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Abstract

This study examined professional development in practice. Interview data from 20 medical attending physicians suggested their professional practice progressed through four stages: (a) becoming familiar with the basic skills and operations of a profession, (b) building professional competence, (c) shifting practice from self-centered to client-centered, and (d) developing a continuous concern for the profession. Professional development is a life-long learning process. Attending physicians must continue learning after residency to acquire not only expert-level clinical competencies but also a set of personal qualities and attitudes that constitute the core of professionalism. Senior attending physicians stressed the importance of providing and receiving mentoring in professional development. A general model of professional development in practice was proposed.

Keywords

professional development residency training professionalism mentoring

Introduction

Professionals such as doctors, lawyers, and architects must possess a vast quantity of domain-specific knowledge, including legal and ethical regulations, and a broad range of skills in their domains (Reed & Evans, 1987). They have high autonomy and authority and make significant independent decisions for their clients (Norman, 2011). These decisions, such as a surgeon’s decisions during heart surgery, may significantly affect their clients. Thus, the performance of each professional is continuously regulated by government and professional associations via licensing or membership (Anderson, Stacey, Western, & Williams, 1983). Usually, accompanying ethical requirements imposed by the professional association are more strict than the legal regulations (Baker, Wrubel, & Rabow, 2011; Levinson, Ginsburg, Hafferty, & Lucey, 2014; Spandorfer, Pohl, Rattner, & Nasca, 2010).

Professionalism refers to a set of values (e.g., altruism), behaviors (e.g., integrity, continuous learning), maintenance of competence (e.g., revalidation of one’s knowledge and skills), and relationships (e.g., working in partnership or service to others) that underpin public trust in professionals. Professionalism encompasses the qualities a professional worker must cultivate and serves as the basis for professional evaluation (Ho, Yu, Hirsh, Huang, & Yang, 2011; Stern, 2006; Wagner, Hendrich, Hoseley, & Hudson, 2007). For example, the professional codes of conduct for doctors in countries such as the United States, Australia, the United Kingdom, and Canada include a strong commitment to the well-being of others, high moral standards, mastery of a body of knowledge and skills, and high autonomy (ABIM Foundations, CP–ASIM Foundation, & European Federation of Internal Medicine, 2002; Arnold & Stern, 2006; Tallis, 2006; The Royal Australasian College of Physicians, 2010). This study aimed to examine how a sense of professionalism is developed and cultivated through practice.

The process of becoming a professional involves extensive steps to gain the qualifications to practice independently within the chosen profession. Due to its importance and effect on patients and society, medicine has developed an elaborate system for training, validating, and revalidating its practitioners’ competencies. Several years of residency training are required before a newly certified doctor becomes an attending physician who can practice medicine independently. During residency, a new doctor works under the close supervision of senior doctors. This type of supervised learning is essential to assure the smooth transformation of a fledgling doctor into a competent medical professional (Sinclair, 1997). Using medicine as an example, this study examined how professionalism develops through practice. Employing three probing questions, a model of professional development through practice is extracted. The questions are as follows: (a) How does the scaffolding of residency training help transform a medical resident into a competent attending physician? (b) What further learning is needed after residency? and (c) What is the senior doctor’s role in mentoring medical residents?

Using the medical hospital of National Taiwan University as an example, becoming an attending physician in internal medicine requires 6 years of medical school education, 1 year of internship, and 5 to 6 years of residency training in a teaching hospital. A resident is a newly certified medical doctor who practices under the supervision of a senior attending physician. In the first 3 years of residency, residents receive clinical training in numerous subfields of internal medicine with different attending physicians. In the last 2 years of residency, residents choose a major field of practice and receive finely tuned training within that field, in addition to teaching in the internal medicine department and participating in medical administration. Residency training and the attending physicians’ role in mentoring residents are instrumental in the development of a medical professional (e.g., Aho et al., 2015; Sinclair, Fitzerald, Hornby, & Shalhoub, 2015).

Studies have examined how a medical resident progresses to become an expert in a profession (e.g., Benner, 1984; Dreyfus & Dreyfus, 2005; Schmidt & Rikers, 2007). For example, Dreyfus and Dreyfus (2005) proposed a five-stage model of expertise acquisition: (a) Novice level. At the beginning, one practices by following explicit, context-free rules and procedures learned from textbooks and instruction. (b) Advanced beginner level. With accumulated experience, novices are able to apply not only general, context-free rules but also context-specific rules. (c) Competence level. Among the vast number of possibly relevant features and aspects of a situation, a competent professional is capable of making decisions regarding which elements of a situation are important and choosing a course of action accordingly. A sense of emotional involvement and responsibility for choices also begins to emerge. (d) Proficiency level. With sufficient experience, context-general or context-specific rules are replaced by situational discernment, accompanied by an associated response to achieve proficiency at work. A proficient performer can intuitively assess each new situation and see the problem but still has to determine solutions. (e) Expert level. Experts can make more subtle and refined discriminations than proficient performers. They have learned to decompose a situation into subclasses, each of which requires a specific response. This allows the making of immediate, intuitive, and situationally appropriate responses.

