professionalism

Youre judged all the time! Students views on professionalism: a multicentre study
Gabrielle Finn,1 Jayne Garner2 & Marina Sawdon1

OBJECTIVES This study describes how medical students perceive professionalism and the context in which it is relevant to them. An understanding of how Phase 1 students perceive professionalism will help us to teach this subject more effectively. Phase 1 medical students are those in the rst 2 years of a 5-year medical degree. METHODS Seventy-two undergraduate students from two UK medical schools participated in 13 semi-structured focus groups. Focus groups, carried out until thematic saturation occurred, were recorded and transcribed verbatim. Data were analysed and coded using NVivo 8, using a grounded theory approach with constant comparison. RESULTS From the analysis, seven themes regarding professionalism emerged: the context of professionalism; role-modelling; scrutiny of behaviour; professional identity; switching on professionalism; leniency (for students with regard to professional standards), and sacrice (of freedom as an individual). Students regarded professionalism as being relevant in three contexts: the clinical, the university and the virtual. Students called for

leniency during their undergraduate course, opposing the guidance from Good Medical Practice. Unique ndings were the impact of clothing and the online social networking site Facebook on professional behaviour and identity. Changing clothing was described as a mechanism by which students switch on their professional identity. Students perceived society to be struggling with the distinction between doctors as individuals and professionals. This extended to the students online identities on Facebook. Institutions expectations of high standards of professionalism were associated with a feeling of sacrice by students caused by the perception of constantly being watched; this perception was coupled with resentment of this intrusion. Students described the signicant impact that role-modelling had on their professional attitudes. CONCLUSIONS This research offers valuable insight into how Phase 1 medical students construct their personal and professional identities in both the ofine and online environments. Acknowledging these learning mechanisms will enhance the development of a genuinely student-focused professionalism curriculum.

Medical Education 2010; 44: 814825

doi:10.1111/j.1365-2923.2010.03743.x
1 Phase one Medicine, School of Medicine and Health, Durham University, Stockton-on-Tees, UK 2 Centre for Developing Professionalism, School of Medical Education, University of Liverpool, Liverpool, UK

Correspondence: Gabrielle Finn, School of Medicine and Health, Durham University, Queens Campus, University Boulevard, Thornaby TS17 6BH, UK. Tel: 00 44 191 334 0737; Fax: 00 44 191 334 0321; E-mail: g.m.nn@durham.ac.uk

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perspective of UK pre-clinical medical students, thus lling a gap in the literature. This study reports on one main cluster emerging from these focus groups: students perceptions of professionalism and the context(s) in which it is relevant to them.

INTRODUCTION

Professionalism is subjective and is neither easily dened, nor quantied.1 Denitions of professionalism are extensive and disparate and most authors list numerous and diverse attributes. For example, Van de Camp et al.2 list 90 attributes compiled from a systematic literature review. Likewise, there are many guidelines on professionalism, with a number of professional guidelines issued to students when they commence their studies, such as the General Medical Council (GMC) documents Good Medical Practice3 and The Duties of a Doctor.4 How much understanding students have of these guidelines and how much they perceive them as relevant are little known. It has been reported that medical students know the professional behaviour that is expected of them and can imitate this in an examination.5 The importance of the informal and hidden curricula in shaping student perceptions of professional behaviour and values in valuable learning experiences has also been highlighted,6 as has the impact of role-modelling.7 More recently, the impact of social networking has been associated with unprofessional behaviour by medical students8 and has raised issues relating to appropriate behaviour on social networking websites such as Facebook.9 Students can develop rhetorical strategies to cope with unprofessional situations, such as by dissociating themselves from the identity of the qualied professional and associating themselves with the identity of the student, and switching between the two; this is known as identity mobility strategy.10,11 Students views on professionalism are well documented in the literature,1216 but few accounts describe the opinions of Phase 1 students.17 Phase 1 medical students are those in the rst 2 years of a 5-year medical degree. An understanding of how Phase 1 medical undergraduate students perceive professionalism may help us to teach professionalism more effectively at this early and formative stage. This investigation was conducted in succession to a quantitative study to strengthen the validity of an explorative measure of professionalism, the Conscientiousness Index,1 through the use of peer assessment.18 Subsequently, students participated in this qualitative study, which sought to determine students perceptions of professionalism, how they thought peer assessments ought to be conducted to optimise reliability, and participation. Our previous research1,1820 was therefore the basis for our conceptual framework. We sought to provide the

