Final year medical students and professionalism: lessons from six Sudanese medical schools?

Introduction

The Royal College of Physicians described professionalism as “a set of values, behaviours, and relationships that underpins the trust the public has in doctors”. Professionalism is one of six core competencies that physicians-in-training must have before graduating (1). As indicated by the “Doctor Charter,” there are three “major standards” and ten “expert obligations” that portray demonstrable skill. The standards are supremacy of patient welfare, independence and social equity (2,3), while, the professional responsibilities include commitment to competence, honesty, confidentiality, appropriate relations with patients, improving quality and access to care, fair distribution of resources, scientific knowledge, maintaining trust, and refuting conflicts of interests (1). A framework for professionalism has been proposed by Arnold and Stern (4). Clinical competence, effective communication skills, and a sound understanding of ethics form the foundation of the framework. The pillars of the framework are accountability, altruism, excellence, and humanism (5). Professionalism is associated with improved medical outcomes (5). Among students, there are many dishonest behaviours and lapses in the academic integrity (6). It is noticed that the issue of autonomy can easily be misunderstood. So, teaching of professionalism is important not only for undergraduate students but also for residents and specialist (7). In the UK the medical curricula were based on the document “Tomorrows Doctors” in which communication skills are the main issue besides the clinical excellence (8). Similarly, the Canadian medical curricula (The CanMed) characterizes the graduate medical students as, Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional (9).

Historically, it has been assumed that ethics and professionalism can be gained through apprenticeship (10). Nevertheless, the emerging inappropriate behaviours, violations in professionalism and financial conflicts of interest (11-15) has fostered health care institutions, medical societies, and accrediting organizations to encourage teaching, assessing, and promoting professionalism. Teaching professionalism leads to positive modifications in students’ attitudes from 48% to 84%. This is associated with a statistically significant difference in pre/post-test conducted in first year students (16). Also, integration of medical ethics, human rights, professionalism and university requirements lessons within the curriculum of the medical schools is recommended (17).

The Sudan Medical Council (SMC) has exerted a lot of efforts to promote the culture of professionalism among the healthcare providers and has designed two courses for ethics and professionalism to be introduced in the medical curricula for undergraduates (10,18). Recently, the international trend and emphasis is notion that the undergraduate medical curriculum should contain courses about social sciences, behavioural sciences and professionalism. Therefore, the aim of this study was to assess the level of professional knowledge and attitude among final year medical students in different types of Sudanese Medical Schools in the capital Khartoum.

Methods

Study design and set up

This was a descriptive cross-sectional study conducted in the period from January to April 2017. The study was conducted in medical schools located in Khartoum State that has graduated at least five batches (12 medical schools were identified—4 public and 8 private medical schools). Systematic sampling of medical schools resulted in the selection of two public (University of Khartoum, Omdurman Islamic University) and four private medical schools: (Ahfad University for Women, University of Science and Technology, Alwatania University and the National Ribat University). We have only selected final year medical students registered in the academic year 2016–2017 in the above-mentioned medical schools to participate in this study. They were consented to fill the questionnaire.

Sampling technique and sample size calculation

Systematic sampling technique for odd numbers of the students’ the school records were done for selecting students. The required sample size was obtained using the formula:

N=N1+N(d)2[1]

where: n, is sample size; N, is the total number of students enrolled in the academic year 2016/2017 in the final year in the six medical schools; d, is the degree of accuracy required and set to 0.05.

n=1,4311+1,431(0.05)2[2]

n=304. This was the minimum required representative sample size. The actual number of final year students enrolled in the study was 675.

Data collection, management and analysis

The data were collected by a self-administrated, semi-structured questionnaire consisted of four sections. Section one on socio-demographic issues. Section two on the curriculum of ethics and professionalism in the related medical school. Section three and four about knowledge and attitude. The questionnaire has been face validated (>7.5/10) and pretested by pilot study. For assessment of knowledge and attitude we used percentage of the total correct response. The collected data were analysed using the Statistical Package for Social Sciences (SPSS) version 23. Descriptive statistics and percentages were calculated.