The Dreyfus model only describes how professional competency is acquired through practice. It does not provide a clear description of what knowledge, skills, attitudes, and personal qualities underlie professional practice. According to Dall’Alba and Sandberg (2006), the “understanding of practice through practice forms the basis for professional skill and its development” (p. 405). One develops professionally only through the integration of self in knowing, acting, and being oneself, as embodied in the work. For example, the understanding of medical professions must include how one practices medicine in a social institution.

In practice, medical diagnosis and treatment are critically affected by a host of factors (Cimino, 1999). The tasks in medical practice include (a) identifying patients’ symptoms and medical history to suggest possible causes of illness, (b) performing physiological examinations to pinpoint the cause(s) of illness, (c) making a diagnosis based on observed symptoms, and (d) choosing a course of treatment. The odds of a patient being successfully treated are a multiplicative function of these factors. Failure to correctly perform any one of the factors in the medical process can be fatal.

A significant portion of clinical knowledge is procedural in nature (e.g., how to perform an abdominocentesis, amniocentesis, or a specific form of surgery). Newly certified medical doctors need clinical experience to transform the declarative nature of textbook knowledge into clinical procedures, such as how to make a diagnosis (Boshuizen, Schmidt, Custers, & Wiel, 1995). Procedural knowledge is often implicit in nature and must be learned by doing or from observing people performing the task (Akkerman & Bakker, 2012; Lave & Wenger, 1991; Orr & Gao, 2013; Polanyi, 1983; Stegeman, Schoten, & Terpstra, 2013). Apprenticeship, therefore, has a long history in medical education (Bui-Mansfiled & Chew, 2001; Sinclair, 1997). Clinical experience is vital to developing medical expertise (Cimino, 1999; Van de Wiel & Van den Bossche, 2013; Wimmers, Schmidt, & Splinter, 2006). Without it, new doctors run the risk of making erroneous diagnoses and prescribing inappropriate treatments (Boshuizen et al., 1995).

Supervision by an attending physician can not only reduce the risk of junior medical practitioners’ malpractice but can also provide a role model of good professional behaviors. Observing and modeling senior doctors’ behaviors is therefore an important part of clinical training (Baker et al., 2011; Kalen, Ponzer, & Silen, 2012; Stegeman et al., 2013). It has been shown that senior doctors who explain the reasoning behind their own practices and who probe junior doctors to reveal the reasons for their decisions can help junior doctors learn better (Schön, 1983; Stegeman et al., 2013). Similar supervised learning can be observed in doctoral training in academia. A young scholar conducts studies assisted by a professor for several years before becoming eligible for college teaching and research.

School teaching also incorporates supervised practice. On the basis of the data of 11 student teachers and the 16 senior teachers who supervised them, Furlong and Maynard (1995) found that a teacher develops professionally through four stages. First, fledgling teachers become familiar with a teacher’s routines and the teaching environment, including classroom management, curriculum planning, student evaluation, and establishing authority in the classroom. The second stage, guided by senior supervising teachers, builds teaching competence and increases understanding of the meaning of education. Next, as competency accumulates, teachers move from self-centered (how to teach) to student-centered (how to learn) teaching practices. Teachers enter the final stage when they become professionals and assume professional responsibilities through continuous learning and reflection on the meaning of education and its social, moral, and policy-level implications.

Apparently, there are similarities in professional development across different professions. Professional development involves not only expertise acquisition but also a growing sense of professionalism. By exploring the role of medical residency training and postresidency learning needs, the present study aimed to propose an improved general model for professional development. The role of mentoring in this process was also addressed.

Method

Participants

Fifteen attending physicians from 10 teaching hospitals and 5 doctors running their own clinics consented to be interviewed (18 male; 2 female). They were recruited through personal contact and the snowball technique. Seventeen of them were physicians of internal medicine; three were surgeons. Their mean age was 45.5 years (range: 31–71), and the mean tenure was 18.2 years (range: 6–41). They were split by the median of their tenure into high- versus low-tenure groups. The low-tenure group was comprised nine attending physicians with 6 to 12 years of clinical practice (M = 9.0, SD = 2.5). Their mean age was 36.6 years (SD = 3.3). The high-tenure group was comprised 11 attending physicians with more than 12 years of clinical practice (M = 25.7, SD = 9.7). Their mean age was 52.7 years (SD = 9.9). Junior and senior attending physicians’ learning experiences during and after residency training were analyzed to determine consensus and differences in opinion regarding learning in professional development and senior doctors’ roles in mentoring residents’ learning. Differences in responses to interview questions served as a proxy of professional development.

Data Collection

In a semistructured in-depth interview, attending physicians were asked to describe their own experiences during residency and provide their views on the role of residency training in educating medical professionals. The interviews were guided by six broad questions: (a) What constitutes medical competence? (b) What are the roles of internship and residency training in making a medical professional? (c) What still needs to be learned after residency training? (d) Did the interviewee have a mentor in his or her professional career? (e) What was learned from the mentor? and (f) What are better ways to train a medical professional? These questions were mailed to participants 1 week before the interview. All attending physicians were interviewed individually at their offices and were assured of the anonymity of their participation. Their responses were tape-recorded and transcribed verbatim for data analysis.

