Perceptions of Postgraduate Trainee’s about Professional Behavior: A Qualitative Content Analysis
INTRODUCTION
Medical professionalism is an integral component of a doctor's toolkit, comprising scientific proficiency, interpersonal skills, time management, proper performance, and professional competencies.1 It is a blend of humanitarian qualities and behavioral expectations surrounding the doctor-patient relationship.2 Medical educators emphasize medical professionalism in medical undergraduate and post-graduate training.3 This rise in attention is driven by increased public expectations, accountability, and a shift from traditional towards evidence-based education.4
Globally researchers have assessed the professional behavior of doctors at either undergraduate or postgraduate levels of their careers.5,6
Historically, it was regarded as an inherent trait in healthcare providers. Later on, recent studies underscore that these traits can be enhanced and refined through applied knowledge, thereby improving patient-doctor relationships and communication skills, both of which are crucial for patient care.7 While professionalism has been assessed among undergraduate level in Pakistan,8,9 however, no qualitative study has explored the perceptions of postgraduate (PG) trainees about professionalism. Understanding the nuances of medical professionalism in a given context is key to addressing issues of impaired professionalism.
From a research philosophy perspective, this study is rooted in interpretivism, where the subjective experiences and perceptions of PG trainees are central. Interpretivism allows for the exploration of how professionalism is understood and practiced by trainees within their unique social and cultural contexts. The constructivist paradigm underpins the study, emphasizing that the meaning of professionalism is co-constructed by individuals within their environment, shaped by interactions, organizational culture, and societal expectations. This approach aligns with qualitative research methodologies, enabling a deeper understanding of the factors that support or hinder professionalism from the perspective of the trainees.
To explore these perceptions, the study will be guided by thematic analysis as a conceptual framework, identifying and analyzing patterns (themes) that emerge from the interviews with PG trainees. This framework allows for an in-depth exploration of their lived experiences and professional challenges, helping to clarify how professionalism is perceived, developed, and applied in practice.
The aim of this study is therefore, to explore the perceptions of PG trainees of three departments of Bolan Medical Complex, Quetta regarding professionalism, the factors supporting and hindering professional behavior, and suggestions to improve professionalism in the Balochistan context. These findings can provide a lens into how medical professionalism is viewed among young PG trainees and guide the development of programs for stakeholders to design a program that fosters professionalism amongst PG trainees in the Balochistan context.
METHODOLOGY
This observational qualitative study conducted in AprilMay 2024, utilized content analysis based on recorded interviews transcribed into text. The study was carried out at Bolan Medical Complex Hospital, Quetta, with data collected till saturation was reached. To get insight into perceptions and diversity, PG trainees from three different departments (Physiatry, General Medicine, and Neurosurgery departments) and non-identical professional levels of PG trainees were selected. Since the Sandeman Provincial Hospital (SPH), Quetta was far away from Bolan medical College and its affiliated hospital i.e. Bolan Medical Complex Hospital, Quetta, we got data only from the affiliated hospital, and PGs of SPH were excluded from this research. The study was approved by the Bolan University of Medical and Health Sciences (IRB No 0036/BUMHS/IRB/24. Dated. 6.5.24).
Informed audio-recording consent was taken and confidentiality and privacy were confirmed. An interview guide with six open-ended questions adopted from studies by Jalil (Pakistan, 2020) and Teo T (Singapore, 2021)1,2 was used to elicit participant's perceptions about of medical professionalism. The methodology of the study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological rigor (Supplementary data).
DATA COLLECTION PROCEDURE
The language used for interview was English. Two research assistants conducted the interview. Both of these interviewers were experienced and worked previously for qualitative data collection in healthcare and undertook pre-interview training. The PG's were interviewed in their departments (Psychiatry, G. medicine and Neurosurgery) at Bolan Medical Complex, Hospital Quetta at their tea breaks and/or at the end of duty shifts, at their convenience. Confidentiality to secure data during the interviews after audio recording was confirmed. They were assured that their identity would not be revealed and any information that might identify the doctor was not transcribed. At the start of interview, the doctors were not ready to give their views and gave researchers socially desirable answers. Due to their tight schedule and lack of interest in the subject they were not willing to spend much time. Many of them give off-therecord statements and comments that were noted by the house officer for further usage in data analysis. Important statements by the participants were kept as notes after the recorder had been turned off. Permission from PGs was taken before jotting down their statements. The data was collected during the month of April to May 2024. Time duration for this interview ranged from 30 to 40 min. The verbatim transcription of the audio recordings was undertaken by the principal investigator and a research assistant. By applying Jalil and Teo T questions, PG Trainees were asked to define professionalism, outline the qualities of ideal doctors, share their perception of the doctor-patient relationship, and reflect on their views about flawed technical expertise, justification of misbehavior, key aspects of professionalism, and reflect on ways to nurture professionalism.
