Search results
The search yielded 11,963 different articles: 202 were identified as relevant after initial screening of titles and abstracts and 46 were included after reviewing the full texts. See Fig. 1. A list of excluded studies with justifications is provided as Additional file 2.
Study characteristics
The review included studies from a wide range of countries, from January 1977–May 2016. See additional file 3 for an overview of the 46 included studies. We included 30 quantitative studies, 11 qualitative and 5 mixed-methods studies. Three of the articles were not written in the English language: two were written in Spanish and one in Greek. From the included articles, 29 described single-institution studies and 17 described multi-institution studies, varying from 2 to 78 institutions. In 28 articles a survey was described, and 16 other articles reported case-studies using interviews, essays, or students’ records from the university administration. Two additional articles reported observational studies. From the 46 articles, 29 were of good quality. For some articles not all quality questions could be answered positively due to a low response rate.
Attention for professional behaviour in medical school started in the US around 1980, firstly emphasised on fraudulent behaviours, followed by attention for disrespectful behaviour and failure to engage. We did not find any articles coming from the other continents that were published before 2000. Around 2000, North-American researchers started to focus on poor self-awareness, while in other continents only dishonest behaviour was described, later followed by other themes. Recently, attention was paid in the literature to unprofessionalism originating from the use of the internet, which can lead to privacy violations and other disrespectful behaviour, as well as to dishonest behaviours. See Fig. 2 for global trends in three time periods.
Themes of unprofessional behaviour
The included articles yielded 205 different descriptions of unprofessional behaviours, which were coded into 30 different descriptors, and subsequently classified into four behavioural themes: failure to engage, dishonest behaviour, disrespectful behaviour, and poor self-awareness. See Fig. 3.
The next paragraphs present the primary findings for each of the four themes. See Additional file 4 for a complete and detailed list of themes, descriptors and behaviours.
Failure to engage
The first theme can be described as failure to engage, which was defined as insufficiently handling one’s tasks. Failure to engage [25,26,27] included descriptions as being late or absent for rounds or other assigned activities [28,29,30,31,32], poor reliability and responsibility [25, 31, 33, 34], poor availability [32], lack of conscientiousness [35], tardiness [32] and poor initiative and motivation [31, 32, 36,37,38], cutting corners [39], and accepting or seeking a minimally acceptable level of performance [25]. General disorganization was mentioned [26, 27], examples of which were illegible handwriting, poor note keeping and not meeting deadlines [32]. Behaviours indicating failure to engage leading to poor teamwork were described as avoiding work [27], escaping teamwork [40], language difficulties [37] and not giving feedback to others [30].
Failure to engage in the clinical phase of medical school was seen in the form of avoidance of patient contact [27, 37], failing to contribute to patient care [26, 37, 39], leaving the hospital during a shift [41], and unsatisfactory participation [33, 36].
Dishonest behaviours
This theme describes students’ integrity problems. It includes cheating, lying, plagiarism and not obeying rules and regulations.
Cheating and lying
Cheating and lying took place in class by forging signatures [40, 42, 43], or giving false excuses when absent [40, 43,44,45,46,47], asking a colleague to sign in on an attendance list [26, 41, 43, 45, 48], asking other students to do your work or doing work for another student [40, 41, 43]. Cheating in exams [32] was extensively described, and consisted of: gaining illegal access to exam questions [40, 43,44,45,46,47], letting someone else take your exam [43, 46, 47], using crib notes [43, 44, 46,47,48,49], exchanging answers during an exam [43,44,45,46,47,48,49], exchanging answers by using mobile phones [43, 45, 48] and passing an exam by using help from acquaintances [43, 48, 50]. Cheating in clinical or research context took place in the form of data fabrication [26, 40, 41, 43,44,45,46, 49, 51,52,53], and data falsification [25, 31, 32, 37, 40, 41, 43, 51,52,53,54], sometimes to disguise mistakes [43], e.g. when a student had forgotten to order a laboratory test or omitted a part of the history taking or physical examination [40, 41, 44, 46, 49, 51, 55]. Also, not asking consent for clinical examination of a patient was mentioned [56, 57]. One study reported cheating in using the hospital’s electronic health record documentation [EHRD]: copy/pasting a colleague’s notes, using auto-inserted data, or documenting while signed in under someone else’s name in the EHRD [58].
