Skip to main content
Download PDF

What we think about professional and unprofessional behaviors: differences between the perception of clinical faculty members and medical students

BMC Medical Education volume 22, Article number: 866 (2022) Cite this article

Abstract

Introduction

Differences in the viewpoints of clinical faculty members and medical students about prioritizing professional norms accepted by the professional community and lack of alignment of these views can lead to distortion of understanding, problems in learning and assessment of professionalism, and failure in students’ professional identity formation. This study aimed to identify the differences in viewpoints of clinical faculty members and medical students about prioritizing the importance and prevalence of professional and unprofessional behaviors among undergraduate medical students.

Methods

A multi-stage qualitative study was conducted at Tehran University of Medical Sciences during 2020–2021. At first, a systematic search was conducted to identify professional and unprofessional behaviors using the directional content analysis method. A panel of experts was formed to check the codes obtained from reviewing the literature and to evaluate its compliance with the context. Then, the modified nominal group technique sessions were held with clinical faculty members and medical students to strengthen the codes extracted from the studies and systematically integrate their views to achieve a comprehensive list of professional and unprofessional behaviors in accordance with the context. Finally, a consensus was made among them about prioritizing the importance and prevalence of these behaviors in undergraduate medical students.

Results

A total of 490 codes of professional behaviors and 595 unprofessional behavior codes were identified in the literature review. In the following sessions of the modified nominal group, 13 clinical faculty members listed 105 codes of professional and unprofessional behaviors, and 51 medical students also listed 313 codes. The results of the modified nominal group technique showed that the faculty members reported the importance of unprofessional behaviors higher than professional ones. At the same time, students rated the importance of professional behaviors higher than unprofessional ones. Both faculty members and students rate the prevalence of professional behaviors as high and the prevalence of unprofessional behaviors as low.

Conclusion

The results showed a difference of views between clinical faculty members and medical students about prioritizing professional and unprofessional behaviors. It is essential to align their viewpoints to understand, learn and value professionalism to develop a professional identity.

Peer Review reports

Introduction

Professionalism is considered one of the core competencies of medical students in medical curricula [1,2,3]. The Royal College of Physicians of England defines professionalism as a set of values, behaviors, and relationships that will strengthen patients’ trust in doctors [4]. Although professionalism may seem abstract, focusing on specific professional behaviors can help make it more tangible and practical in practice. These professional behaviors have been discussed in some articles as key elements of professionalism [5,6,7]. Undoubtedly, the existence of these professional behaviors in clinical faculty members and medical students and strengthening them is essential for improving the outcomes of medical care and maintaining patient safety [8].

In addition to identifying professional behaviors, focusing on recognizing and modifying of unprofessional behaviors is also vitally important for medical education [8,9,10,11,12]. Reconsidering and reflecting on unprofessional behaviors can lead to positive experiences [13]. Studies emphasize that clinical faculty members should also be aware of the importance of identifying and evaluating unprofessional behaviors [14, 15]. They also have a central role in encouraging and strengthening professional behaviors in medical students. If clinical faculty members fail to do so and do not respond appropriately to such behaviors, this message is implicitly conveyed to students that they do not care much about professionalism and that reforming unprofessional behaviors is unnecessary or not worth trying to change [7, 8, 13].

First and foremost, determining the critical elements involved in the concept of professionalism for these undergraduate medical students is essential to develop professional behaviors or modify unprofessional ones. However, reviewing the evidence shows that despite the commonalities in these key elements in different cultures, there are disagreements in the definitions presented in different communities. Therefore, it is imperative that each country and any institution develop its own definition of the professionalism of medical students in accordance with the social norms of the time of their community. They should also identify key elements of professionalism or express other professional or unprofessional behaviors of their undergraduate medical students formed due to the interaction between the individual and the context [4, 16,17,18]. To that end, Tehran University of Medical Sciences (TUMS) has developed a guideline on medical professional behaviors [19]. Teaching and assessing students’ professional behaviors in the educational program are based on these guidelines. Since The Professional Conduct Guide determines the norms of professions [4, 11], it is considered the basis for teaching and assessing subjects related to professionalism.

There are some factors such as population, ethnicity [11, 20], gender [21], various learning environments [12] and, generation differences [22] in the formation of a different understanding of professional and unprofessional behaviors. Most of these studies acknowledge the importance of developing a common language to describe professional behaviors in different generations by considering the context [22, 23]. This leads clinical faculty members and medical students to understand or share views about the professional norms adopted by their community [12]. Despite the importance of this issue, reviewing evidence continues to report a high prevalence of unprofessional behaviors in educational systems [11, 20, 24, 25]. Therefore, creating a shared view between clinical faculty members and medical students alone cannot be achieved by formulating a guideline for professional behaviors and determining unprofessional behaviors and evaluating them; it will require more detailed and coherent planning in this area. In this regard, it is necessary to consider systematic approaches to ensure the understanding and valuation of professionalism in medical education [4]. To the best of our knowledge, studies have not yet examined the differences between clinical faculty members’ and students’ views about prioritizing the importance of professional and unprofessional behaviors and their prevalence among undergraduate medical students using multi-stage qualitative methods. Therefore, our study aims to fill this gap.

