India Lane1 and Liz Mossop2
1College of Veterinary Medicine, University of Tennessee, USA
2School of Veterinary Medicine and Science, University of Nottingham, UK
Professionalism has been a hot topic in medical education for over a decade. The current emphasis on professionalism has rapidly proceeded through a trajectory that included significant consternation over the meaning of the word, a proliferation of educational efforts, and serious challenges to the inclusion of professionalism in formal curricula. For physicians, changes in societal demands and new models of care delivery have led to an extensive discourse around medical professionalism. Increased primacy for patient autonomy, informed consent, and patient confidentiality are examples of societal pressures influencing professional expectations in human medicine. For veterinarians, economic realities spurred exploration of the nontechnical skills, knowledge, aptitudes, and attitudes (SKAs) that aid practice and career success. Two major assessments of market forces and veterinarian incomes in the late 1990s, known as the KPMG and Brakke studies, illuminated the importance of personal characteristics, communication skills, and savvy business practices in veterinary success (Cron et al., 2000; Brown and Silverman, 1999). Recommendations arising from these studies essentially became a call for a new notion of professionalism in veterinary practice. Additional strategic initiatives, including the North American Veterinary Medical Education Consortium Roadmap (NAVMEC, 2011), later included communication; collaboration; management of self, teams, and systems; leadership; and adaptability as core competencies for future veterinary graduates. The veterinary community responded with numerous educational and professional development opportunities, from revised admissions practices, ceremonies, orientation sessions, and workshops to new courses, curricula, and continuing education strategies (Lloyd and King, 2004).
Despite these efforts, professionalism remains an ill-defined competency or competency domain, and still may be neglected in the veterinary curriculum (Mossop, 2012). In veterinary medicine and other health professions, educators have struggled with whether professionalism can be defined, taught, and assessed. The emergent veterinary literature has focused more heavily on concrete skills, such as communication and business skills, and wellness, but includes limited contributions tackling the concept of professionalism.
Medicine’s contemporary “professionalism movement” first called for a useful definition of terms, especially to distinguish professionalism from content areas such as jurisprudence, ethics, and communication (Hafferty and Levinson, 2008). Although related, legal regulations and professional skills such as interviewing, physical examination, and general communication training should be distinct from the professionalism curriculum. Ethics, long a standard component of veterinary curricula, also does not quite capture the essence of professionalism, although ethical dilemmas often underlie professional dilemmas. Educational perspectives in ethics, animal welfare, and communication skills are found elsewhere in this text.
Redefining professionalism was followed by attention to teaching and assessing professionalism across the continuum of undergraduate, clinical, and graduate medical education. A plethora of programs hoped to institutionalize a shared commitment to appropriate conduct. In the aftermath, though, counterpoints arose, where students and others recognized the limitations of professionalism as taught. Evidence grew that empathy and idealism declined, rather than blossomed, during medical training (Hilton and Slotnick, 2005; Patenaude, Niyonsenga, and Fafard, 2003). Students struggled with an idealistic depiction of professionalism in the classroom and a different reality outside it. By recognizing the challenges of professional lives, the reality that professional lapses occur, and the imperfect relationships within healthcare systems, professionalism has become a dynamic and evolving concept and is expected to change just as state-of-the-art medicine changes.
What is Professionalism?
Attempts to define professionalism suffer from the inherent difficulty of defining an ethos that crosses so many intangible and interrelated lines. Birden et al. (2014) listed no fewer than 70 definitional papers published between 1999 and 2007. Drawing on the dictionary definition and literature from multiple professions, Cruess, Johnston, and Cruess (2004) developed an expanded definition of “profession” that can be used to introduce students to the service orientation and accountability that bound organized veterinary medicine:
An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society. (Cruess, Johnston, and Cruess, 2004, p. 74)
Additionally, veterinary students are usually quickly introduced to a form of professional statement or oath, in which we publicly profess to meet core obligations.