Ethical clearance

Ethical approval was obtained from the Ethical Review Board of the Faculty of Medicine, University of Khartoum. Permission from each medical school was obtained. Written informed consent was obtained from students following the insurance of confidentiality of their data. Students were asked not to write their names. In a meeting with the students, a short brief about the study was provided with emphasis on confidentiality, free choice contribution and self-dependent questionnaire filling. The selected students signed agreement sheet and were asked to fill in the questionnaire anonymously. Serial numbers were used for entering data in the SPSS.

Results

Socio-demographic characteristics and general information

The age of respondents ranged from 18–30 years with a mean (±SD) of 22.13 (±1.61) years, 63% of them were females. Out of them 672 (94.9%) were of Sudanese nationality. Table 1 shows the type of their residential places during the study years in Khartoum State. However, 202 (30.7%) lived outside Sudan for more than 10 years of their life (Table 1).

The perception of final year students on the curriculum of medical professionalism and ethics in their schools

Almost 666 (98.8%) of the medical students disclosed that medical professionalism and ethics are taught in their schools, 562 (83.3%) reported that it is taught in a separate course while 104 (15.4%) mentioned that it is incorporated within other courses. About 395 (58.5%), 169 (25.0%), and 32 (4.7%) of the students perceive that the number of courses is 1, 2 and 3, respectively. Nearly 407 (60.3%) of the respondents perceive that the course contents are enough, 169 (25.0%) were not satisfied with the course contents, 90 (13.3%) were not sure about that, in 6 (0.9%) the question is not applicable, while 3 (0.4%) did not respond. There were 536 (79.4%) of the students who answered ‘yes’ for the presence of a psychology course (Table 2).

Knowledge of final year medical schools about medical professionalism and ethics

A total of 647 (96.3%) students, admitted that respect of teachers and colleagues leads to patients’ respect and 582 (86.4%) looked at punctuality as an important professional behaviour. Also, 639 (95.9%) students thought that the good general formal dress increases the respect of others towards them as professionals, and 593 (89.0%) agreed that talking to others with smiley faces is considered a professional behaviour. The concept of patient autonomy was known by 530 (79.5%) of the students. The term non-maleficence was correctly recognized by 392 (59.4%), but 215 (32.6%) were not sure of the meaning of this terminology. The concept of beneficence was known by 508 (76.3%) and missed by 103 (15.5%) students. The information that breaking patient’s confidentiality is allowed if there is a risk to a third party is recalled by 477 (71.5%) and 51 (7.6%) were not certain about that. On the other hand, 611 (91.2%) students didn’t consider that reporting communicable diseases as a break of patient’s confidentiality while 44 (6.6%) did (Table 3). In the knowledge section out of the nine questions: 3 questions answered correctly by >90% of the responders, 5 questions were answered correctly by 70–90 of the responders. Therefore, Sudanese medical students achieved satisfactory knowledge about professionalism.

The professional attitude and behaviour of the final year medical students

The students’ responses towards certain scenarios that they may encounter in their professional life were assessed. Most of the students (76.9%) reflected that they would not agree to accept a gift from any patient (Table 4). Regarding taking consent for treating an adult female and whether the written informed consent should be signed by her husband, this dilemma was gained approval of 25.6% while 59.5% disagree. Importantly, 63.5% agreed that to break bad news to their patients as long as they have capacity irrespective of their depression and psychological status. Questions about protecting community from infectious disease and isolating patients with infectious disease was correctly answered by more than 80% of the respondents. The dilemma of stop working with low resources and less doctor covers in emergency medicine gained approval of 56.9% while 28% disagree. Questions about whether doctor will have judgemental approach and discriminate against his patients when he delivers treatment, 87.4% of medical students agreed to treat even their enemies in front line. Lack of essential working aids in the casualty as a driving cause for concern was agreed upon by 56.9% but, was disagreed upon by 28.0% of the students. Social responsibility question (working in primary health care centres in rural areas) was answered correctly by 87.7% (Table 4). Therefore, it is possible to conclude that Sudanese medical students have an excellent attitude towards non-judgemental and non-discriminatory approach, community protection and readiness to serve rural areas.

