The trouble with assessing students' professionalism: theoretical insights from sociocognitive psychology.

The academic literature on professionalism assessment in medical education is burgeoning, and its focus has primarily been on the assessment of professional behaviors. Consequently, the attitudinal elements of professionalism have largely been ignored in the literature. As a result, educators chiefly rely on professional behavior alone as the primary measure for professionalism without giving proper consideration to students' underlying attitudes. Using theoretical insights from sociocognitive psychology, this viewpoint article begins by discussing the relationship between attitudes and behaviors. It suggests that attitudes are poor predictors of behavior when external constraints, such as social pressure to behave in a particular way, are strong. It continues with a critical examination of the phenomenon of "faking it"--students faking professional behaviors to garner positive reactions from observers. This practice is contrasted with students who at times behave unprofessionally in response to social pressures or other contextual components, despite having professional attitudes. So, in using behavioral assessment alone, we may pass students with professional behaviors but unethical attitudes and fail students with unprofessional behaviors but ethical attitudes. Guided by a sociocognitive model of behavioral explanation, the article ends with some practical recommendations for coupling observation with conversation to assess students' professional behaviors and their attitudes more fairly.