METHODS

Ethics and recruitment Ethical approval for the study was granted by the ethics committees at Durham University and the University of Liverpool. As Lancaster Medical School is a satellite school which delivers the Liverpool curriculum, ethical approval was granted by the University of Liverpool. Participation in the focus groups was voluntary. Theoretical sampling was applied to invite students at the appropriate educational level (i.e. Phase 1 medical students following a 5-year curriculum with supervised clinical contact) to take part in the focus groups. Based upon preliminary research,1,11,19,20 authors from Durham University (GF, MS) collaborated with an author from the University of Liverpool (JG) as a means of triangulating data; this also served to increase the sample size and ensure that any ndings were generalisable to the wider UK context. Theoretical sampling21 allowed the authors to gain a deeper understanding of students views on professionalism in a specic context, namely, that of Phase 1 training. Durham and Lancaster Universities both offer separate Phase 1 training. Other than stage of training (i.e. participants were required to be in Phase 1), there were no exclusion criteria for this study. All students in the Phase 1 cohorts at both institutions were invited by e-mail to attend and were provided with background information sheets and consent forms. Consenting students responded to the researchers by e-mail and agreed to focus group participation, to the recording of the discussion, and to the storage and dissemination of the data. Participants were informed that they were free to withdraw at any time and that non-participation would not incur any negative consequences. The groups were conducted at the two medical sites by the three authors. Transcription was shared between the authors and administrative staff at both institutions. Data were collected through 13 semi-structured focus groups as this method allows for group discussion facilitated by the authors in order to explore multiple and opposing opinions. Groups were conducted

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Table 1 Focus group topic guide and spines used to facilitate discussion on professionalism amongst Phase 1 students

Focus group topic guide Spine Professional behaviours Relevance of professional behaviour Teaching, learning and assessment of professionalism General comments Key points for discussion Denitions, attributes Setting, stage of training, applicability Student opinion: how to teach, learn and assess As directed by participants

until thematic saturation occurred, which took approximately 1 hour for each group. A topic guide was used for the focus groups, derived from previous research by the authors and general literature on professional behaviours and undergraduate medical students.1,1820 This allowed for a semistructured approach and minimised the likelihood that facilitators would inuence the discussion. Table 1 shows the focus group topic guide and spines used to facilitate discussion. The focus group discussions were taped and transcribed verbatim. Transcripts did not identify participants. Students were given the opportunity to approve transcripts before publication. During the focus groups and data analysis stages, authors carried out regular member checking22,23 to conrm their interpretation of the data. Participant prole This study considered the opinions of students from two medical schools in order to ensure that the students were not culturally homogenous. All participants were Phase 1 medical students. The age of participants varied between 18 and 40 years. Phase 1 students at Lancaster were following a problembased learning curriculum, whereas Durham students were following a case-led curriculum. Although Phase 1 represents pre-clinical training, students have a signicant amount of clinical contact. Clinical contact was hospital-, community- and classroom-based. Students at both institutions were taught by academic and clinical members of faculty staff. Following Phase 1 training, students from Durham and Lancaster merge with cohorts from Newcastle and Liverpool Universities, respectively, for their Phase 2 clinical training (Years 35 of medical school). The students backgrounds varied. Participants had either entered medical school straight from secondary (high) school, had previously completed a

Bachelors or Masters degree, or had practised as an allied health professional. Both institutions had UK and international students. The participants who attended the focus groups were representative of their cohorts with respect to age, ethnicity and educational background. Data analysis Data were collected and analysed in iterative cycles and coded by the authors using NVivo Version 8 (QSR International Pty Ltd, Doncaster, Vic, Australia). Data were analysed using a grounded theory approach2225 with constant comparison. The thematic coding of the data was inductive and was undertaken by the authors individually, who then met to agree content groupings and internal interpretation validity.26 Reexivity, microsocial theory and social constructionism With regard to reexivity,25,27,28 none of the authors of this study had any role in the teaching or assessment of professionalism for any of the participants; this avoided the presence of relationships involving power and any inuence over the data collected. A grounded theory approach was utilised as it describes both a methodology and a paradigm. Grounded theory acknowledges the possibilities of biases of which an author may not be aware; by using such a method, the author allows the theory to develop from the data, rather than ndings being subject to author biases.29 As the research focuses upon the personal and immediate social interaction of daily activities and personal experience, it can be classied as representative of microsociology.30 These inter-