Discussion

In this study, there is female predominance. Different studies showed different representation of males and females in medical schools around the world. For example, undergraduate female medical students represent 43% at public (19) and 47.5% at private medical schools in Karachi, Pakistan (20). In Taiwan, there were nearly four times as many males as females with ratio: 3.73:1 (21). Nearly two thirds of the study participants were living in Sudan for the last 10 years, the rest live with their families abroad. Even though professionalism can be taught, the person must have the inherent timbers that form the basis of professionalism (1). In this study, professionalism and ethics are taught in a separate course in the majority of the medical schools. Importantly, the level of knowledge on professionalism and ethics is high in this study compared with other studies such as reported in 2012 in medical schools in Khartoum (22). This may be attributed to the increased awareness about professionalism in general and to the wide introduction of courses of professionalism and ethics in the curricula of medical schools fostered by the SMC. However, basic terminologies of professionalism need to be explained to medical students. For examples, terms like: confidentiality, non-maleficence, beneficence, and autonomy were correctly known by 50%, 59%, 76% and 80% of the respondents, respectively.

In this study the final year medical students do respect punctuality as a professional behaviour and higher than doctors being 86.4% and 78.7% (23). This may reflect that the current curriculum in professionalism may improve the knowledge of participants, however, it may not impress individual attitudes (24). The importance of teaching professionalism by role models, simulations, role plays or case-based scenarios is emphasised (19). Teaching professionalism in the proper way will ensure that students obtain an adequate professional preparation that is well aligned with their future practice setting to support them to properly deal with the ethical dilemmas that they will come across in clinical practice (25). Furthermore, attitudes towards professionalism in medicine were found significantly different between graduate (doctors) and undergraduate medical students (26). Interestingly, graduate entry students showed better attitudes towards various aspects of professionalism, relative to undergraduate students, in a study done in University College Cork, Ireland (27).

Gift-giving is one of the most difficult ethical issues in medical professionalism for the undergraduates to understand. Maintaining appropriate professional limits and at the same time having the flexibility to respond with warmth and appreciation is a great challenge to the clinicians (28). Majority of participants in this study will decline to receive gift from their patients. Should the doctor accept gifts from patients? Some completely decline it so as not to violate physician’s fidelity to the patient; as they think that there are other more meaningful ways to express gratitude (29). On the other hand, Takayama reported the Japanese tradition of a gift giving (30). Nevertheless, some issues such as the purpose of the gift, its value to the patient, the anticipated outcome of accepting or refusing it have to be considered (28). Not only patient-doctor but also student-patient relationships need to be determined (31).

The issues raised in UK by the case of Dr. Bawa-Garba paediatric trainee accepted to work in emergency paediatric unit which was understaff and associated with failure of computer system, have caused worldwide concern. She accepted to work in these circumstances but she was later accused of gross negligence and manslaughter of one of her patients (after many years of legal battles she won an appeal to work again) (32). Therefore, it is not surprising that more than half (56.9%) of the Sudanese tomorrow doctors will stop working at the casualty if the hospital administrative failed to provide the essential aids and facilities for performing their daily duties. The study also showed another social and important issue that 25% respondent agree to operate in females after consent obtained from their husbands. This can be attributed to different factors like: the high level of illiteracy among women in rural areas, the cultural structure of Sudanese community that men should lead negotiation and it can also be a source of pride for majority of women that her husband is caring for her in all aspects of her life. The study also showed that Sudanese medical students have an excellent attitude towards non-judgemental and non-discriminatory approach (87.4%), community protection (81.5%) and readiness to serve rural areas (social accountability) (87.7%). This in part can be attributed to the fact that majority of the medical schools included in this study adopted and transferred significant parts of the curriculum of Faculty of Medicine, University of Gezira (FMUG), Sudan. The curriculum of FMUG is well known to be community oriented and problem-based learning. It worth mentioning that FMUG is one of leading medical schools in social accountability and medical education (33-37).

