Observational Study Medicine ®

OPEN

Professionalism development of undergraduate

medical students
Effect of time and transition
∗
Kamran Sattar, MMEda,b, , Ashfaq Akram, PhDa, Tauseef Ahmad, PhDa,c, Ulfat Bashir, FCPSd

Abstract
Changeover phases are essential and inevitable times in professional life, which let the learners adapt and grasp emerging
opportunities for learning based on the past experiences with the catering of novel creativity as required in the present as well as
emerging time. This study was carried out to examine the effectiveness of a professionalism course, during the transition from a non-
clinical to clinical setting, within the context of undergraduate medical education.
This observational study was conducted during 2019 to 2020, with pre- and post-professionalism course evaluation. We used the
Dundee Poly-professionalism inventory-1: Academic Integrity, among the undergraduate medical students.
Our results are based on the medical student’s professional progress with the transition from 2nd year to 3rd year. During the 1st
phase of the study, the participants at their Pre-Professionalism Course (PrPC) level in their 2nd medical year (only attended the
introductory lectures for professionalism), showed a good understanding of professionalism. For the 2nd phase, when the same
students, at their Post-Professionalism Course (PoPC) level, in their 3rd year (completed professionalism course) filled the same
survey and it was found that there was no decline in their understanding of the topic, even after more than a year. They were even
more aware of the significance of professionalism in their clinical settings.
Despite a year gap, the understanding of professionalism among students was stable. Results helped us infer that time laps did not
affect the professionalism concept learned earlier; rather during clinical settings, students become more aware of professionalism.
Abbreviations: ABIM = American Board of Internal Medicine, ABMS = American Board of Medical Specialties, IBM =
International Business Machines Corporation, IRB = Institutional Review Board, PoPC = Post-Professionalism Course, PrPC = Pre-
Professionalism Course, SPSS = Statistical Package for the Social Sciences.
Keywords: clinical, medical students, non-clinical, professionalism, professionality, transition, undergraduate

Editor: Nesreen E. Morsy. 1. Introduction

The authors extend their appreciation to the Deanship of Scientific Research at
Professionalism is characterized as a gathering of mentalities,
King Saud University for funding this work through research group no. RG-1441-
411. qualities, practices, and communications that go about as the
The authors have no conflicts of interest to disclose.
premise of the wellbeing expert’s agreement with society. Medical
professionalism skill is a central competency for medical students
The datasets generated during and/or analyzed during the current study are not
publicly available, but are available from the corresponding author on reasonable as learners and practising doctors as life-long learners. This group
request. of professionals are exposed to high work demands; henceforth,
Supplemental Digital Content is available for this article. cultivating the best practices has become a significant segment of
a
Department of Medical Education, College of Medicine, King Saud University, medical education.[1–4] According to the American Board of
Riyadh, Saudi Arabia, b Department of Medical Education, School of Medical Medical Specialties (ABMS), “Professionalism is a belief system
Sciences, Universiti Sains Malaysia, Kelantan, Malaysia, c Department of in which group members (‘professionals’) declare (‘profess’) to
Computer Science and Information Technology, NIMS University, Jaipur, each other and to the public, the shared competency standards
Rajasthan, India, d Department of Medical Education, Riphah International
University, Islamabad, Pakistan.
and ethical values they uphold in their work and what patients
∗ can expect from these professionals.”[5] Despite its increasing
Correspondence: Kamran Sattar, Department of Medical Education, College of
Medicine, King Saud University, Riyadh, Saudi Arabia (e-mail: value as a vital competence element, among healthcare stake-
kbaloch@[Link]). holders, there remains a significant distinction of sentiment about
Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc. professionalism methodology in the healthcare setting.
This is an open access article distributed under the terms of the Creative Conceptual variations for professionalism teachings do exist
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is between professionalism, humanism, and individual and expert
permissible to download, share, remix, transform, and buildup the work provided
development, making it challenging to be accepted across
it is properly cited. The work cannot be used commercially without permission
from the journal. different cultures and distant geographical healthcare settings.
How to cite this article: Sattar K, Akram A, Ahmad T, Bashir U. Professionalism
Additionally, varied preferences, aversions, and contrasts in
development of undergraduate medical students; effect of time and transition. professionalism assessments are likewise found in characterizing
Medicine 2021;100:9(e23580). professionalism as indicated by dominating social or cultural
Received: 23 April 2020 / Received in final form: 14 September 2020 / differences.[6,7] No unanimously established theoretical settings
Accepted: 6 November 2020 of professionalism are presently offered. The American Board of
[Link] Internal Medicine (ABIM) recognizes 6 broad elements of