Data Analysis

Furlong and Maynard’s (1995) model of a teacher’s professional development served as the grounding theory in the content analysis of interview data. Attending physicians’ responses were parsed into independent propositions. A proposition consists of a single or unique meaning. Repetitions were removed. The propositions were categorized by the interview questions. Similar responses in each category were further grouped to extract the kinds of learning related to professional development. The resulting coding scheme, with respect to the study questions, is shown in Tables 1 to 5. The number of responses to each type of learning served as a measure of participants’ knowledge or attitude regarding that learning. For example, if an attending mentioned three incidents of learning related to making a diagnosis (e.g., writing the medical record, making the diagnosis, planning treatment) during residency, he or she would receive a score of 3.

Table 1.

Learning Goals: Attending Physician’s Routine Tasks.

Task	Junior		Senior		t	df	Cohen’s d
Task	M	SD	M	SD	t	df	Cohen’s d
1. Medical practice	2.00	1.32	1.64	1.21	0.64	18	0.30
2. Teaching	0.00	0.00	1.09	0.94	3.83**	10^a	−1.65
3. Research	0.78	0.67	0.82	0.75	0.13	18	−0.06
4. Hospital administration	0.11	0.33	0.09	0.30	0.14	18	0.07

^aDegrees of freedom were adjusted for t test due to unequal variances.

p < .01.

Content analysis and scoring were performed by the principal investigator. A second rater independently analyzed 10 attending physicians’ responses according to the scoring scheme. The differences between them were discussed and rescored. Their mean inter-rater reliability in content analysis was .96 (range: .85–1.00). Junior and senior attending physicians’ similarities and differences in scores to these learnings were tested by independent t tests to characterize their stage in professional development. Student t tests were used because the small sample size rendered all statistics with insufficient power to test differences. The observed statistical differences were only to more sharply suggest possible developmental differences. The study was basically descriptive in nature, aiming to explore the possible trajectory of professional development in practice.

Results

Content of Medical Competencies

A junior doctor’s goal is to become an attending physician who practices medicine independently. Learning an attending physician’s routine tasks is the goal of residency training. Junior and senior attending physicians reported that medical practice comprises tasks such as attending to inpatients and outpatients, making differential diagnoses, finding the best treatment for patients, being on call for emergencies, writing medical records, interacting with patients’ families, and learning and improving medical knowledge and skills. These responses were classified into four categories: medical practice, teaching, research, and hospital administration. All attending physicians shared the same opinions regarding the content of an attending physician’s tasks, but senior attending physicians also gave responses regarding teaching responsibility (Table 1). For example, “part of an attending physician’s responsibility is to educate residents, attending physicians must ask themselves, ‘What preparation do I need? What is the best way to teach, and what to teach?’” (Senior #11).

It appears that while the goal for junior attending physicians is performing medical services well, senior attending physicians may also include “educator” in their job profile. The following is the analysis of how differences in junior and senior attending physicians’ responses reflect their stages of professional development.

The Course of Professional Development: Evidence From a Medical Practitioner

Junior and senior attending physicians’ responses to interview questions were organized and compared according to the four-stage model of professional development as follows.

Stage 1: Entering the profession and becoming familiar with routine tasks, the institution, and the environment in which the profession is embedded

It takes some time before a beginning professional becomes familiar with the routine tasks of a professional. In medicine, internships and residency training are designed to provide the scaffolding needed to assist junior doctors in acquiring professional competence via the assistance of senior doctors. As shown in Table 2, junior and senior attending physicians agreed on the learning goals of the internship. Upon retrospection, junior and senior attending physicians reported that the internship was designed to familiarize medical residents with basic medical skills such as drawing blood, changing dressings, and caring for inpatients; it also provided them with knowledge about medical routines and the common diseases in each department; and taught them how to interact with patients and other medical staff (e.g., nurses, pharmacists, and social workers). For example, “… the goals are to help interns understand how attending physicians work with patients, and how residents work in the hospital” (Junior #6).

Table 2.

The Functions of Internship.

Function	Junior		Senior		t	df	Cohen’s d
Function	M	SD	M	SD	t	df	Cohen’s d
1. Learning basic medical skills	1.22	0.97	0.91	1.14	0.65	18	0.31
2. Learning medical routines and institutional environment	1.11	1.17	0.64	1.03	0.97	18	0.45

Residency training begins when one becomes a certified doctor. Upon retrospection, attending physicians recounted many difficulties at the beginning of their practice. Both junior and senior attending physicians agreed that they were unable to apply textbook knowledge (senior, M = 0.09, SD = 0.30; junior, M = 0.33, SD = 0.50, t_12.58 = –1.28) or make medical diagnoses at the beginning of residency. For example, “… in the first year, what you heard in the hospital are familiar medical terms only. The terms you know, but [you] don’t know how to do it” (Junior #6).

They also had difficulty completing the required tasks in a timely manner and had poor interpersonal relationships because they were not familiar with medical procedures or the technical and administrative systems of the hospital. They also lacked the communication skills needed to probe patients for their symptoms, explain patient conditions to patients or their families, or to discuss the patients’ conditions with attending physicians. For example, “… have to learn how to deal with patients … to figure out what they think” (Junior #7) “… the major problem is communication. If you ask residents to contact patients, they cannot even ask a question; they don’t know how to speak to patients” (Senior #8).

