Defining what constitutes professional behavior for medical students has been an important issue for medical schools across the country. In 2009, in response to the need to provide a more consistent, clear and understandable definition of professionalism at the Yale School of Medicine, Dean Robert Alpern charged the Progress Committee with consolidating and clarifying the existing principles of professionalism into a single statement that would be consistent with the principles and ideals of the Yale System and that could be used to provide guidance when professional behavior comes into question. A subcommittee on professionalism, under the leadership of Dr. Deborah Proctor, was formed to specifically review existing professionalism policies from other medical schools and relevant educational organizations and to draft a statement on professionalism that would be appropriate for our school. The Yale University School of Medicine Statement on Professionalism that arose from the deliberations of the subcommittee, and subsequently the full Progress Committee, was approved by the Educational Policy Committee. This statement is an aspirational document that outlines behaviors and ideals we expect from our students from the very first day they begin the educational process.
Alleged unprofessional behavior on the part of a medical student will be considered by the Progress Committee as outlined in the Student Handbook. If the behavior is found to be unprofessional, action will be taken ranging from a warning to academic probation, suspension and even dismissal, depending on the nature of the infraction. It must be understood and emphasized that unprofessional behavior is detrimental to our community, our patients, our colleagues and ourselves, and does damage to the practice of medicine. This document is not meant to be an all inclusive list; behaviors deemed unprofessional by members of our community that do not fit exactly into a single category still may be viewed as unprofessional and will require review by the Progress Committee.
The Yale University School of Medicine takes the professional conduct of all of its members seriously. Students must demonstrate that they are capable of becoming safe and effective physicians. They must display good judgment, a sense of responsibility and morality, sensitivity and compassion for individual needs and the ability to synthesize and apply knowledge.
Professionalism implies that students serve the interests of patients above self-interest. 1,2 Professionalism includes honesty, respect for colleagues, faculty, staff and peers and behavior in public that is not embarrassing to the ideal of the physician. Continual self-reflection about one’s attitudes and behaviors must occur as one strives to be a better physician.
Components of professional behavior include:
1. Nondiscrimination – It is unethical for a student to refuse to participate in the care of a person based on race, religion, ethnicity, socioeconomic status, gender, age, sexual preference, national origin, ancestry or physical handicap. Students must show respect for patients and families as well as everyone involved in their care. This includes physicians, nurses, other students, residents, fellows and administrative staff. 1,2
2. Confidentiality – The patient’s right to the confidentiality of his or her medical record is a fundamental tenet of medical care. The discussion of problems or diagnoses of a patient by students or professional staff in public violates patient confidentiality and is unethical. Email and other internet fora that mention identifying patient information must be properly encrypted and not used other than for the purpose of communicating with the patient or caregivers who have a legitimate need to know about the patient. Medical records may be photocopied only for direct patient care. For presentations or rounds, students are permitted to extract information but not copy wholesale parts of the chart. All students are required to undergo training in the Health Insurance Portability and Accountability Act (HIPAA) and they must adhere to its tenets.
3. Professional Demeanor – The student should be thoughtful and professional when interacting with patients, their families, peers and co-workers. Inappropriate behavior includes the use of offensive language, gestures, or remarks with sexual overtones, extreme lack of interest and/or dishonesty.
Students should maintain a neat and clean appearance, and dress in attire that is generally accepted as professional by the patient population served. Students must dress according to the dress code of the hospital and individual departments when on clinical rotations. Contemporary styles of dress that include for example, low rise pants with exposed navels, low cut shirts with exposed cleavage, or open-toed sandals are inappropriate dress in the hospital, doctors’ offices and clinics. Good judgment should be exercised regarding hair styles (long hair that falls in patients’ faces when examining them should be pulled back). Long nails are not allowed in the hospital and long neckties should be tucked in the shirt or worn under a gown when examining patients to avoid transfer of infections from one patient to another. Excessive wearing of accessories and jewelry is discouraged.
