Professionalism of future medical professionals in Universiti Sultan Zainal Abidin, Malaysia

Professionalism with high moral character should be developed from the schooling time of the students. The objective of this study was to explore the professionalism of medical students. It was a cross-sectional study conducted on 108 year-I and year-II medical students of session 2012-2013 selected conveniently at UniSZA, Malaysia. Data was collected using a mixed type of validated instrument and analyzed using SPSS. Year-I and year-II were 86% and 98% respectively. Only 27% respondents were male and 73% were female. Mean professionalism scores for year-I and year-II were 175.20 and 172.91, while for male and female were 172.31 and 174.58 respectively. No significant differences observed between gender (p=0.536) and study-year (p=0.484). However, 34% year-I and 19% year-II students defined professionalism diversely while 18% and 9% were un-responded. Professionalism is a braod-concept; a burning issue worldwide. Teachers should emphasis on core elements of professionalism which are unique for all professions.


Introduction
Every single profession has its particular social responsibilities and these contracts with society need to be repeatedly amended and renegotiated (Bhugra and Gupta, 2010).Moreover, in the past many years, a number of stern intimidations to professionalism have emerged.Profession such as medicine, education and the law has been confronted by politicians and other stakeholders (Bhugra and Gupta, 2010).Medical professionalism has been a crucial and major feature in medicine from the time of Hippocrates (Orr et al., 1997).Professionalism is the foundation of medicine's indenture with humanity (Medical Professionalism Project, 2002a).Medical professionalism has been particularly challenging to outline and remains poorly understood (Riley and Kumar, 2012).The notion of medical professionalism' possibly developed in late medieval and early renaissance epochs, when doctors organized a specialized society (Sox, 2007).It is considered as an intrinsic part of the practice of medicine (Chard et al., 2006).It was measured as the drill of values and codes of conduct set by the practitioners in earliest time.Even in recent times it is difficult to reach one platform for defining professionalism for health care (Cruess and Cruess, 2009).
Traditionally the growth of professionalism trusted on inherent learning from respected role models, a method that depended seriously on the presence of a similar culture sharing ideologies (Cruess and Cruess, 2006).Throughout the olden days of medicine, individual  Crawshaw and Link, 1996).These statements range from the least proficiencies required of all physicians to the highest expectations and morals of the model physician (The Prayer of Maimonides, 1918;Hafferty, 2006).Now, the medical professionalism is challenged by advances in technology, varying market forces, managed care, other business arrangements in health care, bioterrorism, globalization and a rising sense of the attrition of public trust in the medical profession (Swick, 1998;Ludmerer, 1999).Hence, physicians are experiencing frustration as changes in healthcare delivery systems in many countries.Recently, opinions from many nations have begun calling for a renovated sense of professionalism.Medical professional groups both in Europe and North America has called for an updated sense of professionalism among doctors and for an importance on this set of aspects in undergraduate and postgraduate medical education (Jotkowitz and Glick, 2005).A number of leading publications on medical professionalism have voiced apprehensions about the professional eminence of medical practitioners in some health care systems (Wynia et al., 1999;Medical Professionalism Project, 2002b;Royal College of Physicians, 2005).Daily challenges to professionalism are commonly encountered by novices and practicing doctors, many specialists are disappointed with their preparation in this area and were incapable to deliver a satisfactory answer to these challenges (Barry et al., 2000).There is mounting unanimity among medical professors to encourage professionalism in medical students especially to develop the core humanistic characteristics (Litzelman and Cottingham, 2007).The recent trend in schooling and appraising professionalism for medical students and residents has put substantial demands on medical schools.Professional progress is tough if the school suffers from harmony on clear understanding of the fundamental elements of professionalism (Brown et al., 2009).The fundamental elements of professionalism are unique and equally applicable to any profession for the benefit of common people (Salam et al., 2012a).Professionalism must be trained obviously and assessed commendably (Elnemr, 2010).
One study detects nine conducts that organise medical professionalism and that physicians must reveal if they are to run into their responsibilities to their patients, their communities, and their profession (Swick, 2000).
Researchers reported some patients might not receive comprehensive and precise facts from their physicians, and uncertainties about whether patient-centered care is largely possible without more extensive physician commendation of the core communication principles of openness and honesty with patients (Lezzoni et al., 2012).Henceforth the Charter on Medical Professionalism, recommended by more than 100 professional groups internationally and the US Accreditation Council for Graduate Medical Education, necessitates frankness and trustworthiness in physicians' communication with patients (Lezzoni et al., 2012).The progressive interference of market force into the dominion of medicine is frightening to switch the principles of professionalism with the conflicting ethics of the marketplace.Academic medicine must undertake more obligation and accountability for strengthening the determination of future doctors to withstand their vow to the ethics of professionalism (Cohen, 2006).
Researchers hope and believe medical educators will ensure that students safeguard patient confidentiality (Jotkowitz et al., 2004).The intrinsic susceptibility and habit of patients, certain relationships between physicians and patients must be avoided.In particular, physicians should always respectful and in no occasion abuse patients for any sexual benefit, own monetary gain, or other private fortitude (Project of the ABIM Foundation, 2002).Responsibility and accountability must be boomingly established in order to accomplish the high anticipations placed by society on physicians.
Co-operative fields concern how doctors intermingle with other parties within the community convention (Hilton, 2004).The specific values aided by medicine and the qualities cultured in doctors move from our collective know-how of illness, love, compassion, and caring for those in need.The core values of professionalism, consequently, originate from the universality of ailment and begin with caring or compassion.Caring over time generates the value of responsibility.The shared responsibility for care produces faith and admiration by both physician and patient (Arnold and Stern, 2006).
The basis of modern medicine is every decision should be taken by discussion between patients and doctors.
One of the three essential doctrines of the "Charter of medical professionalism" in the new millennium is the belief of patient sovereignty: "Physicians must empower their patients to make informed decisions about their treatment" (Medical professionalism in the new millennium: A physician charter, 2002).It is essential to acquire at liberty and well-versed consent from patient and is recommended by European and International manuscripts (World Medical Association, 1964).Self-directed learning (SDL) expertise is believed to be connected with all-time erudition.SDL has developed a principal leitmotif in adult education, as demonstrated by meta-analyses, critical reviews of research, and an annual international symposium devoted solely to research on SDL, along with millions of "hits" on this topic on Internet sites (Brookfield, 1993).The capability to direct and control one's own learning practice is the key for achievement in the Bangladesh J Pharmacol 2013; 8: 124-130 medical profession (Mast and Davis, 1994).SDL skills, which are associated with lifelong learning (Candy, 1991), are predominantly imperative in the medical field, where knowledge is unremittingly changing and evolving, and dealing with innovation is an important facet of patient encounters.
This study was conducted to ascertain the conceptual understanding of professionalism with emphasis on its core issues among the students of UniSZA aimed at professional development of future medical professionals.