Junior doctors were afraid of handling patients and did not know how to give medical orders or handle emergency cases. Moreover, because of the high workload, they barely had time to think over the patients’ conditions.

These responses were classified into five categories (Table 3). All attending physicians to a large extent agreed on the difficulties they faced at the beginning of their careers, except junior attending physicians complained significantly more than senior attending physicians that they were unable to make diagnoses, indicating that it is the biggest problem junior attending physicians experienced at the beginning of their careers.

Table 3.

Difficulties Residents Faced in the Beginning of Residency Training.

Difficulty	Junior		Senior		t	df	Cohen’s d
Difficulty	M	SD	M	SD	t	df	Cohen’s d
1. Unable to make diagnosis	1.11	0.93	0.36	0.50	2.17*	11.79^a	1.10
2. Lack of clinical experience	1.00	0.50	0.64	0.67	1.38	17.87^a	0.63
3. Unfamiliar with medical systems	0.44	0.53	0.55	1.04	0.27	18	−0.14
4. Lack of communication skill	0.33	0.50	0.27	0.90	0.18	18	0.08
5. High workload	0.22	0.67	0.18	0.60	0.14	18	0.07

^aDegrees of freedom were adjusted for t test due to unequal variances.

p < .05.

These attending physicians’ self-retrospections suggest that beginning professionals are not yet competent. They should not be left to practice independently. Senior professionals’ scaffolding and supervision are vital to transform a junior professional into a competent professional and to secure safe professional services to clients.

Stage 2: Supervised practice to gain professional competence

A junior doctor’s practices are continuously supervised on a one-to-one basis by a senior attending physician. Junior and senior attending physicians’ opinions regarding the skills and knowledge they developed from residency training were grouped into four categories (Table 4).

Table 4.

Skills and Knowledge Residents Developed During Residency Training.

Skill	Junior		Senior		t	df	Cohen’s d
Skill	M	SD	M	SD	t	df	Cohen’s d
1. Competence in medical diagnosis	3.89	2.20	2.00	3.07	1.55	18	0.73
2. Verification of textbook knowledge	1.44	1.33	0.64	0.67	1.65	11.30^a	0.82
3. Skills to deal with people	0.78	1.56	0.64	1.12	0.24	18	0.11
4. Attitudes relevant to medical practices	0.11	0.33	0.55	1.04	1.20	12.44^a	−0.58

^aDegrees of freedom were adjusted for t test due to unequal variances.

Table 5.

Learning After Residency Training.

	Junior		Senior		t	df	Cohen’s d
	M	SD	M	SD	t	df	Cohen’s d
Self-centered learning
1. Advancement of medical competence	1.11	0.78	0.73	0.79	1.09	18	0.51
2. Communication ability	1.00	1.12	0.18	0.41	2.09*	9.72^a	1.08
Transition
3. Establishing a good relationship with medical teams and patients Client-centered learning	1.22	1.64	0.27	0.65	1.64	10.03^a	0.84
4. Cultivating a professional attitude	0.00	0.00	0.64	1.03	2.06	10^a	−0.88
5. Medical ethics	0.00	0.00	0.27	0.47	1.94	10^a	−0.82
6. Personal qualities	0.11	0.33	1.27	1.42	2.63*	11.33^a	−1.13

^aDegrees of freedom were adjusted for t test due to unequal variances.

p < .05.

There was no difference between junior and senior attending physicians in terms of the number of responses in each category. However, there were differences in the items they mentioned within each category. The similarities and differences between junior and senior attending physicians, in terms of the competencies they built through residency, are described as follows:

Acquiring competence in medical diagnosis. This is the major learning task in residency (Table 4). Participants reported that symptom recognition was at first very difficult for them. Textbooks present only typical cases and typical symptoms. However, symptoms of a disease may be very complex and atypical and vary developmentally from patient to patient. Moreover, a patient may have more than one disease. Junior attending physicians reported significantly more on this gap in knowledge than senior attending physicians (senior, M = 0.36, SD = 0.51; junior, M = 1.44, SD = 1.01, t_11.20 = –2.92, p = .01). Five junior attending physicians (56%) mentioned that the most challenging task for residents is to make a differential diagnosis, that is, given observed symptoms, how to rule out alternative hypotheses and single out the most plausible cause of the illness. For example, “… there is a lot to learn about how to make a diagnosis, including recognizing symptoms, making examinations, interpreting findings, searching for related cases, considering individual differences … , all these are indispensible in making diagnoses’” (Junior #8). Other learning related to medical diagnosis included learning how to prescribe medicine, participation in treatment planning, learning to reason from the symptoms to the causes of the illness, assisting attending physicians with outpatients, visiting inpatients, writing medical records, reading journal papers, making presentations, and discussing a case.

Verification of textbook knowledge. Textbook knowledge is abstract and difficult to grasp. Clinical cases help make abstract knowledge concrete and produce greater learning. Junior attending physicians reported this function of clinical training slightly more than senior attending physicians. For example, “… the diseases you see in patients are only about 30–40% similar to what was depicted in the textbook. Often, it even crosses borders to many other things” (Senior #7).