One of the limitations of this study is the cross-sectional design of the study. Another limitation of the study is the fact that caution is needed about generalization of all the findings of this study to all medical schools in Sudan, as the study was conducted only in the capital Khartoum. Despite these limitations, our study reflected great improvement in professionalism among medical students after the great effort of SMC to promote the culture of professionalism among the healthcare providers.

Conclusions

The level of professional knowledge of the studied final-year medical students is very good and this combined with excellent attitudes in community protection, readiness to serve rural areas and most importantly non-judgemental and non-discriminatory approach. Professionalism can be sensibly taught in medical schools as long as open discussion are allowed to take place about different social factors. In the era of new technologies, Sudanese medical students are not isolated and international events related to medical professionalism may have an influence in their future approach to patient care.

Acknowledgments

We would like to thank the administrations of the six participating medical schools for facilitating conduction of this research. Many thanks with respect are extended to the student coordinators at the six participating medical schools for organizing common meetings for data collection. Dr. Nazik Elmalaika Husain and Dr. Mohamed H. Ahmed are both graduated from Faculty of Medicine, University of Gezira (FMUG) and would like to dedicate this work for both colleagues in batch 13 and staff in Faculty of Medicine, University of Gezira.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mohamed H. Ahmed, Heitham Awadalla and Ahmed O. Almobarak) for the series “The Role of Sudanese Diaspora and NGO in Health System in Sudan” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jphe.2018.08.01). The series “The Role of Sudanese Diaspora and NGO in Health System in Sudan” was commissioned by the editorial office without any funding or sponsorship. MHA serves as an unpaid editorial board member of Journal of Public Health and Emergency from August 2017 to July 2019 and served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Ethical approval was obtained from the Ethical Review Board of the Faculty of Medicine, University of Khartoum. Permission from each medical school was obtained. Written informed consent was obtained from students following the insurance of confidentiality of their data.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Riley S, Kumar N. Teaching medical professionalism. Clin Med (Lond) 2012;12:9-11. [Crossref] [PubMed]
2. Foundation A. Foundation A-A. Medical professionalism in the new millennium: a physician charter. Obstet Gynaecol 2002;100:170-2.
3. Blank L, Kimball H, McDonald W, et al. Medical professionalism in the new millennium: a physician charter 15 months later. Ann Intern Med 2003;138:839-41. [Crossref] [PubMed]
4. Stern DT. A framework for measuring professionalism. Measuring medical professionalism 2006:3-14.
5. Mueller PS. Teaching and assessing professionalism in medical learners and practicing physicians. Rambam Maimonides Med J 2015;6:e0011. [Crossref] [PubMed]
6. Shukr I, Roff S. Prevalence of lapses in academic integrity in two Pakistani medical colleges. Med Teach 2015;37:470-5. [Crossref] [PubMed]
7. Villanueva LA, Collado Pena S. Ginecol Obstet Mex 2004;72:273-8. [Attitudes and hierarchy of medical values in a gynecology and obstetrics department]. [PubMed]
8. Davis CR, Toll EC, Bates AS, et al. Surgical and procedural skills training at medical school - a national review. Int J Surg 2014;12:877-82. [Crossref] [PubMed]
9. Albanese MA, Mejicano G, Mullan P, et al. Defining characteristics of educational competencies. Med Educ 2008;42:248-55. [Crossref] [PubMed]
10. Karrar ZA. Professionalism and good medical practice: the role of Sudan Medical Council. Sudan Med J 2009;45:1-4.
