Laying the Foundation of Medical Professionalism among Pre-clinical Students: Importance of Reflection

This article was migrated. The article was marked as recommended. Introduction: The escalating problem of unprofessionalism calls for teaching medical professionalism in a manner that should lead to deeper learning. Early clinical exposure (ECE) to an Intensive Care Unit (ICU) presents the issues pertaining to medical professionalism to the students in a more explicit and emotionally challenging manner. And reflection note writing evokes the critical process of thought and analysis required for learning. We conducted the present study to sensitize the pre-clinical students towards medical professionalism using these two tools, ECE and Reflection. Methods: Two hundred students of 1st MBBS were given an Objective Structured Clinical Examinations (OSCE). The students were then taken for ECE to an ICU. There, the students observed different ongoing activities and critical patients, a doctor discussed some cases with them, and they also interacted with the relatives of patients admitted in the ICU. Thereafter, students wrote a ‘reflection’ note describing what did you see? so what? and now what? Students were again given an OSCE, similar to the one given before the ECE, for assessing any change in their professional behaviour.Analysis of reflection notes was done thematically and of OSCE scores using paired t-test (p<0.05). Results: The analysis of reflection notes revealed the budding of different elements of professionalism among the students. Post-visit OSCE scores also showed significant improvement. Conclusion: Incorporation of reflection note writing along with ECE is helpful in laying the foundation of medical professionalism among pre-clinical students.

The qualitative data of reflection notes was analyzed thematically. All the points mentioned by the students were taken into consideration, coded and tabulated by both the authors, separately. The authors then exchanged notes and discussed the themes, coding and interpretations for ensuring exhaustive study of the reflection notes and for cross-checking the results. For analysis of OSCE results, only the scores assessing professionalism were taken into consideration. A paired ttest with p<0.05 as significance level was used. Feedback was also analyzed quantitatively by calculating percentage of students agreeing with a particular value of an item. Thematic analysis was done using QDA Miner Lite 2.0.5 and quantitative analysis using Microsoft Excel Professional 2015.

Analysis of ICU visit Reflection notes
The reflection notes revealed the dynamics of perception and attitude of the students as they were remodeled by the clinical exposure and experience. The reflection notes were scrutinized under three domains: what did you see? so what? and now what? Several themes emerged each with its own set of relevant codes (table 1). Analysis of each of these themes reflected the budding of different elements of professionalism (figure 1) among the students. Cited below are a few exemplars from the reflection notes which are suggestive of the inculcation of these different elements.
Exemplar 1: "when we entered the ICU and when I saw the patients, I got to know what must be their mental condition: nothing but painful and helpless. But for this how a doctor takes standing is something that can never be neglected by me." -reveals development of empathy for patients, and of a sense of responsibility. Exemplar 2: ".. after all this I realized that to become a doctor is not an easy task, it requires a lot of hard work... in starting, I was taking studies very lightly, but when I saw patients in ICU, I realized we are the future doctors who would deal with patients' lives. And before all this we should acquire all knowledge ..." -reveals realization of importance of hard work for continuous improvement in knowledge and skill, and willingness for striving for excellence. Exemplar 3: "The family was in agony and we could see their impatience and helplessness. For them we were all doctors. So, the patient's wife asked me if he was out of danger. I felt very helpless. At the same time, I understood what this white coat signifies." -reveals development of empathy for relatives of patients and of sense of accountability. Exemplar 4: "... and just knowledge is not enough. My body language, my words, what I say in front of relatives of my patients, who believe that he will be well as he has come to me, the way I talk, I dress and my overall behavior with staff also matters. And henceforth I need to inculcate all these things in my behavior and most importantly study hard everything thoroughly." -reveals realization of importance of having good communication skills. Exemplar 5: "... After coming outside, I saw another battle of doctors: one of the relatives was so firm in his belief that he was debating with the doctor. But she (doctor) was trying to convince him that they are trying their best to save the patient. But still he was not able to understand." -reveals development of empathy for doctors (other health professionals) and realization of importance of having good communication skills. Exemplar 6: "... One of the things that I noticed was the way doctor interacted with the patient and staff. I am glad that I had such a positive experience. I want to be a good doctor, so it is important for me to stay connected with patient..." -reveals realization of importance of working in association with other health professionals, and that of need of developing good communication skills.