Learning to interact with people. Doctors must interact with patients and their families. Support from nurses and medical technicians is also indispensable. Both groups of attending physicians agreed that getting along with others is crucial to the success of treatment. For example, “… in medical treatments, there are interpersonal interactions which are not mentioned in the books … you have to consider not only patients but also their families” (Junior #4).

Acquiring attitudes relevant to medical practices. Medical technology and knowledge are continuously updated. Medical practitioners need to adopt attitudes of continuous learning. These attitudes can only be appreciated from clinical practice. Senior attending physicians stressed this need slightly more than junior attending physicians. For example, “… be humble, knowing that you don’t know everything, and [be] willing to seek help from others” (Senior #1) and “… be a responsible person … try hard to observe and learn” (Senior #4).

In sum, junior and senior attending physicians agreed about what they had learned from residency training. However, junior attending physicians focused more on building personal competencies, such as making medical diagnoses, whereas senior attending physicians’ focus displayed signs of profession-centered practices, such as continuous learning.

Stage 3: Further advancement of one’s professional knowledge and skills, and shifting from self-centered to client-centered practices

When probed with the question, “What still needs to be learned after residency training?” the interview data showed that six sets of professional competencies remained to be developed after residency (Table 5). There are clear signs of differences between junior and senior attending physicians’ responses to this question:

Advancement of medical competence. Both junior and senior attending physicians agreed that after residency they still needed to further advance their medical competencies in the following areas: conducting research, individualized treatment of patients, diagnosis and treatment of rare diseases, competency in other medical domains, and differential diagnosis. Examples are “… differential diagnosis is the focus of medical training” (Senior #3) and “… there are always new developments, you have to know [them]” (Junior #7).

Junior attending physicians focused more on research competency (f = 4), knowledge updating, and enrichment (f = 3). Only senior attending physicians mentioned individualized treatment of patients (f = 1) and concern for patients’ safety (f = 1).

Communication ability. Patients may not be able to clearly tell what is wrong with their health. Doctors have to talk to patients or patients’ families to probe for symptoms, medical history, or life events that are necessary for making a diagnosis. Foundationally, effective communication among the medical team is important for surgery or diagnosis and treatment of complex diseases. Here, the difference between junior and senior attending physicians was significant (Table 5). Junior attending physicians were particularly keen in sensing the need to communicate effectively. Even with 6 to 12 years of clinical experience, junior attending physicians still have room to improve their communication abilities. For example, “ … be a good communicator … make the meanings of medical terms understood by patients” (Junior #6).

Establishing a good relationship with medical teams and patients. Getting along with patients and their families is important for mutual trust and may reduce possible medical conflicts. A good interpersonal relationship is also critical in securing support and cooperation from the medical team and administration. Junior attending physicians gave slightly more responses than senior attending physicians on this factor (Table 5). For example, “… learn to get along with patients and their families” (Junior #7) and “… have to get along with your colleagues, supervisors and your seniors” (Junior #8).

Cultivating professional attitudes and behaviors such as humility, devotion, seeking help, making tradeoffs, life-long self-learning, and self-reflection. These attitudes and behaviors are the core of professionalism. All these responses were given by senior attending physicians (Table 5). For example, “… professionals must be willing to sacrifice their own interests, devote themselves, be altruistic” (Senior #1) and “… be informed of things outside of medicine” (Senior #5).

The issue of medical ethics. Morality and “do no harm” to clients is also the core of professionalism (Musick, 1999; Walton, Jeffery, Van Staalduinen, Klein, & Rothnie, 2013). The need to cultivate one’s medical ethics was raised by only three senior attending physicians (Table 5). They said ethics is a neglected area in medical education. They thought medical ethics is better understood through real medical cases and examples, and that it is very difficult to learn ethics from classroom instruction. In contrast, one junior attending physician said that medical ethics was easy because it was already covered in the classroom. This response was not included in the data analysis. Examples of senior attending physicians’ responses follow “Ethics … communicate and watch for your patient’s safety” (Senior #8) and “… have medical ethics. You may have good grades or knowledge, but that doesn’t guarantee good ethics” (Senior #11).

Developing and maintaining personal qualities, including compassion, optimism, patience, risk-taking ability, the ability to think independently and to work under tight time constraints, and not becoming a doctor simply to earn a high salary. These personal qualities characterize a doctor who is a truly competent, independent, and responsible professional. These responses were given primarily by senior attending physicians. The difference between junior and senior attending physicians was significant (Cohen’s d = –1.13). Three senior attending physicians also stressed the need to keep themselves psychologically and physically healthy. As examples, “… reflect on your own behaviors … be sympathetic” (Senior #10), “… be loving and patient … and keep yourself physically and mentally healthy” (Senior #5), and “… must cultivate personal traits, such as willingness to share knowledge with others, willingness to teach your juniors, and not [be] concerned about being taking over” (Junior #6).

As shown in Figure 1, junior and senior attending physicians’ opinions about what needs to be learned after residency diverged. Junior attending physicians with 6 to 12 years of clinical practice were still centered primarily on the development of their own medical competence. However, they had developed a keen concern for developing abilities to interact and get along with patients and others in the profession, implying that they were moving toward a more other-centered practice. Only senior attending physicians with 14 to 41 years of practice realized the need to cultivate a proper professional attitude, operate within a code of ethics, and develop personal qualities that characterize the professionalism of Stage 4.

