Overview
An induction session (Anderson, Green, Pickering) on what it means to become a professional in medicine. It moves through four linked ideas: the transition from a student’s previous personal identity to a professional identity via socialisation; what defines a profession and the social contract that binds medicine to society; what counts as a good, and an unprofessional, medical student; and the Code of Professional Conduct that students read, agree to and formally declare. A clinical case in the Emergency Department is used to anchor the discussion with trainee interns.
Structure of the session
The morning ran as follows:
- 9.00 to 9.15 Welcome and becoming a professional (Lynley Anderson)
- 9.15 to 10.00 Case discussion with trainee interns (Suetonia Green, Dean, Dunedin School of Medicine; 2nd and 3rd year and Dunedin 4, 5, 6)
- 10.00 to 10.15 Introduction to professionalism (Lynley Anderson)
- 10.15 to 10.20 Break
- 10.20 to 10.50 What is a ‘good’ medical student (Neil Pickering, Bioethics Centre)
- 10.50 to 11.05 Introduction to the student code (Lynley Anderson and Suetonia Green)
- 11.05 to 11.25 Break to read the code
- 11.25 to 11.45 Discussion about the code, sign, declaration and hand in (assisted by Esther Willing / Tui Kent, Kohatu)
Case for discussion
A 68 year old man who lives alone and has chronic airways disease / emphysema is brought to the Emergency Department at Dunedin Hospital by his daughter with acute deterioration of breathing due to chest infection. He has been a life-long smoker and continues to smoke. His appearance is unkempt and he is very thin. He is found to be in respiratory failure. He is grumpy with ED staff and repeatedly says he wants to be left alone and wants to go home.
Issues to consider:
- How reversible is this man’s chest condition likely to be?
- Specifically, what does respiratory failure mean?
- His arterial oxygen saturations are low. Are there any dangers in giving this man high concentration oxygen?
- What factors should be considered when considering admission to the Intensive Care Unit because of the respiratory failure?
- Who should be involved in the discussion concerning his wish to return home?
The slides pose these as discussion prompts for the trainee-intern session and do not supply answers. [slide does not elaborate]
Professional identity formation
The basic transition: medical students arrive with a previous identity (gender / sexual orientation, race / religion / culture, socioeconomic status and so on) and become doctors with a professional identity. The mechanism sitting between the two is socialisation (Cruess and Cruess 2012).
Inputs feeding into socialisation, as shown in the diagram:
- From above: the learning environment; role models, both positive and negative; isolation with like minded others.
- From below: learning the language and learning to play a role; multiple experiences, both positive and negative; learning the hierarchy and social control.
- Role models and multiple experiences act through both conscious reflection and unconscious reflection.
Key point: professional identity is not simply taught, it is formed by being immersed in the environment, the people and the hierarchy of medicine, with much of the processing happening without awareness.
Where ideas of being a doctor come from
The lecture asks students to trace where their own picture of “being a doctor” originated, and offers these sources:
- Interactions with your own GP
- Having a medical family
- Television (medical dramas)
- The news (public figures associated with health and medical coverage)
What follows from this:
- Some sources are more realistic than others.
- The socialisation process of medicine will fill in the gaps.
- Which leads to the question the session is built around: how to be a ‘good’ doctor?
What is a profession
Medicine is a highly valued profession in our society. Other professions named: the legal profession, priest, nursing, engineer.
A profession is an occupation that has:
- an extensive training
- a specialized knowledge base
- a professional association
- an ethical code
- a process of certification or licensing
Further features of a profession:
- Service to others
- Standing in the community
- Commitment to regulate and govern its members
- A profession sets its own standards of behaviour and practice
- Self-regulating and autonomous
The social contract
Medicine sits embedded within society: a smaller circle (Medicine) nested inside a larger circle (Society), with the social contract as the relationship between them.
Important
‘The Contract is a bargain between medicine and society. Medicine is granted prestige, autonomy, a monopoly, the privilege of self-regulation and rewards, on the understanding that it will be altruistic, self-regulate well, be trustworthy and address the concerns of society’ (Cruess, Cruess and Steinert 2010).