Method

Our qualitative study was conducted in a multi-stage design during 2020–2021. Usually, qualitative research is the best way to explore insight and perception [26]. In the first phase, a systematic search was conducted. Then, the consensus method was used to combine the viewpoints of clinical faculty members and students. One of the best consensus methods while reviewing studies for a structured scientific process is the Modified Nominal Group Technique (MNGT) [27]. In this study, this method was used to strengthen the extracted codes of studies and to systematically integrate the views of all participants to achieve a comprehensive list of professional and unprofessional codes of conduct in accordance with the context [10, 27]. Finally, with consensus between medical students and clinical faculty members, differences of views were determined regarding the importance of professional and unprofessional behaviors and their prevalence among undergraduate medical students.

Stage 1: literature review

Initially, a systematic search was conducted to identify evidence related to medical students’ professional and unprofessional behaviors in pubMed, Eric, ProQuest and Scopus electronic databases. The articles were examined within a limited time frame from 2001 to 2020. The rationale for searching the literature within this time span was that almost all articles had been published between 2001 and 2020. From 2010 to 2020, research activity on professional and unprofessional behaviors increased in terms of volume, with 44 papers being published in 10 years, more than half of the total. Only articles in English were included in the study. Keywords included in the search strategy were (“Professional Behavior”, “Professional Behaviour”, “Professional norm”, “Professional ethic”, “Unprofessional Behavior”, “Unprofessional Behaviour”, “Unprofessional norm”, “Unprofessional ethic”, Medic*, Student, learner, Physician and Doctor).

The second phase of searching used ancestry searching (in the list of references to included studies) and forward tracing (in the citations of included studies) in Google scholar. Reference lists were also used manually. The search investigated various quantitative, qualitative, mixed-method, and review articles.

Stage 2: expert panel

The list was then reviewed for two hours by the panel of experts considering two aspects: (1) Checking the accuracy of the codes categorized in the considered domains, and (2) Their conformity with the context and target groups of undergraduate medical students at TUMS (eliminated if not applicable). The expert panel, including 14 members, was drawn from faculty members in TUMS from different clinical specialties, including surgery, pediatrics, psychiatry, internal medicine, and obstetrics & gynecology. They were familiar with the issues of professionalism.

Stage 3: modified nominal group technique

The stages of the MNGT sessions were conducted for clinical faculty members and medical students according to Fig. 1 [27, 28].

Fig. 1
figure 1

Modify Nominal Group Technique

Full size image

Selecting faculty members to participate in the MNGT meeting was done based on purposive sampling, considering the criteria of their teaching in the undergraduate medical curriculum for at least five years and their familiarity with professionalism topics. The two-hour MNGT session was held in the presence of 13 faculty members from 9 specialized clinical disciplines. Also, five sessions of MNGT were held with medical students of clinical levels (clerkship and internship) with a total of 51 people. Purposive sampling was used to select medical students who have passed at least two semesters of their clinical phase and have passed the professionalism course. The participants’ specifications in the MNGT meetings are presented in Table 1.

Table 1 Demographic information of clinical faculty members and students are presented in the MNGT meetings
Full size table

The participants’ consensus was collected by an Internet form designed in Google Form based on a five-degree Likert scale in which score 1 means low and score 5 means high importance. The item mean and standard deviation for each ratings item were also calculated. Our selection criteria had the highest mean score in each domain, indicating a difference of view between clinical faculty members and medical students about prioritizing the importance and prevalence of professional and unprofessional behaviors.

Results

Literature review

The details of the systematic search are shown in Fig. 2.

Fig. 2
figure 2

systematic search results (Jan. 2001 – Apr. 2020)

Full size image

Extracted articles include

  1. 1.

    Quantitative, qualitative, or mixed-method articles that identify or evaluate the components of professional and unprofessional behaviors in medical students from the viewpoints of faculty members, patients, and other specialists.

  2. 2.

    Quantitative, qualitative, or mixed-method articles that identify or evaluate the components of professional and unprofessional behaviors of clinical faculty members, residents, or other medical students from medical students’ perspective.

  3. 3.

    Review articles and other studies that extensively consider students of different levels of medicine or medical sciences, physicians, and faculty members and identify or evaluate the components of professional and unprofessional behaviors.

Kappa coefficient (K score) was calculated as a measure of agreement. ZST and MKM are two authors that studied all topics and abstracts of the retrieved articles and extracted the related ones. The studies were reviewed by ZST and MKM and the agreement was 97% (1355/1395) with a kappa of 0.95 (CI = 0.847-1.0).

Frequency and content analyses

The analysis of the whole studies was performed by the directed content analysis method. The articles obtained during the analysis were read typicaly two times and in some cases three times. The codes were identified by considering the framework used in Saeedi Tehrani et al. in 2017 because the suggested framework was considered by the researchers to be comprehensive and compatible with the situation [19]. The codes were categorized into six domains: Honor and Integrity, Altruism, Excellence, Justice, Respect, and Responsibility. Code analysis was carried out by two researchers (ZST and MKM). Any difference or disagreement between them regarding the importance of prioritization and the prevalence of professional and unprofessional behaviors was discussed in two 2-hour sessions where the cases were reviewed and a consensus was reached. Then, the frequency analysis of each code of professional and unprofessional behaviors was determined, and a total of 490 codes (with repetition) of professional behaviors and 595 codes (with repetition) of unprofessional behaviors were identified (Table 2 and Fig. 3).

