|Year : 2019 | Volume
| Issue : 1 | Page : 19-24
Assessment of dental students' attitudes and perceptions toward professionalism
N Amritha, MK Vanishree, K Mahesh Chandra, Priya Babu
Department of Public Health Dentistry, AECS Maaruthi College of Dental Sciences and Research Centre, Bengaluru, Karnataka, India
|Date of Submission||15-Sep-2018|
|Date of Acceptance||13-Feb-2019|
|Date of Web Publication||15-Mar-2019|
Dr. M K Vanishree
Department of Public Health Dentistry, AECS Maaruthi College of Dental Sciences and Research Centre, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Professionalism is a broad competency needed by dentists to act effectively and efficiently. It is seen as a central part of both undergraduate (UG) and postgraduate (PG) curricula. Aims: This study aimed to assess the attitude and perceptions of dental students toward professionalism and the influence of gender on the same. Materials and Methods: A cross-sectional descriptive study was carried out in four different dental colleges of Bengaluru city. A stratified random sampling technique was employed to select a sample of 480 dental students. The Professional Assessment Scale was used to assess professionalism. It is a 22-item questionnaire which is divided into three domains, namely, empathy and humanism, professional development and relationship, and professional responsibility domains. The students responded on a 5-point Likert scale, ranging from strongly disagree to strongly agree. The data collected were analyzed using SPSS software version 14.0. Chi-square test, independent Student's t-test, ANOVA, and Pearson's correlation were performed. P < 0.05 was considered statistically significant. Results: The mean overall Professional Assessment Scale scores were 93.12 ± 10.35, 97.41 ± 8.59, and 94.42 ± 10.06 for UGs, interns, and PGs, respectively, and these associations were statistically significant (P < 0.001). No significant gender differences were observed in the overall mean scores. Conclusions: The study concluded that all the participants possessed at least some elements of professionalism; recognizing these concerns and integrating them into professional educational programs can result in a better and more supportive health-care service for the public.
Keywords: Dental students, empathy and humanism, professionalism, Professionalism Assessment Scale
|How to cite this article:|
Amritha N, Vanishree M K, Chandra K M, Babu P. Assessment of dental students' attitudes and perceptions toward professionalism. J Indian Assoc Public Health Dent 2019;17:19-24
|How to cite this URL:|
Amritha N, Vanishree M K, Chandra K M, Babu P. Assessment of dental students' attitudes and perceptions toward professionalism. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2019 Nov 21];17:19-24. Available from: http://www.jiaphd.org/text.asp?2019/17/1/19/254325
| Introduction|| |
“Be professional” is such a versatile ethical imperative that it can give guidance in how we ought to act in almost all aspects of our working lives. Professionalism can be defined as a collection of attitudes, values, behaviors, and relationships that acts as the foundation of the health professional's contract with the society. Medicine has been regarded as a “profession” for centuries. Indeed, over millennia and a wide variety of cultures and locales, oaths, and codes of ethics have described physicians' professional and ethical values and duties. Until recently, it was assumed that trainees in medicine would assimilate and physicians in practice would maintain these values and duties. In recent decades, however, the medical profession has been criticized for perceived and real breaches of professionalism and ethics (e.g., promoting self-interests rather than the interests of patients). In response to this criticism, interest in preserving, promoting, teaching, assessing, and researching medical professionalism has increased. Much attention has been devoted in recent years to the question of professionalism in medical education and practice. Historically, dentistry has followed the path of barber-surgeons, beginning as mainly a business enterprise in the late 19th and 20th centuries, and later moving to a model more analogous to that of the medical profession. Dentistry eventually came to be recognized as a true profession that had a “social contract” with the public. In order for medical students, physicians, and dental students in training to become professionals and physicians in practice to remain professionals, the elements of the framework of professionalism – clinical knowledge and skills, communication skills, ethics, accountability, altruism, excellence, and humanism – should be intentionally taught. This intentionality requires formal curricula and authentic fostering of a culture of professionalism in learning environments. Similarly, professionalism should be intentionally assessed. Clear expectations and rich experiences alone will not guarantee that professionalism is learned. Assessment motivates individuals to learn what is important (i.e., professionalism) and helps determine whether competency in professionalism has been achieved. The American Board of Internal Medicine defines professionalism as requiring “the physician to serve the interests of the patient above his or her self-interest. Professionalism aspires to altruism, accountability, excellence, duty, service, honor, integrity and respect for others.”