Definitions of professionalism have been suggested for physicians. Most are expansive, with lists of principles, attributes, or competencies (see Box 25.2). The many elements that bleed into professionalism are illustrated by Stern’s conceptualization of professionalism as a portico with the “pillars” of excellence, humanism, accountability, and altruism sitting atop a “base” of ethics, jurisprudence, communication, and competence (Arnold and Stern, 2006). Two other frequently cited definitions (the American Board of Internal Medicine Physician’s Charter and the Royal College of Canadian Physicians and Surgeons CANMeds Role of the Professional) are framed as commitments. The CANMeds model is updated every 10 years.
Both Hafferty (2006) and Birden et al. (2014) offer meta-analyses of the definitional literature. Hafferty distills five thematic conclusions, including three common threads – altruism, civic engagement, and self-reflection/mindfulness. He also points out the many ways in which these themes and definitions appear and notes how context influences meaning. Birden makes similar conclusions about context, including geographical region, medical specialty, and personal interpretation. Indeed, Mossop (2012) recognized the importance of context and the limitations of simply adapting a definition created for physicians to veterinary medicine. The unique and foremost responsibility of veterinary professionals to the welfare of the animal creates a complex professional web, including relationships among veterinarians, animal caretakers, and practice employers. Mossop’s proposed definition emphasizes these diverse responsibilities and the attributes employed in meeting them (see Box 25.2).
Eloquent articulations of professionalism can also be complemented by effective personalized sayings, phrases, or mottos for individuals, institutions, or veterinary practices. Veterinary schools often have a professionalism statement or a list of professional values. Detailed codes of conduct, while useful, frequently are too specific to reflect the essence of professionalism. More simply, one or two powerful words can easily be diffused through the daily language of an organization or college. A respected mentor who led several large campuses during his professional career used the single word “dignity” to promote the culture that he expected.
Professionalism as Identity
Those who struggle with defining professionalism can be troubled by the naivety of thinking that such a concept can be reduced to discrete behaviors, attributes, or values. A renewed call has urged medical educators to embrace the development of professionalism as the development of professional identity. Indeed, professional identity has been the end goal of educational efforts all along. Using a definition of identity as “a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting, and feeling like a physician” (Cruess et al., 2014, p. 1447), one can imagine a curriculum tailored to emphasize self-awareness, the relationship of actions and behaviors to core attitudes, and the continual development of identity through a professional lifetime.
Professional identity formation does not replace, but builds on, the foundational knowledge, abilities, and attitudes that we attempt to make explicit in professionalism curricula. The lens of professionalism as identity does shift the emphasis from “doing” professional things to “being” professional, a subtle but effective gradation that influences how professionalism is taught and assessed (Cruess, Cruess, and Steinert, 2015). Using this lens for professionalism education, a higher purpose is kept in the forefront, the charge to “raise the ceiling so that everyone can reach their highest potential” (Gunderman and Brown, 2013, p. 1183).
Why Bother Teaching Professionalism?
History and wordsmithed definitions will not capture students’ passion, nor will a checklist of competencies required for accreditation. A compelling “why” is necessary for students to embrace professionalism content. The lead arguments highlight the impact of poor behavior or communication. Unprofessional physician behavior has been linked to compromised treatment, poor patient outcomes, dysfunctional healthcare teams, and malpractice suits (Johnson, 2009; Bahaziq and Crosby, 2011). Attention to student behavior is imperative as well: physicians disciplined by state medical boards were more likely than control-matched physicians to have been cited for professional breaches during medical school (especially failure to demonstrate responsibility or failure to respond to feedback; Papadakis et al., 2005). While these important consequences grab attention, starting from a negative orientation may set a punitive or preachy tone. Reframing the positive reasons why professionalism is important, with extensive student input, may be more effective and collaborative in gaining buy-in. “Reasons to be professional” usually include meeting client expectations and fostering client satisfaction, preserving the positive public perceptions of veterinarians, and abiding universal norms of morality and decency (e.g., the “golden rule”; Lane, 2006). Professionalism is indeed a core competency, albeit one frequently taken for granted. Notions of professionalism, including “practice with integrity” and “have a good attitude,” were included among the top three most frequently used skills cited by small animal practitioners (Greenfield, Johnson, and Schaeffer, 2004). Five of six themes emerging from diverse groups of exemplars to define veterinary “success” were nontechnical SKAs grounded in a professional work environment: personal fulfillment, pride, and fun in work; a helping orientation; a balanced lifestyle; respect and professional recognition; and personal goal achievement (Lewis and Klausner, 2003).