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Sattar et al. Medicine (2021) 100:9 Medicine

professionalism (altruism, accountability, excellence, duty, psychomotor responses may compromise, because of lack of
honour and integrity, and respect for others).[8] practices. The study aimed to examine the effectiveness of the
Due to difficulties in characterizing professionalism, medical professionalism course, as a professional progress instrument, with
education programs have no other alternative than to show it 1 year apart, during the transition from non-clinical to a clinical
expressly. Different educational program plans have been setting, within the context of undergraduate medical education.
recommended to cultivate the individual and professional
improvement of medical students.[9] Such efforts have focused
1.1. Overview of the professionalism course
on both keeping medical students from unprofessional practices
just as right lapses in professionalism. Yet, unfortunately, the We have an integrated and hybrid curriculum. This allows the
unprofessional behaviors among medical students go from mild learners to get reinforced with the key topics as they study and
to serious.[10] The responsibility lapses are associated with other revise them in different contexts at different stages. There remains
healthcare specialists but alarmingly toward the patients as well. the provision of various knowledge facets to be explored
Therefore, when gaps in the professionalism (which is an ever repeatedly. Still, with increasing detail and complexity with
evolving educational domain), arise, students shall not be progressing levels and because of embracing the spiral approach,
penalized, rather remediation is the choice.[11] it is intended and expected that the knowledge core and
Although creating professionalism and remediating lapses professional skills shall be developing with the progress of the
among pre-clinical, undergraduate medical students are challeng- curriculum. The objective of the medical program is to shift
ing because of the extent of understanding. Instructing and learning educational emphasis from the learning of the facts to teaching
professionals in the pre-clinical phase of undergraduate medical students the professional skills that they will need to be an
education should place the essential morals, qualities, and effective lifelong learner.
convictions, just as their effects on personal and professional This course aimed to indoctrinate the best professional
advancement, within medical students’ everyday experiences, attitudes and the teaching methodology comprised of interactive
which are not constantly identified with clinical practice.[12] The lectures on topics related to the essential elements of profession-
rationale for this study is built around the common understanding alism (ABIM 1994). These qualities of behavior are demarcated
that with the gap in any educational activity where the learners are by the ABIM and universally quoted in the literature (Fig. 1).
not in touch with a particular knowledge or skill set, there lies While in our endeavor to inculcate professionalism attributes,
chances for having a decline in their cognition base and also the align with what is stated by ABIM and our pre-defined objectives

Figure 1. (A) Six essential elements of professionalism as advocated by ABIM, with relevance to the professionalism course components taught to undergraduate
medical students. (B) A brief illustrative representation about teaching and assessment of professionalism course. (C) Graphic demonstration about course
objectives leading to learners’ professional development through teachers–learners participation. ABIM = American Board of Internal Medicine.

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Sattar et al. Medicine (2021) 100:9 [Link]