Figure 1.

Differences between junior and senior attending physicians in professional development. Note: ^aDevelopment in Stage 3: medical competence, communication ability, and interpersonal relationship. ^bDevelopment in Stage 4: professional attitude, medical ethics, and personal qualities.

Stage 4: Becoming a professional and assuming professional responsibility

Progressing from Stage 1 to Stage 4 in professional development apparently requires years of learning. Senior professionals play an important role in guiding their juniors. Thus, mentoring is key to the development of a professional. When questioned on this point, all attending physicians felt they should assist residents in a one-on-one basis. For example:

It is just like BRINGING up your own children. If they don’t know how to do it, you teach them slowly and gradually and give them the opportunity to speak. They will know better once they can present the ideas clearly [themselves]; [until] then, wait till they are more mature, you can let him do the operation; it can be only learned by actually doing it. (Senior #10)

Meeting with an attending physician who is willing to help new professionals is crucial for a resident (Kalen et al., 2012). Junior attending physicians emphasized that senior attending physicians must be willing to teach, guide residents in thinking and reasoning, and be willing to have two-way communication with the residents. Senior attending physicians also stressed their responsibility to give residents more practice, freedom, and autonomy in decision making and to serve as role models. Two senior attending physicians and one junior attending physician also said that because clinical training has no boundaries, residents must take an active role in learning. For example:

It is very important to have someone who is nice to you. He/she can show you and teach you how to practice medicine, can tell you what problems you will encounter later in your own practice … the road to doctorship is full of hardship. It is very important to have this kind of assistance and support. (Junior #1)

Previous studies have also stressed the importance of observation and imitation of the activity (e.g., Dreyfus & Dreyfus, 2005; Stegeman et al., 2013). It has been found that both for those who provided and those who received mentoring, their objective and perceived career success were better than those who did not (mean β = 0.19; Bozionelos, Bozionelos, Kostopoulos, & Polychroniou, 2011). Unfortunately, six senior attending physicians (54.5%) and one junior attending physician complained about their senior attending physicians during residency. For example, one senior attending physician said that some attending physicians were inconsistent in giving orders. Five senior attending physicians (45.5%) mentioned that few attending physicians like to teach.

When probed about whether they had ever met a mentor in their professional careers, 13 out of 20 attending physicians (65%) responded positively. Nine out of 11 senior attending physicians (82%) and 4 out of 9 junior attending physicians (44%) reported having at least one mentor (χ² [1] = 3.04, p < .08, Cramer’s V = 0.39). Senior attending physicians described their mentors with seven of the characteristics that are the goals of Stage 4 professional development: medical competence (f = 5), care for patients (f = 3), inquisitive research attitude (f = 3), patience (f = 2), humility (f = 1), a good teacher to residents (f = 1), and autonomy in judgment (f = 1). Junior attending physicians’ descriptions of their mentors included only three characteristics: a good teacher to residents (f = 4), inquisitive research attitude (f = 1), and care for patients (f = 1). These differences further show that junior attending physicians’ attention is still centered on their own needs; senior attending physicians are able to recognize more features of medical professionalism from their mentors.

The interview data suggest that interns and beginning doctors are at Stage 1 of professional development. Only after several years of supervised clinical experiences, might most senior residents reach Stage 2 and therefore can practice independently. After residency, more learning is required for attending physicians to acquire expertise in their domain. This Stage 3 development also includes, at a later time, a shift from a self-centered to a client-centered practice. Only those who have internalized professional values might reach Stage 4 development.

Discussion

The consensus among 11 senior attending physicians and 9 junior attending physicians regarding the role of internship and residency in the development of medical professionals shows that fledging doctors are not mature medical practitioners. Several years of supervised practice are required to assist new doctors so they have the time and opportunity to transform their textbook knowledge into procedural knowledge in medical diagnosis and treatment. Senior attending physicians play a very important role in this process.

The differences in opinions between junior and senior attending physicians on the role of residency training and the continued learning process after residency may shed light on the time-course of professional development. A minimum of 10 years of deliberate practice is required for the acquisition of expert performance (Ericsson, Krampe, & Tesch-Romer, 1993). Junior attending physicians are still primarily concerned with strengthening their own competencies. Only those with sufficient expertise may have developed more patient- and profession-centered attitudes and behaviors, such as caring for patients, medical ethics, teaching responsibility, self-reflection, and self-learning.

Attending physicians are the major force behind residency training. They supervise residents and serve as their mentors and role models. Thus, they are a key component in shaping future medical professionals. Unfortunately, not all attending physicians are good mentors to, much less role models for, their juniors. Some residents complained bitterly about their attending physicians in the interview. Attending physicians might be harsh in their language and attitudes and were sometimes abusive in their behavior to residents. Therefore, residency training can be very tough for junior doctors and may result in doubt and confusion about the profession. In a collective culture, as is found in Taiwan (Hofstede, Hofstede, & Minkov, 1997; Oyserman, Coon, & Kemmelmeier, 2002), the organizational control system is more hierarchical. To progress professionally and to practice independently can be very difficult in a system where the power distance between people of different ranks and seniority is large. Mentoring and role modeling may play an even more important role in professional development.

