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Original Article
Volume 13 Number 1 February 2020
Copyright © 2020 Tehran University of Medical Sciences.
This work is licensed under a Creative Commons Attribution-NonCommercial
4.0 International license (https://creativecommons.org/licenses/by-nc/4.0/).
Non-commercial uses of the work are permitted, provided the original work is
properly cited.
Professionalism among medical residents in a young second-level
university in Iran: a cross-sectional study
*Corresponding Author
Elaheh Mianehsaz.MD
Physical Medicine and Rehabilitation
Clinic, Shahid Beheshti Hospital, 5th Km
of Ghotbe Ravandi Bulv., Kashan, Iran.
Tel: (+98) 31 55 54 00 26
Fax: (+98) 31 55 57 80 11
Email: Elaheh.mianehsaz@gmail.com
Received: 15 Oct 2018
Accepted: 5 Feb 2020
Published: 23 Feb 2020
Citation to this article:
Mianehsaz E, Tabatabaee SMR, Sharif
MR, Gilasi HR, Shojaee Far HR, Nejad
Tabrizi B. Professionalism among
medical residents in a young second-
level university in Iran: a cross-sectional
study. J Med Ethics Hist Med. 2020; 13:
1.
Elaheh Mianehsaz1*, Seyed Mohammad Reza Tabatabaee2, Mohammad Reza Sharif3, Hamid Reza
Gilasi4, Hamid Reza Shojaee Far5, Behzad Nejad Tabrizi6
1.Assistant Professor, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Kashan University of
Medical Sciences, Kashan, Iran.
2.Assistant Professor, Department of Emergency Medicine, Faculty of Medicine, Kashan University of Medical Sciences,
Kashan, Iran.
3.Professor, Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran.
4.Associate Professor, Department of Epidemiology and Biostatistics, Faculty of Health, Kashan University of Medical
Sciences, Kashan, Iran.
5.Researcher, Student Research Committee, Kashan University of Medical Sciences, Kashan, Iran.
6.Researcher, Student Research Committee, Kashan University of Medical Sciences, Kashan, Iran.
Abstract
Professionalism is a set of behaviors that build trust in
physicians’ relationships with patients and the public. The aim
of this study was to assess professionalism among residents in
Kashan University of Medical Sciences, Kashan, Iran.
This cross-sectional study was conducted on 139 residents
recruited through the census method. Data were collected using
the American Board of Internal Medicine Professionalism
Questionnaire. The first part of the questionnaire was on
residents’ personal characteristics, and the second part contained
fifteen items in the three domains of professionalism, namely
excellence, honor/integrity, and altruism/respect. The mean
scores of the questionnaire and its domains were calculated and
their relationships with residents’ personal characteristics were
evaluated.
The mean scores (± SD) of professionalism and its excellence,
honor/integrity, and altruism/respect domains were 4.93 ± 2.4,
5.92 ± 1.85, 4.94 ± 3.39, and 4.35 ± 3.27, respectively (in a
range of 0-10). Professionalism had significant relationships
only with residents’ specialty and gender.
The level of professionalism in residents was low, which
requires the attention of educational authorities. Moreover, the
mean score of professionalism among residents in surgical
specialties was significantly lower than non-surgical specialties.
Various factors can be considered in this regard and it cannot be
concluded that the lower score means worse professional
behavior.
Keywords: Professionalism; Residency; Surveys;
Questionnaires; Iran
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Introduction
Medical professionalism is a social contract
with the society that builds trust in
physicians’ relationships with patients and
the public (1). Its essence is the mutual
physician-patient trust. The key
characteristic of professional physicians is
the prioritization of patients’ needs over
their own (2, 3). There is no single, universal
definition of physician professionalism.
Professionalism is commitment to altruism,
honesty, confidentiality, excellence, respect
for patients' right to autonomy, and having
appropriate relationships with them (4).
Medical residents are among the main
providers of healthcare services. After
graduation, some of them are employed as
medical faculty members and become role
models for their peers and medical students.
