Developing personal attributes of professionalism ?· RESEARCH ARTICLE Open Access Developing personal…
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Mapukata-Sondzaba et al. BMC Medical Education 2014, 14:146http://www.biomedcentral.com/1472-6920/14/146
RESEARCH ARTICLE Open Access
Developing personal attributes of professionalismduring clinical rotations: views of final yearbachelor of clinical medical practice studentsNontsikelelo Mapukata-Sondzaba1*, Ames Dhai2, Norma Tsotsi2 and Eleanor Ross3
Background: Medical professionalism as a set of behaviours that transcends personal values, beliefs and attitudesto incorporate ethical and moral principles is considered a covenant between society and the practice of medicine.The Bachelor of Clinical Medical Practice (BCMP) a three year professional degree was launched at the University ofthe Witwatersrand in January 2009 in response to a documented shortage of doctors especially in the rural areas ofSouth Africa. The BCMP programme is unique in its offering as it requires a teaching approach that meets theneeds of an integrated curriculum, providing for an accelerated transition from the classroom to the patientsbedside.
Methods: Following five week attachments in designated District Education Campuses, 25 final year BCMP studentswere required to reflect individually on the covenant that exists between society and the practice of medicinebased on their daily interactions with health care workers and patients for three of the five rotations in a one pagedocument. A retrospective, descriptive case study employed qualitative methods to group emerging themes from71 portfolios. Ethical clearance was obtained from the Human Research Ethics Committee at the University of theWitwatersrand.
Results: As an outcome of an ethical analysis, the majority of BCMP students reflected on the determinants ofaccountable and responsible practice (N=54). The commitment to the Oath became significant with a personalisedreference to patients as my patients. Students acknowledged professional health care workers (HCWs) whodemonstrated commitment to core values of good practice as they recognised the value of constantly reflecting asa skill (n=51). As the students reflected on feeling like guinea pigs (n=25) migrating through periods of uncertainityto become teachable learners, they made ethical judgements that demonstrated the development of their moralintegrity. A few students felt vulnerable in instances where they were pressured into pushing the line.
Conclusions: Through their portfolio narratives, BCMP students showed a willingness to shape their evolvingjourneys of moral growth and personal development. This study has highlighted as an ongoing challenge the needto identify a process by which professionalism is sustained by HCWs to benefit health sciences students.
Keywords: Professionalism, Personal attributes, Health sciences students, Clinical rotations
* Correspondence: Nontsikelelo.Sondzaba@wits.ac.za1Division of Rural Health, Faculty of Health Sciences, University of theWitwatersrand, 7 York Road, Parktown, Johannesburg 2193, South AfricaFull list of author information is available at the end of the article
2014 Mapukata-Sondzaba et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms ofthe Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons PublicDomain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in thisarticle, unless otherwise stated.
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BackgroundProfessionalism in the 21st Century has progressed froma hierarchal practice that was defined by social struc-tures to consider not only the knowledge and skills ofthe health care providers but also, their attributes andbehaviours which must be congruent and meet the expec-tations of society and the profession [1-3]. Professionalismremains a topical issue among academics, practitionersand professional bodies . This interest is largely drivenby the fact that the desired doctor-patient relationship de-mands that students are taught professionalism and com-munication, recognizing that patients have rights and thathealth care providers have corresponding obligations totheir patients . Cases of self-reported breaches of pro-fessionalism and ethical misconduct by students such ascheating and plagiarism, as well as clinicians who displaynegative and disruptive behaviours, have been docu-mented as a growing concern [1,3,6,7]. These concernswere further highlighted by results from a longitudinalstudy undertaken by Papadakis et al.  where they dem-onstrated a direct correlation between medical studentsunprofessional behaviour and subsequent disciplinary ac-tion by professional bodies. Based on expressed concerns,there would appear to be a need to preserve the honour ofthe medical profession through teaching, assessment andon-going research on professionalism [6,9]. With thatproviso the clinical training environment is identified as acritical component as it is the culture of the organizationthat fosters the attainment of professionalism [6,10].The Bachelor of Clinical Practice (BCMP), a three-
year professional degree offered by the University of theWitwatersrand (Wits) accepted its first intake of studentsin January 2009 in response to a documented shortage ofdoctors, especially in the rural areas of South Africa .The BCMP programme sought to complement the exist-ing traditional six year medical training programme whichadmits students via two routes the school leavers andthe Graduate Entry Medical Programme (GEMP) .The BCMP programme is unique in its approach astraining is based on the district health care model, a sys-tem of primary health care comprising of a cluster ofclinics, community health centres and a Level 1 hospitalthat seeks to ensure that quality healthcare is accessibleto all [13,14]. Rooted in problem based learning similarto the GEMP curriculum, this degree is based on a rigor-ous, competency based and standardized curriculum(Additional file 1). As part of an integrated curriculum theBCMP students are exposed to the clinical environment inone of the locally based District Education Campuses(DECs) urban underserved or in rural communities from1st year. Progressively they spend more time in the des-ignated DECs learning to manage diseases in areaswhere they had theoretical instruction by consulting pa-tients under the supervision of their clinical tutors. In
their third and final year, only the first rotation is spentin medical school. For the remainder of the year, thefinal year BCMP students rotate through different sites,undertaking learning in different disciplines supervisedby university-appointed supervisors as well as other on-site clinicians. At the end of each block the studentsknowledge and understanding of the curriculum isassessed through written exams and Objective StructuredClinical Exams (OSCE). In their final year, students sit fora national exam together with other final year studentsfrom two other universities offering the same programme,namely: the University of Pretoria and the Walter SisuluUniversity [http://www.twinningagainstaids.org/documents/CABoolketFinal_lowres.pdf].In South Africa, the Health Professions Council of