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actions demonstrate a shared understanding of processes, situations and language from which individuals make sense of their world.31 As researchers, it is important to acknowledge our own denitions and comprehension of professional behaviour because these shaped the questions we asked students in the focus groups. Therefore, this research takes a social constructionist approach as it does not aim to discover scientic facts, but seeks to explore students views and experiences of professionalism. Facilitator and author prole Authors acted as focus group facilitators for this study. The authors were all experienced in qualitative research and focus group facilitation and had no formal roles in the teaching or assessment of professionalism at either institution. The authors backgrounds are varied and include physiology (MS), anatomy (GF) and local government (JG). All authors are currently employed in medical education research posts. focus groups at two institutions. Of the 72 students, 15 came from Lancaster University and 57 from Durham University. Seven major themes emerged from the data. These were: context; role-modelling; scrutiny; identity; switching it on; leniency, and sacrice. Each theme, its sub-themes and mini-themes are described in turn. A diagram of these themes, sub-themes and related mini-themes, and of the relationships between them, is depicted in Fig. 1. Themes are the most prominent clusters of information to emerge from the data; these are the principal concepts. Sub-themes are present within themes. These describe conceptually discrete aspects of the theme which have emerged from the data. Minithemes are smaller concepts which are nested within and explicate the sub-themes, or describe discrete concepts within the overarching sub-theme. We acknowledge that mini-themes are not a conventional reporting method for qualitative data; however, we have devised this hierarchical coding system to demonstrate the development of ideas within a theme. The hierarchy delineates the discrete, yet relational, aspects of concepts within a specic theme. One theme to emerge from the data, which will not be reported in the results, referred to denitions of

RESULTS

Of the 245 students invited, 72 students (31 men, 41 women), all in Phase 1 of their training, attended

Two gears
University context Clinical context Virtual context Applicability
Camaraderie diuses stress

Developing professionals

Context Leniency Role modelling

Camaraderie

Virtual role modelling

Dressing up

Switching it on Sacrice

Scru ny

Resentment of scru ny

Iden ty
Virtual iden ty

KEY:
Theme
Sub-theme

Iden ty nego a on

Mini-theme

Rela onship

Figure 1 Themes emerging from students views on professionalism. Shaded circles depict main themes, ovals depict subthemes and trapezoids indicate mini-themes

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professionalism. Students understandings of professionalism included behaviours, attitudes, values and attributes. This discussion adds nothing new to the literature, nor to the readers understanding of the context of the results outlined below. Many of the denitions provided mirrored those described by Van de Camp et al. (2004).2 Context Students described professionalism as being contextdependent. Three contexts were described: the university, the virtual and the clinical. Clinical context Students regarded professionalism as being predominantly relevant within the clinical context: its most relevant to me to be professional in a hospital setting Students also used an analogy in which they referred to the two gears of professionalism. This analogy of gears alludes to a manual (stick-shift) car. Two gears is interpreted as implying that there are two possible speeds or levels of behaviour. Within the clinical context of professionalism, two gears were repeatedly described: professionalism in the presence of patients, and professionalism in the absence of patients. Furthermore, these gears were often anecdotally described as being exhibited by individuals perceived by students as role models: the medics that we shadow have almost two-gear behaviour. Theres the banter that theyll have with you [students] and then when the patient has walked in, it changes... different degrees, levels of professionalism, like around patients you have to be more professional Virtual context The second context in which professionalism was described was the virtual, with specic reference to the social networking site Facebook. Students allude to their status, a term that refers to a brief statement or headline on the Facebook users personal prole page. This status is often visible to all members of the social networking community: ...Ive noticed that people in medicine seem to constantly have stuff to do with their course as their Facebook status... University context Students made reference to a third context of professionalism, the university environment: ...I think lecturers probably would be a bit more forgiving if you were less professional... Contextual applicability of professionalism There was confusion regarding in which context professionalism was relevant: I dont know what professionalism means in the context of a university student I dont understand where it [professionalism] matters here [Phase 1]. I dont see where it comes from and where the relevance of it all is. Role-modelling When discussing ways in which professionalism may best be taught or learned, participants advocated observing role models, specically within the clinical context: observing doctors when were in the hospitals and on visits thats a good way to see how they behave and thats like a good role model to try and follow. Role models and the virtual context Lapses in professional behaviour on social networking sites were witnessed by students. Incidents involving role models were described: Ive got a friend shes a doctor now and often I notice her [Facebook] status is [about] things like So-and-so is sick of intravenous drug users and Im thinking, This is awful; you cant put that on Facebook and I mean shes not like naming names so maybe she thinks its ok... its always to do with something thats happened at work. Camaraderie There was an association between role models and unprofessional behaviour, excused by students as representing camaraderie. Anecdotally, students described this camaraderie as banter: its a necessity to be able to have fun with your peer groups as doctors and, yes, maybe this will