Above all, professionalism connotes the manner in which we serve the public. Hafferty (2006) includes professionalism in the “three social movements in medicine today: evidence-based medicine; patient safety; and professionalism (p 194),” and relates all three to quality of care. A recent review by Mueller (2015) recaps the positive impact of professionalism on patients and medical practice. Professionalism of the physician improves clinical outcomes by increasing confidence and trust, motivating patients to follow the doctor’s recommendations. A practice culture that prizes high-quality medicine, teamwork, and patient care generates better outcomes as well (Mueller, 2015) and has economic benefits. Veterinary income has been correlated with nontechnical skills (Cron et al., 2000). In a limited veterinary market, nontechnical SKAs can distinguish an exemplary veterinarian from competitors (Lloyd, 2006). Unprofessional behavior has negative impacts on practice reputation and referrals.
Further, contemporary professionalism education emphasizes self-awareness, self-management, and reflection, all skills that foster adaptability and ongoing personal growth. Professionals who have the ability and the opportunity to shape their working environment and respond constructively to professional challenges may be more likely to avoid burnout.
All of these are compelling reasons to include professionalism explicitly in the curricula for veterinarians in training. Of course, the primary reason to embrace professionalism is to preserve the health of the profession. A commitment to the manner in which we meet professional obligations should be just as strong as our commitments to quality medical care and rigorous biomedical research.
The steps in creating a professionalism curriculum are no different than for curriculum development in general (see Part One, Chapter 1: Curriculum Design, Review, and Reform). The most important decisions surround the content to be included and how it will be framed in theoretical and structural terms. The anticipated goals and outcomes must be articulated so that the content, delivery, and assessment of students and the program follow purposefully. Outcomes can be described as competencies or behaviors, including knowledge of a cognitive foundation. Professionalism can also be considered a competency domain or thread that weaves throughout the curriculum. Within this framework, professionalism is a curricular theme that appears in all courses or blocks, presented in a manner relevant to the setting.
Regardless of the approach, the curricular goals must be intentional and clearly communicated to students and faculty. If the content appears haphazard, it may feel like multiple, orphaned topics have been thrown together into a professionalism or “doctoring” course. Organizing such a course so that it appears in the schedule prominently, alongside “regular” courses, can also raise credibility and status (Hafferty, Gaufberg, and O’Donnell, 2015). Common topics that form or complement a professionalism curriculum are listed in Table 25.1, and Box 25.3 considers who should deliver the curriculum.
Table 25.1 Suggested content for professionalism curricula
|Frequent core curricular topics
|Contemporary issues to consider
|AVMA Principles, Veterinarian’s Oath
Practice Acts or equivalent
Professional values and behaviors
Evidence-based practice and continuing education
Integrity and responsibility
Teamwork and conflict management
Self-awareness and self-management
The veterinary team–patient–client relationship
Professionalism in the classroom and student groups
|Corporate veterinary medicine
Industry relationships and conflicts of interest
Professional and personal use of images
Social media, blogs, and internet presence
Professional use of smartphones
Referrals and consultations with veterinary specialists
Giving and receiving feedback
Veterinarian or veterinary student impairment
Veterinary students/veterinarians on reality TV
Structurally, professionalism curricula usually balance formal and informal approaches so that delivery of a cognitive base and experiential and reflective work are included (Cruess and Cruess, 2009; Inui et al., 2009). Ideally, content flows from the early preclinical curriculum to clinical and postgraduate scenarios in a fashion that builds an individual’s “capacity to personalize professionalism” (Cruess and Cruess, 2009, p. 78). Modules or vignettes that can be revisited at various points in the educational continuum can be useful for this purpose. A sample longitudinal curriculum for veterinary students is posed by Mossop and Cobb (2013; see Box 25.4), who emphasize early immersion in clinical practice or the community. These opportunities create space for students to reflect on the behavior of role models and to shape their own professional identity. Mossop and Cobb (2013) also highlight the guidance needed to help students learn how to learn in this new educational landscape. The contrast between material requiring rumination, empathy, and nuance and the rest of the curriculum, or a busy practice, is strong (Piemonte, 2015).