South Africa (HPCSA) has a mandate to ensure thatfaculties of Health Sciences include in their core cur-riculum, academic instruction on professional ethics,human rights and medical law. Furthermore, it is theresponsibility of the HPCSA to ensure that all educationand training programmes are academically rigorous andclinically relevant . Responding to this call by theHPCSA, a course in bioethics was introduced into theBMCP curriculum in order to humanize the educationand practice of these professionals. Through the infusionof human values and the humanities in health scienceseducation, it was hoped to achieve the ideal of training notonly of scientifically competent but also humanisticallyresponsive practitioners . In meeting the needs of theBCMP students, the three basic actions described by Sternand Papadakis  were applied, namely setting expecta-tions (Oath taking); providing experience; and, teachingand evaluation as broad concepts of teaching profes-sionalism. The class was divided into groups to facilitateteamwork and reflective practice. Case reports and clinicalvignettes were used to facilitate the process of attainingacademic and professional integrity. Group discussions fo-cused on a patient-centred approach described by Mueller and the role of BCMP students as future professionals.Their knowledge and understanding was assessed as partof the integrated curriculum .Upon qualification these middle level health care
professionals (HCPs) are known as Clinical Associates.In the US, they are known as Physician Assistants(PAs), while in the rest of Africa they are referred to asClinical Officers, a cadre of HCPs who substitute for,and/or complement, medical officers . In order tostrengthen the training of Clinical Associates, Wits en-tered into a twinning partnership with Emory UniversitySchool of Medicine [http://www.twinningagainstaids.org/documents/CABoolketFinal_lowres.pdf]. In terms of theHuman Resources for Health (HRH) strategy , ClinicalAssociates have been identified as one of the categories ofHCPs who will contribute to the strengthening of health
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care services in the district in the implementation of there-engineering of primary health care . It should benoted that in our context it is not unusual for the categor-ies of HCPs to be referred to as health care workers(HCWs) especially in instances where collective responsi-bility is acknowledged. In this article, personal attributesof professionalism are described as the highest standardsto which health sciences students are willing to commit sothat they can develop through reflective practice the skillsand abilities that include an understanding of ethics andthe legal framework, critical evaluation and self-directedlearning as described by Klenowski and Carnell .Mueller  is of the view that these skills enable studentsto be in a position to integrate acquired theoretical know-ledge with professional experiences and promote patientautonomy, social justice and primacy of welfare. In thisstudy, personal attributes were evaluated in terms of ac-countability and responsibility, critical reflection linked toprofessional development, as well as personal growth.
MethodsIn conducting the study, the research question soughtto establish if current teaching and assessment strat-egies as evidenced through exhibited personal attributesadequately prepared BCMP students to be reflectivepractitioners. This paper reflects on views expressed byfinal year BCMP students in developing personal attri-butes of professionalism by assessing their ability to in-tegrate theoretical knowledge with clinical experienceand function as accountable, responsible and criticallyreflective practitioners.Following five week attachments in purposely selected
clinical departments in designated DECs, all 25 final yearBCMP students were required to reflect on the covenantthat exists between society and the practice of medicinebased on their daily interactions with health care workersand patients as a one-page activity in their portfolios.Ethical clearance was obtained from the Human Re-search Ethics Committee (HREC- Medical: M110740) ofthe Faculty of Health Sciences at the University of theWitwatersrand. All 25 students agreed to participate inthe study and submitted written informed consent fortheir portfolios to be included in the research. Onlyportfolios that reflected on time spent in three of thefive rotations, namely: Paediatrics (Paeds), EmergencyMedicine (EM) and Adult in-Patient wards (AIPW)formed part of the study as students rotated in sites inthe Gauteng province and rural communities in theNorth West province. With the closet site being a mere10 km away from medical school, and the most distantsite some 450 km away, this adequately covered theBCMP scope of practice and represented the maximumspectrum of a clinical training environment . Thusthe portfolios reflecting on the time spent in Surgery
and in the Outpatients department were excluded fromthis analysis as the researcher was of the view that stu-dents would have similar experiences as reported in EMand in AIPW. Also, including all five clinical departmentswould have extended the scope beyond the researchmandate.A retrospective design method was employed as data
was obtained from portfolios that were initially designatedas tools for the formative assessment of a block placement.Whilst a retrospective case design is perceived to be aquick and easy approach, its main challenge is that it tendsto rely on recall. For the BCMP students, reflecting ontheir experiences was considered to be a critical exerciseas this was used to evaluate both moral and academicfunctioning as a measure of professional integrity as thestudents personally decided on the content of their dis-cussions . Also in the context of Wits as a learningenvironment, written reflections in the form of portfo-lios are used extensively to link theoretical knowledgewith clinical experiences undertaken under supervision. An exploratory, descriptive approach allowed for agreater understanding of the BCMP students experi-ences considering the context, the behaviours and atti-tudes related to professionalism [22-24].A total of 71 portfolios received for formative assess-
ment as hard copies were available for analysis insteadof the 75 that were expected. The other four that weresubmitted electronically were lost with the theft of theprogramme coordinators computer. Thus the return ratefor the portfolios was 100% (n = 25) for EM only, for AIPthe rate was 92% (n = 23), similar to Paeds at 92% (n = 23).Portfolios were chosen as the ideal instruments as they fa-cilitate independent reporting by students and also allowfor critical reflection and an honest discussion [24-26].They are also considered to be effective and efficient toolsof assessment in primary care . The portfolios were allwritten in English and submitted as hard copies rangingfrom one to five pages dependant on whether the docu-ment was typed or handwr...