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involve sarcasm, a bit of joking around and things like that, maybe discussing patients, you know, probably not in the most professional way, between yourselves what youre saying in a group of clinicians together, isnt going to be what youre going to say in front of a patient anyway. Camaraderie as a stress diffuser This camaraderie was condoned as a legitimate means by which medics can diffuse stress: I think you should always be able to relax a bit you know when youre with your peer group otherwise you just turn into robots... then you would probably zzle out pretty quickly... Scrutiny Students were aware that their professional behaviour will be scrutinised, both within and outwith the clinical environment: Our behaviour outside the surgery will be [under] scrutiny; you know if you get a skinfull and have a ght in a pub as a practising medic, youre not going to be practising for very long. So in a way, learning to live within those boundaries is important. Resentment over scrutiny Not all students were accepting of this scrutiny: God youre just judged all the time! Its a terrible burden to place on people. Identity Another major theme to emerge was that of identity. Sub-themes included identity negotiation and virtual identity negotiation. Students struggled with the distinction between their identities as medics and as individuals: ...theres like a blur between them. Identity negotiation In addition, students talked of identity negotiation, often related to context and environment: were probably all acting professionally in the situation were in, as students, were acting as we should as students when you go into the hospitals you have to act differently around patients. Dressing up Dressing up as a doctor was strongly perceived by students as a characteristic of being professional. Clothing appears to be a means by which students switch on their professionalism: [if] you dress smart, people will see you as professional ...we all dress up in our smart gear and ... it kind of gets you into a different mind set. Leniency The penultimate major theme was leniency. Students strongly called for leniency regarding professional Students spoke about a separation between their personal and professional identities on Facebook: Like keeping it completely separate I have a lot of people I know in the course; I dont have very many medical friends on Facebook because I want to keep it completely separate and people cant nd me because I know that can affect your career later, so part of me wants to quit [Facebook] anyway. Switching it on A major theme to emerge concerned students ability to switch into a professional mode on demand. The sub-theme of dressing up was associated with this. Participants discounted the applicability of professional standards outside the clinical setting and talked of acting professionally and having the ability to switch it on within the clinical environment: I see myself as a medical student so I think that the medical part comes out when I go to hospital and then the student part comes out in like lectures and outside of work so I kind of think Im allowed to be more studenty when Im not in hospital and Im supposed to more medically when Im in hospital. I kind of split it like that. Virtual identity negotiation

