ORIGINAL ARTICLE Year : 2022  |  Volume : 29  |  Issue : 1  |  Page : 27-32  

Perception of medical professionalism among ophthalmology residents in Saudi Arabia: A national survey study

Fahad A Alghulaydhawi1, Reem M Hersi2, Sami Al-shahwan3
1 Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
2 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
3 Glaucoma Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia

Date of Submission16-Aug-2021Date of Acceptance06-Jun-2022Date of Web Publication23-Nov-2022

Correspondence Address:
Dr. Fahad A Alghulaydhawi
Sattam Bin Abdulaziz University Hospital, Alkharj
Saudi Arabia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/meajo.meajo_239_21

   Abstract 

PURPOSE: Studies have shown that there are significant differences in the concepts of medical professionalism among residents. Very few studies have specifically evaluated the perception of medical professionalism in a specific specialty. The aim of the study is to evaluate the perception of medical professionalism among ophthalmology residents and to assess the differences in the concept of professionalism between junior and senior residents.
METHODS: This cross-sectional study used a questionnaire to survey ophthalmology residents enrolled in different regions of Saudi Arabia in 2020. The ophthalmology residents included both junior and senior residents. In this study, “professionalism” concurred with the definition in the American Board of Internal Medicine's “Project Professionalism” and the Accreditation Council for Graduate Medical Education.
RESULTS: A total of 167 participants were recruited in the study. Out of the 127 participants who completed the survey, 60 (47.24%) were junior residents and 67 (52.76%) were senior residents. The scores for the attributes varied markedly. The lowest score obtained was 6.54 ± 3.349 for the attribute “In an emergency putting the welfare of others over my own safety” in the “Altrusim” domain and the highest score obtained was 9.62 ± 0.854 for the attribute “respect for co-workers” in the “Respect for others” domain. Out of the total residents who completed the survey (n = 127), 84 (66.14%) agreed that professionalism is teachable through a residency curriculum and 85 (66.93%) thought that it is testable.
CONCLUSION: The characteristics of different attributes of professionalism varied significantly among the residents. The findings of the present study highlights that the conceptualization and perception of professionalism is changing and there is a need to focus on the resident curriculum to instill the values of professionalism. Targeted training is needed on the concepts of professionalism to develop behaviors consistent with medical professionalism and to evaluate the levels of professionalism among residents.

Keywords: Altruism, ophthalmology, professionalism, residents

How to cite this article:
Alghulaydhawi FA, Hersi RM, Al-shahwan S. Perception of medical professionalism among ophthalmology residents in Saudi Arabia: A national survey study. Middle East Afr J Ophthalmol 2022;29:27-32
How to cite this URL:
Alghulaydhawi FA, Hersi RM, Al-shahwan S. Perception of medical professionalism among ophthalmology residents in Saudi Arabia: A national survey study. Middle East Afr J Ophthalmol [serial online] 2022 [cited 2022 Nov 24];29:27-32. Available from: http://www.meajo.org/text.asp?2022/29/1/27/361874    Introduction 

The American Board of Medical Specialties (ABMS) defines medical professionalism as “Medical professionalism is a belief system, in which group members (“professionals”) declare (“profess”) to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals.”[1] Despite such an important role of professionalism in medical practice, there is a lack of uniformity in the understanding and perception of professionalism in the medical community.[2]

Medical residents provide some of the main healthcare worldwide. Many of them go on to serve as faculty members and become role models for their peers and medical students after the completion of their residency. As a result, any issues with residents' professional behavior would not only affect their patients care but their colleagues and medical students observing them as well.[3] Therefore, they should be constantly monitored and promoted throughout their training program to ensure their professionalism which is considered among one of the six essential core competencies of the Accreditation Council for Graduate Medical Education (ACGME).[4],[5]

In the literature, there are a variety of measuring tools, but few of them attempt to measure professionalism as a whole concept.[6] Among them, Jauregui et al. have developed a questionnaire containing seven domains (clinical excellence, humanism, accountability, altruism, duty and service, honor and integrity, and respect for others) which assess professionalism in medical practice. The survey was based on the American Board of Internal Medicine's (ABIM's) “Project Professionalism” and the ACGME's definition of professionalism.[7] They studied these domains across emergency medicine residents on Iran. They concluded that a difference in professionalism perception among residents from different levels and regions which may be interpreted as difficulties in apprehending and professionalism education.[7]

In addition, it is sparsely known how the residents perceive medical professionalism in Saudi Arabia. Very few studies have discussed how ophthalmology residents understand this essential attribute for medical training. In one study, Alkahtani et al. explored professionalism among ophthalmology physicians of different levels including (consultants, fellows, and residents). A conclusion was drawn that the period of experience highly impacted the way physicians comprehend professionalism. However, the aforementioned study was done at a single tertiary hospital and among all levels of training not only residents.[8]

Hence, it is quite essential to understand ophthalmology residents' perception of professionalism and how much they rate it to further establish the definitions and to design curriculum at the graduate level to develop professionalism skills in the residents. Furthermore, there is a need to understand the residents' views about medical professionalism as they learn and develop this skill during their initial days of residency.