It is clear that any problem in physicians’
professional behavior can compromise
patients’ health. Several studies showed that
medial students and residents who
demonstrated limited accountability and
professionalism during their university
education committed medical errors several
times more than their peers after graduation
(5 - 7). Therefore, medical residents’
professionalism needs to be continuously
monitored and promoted throughout their
training program (8). The Accreditation
Council for Graduate Medical Education
(ACGME) considers professionalism as one
of the six core competencies based on which
residents are to be regularly evaluated (9).
The importance of the issues of
professionalism may be differently ranked and
valued by different subspecialties (10, 11).
There are different instruments for
evaluation of professionalism, many of
which have not been fully tested for
reliability and validity. The most commonly
used methods for assessment of
professionalism are direct observation,
patient assessment, objective structural
clinical examination (OSCE), clinical
incident report, resident portfolio,
professionalism Mini-Evaluation Exercise,
videotape analysis and peer assessment (9,
12, 13). In peer assessment, peers with the
same professional position who have been in
direct unplanned contact with the intended
person and have no superiority over him/her
are asked to comment on his/her
professional practice. This method provides
valuable information about professionalism
(14, 15). One of the instruments for peer
professionalism assessment is the
questionnaire developed by the American
Board of Internal Medicine (2). This
questionnaire was used in previous studies to
assess professionalism among physical
medicine residents in the United States (16),
medical residents in all specialties in two
universities in Tehran, Iran (2), and physical
medicine and rehabilitation residents in Iran
(17).
All previous studies into medical residents’
professionalism in Iran were conducted in
leading universities (2, 18), and hence, there
is limited information about medical
residents’ professionalism in other
universities. The present study aimed to
evaluate medical residents’ professionalism
in a second-level university, i.e., Kashan
University of Medical Sciences, Kashan,
Iran. This university was established around
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thirty years ago and is considered a young
university. Most residency programs in this
university have a history of less than ten
years, and there are no subspecialty
fellowship programs at the moment.
Professors and senior residents are direct
role models for junior students and residents.
Therefore, the present study aimed to assess
professionalism among residents in this
university.
Methods
This cross-sectional study was conducted
between July and September 2017.
Study setting was Kashan University of
Medical Sciences, Kashan, Iran, and study
population comprised all medical residents
in this university, including residents in
pediatrics, internal medicine, general
surgery, neurology, neurosurgery,
gynecology, anesthesia, psychiatry,
infectious diseases, pathology, and
radiology. All residents in the university
were recruited to the study via the census
method. They were provided with
explanations about the aim of the study and
confidentiality of their information, and
then, their verbal informed consents were
secured. Residents were included if they
agreed to participate.
Data collection tool was the Persian version
of the American Board of Internal Medicine
(ABIM) Professionalism Questionnaire (2).
The reliability and content validity of the
questionnaire were confirmed at 0.88 by
Aramesh et al. (2). In the present study, the
Cronbach's alpha coefficient of the
mentioned questionnaire was estimated at
0.878.
This questionnaire included two main parts.
The first part was related to residents’
personal characteristics, namely age, gender,
academic year, residency specialty,
familiarity with the concept of
professionalism, participation in
professionalism workshops, and self-study
about professionalism. Participants’
specialties were divided into the main two
categories of non-surgical specialties
(consisting of general surgery, neurosurgery,
gynecology, and anesthesia) and surgical
specialties (consisting of pediatrics, internal
medicine, neurology, psychiatry, infectious
diseases, pathology, and radiology). The
second part of the questionnaire contained
fifteen items on professional behaviors in
three domains, namely excellence (four
items), honor/integrity (four items), and
altruism/respect (seven items). The items of
the excellence domain (items 1 - 4) assessed
residents’ beliefs about the availability of
good role models in the areas of professional
conduct, patient education, and student
training. The honor/integrity domain (items
5 - 8) dealt with residents’ belief in their
peers’ honesty and avoidance of
nonprofessional practice. For instance, items
in this domain were related to the possibility
of lying to patients and asking junior
residents to extract data from patients’
medical records. The altruism/respect
domain (items 9 - 15) had items on
residents’ respect for patients, peers, and
hospital regulations, avoidance of wasting
hospital resources, and consideration of
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patients’ convenience in performing
diagnostic and medical procedures. Items
were scored from 0 (i.e., “Lowest level of
professionalism”) to 10 (i.e., “Highest level
of professionalism”). Thus, the possible total
score of the questionnaire was 0 - 150, and
the possible total scores of its three domains
were 0 - 40, 0 - 40, and 0 - 70, respectively.