4. Representation of Level of Training and Knowledge – A student should accurately represent herself or himself to patients and others on the medical team. Students should never introduce themselves as “Doctor” as this is clearly a misrepresentation of the student’s position, knowledge, and authority. A student should never provide care beyond what is appropriate for his or her level of training. The student must seek consultation and supervision whenever their care of a patient may be inadequate because of lack of knowledge and/or experience.
5. Honesty – Students are expected to demonstrate honesty and integrity in all aspects of their education and in their interactions with patients, staff, faculty, and colleagues. They may not cheat, lie, steal or assist others in the commission of these acts. Students must not commit fraud nor misuse funds intended for professional activities. The student must assure the accuracy and completeness of his or her part of the medical record and must make a good-faith effort to provide the best possible patient care. Students must be willing to admit errors and not knowingly mislead others or promote themselves at the patient’s expense. The student is bound to know, understand, and preserve professional ethics and has a duty to report any breach of these ethics by other students or health care providers through the appropriate channels. Plagiarism is dishonest and unethical. To consciously incorporate the words of others, either verbatim or through paraphrasing, without appropriate acknowledgment is unacceptable in scientific literature or in medical writings.
6. Research – The basic principle underlying all research is honesty. Scientists have a responsibility to provide research results of high quality; to gather facts meticulously, to keep impeccable records of work done; to interpret results realistically, not forcing them into pre-conceived molds or models; and to report new knowledge through appropriate channels. Co-authors of research reports must be acquainted with the work of their co-workers that they can personally vouch for the integrity of the study, validity of the findings, and must have been active in the research, or writing, itself.
7. Commitment to Life-long Learning – A personal commitment to life-long learning is an essential precept for a physician or a student of medicine. New medical and scientific knowledge is continually being discovered. In order to stay abreast of new technology, treatments and tools, students must make a commitment from the very beginning to be responsible for learning and maintaining the necessary skills to provide appropriate quality care throughout their careers as physicians and scientists.
8. Conflicts of Interest – Recognition, avoidance and management of conflicts of interest represent a core issue of professionalism. 1,2 As is required of the Yale University faculty, any student with a proprietary or other interest in any material he or she is presenting or discussing must properly disclose that conflict of interest. When a conflict of interest arises, the welfare of the patient must at all times be paramount. A student may challenge or refuse to comply with a directive if its implementation would be antithetical to his or her own ethical principles, when such action does not compromise patient welfare.
Gifts, hospitality or subsidies offered by medical equipment, pharmaceutical or other manufacturers or distributors including companies that write or distribute board review materials must not be accepted.
9. Sexual Misconduct – Students must not engage in romantic, sexual, or other non-professional relationships with a patient while involved in the patient’s care, even at the apparent request of a patient. In addition, students must not engage in romantic, sexual or other non-professional relationships with mentees, tutees or others for whom the student is in a position of authority. Students are not expected to tolerate inappropriate sexual behavior on the part of patients, their families or other health professionals.
Yale University has a strict policy regarding sexual harassment and assault http://www.yale.edu/equalopportunity/policies/index.html. Training in sexual harassment and assault takes place twice during medical school, once in the first year during orientation, and again before students start their clinical rotations.
10. Impairment – The student will not use alcohol or drugs in a manner that could compromise patient care or bring harm to themselves or others. It is the responsibility of every student to protect the public and to get the appropriate help for him or herself and to assist a colleague whose capability is impaired because of ill health. The student is obligated to report members of the health care team whose behavior exhibits impairment or lack of professional conduct or competence. A program on the appropriate and non-abusive use of alcohol is presented early in the first year of medical school.
11. Behavior Towards Colleagues – The student will deal with professional, staff, and peer members of the health team in a cooperative and considerate manner, including their mentors and teachers. Professional relations among all members of the medical community should be marked with civility and each person should recognize and facilitate the contributions of others to the community.