The main objective of this study is to discover current general conceptualizations of professionalism among ophthalmology residents in four different regions in Saudi Arabia by assessing the relative values these trainees place on various professionalism attributes. Secondarily, this study evaluates the difference between the junior and senior residents on the rating and perception of different attributes of professionalism.

   Methods 

Study design and participants

In this cross-sectional study, a survey was conducted on ophthalmology residents placed in the Hospitals of Riyadh, Jeddah, Eastern Region and Abha in Saudi Arabia, in the year 2020. The residency programs represented four regions of Saudi Arabia: Riyadh, Eastern, Jeddah, and Abha regions. The ophthalmology residents included both junior and senior residents. The junior residents were surveyed within the first 2 months of their residency and the senior residents were surveyed within the past 2 months of their residency.

Survey questionnaire

An English-language electronic questionnaire was distributed to the participating residents. The questionnaire was adopted from Jauregui et al.[7] The questionnaire uses the definition of professionalism given by the ABIM's “Project Professionalism” and the ACGME.[9] The survey questionnaire has seven domains of professionalism: clinical excellence, humanism, accountability, altruism, duty and service, honor and integrity, and respect for others. Each domain included several attributes, and an individual item represented each attribute. The participants provided their perception of medical professionalism by rating each of the 27 attributes on a 10-point scale. There were options of “None” and “completely” to answer or rate an attribute. The residents were also asked if medical professionalism was teachable and if it could be assessed. The scores of each domain or attribute were classified as “suboptimal” (<0.70), “good” (0.70–0.89), or “substantial” (>0.90).[10] Other demographic details and the location of residency were also collected.

Recruitment of the study participants

The study participants were recruited via electronic correspondence (phone calls and E-mails), and personally. The website was used to distribute the questionnaire electronically. There was no compensation for participation in the survey.

Statistical analysis

The data analysis was performed by the SPSS version 21 (IBM Corporation, Chicago, IL, USA).

The scores were presented as mean with standard deviation (mean ± SD) and median. Between-group scores were compared with two-tailed t-tests and the comparison between more than two groups was performed by one-way analysis of variance (ANOVA) with the Bonferroni correction. P < 0.05 were considered statistically significant.

   Results 

A total of 167 participants were recruited for this study. Out of the 167 participants, 127 (76.05%) participants completed the survey. Out of the 127 participants who completed the survey, 60 (47.24%) were junior residents and 67 (52.76%) were senior residents [Figure 1]. All the residents were in the age group of 26–29 years.

Figure 1: Number of junior and senior residents participated in the survey

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Out of the residents who completed the survey, 61 (48.03%) were from Riyadh, 32 (25.20%) were from the Eastern region, 20 (15.75%) were from Jeddah, and 14 (11.02%) were from Abha.

[Table 1] represents the scores of each of the 27 attributes to measure the level of professionalism among the residents (both junior and senior residents). The scores for the attributes varied markedly. The lowest score was 6.54 ± 3.349 for the attribute “In an emergency putting the welfare of others over my own safety” in the “Altrusim” domain and the highest score was 9.62 ± 0.854 for the attribute “respect for co-workers” in the “Respect for others” domain [Table 1].

Table 1: Value placed by residents on each medical professionalism attributes

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The mean scores of the domains were statistically significantly different (F = 29.42, P < 0.0001). The domain “Respect for others” had the highest mean score of 9.50 ± 1.138 and the domain “Altruism” scored the lowest at 7.89 ± 2.534 [Figure 1].

Note: Significance of mean domain differences: differences in mean scores for each domain were compared using repeated-measures analysis of variance with Bonferroni-corrected post-hoc comparisons. F = 29.42, P < 0.0001. Altruism < all others; Respect for others > all others.

The scores of each attribute were compared between the junior residents and the senior residents. There were nine attributes from different domains were statistically significantly different between groups (P < 0.05) [Table 2] and [Figure 2].

Figure 2: Comparison of scores of each attribute among the junior and senior residents

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The “Technical competence, skill, excellence” (P = 0.004) and “My behavior should be used as a model for the community” (P = 0.015) attributes belonging to the domains “Excellence” and “Honor and integrity,” respectively, were statistically significantly different among the residency programs.

Comparing attribute scores among four different residencies using one-way ANOVA. F, F statistic. Number of responses = 127.