In order to generate a uniform 0 - 10 scoring
scale for all domains, the total score of each
domain was divided by the number of its
items.
After obtaining the legal and ethical
approvals from Kashan University of
Medical Sciences, Kashan, Iran, (code:
IR.KAUMS.REC.1394.146), two research
assistants (medical interns who were well
aware of the study aims) provided the study
questionnaires to participants and asked
them to complete them at their convenience.
Some participants completed and returned
their questionnaires on the same day, while
others returned their questionnaires days
afterwards. Participants were reminded to
complete the questionnaires through follow-
up personal contact or telephone calls.
Data Analysis
Study data were analyzed using the SPSS
program (v. 21.0). The independent-sample
t-test was conducted to compare
professionalism scores based on
participants’ characteristics, and it had two
levels. Similarly, the one-way analysis of
variance or the Kruskal-Wallis test was
performed for characteristics with three or
more levels. The level of significance was
set at less than 0.05.
Results
Among all 181 residents in the study setting,
four refused to participate and seventeen
were in other universities in Iran as guest
students. Thus, 160 residents participated in
the study. Despite frequent follow-up
contacts, twelve residents did not return their
questionnaires. Moreover, nine
questionnaires were partially filled out.
Thus, 139 questionnaires were entered in the
final data analysis (a response rate of
86.87%). Around 73% of the participants
were familiar with the concept of
professionalism, 11.5% had attended
professional ethics or professionalism
workshops or courses, and 24% had had
self-study in this area.
Participants’ mean score of professionalism
was 73.93 ± 36.01 (in the possible range of 0
- 150). The total mean scores of
professionalism and its excellence,
honor/integrity, and altruism/respect
domains on the 0 - 10 scale were 4.93 ± 2.4,
5.92 ± 1.85, 4.94 ± 3.39, and 4.35 ± 3.27,
respectively.
The mean score of professionalism was
significantly greater among residents in non-
surgical specialties than in surgical
specialties (5.64 ± 2.40 vs. 3.54 ± 1.62; P <
0.001). Moreover, female participants’ mean
score of professionalism was significantly
greater than their male counterparts (P =
0.006). However, there was no significant
relationship between the mean score of
professionalism and the other personal
characteristics of participants (P > 0.05;
Table 1).
