What medical students are really learning from family doctors: professionalism in practice

Julie Y Chen 陳芸

HK Pract 2011;33:137-138

Midway through their undergraduate studies, medical students at the University of Hong Kong have the opportunity to be attached to family doctors in the community to get a sense of what it is like to be a family doctor and to observe and practice clinical skills including history taking and physical examination. These objectives they meet, but the deepest impression is left by the personal contact with these community doctors - observing their interactions and the way they practice their art. What medical students have to say about this, in their own words, is at the same time very revealing and most heartening.

Consider the following:

"…as the patient greeted the doctor, you could immediately sense the trust the young child had with his doctor and from thence on how a 7 year old boy had no shyness in telling his problems to a grown adult…"

"…it was the first time I have even observed a real family doctor. It seemed effortless for him to identify or diagnose certain problems or disease even before asking the history. I realized these kinds of skills are based on the years of experience he had. He taught me a few tricks that had become very useful…and are the most useful skills I have learnt…"

"…It was amazing how he tackled a compliance issue in an Alzheimer's patient. I will never forget the tone, the smart use of tailoring timing of medication and going the extra mile to help certain patients. It is so rewarding [to see] and [this goes] beyond the science, anatomy and pharmacology – it was sensible and delivered so lovingly!"

"…attachment was really meaningful especially as my tutors are so willing to teach me…I witnessed the first proctoscopy in my life. I am very glad that the doctor granted me an opportunity to see the procedure. I was very honoured to be able to hold the torch and apply KY jelly."

The quotations above were extracted from the logbooks of Year 3, HKU medical students written during the 2010-11 academic year. All students were required to reflect on what they considered to be the most significant or memorable of their learning encounters during a junior clerkship teaching block which involved 10 different disciplines, including family medicine. Over 50% of students chose to write about their learning experience in family medicine, particularly their community family doctor attachments.

What students are telling us is that they are, in fact, learning "professionalism".

Medical professionalism is a multifaceted concept which can be approached from educational, sociological and clinical perspectives. However, for practical purposes, I would suggest combining the views proposed by the Royal College of Physicians ¹ describing medical professionalism as "a set of values, behaviours and relationships that underpin the trust the public has in doctors" with the expected professional roles of a medical practitioner as described by the Medical Council of Hong Kong ² namely, a "communicator, educator, humanist, collaborator, health advocate, resource manager, scientist and scholar". Framed in this way, it is clear that professionalism has to do with what we already do as family doctors and what is already engrained as the core values in the practice of family medicine. These focus on the patient-centred consultation, doctor-patient relationship and holistic care. The representative entries above demonstrated several domains of professionalism as roles expected of doctors:

■ professionalism as a skilled practitioner, in terms of knowledge and clinical skills (e.g. interpersonal communication, diagnosis and management, link of clinical to basic science),

■ professionalism as a humanist, manifesting as attitudes or behaviours (e.g. showing respect, compassion, common courtesy, honesty and integrity), and

■ professionalism as an educator who is conscious of supporting the learning needs of the student (e.g. facilitating learning opportunities, sharing life experience, establishing a positive learning environment)

In addition to telling us they are learning professionalism in family medicine (though they were not specifically identifying professionalism as such), students are also telling us that family doctors are good at "teaching" it.

As the 2010 HKCFP Visiting Professor Amanda Howe described in her presentation "Teaching professionalism in the surgery,"³ we know that family doctors are very well placed for facilitating students to learn about professionalism for several reasons. She noted that primary care is where the patients are, and interacting with a diverse mix of patients inside the surgery helps to develop professionalism especially respect and understanding. She also expressed that role models of doctorpatient relationships in family medicine practice are very strongly professional as the focus is comparatively less on the biomedical and more about values and communication. In fact, role modeling is perhaps the most powerful means of learning professional attributes, and students are keenly aware of this.⁴

So, if students are already learning professionalism through existing attachment experience with family doctors, why should we do anything more about it?

Medical professionalism remains a fixture in the media, a concern for professional and regulatory bodies and, rightly so, a focus for undergraduate and postgraduate medical education. As members of a self-regulating profession, we have a responsibility to maintain the standards of our profession, and through teaching our medical students in their early years we have the unique opportunity to shape the values and attitudes of our youngest future colleagues from the earliest stages of their development into doctors. A systematic review ⁵ of the outcomes of early clinical contact in undergraduate medical education supports this view and in particular noted that such initiatives helped students develop professionally and develop a professional identity. Evidence has also shown that students who experienced early patient interaction with engagement in clinician-led small groups had a broader and more complex understanding of professionalism compared with those who had non-clinical teaching only.⁶ Earlier clinical contact with family doctors does have a profound impact.

Drawing on the enthusiasm, the relative open-mindedness and the keen desire to "be a doctor" that all freshly minted medical students exhibit, early clinical attachments to a family doctor starting from the first year of medical school, would be an ideal training ground to foster this interest, introduce elementary clinical skills in a real practice context, introduce the discipline of Family Medicine, and most of all, start the professionalism ball rolling. Moreover, the influence of family doctor teaching can be strengthened through repeated brief contacts over the first 3 years of medical school, and potentially for the duration of the student's undergraduate education, to allow for a mentorship relationship to develop between individual doctors and students.

It is very exciting to work with family doctors in the community to develop a programme based on these ideas: Becoming a Doctor: Professionalism in Practice. The programme will complement the existing Family Medicine and professionalism, medical ethics, and humanities undergraduate curricula and it is proposed to begin in the next academic year with the generous ongoing support of family medicine colleagues.