R E S E A R C H R E P O R T

Senior Residents’ Views on the Meaning of

Professionalism and How They Learn about It
A. Keith W. Brownell, MD, and Luc Côté, MSW, PhD
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ABSTRACT

Purpose. To determine senior residents’ views on the
meaning of professionalism and how they learned about
it.
Method. By means of a modified Dillman technique, all
senior residents at two faculties of medicine (n = 533)
were surveyed about professionalism during the 1998–99
academic year. The residents were asked to list attributes
of professionalism and to rank methods they found most
useful for learning about professionalism, to rate the ad-
equacy and quality of their teaching about professionalism
and their comfort in explaining the concept of profes-
sionalism to a more junior trainee, to list suggestions
about how teaching about professionalism could be im-
proved, and to name the medical organization most con-
cerned with matters of professionalism.
Results. A total of 258 residents (48.4%) responded.
They listed 1,052 attributes they associated with profes-
sionalism. The three most common attributes, all listed
by more than 100 respondents, were respect, competence,
and empathy. The respondents had learned the most
about professionalism from observing role models, they
rated the quantity and quality of teaching about it posi-
tively, and they felt comfortable explaining professional-
ism to a junior resident. Only 56% of the residents cor-
rectly identified the Canadian medical organization most
concerned with professionalism.
Conclusion. Residents’ knowledge about professional-
ism reflects their early stage of development as physicians
and their daily activities, where such aspects of profes-
sionalism as the social contract, codes of ethics, partici-
pation in professional societies, and altruism are not high-
lighted. Residency programs should develop teaching
activities focusing on professionalism that relate to issues
residents face in their daily work.
Acad. Med. 2001;76:734–737.

Medical professionalism and the profes-
sion of medicine are attracting consid-
erable attention in the medical litera-
ture, particularly with regard to the
need for teaching about these topics
during undergraduate and residency ed-
ucation.1–7 Yet, despite this discussion,
few data are available to indicate what
Dr. Brownell is professor, Department of Clinical
Neurosciences, University of Calgary, Calgary, AB,
Canada. Dr. Côté is associate professor, Department
of Family Medicine, Laval University, Québec, QC,
Canada.
Correspondence should be addressed to Dr. Brownell,
Department of Clinical Neurosciences, University of
Calgary, Foothills Hospital, 1403 29th Street NW,
Calgary, AB, Canada, T2N 2T9; e-mail: 具kbrownel
@ucalgary.ca典. Reprints are not available.
medical students, residents, or even
practicing physicians actually know
about the topics. Therefore, we assessed
senior residents’ views about profession-
alism and how they had learned about
it; the results of which are reported
here.
METHOD
During the 1998–99 academic year, we
invited all senior residents at Laval
University (LU) (n = 334) and the
University of Calgary (UC) (n = 199)
to participate in this study. We defined
a senior resident as any resident in one
of the following groups:
䡲 year two of a family medicine pro-
gram;
䡲 year three (and beyond) in a Royal
College of Physicians and Surgeons of
Canada (RCPSC) primary certifica-
tion program;
䡲 any subspecialty program; and
䡲 any non-accredited training program
beyond a primary certification or sub-
specialty program.
Medical and surgical specialties and
subspecialties were classified according
to the listing used by the RCPSC.
For this study, we used a modified
Dillman8 method. In the fall of 1998,
we sent all senior residents a package
containing a letter of introduction from