Literature search revealed that instruments to assess professionalism were developed based on the theoretical framework of the American Board of Internal Medicine (ABIM), Accreditation Council for Graduate Medical Education, and General Medical Council standards, and other instruments were constructed based on literature review or on qualitative analysis involving focus group discussions, the Delphi method, or interviews with experts. No single method exists for the reliable and valid evaluation of professional behavior. Some works evaluate professional behavior as part of clinical performance. Other studies evaluate only professional behavior, as a comprehensive entity in and of itself. Still, other researches evaluate single elements of professional behavior such as humanism, self-assessment, dutifulness, altruism, empathy and compassion, honesty, integrity, and ethical behavior, as well as communication. Arnold classified instruments assessing medical professionalism into the following three groups: those assessing professionalism as a facet of competence; those assessing professionalism as a comprehensive construct; and those assessing separate elements of professionalism, such as humanism and empathy. As such, there is no gold standard for the assessment of professionalism. There are various instruments that can be found in literature review such as Arnold et al. developed a self-assessment instrument based on the American Board of Internal Medicine (ABIM) definition of professionalism. This instrument focuses on specific negative (unprofessional) behaviors associated with the ABIM domains of professionalism. DeLisa et al. developed the Amsterdam Attitude and Communication Scale (AACS). This 9-item behavioral scale used by preceptors to evaluate trainees is time efficient but not comprehensive. Papadakis et al. developed the Physicianship Evaluation Form. In this instrument, 20 items, over four domains, are used by preceptors to assess student professionalism. This behavioral instrument is more comprehensive than the AACS tool with respect to the possible domains of professionalism, but does not include the domain of engagement with one's profession. The Penn State College of Medicine (PSCOM) Professionalism Questionnaire, The Jefferson Scale of Physician Empathy measure only certain specified elements of professionalism.
The Professional Assessment Scale, developed and validated by Klemenc-Ketis and Vrecko, proved to be valid and reliable in assessing professionalism among undergraduate (UG) medical students, with the following three factors: empathy and humanism, professional relationship and development, and professionalism responsibility. Professionalism is a broad competency needed by dentists to act effectively as well as efficiently and is seen as a central part of both UG and postgraduate (PG) curricula. Since there is not much difference between the clinical setting, curriculum, and exposure among medical and dental students, we aimed to use this scale to assess the dental students' attitudes toward professionalism in our study.
| Materials and Methods|| |
A cross-sectional descriptive study was conducted on 480 students of different dental colleges of Bengaluru city. In this study, stratified random sampling technique was employed. Four colleges were randomly selected for the purpose of the study. Each college includes 1st-year, 2nd-year, 3rd-year, 4th-year UG students, interns, and PG students; from each college, 120 participants were selected. Using systemic random sampling, every 3rd student was taken as a sample unit from the groups until the desired sample size of 20 per group was reached. The duration of the study was about 2 months from August to October 2017, during which the specified sample size was attained. On an average, 25–30 students were assessed per day. The required ethical clearance was obtained from the Institutional Ethical Review committee (120A/2017-18). The sample size was estimated based on the pilot study data using the following formula:
n = (Zα/2)2 × P × (1 − P) × D/E2
where Zα/2 (confidence interval) =1.96, Prevalence (P) =50%, Design effect (D) =1, Error (E) =10%. Dropout rate = 25%.
According to the above-given formula, the final sample size was:
Considering nonresponse rate to be 25% and sample loss due to attrition, the minimum sample size needed would be n = 480.
A specially designed pro forma was used in our study. The pro forma comprised two sections. Section 1 included informed consent. Section 2 included the Professional Assessment Scale. The first part of the questionnaire contains information related to demographic characteristics, particularly age, sex, and education of the participants. The second part of the questionnaire contains the Professional Assessment Scale questions. The Professional Assessment Scale was developed by Klemenc-Ketis and Vrecko. The scale contains 22 items related to professionalism. The first ten questions are related to empathy and humanism domain. The next eight questions are related to professional development and relationship domain. The last four questions are related to professional responsibility domain. The students were required to tick on the appropriate response on the 5-point Likert scale, which ranged from strongly disagree (1) to strongly agree (5). Thus, the final scores ranged between 22 and 110. Respondents scoring higher scores were considered having higher professional attitudes. A pilot study was carried out on 48 participants of a dental college to check for the validity and reliability of the questionnaire items and for calibration of the examiner. The Cronbach's alpha value was 0.767, which is good and warrants the expansion of the scale to dental students.