Table 2 Prioritizing the importance of professional and unprofessional behaviors for undergraduate medical students from the viewpoints of clinical faculty members and medical students and literature review
Full size table
Fig. 3
figure 3

Results extraction Modified Nominal Group Technique

Full size image

Expert panel

In the expert panel, each code was reviewed and categorized in terms of conformity with the context, and the framework was modified during the expert panel. In this category, six codes were deleted, four binary codes were merged, four codes were corrected or clarified, and twenty-one were moved between domains (Fig. 3).

Modified nominal group technique (MNGT)

Explaining participants’ perceptions and insights about professional and unprofessional behaviors in accordance with the context

At the beginning of the MNGT session, the participants were asked to produce 5–7 common professional and unprofessional behaviors in TUMS undergraduate medical students to evaluate their understanding and insights about professional and unprofessional behaviors based on the context and in response to an open question. On the whole, clinical faculty members produced 105 professional and unprofessional behavior codes (with repetitions), of which 49 codes (46.7%) were for professional behaviors, and 56 codes (53.3%) were for unprofessional behaviors among undergraduate medical students (Tables 3, 4 and 5). In the list developed by students, 313 codes of professional and unprofessional behaviors (with repetition) were produced in total, of which 135 codes (43.13%) were related to professional behaviors and 178 (56.87%) were those related to common unprofessional behaviors among undergraduate medical students (Tables 3, 4 and 5). The Generated codes by medical students and clinical faculty members were limited and referred to some of the output codes from the panel of experts (Tables 3, 4 and 5). Most of the generated codes by medical students and clinical faculty members in both professional and unprofessional behaviors were related to respect and the fewest number were related to justice (Table 3). Most of the codes extracted from studies were related to respect and excellence, and the fewest pertained to justice (Table 2). Then, after presenting the output codes from the panel of experts to the participants and after discussion, clarification and elimination of repetitive codes, only one code of unprofessional behaviors was removed by the clinical faculty members and four codes of professional behaviors were completed by the students.

Table 3 Prioritizing the prevalence of professional and unprofessional behaviors in undergraduate medical students from the viewpoints of clinical faculty members and medical students
Full size table
Table 4 Production and prioritization of professional codes of conduct in terms of their importance and prevalence
Full size table
Table 5 Production and prioritization of unprofessional codes of conduct in terms of their importance and prevalence
Full size table

Prioritizing views between the two groups of participants

Finally, with the consensus of participants, the differences of viewpoints were identified between clinical faculty members and medical students about prioritizing the importance and prevalence of professional and unprofessional behaviors among undergraduate medical students of TUMS. Also, the difference between frequency analysis of articles and behaviors developed by the clinical faculty members and the medical students regarding professional and unprofessional behaviors among undergraduate medical students was determined. The results can be seen in Tables 2, 3, 4 and 5.

Importance

From the professional behavior codes extracted from the studies, the code with the most repetition belonged to the domain of Excellence and then the domain of Respect. Regarding unprofessional behavior, the codes with the most repetition belonged to the domain of Honor and Integrity and then the domain of Respect (Please see Table 2). It is also noteworthy that the number of professional and unprofessional behavior codes generated by both groups of faculty members and students at the beginning of MNGT belonged to the domain of Respect (Please see Table 3). Moreover, in prioritizing the importance of professional and unprofessional behavior, from the point of view of clinical faculty members, the domain of Respect was given the highest priority (Please see Table 2). Furthermore, in prioritizing the importance of professional behavior, from the students’ point of view, the domain of ​​Altruism and unprofessional behavior and the domain of ​​Responsibility/conscientiousness were given the highest priority (Please see Table 2). The most essential codes prioritized by clinical faculty members are related to unprofessional behaviors, and the less important prioritized codes are related to professional behaviors. Consequently, clinical faculty members understand the importance of unprofessional behaviors more than professional ones (Tables 4 and 5). Also, the most important codes prioritized by medical students are related to professional behaviors and the prioritized codes with low importance are related to unprofessional behaviors. Therefore, unlike the clinical faculty members, students consider the importance of professional behaviors more than unprofessional ones (Tables 2 and 3). Studies show that out of 1085 of the identified and extracted codes (total number of professional and unprofessional behaviors codes with repetitions), 595 (54.84%) codes of behaviors are related to unprofessional ones (Table 2).

Prevalence

Regarding the prioritizing of the prevalence of professional behaviors by both clinical faculty members and medical students, the domain of Justice was given the highest priority. In prioritizing the prevalence of unprofessional behaviors, from the point of view of clinical faculty members, the domain of Excellence had the highest prevalence, and according to medical students, the domain of Altruism had the highest prevalence (Please see Table 3). Furthermore, in prioritizing the prevalence of unprofessional behaviors in each group of clinical faculty members and medical students, the domain of Justice had the lowest prevalence (Please see Table 3). The codes prioritized with high prevalence by clinical faculty members and medical students are related to professional behaviors and those prioritized by them with low prevalence are related to unprofessional behaviors. As a result, both clinical faculty members and medical students rate the prevalence of professional behaviors in undergraduate medical students as high and the prevalence of unprofessional behaviors as low. However, differences of views about prioritizing the prevalence of professional and unprofessional behaviors are visible in most codes (Tables 3 and 5).