The present study shows that professional development includes the need for not only a building of expertise but also of a persona: internalization of a set of personality traits and attitudes toward the profession. Good mentoring is a key to transform a beginner into a good professional (Connor, Bynoe, Redfem, Pokora, & Clarke, 2000). In the study, 9/11 senior attending physicians reported having met a mentor during their residency training; only 4/9 junior attending physicians reported having a mentor. This suggests that those who have met a good mentor may be more likely to continue in the profession; certainly, this is speculative but should be assessed in further research. The curriculum of medical education needs, therefore, to include instruction on how to be an educator or mentor to medical staff and patients (Sinclair et al., 2015).

The findings in the present study not only provide additional support to previous models of professional development (e.g., Benner, 1984; Dreyfus & Dreyfus, 2005) but also go beyond previous models to show how a professional grows through practice. The proposed model of professional development in practice has implications for the education, training, and management of professional workers.

Professional development is a time-consuming and effortful process. Education should provide not only professional knowledge and skills but also a philosophy about the importance of the profession to society and its relationship to other professions (Hays, 2013). Training beginning professionals, including the cultivation of certain important personal qualities, are better accomplished through supervised learning in general and mentoring in particular (Sheila, 2006; Ogunyemi, Solnik, Alexander, Fong, & Azziz, 2010). That means professional development must also include the goals of becoming a good mentor and role model. Organizations must take into account the needs of their professional workers at their different stages of professional development. Support must be provided for them to successfully move from one stage to another, and persons with Stage 4 professionalism should be publicly recognized by the organization to serve as role models for other professionals.

It is proposed that the professional development model observed in medicine may be generalized to other professions. However, due to variations in the knowledge and skills required for different professions, the time needed to progress through the stages of professional development may vary. Even within the same profession, individuals may progress at different rates in the course of professional development; some may never reach the later stages. Due to the small and nonrandom sample of this study, and with most of the attending physicians drawn from teaching hospitals in Taiwan, the findings of the present study must be generalized with caution. In future study, residents’ inputs need to be included to get a deeper and finer understanding of their learning, and how senior attending physicians can assist them.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) received no financial support for the research,authorship,and/or publication of this article.

Author Biographies

S.-H. Hou is a doctoral candidate of the Department of Management Science,National Chiao Tung University,Tawian. Her Research interests include professional development,human resource management,mentoring,and medical expertise.

R.-Y. Horng,PhD in Educational Psychology from University of Georgia,USA,is a professor in the Human Factors Engineering Program of the Department of Industrial Engineering and Management,National Chiao Tung University,Taiwan. Her research interests include imagination,creative thinking,decision making,argumentation,and human factors engineering.

P.-H. Chen,PhD in Educational Psychology from the University of Texas at Austin,USA,is an associate professor of the Department of Management Science,National Chiao Tung University,Taiwan. Her research interests include personnel selection,automated test assembly,psychometrics,and applied statistics.

References

ABIM Foundation, CP-ASIM Foundation, & European Federation of Internal Medicine. (2002) Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine, 136(3), 243–246.

Aho

J. M.

Ruparel

R. K.

Graham

Zendeljas-Mummert

Heller

S. F.

Farley

D. R.

Bingener

(2015) Mentor-guided self-directed learning affects resident practice. Journal of Surgical Education 72(4): 674–679.

Akkerman

S. F.

Bakker

(2012) Crossing boundaries between school and work during apprenticeship. Vocations and Learning 5: 153–173.

Anderson

D. S.

Stacey

B. G.

Western

J. S.

Williams

T. H.

(1983) Career development in four professions: An empirical study. Psychological Reports 53: 1263–1270.

Arnold

Stern

D. T.

(2006) What is medical professionalism? In: Stern

D. T.

(ed.) Measuring medical professionalism, New York, NY: Oxford University Press, pp. 15–38.

Baker

Wrubel

Rabow

M. W.

(2011) Professional development and the informal curriculum in end-of –life care. Journal of Cancer Education 26: 444–450.

Benner

(1984) From novice to expert: Excellence and power in clinical nursing practice, Menlo Park, CA: Addison-Wesley, pp. 1–11.

Boshuizen

H. P. A.

Schmidt

G. H.

Custers

E. J. F. M.

Wiel

M. W. J.

(1995) Knowledge development and restructure in the domain of medicine: The role of theory and practice. Learning and Instruction 5: 269–289.

Bozionelos

Kostopoulos

Polychroniou

(2011) How providing mentoring relates to career success and organizational commitment: A study in the general managerial population. Career Development International 16(5): 446–468.

10.

Bui-Mansfiled

L. T.

Chew

F. S.

(2001) Radiologists as clinical tutors in a problem-based medical school curriculum. Academic Radiology 8: 657–663.

11.

Cimino

J. J.

(1999) Development of expertise in medical expertise. In: Sternberg

R. J.

Horvath

J. A.

(eds) Tacit knowledge in professional practice, Mahwah, NJ: Lawrence Erlbaum Associates, pp. 101–120.

12.