Statistical analysis was performed using Statistical Package for the Social Sciences for Windows, Version 14.0 (IBM Corp., Armonk, NY, USA). Descriptive analysis of all the study parameters was done using mean and standard deviation for continuous data and frequency and percentage for categorical data. Chi-square test was used to compare the gender-wise proportional differences in the responses for various questionnaire items. Independent Student's t-test was used to compare the gender-wise, mean differences for different domains of the scale. Comparison of mean sum scores of different domains of the scale between different academic years of dental students was done using one-way ANOVA test. Pearson's correlation test was used to assess the relationship between various domains of the scale and different academic years of dental students. The level of significance was set at P < 0.05.
| Results|| |
Analysis of the demographic data revealed that the mean age of the study participants was 22.2 ± 3.06 years. Among the 480 participants, 135 (28.1%) were male and 345 (71.9%) were female [Table 1]. Among the different age groups studied, respondents belonging to the 18–21 years' age groups were maximum (n = 255), whereas respondents belonging to the age group of 26 years and above were found in least number (n = 79) [Table 2]. Nearly 78.8% of the study participants possessed high attitude toward professionalism, whereas 2.3% only had low professionalism. No significant gender differences related to professionalism were observed [Table 3]. However, the mean scores of females were greater than that of males. When mean scores in comparison to gender and subdomains were analyzed, it was observed that UG females were more oriented toward the responsibility domain than males, whereas vice versa was observed in PGs that males appeared to be more responsible than females. Comparison of mean overall scores revealed that interns had the highest professionalism assessment score of 97.41 ± 8.59 than UGs (93.12 ± 10.35), and PGs (94.42 ± 10.06) had a statistical significance of P < 0.001. Comparisons among the subdomains showed that interns scored higher in empathy and humanism domain (P < 0.001) and professional relationship and development domain (P < 0.002), whereas the responsibility domain did not show any statistically significant results within the different academic years [Table 4]. Pearson's correlation test analysis showed that UGs had a negative correlation with the total scores of professionalisms, whereas interns and PGs showed slightly positive correlation with the total professionalism scores [Table 5].
|Table 1: Age- and gender-wise frequency distribution of the study participants|
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|Table 2: Frequency distribution of professional attitude scores among the study participants|
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|Table 3: Gender-wise comparison of mean sum scores of different domains of the scale and overall scores among the study participants|
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|Table 4: Comparison of mean sum scores of different domains of the scale between different academic years of dental students|
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|Table 5: Relationship between academic year and various domains of the scale in different academic years of dental students|
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| Discussion|| |
A cross-sectional descriptive study was conducted to assess the professionalism in dental students of Bengaluru city. On reviewing literature, it was found that not many studies have been conducted on dental students to assess their professionalism. To our knowledge, this is the first of a kind study to be conducted in India among dental students to assess professionalism. Dental professionalism is an essential requirement to practice dentistry in the current environment. It is a construct that covers both abilities and personal qualities. There is, therefore, a need for programs of assessment within dental education that are both formative, to aid professional development, and summative, to determine whether students have reached appropriate standards. Methods and systems that have been used to assess medical professionalism are well documented and may be useful within dentistry.
In the present study, female participants were high in number (n = 345, 71.9%) than males (n = 135, 28.1%). These findings are similar to the study done by Javadi et al., in which out of 447 participants, 240 (53.7%) were female and 207 (46.3%) were male participants, and studies conducted by Salam et al. and Duke et al. showed similar findings. In a study conducted by Ojuka et al. to determine the perceptions of medical professionalism, male–female ratio was 1.7:1.
In our study, 378 (78.8%) dental students showed higher attitude toward professionalism, whereas only 11 (2.3%) students demonstrated lower attitude toward professionalism. In a study done by Al-Sudani et al., 59% of the study participants demonstrated high professional attitudes and behavior. The study results are similar to those of Javadi et al. where 78.8% had higher attitudes and 0.2% demonstrated lower attitude.
In our study, females had scored higher professionalism scores (93.63 ± 9.57)than males; however, the results are not statistically significant. In this 21st century, India, being a developing country, has seen an upsurge in female education. Gone are those times when females were only homemakers. Medical field specially has seen growth in females pursuing higher degrees and the high proportion of female patients, and hence the issue of gender-based differences in medical care rendered by male and female doctors requires much more attention. The findings of our study are analogous with studies of Duke et al. and Javadi et al. where no gender differences regarding professionalism were observed. Contrary to our findings, a study done by Salam et al. in Bangladesh showed that male participants scored better than female participants. Whereas studies by Johnston et al., Salam et al. in Malaysia, Haque et al., and Seif-Farshad et al. observed that female participants were more professional than male participants.
