The "Pyramid of Professionalism": Seven years of experience with an integrated program of teaching, developing, and assessing professionalism among medical students

The authors report on an integrated program of teaching, developing, and assessing professionalism as well as managing unprofessional behavior referrals and supporting students through the Personal and Professional Development Committee (PPDC) in the four-year, graduate-entry medical program at the School of Medicine, University of Queensland, Australia.Two thousand six hundred thirty medical students have participated in the ethics and professional practice teaching program from 2000 to 2006. They were assessed through formal examination; students who did not satisfy requirements completed supplementary examinations. One student failed a year on the basis of formal examination. Instructors referred 507 students (19% of all enrolled) during the seven-year period to the PPDC, which interviewed 142 (25%; 5% of all enrolled) at least once; 25 of these more than once. In all, 711 reports were submitted to the PPDC, 420 (55%) for unsatisfactory attendance only and 291 (45%) for other concerns. Most of these (51%) related to "responsibility/reliability" and "participation" combined; 12% related to "honesty," "discrimination," and "doctor-patient relationship." The PPDC referred four students to the board of examiners, and two students failed a year for persistent unprofessional behavior.The authors established a Pyramid of Professionalism whose foundation is a formal curriculum of medical ethics, law, and professionalism. At higher levels, the pyramid mirrors Australia's medical regulatory processes, combining nonpunitive support with the possibility of sanctions, by mediating and sometimes remediating a range of notified concerns. Students who persist in behaving unprofessionally or in seriously unacceptable ways have failed academically on professionalism grounds.