Already in 1978, a law scholar, Simpson, emphasised the phenomenon of deceptive introduction [59] Students being introduced as “doctors” to patients is a form of lying that directly influences patient care. This type of misrepresentation has also been described more recently [35, 57].
Plagiarism
Plagiarism consisted of self-plagiarism [43], plagiarizing work of seniors or peers [46, 52], and plagiarizing from other sources without acknowledging the reference [40, 42, 47, 60]. Copying text directly from published books or articles was seen as unprofessional even when the source was included in the reference list [43].
Not obeying rules and regulations
Unprofessional activities mentioned were: acceptance of failing to obey rules and regulations [26] for example by not following infection control procedures [43, 57] and using phones in restricted areas [61].
Unlicensed activities that were mentioned in the included articles were: significant misconduct [32, 42], stealing [62], damaging another’s property [62] or physically assaulting a university employee or fellow student [43].
Disrespectful behaviour
Another theme was found to be disrespectful behaviour, which was defined as behaviour that has a negative effect on other people. Behaviours in this theme vary widely in severity.
Disrespectful behaviour was described as poor verbal or non-verbal communication: inappropriate spoken language [25, 26, 32, 56, 63] inappropriate body language [26,27,28, 32], disrespectful communication by email [32] and also ignoring emails or other forms of contact from teaching or administrative staff [26, 36]. Recent articles mentioned unprofessional behaviour on Facebook or other social media, for example discussing clinical experiences with patients [64] discussing a clinical site or the university in a negative light [64] and posting compromising pictures of peer students [63, 65]. Other disrespectful behaviours that are exemplary for the lack of sensitivity to others’ needs were cultural and religious insensitivity [35], discrimination [33, 35], and sexual harassment [35, 43, 63]. These disrespectful behaviours can affect all persons with whom these students interact: teachers and other staff or health personnel, patients and their families, or fellow students.
Teachers can be treated disrespectfully by negative responses or disruptive behaviour in teaching sessions [26, 34, 36, 66], writing rude/inappropriate comments on exam papers [26] or other failure to show respect for the examination process [28].
Patients can be affected by a student’s disrespectful behaviour when the student shows a lack of empathy [26, 28], insensitivity to the needs of others [25, 26, 62], and abrupt and non-empathetic manner with patients [26], referring to patients in a derogatory way [29, 30, 39, 56, 57], placing own learning above patient safety [57], making a patient feel uncomfortable during an exam [56] or treating simulation patients as passive objects rather than as people with feelings and concerns [28] were examples of behaviours that were seen as a lack of empathy. Also, overly informal behaviour [27], and failure to maintain professional appearance and attire [25, 26, 28, 30, 37] and poor condition of white coats [29, 30] belong to this theme. Furthermore, discussing patients in public spaces [29] and therefore failing to respect patient confidentiality [25, 30, 35, 56, 63] or using Google to research patients [67] were described as unprofessional.
Fellow students can be treated disrespectfully through bullying by peers, which consist of verbal, written, physical or behavioural abuse and victimizing, which is the ignoring of someone’s existence [43, 62, 68, 69]. Students can also be affected by their peers‘ unprofessional behaviour by reporting a peer’s improper behaviour to faculty before approaching the person individually [29, 30].
Poor self-awareness
The last theme is poor self-awareness, which was defined as inappropriately handling one’s own performance. Poor self-awareness was described as avoiding feedback, inability to accept and incorporate feedback [30, 31, 38], and resistant or defensive behaviour towards criticism [25, 34, 37], lack of insight into behaviour [26, 28], blaming external factors rather than own [28] and failing to accept responsibility for actions [25, 28]. Furthermore, not being aware of limitations [32], acting beyond own level of competence [56, 57], or not respecting professional boundaries [26, 63] was categorised in this theme. These behaviours seem to indicate a diminished capacity for self-improvement [32, 34, 37, 70].