In this study, students perceived ‘good doctor’ and ‘professional doctor’ as two separate constructs with different characteristics and some overlap. Being a good doctor was identified with achieving a balance between the art and science of medicine, between a sound clinical competence and the ability to communicate that knowledge appropriately to patients, relatives and the rest of the medical team. Students’ understandings encompassed elements from canMEDS ‘communicator’ and ‘collaborator’ roles , and tended to be aligned with the elements of intrapersonal professionalism described by Van de Camp and colleagues . Somewhat in contrast with findings by Maudsley and colleagues , students in our study perceived sound clinical competence as an essential attribute of the good doctor, and their understandings fitted with the ‘3 Cs’ of communication, competence and care that patients seek in a good doctor . Good communication was seen as a core attribute of the good doctor, and was conceptualised as the ability to ‘connect’ with patients and communicate effectively with the rest of the medical team. This result is somewhat consistent with other research conducted with clinicians  and medical students ; however, in contrast with findings from Bennet and colleagues , students in our study did place emphasis on the importance of team work and collaboration.
Professionalism was perceived as an external, imposed construct. Students tended to have one-dimensional views on professionalism and, similarly to participants in Monrouxe and colleagues’ study, they struggled to articulate their understandings . Adopting a ‘professional persona’ was widely associated with professionalism, and the enactment of this ‘persona’ involved dressing appropriately and adopting a certain detachment when dealing with patients, attributes which had negative connotations for students and elicited feelings of scepticism. Consistent with research showing that dressing up is part of ‘switching on’ the professional persona , clothing was a recurrent theme in the discussions on professionalism. Students’ perception of the lack of importance of dress standards is problematic, given that evidence shows that doctors’ appearance is important to patients [29, 30]. This discord between students’ and patients’ views has implications for PPD education and supports the need to address the importance of appropriate dress standards from a patient perspective.
Students generally viewed professionalism as something that can be activated on demand  in order to ‘perform’ as expected, lending support to Brainard and Brislen’s view that students become ‘professional and ethical chameleons’ as a way to navigate medical schools . This finding has implications for medical educators, as it casts doubt on the ability of commonly used assessment items such as Objective Structured Clinical Examination (OSCE) stations or case-based discussions to authentically demonstrate professional behaviour.
In this study, students sometimes perceived the two constructs as acting in opposition, leading to internal conflict on how students perceive situations and feel about themselves and others. Consistent with Bennet and colleagues , results from our study suggest that there is conflict between what is being taught and what is being modelled, and there was evidence that students wished to hold on to what they perceived as patient-centred values . There was evidence that students felt more connected to the construct of the ‘good doctor’ – which they perceived as a personally meaningful aspiration – and would forgo professionalism if both constructs came into conflict.
Despite the apparent tension between the construct of professionalism and that of the ‘good doctor’, an area of overlap was observed. Students clearly honoured elements that are core to professionalism, such as respect, team work, communication and having an adequate knowledge base. This finding suggests that these elements, which require internally-motivated behaviour and are associated with both being a professional doctor and a good doctor, should be a starting point upon which medical educators can scaffold discussion about professionalism.
Our findings have curriculum implications, and support the need for greater curricular attention to practical ethics . Our findings suggest that the teaching of professionalism should incorporate more formal reflection on the complexities of medical practice, allowing students and educators to openly explore and articulate any perceived tensions between what is formally taught and what is being observed in clinical practice.
In addition, our findings, which indicate students substantially learn about practice from role models, suggest that identifying clinicians who exemplify what the students most esteem should be a key part of PPD teaching. Mentoring by these clinicians may enable students to integrate what they perceive as the more mechanistic aspects of professionalism with the more competence-based and interpersonal aspects of being a ‘good doctor’. However, given cohort sizes in most institutions and the requirement to rotate students through a number of teaching locations, restricting mentoring to those clinicians identified as exemplifying required behaviours would be impractical. Instead, all mentors could be given assistance in discussing with students how to integrate these topics.
We acknowledge some limitations. Firstly, participants in the study were self-selected, and we cannot discount that they might have been more attuned to ethical and professional dilemmas than the general population of students. Secondly, focus groups may emphasise the stronger voices to the detriment of the weaker ones; in our study, efforts were made to be inclusive and allow all students to express their opinions. Thirdly, only one focus group was conducted with sixth-year students; however, this does not preclude the validity of the data as data saturation was reached.