Medical students' experiences and perspective on unprofessional behavior in clinical practice.

INTRODUCTION: Recognition of professional and unprofessional behaviors is the most important and fundamental factor which affects the relationships between the doctors and patients. Therefore, in order to progress in their professional life, doctors are supposed to understand and follow these behaviors.
METHODS: This is a cross-sectional, descriptive analytical study. All students in teaching hospital of Shiraz University of Medical Sciences were eligible to participate (374 individuals with census method). The data were collected using a questionnaire containing 29 questions about the concept of medical professionalism. Here, participation of medical students in unprofessional behaviors and the relevance of this participation with the perception of these behaviors were considered. Data were analyzed through SPSS version 15, using descriptive statistics, t-test and Pearson correlation test.
RESULTS: According to the obtained data, despite the fact that all students (140 students in the junior and 234 in the senior years as interns) had passed the course of professionalism (95.7%), the perception of unprofessional behaviors between the two groups was significantly different (p<0.001) and the mean of the perception among junior students was higher than the interns. No significant difference was observed in participation in unprofessional behavior rates of the two groups (p=0.451).Moreover, the data did not reveal a strong relationship between participation in unprofessional behavior and what is taught in the curriculum (p=0.079).
CONCLUSION: Medical students' perception of unprofessional behaviors as acceptable may increase their participation in these behaviors. Thus, medical policy makers should consider approaches beyond simply providing ethical and professional guidelines or policies, and students should be regularly evaluated for their activities; their professional behaviors should be evaluated in order to temper them, when appropriate.

Introduction

There is a great concern in the medical field toward reinforcing medical professionalism as it is subjected to various kinds of threats such as environmental forces of commercialism, particularly within the organization and practice of medical education (1).

Professionalism is defined as a set of structural (moral codes and rules) and attitudinal attributes believed to be appropriate to a particular professional practice (2,3). As it is stated in this definition, further describing the professionalism, as formulated attributes of attitudes and behaviors that individuals possess toward their profession, in turn, help programmanagers in medical schools, to develop and measure them in their students. On the other hand, students’ unprofessional behaviors have been associated with their perception about it. The measurable definition of professionalism plays an important role regarding the development of effective strategies against lapses in medical students' behaviors and implementing the principles and professional ethical values and humanity (2). Such strategies should provide measures to prevent unprofessional behavior and minimize the lapses, making it clear to medical students and staff that threats or unprofessional behaviors are not acceptable. Although there are several variables that have effects on the prevention of unprofessional behaviors, researches have given attention to the importance of the learning environment and its effects on medical students’ professional development (4). These researchers believe that several agendas are needed to be scheduled so to train the students on these skills and create new insights in this area (5-8).

A few studies indicated an increase in unprofessional behaviors during the internship. These interns did not have sufficient knowledge about the professional behaviors and believed that their behavior should not be considered as unprofessional. Therefore, the promotion of professional and non-professional training of students can increase their knowledge in this area and also change their attitude (9,10). Therefore, increasing cognitive behavioral training promotes the students’ awareness and this subsequently reduces medical errors and improves interpersonal relationships (11,12). Overall, there has been little research focusing on kinds of unprofessional behaviors among clinical medical students. The aim of the present study was to investigate participation in and perceptions of unprofessional behaviors and the relationship between these behaviors among clinical medical students at Shiraz University of Medical Sciences during the study period.

Methods

This is a cross-sectional, descriptive analytical study. All medical students in the clinical period (374 individuals) studying in teaching hospital of Shiraz University of Medical Sciences in 2016 academic year, including junior students and interns, were eligible to participate (census method). Obviously, the majority of the samples were interns who were more familiar with the practical setting than clinical junior students. It should be mentioned that the junior students were selected from the students who had passed the theoretical course on professional ethics.

The questionnaire was prepared in two parts. The first part consisted of the general information about personal characteristics including age, gender, year of entry, and four Yes/No questions regarding the previous information about professional ethics. At the end, there was an open question asking the participants to define professional ethics and its components. For each student, the summation of these questions represented their self-reported knowledge and perception about the professional ethics (higher scores indicated greater knowledge). In the second part of the questionnaire, item-wise perception of 29 unprofessional behaviors among the students and their participation in these behaviors was examined. This part of questionnaire contained questions about the participants' perceptions of common components of professionalism including altruism, accountability and responsibility, dignity and integrity, respect for others, and excellence.

The students’ opinions about the behavior as unprofessional were rated on a three-point scale (1=disagree, 2=agree and 3=strongly agree). Total student’s perception score was calculated by the sum of all the questions in this section. Finally, the survey asked the students about their experiences of unprofessional behaviors in clinical setting. Participants were asked to report any unprofessional behaviors that they participated in or observed.

In order to study the face and content validity of the questionnaire, we gave its preliminary drafts to four professors, four PhD students of medical ethics and 15 clinical students. Then, iterative revisions were made according to their constructive advice. Test-retest reliability and internal reliability of the final questionnaire were determined. To check the reliability of the questionnaire, first we selected 30 medical students to carry out preliminary tests. After two weeks, the questionnaires were again given to the same people for the second time. Overall internal reliability (Cronbach's alpha=0.79) and test-retest reliability (0.80) were still pretty acceptable, implying that the questionnaire was considered as sufficiently reliable.