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behaviour in Phase 1. The developing nature of professionalism was a sub-theme: I think were allowed to be a little bit unprofessional, its sort of student life isnt it? Its the 2 years of medicine that you actually get to be a dosser* [*dosser: British slang for a lazy person or idler] I dont think we should be expected [to show] the same amount of professionalism as proper doctors because we are learning, arent we? Developing professionals Calls for leniency were accompanied by descriptions of professionalism as a developing, scalar attribute: We are learning also to be professional within the next 5 years and we will rise to it within the next 5 years and we will get better and better at it through the course. Sacrice The nal major theme to emerge from the data was that of sacrice. Students narratives described a feeling of being constantly observed and likened this to making a sacrice regarding their freedom as individuals: There is a certain amount of freedom that people need to have though how much of your freedom is it right to sacrice for a career? As a person, as an individual? It can be tough to understand that thats what youre giving up to be a doctor. And you are giving it up. learner masters skills and knowledge and becomes embedded within the socio-cultural practices of the community. Eraut describes this as learning from experience33 and also attributes learning to the social interactions within the place of work. As undergraduates, medical students are at the periphery of their eventual community of practice, the health care system. Not yet fully skilled, they acquire knowledge from the masters and develop their attitudes by observing the community. This developing of socio-cultural attitudes and skills whilst integrating into the community may occur on placements and from observing role models in both the university and clinical contexts. Learning, as it normally occurs, is a function of the activity, culture and content in which it occurs (the community).32 This is also true of professionalism, despite the lack of consensus on whether professionalism can be learned; professional behaviours and attitudes are developed in the community of practice. Students future clinical practice is moulded through direct observation of experts, those whom students perceive to be the masters. Learning has been described as context-dependent.32,33 This parallels the testimonies of students that professionalism is best learned within the practice community and specically through observation of role models. Students described role-modelling in the clinical context explicitly, both anecdotally and as a favoured means by which professionalism can be taught. Role models were on occasions described positively; however, most students gave accounts of lapses of professionalism and associated camaraderie. This behaviour was sign-posted by role models as acceptable, with students drawing the conclusion that it is legitimate to behave in an unprofessional manner provided that patients do not witness this behaviour. Narratives of events in which patients had been mocked by role models were provided, which is consistent with issues in current literature around professional socialisation and the use of cynical humour about patients.34 Students seemed to nd the associated camaraderie with their superiors gratifying and considered it to represent a sign of their acceptance into cultural insider knowledge.35 These ndings corroborate recent research reporting that students experience pressure to conform to and adopt values and behaviours that are not acknowledged by the formal curriculum.36

DISCUSSION

Of the three contexts university, virtual and clinical undergraduate medical students appeared to feel that it is the clinical context in which professionalism is most relevant. This nding is not surprising as professionalism is often taught within this context by practising clinicians. Students professional development is facilitated by both clinical and academic staff; however, students appear to place more signicance on the clinical perspective. Lave and Wenger32 coined the term legitimate peripheral participation to describe the view that learning is a situated activity, in which the learner ultimately becomes a participant in the community of both knowledge and practice. This occurs when the

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The two gears of professionalism professionalism displayed in the presence of the patient and that displayed amongst peers were strongly advocated by students as they had witnessed their superiors displaying both. Furthermore, the banter described was condoned on the premise that camaraderie and banter are acceptable methods by which medics can unwind. This perception may reect a contemporary representation of Lave and Wengers statement that an understanding of what old-timers collaborate, collude and collide, and what they enjoy, dislike, respect and admire32 is required to become a full practitioner. Similarly, this mirrors Turners37 nding that within new groups people surrender their idiosyncratic self-views in favour of those supported by the group. In other words, students may not truly condone the behaviour of their role models, but they do accept it. The literature suggests that role-modelling is fundamental to developing professional behaviour38 and some studies suggest that role models are the primary inuence.17 With this in mind, educators, especially within the clinical context, must be aware that students appear to acquire professional behaviours by imitating those they perceive to be role models. In order to uphold good professional standards and negate the effects of negative role-modelling, great care must be taken to signpost appropriate professional behaviours, thus ensuring that students eventually become legitimate members of the clinical community. This is in accordance with suggestions made by Baernstein et al.17 that: medical schools should ensure that students are exposed to excellent role models ideally, faculty who can articulate the ideals of professionalism and work with students longitudinally in a clinical setting. Identity was a recurring theme within the data. Identity represents the process by which a person seeks to integrate his or her various statuses and roles, as well as diverse experiences, into a coherent image of self.39 Epsteins statement highlights a complex phenomenon with which most individuals struggle: Who am I? This question is likely to be asked by many medical students, in their capacities as both learners and individuals. Students statements were indicative of personal grappling with identity and social standing, and often implied resentment of the dilemma resulting from friction between the two. Although students acknowledged an understanding that their behaviour will be under scrutiny throughout their careers, this understanding was accompanied by a sense of loss of identity. Students often made a clear distinction between themselves as doctors and themselves as individuals, but expressed concerns that society and their community of practice failed to do so. However, the literature reports medical students identities as closely tied to their chosen profession, often leading to deep internal prohibition of criticism of the profession or of fellow physicians.40 This dilemma draws a parallel with the notion of identity negotiation, whereby an individual negotiates with society regarding the meaning of his or her identity.41 Identity negotiation in this group of students related to the context and applicability of professionalism, as identied by themselves, in that students were confused as to when and where professionalism was required, and to what degree. They were attempting to resolve questions such as: should the professional standards required of a practising doctor be required of a student? Is professionalism required out of hours? Am I an individual or always a professional? Should there be a distinction? Identity negotiation is analogous with professional socialisation. Professional socialisation, the process by which an individual learns the roles and responsibilities of his or her chosen profession before emerging as a member of the professional culture, is comparable with the mastery of a profession described by Lave and Wenger.32 Professional socialisation is tri-phasic; it involves recruitment, professional preparation and organisational socialisation. Recruitment and professional preparation are dened as the pre-service phases. According to Klossner, these anticipatory phases occur before and during the professional education period and there is overlap between the three phases.42 Furthermore, legitimation was found to initiate the process of professional socialisation. This results from its role in stimulating meaningful experiential learning and, thus, the formation of professional identity.42 When students look to others for acceptance, in order to afrm their developing professional identity, legitimation occurs.42 If we consider legitimation, situated learning, professional socialisation and identity negotiation, the comments of our students regarding camaraderie and role-modelling are contextualised and perhaps comprehensible. In order to develop a professional identity, students must gain a realistic view of the challenges and opportunities inherent in a profession.43 Experiencing unprofessional camaraderie and