Figure 1. Continued

within our course outline comprised of teaching through recommended sanctions for the professionalism lapses, was done
interactive lectures on the topics associated with essential using The Dundee Poly-professionalism inventory-1: Academic
elements of professionalism, and for that we had utilized Integrity “Supplemental Digital Content (Appendix 1, http://
experienced teaching faculty both from pre-clinical and clinical [Link]/MD/F820)” which previously has been success-
subjects, who all volunteered for this course. The endeavor was fully used in the UK, Pakistan, and Egypt.
anticipated to build up learner professional identity.
Assessment of the course, at 2 different phases, was carried out 2.2. Demography of participants and study size
by using Polyprofessionalism Inventory.
This study had 2 phases, and the subject population in both phases
With the importance of the subject, that is, professionalism and
was the same medical students (phase 1 = while in their 2nd year 2
its attributes, this study aims at assessing the effectiveness of
at pre-course level, and phase 2 = while in their 3rd year at post-
professionalism course, during the transition from non-clinical to
course level) enrolled in the medical program. We target the current
the clinical setting, within the context of undergraduate medical
course design with potential impact on student’s professional
education. Moreover, authors hypothesize that with the passage of
development with the main components of professionalism course
time learning of essential elements might have gone on a decline.
based on essential elements of professionalism.
Phase 1 of the study took place between January 2019 and
2. Methods May 2019, and the participants were in their starting week of 2nd
2.1. Study design and setting year. An introductory interactive lecture of 2-hour duration, with
the title “introduction of professionalism course” was arranged.
This observational study was carried out at a public sector The objectives of this lecture were to let students orient with
university, in Riyadh, Saudi Arabia during the period January definitions and brief explanations of the essential elements of
2019 to November 2019. Collection of participants’ responses as professionalism. Proper arrangements were carried out for

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advertising this lecture through students’ email systems as well We entered the collected data into Microsoft Excel 2010 and
through the college notice board. At the same time, the aims of the carried out an extensive analysis using International Business
study were also announced, so that students shall have a clear Machines Corporation (IBM) Statistical Package for the Social
idea of what is expected of them. Sciences (SPSS) Program. A P-value of <.05 was deliberated
The course was implemented in an undergraduate medical statistically significant.
program; therefore, all medical students were eligible to
participate in the study. Ethical approval was obtained by the
3. Results
Institutional Review Board (IRB-E-20–4592). However, using
the University of Helsinki ethical guidelines, they had the option Our results are mainly based on the medical student’s
to withdraw from the study. professional progress with the transition from 2nd year to 3rd
A convenience sampling technique was adopted to collect the year. The participants during their Pre-Professionalism Course
data. A total of 227 students were in the 2nd year of college of (PrPC) level, in their 2nd medical year, who attended only the
medicine. Out of 227 students, 157 (69.16%) students attended introductory lecture about the professionalism course were
this lecture. After the lecture, another announcement as a requested to recommend their sanctions for 34 lapses as items of
reminder was made to inform the students about the study, its the survey (right after the introductory lecture). The results
objectives, and potential outcomes. Later, 146 students agreed to showed that these students have a good understanding of
join in this study voluntarily, and the survey questionnaire was professionalism. These same students, again (now in 3rd medical
distributed to them. A total of 139 properly filled responses were year) during Post-Professionalism Course (PoPC) level have
collected back. Whereas, 7 forms were found to be incomplete so recorded their responses for the same survey items, so that a
were not included. Out of a total of 139 participants, 90 (46.7%) comparison of recommended sanctions for 34 professionalism
were male and 49 (35.3%) female. lapses be carried out for any changeover, with time especially
During phase 2, which was carried out in November 2019, the when the participants have attended the full course (profession-
same questionnaire was distributed to the agreed participants alism) and they transit from pre-clinical to the clinical setting.
(among the ones who attended phase 1). The student cohort These results help to identify changeover progress in terms of the
remained the same as was in phase 1. Still, the main difference is congruence and the differences among the same students in the
that now these participants have already been through a full beginning and after completion of the professionalism course.
course of professionalism (while in phase 1 they had only
attended the introductory lecture about the course with 3.1. Congruence
definitions and brief explanations of essential professionalism
elements) and are in their 3rd year, which is a clinical year (during We explored the recommended sanctions of the same students,
phase 1 they were in 2nd year which is a pre-clinical year). but at 2 different occasions. Firstly when these students were at
their pre-course stage (in their 2nd year) and had attended only
the introduction part of the professionalism course, and again at
2.3. Study instrument post-course stage (in their 3rd year) while they had completed
We used a self-administered, anonymous, survey questionnaire, their professionalism course. We also compared the recom-
that is, the Dundee Poly-professionalism inventory-1: Academic mended sanctions, as median, in terms of gender, for attending
Integrity “Supplemental Digital Content (Appendix 1, http:// participants.
[Link]/MD/F820).” This also incorporated the written
3.1.1. Congruence between pre- (2nd year) and post-course
consent of the participants. The survey was manually distributed
to the agreed participants and collected back. Respondents group (3rd year). There was a congruence as (reported as the
commended the endorsements, based on a report,[13] in the form median) for the recommended sanction by the same students at 2
different stages of our study (i.e., pre-course and post-course)
of 1 to 10 sanctions (Table 1) addressing 34 types of
from a Saudi medical school for the unprofessional behaviors
professionalism lapses in the undergraduate medical education
(Table 2), for example, For the item, “Giving help for course
context. These 34 statements served as the variables. Participants’
work against a teacher’s rule,” both phase 1 and phase 2 groups
responses were recorded on 5 points Likert scale, that is, strongly
(i.e., pre- and post-course level consequently) recommended the
disagree, disagree, neutral, agree, and strongly agree.
sanction 4; “Removing an assigned reference from a shelf in the
library to prevent other students,” both groups recommended a
higher sanction, that is, 6; “Forging a healthcare worker’s
Table 1 signature on a piece of work, patient chart, grade sheet or
List of 10 sanctions for students to recommend while responding attendance form,” both groups students marked a higher
against the 34 items of survey. sanction, that is, 8; “Claiming collaborative work as one’s
1. Ignore (none) individual effort,” both phase 1 and phase 2 students
2. Reprimand (verbal warning) recommended sanction 6; “Threatening or verbally abusing a
3. Reprimand (written warning) university employee or fellow student,” both groups’ recom-
4. Reprimand, plus mandatory counselling
mendations were a very high sanction, that is, 8. “Attempting to
5. Reprimand, counselling, extra work assignment
6. Failure of specific class/remedial work to gain credit
use personal relationships, bribes or threats to gain academic
7. Failure of specific year (repetition allowed) advantages by, for example, getting advance copies of exam
8. Expulsion from college (readmission after 1 yr possible) papers or passing exam by such pressures on staff,” both groups
9. Expulsion from college (no chance for readmission) recommended similar sanction 8. “Engaging in substance misuse
10. Report to a regulatory body (e.g., drugs),” both groups marked sanction 8. “Physically
assaulting a university employee or student,” both groups’