Experience of ICU and interaction with relatives of patients
Most of the students had not been to an ICU before. The students wore cap, mask and shoe covers for going inside ICU. Inside ICU, there were critically ill patients. There was cleanliness and discipline. The silence was broken by sounds of equipment and patients' cries of agony. There was more staff in ICU than number of patients. Various devices and equipment were attached to the patients for monitoring their condition and treatment. Doctors were examining patients and communicating with ICU staff, including other doctors and nurses. All ICU staff was carefully tending to the patients. A doctor discussed cases of some critical patients admitted there, with the students and answered their queries. Doctors apprised the relatives of patients about their condition and reassured them. There was a confrontation between relatives of a patient and a doctor. One patient's condition deteriorated. Despite best resuscitation efforts, the patient passed away. The doctor informed his relatives about the same. Students interacted with the relatives of patients admitted waiting outside ICU. There was an initial hesitation but following an exemplar demonstration by the teacher, they asked the relatives about the condition of their patient and about the problems they faced. The relatives treated the students with respect and told them about their problems: monetary constraints, accommodation, food, not being allowed to meet their patient often, not being more informed about the condition of their patient, having to come from far off rural places, unsuccessful diagnosis and treatment at some clinics and hospitals, etc.  -reveals a sense of social justice and altruism being developed.

Perception
Exemplar 8: "... just stay honest towards the profession and work hard for your patients." -reveals inculcation of sense of integrity.
Exemplar 9: "The doctor-patient relationship is the foundation of medical ethics. Patients, the innocent problem holders, come up to doctors for all sorts of problems, be it physical, mental or social. They expect doctors to give solution to every kind of problems. And so, it is our duty to stand up to their mark." -reveals a sense of accountability and integrity. Table 2 summarizes the OSCE scores of students before and after the ICU visit. A significant improvement was seen in the performance of students in the OSCE given after the ICU visit.

Analysis of feedback
Most of the students strongly agreed with the positive influence of ICU visit on various aspects of their medical professional learning (Supplementary file 1). The students either agreed or strongly agreed that seeing critically ill patients aroused their interest in the profession (89.0%), that the agony of relatives for their patients taught them to look at patients sympathetically (91.5%) and that they now had better understanding of importance of communication skills (91.5%). The students also agreed or strongly agreed that the experience motivated them to learn more (95.0%). Most of them agreed or strongly agreed that the experience changed their perception of medical field (82.5%), that they became more sensitive towards their profession (84.5 %), and that they found that their professional attitude has changed after the visit (77.5%). Also, the experience was rated as being quite relevant to pre-clinical phase (88.5%) by the students and found to be helpful in enhancing academic learning (95.0%). These findings suggest that the students were indeed able to identify the different elements of professionalism with the help of the ICU visit and their reflection on it.