Discussion

Identifying professional and unprofessional behaviors in clinical faculty members and medical students and strengthening them is essential for improving the outcomes of medical care [8]. Our study proposes a process to assess the differences between clinical faculty members’ and students’ views on prioritizing the importance and prevalence of professional and unprofessional behaviors by creating consensus. The aim is to bring these views closer to each other to promote and strengthen professional behaviors.

Previous studies have primarily focused on identifying and describing professional and unprofessional behaviors [8, 18] or evaluating physicians, medical students, and clinical faculty members’ perceptions of professional and unprofessional behaviors in the form of quantitative studies and qualitative interviews [2, 12, 15, 19, 29]. Some of these studies examine factors affecting professional and unprofessional behaviors such as population, ethnicity [11, 20], gender [21], different learning environments [12] and generational differences in professional perception [22]. There are also articles on evaluation strategies and methods for diagnosing and correcting unprofessional behaviors in students [9, 13, 30, 31]. Other examples of these strategies include detecting abusive behaviors [32] or addressing student characteristics associated with an increased risk of professional misconduct [33, 34]. Several other studies have also been conducted to help faculty members identify unprofessional behaviors in undergraduate medical students. By presenting a model, these studies facilitated the identification of students who performed poorly in professional skills [10, 35]. However, according to our studies, no existing research has investigated the differences of views about prioritizing the importance and prevalence of professional and unprofessional behaviors and identifying different priorities of such behaviors between clinical faculty members and medical students by creating consensus. In this study, the overall view of the results obtained in the prioritization of the importance of professional and unprofessional behaviors indicates that clinical faculty members have reported the importance of unprofessional behaviors above professional ones. On the contrary, students have reported the importance of professional behaviors higher than unprofessional ones. In prioritizing the prevalence of professional and unprofessional behaviors, faculty members and medical students reported the prevalence of professional behaviors higher than the prevalence of unprofessional ones; however, in prioritizing the prevalence of codes, some differences of view were visible among them. Reporting a higher prevalence of professional behaviors than unprofessional ones by clinical faculty members can have several reasons. For instance, although clinical faculty members observe unprofessional behaviors in 20% of all medical students, they only report 3–5% [8, 36,37,38]. Another reason is the greater tendency of clinical faculty members to report positive findings because focusing on positive behaviors may be more effective in learning [39, 40]. Finally, other possible reasons include a lack of transparent criteria for unprofessional behaviors (lack of professionalism) in medical school, concerns about the subjectiveness of one’s judgment, and concerns about damage to student credibility [8, 41]. However, it seems that focusing on unprofessional and professional behaviors is part of learning. Clinical faculty members should be prepared to identify these behaviors more accurately and provide feedback to the students [8]. Their lack of response to medical students’ unprofessional behaviors means that being unprofessional is acceptable and that responding to it is unnecessary [7, 8, 13].

Altruism domain

A closer look at prioritizing codes of conduct by clinical faculty members and medical students shows that students have assigned the highest importance to the altruism domain in prioritizing professional codes of conduct and the highest prevalence in prioritizing unprofessional behaviors codes. One of the most important codes indicating the difference of views between clinical faculty members and medical students was “paying attention to the necessary safety measures for oneself and others”. This code was the most important code of professional and unprofessional behaviors prioritized by medical students and the least important code of such behaviors prioritized by clinical faculty members from all domains. The results can be interpreted in this way: clinical faculty members are usually less concerned about this issue due to multiple and frequent encounters with clinical situations associated with lack of equipment and facilities and because of formation of their professional identity in providing services to patients. However, students show more concern in this respect due to the training received during their studies and little experience. Also, medical students assigned the highest rank to this code in prioritizing the prevalence of unprofessional behaviors. This finding did not align with the results of the 2020 McGurgan et al. study in which medical students were asked about the acceptability of a range of professional behaviors in challenging situations, whether they faced similar situations, and what measures they would take in those situations. Of 1413 students who were involved with real-life infectious diseases, 98.5% agreed with not attending clinical settings in these conditions. Also, out of 1473 people who encountered lack of personal equipment, 97.9% stated that they agreed with refraining from continuing to work under these conditions [11], indicating a low prevalence of this unprofessional behavior among students.

Honor and integrity domain

Most of the codes identified in the literature review phase of our study discuss unprofessional behaviors related to the domain of honor and integrity. In similar cases, Ainsworth’s article in 2018 showed that the most reported unprofessional behaviors pertained to the domain of integrity [42]. Also, the code “observing honesty and trustworthiness in actions, speech and writing” related to the domain of honor and integrity was one of the highest prioritized codes with high prevalence according to clinical faculty members. Despite clinical faculty members’ lower priority reports of unprofessional behaviors among undergraduate medical students in this domain in general, in some codes of professional and unprofessional behaviors here, clinical faculty members reported a higher prevalence of unprofessional behaviors. For example, one can refer to the following code: “Not asking for help from clinical faculty members, peers and healthcare team when one is unable to take care of the patient or lacks the required skills and informing the patient about such matters.“ Students considered unprofessional behaviors such as “alcohol, drugs and psychoactive consumption in clinical settings” to be more prevalent as compared with clinical faculty members’ views on the same topic. Perhaps the reason for that is the student’s knowledge of and relationship with each other, both in and outside the clinical setting. In a similar study conducted by Brockbank et al. in 2011, people, medical students, and physicians rated the unprofessional behavior “criminal activity and drug abuse” more seriously than other unprofessional behaviors [43]. In 2017, Cullen et al. expressed the greatest concern about unprofessional behaviors in the integrity domain. The study stated some of the related unprofessional behaviors, like “showing clear signs of substance abuse,“ are critical even if they happen once [32].