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Table 2
∗
Congruence in recommended sanctions (median) between PrPC level and †PoPC level students.
(PrPC responses) (PoPC Responses)
Phase 1, i.e., pre-clinical year Phase 2, i.e., clinical year
2nd year Male Female 3rd year Male Female
students (n = 90) (n = 49) students (n = 48) (n = 45)
S. No Items (n = 139) (64.7%) (35.3%) (n = 93) (51.6) (48.4)
1 Getting or giving help for course work against a teacher’s rule (e.g., lending work to another 4 4 4 4 4 5
student to look at)
2 Removing an assigned reference from a shelf in the library in order to prevent other students 6 5.5 6 6 6 6
from gaining access to the information in it
3 Forging a healthcare worker’s signature on a piece of work, patient chart, grade sheet, or 8 8 8 8 8 8
attendance form.
4 Claiming collaborative work as one’s individual effort 6 5 6 6 6 6
5 Threatening or verbally abusing a university employee or fellow student 8 8 8 8 8 9
6 Attempting to use personal relationships, bribes or threats to gain academic advantages by, 8 7.5 8 8 8 8
e.g., getting advance copies of exam papers or passing exam by such pressures on staff
7 Engaging in substance misuse (e.g., drugs) 8 7 9 8 7.5 9
8 Physically assaulting a university employee or student 9 8 9 9 9 9
9 Purchasing work from a fellow student or internet etc supplier 6 6 6 6 6 6
10 Sabotaging another student’s work 6 5.5 6 6 6 6
11 Sexually harassing ( ) a university employee or fellow students 10 10 10 10 10 10
12 Resubmitting work previously submitted for a separate assignment or earlier degree 4 4 4 4 4 4
13 Plagiarizing ( ) work from a fellow student or publications/internet 5 4.5 5 5 5 5
14 Involvement in pedophilic activities – possession/viewing of child pornography images or 10 10 10 10 10 10
molesting children
∗
Pre-Professionalism Course.
†
Post-Professionalism Course.