Discussion
The Experiential Learning Theory given by Kolb (Kolb, 1984), states that "learning is the process whereby knowledge is created through the transformation of experience". There are two processes that are integral to the 'transformation of experience'-'reflection' on the experience to assimilate information from it and 'abstract conceptualization' involving critical comprehension of the events, thereby forming some hypotheses for the observations and an intent to bring that understanding into practice. Without reflection and conceptualization from it, learning cannot take place and the experience loses its meaning. We based our study on this concept.
Early clinical exposure lets the pre-clinical and para clinical students become involved in their future work, i.e. clinical setup, at an early stage. Observing the clinical set up, its activities, interaction with patients and doctors, discussions, etc. provide myriads of learning opportunities to the students. One of the earliest published articles on early clinical exposure dates back to 1970s (Benbassat and Schiffman, 1976;Ali M et al., 1977) that brought out its benefit in improving academic learning. ECE rekindles the students' interest in medical sciences, helps them identify their role as a student and as a future doctor (Johnson and Scott, 1998). Over years, other benefits of ECE were revealed and it has been effectively used to teach communication, time management, cultural issues, identity formation, professionalism and self-appraisal as well (Lie et al., 2006;McLean, 2004;Basak et al., 2009;Dornan et al., 2009;Helmich et al., 2011;Ali M et al., 2018). In the present study, the students were taken for a visit of an ICU, the early clinical exposure. The students were then made to write a note on the visit 'reflecting' on it. This made them revisit their experience in mind and made them 'think and analyze it critically'. It made them become more aware of the experience and helped them in developing an insight into it. In turn, this made them seek rationalizations for their thoughts and feelings. Their critical comprehension then reformed their attitude and perception of the experience. And different components of the experience inculcated different elements of medical professionalism among the students ( figure 3).
There is no one globally acceptable definition of medical professionalism and the critically relevant attributes of medical professionalism vary (Cruess et al., 2010;Riley and Kumar, 2012;Birden et al., 2013;Jha et al., 2014;Al-Rumayyan et al., 2017) with the socio-economic and cultural environment of work of the professional individual. However, there are some broad elements that can be identified to be characteristic of any good medical professional (Swick, 2000;Passi et al., 2010;Riley and Kumar, 2012;Jha et al., 2014) as depicted in figure 1. The clinical experience introduced the pre-clinical students to these very broadly identified elements of medical professionalism and the critical reflection process helped to lay its foundation in them. Learning from the experience was, therefore, made more concrete with the help of reflection.
From being clueless about what the medical profession actually means, the students now began to identify their role as a medical student as well as a future professional doctor.
The significant improvement in the performance of students in OSCE also implies an improvement in their attitude towards the subject on whom the examination was performed. Considering the OSCE result together with students' reflection notes, it suggests the beginning of development of medical professionalism among them. And thereby, supports our interpretation of the data from their reflection.
Some earlier studies (Pitkälä and Mäntyranta, 2004;Elliott, 2009;Helmich et al., 2012;Wong and Trollope-Kumar, 2014;Borgstrom et al., 2016) have explored reflection as a tool for learning medical professionalism. The results of our study are in conformation with their results. But these studies traced the dynamics of perception and attitude as the students entered the clinical learning stage and maintained a portfolio of the same. While, our study used reflection to teach the same to pre-clinical students during their early clinical exposure. Also, most of these studies involved only few scores of students. Our study analyzed reflection notes of 200 students which makes it very exhaustive. Some of the earlier studies (Pitkälä and Mäntyranta, 2004;Elliott, 2009) were prospective in nature and assessed if reflection helped them be better professionals. But our study was done to sensitize the pre-clinical students towards the same.
In due course of time, as their medical course advances, these students will gain more clinical experience. Then the 'beginning of medical professionalism' made in pre-clinical period may guide the future dynamics of their perceptions and attitudes, and may serve to be the foundation of medical professionalism in them.
Therefore, we may hypothesize that such students, who get clinical exposure and reflect on it in in the pre-clinical period, may become better professionals than those who did not get this opportunity (figure 4). The same may be studied by means of prospective studies.
Limitations: An inherent limitation of a qualitative analysis is that it depends on the comprehension of the researchers. But our study analyses the results in a quantitative manner as well, and thereby, tests our qualitative analysis. This gives an edge to our interpretation of the reflection notes and partially overcomes the limitation. And for the same reason, our results are more generalizable than that of a qualitative study alone. The results of our study may be confounded by the effect of discussion that the students had among themselves and with the teacher after the visit. But learning cannot occur in isolation. It is only appropriate, therefore, to consider it as a part of the process of reflection.
Considering that the students always knew what was the appropriate response, the better performance of the students seems expected. But the purpose of addressing the issue of professionalism is inculcating the same among the students using all available means. The students have to know what is appropriate and that knowledge has to be reinforced repeatedly so that it becomes a part of their spontaneous professional behaviour and attitude.
Another factor that confounds our result, both reflection note writing and OSCE performance, is the student's tendency to perform better when they know that they are being observed. We would like to bring into consideration here that it's not a blind study and this bias cannot be done away with; it is an inherent limitation in such studies. However, repetition of any behaviour is essential for learning to occur. The students' consciously performing better aided in their learning of good professional behaviour and helped in inculcating medical professionalism among the students, which was our aim.

Conclusion
We conclude that incorporation of reflection note writing with early clinical exposure in the pre-clinical period maybe helpful in inculcating the elements of medical professionalism among the students and may also be helpful in addressing the issue of rising unprofessionalism in medical field.

Take Home Messages
Early clinical exposure may be helpful in presenting conundrums of medical professionalism to pre-clinical students.
Reflection note writing may be helpful in invoking the critical thought and analysis process required for addressing these conundrums.
Reflection may be helpful in consolidating learning from clinical experience to improve professional behaviour and attitude.
Early clinical exposure followed by reflection may be helpful in sensitizing pre-clinical students towards medical professionalism. Notes On Contributors Dr. Prerna Agarwal (ORCID iD:https://orcid.org/0000-0001-9466-1253) The author obtained her post graduate degree in the year 2013 and has since dedicatedly worked in academics. While teaching undergraduate and post graduate students, she realized that there is immense need of improvising medical education. This research work is her first step in this direction.
Dr. Alka Rawekar (ORCID iD: https://orcid.org/0000-0002-1372-6332) The author is a professor of Physiology and is currently positioned as Dean-Allied Health Sciences, JNMC, DMIMS (DU), Wardha. During her academic career of more than 15 years now, she has several articles, both in physiology and medical education, to her credit as she continues to work in the direction of improvising medical education.

Declarations
The author has declared that there are no conflicts of interest.

External Funding
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