Respect domain

As for respect, the extracted codes of the literature review phase and the codes produced by clinical faculty members and medical students in the present study were higher than other domains. Several studies show that students were more willing to express experiences related to respect than other types of experiences [3, 13, 44] or ranked them among the highest. In this regard, the study by Byszewski et al. in 2012 showed that in the ranking of professional behaviors by students, the highest rank was related to the respect domain [45]. Also, most of the produced codes related to unprofessional behaviors by medical students were in the domain of respect. In this regard, Cuesta-Briand et al. also stated in their 2014 study that students are more inclined to describe examples of “unacceptable” or “unprofessional” behaviors observed in clinical settings [46] when they discuss the importance of respectful treatment of patients and colleagues. However, it is worth noting in our study that there was a distinct difference between clinical faculty members and medical students in prioritizing the importance and prevalence of behaviors in this domain, especially in the field of unprofessional behaviors.

One of the cases where clinical faculty members reported a higher prevalence of unprofessional behaviors than medical students in their prioritization is a “lack of respect for clinical faculty members and more experienced students.“ These can indicate higher expectations of clinical faculty members in observing professional behaviors in interaction with seniors and clinical faculty members. In addition, students’ attention and respect for the position of clinical faculty members can be one of the reasons emphasized in the culture of Eastern societies because of the valuable position of clinical faculty members in the process of further education by teachers and educators. Besides, the difference of perspective in defining instances of respect can be effective because of the generational difference between clinical faculty members and medical students.

Responsibility/conscientiousness domain

In the domain of responsibility/conscientiousness, the codes extracted from the literature review phase of the present study and the codes produced by clinical faculty members and medical students were more moderate as compared to other domains. In contrast to our research, Cullen et al. in 2017 considered the field of conscientiousness as creating the least concern in unprofessional behaviors [32]. In ranking the importance and prevalence of professional and unprofessional behaviors, the proximity of medical students’ and clinical faculty members’ views in this domain was more than other areas. In this regard, Mak-Van Der Vossen et al. believe that the views of faculty members and medical students regarding their duties and responsibilities can be improved by strengthening the teamwork among them [18]. Regarding the code “Not asking for help in providing services to patients in case of illness or personal problems, etc. and not informing the person in charge, “we can point to the significant difference of opinion in the discussion of prioritizing the importance of professional behaviors. Clinical faculty members have considered less important than medical students while students have prioritized the prevalence of this unprofessional behavior over clinical faculty members. One of the reasons for the report of the prevalence of unprofessional behaviors in the domain of responsibility and conscientiousness from the point of view of medical students can be this: Because medical students at TUMS have perfectionist tendencies in accepting responsibilities and performing duties, they may have higher professional expectations in the domain of conscientiousness and professional responsibilities.

Justice domain

In the domain of justice, the codes extracted from the literature review phase of the present study and the codes produced by clinical faculty members and medical students were very few. This finding is similar to the results of a 2014 study by Al-Abdulrazzaq et al. In that study, out of the total professional behaviors listed by medical students, justice was one of the lowest domains listed [44]. One reason for this could be that the word justice has conceptual complexities and it is difficult for people to determine the codes associated with this domain. In prioritizing the importance and especially the prevalence of professional behaviors, the viewpoints of clinical faculty members and medical students from all other domains are very close together. According to medical students and clinical faculty members, the prevalence of justice, compared with other domains, is of high priority in professional behaviors and lower priority in unprofessional ones.

Excellence domain

In our study, in the domain of excellence, codes extracted from the literature review phase were numerous; however, the codes produced by clinical faculty members and medical students were very few. From the viewpoint of medical students and clinical faculty members, the importance of excellence in prioritizing professional and unprofessional behaviors was low. Its prevalence in prioritizing professional and unprofessional behaviors was low and high, respectively. In 2017, Cullen et al. expressed less concern from the perspective of experts about unprofessional behaviors in this domain [32]. The low prevalence of codes in this domain in the discussion of professional behaviors and its high prevalence in unprofessional ones, as reported by medical students and clinical faculty members, can be due to the fact that the issues related to excellence have not been systematically addressed in the curriculum. In addition, the low prevalence of these professional behaviors in medical students can be the result of inadequate recognition of the instances related to professional excellence among clinical faculty members and medical students due to the newness of the subject and only addressing the issue in the medical education literature in recent years [18, 47].

Ideally, professional behaviors are developed in collaboration with clinical faculty members and medical students [8, 48]. In this regard, clinical faculty members should create a clear (implicit and explicit) concept for themselves and their students by carefully planning and empowering themselves regarding existing professional and unprofessional behaviors based on the context. By determining transparent, professional expectations, professional and unprofessional behaviors can be evaluated in medical students and clinical faculty members using standards that will ultimately lead to a fair assessment and effective formative learning experience [8, 18]. Also, by clarifying professional and unprofessional behaviors and discussing them with clinical faculty members and medical students, in addition to understanding these behaviors better, conflicts between them will be resolved and a common dialogue will be formed between them [18, 49]. Therefore, in addition to adequately understanding professional and unprofessional behaviors in accordance with the field, medical students will learn how to strengthen professional behaviors and avoid being unprofessional.