In our study, interns demonstrated the highest total professionalism scores. This could be because they are more career oriented and they need to conduct themselves as professionals as they have the responsibility toward the society and their patients and the fact that they start working in private clinical setup where they observe the dentist–patient coordination in person. This is in contrast to a study conducted by Al-Sudani et al. where interns showed the most unprofessional attitudes. In a study conducted by Peters et al., PGs scored higher professional mean scores than medical students with a statistical significance of P < 0.05. A study done by Morreale et al. reported that resident physicians scored the highest mean professionalism scores.
In our study, UGs had a negative correlation with the total professionalism scores. Interns and PGs had a positive correlation with the total professionalism scores, which was not statistically significant. Whereas in a study by Bazrafcan et al., there was no significant correlation between age and mean scores of professional ethics.
In our study, it was observed that, as the training period increased, there was an increase in empathy from 1st year to postgraduation, except in the final year; this could be due to exam-related stress and burden of patients from various departments. There was again observed an increase in empathy when they became interns and empathy scores decreased as they enter postgraduation; these results were statistically significant (P = 0.01). Chen et al. in their study observed that the first-year medical school class has the highest empathy scores (118.5), whereas the fourth-year class has the lowest empathy scores (106.6). No difference was observed between the first- and second-year classes (118.5 vs. 118.2, P = 0.77), or between the third- and fourth-year classes (112.7 vs. 106.6, P = 0.10). Similarly, a study by Sherman and Cramer documented that first-year dental students had significantly higher empathy scores than students in any subsequent years, which is in contrast to our study findings. In our study, UGs had statistically significant negative correlation with empathy and humanism domain.
There was a significant increase in the mean scores of professional relationship and development domain across various study years. In a study by Javadi et al., 84% of pharmacists scored higher, with regard to working relationship with physicians. Aspects such as lifelong learning and communication skills are adapted as the students are exposed to the clinical environment. Students have some prior knowledge about professionalism before entering medical curriculum, but the reality check is when they enter the clinical setting, the importance of relationship development skills is imbibed through the clinical training period. One could anticipate that UG students might not be fully aware of the need for professional development as this is usually a feature of lifelong learning. Professional relationship and development showed a weak reverse relationship between work experience and working relationship with physicians. In the responsibility domain, females scored a mean of 17.3 and males scored a mean of 16.31, which was statistically significant (P = 0.009). Assessment of dental students' professionalism by Zijlstra-Shaw et al. showed higher mean scores of females compared to males in the responsibility domain. In a study conducted by Cain et al., female students significantly demonstrated more accountability for illegal actions and unprofessional behaviors than their male counterparts did. In a study by Peter et al., PGs had higher mean scores with respect to the responsibility domain, which is in line with our study findings. Similarly, older pharmacists scored higher in accountability/responsibility domain in a study conducted by Chisholm et al. In contrast, both medical students and attending psychiatrists rated the category of social responsibility significantly less important than did residents. In a study by Javadi et al., age showed a positive correlation with the score of accountability/responsibility. In our study, older students showed very weak correlation with responsibility domain compared to younger students who showed a negative correlation. Chisholm et al. showed that there was a weak relationship between age and accountability. It is a general notion that, the younger the people, the more irresponsible they are, this can be applied here, as UGs and interns are in a carefree phase, they are not serious about their life and future and do not wish to be accountable for their actions or behaviors.
In the present study, the Professionalism Assessment Scale has proved to be valid and reliable in assessing professionalism in dental students across the study years. These study results could be generalized, as the sample was quite adequate. The majority of the study participants were females, which could have led to the disproportionate results regarding gender. Studies with equal gender sample must be undertaken to eliminate this bias. In addition, this instrument is designed to measure attitudes (beliefs), not behaviors. It does not identify whether the respondents actually behave in a manner consistent with the reported attitudes. Beliefs drive behavior. However, the actual demonstrated behavior not only depends on beliefs, but also on other factors, such as the environment and students' competencies.
| Conclusions|| |
We recommend provision of a well-organized ethics course in the dental curriculum, which seems to be of paramount importance. In order for us to achieve this goal, it can be suggested that the obstacles between practice and communication and workspace be thoroughly evaluated from environmental, clinical, personal, economic, and social aspects. We believe that recognizing these concerns and integrating them into professional educational programs can result in a better and supportive health-care service for the public.
We would like to thank the authorities and students who supported us in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Trathen A, Gallagher JE. Dental professionalism: Definitions and debate. Br Dent J 2009;206:249-53.
Klemenc-Ketis Z, Vrecko H. Development and validation of a professionalism assessment scale for medical students. Int J Med Educ 2014;5:205-11.
Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75:612-6.
Mueller PS. Incorporating professionalism into medical education: The mayo clinic experience. Keio J Med 2009;58:133-43.
Stern DT, Papadakis M. The developing physician – Becoming a professional. N Engl J Med 2006;355:1794-9.
Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79:244-9.
Arnold L. Assessing professional behavior: Yesterday, Today, and Tomorrow. Acad Med 2002;77:502-15.
Arnold EL, Blank LL, Race KE, Cipparrone N. Can professionalism be measured? The development of a scale for use in the medical environment. Acad Med 1998;73:1119-21.
DeLisa JA, Foye PM, Jain SS, Kirshblum S, Christodoulou C. Measuring professionalism in a physiatry residency training program. Am J Phys Med Rehabil 2001;80:225-9.
Papadakis MA, Loeser H, Healy K. Early detection and evaluation of professionalism deficiencies in medical students: One school's approach. Acad Med 2001;76:1100-6.
Akhund S, Shaikh ZA, Ali SA. Attitudes of Pakistani and Pakistani heritage medical students regarding professionalism at a medical college in Karachi, Pakistan. BMC Res Notes 2014;7:150.
Chen D, Lew R, Hershman W, Orlander J. A cross-sectional measurement of medical student empathy. J Gen Intern Med 2007;22:1434-8.
Zijlstra-Shaw S, Roberts T, Robinson PG. Evaluation of an assessment system for professionalism amongst dental students. Eur J Dent Educ 2017;21:e89-100.
Javadi M, Asghari F, Salari P. Assessment of professionalism in Iranian pharmacists. J Med Ethics Hist Med 2011;4:6.
Salam A, Haque M, Islam MZ, Helali AM, Yousuf R, Yesmin F, et al
. Comparative study of professionalism of future medical professionals among three private medical colleges of Bangladesh. Asian J Pharm Clin Res 2013;6:170-9.
Duke LJ, Kennedy WK, McDuffie CH, Miller MS, Sheffield MC, Chisholm MA. Student attitudes, values, and beliefs regarding professionalism. Am J Pharm Educ 2005;69:104.
Ojuka DK, Olenja JM, Mwango'mbe NJ, Yang EB, Macleod JB. Perception of medical professionalism among the surgical community in the University of Nairobi: A mixed method study. BMC Med Educ 2016;16:101.
Al-Sudani D, Al-Abbas F, Al-Bannawi Z, Al-Ramadhan A. Professional attitudes and behaviors acquired during undergraduate education in the college of dentistry, King Saud University. Saudi Dent J 2013;25:69-74.
Johnston JL, Cupples ME, McGlade KJ, Steele K. Medical students' attitudes to professionalism: An opportunity for the GP tutor? Educ Prim Care 2011;22:321-7.
Salam A, Yousuf R, Islam MZ, Yesmin F, Helali AM, Alattraqchi AG, et al
. Professionalism of future medical professionals in University Sultan Zainal Abidin, Malaysia. Bangladesh J Pharmacol 2013;8:124-30.
Haque M, Zulkifli Z, Haque SZ, Kamal ZM, Salam A, Bhagat V, et al.
Professionalism perspectives among medical students of a novel medical graduate school in Malaysia. Adv Med Educ Pract 2016;7:407-22.
Seif-Farshad M, Bazmi S, Amiri F, Fattahi F, Kiani M. Knowledge of medical professionalism in medical students and physicians at Shahid Beheshti University of medical sciences and affiliated hospitals-Iran. Medicine (Baltimore) 2016;95:e5380.
Peters D, Ramsewak SS, Youssef FF. Knowledge of and attitudes toward medical professionalism among students and junior doctors in Trinidad and Tobago. West Indian Med J 2015;64:138-44.
Morreale MK, Balon R, Arfken CL. Survey of the importance of professional behaviors among medical students, residents, and attending physicians. Acad Psychiatry 2011;35:191-5.
Bazrafcan L, Amini M, Lotfi F, Jalali Z. Professionalism among clinical faculty in shiraz medical school by self-assessment. Bimonthly J Hormozgan Univ Med Sci 2012;16:387-94.
Sherman JJ, Cramer A. Measurement of changes in empathy during dental school. J Dent Educ 2005;69:338-45.
Zijlstra-Shaw S, Robinson PG, Roberts T. Assessing professionalism within dental education; the need for a definition. Eur J Dent Educ 2012;16:e128-36.
Cain J, Scott DR, Akers P. Pharmacy students' Facebook activity and opinions regarding accountability and e-professionalism. Am J Pharm Educ 2009;73:104.
Chisholm MA, Cobb H, Duke L, McDuffie C, Kennedy WK. Development of an instrument to measure professionalism. Am J Pharm Educ 2006;70:85.
Barnhoorn PC. What does a professionalism assessment scale measure? Int J Med Educ 2015;6:62.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]