When distributing the questionnaires, the importance of the study and ethical issues such as confidentiality of the data were described to each contributor. They were also given full autonomy to participate in the study or withdraw from it at any time. Data were analyzed through SPSS version 15, using descriptive statistics. To evaluate the relationship between the variables, t-test and Pearson correlation test were used. P≤0.05 was considered statistically significant.

Results

All 374 students (140 junior students and 234 interns) filled out the questionnaire. There were 176 (47.1%) female respondents and 198 (52.9%) males.

The results showed that almost half (49.5%) of the students were not familiar with the concept of professional ethics (Table 1). The other half (50.5%) had an acceptable understanding of the concept. It should be noted that most of the students had passed the course of Medical Ethics (95.7%); for almost all of them (98.7%), it had been the only ethics course they had passed. The majority of the participants (96.3%) had no self-directed studying in this field.

Table 1

The students’ previous knowledge about professional ethics

Questions	Junior students N (%)		Interns N (%)		Total N (%)
	Yes	No	Yes	No	Yes	No
Are you familiar with the meaning and application of professional ethics?	94 (67.1%)	46 (32.9%)	95 (40.6%)	139 (59.4%)	189 (50.5%)	185 (49.5%)
Have you passed a course in medical ethics before?	131 (93.6%)	9 (6.4%)	227 (97%)	7 (3%)	358 (95.7%)	16 (4.3%)
Have you passed another training course, other than medical ethics course, about professional ethics?	3 (2.15%)	137 (97.85%)	2 (1%)	232 (99%)	5 (1.3%)	369 (98.7%)
Do you have any self-directed study in the context of professionalism?	3 (2.15%)	137 (97.85%)	11 (5%)	223 (95%)	14 (3.7%)	360 (96.3%)
Average score of "self-reported knowledge"of professional ethics	5.65±0.574		5.43±0.554		5.51±0.576
Average score of perception about the importance of each behavior	69.57±13.864		72.07±11.606		71.13±12.451

As shown in Table 1, even though more interns have passed the academic ethics course, comparing the results demonstrates a higher mean score of "self-reported knowledge"of professional ethics among juniors. The result of the t-test performed showed a significant difference between the two groups (p<0.001).

It was indicated that there was no significant difference in the mean scores of perception about the importance of each behavior between the two groups of (p=0.062).

In another part of the questionnaire, participation of the students in unprofessional behavior was evaluated (Table 2).

Table 2

Students' Participation in Unprofessional Behaviors

Behaviors	Junior students (n=140)			Interns (n=234)			Total (n=374)
	P*	O£	P&O¥	P*	O£	P&O¥	P*	O£	P&O¥
Lack of maintaining medical dignity in their relationship, talking, dressing	10	77	23	17	151	26	27	228	49
Lack of respect for people's religious and cultural differences	11	62	15	13	123	21	24	185	36
Lack of self-assessment and refusal to accept and apply constructive critiques	21	46	18	28	90	24	49	136	42
Lack of commitment to continuous learning	20	55	28	41	94	37	61	149	65
Lack of equity and fairness in serving patients	19	61	26	32	108	24	51	169	50
Lack of acceptance of probable health risks him/herself in front of the patient's	19	41	27	42	97	32	61	138	59
Failure to comply with hospital regulations and policy	21	45	39	53	71	47	74	116	86
The lack of bearing difficulty and discomfort in responding to the medical needs of the patients	26	49	31	48	77	32	74	126	63
Disregard educational activities(e.g., arriving late to rounds for nonclinical reasons, skipping a lecture or seminars in which attendance is required	25	47	34	43	88	36	68	135	70
Denial of any errors, mistakes and wrongdoing	20	53	27	47	82	27	67	135	64
Medical negligence in duties in the hospital setting	35	49	27	56	97	26	91	146	53
Dishonest behavior in the workplace	29	47	28	37	108	30	66	155	58
Lack of observance of discipline in medical work	34	44	30	46	101	36	80	145	66
Lack of commitment to be available and responsive when "on call"	38	45	16	29	115	28	67	160	44
Prefer their interests to the interests of the patient	28	43	22	43	90	31	71	133	53
Not suggesting treatment options to patients who cannot afford them	28	39	17	50	75	36	78	114	53
Lack of commitment to patient privacy	26	40	30	58	48	42	84	108	72
Lack of commitment to privacy of the patient-physician relationship	9	50	30	41	79	31	50	129	61
Failure to perform duties in teamwork	23	52	27	52	76	33	75	128	60
Play down feelings, needs and wishes of the patient	40	48	28	54	82	47	94	130	75
Failure to maintain a professional boundary in relation to patients or colleagues	13	44	25	33	90	4	46	134	29
The use of alcohol or drugs in the workplace	19	38	19	43	70	9	62	108	28
Addressing patient inappropriately	28	49	25	39	91	23	67	140	48
Lack of empathy and compassion with patients	23	49	38	44	112	22	67	161	60
Failure to report the risky and/or inappropriate behavior of a colleague. (after approaching the individual)	31	40	32	33	94	41	64	134	73
Failure to introduce yourself and nurses and physician assistants to the patient and his family	27	29	41	30	78	88	57	107	129
Performing procedures without having sufficient skills (without supervision)	38	43	35	37	62	74	75	105	109
Having personal conversations or making fun of students, other physicians, peers, or staff in the corridors of the hospital	39	35	43	52	66	70	91	101	113
Eating or drinking in the hallway of the hospital	48	27	23	59	68	56	107	95	79
Average score of participation	70.81			69.75			70.15
St Deviation	14.302			12.557			13.255