Some limitations of this study that should be considered are the small sample size. A limitation of the method we used is that the participants who attended in one MNGT for clinical faculty members and five MNGT for medical students did not interact with each other. Thus, they were not able to comment on ideas from other groups. We addressed this limitation by performing a member checking of the combined results of all MNGTs. Further research is needed to identify differences of views about prioritizing the importance and prevalence of professional and unprofessional behaviors among managers and graduates. Also, it is essential to effectively plan for aligning the views for learning and valuing the principles of professionalism and the correct formation of professional identity in undergraduate medical students.

Conclusion

Our study showed that clinical faculty members reported the importance of unprofessional behaviors as higher than professional ones, while medical students, on the contrary, considered the importance of professional behaviors as higher than unprofessional ones. In prioritizing the prevalence of professional and unprofessional behaviors in undergraduate medical students, clinical faculty members and medical students reported the prevalence of professional behaviors higher than the prevalence of unprofessional ones. However, differences of views about prioritizing the prevalence of professional and unprofessional behaviors were visible in most codes. Also, the most important code of professional and unprofessional behaviors, as prioritized by medical students, turned out to be the least important code ranked by clinical faculty members. Therefore, identifying these differences of views about ranking the importance and prevalence of professional and unprofessional behaviors and aligning them among clinical faculty members and medical students leads to understanding, learning and valuation of professionalism principles and ultimately leads to the correct formation of professional identity in undergraduate medical students.

Availability of data materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon request.

References

  1. Ong YT, Kow CS, Teo YH, Tan LHE, Abdurrahman ABHM, Quek NWS, et al. Nurturing professionalism in medical schools. A systematic scoping review of training curricula between 1990–2019. Med Teach. 2020;42(6):p.636–49.

    Article  Google Scholar 

  2. Jalil A, Mahmood QK, Fischer F. Young medical doctors’ perspectives on professionalism: a qualitative study conducted in public hospitals in Pakistan. BMC Health Serv Res. 2020;20(1):p.1–10.

    Article  Google Scholar 

  3. Sullivan ME, Trial J, Baker C, Inaba K, Etcheverry J, Nally M, et al. A framework for professionalism in surgery: what is important to medical students? Am J Surg. 2014;207(2):p.255–59.

    Article  Google Scholar 

  4. O’Sullivan H, Van Mook W, Fewtrell R, Wass V. Integrating professionalism into the curriculum: AMEE Guide No. 61. Med Teach. 2012;34(2):p.64–77.

    Article  Google Scholar 

  5. Hall DR. ‘Colleague bashing’is unprofessional behaviour: opinion. South Afr J Obstet Gynecol. 2013;19(2):p.28–9.

    Google Scholar 

  6. Project MP. Medical professionalism in the new millennium: a physicians’ charter. The Lancet. 2002;359(9305):520–22.

    Article  Google Scholar 

  7. van Mook WN, van Luijk SJ, O’Sullivan H, Wass V, Zwaveling JH, Schuwirth LW, et al. The concepts of professionalism and professional behaviour: Conflicts in both definition and learning outcomes. Eur J Intern Med. 2009;20(4):p.85-.

    Article  Google Scholar 

  8. Mak-van der Vossen M, Teherani A, van Mook W, Croiset G, Kusurkar RA. How to identify, address and report students’ unprofessional behaviour in medical school. Med Teach. 2020;42(4):372–9.

    Article  Google Scholar 

  9. Barnhoorn PC, Houtlosser M, Ottenhoff-de Jonge MW, Essers GT, Numans ME, Kramer AW. A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity. Med Teach. 2019;41(3):303–8.

    Article  Google Scholar 

  10. Mak-van der Vossen MC, de la Croix A, Teherani A, van Mook WN, Croiset G, Kusurkar RA. Developing a two-dimensional model of unprofessional behaviour profiles in medical students. Adv Health Sci Educ. 2019;24(2):p.215–32.

    Article  Google Scholar 

  11. McGurgan P, Calvert K, Narula K, Celenza A, Nathan E, Jorm C. Medical students’ opinions on professional behaviours: the Professionalism of Medical Students’(PoMS) study. Med Teach. 2020;42(3):p.340–50.

    Article  Google Scholar 

  12. Roberts NK, Dorsey JK, Wold B. Unprofessional behavior by specialty: A qualitative analysis of six years of student perceptions of medical school faculty. Med Teach. 2014;36(7):p.621–25.

    Article  Google Scholar 

  13. Hoffman LA. An exploration of reflective writing and self-assessments to explain professionalism lapses among medical students. 2014.

    Google Scholar 

  14. Murden RA, Way DP, Hudson A, Westman JA. Professionalism deficiencies in a first-quarter doctor–patient relationship course predict poor clinical performance in medical school. Acad Med. 2004;79(10):p.46–8.

    Article  Google Scholar 

  15. Sattar K, Roff S, Meo SA. Your professionalism is not my professionalism: congruence and variance in the views of medical students and faculty about professionalism. BMC Med Educ. 2016;16(1):p.1–7.

