Mapping Norms of Academic Integrity as an Aid to Proactive Regulation Open Access

Nearly 60 years ago Robert K. Merton noted in his pioneering study of The Student-Physician:

“The profession of medicine, like other occupations, has its own normative subculture, a body of shared and transmitted ideas, values and standards towards which members of the profession are expected to orient their behavior. These norms and standards define technically and morally allowable patterns of behavior, indicating what is prescribed, preferred, permitted, or proscribed. The subculture, then, refers to more than habitual behavior; its norms codify the values of the profession.”1 

More recently, Lave and Wenger2 (1991) have described the “community of practice” among members of specialist work forces. Within the medical profession, there has been increasing interest in the process of professional identity formation from novices in undergraduate education and training to licensed physicians within the social organizations of the medical school and residencies and their communities of learning and practice.

Merton introduced the concept and theory of “reference groups” as a way of understanding both the formation and dynamics of highly socialized social groups such as the medical and other health professions. Reference group theory “aims to systematize the determinants and consequence of those processes of evaluation and self-appraisal in which the individual takes the values or standards of other individuals and groups as a comparative frame of reference”3 (p.50) and thereby “signs on” to a particular social group. The individual accepts the personal salience of what “appear to be frames of reference held in common by a proportion of individuals within a social category sufficiently large to give rise to definitions of the situation characteristic of that category”3 (p.62).

In 1957 Merton noted that “Since the writings of George Mead were published a generation ago, there has gradually developed a socio-psychological theory of the sources and consequences of self-images and self-appraisals. But only recently has there developed a body of inquiry which empirically tests and develops the implications of this theory, say, within the sphere of formal education. Yet it would seem important to learn how students arrive at self-appraisals, the standards they use in evaluating themselves, and the consequences of all this for professional development”4 (p.299, Appendix B).

Merton and Kitt3 (1950) saw that “these frames of reference are common because they are patterned by the social structure” (p.62).

The aim of this study is to investigate whether it is possible to map norms of professionalism among cohorts. The purpose is to provide ongoing information regarding the validity of this approach in multiple settings both within the UK and internationally.

Norms of professionalism were mapped among cohorts by using the strategy of soliciting recommended sanctions as an indication of the severity with which particular lapses are regarded in order to delineate “the development of relatively precise, statistical indices of social structure”3 (p.81). The recommended sanction, ranging from “Ignore” to “Report to Regulator,” serves as a proxy statement of the degree of unprofessionalism of each behavior as viewed by the respondent. In this study the relations between a respondent's recommended sanction and his or her actual behavior are not explored, although we note the work of Papadakis and her colleagues5 relating student poor professionalism with likelihood of disciplinary action after licensure.

Through the use of an online inventory the present paper aims to “explicate iterative connections between the properties of a social system and the action of individuals”6 in order to understand and facilitate the learning of professionalism by medical students and trainees as proactive regulation.

Following the initial descriptive analysis in this paper and further analysis in subsequent papers, we intend to identify where enhanced teaching and learning of professionalism should be targeted in order to facilitate the successful process of professional identity formation in medical students.

The Dundee Polyprofessionalism Inventory I: Academic Integrity was used. This inventory, and a related inventory for early clinical professionalism,7 ,8 were developed as online tools to “map” the norms of organizational culture in health professionals' learning, from novice to fully licensed practitioners, to enable us to explore those iterative connections between organizational culture and individual praxis.

In order to generate items for the Dundee Poly-professionalism Inventory I: Academic Integrity, Roff et al9 (2011) identified more than 30 research studies on undergraduate academic integrity in the health professions and their methodologies and items reviewed. One hundred items were identified by two of the researchers in the field of Academic Integrity in the Health Professions at the junior undergraduate level. Two researchers condensed these into 41 items which were reviewed by the other researchers.

The items were further reduced to 30 by amalgamating several of them. The inventory was subsequently adapted for use with UK osteopathy students by Browne et al10 (2014) during which process four items were added to the 30-item inventory. In administration to Scottish students and staff, of the core 30 items, one was worded slightly differently: “Exchanging information about an exam before it has been taken” (e.g. OSCE) was presented to the Scottish respondents as “Receiving information about a paper from students who have already sat the exam or providing information about a paper to students who have yet to sit it,” which may affect responses from the Scottish school.

Following Teplitsky11 (2002), medical students and medical faculty were asked to recommend appropriate sanctions for a first time offense with no mitigating circumstances from the following hierarchy of options, which are theoretical rather than necessarily available within the regulations in each of the medical schools:

• 1. None

• 2. Reprimand (verbal warning)

• 3. Reprimand (written warning)

• 4. Reprimand, plus mandatory counselling

• 5. Reprimand, counseling, extra work assignment

• 6. Failure of specific class/remedial work to gain credit

• 7. Failure of specific year (repetition allowed)

• 8. Expulsion from college (re-admission after one year possible)

• 9. Expulsion from college (no chance for re-admission)

• 10. Report to professional regulatory body

After ethical permission was secured from the relevant internal institutional committees, the core 30 items were administered in two London and one Scottish medical school using the Bristol Online Survey.