P: Number of students Participated in unprofessional behaviors

O: Number of students and colleagues, their unprofessional behaviors were Observed

P&O: Number of students Participated in and observed their colleagues’ unprofessional behaviors

The results showed that theme and scores of participation in unprofessional behavior in the junior student group were slightly higher than the interns. However, the result of t-test did not show any significant differences in participation rates between the two groups (p=0.451).

The most unprofessional behavior was seen in the clinical settings was "Lack of commitment to privacy of the patient-physician relationship". "Addressing patient inappropriately", and "Lack of maintaining medical dignity in their relationship, talking, and dressing", were the next unprofessional behaviors, respectively. The least unprofessional behavior observed was "preference of their interests to the interests of the patient" (Table 2).

For detailed examination of the relationship between the participation in unprofessional behaviors and their perception, the Pearson correlation coefficient was calculated (Table 3). Based on the results, the correlation coefficient was 0.091. Therefore, there was no significant relationship between the two variables (p=0.079) in total.

Table 3

Pearson correlation coefficient of the two variables, perception and participation in unprofessional behavior

	Pearson correlation	P
Total	0.091	0.079
Junior	0.06	0.479
Interns	0.103	0.117

However, no major relationship was reported in juniors (p=0.479) and interns (p=0.117).

Discussion

Attitudes have a lot to do with the mind which highly relates to human behavior. The way a person behaves depends a lot on how he/she looks at the situation and what they expect to gain from it.

People's behavior is based on their state of perception and thoughts that are raised from reality. A recent research showed that the mere perception of a person triggers the tendency to behave correspondingly. In a series of studies, Bargh et al. discussed a direct impact of perception on social behavior (13).

When a person tends to perform or not to perform an action which is important for him, the question arises that to what extent his/her perceptions as to the acceptability of any act affect how he/she behaves in his/her environment.

To check this, we should analyze the performance of a behavior by a person in relation to his/her perception and knowledge about it.

In this study, the perception of students about the importance of each behavior has been calculated by the sum of the individual opinion about each question asked. "Lack of maintaining medical dignity in their relationship, talking and dressing", were seen to a greater extent in the clinical settings (Table 2).

The students' responses to the questions are listed in Table 1; reflecting their overall self-reported knowledge of professional ethics that affects the perception of the two groups of students, juniors and interns. This table indicated that the value of self-reported knowledge in the junior group was 0.22, which is more than that of the interns. T-test showed a significant difference between the two groups (p<0.001). In contrast, there are some other studies which state that participation in unprofessional behavior does not increase with higher level theoretical teaching (5).

Based on the results, a higher rate of participation in unprofessional behavior was observed in junior students. Therefore, it can be concluded that the interns have achieved professional experience during their clinical rotations that helped them to avoid unprofessional behaviors.

In the present study, the correlation between perception and behavior was examined. This study did not generally indicate the relationship between the student's perception and participation in unprofessional behavior, while the relationship of these variables with regard to the previous knowledge was significant. It is worth mentioning that professional conduct depends on the person's perception and knowledge about it.

A study conducted by Shalini et al. showed that student observation and participation in unprofessional conducts increased in almost all areas, with the transition to more intense clinical activities during clerkships (14). Participation in unprofessional conducts was associated with diminished likelihood of perceiving a behavior as unprofessional. It may be due to negative learning experiences that may adversely affect the development of professionalism among students (14,15).

Since students learn more in practical environments (when visiting patients) than in classrooms, the teaching environment must be designed in such a way which includes the highest standards of professionalism and excellence in education and is accompanied with practical education (16). In addition, it was found out that the major information the students attain regarding professional ethics are through preclinical education. Hence, the best time for cultivating the basic attitudes against unprofessional behaviors in students' minds is on the early years of their medical education (before getting into clinic) (17).

Conclusion

There should be an increased emphasis on policy change and implementation of programs to teach and assess professionalism throughout the medical student curriculum. This program should emphasize the range of professional competencies expected of the future physicians, common lapses of professional behavior and consequences of unprofessional behaviors to students, patients, staff, colleagues and the healthcare organization.

Something that should be taken into account is that the behavior and attitude of faculty members and professionals play an important role in promoting professional behavior. With changes in the attitudes and behaviors of the faculty members, changes in the attitudes of the learners can be assumed. Passing over this issue can be a serious cause of creating unprofessional behaviors, which reflects the shortcomings of the educational system.