudes, and behaviors that characterize medical professionalism.
The survey results presented in this article reflect the status in 1998
of the explicit teaching of professionalism in US medical schools. To the
best of our knowledge, this study is the first designed to gain insight into
whether and how medical schools are teaching professionalism. The survey data
must be interpreted with caution because the responses to the survey questions
are undoubtedly affected by the general lack of a common understanding of
the meaning of medical professionalism. Nonetheless, a few general observations
Both the surveys and the review of curriculum
materials indicate that the great majority of schools recognize the need to
address professionalism as a critical element of the education of their students.
However, it is noteworthy that 10% of the respondents to the initial survey
reported that their school did not have any recognized curriculum content
that addressed professionalism, whether explicitly or implicitly. Also of
note, only one half of the schools that reported having curriculum content
related to professionalism indicated having formal methods for assessing the
professional behaviors of students. Finally, the review of the course materials
submitted by 41 (76%) of the 54 schools that indicated they had such materials
suggests that schools do not cover, in an explicit manner, several of the
essential attributes of medical professionalism.
The results of
this study suggest that the teaching of professionalism in US medical schools
needs to be enhanced. Schools would benefit from examples or models of how
professionalism might be defined, taught, and assessed. While most medical
schools seem to recognize that explicit learning experiences are necessary
to promote professional values and behaviors in medical students, the strategies
used to achieve that goal appear inadequate. Although some schools are quite
organized in their approach to teaching professionalism, many are not. Few
have an approach that attempts specifically to foster the development of professional
values and behaviors. Many schools do not provide instruction on the characteristics
of a profession or on the history and meaning of medical professionalism in
the context of the current health care system. In the past few years, several
observers have argued that if physicians are to meet their responsibilities
to their patients, to the profession, and to society, formal teaching of professionalism
should be embedded in the medical school curriculum.7- 10
The results of this study underscore the importance of responding to their