The cohort included students (996 UK medical students: 189 from London school A, 432 from London school B, 372 from a Scottish school12)and medical faculty (165 medical faculty: 107 from London school A and 58 from a Scottish school).

The results were compared to previous published studies using the Dundee Polyprofessionalism Inventory in three overseas medical schools comprising Egyptian (n=219),13 Saudi Arabian (n=96),14 and Pakistani (n=480)15 medical students.

For 15 (50%) of the 30 items in the inventory there was high congruence (no more than one level of difference) between all the median sanctions recommended by the five sets of respondents.

There were differences of two or more levels in median recommended sanctions for 15 (50%) of the 30 items.

There were differences of two levels in median recommended sanctions between the London and Scottish staff for four items; three levels for three items; and four levels for one item. In all but two of these responses, the Scottish staff respondents were stricter than the London staff respondents.

There were differences of two or more levels in median sanctions recommended by the London and Scottish students in relation to seven items.

There were differences of two levels in the median sanctions recommended by the two cohorts of London students in relation to two items.

The items with the lowest levels of congruence are listed in Table 6.

The median recommended sanctions reported above from UK respondents differ substantially for nearly half of the items from those reported for Egyptian, Saudi Arabian and Pakistani medical students.

For nine (30%) items non-UK respondents recommended lower median sanctions as listed in Table 8.

While there is a broad congruence between recommended sanctions for around half of the lapses in professionalism both between the UK respondents and in relation to the non-UK respondents, there are six items where there is variance both within the UK responses and with the non-UK responses as set out in Table 9.

While there is a broad consensus around half of the examples of poor academic professionalism, Tables 6 and 9 suggest that there are specific issues on which there are different norms about poor professionalism at both individual medical schools in a country such as the UK and between different national cultures.

The medians are reported in this initial analysis but the range of recommended responses will also help us to understand the “professionalism climate” in individual schools. For instance, in the UK schools there is virtual unanimity on the severity of sanction required in response to pedophilic activities. But there is a far greater range of responses for exchanging information about an exam before it has been taken (e.g., OSCE) where 18% of one London school and 40% of the other London school student respondents recommended that this behavior should be ignored. It is to be expected that such a range will be reflected in means at some variation from the medians. The responses will be analyzed in more granularity in a separate paper to see how the data can be used to understand differences in the culture and expectations of medical schools in relation to professionalism.

The inventory maps one domain of professionalism, namely academic integrity and attitudes to and suggested sanctions for lapses of such integrity.

It is clear from the results that there are a great number of similarities between staff and students within institutions and also across institutions (and indeed countries). However there are also a number of areas in which there are notable differences between median sanctions suggested by staff and students for particular “lapses.” There are fewer areas in which there are greater than two levels of difference of median suggested sanction for students across national boundaries (London and Scotland) or staff across the same national boundaries. Nonetheless, these data — and also the results when compared to similar data collected from several institutions around the world — suggest that there are specific issues on which there are different norms about poor professionalism at both individual medical schools in a country such as the UK and between different national cultures.

It is important to note, however, that the significance of “median sanction” has not been fully explored. It is an expression of an attitude towards a given professionalism lapse, but it is not clear at present whether it correlates with other features of student attitude or behavior. It may also be interesting to look at the range as well as the median, as items with a broad range as selected in responses to the inventory may reflect a degree of ambivalence or uncertainty regarding the item, compared to items with a narrow range of sanctions suggested. It should also be noted that in more demographically similar groups (such as the two cohorts of students in London), there were fewer items that were non-congruent in terms of median sanctions and these tended to be at the lower end of severity of both the type of lapse and the sanction suggested. This highlights the fact that the list of misdemeanors and scale of sanctions are not necessarily linear and there appears to be more room for doubt, discussion and variance among the items that accrued the least stringent sanctions.

The differences between UK and non-UK respondents in terms of which items had the least congruence may tell us something interesting about the normative subculture regarding professionalism in medicine across the globe.

An understanding of the existing views of students and staff regarding appropriate professional behavior is an important step towards devising suitable guidance for medical students regarding professionalism. We note the use of survey data as part of the current review of student professional values and fitness to practise guidance being conducted by the UK General Medical Council (http://www.gmc-uk.org/Student_professionalism_our_survey_of_medical_students.pdf_60873369.pdf).

Mapping existing norms, as well as those of patients and lay public, can be followed by helping students and the profession move closer towards an “ideal” defined state of professional conduct and can also help to characterize appropriate sanctions for professionalism lapses. As Struckmann et al16 (2015) have commented, “a common understanding of definitions of what constitutes competence to practise, its impairment and its potential impact on patient safety becomes particularly important” in an era of international mobility for doctors. Longitudinal prospective cohort studies using the mapping approach outlined above could be combined with individualized feedback to enable targeted interventions to remediate poor understandings of professionalism before students become licensed practitioners, as Papadakis et al5 (2005) urged a decade ago.

This paper reports data from three UK schools and three other countries, which indicate a broad base of congruence but also important inter-school and regional differences that may be a function of different national and ethnic cultures. The applicability of the resource needs to be further explored to confirm its usefulness as tool in professionalism learning.