Out of all the residents who completed the survey (n = 127), 84 (66.14%) agreed that professionalism is teachable through a residency curriculum and 85 (66.93%) thought that it is testable.

   Discussion 

The present study evaluated the concept and perception of medical professionalism among the ophthalmology residents and revealed some significant differences in the values given to different domains and attributes of professionalism. The present study expands on available knowledge and literature on the perception of medical professionalism.[6],[11],[12],[13],[14],[15] To the best of our knowledge, this is the first study conducted to evaluate the perception of medical professionalism among ophthalmology residents.

Due to different experiences during training, the unique cultural environments, and clinical practices, residents from different specialties had different concepts and perceptions of medical professionalism.[12]

In the present study, we observed a wide range of scores between different domains. The lowest rating was given to the domain “Altruism.” A similar study conducted on the emergency residents also reported similar findings where the residents gave the lowest rating to the domain “Altruism.”[2] Altruism is adhering to the best interest of the patients and putting the interest of the patients above self-interest.[14] The ACGME also advocates the same for Altruism.[16] This finding in the present study indicates that the residents are less focused on the patient relationship and there are several studies that have reported conflicting interpretations of Altruism.[17]

The attribute of the domain, Altruism “In an emergency putting the welfare of others over my own safety” was scored significantly lower by the junior residents as compared to the senior residents. This finding indicates that with the duration of practice and learning, residents develop a sense of the patient–physician relationship. During junior residency, the cultural differences and the exposure of students to a new curriculum and the related stress might result in lower scores for this domain.

Other studies have also reported a similar decrease in qualities related to Altruism among residents, however, there are no concrete causes for this trend.[6],[18],[19],[20],[21] This might be associated with the devaluing curriculum the residents are following and the profit-oriented practices in the clinical settings or hospitals.[22],[23],[24]

In the present study, respect for others was the highest scored domain. There was no significant difference in the scores for this domain across the residencies and the regions indicating that the residents (junior and senior) irrespective of the regions they belong to value respecting others and believe that all patients should be treated equally. These are imperative values that should be instilled in the residents, especially in an environment where the medical profession is becoming more of a profit-oriented organization.

We found that the majority of the residents agreed that professionalism can be taught through the medical curriculum. This indicates that the present curriculum should be adapted to further incorporate the value of the various aspects of professionalism.

In the present study, we observed that there was not much difference among the attributes of professionalism among the residents from different regions. The only two attributes that differed significantly among the residents from different regions were “Technical competence, skill, excellence” and “My behavior should be used as a model for the community.” This may be a result of the educational culture of an institute which greatly influences the character of the residents and their perception of professionalism.[25]

Given these points, most of these prior studies on this topic were very general as they utilized the concept of pooling residents from different specialties together for the study. This pooling of residents from different specialties results in the dilution of the perception of professionalism of individual specialties. Hence, the findings in these studies cannot be generalized to other specialties. Therefore, the present study was conducted on the residents of a single specialty, Ophthalmology. Hence, the findings of the present study pertain to a specific specialty.

Most of the previous studies that evaluate the concept and perception of medical professionalism were conducted through interviews.[11],[12],[13],[14] In interview-based studies there is always a risk of the interview effect that influences the overall credibility of the study findings.[2] There is also the risk of judgment of the residents based on their rating of different attributes of professionalism. However, the present study employed an anonymous questionnaire-based survey that evaluated the ratings or values of the residents on different attributes of medical professionalism. The anonymity of this type of study allows the residents to rate or place value on different aspects of professionalism without being judged.

Limitations of the study

The major limitation of this study is the sample size and the findings should be further confirmed in larger cohorts of residents. Another limitation was the process of recruitment. We recruited the junior residents in the initial days of their internship and the senior residents during their final days of internship. This might have affected the findings of the study because we did not investigate the perception of professionalism among the residents at different time points of their residency. Another limitation was that a majority of the residents initially recruited did not respond to the survey.

   Conclusion 

The values given to different attributes of professionalism varied significantly among the residents. The findings of the present study highlight that the conceptualization and perception of professionalism are changing and there is a need to focus on the curriculum of the residents to incorporate the values of professionalism. Extensive research is needed to better understand the concepts of professionalism among residents, and tutors must be properly trained to better incorporate professionalism values in residents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