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Table 1- The mean scores of professionalisms and its domains based on participants’ personal
characteristics
Professionalism
Characteristics
N (%)
Total
score
P-value Excellence P value
Honor/
Integrity
P value
Altruism
/
Respect
P value
Gender
Male
67
(47.97)
4.35±2.16
0.006
5.73±1.92
0.24
4.01±3.24
0.22
3.57±2.90
0.001*
Female
72
(52.03)
5.47±2.50 6.10±1.77 5.79±3.32 4.91±3.49
Marital status
Single
43
(31.08)
4.94±2.30
0.94
5.58±1.95
0.23
5.34±3.09
0.33
4.35±3.26
0.95*
Married
96
(68.92)
4.89±2.44 6.06±1.80 4.73±3.51 4.32±3.28
Specialty
Non-
surgical
91
(65.54)
5.64±2.43
<0.0001
5.93±1.97
0.96
5.81±3.48
>0.0001
5.37±3.26
0.0001*
Surgical
48
(34.46)
3.54±1.62 5.91±1.60 3.22±2.46 2.37±2.19
Academic year
First
46
(33.11)
4.91±2.62
0.42
5.51±1.84
0.13
4.85±3.34
0.28
4.60±3.4
0.27†
Second
33
(23.65)
5.48±2.40 5.83±1.83 5.86±3.38 5.05±3.32
Third
28
(20.27)
4.66±2.27 6.59±1.79 4.53±3.26 3.62±3.25
Fourth
32
(22.97)
4.59±2.17 5.92±1.85 4.39±3.55 3.91±2.96
Familiarity
with
professionalism
Yes
101
(72.97)
4.79±2.40
0.24
6.01±1.86
0.29
4.75±3.44
0.28
4.1±3.28
0.14*
No
38
(27.03)
5.31±2.38 5.67±1.83 5.45±3.25 5.03±3.16
Participation in
workshops
Yes
16
(11.49)
4.75±2.23
0.77
5.77±2.07
0.67
4.83±3.55
0.58
4.32±3.08
0.97#
No
123
(88.51)
4.95±2.43 5.94±1.83 4.99±3.38 4.36±3.29
Self-study on
professionalism
Yes
33
(23.65)
4.69±2.57
0.53
5.12±2.23
0.01
4.66±3.56
0.60
4.45±3.42
0.85*
No
106
(76.35)
5±2.36 6.17±1.66 5.02±3.35 4.32±3.24
Number of
learning hours
per week
50–60
47
(33.78)
4.87±2.51
0.38
5.86±1.79
0.16
4.91±3.45
0.79
4.28±3.33
0.68 ̂
61–70
33
(24.32)
4.73±2.14 5.30±2.23 4.49±3.17 3.76±3.08
71–80
25
(17.57)
5.29±2.61 6.52±1.94 5.20±3.64 4.65±3.63
81–90
9
(6.76)
6.15±2.05 6.82±1.45 6.22±2.96 5.73±2.87
> 90
25
(17.57)
4.89±2.45 5.99±1.19 4.70±3.60 4.38±3.31
*: The results of the independent-sample t-test; †: The results of the one-way analysis of variance; ^: The results of
the Kruskal-Wallis test; #: The results of the Mann-Whitney U test
Discussion
This study evaluated professionalism among
medical residents in Kashan University of
Medical Sciences, Kashan, Iran. The total
mean score of professionalism was 73.93 ±
36.01 on the 0 - 150 scale, and 4.93 ± 2.4 on
the 0 - 10 scale. A study on residents in
Tehran and Shahid Beheshti Universities of
Medical Sciences, Tehran, Iran, reported a
professionalism mean score of 6.12 ± 0.37,
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indicating moderate professionalism (2). All
these findings may demonstrate the
ineffectiveness of the interventions that have
been implemented for promotion of
professionalism in recent years.
Other studies on physical medicine and
rehabilitation residents throughout the
United States and Iran found that their mean
scores of professionalism were 7.7 and 7.67,
respectively (16, 17). The significantly
higher total professionalism scores in those
studies compared to the present study may
be due to the fact that they were conducted
on physical medicine and rehabilitation
residents who did not do night shifts and did
not attend the operating room, while samples
of the present study consisted of residents
from different specialties and different work
shifts.
Our findings also showed a significant
relationship between the type of specialty
and the total mean score of professionalism,
so that residents in non-surgical specialties
obtained significantly greater scores than
their counterparts in surgical specialties.
High occupational stress, emergency
situations, high frequency of night shifts,
lack of sleep, lack of adequate time for self-
study, and role multiplicity might have
contributed to the lower professionalism
mean score among residents in surgical
specialties. Further studies are needed to
determine the factors affecting
professionalism.
The mean scores of the excellence,
honor/integrity, and altruism/respect
domains of professionalism in the present
study were 5.92 ± 1.85, 4.94 ± 3.39, and
4.35 ± 3.27, respectively. Thus, the highest
and the lowest scores were related to the
excellence and the altruism/respect domains,
respectively. These findings indicate that
participants’ practice was better in terms of
prioritizing patients’ needs over their own
needs, attempting to broaden their
knowledge, and training junior residents
compared to their practice in terms of
respecting hospital regulations, saving
resources, and ensuring patients’
convenience. Further studies are needed to
provide reasons for such findings.