734 ACADEMIC MEDICINE, VOL. 76, NO. 7 / JULY 2001

the investigators outlining the purpose One of the investigators (LC) and Table 1
of the study, the methods used to main- the research assistant independently
tain confidentiality, an invitation to carried out an initial content analysis of Senior Residents’ Responses to the
participate, the questionnaire, and a the qualitative data (triangulation pro- Attributes of Professionalism by
self-addressed envelope for returning cess) as outlined by Miles and Huber- Frequency of Selection, Laval University
the questionnaire. About two months man.9 The two investigators jointly car- and University of Calgary, 1998–99
later, we sent to non-responders a sec- ried out the final classification by
ond mailing that contained a letter of consensus and then the data were rank- No. of
Residents’
introduction along with all the material ordered. We calculated means and stan-
Attribute Responses*
that had been circulated with the first dard deviations for the quantitative
mailing. About a month later, we car- data and subjected the results to mul- Competence 129
ried out a third mailing to non-respond- tiple regression analysis. Respect 123
ers with the same material. To maintain Empathy 101
Both faculties of medicine gave eth-
Honesty/integrity 62
the confidentiality of both respondents ical approval to the study. Responsibility 62
and non-respondents, neither of the in- Collegiality 55
vestigators took part in developing the RESULTS Confidentiality 50
nominal–numerical lists, the handling Up-to-date medical
of returned questionnaires to determine Demographics knowledge 49
who had responded, or the construction Courteous 45
of the lists for any of the three mailings. Good communicator 44
The overall response rate, 48.4% (258 Ethical 44
The questionnaire was developed
of 533 residents), was virtually identical Good clinical judgment 34
specifically for this study and was field
to that for each of the faculties. Of the Good organization 33
tested on a small number of residents Self-appraisal 32
total number of residents surveyed,
and faculty before being finalized. The Calm 30
22.1% were in family medicine, 56.4%
questionnaire collected demographic Devoted 19
were in medical specialties, and 21.5%
data that included each resident’s train- Manage uncertainty 18
were in surgical specialties, and those Scientific rigor 17
ing level, program, gender, and age. We
responding, 26% were from family med- Justice 16
asked each resident to list five words or
icine, 51.5% from medical specialties, Passion for medicine 16
phrases (attributes) he or she associated
and 21.3% from surgical specialties. Openness of spirit 16
with the term professionalism and to Tact 16
There were 1.2% of respondents who
rank-order a list of seven methods (in- Pay attention to details 11
could not be classified because of in-
cluding an option to write in methods Humble 10
complete data. Women made up 54.8%
not listed) he or she had found most Leadership 7
of the total resident body at LU and Put patient needs first 6
useful for learning about professional-
42% of the total resident body at UC, Climate of confidence 4
ism. The resident was asked to indicate,
and the response rates for women were Balance between personal
by means of a Likert scale (ranging from
55.3% from LU and 42.7% from UC. and professional life 3
1 = very inadequate to 7 = very ade-
The mean ages of respondents, 29.2 *Numbers refer to the total numbers of residents
quate), his or her view on the quantity
years at LU and 31.3 years at UC, were listing the attributes.
and quality of teaching about profes-
similar to the mean ages for all residents
sionalism in his or her program. The
resident was asked to list suggestions at LU (30.1 years) and at UC (32.1
whereby teaching about professionalism years). (123), and empathy (101), and the
could be improved in his or her pro- three least commonly listed attributes
gram. Again, by means of a Likert scale Attributes were put patient needs first (6), climate
(ranging from 1 = very uncomfortable of confidence (4), and balance between
to 7 = very comfortable), we asked the The 258 respondents listed a total of personal and professional life (3).
resident to indicate his or her degree of 1,052 attributes of professionalism. A majority of the residents in either
comfort in explaining the meaning of Qualitative analysis yielded 28 groups of program listed contact with positive
professionalism to a more junior trainee. attributes (see Table 1). Fifteen of the role models as their preferred method of
Finally, we asked the resident to name attributes were selected by 30 or more learning about professionalism (Table
the Canadian medical organization or respondents. The three most commonly 2), followed by contact with patients
body he or she believed to be most con- listed attributes were (in order of fre- and their next of kin, and contact with
cerned with matters of professionalism. quency) competence (129), respect negative role models.