Materials and Methods
This was a cross-sectional study conducted on medical students of UniSZA.

Results
Out of 108 respondents, 50 (46%) were from year-I and 58 (54%) were from year-II.Among the year-I students 16 (32%) were male and 34 (68%) were female and among the year-II students 13 (22%) male and 45 (78%) were female.Only 27% of total respondents were male and the rest 73% were female.Mean professionalism score of male respondents was 172.3 and female was 174.6 (Table I).Mean professionalism scores for year-I was 175.2 and year-II 172.9 (Table II).There has no significant difference between gender (p= 0.536) and study year (p= 0.484) in total scores of core elements of professionalism.
Investigation on what professionalism is meant to the respondents, how it should be taught, how they learnt and how professionalism should be assessed for year-I (Table III) and year-II (Table IV).These tables revealed that 48% of year-I and 72% of year-II students expressed professionalism as positive attitude and behavior towards job.Eighteen percent of year-I students and 9% of year-II did not answer the questions.Twenty-four percent and 33% of year-I and II students respectively opined that professionalism should be taught through experience.Forty-two percent and 34% of year-I and II pupils respectively felt professionalism is learnt by experience.Only 12% of year-I students' impression is professionalism should be assessed formally but in contrast nearly half (49%) of year-II students opinion is it should be assessed formally.

Discussion
Medicine is a profession that practices the center of agreement between physicians and civilization (Hislton and Slotnick, 2005;Irvine, 2003;McDonagh, 2008).The proficient character of physicians comprises a promise to preserve community obligation by providing rational practices of medicine on the basis of science (Fadar et al., 1989;ABIM, 2002;Patenaude, 2003;Bryan et al., 2005).The aim of modern medicine should be the "Good life" (Anderson, 1945).Hence, medicine has two wide-ranging objectives: To defer dying due to disease and to alleviate the misery (pain, disability, anguish) of disease (Tallis, 2006).Many researchers think to include 'comfort always' in the aim of physicians (Lloyd and  Bor, 1996;Salam et al., 2008).Hence, physicians need a high standard of performance that safeguards use of core issues of professionalism in addition to the mastery of knowledge and clinical skills (Litzelman and Cottingham, 2007).
This study was about a group of UniSZA medical students of year-I and II where number of female students is more than male students.This finding is similar with the study done at UKM Medical Center (Salam et al., 2012b).In terms of scores of cores elements of professionalism such as honesty, accountability, confidentiality, respectful, responsibility, compassion, communication, maturity and self-directed learning between male and female students with different socioeconomic and educational upbringing were found with no significant differences.In contrary with UKM study (Salam et al., 2012b), present works found female (174.6)scored a little higher than male (172.3).Similarly there were no significant differences between year-I and II but slightly higher score in year-I (175.2) than year-II (172.9).Study done in West Virginia University School of Medicine the core values of professionalism may vary widely with gender, studyyear and socio-cultural background (Nath et al., 2006).This study does not agree with the work of West Virginia.Professionalism score in core issues among the undergraduates of different study-years also were found closely analogous with no significant difference.Environment plays as a vibrant protagonist in persuading the growth of professionalism (Cruess et al., 2008).The nearing scores in core issues of professionalism between different gender and studyyears of the respondents in the present may denotes a congenial, shared educational setting is working in this University.Intradepartmental and interdepartmental teamwork, livelihood and mutual respect are very much needed for promoting educational development rather than competitive insolence (Salam et al., 2011c).Multiple studies reported that students' assertiveness headed for professionalism have a tendency to decline for the period of the years of training (Brown et al., 2009;Duke et al., 2005).The current study revealed that out of the total score of 220, year-I and II respondents score was 175.2 and 172.9 respectively.Although there was no significant differences but it corresponds with the publication of others (Brown et al., 2009;Duke et al., 2005).
About 48 and 72% of year-I and II students defined professionalism as positive attitudes towards their occupation and 9-18% students did not respond.This data has similarity with other studies (Salam et al., 2012b;Swick, 2000).Scholars identified that professionalism is easy to recognize but notoriously difficult to define and poorly understood (Riley and Kumar, 2012;Swick, 2000).This is the place where faculty member must get in to make a clear understanding and prepare students to practice on fundamental concerns