Our findings also showed that residents in
non-surgical specialties obtained
significantly greater professional scores than
those in surgical specialties (5.64 ± 2.40 vs.
3.54 ± 1.62; P < 0.001). However, we could
not find any study in this area for the
purpose of comparison. This finding may be
due to the fact that residents in surgical
specialties worked in the stressful
environment of operating rooms and needed
to make prompt clinical decisions in
emergency conditions.
Another finding of the present study was the
significantly greater professionalism mean
score among female participants compared
to their male counterparts. However, there
was no significant relationship between
professional mean score and the other
personal characteristics of participants.
Similarly, a former study indicated no
significant relationship between residents’
professionalism and their personal
characteristics (17).
Findings also indicated that around 73% of
the participants were familiar with the
concept of professionalism, and 24% had
had self-study about it. A study on medical
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students in Shiraz, Iran, showed that only
40% of them were familiar with the concept
(18), and another study reported that only
10% of the residents had had self-study in
this area (17). Personal attitudes towards
professionalism, self-study on the subject,
and participation in conferences and
workshops can affect residents’ perceptions
of their peers’ professionalism. In other
words, residents with greater knowledge
about professionalism more seriously expect
their peers to adhere to the principles of
professional practice and may therefore
score their peers’ professionalism more
strictly and cautiously. Similarly, our
findings showed that residents who were
familiar with the subject of professionalism,
had had self-study in this area, or had
participated in relevant workshops evaluated
their peers’ professionalism more poorly. Of
course, the difference was not statistically
significant.
Conclusion
Based on the results, the medical residents in
this study had a low level of
professionalism. The high score of the
excellence domain and the low score of the
honor/integrity and altruism/respect domain
denote that the residents had a better
condition in prioritization of the needs of
patients over their own interests, trying to be
scientifically updated, and improving
education quality compared to respecting
hospital laws, avoiding resource loss, and
paying attention to patients’ comfort in the
treatment procedures.
The findings showed that residents in non-
surgical specialties obtained significantly
greater professional scores than those in
surgical specialties. This may be due to the
fact that residents in surgical specialties
worked in the stressful environment of
operating rooms and needed to make prompt
clinical decisions in emergency conditions.
Recommendations
We evaluated the relationship between
professionalism and some personal
characteristics such as the type of specialty,
gender, and marital status. It is
recommended that future studies evaluate
the relationship between professionalism and
other factors such as patients’ conditions,
faculty-resident ratio, patient-resident ratio,
and workload. Moreover, we found that
despite having good role models, residents
believed that their peers had poor
professional conduct. Thus, studies are
needed to evaluate the reasons behind the
insignificant effects of role models on
residents’ professional conduct. Moreover,
only 11.5% of the participants had
participated in professionalism and
professional ethics workshops and courses;
thus, studies are needed to evaluate the
effects of such workshops on medical
residents’ professionalism.
Acknowledgements
This study was financially supported by the
National Center for Strategic Research in
Medical Education, Tehran, Iran (project
number: 960303), and the Research and
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Technology Administration of Kashan
University of Medical Sciences, Kashan,
Iran (project number: 94146). We would like
to extend our gratitude to these two centers
for their cooperation and support.
Conflict of Interests
All authors declare that they have no
significant competing interests that might
have influenced the performance of the work
or presentation of the article.
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15. Arnold L, Shue CK, Kalishman S, et al. Can there be a single system for peer assessment
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17. Ahadi T, Mianehsaz E, Raissi G, Moraveji SA, Sharifi V. Professionalism in residents of
physical medicine and rehabilitation in Iran. J Med Ethics Hist Med. 2015; 8: 3.
18. Askarian M, Ebrahimi Nia MJ, Sadeghipur F, Danaei M, Momeni M. Shiraz medical
students' perceptions of their colleagues' professional behavior. J Adv Med Educ Prof.
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