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role-modelling, followed by negotiating a moral judgement on whether to engage with it, may be a learning opportunity for students. The learning opportunity presented will challenge students with respect to professionalism and professional identity. The conict between self and profession continues in the virtual environment. To students, both the onand ofine environments are realities; these environments are equally constitutive. Online and ofine life will continue to exist side by side;44 professionalism is applicable to both. In our data, responses regarding the virtual context of professionalism, specically views on social networking sites and the rights of a medical student as an individual, were in opposition to one another. Most examples made reference to the social networking site Facebook. Examples were given of peers posting details of the course and their clinical experiences as their status on Facebook. Some students made a clear distinction between their working and personal lives, and could not understand why colleagues posted this type of information on public forums. This once again reinforced students struggle with identity negotiation, but from the perspective of another peers identity. Students described airing caution and using privacy settings on Facebook, or fostering a pseudonym so that they could not be identied. They were aware that lecturers and tutors used the site and thus students could be held accountable for any issues resulting from online social networking activity. Recent research on this topic45,46 has also reported concerns regarding inappropriate and unprofessional behaviours that are publicly accessible on individual proles and in groups. Literature on gaming sheds light on the virtual world, to which this generation of students is well accustomed. A virtual mask in the form of an avatar is described, whereby the avatar provides opportunities for the player to experiment with identity in original ways. The adoption of such a mask simultaneously secures both anonymity and identity; this enables the player to be concurrently known and unknown.44 This gaming behaviour resonates with the behaviour displayed by medical students on social networking sites such as Facebook, such as with the acquisition of a pseudonym as described previously. Heim states that a virtual existence allows people to keep a distance while putting themselves on the line.47 This appears to be true for medical students; they feel able to express unprofessional attitudes on social networking sites when they are hiding behind their virtual prole, which may be a realistic, an idealised or a masked version of themselves. This online masked persona enables students to distance themselves from ofine reality in the form of the clinical community and to express attitudes that they may not otherwise feel comfortable projecting. Incidents of negative role-modelling online were reported, demonstrating the extent to which social networking inuences students and their professional practice. As social networking continues to dene social progress, this raises questions with regard to professionalism and the public domain, something individuals and institutions may wish to consider. Institutions may need to formalise their stance on behaviour exhibited online; we feel this issue is likely to be raised in future tness-to-practise proceedings at some institutions. Crowe and Bradford state that: cyber space, and its practices, clearly have potential for fomenting new moral panics centred on young peoples leisure lives.44 In 2008, The Times reported the suspension of a Swedish nurse who had posted photographs of surgical procedures on Facebook.48 The article suggested that posting of inappropriate material, such as photographs from clinics, is designed to provoke envy among friends.48 Institutions are now faced with a dilemma: do they hold students accountable on the grounds of tness to practise over violations of privacy rules and other related unprofessional postings on social networking sites? Could social networking be the source of just another moral panic like that described by Crowe and Bradford?44 Do medical schools have the right to scrutinise students proles, whether they be private or publicly accessible? There was an overwhelming call from participants for institutions to be lenient with regard to professional standards whilst students are in an undergraduate setting. The rationale for this was multi-factorial and included age, hierarchical status and inexperience, amongst other reasons. Coupled with this was the notion of a developing professional; students often described the construct of professionalism as a cumulative attribute which would come to completion at the end of the 5-year undergraduate period when students graduated as professionals, or proper doctors. These comments are indicative of proto-professionalism as described by Hilton and Slotnick,49 which encompasses the developmental period of professionalism, prior to the gaining of clinical experience. Without this practical experience the evolution of