Additional steps in curriculum planning include planning ahead for individual and programmatic assessments, and methods for updating or adjusting the curriculum. Finally, the curriculum must be dynamic and flexible. Educators must be on the alert for and proactively address contemporary issues that challenge or reshape our notions of professionalism (Table 25.1). Recent examples include industry influences on veterinary students, appropriate use of social media, and the ubiquitous photographs that are easily taken with smartphones (Coe et al., 2011). Digital professionalism is now a distinct field of study (Ross et al., 2013; Ellaway et al., 2015).
Student Feedback and the Hidden Curriculum
When designing a professionalism curriculum, much can be learned from the experiences of others, including students. Medical students pointedly reveal the limitations of a formal course or curriculum in professionalism. Leo and Eagen (2008), nearing graduation, wrote: “How can medical students, who are hopefully the proponents of professionalism, be so hostile towards the subject?” (p. 509) They suggest that students quickly tire of the subject due to a primary orientation on unprofessional behaviors versus professional ones; a double standard and “do as I say, not as I do” view of faculty and staff behavior; and a perceived personal affront – professionalism curricula seem to suggest that one might not be a good person, much less a good doctor. Furthermore, curricular content was perceived to project positive behaviors as unachievable, abstract ideals, whereas unprofessional behaviors were common, realistic, and worthy of a scolding. The most disturbing aspect of the curriculum for these students was the disconnect between what was taught and what was observed; a laundry list of unprofessional faculty behaviors was noted (Leo and Eagen, 2008). Other medical students have chimed in on the apparent double standard (Brainard and Brislen, 2007). Students who stood up for principles appeared more likely to be punished for rocking the boat than applauded. The latter authors write: “Students are genuinely confused as to what constitutes professional behavior (p. 1010).”
Despite this disappointing pushback, Levinson et al. (2014) point out the value of struggling with definitions of professionalism and with professionalism education: “In short, the arrival of medicine’s modern-day professionalism movement helped both to uncover, but also to create and label, the very tensions between professionalism-as-an-ideal and professionalism-in-practice.” (p. 44) It is important that students have the ability to recognize lapses in professionalism and to use these observations to reflect on what is and is not professional behavior. With this insight, conversations about professionalism can emphasize: “We are generally good people; what are the stressors and situations that challenge us?”
Additionally, students resent the time devoted to professionalism and, by default, “taken away” from scientific courses. Resentment may be particularly strong when the content feels patronizing (Leo and Eagen, 2008; Hafferty, Gaufberg, and O’Donnell, 2015; Stockley and Forbes, 2014). Students are offended by content that feels like common sense, a kindergarten lesson, or a sermon. Faculty may also resent the time devoted to professionalism and other nontechnical competencies – curricular time has long been symbolic of relative importance and power among academic disciplines or departments (Lane, 2007).
Hafferty, Gaufberg, and O’Donnell (2015) suggest that these student reactions result from the hidden curriculum; they describe early medical students as “hypersensitive readers of the environment (p133).” The set of unseen influences known as the hidden curriculum contribute as much, if not more, than any formal curriculum to the process of professional identity formation of veterinary students (Figure 25.1). The hidden curriculum is difficult to define precisely, but the definition of Karnieli-Miller et al. (2010) is useful: “the physical and workforce organizational infrastructure in the academic health center that influences learning process and the socialization to professional norms and rituals.” Important components of this are the people, rituals, regulations, and language that students encounter on a daily basis, in both the academic environment and the clinical environment. Role models are one of the strongest influences on the hidden curriculum (Cruess, Cruess, and Steinert, 2008); faculty must be aware of this aspect of student learning and consider their professional behaviors accordingly. Students must also be introduced to the powerful influence of the hidden curriculum early in a professionalism curriculum. Students who are aware of the influence of role models and language can be encouraged to identify and reflect on both positive and negative incidents, hopefully encouraging them to mirror appropriate rather than inappropriate behaviors.
