Professionalism and culture
Professionalism is an important competence in medical education. In the United States, both undergraduate and graduate medical education accreditation standards include professionalism. Many countries around the world adopt medical professionalism according to American accreditation standards for both undergraduate and graduate medical education. In terms of professional organizations, ninety professional organizations worldwide have endorsed the Physician Charter which reaffirms “the fundamental and universal principles and values of medical professionalism” based on attributes identified by the representatives from the American Board of Internal Medicine, the American College of Physicians and American Society of Internal Medicine, and the European Federation of Internal Medicine.1-3 Although when the Charter was published, the editor asked, “Does this document represent the traditions of medicine in cultures other than those in the West, where the authors of the charter have practiced medicine?”, the charter quickly spread across specialties and countries internationally.2
Medical professionalism is about meeting societal expectations of the medical professions.4 Although there is common knowledge, skills, and attitudes that most societies expect of their medical professionals, there are differences in the expectations of the medical profession across cultures. Studies from Taiwan, Japan and the Arab world have demonstrated the role of cultural values in shaping professionalism in various societies.5-8 For instance, in Taiwan and China, Confucian values, including integrity, morality, and relationalism, are reflected in the perception and practice of professionalism.5-7 The seven virtues of Bushido, a Japanese code of conduct originating from the samurai warriors, are used to interpret professionalism in Japan.8 The Four-Gates model conceptualizes professionalism in the Arabian context at four levels of professional conduct while (1) dealing with self, (2) dealing with task, (3) dealing with others and (4) dealing with God. The framework acknowledges Islamic values in shaping medical professionalism.9
Define professionalism with culture in mind
Considering the cultural variations in medical professionalism, when we design professionalism curriculum, we must define professionalism with culture in mind. How do we define professionalism with culture in mind? Studies from Taiwan and China have employed the method of nominal group technique (NGT).5,6 What is NGT? NGT is a structured procedure to gather opinions from groups of people. In the NGT process, every participant has equal opportunity to present his or her views. The process for everyone to list all their ideas for discussion and give all views equal weight avoids problems associated with traditional focus group methodology, such as dominating personalities or conformity to the established order.10-13
Here are the five steps of NGT to define professionalism. The first step is for each participant to write down what he or she considers to be the essential elements of medical professionalism. The purpose of this exercise is to capture each participant’s expectations regarding medical professionals without the interference of other participants. In the second step, participants take turns to name one item from their list at a time without further discussion. This process continues until all participants have expressed all of their ideas. In step three, the participants discuss all items and combine any closely related ideas into a single item. When there is disagreement among the group, the person who initially raised the item can decide whether or not to combine the idea or leave it as a separate item.
In the fourth step, participants vote on the importance of the combined items. There are different ways of voting. For instance, each participant can select five items he or she regarded as most important and vote on these five items using a five-point Likert-type scale, where 5 is most important and 1 is least important. The fifth step is to sum the voting results and rank the items.