response was a very strong sanction (i.e., 9) as they believed such any changes pre- and post-students strict with their previously
activity should result in the expulsion from the college. recommended sanction 8. Similarly, not any sanction changes
“Purchasing work from a fellow student or internet etc. Supplier” reported for the statement, “Sexually harassing a university
both groups reported a similar high sanction (i.e., 6) again. employee or fellow student and Involvement in pedophilic
“Sabotaging another student’s work,” they reported sanction 6. activities – possession/viewing of child pornography images or
“Resubmitting work previously submitted for a separate molesting children.”
assignment or earlier degree,” both groups agreed about sanction
4. “Plagiarizing work from a fellow student or publications/
internet,” both groups agreed with sanction 5. Both groups 3.2. Differences in recommended sanctions, at PrPC and
recommended the most severe sanction, that is, 10 against the 2 PoPC level
behaviors; “Involvement in pedophilic activities – possession/
We found the sanctions difference between PrPClevel (2nd year)
viewing of child pornography images or molesting children” and
and post-PoPC level (3rd year). We collected the information and
“sexually harassing a university employee or fellow student.”
report below our results comprising on 2 basic measures, firstly
3.1.2. Congruence between gender within PrPC (2nd year) for one-level difference secondly for two-levels or more difference
and PoPC (3rd year) groups. Table 2 also shows the in recommended sanctions.
comparison (gender-based) of responses as recommended
sanctions from the participants. It was found that there was a 3.2.1. Items with a one-level difference as the median for the
congruence among both groups (PrPC and PoPC), from a Saudi recommended sanction. In this section we reported that one-
medical school for the following behaviors. level stricter sanction was recorded by PoPC level students (i.e.,
“Giving help for course work against a teacher’s rule,” where, by the students at 3rd year/clinical setting) as median in
both male and females from the 2 groups recommended the similar comparison to their own responses when they were at PrPC
sanction, that is, 4, however, female participants found to differ in level (2nd year/pre-clinical setting), for a total of 11 behaviors
their opinion after the post-course training and as shown to mark a (Table 3) and some notable statements are mentioned here;
strong sanction (5). For the behavior, “Removing an assigned “Signing attendance sheets for absent friends, or asking class-
reference from a shelf in the library to prevent other students,” at mates to sign attendance sheets for you in labs or lectures” (3:4);
the PoPC level male students were found to have changed their “Altering or manipulating data (e.g., adjusting data to obtain a
opinion and found to increase their previous sanction from 5.5 to 6. significant result)” (6:7); “Failure to follow proper infection
Furthermore, for the behavior, “Claiming collaborative work as control procedures” (6:7); “Completing work for another
one’s individual effort,” male students again are shown to change student” (3:4); “Examining patients without knowledge or
their point of view when they recorded their responses at PoPC consent of supervising clinician” (4:5); “Cheating in an exam by,
level. Moreover, “Forging a healthcare worker’s signature on a for example, copying from neighbor, taking in crib material
piece of work, patient chart, grade sheet, or attendance form,” no or using a mobile phone or getting someone else to sit for you”

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Sattar et al. Medicine (2021) 100:9 Medicine

Table 3
∗
PoPC level students being one-level stricter for recommended sanctions (median) as compared to PrPC level† students.
Questions (PrPC level) (PoPC level)
Phase 1, i.e., pre-clinical year Phase 2, i.e., clinical
2nd year Male Female 3rd year Male Female
students (n = 90) (n = 49) students (n = 48) (n = 45)
S. No Items (n = 139) (64.7%) (35.3%) (n = 93) (51.6) (48.4)
1 Signing attendance sheets for absent friends, or asking classmates to sign attendance sheets 3 4 3 4 5 4
for you in labs or lectures
2 Altering or manipulating data (e.g., adjusting data to obtain a significant result) 6 6.5 6 7 7 7
3 Failure to follow proper infection control procedures 6 5 6 7 6.5 7
4 Completing work for another student 3 3 3 4 4.5 4
5 Lack of punctuality for classes 3 3 3 4 4.5 4
6 Not doing the part assigned in group work 4 4.4 4 5 5 5
7 Examining patients without knowledge or consent of supervising clinician 4 4 4.5 5 4.5 5
8 Cheating in an exam by, e.g., copying from neighbor, taking in crib material, or using mobile 7 7 7 8 8.5 8
phone or getting someone else to sit for you
9 Cutting and pasting or paraphrasing material without acknowledging the source 5 5 5 6 6 6
10 Drinking alcohol over lunch and interviewing a patient in the afternoon 6 5 6 7 7 7
11 Photographing dissection or prosecution or cadaver materials 5 5 5 6 6 5
∗
Post-Professionalism Course.
†
Pre-Professionalism Course.