ACADEMIC MEDICINE, VOL. 76, NO. 7 / JULY 2001 735

Table 2 residency did not make a difference to
at least the main attributes the residents
chose. Looking at the data by gender,
Senior Residents’ Responses for the Most Useful Methods for Learning Professionalism by
Program and Gender, Laval University and University of Calgary, 1998–99
men and women listed the same top
three attributes (competence, respect,
Method* and empathy). Since there is no other
study like ours in the literature, it is im-
Contact with Contact with Contact with
possible to compare directly the list of
Positive-role-model Patients and Their Negative-role-model
Clinical Teachers Next of Kin Clinical Teachers
attributes that emerged from our data
Speciality % % % with those from other reports. Yet, in
our review of articles that list attributes
Family medicine commonly associated with profession-
Men (n = 28) 89 42 28
alism,1,7,10 we found many of the same
Women (n = 39) 90 63 34
terms, which indicates that there are
Medical specialties
similarities between our findings and
Men (n = 69) 94 52 38 those of others, at least qualitatively.
Women (n = 63) 99 47 52 Residents spend the vast majority of
their time involved with patient care.
Surgical specialties In these activities they act as medical
Men (n = 29) 93 39 63 experts and clinical decision makers for
Women (n = 26) 89 52 52 their patients, they deal with the doc-
tor–patient relationship, and they con-
Total
stantly deal with ethical issues. The im-
Men (n = 126) 93 47 41
Women (n = 128) 94 53 46
portance of personal qualities is much
in evidence as they communicate with
*Percentages shown represent the residents’ first and second choices combined.
families, health care team members,
other medical and paramedical profes-
sionals. The 15 most commonly listed
attributes of professionalism we found
The mean rating by residents in all ical organization most concerned with all relate to one of these categories. For
programs for the adequacy of the quan- professionalism (i.e., either the Collège example, the attributes of competence,
tity of teaching about professionalism des médecins du Québec or the College up-to-date medical knowledge, good
was 4.13 (SD ⫾ 1.44). The mean rating of Physicians and Surgeons of Alberta). clinical judgment, and good organiza-
for the quality of the teaching about tion all relate to residents’ activities as
professionalism was 3.79 (SD ⫾ 1.44). DISCUSSION medical experts and clinical decision
Multiple regression analysis of these makers. Further, the attributes of re-
data showed statistically significant dif- In this study, we wanted to determine spect, empathy, confidentiality, cour-
ferences of the responses by university the views of residents who were the tesy, and good communication are all
for both quantity and quality of teach- closest to completing their program, so related to the doctor–patient relation-
ing, with these factors explaining 8.8% we sampled the opinions of senior resi- ship; the attributes of honesty and in-
and 6.8% of the variance, respectively. dents only. This still led to a consider- tegrity, responsibility, collegiality, self-
The most commonly selected sugges- able range in the number of years train- appraisal, and calm are related to
tions for learning more about profes- ees had actually been residents (most personal qualities; and non-medical is-
sionalism were better examples of family medicine residents were in their sues that figure in the complex decision
teachers as role models (30%, n = 61); second and last year of their program, making that is a common part of man-
discussion with peers, teachers, and pa- whereas the specialty and subspecialty agement of patients today, especially in
tients (23%, n = 47); workshops and residents were all at least in the third the inpatient setting, are related to eth-
seminars (19%, n = 40); and formal year of their training). However, despite ical issues. The larger view of profes-
teaching (19%, n = 39). The mean of differences in years of training, the res- sionalism, which includes the social
the residents’ ratings of their comfort in idents in family medicine listed the vision of medicine (i.e., altruism, im-
explaining what professionalism is to a same attributes in their top three portance of the social contract, serving
more junior resident was 4.86 (SD ⫾ choices (competence, respect, and em- the needs of patients and society before
1.32). A total of 56% of the residents pathy) as did the residents in the spe- one’s own, speaking out on behalf of is-
correctly identified the Canadian med- cialties, which suggests that the year of sues within the community), self-gov-