Fortunately, students tend to recognize the value of nontechnical content increasingly as they progress through the overall curriculum. Heath, Lanyon, and Lynch-Blosse (1996) found that Australian veterinary students’ attitudes toward the importance of communication skills, self-management, and understanding of others in the curriculum increased from the first to the fifth year of training and beyond. The importance of professional skills as compared to other technical skills also increased in fourth-year students and graduates of a Canadian veterinary college (Tinga et al., 2001). Third-year students in another veterinary college felt confident that they would “turn on” professionalism when it mattered (Lane, 2006). Not surprisingly, professionalism curricula in residency training programs tend to be highly effective and well received, given the immersion of residents in clinical work (Deptula and Chun, 2013). Although reassuring, this reality presents significant dilemmas regarding what to include in formal curricula and when to include it.
Educational Theory Relevant to the Teaching of Professionalism
As with any curricular component or approach, it is important to consider relevant educational theory when developing a curriculum of professionalism. There are several useful theories that help faculty consider how to deliver this teaching, and all have reflective practice as a core component.
The concept of situated learning (Lave and Wenger, 1991) is often used as an overarching framework for professionalism curricula (Cruess and Cruess, 2006). This framework acknowledges classroom learning as a fairly ineffective contribution to the development of professionalism as a standalone element. Cognitive foundations must be brought together with contextualized experience to make professionalism authentic and recognizable to students (Table 25.2). Situated learning is the notion of putting knowledge acquisition in a real-life context, ensuring the development of the novice to an expert with a professional identity and a core set of common values (Maudsley and Strivens, 2000). By nature, situated learning is a social learning process, requiring interaction and collaboration with others. Students go through a phase of “legitimate peripheral participation,” being allowed to learn from the skills and behaviors of others, before developing these things themselves and becoming firmly embedded in the workplace and entrusted to carry out appropriate tasks. The key components of situated learning as described by McLellan (1996) are outlined in Table 25.2. The experience-based learning model of clinical students learning in the workplace draws much from situated learning, and has “supported participation” at its core, leading to both emotional and practical learning (Dornan et al., 2007).
Table 25.2 Key components of situated learning
|The traditional apprenticeship model is expanded where teachers make task elements explicit and ensure that relevance is explained to the learner
|Learning takes place with others, encouraging group problem-solving, often in an interprofessional context
|Reflection on action and considering future actions are essential
|A chance to practice skills
|Repetition of tasks allows development of automation and the ability to perform tasks in a range of situations
|Articulation of learning skills
|The overt description of task elements and the way in which problems have been solved is important to developing experts
Source: McLellan, 1996.
Experiential Learning and Reflection
The concept of experiential learning is well recognized in clinical curricula, and is of great importance when developing a curriculum of professionalism. The classic experiential learning cycle (Kolb and Fry, 1975) explains how experience contributes to learning in four cyclical steps: concrete experience, reflective observation, abstract conceptualization, and active experimentation (see Figure 6.1 in Part Two, Chapter 6: Collaborative Learning).
A prominent way in which students will learn professionalism is by participating in tasks and reflecting on their performance; ample opportunities for workplace-based experience form a key component of ensuring that this occurs, alongside teaching students to engage in reflective practice. Simulation can also be used to deliver experiential learning, and this can be an effective way to improve readiness for the workplace and a smooth transition (Kneebone et al., 2002).