DATA ANALYSIS
After collecting data it was analyzed by using qualitative thematic analysis. Following the 32-item checklist Consolidated Criteria for Reporting Qualitative Research we reported results of current work. Current study confirms inter-rater reliability, as principal investigator and research assistant each coded the data. The two researchers discussed and compare the notes prepared during interview and decided at common and variant codes. These codes were then grouped into common themes. Finally, the themes were grouped into categories and relationship identification was performed. After compiling the data and its analysis, the findings were showed to those study participants, who had expressed their interest in current research topic during the interviews, which ensure the credibility. Thematic analysis was conducted by two researchers, which were involved in data coding, and categorizing, similar codes were placed in subthemes, and themes were refined. The sub-themes if represent similarities were merged. The analysis yielded four main domains of professionalism including 1) Self-assessment, 2). Interprofessional relationship, 3). Professional Ethics and 4). Communication skills. For these themes, 19 subdomains emerged.
RESULTS
All invited PG trainees from 3 different departments of Bolan Medical Complex Hospital, Quetta participated in the study giving a very good response rate (100%) which suggest PGs strong engagement PGs to professional. Thematic analysis generated four main domains and 19 subthemes (Fig 1, and Fig 2 respectively).
A common theme among participants was the importance of teamwork and collaboration with para-medical staff. Most trainees acknowledged that "best teamwork ensures better patient care." Furthermore, all participants agreed
Figure 1: Themes and sub-themes generated after coding PG perceptions
that "Medical professionalism is non-negotiable nor optional and it's an essential part of being a doctor, regardless of the challenges a doctor can face." Suggestions for promoting professionalism included "Instituting clear protocols and conflict resolution training to manage workplace security and safety concerns."
However, when we discussed the doctor-patient relationship, responses were mixed. Except few, most of
Figure 2: Description of Sub-Themes
Table 1: Presents the Quantitative analysis
the trainees believed that extending beyond the doctor's scope to meet patient's demands is unnecessary, as some needs might be beyond the doctor's scope of practice. They said, "A doctor's ability to meet the needs of patients would be sufficient." One trainee mentioned, "I think the doctor just needs to listen carefully to the patient it is plenty as a doctor might not have enough time."
Regarding attire, PG trainees recognized the symbolic value of the white coat, noting that it fosters trust and reassures patients. One of them stated, "A doctor wearing a white coat presents a positive attitude and symbolizes professionalism."
They recognize that a "Doctor's good behavior, proper communication skills and providing reassurance not only lessen anxiety but also boost the quality of life of the patient by upgrading their overall health care experience."
In terms of learning, participants recognize self-directed learning (SDL) as an essential tool for fostering critical thinking and self-assessment. Trainees remarked," SDL heightens critical thinking, boosts our confidence, and enhances our learning desire."9
DISCUSSION
The findings show that PG trainees have a positive perception of professionalism, (100% response rate) with a strong emphasis on teamwork, communication, and professional behavior. Except few most of the PG trainees were eager to overcome their shortcomings. Interestingly, it is found that the roots of this behavior demonstrated a good family background and society-based norms.
PG trainees define professionalism differently with the same main theme. They agreed and were confident by adopting professional behavior they work better for the care and cure of patients.5 However, controversially participants of Jalil et al (2020) disagree with the necessity of teaching professionalism in medicine nor do they feel any need for professional and humanity course modules in the medical curriculum.1
However, there were discrepancies in the perceived importance of time management and patient communication. Participants expressed the challenge of balancing limited time with the need to effectively communicate with patients, a tension that has been noted in other studies.3 While this study presents valuable insight, it would have benefited from a more critical comparison with existing literature. For example, the research participants of Jalil et al (2020) regarded professionalism as an unnecessary to teach in medicine curriculum,1 a viewpoint that differs from the findings of our study. These conflicting perspectives could have been more deeply explored.
