An important issue that is gaining increasing prominence in modern medical education is the matter of student professionalism and its subsequent influence in the practice world. Professionalism is now a subject of greater empirical study and qualitative analysis in health professions education in efforts to better define what is meant by professionalism and to determine how to measure and imbue these qualities in students and future practitioners.

Core PA Competencies

The PA profession has taken on the task of defining the essential competencies of PA clinicians. Professionalism is one of the five core competencies (the others are medical knowledge, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) as stated in "Competencies for the Physician Assistant Profession."¹ This document is the outcome of a joint effort initiated in 2003 by the National Commission on Certification of Physician Assistants and later involving the profession's other three organizations, the Association of Physician Assistant Programs, the Accreditation Review Commission on Education for the Physician Assistant and the American Academy of Physician Assistants.

The document presents an outline of expected competencies that PAs, regardless of specialty or setting, are expected to acquire and maintain throughout their careers. The PA competency document represents an important step in defining to the public, and to others such as medical regulators, the competencies that all PAs should possess. This effort to define PA competencies parallels similar efforts being conducted in other health professions as part of the growing demand for accountability and assessment in clinical practice.

Professionalism has become an important issue for a number of reasons. First and most obviously, in modern medical practice it is vital for all health care practitioners to develop and adhere to established standards of conduct in relation to interactions with patients, teachers, researchers and others. The notion of establishing full trust and confidence in discharging one's activities is at the very core of a professional. Breaches of professional conduct not only can bring disgrace to medical practitioners, but also can endanger patient safety.

PAs and Professionalism

The issue of professionalism has become one of particular importance within the PA profession, since data on PA students show that the mean age of those enrolled in PA education programs has been declining.² As a consequence, students today are more likely to enter PA programs without the benefit of important life experiences that help to mature and develop individuals in terms of critical determinants of professionalism. The falling mean age of entering students can bring a variety of new problems for PA program faculty, including issues of non-comportment in the academic phase and breaches of professionalism in the clinical year.

Anecdotally, when one speaks to PA preceptors and clinical instructors, the comments often paint a picture of a higher proportion of students who have difficulty adjusting to the comportment demands of the clinical setting in areas such as punctuality, responsibility, appearance and communication.

An interesting paper related to the topic of medical professionalism recently appeared in the New England Journal of Medicine.³ The paper describes a case-controlled study conducted among three U.S. medical schools examining the association between behavior problems among medical students and subsequent occurrences of disciplinary actions by state medical boards. The study revealed what is, on the surface, a very logical conclusion: There is a strong correlation between unprofessional behaviors among individuals while they were medical students and subsequent disciplinary actions. Individuals who had documented episodes of unprofessional behavior while in medical school were three times more likely to have had disciplinary actions taken against them. The strongest associations were among those medical students who were described as irresponsible or who had diminished ability to improve their behavior. Of concern in this study was the finding that among certain students, unprofessional behavior is sustained over decades. Reassuring was the finding that disciplinary action by state medical boards occurs much less frequently than does unprofessional behavior in medical school.

Educating About Professionalism

The outgoing president of the Association of American Medical Colleges believes that professionalism is one of the most critical issues facing today's medical educators. He states frankly that "Students emulate what we do, not what we say. And what we too often do is patently unprofessional. Every time we

• demean a nurse,
• disrespect a patient,
• harass a student,
• exploit a resident,
• overbill for services,
• fudge data to gain a favorable journal review,
• permit commercial interests to bias educational offerings,
• shill for a pharmaceutical company,

or do anything that would embarrass us if published on the front page of a newspaper, we chip away at the character we profess to cherish among the learners in our midst."⁴

The need to demand, monitor and maintain high levels of professionalism in all spheres of medicine-patient care, education and research-is clear. It is a poignant commentary on professionalism, or the lack thereof, that all new faculty now appointed at The Johns Hopkins Medical Institutions are given a small beautifully written booklet reminding them of a value that at one time was a given ethical standard.⁵

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.

References

1. American Academy of Physician Assistants. Competencies for the Physician Assistant Profession [policy paper]. Available at: http://www.aapa.org/policy/competencies.html. Accessed January 11, 2006.

2. Simon AF. 20th Annual Report on Physician Assistant Educational Programs in the United States, 2003-2004. Alexandria, Va: Association of Physician Assistant Programs; 2004.

3. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005;353:2673-2682.

4. "The work ahead": AAMC president's address 2005 [press release]. Washington, DC: Assn of American Medical Colleges; November 6, 2005. Available at: http://www.aamc.org/newsroom/pressrel/2005/051106.htm. Accessed January 11, 2006.

5. Jackson CI. Honor in Science. Research Triangle Park, NC: Sigma Xi, The Scientific Research Society; 2000.