The bargain, set out as a reciprocal exchange:
| What medicine gets | What society expects |
|---|---|
| Good standing in the community | Altruism |
| Good pay | Self-regulate well |
| Ability to self-regulate its members | Be trustworthy |
| An autonomous profession | Meet the needs of society |
Some components of the social contract are written:
- Health care legislation
- Codes of ethics
- Requirements of medical licensing bodies
Values that must be present for the relationship to function and flourish
(Jonsen, Braddock III and Edwards, Professionalism)
- Altruism: a physician is obligated to attend to the best interest of patients, rather than self-interest.
- Accountability: physicians are accountable to their patients, to society on issues of public health, and to their profession.
- Excellence: physicians are obligated to make a commitment to life-long learning.
- Duty: a physician should be available and responsive when “on call”, accepting a commitment to service within the profession and the community.
- Honour and integrity: physicians should be committed to being fair, truthful and straightforward in their interactions with patients and the profession.
- Respect for others: a physician should demonstrate respect for patients and their families, other physicians and team members, medical students, residents and fellows.
Professional status is conditional
Important
‘Professional status is not an inherent right, but is granted by society. The maintenance of professional status thus depends on the public’s belief that professionals can be trusted. To remain trustworthy, professionals must meet the obligations set by society. Human nature, self interest, pressure from peers and commercialism are well recognised challenges to professionalism’ (van Mook et al, 2009).
The four recognised challenges to professionalism named here: human nature, self interest, pressure from peers, commercialism.
What is a ‘good’ medical student
The visual analogue scale exercise
Students are given a sheet headed “Characteristics of a good medical student. And their opposites.” The instruction: choose the characteristics you view as the six most important and indicate on the Visual Analogue Scale (VAS) where you think you currently stand. The nearer the right of the line, the better you see yourself as doing on that characteristic. The sheet has six numbered rows, each with a “Characteristic:” label and a blank horizontal scale line. The slides build the sheet up with example names placed at opposite ends of row 1 (Neville Longbottom on the left, Hermione Granger on the right), illustrating the two poles of a characteristic. The characteristic labels themselves are left blank for students to fill in. [slide does not elaborate]
Characteristics identified by a previous year’s cohort
- Happy, balance, well rounded individual
- Ordered, organised
- Integrity: true to yourself, motivated by desire to help others
- Maturity: being responsible
- Accountable: responsible for your actions
- Humility: open to self improvement
- Open-minded: willing to take on new ideas
- Non-judgemental
- Respectful of others
- Co-operative: working with peers
- Insightful regarding behaviour
- Empathy: relate to others’ experiences
- Good communicator
- Altruism: putting others before yourself
A slide titled “Characteristics of a medical student 2025” is present but left blank, that is, to be generated live by the class. [slide does not elaborate]
Unprofessional behaviour of medical students: four categories
Mak-Van Der Vossen et al, “Descriptors for unprofessional behaviours of medical students: a systematic review and categorisation”, BMC Medical Education 17.1 (2017): 164. The four quadrants and their descriptors:
- Failure to engage: absent or late for assigned activities; not meeting deadlines; poor initiative; general disorganisation; cutting corners; poor teamwork; language difficulties.
- Dishonest behaviours: cheating in exams; lying; plagiarism; data fabrication; data falsification; misrepresentation; acting without required consent; not obeying rules and regulations.
- Disrespectful behaviour: poor verbal / non-verbal communication; inappropriate use of social media; inappropriate clothing; disruptive behaviour in teaching sessions; privacy and confidentiality violations; bullying; discrimination; sexual harassment.
- Poor self-awareness: avoiding feedback; lacking insight into own behaviour; not sensitive to another person’s needs; blaming external factors rather than own inadequacies; not accepting feedback; resisting change; not aware of limitations.
The Code of Professional Conduct
Full title: Code of Professional Conduct for Medical Students at the Universities of Auckland and Otago.
Origin and revision history:
- Adopted by Auckland Medical School at the end of 2012.
- Major reviews undertaken throughout 2015 and 2020, involving Auckland and Otago representatives and students from OUMSA, AUMSA and NZMSA.
- Next planned revision 2025.
How to access it and record agreement:
- Go to the Moodle ELM home page, your Course, general section.
- Read the Code and come back to class in 20 minutes.
- Go to the Resources section, then Induction (near the bottom of the page), and complete the one question in the quiz: “I have read the Code. I undertake to comply with it and seek clarification on any areas of uncertainty. I agree to familiarise myself with any subsequent revisions.”
- The session then discusses the Code: any questions or comments, and anything that surprised you.