    Article  Google Scholar 

  16. Modi JN, Gupta P, Singh T. Teaching and assessing professionalism in the Indian context. Indian Pediatr. 2014;51(11):p.881–8.

    Article  Google Scholar 

  17. Morrow G, Burford B, Rothwell C, Carter M, McLachlan J, Illing J. Professionalism in healthcare professionals. Report to the health: HCPC; 2011.

    Google Scholar 

  18. Mak-Van Der Vossen M, Van Mook W, Van Der Burgt S, Kors J, Ket JC, Croiset G, et al. Descriptors for unprofessional behaviours of medical students: a systematic review and categorisation. BMC Med Educ. 2017;17(1):p.1–12.

    Article  Google Scholar 

  19. Tehrani SS, Nayeri F, Parsapoor A, Jafarian A, Labaf A, Mirzazadeh A, et al. Development of the first guideline for professional conduct in medical practice in Iran. Arch Iran Med. 2017;20(1):12–5.

    Google Scholar 

  20. Abu OR, Abu SO, Flaherty G. Clinical medical students’ experiences of unprofessional behaviour and how these should inform approaches to teaching of professionalism. MedEdPublish. 2016;5:40.

    Article  Google Scholar 

  21. Spiwak R, Mullins M, Isaak C, Barakat S, Chateau D, Sareen J. Assessing perceptions of professionalism in medical learners by the level of training and sex. Educ Health. 2020;33(1):13–9.

    Google Scholar 

  22. Strowd RE, Saylor D, Salas RME, Thorpe R, Cruz TE, Gamaldo CE. Speaking the same language: cross-sectional assessment of perceived contributors to professionalism across generations. Neurology: Clin Pract. 2016;6(3):p.230–40.

    Google Scholar 

  23. Mavis B, Sousa A, Lipscomb W, Rappley MD. Learning about medical student mistreatment from responses to the medical school graduation questionnaire. Acad Med. 2014;89(5):p.705–11.

    Article  Google Scholar 

  24. Fargen KM, Drolet BC, Philibert I. Unprofessional behaviors among tomorrow’s physicians: Review of the literature with a focus on risk factors, temporal trends, and future directions. Acad Med. 2016;91(6):p.858–64.

    Article  Google Scholar 

  25. Franco RS, Franco CAG, Kusma SZ, Severo M, Ferreira MA. To participate or not participate in unprofessional behavior–Is that the question? Med Teach. 2017;39(2):p.212–19.

    Article  Google Scholar 

  26. Yazdani S, Farajpour A, Shakerian S. Practice-based learning and improvement (PBLI) from the perspective of Iranian medical education experts: a thematic content analysis. Iran Red Crescent Med J. 2017;19(7).

  27. Humphrey-Murto S, Varpio L, Gonsalves C, Wood TJ. Using consensus group methods such as Delphi and Nominal Group in medical education research. Med Teach. 2017;39(1):9–14.

    Article  Google Scholar 

  28. Harvey N, Holmes CA. Nominal group technique: an effective method for obtaining group consensus. Int J Nurs Pract. 2012;18(2):p.188–94.

    Article  Google Scholar 

  29. Jamalabadi Z, Ebrahimi S. Medical students’ experiences and perspective on unprofessional behavior in clinical practice. J Adv Med Educ Professionalism. 2018;6(1):p.31.

    Google Scholar 

  30. Lack L, Yielder J, Goodyear-Smith F. Evaluation of a compulsory reflective group for medical students. J Prim Health Care. 2019;11(3):p.227–234.

    Article  Google Scholar 

  31. Shiozawa T, Glauben M, Banzhaf M, Griewatz J, Hirt B, Zipfel S, et al. An insight into professional identity formation: qualitative analyses of two reflection interventions during the dissection course. Anat Sci Educ. 2020;13(3):320–32.

    Article  Google Scholar 

  32. Cullen MJ, Konia MR, Borman-Shoap EC, Braman JP, Tiryaki E, Marcus-Blank B, et al. Not all unprofessional behaviors are equal: The creation of a checklist of bad behaviors. Med Teach. 2017;39(1):85–91.

    Article  Google Scholar 

  33. Yates J. “Concerns” about medical students’ adverse behaviour and attitude: an audit of practice at Nottingham, with mapping to GMC guidance. BMC Med Educ. 2014;14(1):p.1–9.

    Article  Google Scholar 

  34. Yates J, James D. Risk factors at medical school for subsequent professional misconduct: multicentre retrospective case-control study. Bmj. 2010;340:c2040.

    Article  Google Scholar 

  35. Mak-van der Vossen MC, van Mook WN, Kors JM, van Wieringen WN, Peerdeman SM, Croiset G, et al. Distinguishing three unprofessional behavior profiles of medical students using latent class analysis. Acad Med. 2016;91(9):1276–83.

    Article  Google Scholar 

  36. Mak–van der Vossen M, Peerdeman S, van Mook W, Croiset G, Kusurkar R. Assessing professional behaviour: overcoming teachers’ reluctance to fail students. BMC Res Notes. 2014;7(1):1–4.

    Article  Google Scholar 

  37. Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005;353(25):p.2673–82.

