Professionalism in Medical Education – What Makes for an Effective Student-Faculty Relationship?

Introduction

There is significant literature on professional ethical codes of conduct, charters and declarations on the doctor-patient relationship both in clinical care and medical research, but relatively few in medical education on the student-faculty or resident-faculty relationship.

There is ample evidence in the education literature that when students are actively engaged with their teaching faculty while they are in school, they achieve academic success, personal development and career success upon graduation. Conversely, disengaged students who isolate themselves from the school community and do not develop meaningful relationships are more vulnerable to academic failures and poor adaption to working life as professionals. Medical students are more significantly influenced by positive role models in the faculty than what is taught in the classroom.¹

This article aims to discuss the professional and ethical principles that influence the student-faculty relationship in the education of doctors and other healthcare professionals.

The student-faculty relationship

The fiduciary nature of the relationship

A fiduciary is someone who has undertaken the task of acting for and on behalf of another in a particular matter in circumstances which gave rise to a relationship of trust and confidence. A student is dependent on a teacher in more than one way. The teacher has a duty to offer knowledge, skills and advice that the student needs. At the same time, the teacher is responsible for academic evaluation and the student's academic grades. It is important to recognise the imbalance of knowledge, experience and power that makes the relationship unequal and the student vulnerable to abuse and exploitation. To correct the imbalance, the primary goals of this relationship are the student's academic progress and welfare; this must be upheld above the interest of the teacher and other parties involved.

Managing conflicts of interests and boundaries

The faculty in most medical schools hold only part-time or adjunct roles and may have other obligations which can often cause conflicts with the education of the student. Such obligations include patient care, research, personal academic advancements and administrative duties. Although teachers should not use students to forward their research or academic progress, there are overlapping interests in many situations. Individual, independent and system levels of managing these conflicts of interest should be in place and monitored such that the student's interest and the medical education mission are not sidelined.

There is also a fine balance to be achieved in managing boundaries in the student-faculty relationship. Too rigid an approach to managing boundaries would lead the teacher to be unapproachable, distant and unavailable for emotional support. Conversely, when boundaries are too loose, the initial purpose of the relationship of mentoring, coaching and counselling would be lost in a friendly social relationship. Teachers must be aware of their own mental and emotional state, as this would impact the quality of the teacher-student relationship and risk of blurring of boundaries. Even the best of faculty can unknowingly be drawn into situations of inappropriate self-disclosure, exchanging of gifts, forming intimate or romantic relationships, gossiping about other students and faculty, or inappropriately favouring a few students over others. Faculty needs to be trained and supported by a learning community to grow into healthy role models as mentors, coaches, counsellors and professional colleagues.

Principles of fairness and justice

By recognising one's own biases and prejudices, faculty must be aware not to inadvertently discriminate students based on gender, age, ethnicity, religion, political affiliation, sexual orientation or socio-economic status. The faculty should provide equal access of educational opportunities to all students under his/her assignment.

Commitment to effective educational methods

Using intimidation, shaming and other invalidated methods of motivating students to learn by fear leads to significant moral distress among students. The "name, blame and shame" culture should be replaced with a safe learning environment that has a system of progressively increasing challenging work for the student with a decreasing intensity of supervision. This allows students to gain the skills and confidence to achieve entrustable professional activities.

Good educational governance should put in place a credentialing process to ensure the evaluation and continuous improvement of teaching skills of faculty.

Commitment to effective management of moral distress in medicine

When a medical student is uncertain about the appropriateness of the behaviour of any other person involved in patient care, faculty must be available to discuss the matter. Any student who feels that he/she has been subjected to unfair treatment because of a refusal to do something that seems to be wrong should seek advice from faculty.

Students struggle with ethical issues in clinical situations, and in research and education. They are fully aware of their lack of knowledge and experience, face pressure to conform to hierarchy and professional culture, and fear jeopardising academic progress and evaluation.

Students should be encouraged to raise ethical issues with the faculty throughout their training and not just when a specific issue arises. Teachers should be receptive of ethical dilemmas or problems that students face and seek to explain the ethics involved, or change the circumstances so that students are not ethically compromised and ensure that patients are respected. Moral distress is described as a silent epidemic that undermines the efforts to promote professionalism and compassion.²

Commitment to maintaining professionalism in an educational environment

Lapses in professionalism, such as medical errors and diagnostic errors, are common and inevitable, but some are preventable. The extent of frequency and severity of lapses in professionalism has not been proactively researched and documented. What is clear is that the faculty and medical leadership do not have effective ways of managing professional lapses and continue to tolerate them until they deteriorate into formal complaints.³ As a profession, we can learn from experience of patient safety governance and culture, that in dealing with lapses of professionalism, there are a combination of systems, contextual factors and individual factors. Faculty must be enabled and the institutional governance must be sufficiently rigorous to analyse, learn from and deal effectively with violations of professional standards and conduct by students, residents and faculty.

Appropriate supervision and delegation

It is important that students should ask for supervision and faculty be readily available to provide supervision when necessary. Faculty must take responsibility not only for the care they provide to patients but also for the care they direct and supervise. The degree or nature of the supervision would depend on the competence, readiness and experience of the student involved. The training system must ensure that students and residents are not pressured to take on clinical responsibilities for care of patients beyond their experience and competence. An effective student-faculty relationship thus can ensure that faculty are keenly aware of the developmental stage of the trainees so that appropriate delegation can take place.

Confidentiality

Faculty and students must respect the confidentiality of information that is given in confidence in the learning environment and the student-faculty relationship, unless there are strong ethical or legal reasons not to do so. Earning trust and confidence in any relationship requires the appropriate confidentiality measures to be applied. Issues that may override the confidentiality promise would include considerations of patient safety, the interest of other students or the school, and public interest.

Conclusion

Going back to our Hippocratic traditions, before the development of medical universities, the teacher-apprentice or guru-disciple relationship was deep and elaborate.⁴ Although many old traditions may not be relevant today, it behoves us to reflect the critical factors of the student-faculty relationship of the past, to meet today's challenges such as high levels of burnout in the profession and leadership.⁵ A reaffirmation of the professional values in the student-faculty relationship can help in developing positive role modelling habits in the faculty and be an effective way for students to engage the faculty in a more meaningful approach.

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