Our PG trainees were cognizant of poor and illiterate patients visiting from far away, and developed sympathetic relations with patients to provide good treatment.9 Content analysis presented almost all (n=20/22, 95%) PG trainees accepted that doctors must be trained to handle situations calmly and effectively while prioritizing the well-being of everyone involved and stressed the significance of teamwork, respectful behavior to seniors, juniors, and staff is crucial for the care of the patient. For quality results in patient care, good cooperation with colleagues and staff is needed.3 Participants of the Khan NF study agree that good attitude satisfied patients (p. <001).10 Controversies however existed about the behavior of doctors towards their colleagues and
para-medical staff, as participants of Jalil presented noncooperated behavior towards paramedical staff and doctors.1
A good doctor must be a master of tongue and body language when communicating with their patients. The quality of and not the quantity of doctor-patient interaction is crucial.15 Content analysis displays 85% of our study participants (85%) stressed the importance of communication skills for a professional doctor and inappropriate communication skills cause poor interaction with patients and colleagues. They accept negative personality traits like lack of empathy, poor communication, and unethical behavior can hinder professionalism in healthcare by compromising patient relationships, impeding teamwork, and lacking trust in the healthcare provider.4 Similarly Fong's detected effective communication between patients and his study population.3
According to researchers, doctors wearing white coats is a sign of medical profession and expertise.16 Patients accepted that doctors wearing white coats seemed more hygienic, professional, authoritative, and scientific which presented a positive effect associated with wearing a white coat. Indistinguishable doctors also believe that wearing white coats makes them more professional, hygienic, authoritative, scientific, competent, knowledgeable, and approachable.17 PG trainees of current study were known of its importance and they merely wear it to satisfy patients and to gain their trust. They wear white coat that is of symbolic importance, improve consistent cognitive identification, and foster empathy for patients.
PG trainees of our study were conscious and acquainted with the fact that self-assessment is crucial for heightening cognitive levels. Content analysis indicated that 83% of PGs were doing self-assessments. Self-assessment was highly appreciated by the study participants of Khan NF (2024).14 One can observe physical harm, obstetric trauma, misdiagnosis, inaccuracy in drugs, hurdles in communication, deficient awareness about education, and low cognizance of medicine when physicians and patients are not communicated properly.4 Current study participants mentioned some incidents when patients disrespect unprofessional PG trainees. Previous studies confirmed this situation when patient's inappropriate behaviors were observed.11,12 These challenging patients were obstacles hindering the doctor/clinician/PG trainee's professional behavior. Healthcare workers (doctors, physicians, staff, and PG trainees) exhibiting powerful communication skills can manage such hostile situations. Patients sometimes complained about doctors using cell phones and the internet during duty hours which demonstrates their non-serious attitude.13 Our research participants (70%) were conscious about patient health and believed that a good attitude, patience, and punctuality during their training is crucial for patients' better health cure better care and cure.
Moreover, while this study identifies tensions in managing time and patient communication, further discussion could explore how these challenges are influenced by the high patient load and resource limitations in healthcare settings, which may vary across contexts. The differing results between studies may also stem from variations in research design, sample populations, or healthcare systems, all of which deserve a more thorough examination.
This was the first study that assessed the perceptions of PG trainees regarding professionalism. We do our best to keep away from biases during the audio interview, data reporting, and analysis. The interview was 6 open-ended items that explored the perceptions of PG trainees. Limitations of current study opens venues for future research. The small sample size, potentially limiting the generalizability of the results to larger populations, and limited demographic information (e.g. age, socioeconomic status) could not provide a more comprehensive understanding of the factors influencing the perceptions of PGs about professionalism. The coding process could also have been described in more detail, particularly regarding how thematic saturation was determined. Multi-centric studies exploring the PG trainee's perceptions as well as faculty about professionalism needed to be done. The discussion could develop deeper into discrepancies or conflicts within the findings, such as the challenges PG trainees face in balancing time management and patient communication. Another limitation of current study was the lack of clarity in describing how the researchers handled coding and resolved inconsistencies in interpretation remains a critical limitation. This gap in detail could obscure therigor and validity of the data analysis process.
CONCLUSION
The study sheds light on PG trainee's strong perspective demonstrated about awareness of professionalism and its importance for patient care. They emphasized the need for effective communication, self-assessment, and teamwork as key domains of professionalism. While most trainees viewed professionalism as non-negotiable, they acknowledged the challenges of maintaining professional behavior, especially in the context of time management and patient demands. They accept the usefulness of self-assessment and selfreflection. However, PG Trainees demonstrate their concern to stretch themselves to assure patients. However, there was a potential for bias and the limited scope of the sample.
RECOMMENDATIONS
Future research should expand on this study by exploringperceptions of professionalism among a larger, more diverse group of trainees across different hospitals. Additionally, curriculum reforms that align with the WFME standards should be implemented, with a focus on competency-based and context-specific training for both undergraduate and postgraduate medical students. Patient-centered medical practice is a prerequisite, as highlighted by the WFME standards. This training should address the practical challenges of professionalism, particularly in resource-limited settings like Balochistan.
ACKNOWLEDGMENT
The authors would like to thank all PG trainees who participated in this study.
CONFLICT OF INTEREST
None
FUNDING RESOURCES
None
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