736 ACADEMIC MEDICINE, VOL. 76, NO. 7 / JULY 2001

ernance, and codes of ethics, seemed to
be less appreciated by the residents.
In a recent editorial,11 commenting
on an article describing residents’
choices of attributes of excellent at-
tending-physician role models,12 the re-
lationship between the choices resi-
dents made and their daily work was
also noted. The editorial stated that
since residents spend the majority of
their time caring for patients and teach-
ing, it was likely that they would focus
on the teachers’ behaviors that had the
greatest congruence with their daily
work. It would also be understandable
that they would model themselves on
physicians whose careers focused on pa-
tient care and teaching.
The importance of role models for
residents to learn about professionalism
is reflected in the overwhelming num-
ber of residents who selected contact
with positive role models (first choice
by 93.5% of all residents) and contact
with negative role models (third choice
by 43.5% of all residents). Their second
choice, selected by 50% of all respon-
dents, was contact with patients and
their next-of-kin. All three of these
choices reveal the importance of learn-
ing through contact with others, and
again, support the validity of classifying
the attributes and learning about them
in terms of the daily working life of the
trainee.
The fact that almost half of the res-
idents (46%) did not correctly identify
the provincial licensing body as the Ca-
nadian medical organization most con-
cerned with professionalism again
points to the fact that residents are less
knowledgeable about those aspects of
professionalism that do not relate to
their current daily activities.
Multiple regression analysis of the
data regarding adequacy of quantity and
quality of teaching about professional-
ism showed statistically significant dif-
ferences in the responses by university
for both. However, because these factors
explained only 8.8% and 6.8% of the
variance, we felt the differences were
unlikely to be meaningful in terms of
ACADEMIC MEDICINE, VOL. 76, NO. 7 / JULY 2001
basic differences between the two fac-
ulties of medicine.
Two interpretations can be derived
from our study’s results. One view is
that residents have a very incomplete
knowledge of what professionalism is,
while the other is that residents are de-
veloping their knowledge of profession-
alism in terms of what they actually do
and that, although limited in scope,
their knowledge is quite good. The lat-
ter view, which is the one we favor,
holds that what one needs to know
about professionalism will change and
needs to be continually upgraded and
refined throughout the physician’s prac-
tice life. This means the topic of pro-
fessionalism needs to be high on the list
of topics for life-long learning for phy-
sicians. So, just as physicians will find
that they must upgrade their knowledge
because of advances in science as well
as changes in practice focus, similarly,
they will need to continually upgrade
their knowledge and skills related to
professionalism. The aim, then, for res-
idency education programs on profes-
sionalism should not be to try to teach
the trainee everything during residency.
Instead, the aim should be to instill the
basic principles and develop the atti-
tude that professionalism is of great im-
portance to the physician at every stage
of his or her practice life and that it
needs to be tied to life-long learning.
Individual residency programs will
have to decide on the topics they plan
to focus on in any educational interven-
tions. Our findings and the detailed list
of proposed topics for instruction about
professionalism that was published re-
cently2 could serve as the starting point
for making such decisions.
Although our response rate of 48.4%
may be considered somewhat low, we
believe that our results are generalizable
because (1) there were a large number
of responders in total (258), (2) the re-
sponders came from two faculties of
medicine that are geographically sepa-
rated by over 4,000 km and in very
different parts of Canada (one English-
speaking and the other French-speak-
ing), and (3) the individuals who re-
sponded were similar in make-up to the
overall groups of residents sampled in
terms of age, sex, and distribution
within the different programs (family
medicine, medical specialties, and sur-
gical specialties).
Further research is needed to deter-
mine teachers’ perceptions of profes-
sionalism in medicine and their pre-
ferred ways of teaching and learning
about it, and the teachers’ and resi-
dents’ perceptions of the social vision of
medicine.
This research was supported by a grant from the
Association of Canadian Medical Colleges/Med-
ical Research Council Committee on Research in
Medical Education. The authors gratefully ac-
knowledge the valuable comments made by Ms.
Jocelyn Lockyer during the final stages of the
writing of the manuscript.
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