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students knowledge and their skills base is limited. During this phase of proto-professionalism, their behaviour is perhaps determined by moral and reective judgements rather than by their experiential learning and subsequent practical wisdom.49 Conversely, Cordingley et al.50 demonstrated that as students progress through medical school, their levels of moral reasoning ability and ethical sensitivity do not increase. Students descriptions portrayed professionalism as a persona and a professional as a character they were able to act as on demand. This was further supported by their accounts of dressing as a professional. When discussing professional behaviour and attributes, a surprising degree of emphasis was placed on clothing. Students remarks indicated an element of costume dressing: they dress up as they perceive a doctor should; attire therefore makes them professionals. Their struggle with identity and social standing becomes evident once again. Students are mimicking, through dress, the masters of their community of practice in order to become legitimate participators; they are mimicking how masters talk, walk, work, and generally conduct their lives.32 The emphasis on clothing ought not to be dismissed. Research has shown that simulating seemingly trivial aspects of the clinical context, such as clothing, in undergraduate teaching demonstrates that for a high degree of authenticity in simulation approaches, small details are important.51,52 To conclude, the most consistent theme in our data was that of the context of professionalism: in which context is it relevant and to what extent, and in which context is a student a medic or an individual? There was a tremendous sense of confusion evident across student bodies at both institutions. More striking was the impact of role models on undergraduate students, and the magnitude of the less-than-positive hidden curriculum. We have demonstrated that students are aware that professional behaviour is expected of them; however, the level to which it should be exhibited is not clear. Interestingly, professional behaviour was described as a burden and metaphors such as like a robot were used. Upholding professional standards was perceived to involve sacricing the freedom of the individual; this was mostly attributed to being watched. Again, this was more suggestive of the students struggles with personal and professional identity and the inuence of societal expectations upon this conict. More importantly, this should highlight to faculty the need for explicit guidance on professional standards and the expectations of students as both trainee medics and as individuals. Furthermore, faculty should be aware that this scrutiny is not always welcome and may have a detrimental effect upon students. An article in the Student BMJ53 reported arguments against measuring professionalism and overly intrusive assessment of professionalism was reported to be a cause of concern and anger for medical students.53,54 The limitations of this study include the voluntary nature of participation, which results in a biased population, and focus group dynamics. Focus groups were utilised because they allowed the researchers to access multiple, diverse opinions in an efcient manner. The information exchange within the group can be interactive and dynamic, allowing the exploration of contrary opinions and reection. The authors acknowledge that focus group dynamics can be easily unbalanced by one individual who may be inuential or opinionated; this limitation is inherent to focus groups. Outspoken participants may silence any contrary views; Noelle-Neumann described this as the spiral of silence theory whereby people shape their opinions to prevailing attitudes about what is acceptable.55 Furthermore, the presence of other research participants may compromise the condentiality of the focus group session.56 However, this likelihood was kept to a minimum by our use of experienced facilitators and the fact that we established ground rules at the beginning of all focus groups. Ground rules were established by the facilitators and addressed issues of condentiality, speaking in turn and accepting others views. These rules enabled participants to feel comfortable discussing personal experiences. A further limitation of qualitative research concerns potential author and facilitator bias. The facilitators of focus groups may have presuppositions; we minimised this by adhering to the focus group spines and by choosing facilitators who had no role in the teaching of professionalism. With regard to author bias, the initial independent coding of data, followed by collective axial and selective coding, minimises the likelihood that authors will interpret data in a personal manner. Further research on the themes identied in this paper is required to increase our exploration of students understanding of the development of their own professional behaviours.

Contributors: all authors made substantial contributions to the conception and design of the study, the acquisition, analysis and interpretation of data, and the drafting and

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