    Article  Google Scholar 

  38. van Mook WN, Van Luijk SJ, Fey-Schoenmakers MJ, Tans G, Rethans J-JE, Schuwirth LW, et al. Combined formative and summative professional behaviour assessment approach in the bachelor phase of medical school: a Dutch perspective. Med Teach. 2010;32(12):p.517–31.

    Article  Google Scholar 

  39. Cendán JC, Castiglioni A, Johnson TR, Eakins M, Verduin ML, Asmar A, et al. Quantitative and qualitative analysis of the impact of adoption of a mobile application for the assessment of professionalism in medical trainees. Acad Med. 2017;92(11S):p.33–42.

    Article  Google Scholar 

  40. Macneill P, Joseph R, Lysaght T, Samarasekera DD, Hooi SC. A professionalism program in medical education and training–From broad values to specific applications: YLL School of Medicine. Singap Med teacher. 2020;42(5):p.561–71.

    Article  Google Scholar 

  41. Ziring D, Frankel RM, Danoff D, Isaacson JH, Lochnan H. Silent witnesses: faculty reluctance to report medical students’ professionalism lapses. Acad Med. 2018;93(11):1700–6.

    Article  Google Scholar 

  42. Ainsworth MA, Szauter KM. Student response to reports of unprofessional behavior: assessing risk of subsequent professional problems in medical school. Med Educ Online. 2018;23(1):1485432.

    Article  Google Scholar 

  43. Brockbank S, David TJ, Patel L. Unprofessional behaviour in medical students: A questionnaire-based pilot study comparing perceptions of the public with medical students and doctors. Med Teach. 2011;33(9):501–8.

    Article  Google Scholar 

  44. Al-Abdulrazzaq D, Al-Fadhli A, Arshad A. Advanced medical students’ experiences and views on professionalism at Kuwait University. BMC Med Educ. 2014;14(1):p.1–7.

    Article  Google Scholar 

  45. Byszewski A, Hendelman W, McGuinty C, Moineau G. Wanted: role models-medical students’ perceptions of professionalism. BMC Med Educ. 2012;12(1):p.1–9.

    Article  Google Scholar 

  46. Cuesta-Briand B, Auret K, Johnson P, Playford D. A world of difference’: a qualitative study of medical students’ views on professionalism and the ‘good doctor. BMC Med Educ. 2014;14(1):p.1–9.

    Article  Google Scholar 

  47. Whitehead C, Selleger V, van de Kreeke J, Hodges B. The ‘missing person’in roles-based competency models: a historical, cross‐national, contrastive case study. Med Educ. 2014;48(8):p.785–95.

    Article  Google Scholar 

  48. O’Brien BC, Bachhuber MR, Teherani A, Iker TM, Batt J, O’Sullivan PS. Systems-oriented workplace learning experiences for early learners: Three models. Acad Med. 2017;92(5):p.684–93.

    Article  Google Scholar 

  49. Byszewski A, Gill JS, Lochnan H. Socialization to professionalism in medical schools: a Canadian experience. BMC Med Educ. 2015;15(1):p.1–9.

    Article  Google Scholar 

Download references

Acknowledgements

Special thanks to all the clinical faculty members and medical students for generously contributing their time and expertise.

Funding

This study was part of a Ph.D. thesis done and supported by Tehran University of Medical Sciences.

Author information

Authors and Affiliations

  1. Department of Medical Education, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

    Zahra Sadat Tabatabaei

  2. Education Development Office, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

    Zahra Sadat Tabatabaei

  3. Department of Internal Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

    Azim Mirzazadeh

  4. Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran

    Homayoun Amini

  5. Health Professions Education Research Center, Education Development Center, Department of Medical Education, Tehran University of Medical Sciences, Tehran, Iran

    Mahboobeh Khabaz Mafinejad

Authors
  1. Zahra Sadat Tabatabaei
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Azim Mirzazadeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Homayoun Amini
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mahboobeh Khabaz Mafinejad
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

ZST and MKM were involved in the conceptualization, design, and implementation of the study. ZST and MKM made substantial contributions to the analysis and interpretation of data. ZST and MKM have drafted and revised the manuscript. HA and AM have revised the manuscript. All authors reviewed the entire manuscript for editing, feedback, and approval.

Corresponding author

Correspondence to Mahboobeh Khabaz Mafinejad.

Ethics declarations

Ethics approval and consent to participate

Our study was confirmed by the Institutional Review Board and the TUMS Ethics Committee (Code of Ethics IR. TUMS. MEDICINE. REC.1398.960). The objectives and methods of study and confidentiality of information were explained orally to the participants. Participation in the study was entirely voluntary and participants could withdraw from the study if they wished. Informed consent of the participants (clinical faculty members and medical students) was obtained. We explicitly confirm that our research methods were carried out in accordance with the relevant guidelines and regulations of the Ethics Committee of Educational Research at TUMS. Furthermore, the experimental protocol was assessed and approved by the department of medical education at TUMS.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tabatabaei, Z.S., Mirzazadeh, A., Amini, H. et al. What we think about professional and unprofessional behaviors: differences between the perception of clinical faculty members and medical students. BMC Med Educ 22, 866 (2022). https://doi.org/10.1186/s12909-022-03874-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12909-022-03874-x

Keywords

BMC Medical Education

ISSN: 1472-6920

Contact us