Overview
This session introduces integrity as a professional value and traces how it changes as a student moves from first-year health sciences (FYHS) into medical school (ELM) and eventually into practice as a doctor. It covers what integrity means, the socialisation process of professional identity formation, the shift in expectations that comes with starting medical school, a worked scenario (Jake) used to test judgement about integrity, and practical advice for practising integrity as a student now rather than waiting until graduation.
Session learning outcomes: develop awareness of oneself as an ELM2 student within the structure of medicine; begin to understand professional identity formation; become aware of the cognitive and professional demands placed on medical students; begin to understand the level of expectations placed on doctors in clinical practice; and develop a sense of the importance and magnitude of integrity and responsibility to society through the social contract.
Integrity: meaning
Formal definition (Miller-Keane & O’Toole, 2003): integrity is “a virtue consisting of soundness of and adherence to moral principles and character and standing up in their defense when they are threatened or under attack.” This involves consistent, habitual honesty and a coherent integration of reasonably stable, justifiable moral values, with consistent judgment and action over time.
In healthcare settings, integrity encompasses honesty, keeping one’s word, and consistently adhering to principles of professionalism, even when this is not easy to do.
Other, more informal descriptions given in the lecture:
- What you do when nobody else is around.
- What you do and how you do it on a daily basis.
- A concept that includes consistency in actions, expectations, measures, methods, outcomes, principles and values.
- Integrity means our actions are honest and trustworthy.
Professional identity formation
Medical training is framed as a transition from a “previous identity” to a “professional identity”:
- Previous identity (as a medical student): shaped by gender/sexual orientation, race/religion/culture, socioeconomic status, and similar personal background factors.
- Professional identity (as a doctor): trustworthy, demonstrates integrity, accountable for actions, has adopted professional values.
Following Cruess and Cruess (2012), this transition happens through a process of socialisation, driven by six inputs:
- The learning environment.
- Role models, both positive and negative.
- Isolation with like-minded others.
- Learning the language of medicine / learning to play the professional role.
- Multiple experiences, both positive and negative.
- Learning the hierarchy and social control of the profession.
Each of these six inputs is processed through either conscious reflection or unconscious reflection on the way to shaping professional identity.
Alongside this socialisation process, there is a broader cultural shift: FYHS is described as highly competitive, while medical school and the profession are framed as focused on collaboration and caring for each other.
Changes in expectations from FYHS to ELM
Starting medical school brings new pressures beyond FYHS: collaboration, different forms of assessment, attendance pressure, growing into a professional skin (professional training), concern about the depth and breadth of content required in medicine, and academic assessment demands that remain in place alongside these new pressures.
Students are unlikely to trip up on academic ability at this stage. Instead, professional issues are more likely to be of concern, including: non-attendance, communication, teamwork, boundaries, honesty (e.g. falsifying log books), manner, and not engaging in learning opportunities (i.e. not being proactive in taking up tasks in the clinical area).
Applying integrity: the Jake scenario
A three-part scenario was used with a 0-5 rating scale (“does not demonstrate integrity” at 0, to “demonstrates integrity” at 5) to test judgement at each stage:
- Jake is unwell. His peers set up a system to take notes for him and help him catch up on what he has missed.
- Before becoming unwell, Jake already had a poor attendance record; his illness pushes his attendance further outside what is expected of a second-year student. His friends start checking him in on attendance registers when they can, even though he is not actually attending.
- During end-of-year assessment, Jake is in the last OSCE group to go through. Friends who have already finished send him a message telling him what condition the OSCE patient has and the likely questions.
The scenario is built to escalate: stage 1 is peer support with no dishonesty involved; stage 2 introduces dishonesty (falsifying an attendance record) to cover for a pre-existing problem; stage 3 introduces assessment misconduct (leaking exam content), which compromises the validity of a formal, high-stakes assessment. The transcript does not record a specific “correct” rating for each stage, only the scale used to prompt discussion.
Guest discussion: integrity dilemmas as a doctor
A general surgeon and former Head of Department of Surgical Sciences (Southern DHB / Te Whatu Ora, Health NZ) discussed integrity dilemmas encountered in clinical practice. The discussion questions posed were: what examples of challenges to integrity has he faced in clinical practice; has he ever had to consider the behaviour of colleagues; and what advice would he give medical students about professional identity formation and integrity. [slide does not record his answers, only the discussion prompts]
Practising integrity now, as a student
The lecture argues against the position “I’ll act with integrity once I graduate as a doctor,” instead recommending:
- Treat medical school as an opportunity to practice integrity now, not after graduation.
