Need for Professionalism 

There are a number of studies that describe widespread unprofessional behaviors by a variety of healthcare professionals, including faculty, students and staff. These behaviors have contributed to medical errors, unsafe working environments and high levels of cynicism and burnout (Feudtner, 1994; Christakis, 1993; Reddy, 2007; Campbell, 2007).

 Unprofessional behaviors in superiors and peers can lead to ethical erosion in trainees. In one study, third-year medical students anonymously reported observation, participation in and perceptions of 27 unprofessional behaviors before and five months after clerkships. Student observation of (21 of 27) and participation in (17 of 27) unprofessional behaviors increased. Students perceived unprofessional behaviors as increasingly appropriate. Participation in unprofessional behaviors was associated with diminished likelihood of perceiving a behavior as unprofessional (Reddy, 2007).

Surveys and other studies of U.S. medical schools and practicing physicians identify a need for improvement in professionalism education (Reddy, 2007: Swick, 1999; Ziring, 2015; Campbell, 2007).  An American Osteopathic Association publication highlighted difficult issues in professionalism assessment and remediation (Byyny, 2015). 

Many studies have shown the effects of unprofessional behaviors in medical education. In one study, 98 percent of medical students at six schools reported observing unethical and unprofessional behaviors among faculty (Feudtner, 1994).  In another study, many students admitted to participating in what they considered unethical behavior (Christakis, 1993). 

Learners have reported high levels of cynicism and burnout related to their exposure to unprofessional behaviors (Reddy, 2007). Moreover, because of the pressures of the hidden curriculum, students who observe and participate in unprofessional behaviors find them to be more acceptable than they had previously indicated (Reddy, 2007).


Byyny RL, Papadakis M, Paauw DS. Medical Professionalism: Best Practices. Menlo Park, California: Alpha Omega Alpha Honor Medical Society; 2015.

Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. Dec 4 2007;147(11):795-802.

Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med. 1993;68(4): 249–254.

Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion: students’ perceptions of their ethical environment and personal development. Acad Med. 1994;69(8):670–679.

Reddy ST, Farnan JM, Yoon JD, et al. Third-year medical students' participation in and perceptions of unprofessional behaviors. Acad Med. Oct 2007;82(10 Suppl):S35-39.

Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA. Sep 1 1999;282(9):830-832.

Ziring D, Danoff D, Grosseman S, et al. How Do Medical Schools Identify and Remediate Professionalism Lapses in Medical Students? A Study of U.S. and Canadian Medical Schools. Acad Med. Jul 2015;90(7):913-920.

Pilot program Description and Results

The Josiah Macy Jr. Foundation awarded Drexel University College of Medicine and College of Nursing and Health Professions a three-year grant for a “Multi-Institution Effort to Advance Professionalism and Interprofessional Education with” in 2017. Drexel University enlisted 13 institutions to participate in the pilot program and to incorporate modules in professional disciplines including medicine, nursing, pharmacy, social work, physician assistants, law, anesthesiology and dental. These institutions included:

 1. Alabama College of Osteopathic Medicine


2. Albert Einstein College of Medicine

3. Drexel University

4. Duquesne University

5. Geisinger Commonwealth Medical College

6. Indiana University

7. Jefferson University Sidney Kimmel Medical College

8. Ohio State University

9. Stony Brook

10. University of Florida

11. University of Pennsylvania

12. University of Texas - Rio Grande Valley

13. Western Michigan University School of Medicine          

Nearly all of the collaborating institutions incorporated Professional Formation modules into their professionalism and interprofessional education programs. The pilot institutions hosted nearly 50 sessions using the 12 modules for thousands of learners. Institutions used the modules in a variety of ways: pre-session assignment with discussion in small groups, background reading with writing assignments, video viewing and discussion.

Module pre and post tests gauge the change in the learners’ attitudes and self-efficacy after interacting with the modules. By the end of the pilot program, nearly 2,000 results from students’ pre and post tests indicated a change of over 20 percent in most of the modules and over 30 percent change in two modules.

Grant participants presented the results of research at the Ain Shams Obstetrics and Gynecology International Conference in Cairo, Egypt and at the Academy for Professionalism in Health Care conference. Research results were also published in Nursing Ethics.

Description of Scales and Exercises

Professional Formation includes five assessment scales that can be assigned through a course or longitudinally throughout a program. Learners can see how their scores change and whether their life experiences either positively or negatively impact that scores. 

Cohen Perceived Stress Scale

The Cohen Perceived Stress Scale (PSS) measures the degree to which situations in one's life are appraised as stressful. Higher scores on the PSS scale mean higher levels of stress. Mean scores on the PSS in the general population are higher for women than for men. In the general population, scores tend to decrease over each decade. Scores on the PSS for trainees in the health professions tend to be higher than those of the general population. Learners can reflect on scores in terms of whether they score above, at or below where others score. Most people know that they are experiencing stress, but sometimes the scores help put their own experiences into perspective. Learners can also track their own scores over time, which can help give them a sense of whether their stress is increasing or decreasing. In the health professions, there have been a few studies. One study found that clinicians with the highest levels of stress communicated more poorly with patients.

Gronigen Reflective Ability Scale

The Groningen Reflective Ability Scale (GRAS) is a one-dimensional scale, covering three aspects of personal reflection: self-reflection, empathetic reflection and reflective communication. Higher scores on the GRAS scale reflect a greater tendency or capacity for reflection on oneself and relationships with others. An individual’s scores highlight the degree to which reflection is important to that person.

Interprofessional Education Collaborative

The Interprofessional Education Collaborative (IPEC) scale assesses individual learners’ competencies related to a team practice. The tool measures students' self-efficacy on 42 core competency statements developed by IPEC, a consortium of professional associations in the U.S. representing six disciplines. The results of the questionnaire can help learners rate their ability in each competency using a five-point Likert scale.

 Interpersonal Reactivity Index

The Interpersonal Reactivity Index (IRI) is a widely used scale that measures dimensions of empathy. One of two subscales focuses on perspective-taking and the other focuses on empathic concern. The perspective-taking subscale measures the learner’s tendency to imagine being in another person's shoes while the empathic concern subscale measures feelings of compassion for others in distress. Having higher empathy is generally considered to have positive consequences for patient care. The learners’ levels of empathy may change depending on how stressed they are.

Novack Values Behavior Concordance Scale

The Novack Values Behavior Concordance Scale (NVBCS) asks learners to choose the two most important values that guide them now and two key values to which they aspire. Values contribute to how others perceive the person’s character. The chosen profession promotes shared values that reflect the highest ideals of that profession. (Although this scale is not validated, it can be used for learners’ self-evaluation.)