Connor

M. P.

Bynoe

A. G.

Redfern

Pokora

Clarke

(2000) Developing senior doctors as mentors: A form of continuing professional development. Report of an initiative to develop a network of senior doctors as mentors: 1994-99. Medical Education 34: 747–753.

13.

Dall’Alba

Sandberg

(2006) Unveiling professional development: A critical review of stage models. Review of educational research 76(3): 383–412.

14.

Dreyfus

H. L.

Dreyfus

S. E.

(2005) Expertise in real world contexts. Organization Studies 26(5): 779–792.

15.

Ericsson

K. A.

Krampe

R. T.

Tesch-Romer

(1993) The role of deliberate practice in the acquisition of expert performance. Psychological Review 100: 363–406.

16.

Furlong

Maynard

(1995) Mentoring student teachers, New York, NY: Routledge.

17.

Hays

(2013) Interprofessional education. The Clinical Teacher 10: 338–341.

18.

M.-J.

K.-H.

Hirsh

Huang

T.-S.

Yang

P.-C.

(2011) Does one size fit all? Building a framework for medical professionalism. Academic Medicine 86: 1407–1414.

19.

Hofstede

G. J.

Minkov

(1997) Culture and organizations, New York, NY: McGraw Hill.

20.

Kalen

Ponzer

Silen

(2012) The core of mentorship: Medical students’ experience of one-to-one mentoring in a clinical environment. Advances in Health Science Education 17: 389–401.

21.

Lave

Wenger

(1991) Situated learning: Legitimate peripheral participation, New York, NY: Cambridge University Press.

22.

Levinson

Ginsburg

Hafferty

F. W.

Lucey

C. R.

(2014) Understanding medical professionalism, Beijing, China: McGraw-Hill Education.

23.

Musick

D. W.

(1999) Teaching medical ethics: a review of the literature from North American medical schools with emphasis on education. Medicine, Health Care and Philosophy 2(3): 239–254.

24.

Norman

(2011) Issues in (inter)professionalism. Advances in Health Science Education 16: 1–3.

25.

Ogunyemi

Solnik

M. J.

Alexander

Fong

Azziz

(2010) Promoting residents’ professional development and academic productivity using a structured faculty mentoring program. Teaching and Learning in Medicine 22(2): 93–96.

26.

Orr

Gao

(2013) Becoming an architect: The role of work-based learning in architect training. Vocations and Learning 6: 221–235.

27.

Oyserman

Coon

H. M.

Kemmelmeier

(2002) Rethinking individualism and collectivism: Evaluation of theoretical assumptions and meta-analyses. Psychological Bulletin 128: 3–72.

28.

Polanyi

(1983) The tacit dimension, Gloucester, MA: Peter Smith.

29.

Reed

R. R.

Evans

(1987) The deprofessionalization of medicine: Causes, effects and responses. Journal of the American Medical Association 258(22): 3279–3282.

30.

Schmidt

H. G.

Rikers

R. M.

(2007) How expertise develops in medicine: Knowledge encapsulation and illness script. Medical Education 41(12): 1133–1139.

31.

Schön

D. A.

(1983) The reflective practitioner, New York, NY: Basic Books.

32.

Sheila

L. A.

(2006) Mentoring: The magic partnership. Canadian Operating Room Nursing Journal 24(4): 30–38.

33.

Sinclair

Fitzgerald

J. E. F.

Hornby

S. T.

Shalhoub

(2015) Mentorship in surgical training: Current status and a needs assessment for futurte mentoring programs in surgery. World Journal of Surgery 39: 303–313.

34.

Sinclair

(1997) Making doctors: An institutional apprenticeship, Oxford, England: Berg.

35.

Spandorfer

Pohl

C. A.

Rattner

S. L.

Nasca

T. J.

(2010) Professionalism in medicine, New York, NY: Cambridge University Press.

36.

Stegeman

J. H.

Schoten

E. J.

Terpstra

O. T.

(2013) Knowing and acting in the clinical workplace: Trainees’ perspectives on modeling and feedback. Advances in Health Sciences Education 18(4): 597–615.

37.

Stern

D. T.

(2006) Measuring medical professionalism, New York City, NY: Oxford University Press.

38.

Tallis

R. C.

(2006) Doctors in society: Medical professionalism in a changing world. Clinical Medicine 6(1): 7–12.

39.

The Royal Australasian College of Physicians. (2010). Supporting physicians’ professionalism and performance – A literature review. Retrieved from http://www.racp.edu.au/page/sppp/.

40.

Van de Wiel

M. W. J.

Van den Bossche

(2013) Deliberate practice in medicine: The motivation to engage in work-related learning and its contribution to expertise. Vocations and Learning 6: 135–158.

41.

Wagner

Hendrich

Hoseley

Hudson

(2007) Defining medical professionalism: A qualitative study. Medical Education 41: 288–294.

42.

Walton, M., Jeffery, H., Van Staalduinen, S., Klein (nee Kehoe), L., & Rothnie, I. (2013). When should students learn about ethics, professionalism and patient safety? The Clinical Teacher, 10(4), 224–229.

43.

Wimmers

P. F.

Schmidt

H. G.

Splinter

T. A. W.

(2006) Influence of clerkship experiences on clinical competence. Medical Education 40: 450–458.