Comparison of mean value of fundamental elements of professionalism between year-I and -II students
Mean  of humanistic characteristics of professionalism.Clear unity among the faculty member is much important for the development of professionalism (Brown et al., 2009).
Archaeologically, society has tried to reassure its inhabitants of safe and effective medical care through the licensure of the profession.Beyond licensure, it has trusted on the ethical values of the profession and its social agreement with society to run an acceptable resource of physicians through medical education and training (Richmond and Eisenberg, 2000).Medical professionalism follows the foundation of the convention between doctors and society and it is thus imperative that professionalism must integrated into the undergraduate curriculum (Hislton and Slotnick, 2005;Irvine, 2003).Thus, educators play crucial role in the development of undergraduate' expertise during their course work (Salam et al., 2011a;Nabishah et al., 2009).
The lectures personal charisma act as role model and has concrete influence on students for the development of professionalism (Wright et al., 1998;Paice et al., 2002;Yazigi, 2006;Kenny, 2003).This mode has long been used as unceremonious part of medical training.Twenty-four percent to 33% of the respondents feel that professionalism should be taught through experience (Table III and IV).Again 34-42% of students think it should be learned through experience.Various studies although concluded that professionalism is best learned from faculty role models (Brown et al., 2009;Cruess et al., 2008;Wright et al., 1998;Paice et al., 2002;Yazigi et al., 2006;Kenny, 2003;Salam et al., 2010;Goldie et al., 2007;Cote and Leclere, 2000;Reynolds, 1994;Salam et al., 2012a) the present work is contrary as only 10-28% of students stated for role models (Table III and IV).The study respondents were very fresh students hence authors believe that they do not have enough experience about role models.Moreover MBBS course is very new also in very new UniSZA.Thus they fail to interpret how role model helps for the development of holistic doctors.Societies identify role models with high potentials.Again people have strong desire to be like role models.Hence, role model is a great way to inculcate professional values, attitudes, and behaviours in students and young doctors (Swick et al., 1999;Wear, 1998).Moreover, medical educationist believes students pick-up the skills of observation, communication and professionalism by copying role models (Salam et al., 2011b).
In the past many years, several studies have argued that if physicians are to meet their responsibilities to their patients, to the profession, and to society, formal teaching of professionalism should be embedded in the medical school curriculum (Hislton and Slotnick, 2005;Irvine, 2003;Swick et al., 1999;Cruess and Cruess, 1997).Majority of study respondents of year-I (40%) and year-II (36%) think formal education is way to be taught professionalism and ranking it as first.This finding corresponds to many studies (Hislton and Slotnick, 2005;Irvine, 2003;Swick et al., 1999;Cruess and Cruess, 1997).Again, 22-30% of the students think they learnt professionalism by formal education and it is second in their grading (Table III and IV).UniSZA students feel 12-49% professionalism should be assessed formally.In contrary to many studies mentioned earlier 7-10% respondents give emphasis on role models (Wear, 1998;Salam et al., 2011b).
The schooling and refinement of professionalism has long been part of medical education and have had fresh distinctive importance because professionalism has been recognized as a fundamental qualification in both developed and developing countries.The present study found there has almost equal level of understanding on principal humanistic concerns of professionalism with insignificant differences between gender and years of study.This study gives more emphasis to conduct formal education on professionalism.There is urgent need to create more role model to enhance adequate professionalism among the medical students.Welldesigned prospective study is suggested in this regard.Hence it will ensure more holistic and rational medical doctors for the community who will work on the basis of science and humanity.
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Table I Comparison of mean value of fundamental ele- ments of professionalism between males and fe- males
a Independent T-test