   References 
1.The Center of Professionalism and Value in Health Care [Internet]. Washington, DC: American Board of Family Medicine; NA. ABMS Definition of Medical Professionalism; 2012. Available from: https://professionalismandvalue.org/the_prof_library/abms-definition-of-medical-professionalism/ [Last accessed on 2021 Aug 01].  
    2.Steinert Y, Cruess S, Cruess R, Snell L. Faculty development for teaching and evaluating professionalism: From programme design to curriculum change. Med Educ 2005;39:127-36.  
    3.Mianehsaz E, Tabatabaee SM, Sharif MR, Gilasi HR, Shojaee Far HR, Nejad Tabrizi B. Professionalism among medical residents in a young second-level university in Iran: A cross-sectional study. J Med Ethics Hist Med 2020;13:1.  
    4.The Accreditation Council for Graduate Medical Education Core Competencies. Available from: https://www.acgme.org. [Last accessed on 2021 Aug 01].  
    5.Medical Council of India, Regulations on Graduate Medical Education; 2012. Available from: http://www.mci.org. [Last accessed on 2021 Aug 01].  
    6.Aramesh K, Mohebbi M, Jessri M, Sanagou M. Measuring professionalism in residency training programs in Iran. Med Teach 2009;31:e356-61.  
    7.Jauregui J, Gatewood MO, Ilgen JS, Schaninger C, Strote J. Emergency medicine resident perceptions of medical professionalism. West J Emerg Med 2016;17:355-61.  
    8.Alkahtani E, Assiri A, Alrashaed S, Alharbi M, Almotowa S, Khandekar R, et al. Medical professionalism in ophthalmology: Design and testing of a scenario based survey. BMC Med Educ 2020;20:160.  
    9.Available from: https://docs.google.com/formsd/e/1FAIpQLScgpHEPanJm-AhlzMHez8M-NpwuexvoK4dnsq3p2uOMPhKerA/viewform?vc=0&c=0&w=1&fbzx=2808098366095262541. [Last accessed on 2021 Aug 01].  
    10.Nunnally J. Psychometric Theory. 2nd ed. New York, NY: McGraw- Hill; 1978.  
    11.Cho CS, Delgado EM, Barg FK, Posner JC. Resident perspectives on professionalism lack common consensus. Ann Emerg Med 2014;63:61-7.  
    12.Krain LP, Lavelle E. Residents' perspectives on professionalism. J Grad Med Educ 2009;1:221-4.  
    13.Regis T, Steiner MJ, Ford CA, Byerley JS. Professionalism expectations seen through the eyes of resident physicians and patient families. Pediatrics 2011;127:317-24.  
    14.van Mook WN, De Grave WS, Gorter SL, Zwaveling JH, Schuwirth LW, van der Vleuten PM. Intensive care medicine trainees' perception of professionalism: A qualitative study. Anaesth Intensive Care 2011;39:107-15.  
    15.Rider EA, Nawotniak RH, Smith G. A Practical Guide to Teaching and Assessing the ACGME Core Competencies. Marblehead, MA: HCPro, Inc.; 2007.  
    16.ACGME. Accreditation Council for Graduate Medical Education Common Program Requirements. Available from: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. [Last accessed on 2015 May 06].  
    17.Ratanawongsa N, Bolen S, Howell EE, Kern DE, Sisson SD, Larriviere D. Residents' perceptions of professionalism in training and practice: Barriers, promoters, and duty hour requirements. J Gen Intern Med 2006;21:758-63.  
    18.Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Teaching professionalism in medical education: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. Med Teach 2013;35:e1252-66.  
    19.Newton BW, Barber L, Clardy J, Cleveland E, O'Sullivan P. Is there hardening of the heart during medical school? Acad Med 2008;83:244-9.  
    20.Rabow MW, Remen RN, Parmelee DX, Inui TS. Professional formation: Extending medicine's lineage of service into the next century. Acad Med 2010;85:310-7.  
    21.Stephenson AE, Adshead LE, Higgs RH. The teaching of professional attitudes within UK medical schools: Reported difficulties and good practice. Med Educ 2006;40:1072-80.  
    22.Bernard AW, Malone M, Kman NE, Caterino JM, Khandelwal S. Medical student professionalism narratives: A thematic analysis and interdisciplinary comparative investigation. BMC Emerg Med 2011;11:11.  
    23.House JB, Theyyunni N, Barnosky AR, Fuhrel-Forbis A, Seeyave DM, Ambs D, et al. Understanding ethical dilemmas in the emergency department: Views from medical students' essays. J Emerg Med 2015;48:492-8.  
    24.Kim JY, Kang SJ, Kim JW, Kim YH, Sun H. Survey of attitudes on professionalism in plastic and reconstructive surgery. Arch Plast Surg 2013;40:134-40.  
    25.Hafferty FW, Wynia MK, Papadakis MA, Sullivan WM. In reply to Barnhoorn and Youngson and to Jones and Thaxton. Acad Med 2014;89:1579-80.  
    
  [Figure 1], [Figure 2]
 
 
  [Table 1], [Table 2]