Section 11: holding a positive attitude to learning
As a medical student I will:
- Commit to continued learning and the development of skills.
- Recognise that my learning needs are valid and important.
- Be prepared to seek and respond to constructive feedback on my own performance.
- Identify barriers that impede my learning and notify my academic supervisor.
- Show respect and observe tikanga in working with human cadavers, human tissue and animal tissue.
- Engage in self reflection to enable me to identify my learning needs.
- Actively engage to make the most of educational and clinical opportunities to extend my knowledge and further my skills with appropriate support and supervision.
- Care for my peers, provide support in learning opportunities, and work collaboratively and respectfully in all situations.
- Be prepared, when called upon, to provide constructive feedback to my peers on their performance.
The declaration
DECLARATION
I have read the ‘Code of Professional Conduct for Medical Students’ and I understand I must comply with all that is expected of me.
HE WHAKAPUAKITANGA
Kua pānui au i te ‘Tikanga Tātaki Ngaio mō ngā Tauira Tākuta’ ā E mārama ana ahau me ū rawa ahau ki ērā kua tohua ki ahau
Cultural safety commitment
The Otago Medical School recognises that our students and staff bring with them their own identities, values, cultures and experiences. Our teaching and learning environments will be culturally safe spaces for all students, staff, patients and their whānau. We are committed to transformative change, where acts or systems that perpetuate racism and discrimination will not be tolerated.
Warning
Several pages of the source deck are handout-style pages (grids of six miniature slide reproductions, dated 19/02/25) rather than new slides, and the transcript flags them as such. They reproduce material already covered above, and some of their slide-number labels and page-position markers were not confirmed with full certainty at review time. No unique content is lost by skipping them. The transcript also flags one page whose rendered content repeats the cultural safety commitment slide, and several build-stage repeats of the VAS sheet.
Self-test
- Define a profession, listing the five features of the occupation given in the lecture.
- Beyond those five features, list the further characteristics of a profession the lecture names.
- In the Cruess and Cruess model, describe how a student’s previous identity becomes a professional identity, naming the process at the centre.
- List the six influences that feed into socialisation in that model, and name the two forms of reflection through which some of them act.
- List the sources the lecture gives for where students’ ideas of being a doctor come from, and state what it says about their reliability and about the gaps.
- State the social contract as defined by Cruess, Cruess and Steinert (2010).
- Distinguish what medicine gets from what society expects under the social contract.
- List the written components of the social contract.
- List the six values that must be present for the relationship between medicine and society to function and flourish, with a one-line gloss on each.
- Explain why, according to van Mook et al (2009), professional status can be lost, and name the four recognised challenges to professionalism.
- List the four categories of unprofessional behaviour of medical students (Mak-Van Der Vossen et al, 2017), giving two descriptors of each.
- Distinguish “failure to engage” from “poor self-awareness”, with an example of each.
- Describe the visual analogue scale exercise, including what the direction of the scale means.
- List at least eight characteristics of a good medical student identified by a previous year’s cohort.
- Describe the clauses of section 11 of the Student Code of Conduct on holding a positive attitude to learning.
- State the origin and revision history of the Code of Professional Conduct, and explain how a student accesses it and records agreement to it.
- State the Otago Medical School cultural safety commitment.
- For the 68 year old man presented in the Emergency Department, list the five issues the lecture asks you to consider.
- Integrative: using the social contract and the categories of unprofessional behaviour, explain why a medical school asks students to sign a code of conduct rather than simply teaching clinical skills.
Answers
Reveal answers
- A profession is an occupation that has an extensive training, a specialized knowledge base, a professional association, an ethical code, and a process of certification or licensing.
- Service to others; standing in the community; commitment to regulate and govern its members; it sets its own standards of behaviour and practice; it is self-regulating and autonomous.
- Students arrive with a previous identity (gender / sexual orientation, race / religion / culture, socioeconomic status and so on) and move to a professional identity as doctors. The process sitting between the two is socialisation.
- From above: the learning environment; role models, positive and negative; isolation with like minded others. From below: learning the language and learning to play a role; multiple experiences, positive and negative; learning the hierarchy and social control. Role models and multiple experiences act through both conscious and unconscious reflection.
- Interactions with your own GP; having a medical family; television; the news. Some sources are more realistic than others, and the socialisation process of medicine will fill in the gaps.