- Recognise that some things are unacceptable right now, not just once qualified.
- Be the person you want to be, and start now.
- Use reflection, mentoring and self-awareness as tools for developing integrity.
- Practise self-regulation.
- Hold a standard of zero tolerance for integrity breaches.
- Recognise that the course expects students to behave as they should as a professional, i.e. professional expectations already apply during training.
- Aim for constant striving and vigilance, as opposed to perfectionism.
- Monitor colleagues’ behaviour and clinical practice, including being alert to the risk of simply tolerating the behaviours of others.
Self-test
- Define integrity, using the lecture’s formal definition and its two key components.
- What are the informal, everyday descriptions of integrity given in the lecture, beyond the formal definition?
- Describe the process of professional identity formation according to Cruess and Cruess (2012): name the six inputs feeding into socialisation and the two ways each is processed.
- Distinguish the traits associated with a medical student’s “previous identity” from the traits associated with a doctor’s “professional identity” in this lecture.
- List the specific pressures that new ELM students face which differ from FYHS, and describe the areas where professional issues, rather than academic ability, are more likely to be of concern.
- For each stage of Jake’s scenario, describe the integrity issue introduced and explain how it escalates from the previous stage.
- List at least four of the practices this lecture recommends for practising integrity now as a student, rather than waiting until qualifying as a doctor.
- Integrative: explain how professional identity formation, the shift in expectations from FYHS to ELM, and the advice to practise integrity now are connected.
Answers
Reveal answers
- Integrity is a virtue consisting of soundness of and adherence to moral principles and character, and standing up in their defence when threatened or under attack; it involves consistent, habitual honesty and a coherent integration of reasonably stable, justifiable moral values, with consistent judgment and action over time (Miller-Keane & O’Toole, 2003).
- What you do when nobody else is around; what you do and how you do it on a daily basis; consistency in actions, expectations, measures, methods, outcomes, principles and values; and that integrity means our actions are honest and trustworthy.
- The six inputs are: the learning environment, role models (positive and negative), isolation with like-minded others, learning the language/how to play the professional role, multiple experiences (positive and negative), and learning the hierarchy and social control of the profession. Each is processed through either conscious reflection or unconscious reflection as it feeds into socialisation, which in turn shapes professional identity.
- Previous identity (medical student) is shaped by personal background factors such as gender/sexual orientation, race/religion/culture, and socioeconomic status. Professional identity (doctor) is characterised by being trustworthy, demonstrating integrity, being accountable for actions, and having adopted professional values.
- New pressures include collaboration, different forms of assessment, attendance pressure, growing into a professional skin, concern about the depth and breadth of content required, and continuing assessment demands. Professional issues more likely to be of concern than academic ability include non-attendance, communication, teamwork, boundaries, honesty (e.g. falsifying log books), manner, and not proactively engaging in learning opportunities.
- Stage 1: peers take notes for an unwell Jake and help him catch up, no dishonesty involved. Stage 2: escalates to dishonesty, as friends falsely check Jake in as present on attendance registers to cover his now out-of-range attendance. Stage 3: escalates further to assessment misconduct, as friends who already sat the OSCE leak the patient’s condition and likely questions to Jake before his attempt, compromising a formal high-stakes assessment.
- Any four of: treat medical school as an opportunity to practise integrity now; recognise some things are unacceptable right now; be the person you want to be and start now; use reflection, mentoring and self-awareness; practise self-regulation; hold zero tolerance for breaches; recognise the course already expects professional behaviour; aim for constant striving and vigilance rather than perfectionism; monitor colleagues’ behaviour and avoid simply tolerating it.
- Professional identity formation describes how a student’s previous identity is socialised into a doctor’s professional identity through experiences and reflection. The shift in expectations from FYHS to ELM marks the start of that socialisation, since students face new professional (not just academic) demands. The lecture’s advice to practise integrity now argues that students should not wait for professional identity formation to be “complete” at graduation, but should actively build integrity into that socialisation process from the start of medical school.