11. Brennan MD, Monson V. Professionalism: good for patients and health care organizations. Mayo Clin Proc 2014;89:644-52. [Crossref] [PubMed]
12. Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA 1998;279:1889-93. [Crossref] [PubMed]
13. Greysen SR, Chretien KC, Kind T, et al. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA 2012;307:1141-2. [Crossref] [PubMed]
14. Campbell EG, Gruen RL, Mountford J, et al. A national survey of physician-industry relationships. N Engl J Med 2007;356:1742-50. [Crossref] [PubMed]
15. Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med 2007;147:795-802. [Crossref] [PubMed]
16. Elcin M, Odabasi O, Gokler B, et al. Developing and evaluating professionalism. Med Teach 2006;28:36-9. [Crossref] [PubMed]
17. Ibnouf M, Mardi T, Hag M, et al. Prospective Randomised Controlled Trial of Teaching Medical Students Behavioural Sciences. Sudan J Med Sci 2007;7:189-95.
18. Inaam N, Mohamed ZAK. Evaluation of teaching professionalism in undergraduate medical curricula - Sudan: situational analysis. Khartoum Med J 2018;11:1454-9.
19. 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. [Crossref] [PubMed]
20. Sobani ZU, Mohyuddin MM, Farooq F, et al. Professionalism in medical students at a private medical college in Karachi, Pakistan. J Pak Med Assoc 2013;63:935-9. [PubMed]
21. Tsai TC, Lin CH, Harasym PH, et al. Students' perception on medical professionalism: the psychometric perspective. Med Teach 2007;29:128-34. [Crossref] [PubMed]
22. Imam JA, El Kheir DY. Assessment of the concepts of medical professionalism among medical students. Khartoum Med J 2014;7.
23. Doumi EA. Awareness and practice of the basic medical ethics among doctors at El Obeid Hospital, Western Sudan. Sudan Med J 2014;50.
24. Hultman CS, Halvorson EG, Kaye D, et al. Sometimes you can't make it on your own: the impact of a professionalism curriculum on the attitudes, knowledge, and behaviors of an academic plastic surgery practice. J Surg Res 2013;180:8-14. [Crossref] [PubMed]
25. Hudon A, Laliberte M, Hunt M, et al. What place for ethics? An overview of ethics teaching in occupational therapy and physiotherapy programs in Canada. Disabil Rehabil 2014;36:775-80. [Crossref] [PubMed]
26. Hultman CS, Wagner IJ. Professionalism in plastic surgery: attitudes, knowledge, and behaviors in medical students compared to surgeons in training and practice--one, but not the same. Ann Plast Surg 2015;74:S247-54. [Crossref] [PubMed]
27. O'Flynn S, Power S, Horgan M, et al. Attitudes towards professionalism in graduate and non-graduate entrants to medical school. Educ Health (Abingdon) 2014;27:200-4. [Crossref] [PubMed]
28. Brendel DH, Chu J, Radden J, et al. The price of a gift: an approach to receiving gifts from patients in psychiatric practice. Harv Rev Psychiatry 2007;15:43-51. [Crossref] [PubMed]
29. Weijer C. Point-counterpoint: should physicians accept gifts from their patients? No: Gifts debase the true value of care. West J Med 2001;175:77. [Crossref] [PubMed]
30. Takayama JI. Giving and receiving gifts: one perspective. West J Med 2001;175:138-9. [Crossref] [PubMed]
31. Alamri YA. Gift-giving in the medical student--patient relationship. J Med Ethics 2012;38:506-7. [Crossref] [PubMed]
32. Available online: https://www.bmj.com/bawa-garba
33. Elsanousi S, Elsanousi M, Khalafallah O, et al. Assessment of the social accountability of the faculty of medicine at University of Gezira, Sudan. East Mediterr Health J 2016;22:258-66. [Crossref] [PubMed]
34. Ahmed MH. Reflection for medical undergraduate: learning to take the initiative to look back to go forward. J Hosp Manag Health Policy 2018;2:31. [Crossref]
35. Mirghani OA, el Amin EO, Ali ME, et al. A combined course of primary health care practice and family medicine at the University of Gezira. Med Educ 1988;22:314-6. [Crossref] [PubMed]
36. Hamad B. Interdisciplinary field training research and rural development programme. Med Educ 1982;16:105-7. [Crossref] [PubMed]
37. Hamad B. Problem-based education in Gezira, Sudan. Med Educ 1985;19:357-63. [Crossref] [PubMed]