It is important to ensure that students reflect on action as well as the more spontaneous reflection in action (Schön, 1983), and this can be facilitated by the use of reflective diaries or portfolios, in which students describe their thoughts and actions and their impact on others. Formal reflection should also ensure that students plan learning goals, which is important as they develop their professional identity. Reflective practice is also generally included as a component of professionalism, and so it is not only a part of students’ learning, but something that they must be able to do effectively in order to progress to being an expert with the ability to think critically and solve problems (Lachman and Pawlina, 2006).
The relevant educational theories inform delivery methods: methods for highlighting professionalism are by necessity experiential and interactive. The nature of the material to be delivered also compels there to be a variety of methods employed in a variety of settings (Table 25.3). Intensive sessions during orientation or inter-semester periods can provide some space for exploration, but may suffer from a lack of context and experience (Walton et al., 2013). The separation also may place the professionalism symbolically outside of the “regular” curriculum. Didactic presentations should be limited, but are sometimes necessary for foundational material. Lectures or large-group discussions can be enhanced by using student response systems (clickers) to unveil diverse or consensus student opinions (Mueller, 2015). Formal courses also employ small groups for discussion of case studies or critical reflections. Periodic faculty-led case presentations and guest speakers can be effective too (Byszewski et al., 2012). The use of critical incident reporting and reflection has been described to formalize debriefing of real-life observations (Branch, 2005). Students discuss behaviors and situations that they have encountered in small groups, and consider professionalism issues. These conversations also serve to uncover the hidden curriculum and make it an identifiable component of their professional development. Simulation, role play, and interviews with veterinary team members, clients, producers, or public health officials are other commonly used methods (Ramani and Orlander, 2013; MacPherson et al., 2014).
Table 25.3 Curricular activities for professionalism education
|Ceremony or orientation
|Introduces necessary basic knowledge
Symbolism can be powerful
|Usually prior to context
Empty gesture if not followed up in practice
Can empower students excessively
|Not usually done; quiz could cover basic points or reflective writing
|Intensive workshops or bootcamps
|Particularly useful for house officers Provides space for reflection and dialog
|Time and labor intensive
|OSCE or performance-based assessment
|Didactic cognitive foundation course
|Provide cognitive base in consistent message Offers opportunity to build
|Students may resent time commitment May not be in experiential context
|Multiple options: exam, OSCE, portfolio
|Personal mission statements or projected obituary exercises
|Student directed and personal
|Lack of relevance for early curriculum
Students may not engage
|Ability to see another’s point of view Create meaning independently
|Brief exposures may not be effective
Students may not engage
|Role modeling (e.g., mentoring program)
|Situational and resource independent Most effective for learners, especially with debriefing opportunities
|Role-modeled behaviors are positive and negative Message can confuse students
|Can cover many different types of scenarios Delivered to small groups or in online fora
|Often feel open-ended for students
May not be realistic
|Reflection or discussion
|Capture situations or interactions for review in multiple settings
|May not appear realistic or authentic Can be expensive to produce
|Reflection or discussion
|Peer group discussions
|Student directed authentic and relevant to student experience
|Schedule coordination may be difficult Peer training required for consistency
|Reflective writing or group report
|Owner or veterinarian interviews, panels, or testimonials
|Authenticity Most effective with small groups of students
|Labor intensive to coordinate
Outcome of sessions may be unclear
|Allows individual exploration and safe practice in making decisions
|Authenticity can be challenging in online delivery
|Provides safe space for practice and simulates actual workplace
|Can be labor intensive or expensive
|Early clinical experience
|Allows situated learning and context Fosters the socialization process
|Experiences are likely to be inconsistent
|Reflection or journal review
|Journals or narrative reflections
|Personal interaction with content Skill-building for reflection in practice
|Time consuming for students require practice and feedback
|Community service or service learning experiences
|Authentic experiences Develop multiple skills
|Labor intensive to facilitate
Hidden curriculum difficult to control
Narrative or reflective report
|Critical incident discussions
|Use real-life content, foster reflective practice
|Facilitators must foster safe and confidential disclosure and reflection
Note: OSCE = objective structured clinical examinations.