(7:8); “Cutting and pasting or paraphrasing material without mended sanctions for unprofessional behavior. This undeniably
acknowledging the source” (5:6). calls the attention of healthcare stakeholders. In this study, we
explored the students’ perceptions while being in phase 1 and
3.2.2. Items with 2 levels or more difference between pre- phase 2, with clear reflections from behavioral or environmental
and post-course. Table 4 summaries the 9 statements, changes occurring for their understanding of professionalism,
indicating unprofessional behaviors, and represents substantial especially after the creation and professional growth following a
sanction differences (toward the stricter side) in the recommen- 6-week course. The assessment is based on the evidence
dations between PrPC and PoPC level students. Here 4 of such composed via a validated instrument, Dundee Polyprofession-
behaviors are mentioned, “Intentionally falsifying test results or alism Inventory.[14] Lapses in academic integrity are a widespread
treatment records to disguise mistakes” (5:8); “Providing illegal concern. Sustaining polished skills appropriately and speedily,
drugs to fellow students” (7:9); “Joking or speaking disrespect- providing the required remediation of the emerging lapses among
fully about bodies/body parts” (4:7); “Inappropriate representa- undergraduate students can be excitingly challenging because of
tion of Medicine in social media by posting photos/videos/texts the degree of understanding required for such an essential and
about class or clinic activities” (4:6.5). huge task. Learning time spent in medical school serves as the
foundation stone for ethical and moral value carried by future
physicians of the society. An international study reported that the
4. Discussion
medical students who demonstrated unprofessional behavior in
The present study investigates the enlightening suggestions medical colleges were more expected to have a consequent
gathered while recording the students’ responses as recom- College Board disciplinary action.[14,15] In our finding emerging

Table 4
PoPC level students being 2 or more level stricter for recommended sanctions (median) as compared to PrPC level students.
Questions Pre-course responses (Phase 1) Post-course responses (Phase 2)
2nd year Male Female 3rd year Male Female
students (n = 90) (n = 49) students (n = 48) (n = 45)
S. No Items (n = 139) (64.7%) (35.3%) (n = 93) (51.6) (48.4)
1 Exchanging information about an exam before it has been taken (e.g., OSCE) 1 1 2 4 4 4
2 Intentionally falsifying test results or treatment records in order to disguise mistakes 5 5 5.5 8 8 8
3 Providing illegal drugs to fellow students 7 7 7 9 8 9
4 Inventing extraneous circumstances to delay sitting an exam 5 5 4 7 6 8
5 Damaging public property, e.g., scribbling on desks or chairs 4 3.5 4 6 6 6.5
6 Falsifying references or grades on a curriculum vitae or altering grades in the official 6 5.5 6.5 8 8 8
records
7 Joking or speaking disrespectfully about bodies/body parts 4 4.5 4 7 7 7
8 Inappropriate representation of Medicine in social media by posting photos/videos/texts 4 4 4 6.5 6.5 7
about class or clinic activities
9 Posting inappropriate material about fellow students, teachers, or patients on social 5.5 6 5 7.5 7 7
media