- ‘The Contract is a bargain between medicine and society. Medicine is granted prestige, autonomy, a monopoly, the privilege of self-regulation and rewards, on the understanding that it will be altruistic, self-regulate well, be trustworthy and address the concerns of society.’
- Medicine gets good standing in the community, good pay, the ability to self-regulate its members and an autonomous profession. Society expects altruism, good self-regulation, trustworthiness and that medicine meets the needs of society.
- Health care legislation; codes of ethics; requirements of medical licensing bodies.
- Altruism (attend to patients’ best interest rather than self-interest); accountability (to patients, to society on public health, and to the profession); excellence (commitment to life-long learning); duty (available and responsive when on call, committed to service within profession and community); honour and integrity (fair, truthful and straightforward with patients and the profession); respect for others (patients and families, other physicians and team members, medical students, residents and fellows).
- Because professional status is not an inherent right but is granted by society, and its maintenance depends on the public’s belief that professionals can be trusted; to remain trustworthy professionals must meet the obligations society sets. The four recognised challenges are human nature, self interest, pressure from peers and commercialism.
- Failure to engage (for example absent or late for assigned activities, not meeting deadlines); dishonest behaviours (for example cheating in exams, plagiarism); disrespectful behaviour (for example inappropriate use of social media, bullying); poor self-awareness (for example avoiding feedback, not aware of limitations).
- Failure to engage concerns participation and reliability in assigned work: absence or lateness, missed deadlines, poor initiative, disorganisation, cutting corners, poor teamwork, language difficulties. Poor self-awareness concerns insight into oneself: avoiding or not accepting feedback, lacking insight into one’s own behaviour, insensitivity to others’ needs, blaming external factors rather than one’s own inadequacies, resisting change, not being aware of limitations.
- Students choose the six characteristics of a good medical student they view as most important and mark on a visual analogue scale where they think they currently stand on each. The nearer the right of the line, the better they see themselves as doing on that characteristic. The sheet has six numbered rows, each with a characteristic label to fill in and a blank scale line.
- Any eight of: happy / balanced / well rounded; ordered and organised; integrity; maturity; accountable; humility; open-minded; non-judgemental; respectful; co-operative; insightful; empathy; good communicator; altruism.
- Commit to continued learning and skill development; recognise that my learning needs are valid and important; be prepared to seek and respond to constructive feedback on my own performance; identify barriers that impede my learning and notify my academic supervisor; show respect and observe tikanga in working with human cadavers, human tissue and animal tissue; engage in self reflection to identify my learning needs; actively engage to make the most of educational and clinical opportunities with appropriate support and supervision; care for my peers, support them in learning opportunities and work collaboratively and respectfully; be prepared, when called upon, to give constructive feedback to peers on their performance.
- It is the Code of Professional Conduct for Medical Students at the Universities of Auckland and Otago, adopted by Auckland Medical School at the end of 2012, with major reviews throughout 2015 and 2020 involving Auckland and Otago representatives and students from OUMSA, AUMSA and NZMSA, and a next planned revision in 2025. Students access it via the Moodle ELM home page, their Course, general section, read it, then go to Resources, Induction, and complete the one-question quiz agreeing that they have read the Code, undertake to comply with it and seek clarification on areas of uncertainty, and will familiarise themselves with subsequent revisions. They also sign the written Declaration.
- That the Otago Medical School recognises students and staff bring their own identities, values, cultures and experiences; that its teaching and learning environments will be culturally safe spaces for all students, staff, patients and their whānau; and that it is committed to transformative change, where acts or systems that perpetuate racism and discrimination will not be tolerated.
- How reversible his chest condition is likely to be; what respiratory failure specifically means; whether there are dangers in giving him high concentration oxygen given his low arterial oxygen saturations; what factors should be considered when considering ICU admission for the respiratory failure; who should be involved in the discussion about his wish to return home.
- Medicine is granted prestige, autonomy, a monopoly, self-regulation and rewards only on the understanding that it is altruistic, self-regulates well, is trustworthy and addresses society’s concerns, and professional status is granted by society rather than held by right. Self-regulation therefore has to begin during training, and the categories of unprofessional behaviour (failure to engage, dishonesty, disrespect, poor self-awareness) are exactly the behaviours that would break the public trust the contract depends on. A signed code makes the standards explicit, gives the profession a basis on which to govern its own members, and supports the identity formation the lecture describes, since much of professional socialisation otherwise happens through unexamined role models and experiences.