The importance of role modeling as an educational method cannot be overemphasized. Role modeling tends to be a preferred opportunity for learners of all levels (Riley and Kumar, 2012; Morihara, Jackson, and Chun, 2013; Byszewski et al., 2012). Faculty and staff should be aware that students are continually watching for clues as to how to act. In the clinical environment, students are expected to absorb constant messages from observing and participating in client interactions, diagnostic and treatment decisions, and veterinary team operations. The professionalism component can be made more explicit by educators, however. Attention to positive and negative expressions of professionalism can be regularly added to discussions of medical or surgical details. Activities can also be designed to raise awareness of language, communication, teamwork, respect, and responsibility (Lane and Cornell, 2013). Debriefing of critical incidents is useful as well. Again, educators must be prepared to elicit observations and discussion from students, rather than simply relaying their own experience or perspective.
Preparing Content and Using Examples
Content used for teaching and assessing professionalism must be current, authentic, and relevant. Content organization requires a challenging balancing act to hit the mark for context and relevance at each point in the curriculum, avoiding redundancy to maintain student interest. As illuminated by medical student pushback, content must avoid the appearance of simply trying to teach morality. By focusing on the impact of professional actions and decisions, rather than the moral grounds for decisions (as important as that seems), messages may find better reception. Additionally, the circumstances that make just doing the right thing more challenging in practice can be emphasized, especially when peer behavior or role-model behavior alters the context (Levinson et al., 2014; Huddle, 2005). Attention to professional lapses must be balanced with sufficient examples of positive behavior. Elementary points about professional dress, classroom etiquette, and respect for others may be best addressed separately, or left up to the students themselves to explore (Leo and Eagen, 2008).
Listening to student input or client input is particularly useful when forming content and illustrative examples. In one medical school, students in internal medicine and pediatrics clerkships wrote case observations identifying ethical or professional issues, and redacted versions were used to facilitate seminar discussion. Based on qualitative analysis of hundreds of student reports, the most frequent issues included (in decreasing order) inadequate communication, end-of-life or quality-of-life treatment concerns, discord between doctor’s and patient’s wishes, disrespect to patient or family, resuscitation decisions, and lapses in patient confidentiality. Student roles and reactions were also themes in the observations (Kaldjian et al., 2012). Public views of professionalism can inform content too: the most prized elements of medical professionalism include doctors’ genuine (attentive, empathetic, compassionate) interactions with patients and colleagues, confidentiality, fairness, accessibility, and accountability (Chandratilake et al., 2010).
Other examples can be pulled from news articles, videos, television shows, or other narratives. Literature and art are particularly rich media for expanding a learner’s ability to see through others’ eyes (Marchalik, 2015; Stone and Weisert, 2004). A young academic physician who teaches literature in medicine poignantly relates how this is usually learned – the hard way:
As interns we learned that recognising the depth of another’s suffering is a skill earned the hard way – by repeatedly bearing witness to it – because we were seldom taught to imagine the world from another’s point of view in the classroom. (Marchalik, 2015, p. 2346)
He reminds us how storytelling is a compelling educational strategy, provided that learners are allowed to explore personal thoughts and feelings in a safe environment.
Organizational Professionalism and the Learning Environment
The success of a professionalism curriculum also depends on the professionalism and support of the institution. While a few dedicated individuals often carry professionalism efforts in veterinary schools, visible institutional support can make these efforts truly successful. Institutional support is usually found in mission and values statements, participation by top leaders, and commitment of resources.
In the health professions, organizational professionalism can go further than the student curriculum. Stern and Papadakis (2006) plead for a systemic environment of professionalism in academic medical centers and professional organizations, where all personnel are trained to role model professional behavior and administrative decisions prioritize the delivery of compassionate and professional healthcare. Levinson et al. (2014) summarize institutional professionalism as a pie chart of prevention, education, intervention, and reward, spanning all units and levels of the school and hospital. Rewards and scholarships are popular and meaningful ways to visibly recognize exemplary professional behavior (Byszewski et al., 2012; Hammer, 2000).