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from recorded responses in both phases, students found to be well course as the students (after the course) have shown to become
aware and hence recommended sanctions but while in phases 2 more aware and strict with unprofessional behaviors. The
(after the course was completed) they were found to recommend a authors conclude that teaching of professionalism (especially
more appropriate sanction. Some previously published studies targeting the pre-clinical students) is an area requiring proper
also reported that the professionalism component of professional implementation and shall be explored through future research.
development and addressing cognitive and behavioral out- The authors believe that this study has reported essential findings
comes.[16,17] Similarly, a previous study also reported that yet is limited because the comparison of students’ understanding
Professionalism assessments addressed cognitive and behavioural and retention of knowledge was carried out with a year gap. In
outcomes.[18] In 2012, when the same inventory was used, it was the future, we aim to conduct it with a larger gap, that is, 2 or
informed that 54 of the Scottish students suggested sanctions in more years. For achieving an outcome feasible for the general
association with lapses in academic integrity.[19] Corresponding- implementation of current results, we aim to collaborate with
ly, there had been recognized apprehensions concerning other medical colleges in the country and abroad.
academic integrity that necessitate documentation and their
solution. The disclosures of our study were consistent with the
5. Conclusion
above findings.[20,21] Current study showed that the statements
about the academic integrity lapses, were dealt well, for example, Our study concluded that despite the gap of 1 year, the
“Attempting to use personal relationships, bribes or threats to understanding of professionalism attributes among the medical
gain academic advantages by, for example, getting advance student did not decline. Moreover, the participants’ responses
copies of exam papers or passing the exam by such pressures on helped us infer that time laps did not affect many of the
staff,” very good in both phases 80% which is high than the professionalism concepts they learned in the past, rather after the
previous publish study through the Dundee Polyprofessionalism transition into the clinical phase, they were more aware of the
Inventory.[22] Medical professionals, in the long run, were aspects of professionalism especially related to the clinical
perceived as experts who have had social collaboration and good settings. These formal educational endeavors should be system-
commitments to satisfy their patients.[23] A study publishes in atically developed and further enhanced, and one way to do so is
China that clinical education programs for undergraduate by hearing the students’ voice on this topic. It is of note that in the
students, they reported before teaching medical professionalism, early stages of the medical curriculum, there are serious behavior
the students were well aware of the professionalism of the dilemmas. Therefore, more attention should thus be given toward
medical curriculum.[24] A similar report in surveying information role modelling and the unprofessional learning environment (if it
and attitudes toward medical professionalism among pre-clinical happens to occur). Our finding also reported that the proper and
students demonstrated that there is restricted information but a professional guidance to students resulted in their Professionality
good attitude toward medical professionalism and formal development as evidently, their professional values were increased.
training, and educational programs must be changed right
now.[25] Present study also found that pre-clinical (phase 1) 6. Recommendation
students showed a good understanding of professionalism by This study implies the need to conduct robust and long-term
recommending actions for all of the 34 survey statements. projects as a course, which shall allow pre-clinical students to
According to Velayo et al,[26] the pre-clinical performance is
have inculcated and implement professional values as well as
positively correlated with the clinical success of the medical develop their professional identities before they become more
students. Thus, it is essential to inculcate the essence of involved in the community of healthcare practitioners during
professionalism among medical students during their pre-clinical their clinical rotations at a later stage, during the clinical year.
training. According to the current study, when the students from
phase 1 and phase 2 were compared, a full consistency for 14
(41.17%) statements in the response as median was recorded Author contributions
with additional up to one-level difference in between phase 1 Conceptualization: Kamran Sattar.
students and phase 2 for 11 (32.35%) statements. Such response Data curation: Tauseef Ahmad.
consistency among the respondents was also reported in an Formal analysis: Tauseef Ahmad, Ulfat Bashir.
earlier study, but for the different set of 8 behaviors.[27] Present Investigation: Kamran Sattar.
study has reported an interesting finding as students found not to Methodology: Ashfaq Akram.
select “ignore” as a recommended sanction in either phase 1 or Project administration: Kamran Sattar, Ashfaq Akram.
phase 2 for any of the 34 survey statements. This finding was a Resources: Ulfat Bashir.
notable contrast to the responses collected using the same Software: Tauseef Ahmad.
inventory in the past at various educational institutes, within Supervision: Kamran Sattar.
different geographical locations.[28] A study reported after the Validation: Ashfaq Akram, Ulfat Bashir.
professionalism course, the medical students’ understanding Visualization: Kamran Sattar.
about professionalism improved = making them more aware Writing – original draft: Kamran Sattar, Ashfaq Akram.
about the essential elements, for example, patient care, integrity, Writing – review & editing: Kamran Sattar.
altruism, etc.[29] Similar finding was also reported in our study as
phase 2 students recommended higher sanctions as compared to References
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