With the above procedure of NGT, Taiwanese medical education stakeholders constructed a professionalism framework that differs from Western frameworks based on the Hippocratic tradition, stressing the primacy of patients. Taiwanese professionalism framework based on NGT reflects the Confucian tradition of Taiwan and emphasizes that one should become a person with integrity in order to serve others. Confucians believe that people with integrity will make ethical choices even under temptation and confusion. The concept of integrity is placed centrally visually in Taiwanese professionalism framework because the Confucian tradition is more powerful than the Hippocratic tradition in the Taiwanese context. This framing reminds Taiwanese medical students and practitioners that the cultivation of integrity would guide them to choose the right path and to harmonize potential conflicts.5
Integrate professionalism with culture in mind
After defining key elements of professionalism with culture in mind, medical educators can develop a longitudinally integrated professionalism curriculum. At National Taiwan University College of Medicine, a systematic six-step approach was adopted with special attention to the needs of Taiwanese society.14 The six steps are: (1) problem identification and general needs assessment, (2) targeted needs assessment, (3) goals and specific measurable objectives, (4) educational strategies, (5) implementation, and (6) evaluation and feedback.15 General needs were assessed by NGT.5 For the targeted needs assessment, medical students were surveyed. For step 3, the teachers in charge of the related courses drafted goals and specific measurable objectives. Then suitable educational strategies from the global medical education community were implemented such as experiential learning, standardized patients, and narrative medicine within the allowance of local resources. Western educational content and methods were not imported en masse, additional strategies were employed to increase students’ understanding of local needs and cultural contexts such as visiting local historical sites, role-playing family members of standardized patients, and reading local literature. Finally, an assessment system with multi-source feedback and a learning portfolio was developed which reflects Taiwanese cultural value on integrity.14
In conclusion, professionalism is a social contract between the society and the medical profession, reflecting cultural values. This article describes some methods to identify and integrate cultural values into medical professionalism curriculum. Medical educators could utilize these tools to develop professionalism curriculum with their local cultures in mind.
- Blank L, Kimball H, McDonald W, Merino J. Medical professionalism in the new millennium: A physicians’ charter 15 months later. Ann Intern Med. 2003;138:839–841.
- ABIM Foundation; ACP-ASIM Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002;136:243–246.
- Medical Professionalism Project. Medical professionalism in the new millennium: A physicians’ charter. Lancet. 2002;359:520–522.
- Cruess SR. 2006. Professionalism and medicine’s social contract with society. Clin Orthop Relat Res 449:170–176.
- Ho M-J, Yu K-H, Hirsh D, Huang T-S, Yang P-C. Does one size fit all? Building a framework for medical professionalism. Acad Med. 2011;86(11):1407–14.
- Ho M-J, Yu K-H, Pan H, Norris JL, Liang Y-S, Li J-N, et al. A tale of two cities: understanding the differences in medical professionalism between two Chinese cultural contexts. Acad Med. 2014;89(6):944–50.
- Ho M-J, Lin C-W, Chiu Y-T, Lingard L, Ginsburg S. A cross-cultural study of students’ approaches to professional dilemmas: sticks or ripples. Med Educ. 2012;46(3):245–56.
- Nishigori H1, Harrison R, Busari J, Dornan T. Bushido and medical professionalism in Japan. Acad Med. 2014 Apr;89(4):560-3.
- Al-Eraky MM, Donkers J, Wajid G, van Merrienboer JJG. A Delphi study of medical professionalism in Arabian countries: the Four-Gates model. Med Teach. 2014;36 Suppl 1:S8–16.
- Delbecq A, Van de Ven A. A group process model for problem identification and program planning. J Appl Behav Sci. 1971;7: 466–492.
- Gallagher M, Hares T, Spencer J, Bradshaw C, Webb I. The nominal group technique: A research tool for general practice? Fam Pract. 1993;10:76–81.
- Dobbie A, Rhodes M, Tysinger J, Freeman J. Using a modified nominal group technique as a curriculum evaluation tool. Fam Med. 2004; 36:402–406.
- Tsai SS, Chang SC, Ho MJ. Defining the core competencies of medical humanities education through the nominal group technique. J Med Educ. 2008;12:70–76.
- Shih-Li Tsai, Ming-Jung Ho, David Hirsh & David Kern. 2012. Defiance, compliance, or alliance? How we developed a medical professionalism curriculum that deliberately connects to cultural context. Medical Teacher 34(8):614-7.
- Kern DE, Thomas PA, Hughes MT (eds). 2009. Curriculum development for medical education: A six-step approach. 2nd ed. Baltimore, MD: The Johns Hopkins University Press.
Written for May 2016 by
Ming-Jung Ho, MD, DPhil
Assistant Dean for International Affairs
Vice Chair, School of Medicine
Professor, Department / Graduate Institute of Medical Education & Bioethics
National Taiwan University College of Medicine