Under no circumstances will the student exhibit prejudice in words, action or deed towards a colleague based on ethnicity, race, religion, gender, age, sexual orientation, or physical disabilities. It is unethical and harmful for a student to disparage without good evidence the professional competence, knowledge, qualifications or services of a colleague. It is also unethical to imply by word, gesture, or deed that a patient has been poorly managed or mistreated by a colleague without tangible evidence.
12. Evaluation – Becoming a physician requires continuous personal growth and improvement. Students should seek feedback and are expected to respond to feedback and constructive criticism by appropriate modification of their behavior. Resistance or defensiveness in accepting criticism or in receiving feedback, remaining unaware of one's own inadequacies and not accepting responsibility for errors or failure are examples of a poor professional attitude. 3
Students should actively participate in the process of evaluating their teachers, including faculty and house staff. When evaluating their performance, students are obliged to provide prompt, constructive comments. Evaluations may not include disparaging remarks, offensive language or personal attacks, and should maintain the same considerate, professional tone expected of faculty when they evaluate student performance.
13. Teaching – The very title “Doctor” – from the Latin docere, “to teach” – implies a responsibility to share knowledge and information with colleagues and patients. It is incumbent upon those entering this profession to teach what they know of the science, art, and ethics of medicine. It includes communicating clearly with and teaching patients so that they are properly prepared to participate in their own care and in the maintenance of their health.
14. Disclosure – Students must understand the ethics of full disclosure. The patient must be well informed to make health care decisions and work intelligently in partnership with the medical team. Information that the patient needs for decision-making should be presented in terms the patient can understand. If the patient is unable to comprehend, for some reason, there should be full disclosure to the patient’s authorized representative. Students who participate in disclosing information to patients must do so only with the guidance and supervision of the attending physician.
15. Informed Consent – Students must understand the obligation to obtain informed consent from patients, but are not responsible for obtaining such consent. It is the physician’s responsibility to ensure that the patient or his/her surrogate be appropriately informed as to the nature of the patient’s medical condition, the objectives of proposed treatment alternatives, and risks involved. The physician’s presentation should be understandable and unbiased. The patient’s or surrogate’s concurrence must be obtained without coercion. Students who participate in obtaining informed consent must do so only with the guidance and supervision of the attending physician.
16. Lack of Conscientiousness – Students are expected to be thorough and dependable, and to commit the time and effort required to meet his or her responsibilities. Students should not require continual reminders about responsibilities to patients, to the institution, other health care professionals and to administrative staff. 1,2,3 Responding in a timely and appropriate fashion to phone calls, pages, notices and emails from faculty, nurses, other health care team members, and administrative staff is a responsibility that must be honored by students.
17. Arrogance – Arrogance means an offensive display of superiority and self-importance and will not be tolerated. Arrogance denotes haughtiness, vanity, insolence and disdain. All of these qualities run counter to the demeanor of the professional. 1
Professionalism also requires adherence to all university and medical school rules, policies and requirements, including both the Human Relations Code of Conduct of the Yale University School of Medicine and the Yale College Code of General Conduct and Discipline http://www.yale.edu/yalecollege/publications/uregs/general.html.
Helpful source materials used in the preparation of this document were obtained with permission from the American Board of Internal Medicine and the University Of Kansas School Of Medicine. The Progress Committee is grateful for their intellectual generosity in freely sharing these materials.
1. American Board of Internal Medicine, Project Professionalism 2001, http://www.abimfoundation.org/Resource-Center/Bibliography/General-Materials-on-Professionalism.aspx, April 7, 2010.
2. American Board of Internal Medicine Foundation, American College of Physicians, European Foundation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine 2002;136:243-246.
3. University of Kansas School of Medicine, Professionalism Initiative 2009, http://medicine.kumc.edu/school-of-medicine/pdfa/professionalism-initiative.html, November 16, 2009.