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Medical professionalism and assessment systems

Essay for the module of ‘Learning and Teaching for Adults’

Master of Arts in Clinical Education, Institute of Education, University of London

Module tutor: Dr. Tony Nasta; Essay supervisor: Dr. Norman Lucus


Current usage and limitation in assessment for medical professionalism in the UK

Akira Naito, Aug. 2008

(4893 words)

As much as or more than through the constraints of curriculum and syllabus,

the acquisition of legitimate culture and the legitimate relation to culture is

regulated by the customary law which is constituted in the jurisprudence of

examinations and which owes its main characteristics to the situation in

which it is formulated.

Pierre Bourdieu and Jean-Claude Passeron 1990; p.142

‘Society’ is increasingly viewed and treated as a ‘network’ rather than a

‘structure’: it is perceived and treated as a matrix of random connections

and disconnections and of an essentially infinite volume of possible


Zygmunt Bauman 2005; p.3

Medical professionalism and assessment systems


Assessment systems for medical professionals, in all aspects of knowledge, skills and

attitudes, have constantly been developing and revising their structure. The assessment

system in the workplace was recently introduced in the foundation years and individual

speciality training phases. Time period for the workplace assessment may soon extend to

include one’s entire professional lifetime. The forthcoming revalidation scheme is one

example. Assessment systems for both formative and summative purposes have increasingly

involved more in the attitudinal aspect, namely medical professionalism.

The General-Medical-Council (GMC) published the Tomorrow’s-Doctors [1993, and a revision

in 2003] and the Good-Medical-Practice [1995 and 2006] as guidelines for pre-registration

curricula and clinical practice, respectively. According to those documents, practical

governing organisations (e.g. the Royal Colleges and medical schools) have refined their

programmes. To define the attitudinal domain that should be the focus in the workplace, the

Royal-College-of-Physicians [2005] conducted a survey regarding medical professionalism,

and reported their agreed definition in the Doctors-in-society with results of their survey.

The present essay examines the contemporary concept of medical professionalism and its

assessment system in the UK to understand current values and expectations on medicine

and to investigate potentials and limitations of its assessments.

(194 words)
Medical professionalism and assessment systems


From its beginning in 1948, when the National-Health-Service (NHS) was established, the

healthcare system in the UK (including medical education and its curriculum) frequently

revises its structure. The introduction of the Modernising-Medical-Careers programme

[2005] was a recent example of this revision. The initial practical implementation process of

this programme was heavily criticised, leading to labelling it ‘disastrous’ because it left

thousands of junior doctors without careers. Subsequent adjustments (see the

recommendations made in the-Independent-Inquiry-into-Modernising-Medical-Careers

[Tooke et al., 2008] for details) have been made in the programme. However, the basic

underlying principles and goals of the re-structuring remain the same: that is, the creation of

a transparent unified and integrated curriculum that lasts throughout a clinician’s entire

career pathway from his/her undergraduate education [General-Medical-Council, 2003],

postgraduate training(s) [Postgraduate-Medical-Education-and-Training-Board, 2007; The-

Foundation-Programme, 2007], through a lifelong programme of continuous professional

development (including ongoing revalidation, re-licensing and re-certificating [Chambers et

al., 2008; Royal-College-of-General-Practitioners, 2008]). This trend of unification reflects a

proposal to integrate two governing educational bodies (i.e. the General-Medical-Council:

GMC and the Post-graduate-Medical-Education-and-Training-Board: PMETB) starting in 2010.

These revisions in the UK aim to improve medical education by integrating the educational

systems within the entire healthcare system in order to espouse public inquiries (the-NHS-

Next-Stage-Review [Darzi, 2007], for example) which reflect contemporary expectations, of

Medical professionalism and assessment systems

the public and also of doctors, on medicine as a healthcare profession. The aim of the

revisions also mirrors contestations against continually emerging socio-cultural and political

challenges associated with, and generated by, the ongoing advancements particularly in

medicine and technological science. These changes have resulted in altering the concepts of

knowledge and profession.

Concepts of knowledge and profession at the present era

Over the recent decades, socio-cultural and technological advancements have contributed to

the development of explicit detailed specialised knowledge and skills that have lead to a

number of specialities as individual professional bodies. At the same time, the

advancements have also enabled non-professional individuals to have an access to myriads

of explicit information, to which only professionals would traditionally have had access. As a

result, professionals act more as an ‘interpreter’ (or even a mediator) than a ‘legislator

[Bauman, 1987].’ Bauman explained this shift of social role by describing the work of the

profession as changing from serving their professional knowledge (by stating ‘what was the

case,’ and offering definitive judgement and prescriptions to the case) to offering their

professional insights into problems/conditions and professional support so that individuals

can judge and manage themselves with minimum help.

Medical professionalism and assessment systems

Together with this recent transformation, a professional individual may have become

categorised himself/herself as a non-professional in the other (but closely-related) areas of

specialities. Therefore, a capability and expertise of collaborative teamwork across multi-

and inter-disciplinary professional members, which could also include ‘non-professionals,’

becomes increasingly important to effectively practise any vocational work as a modern

professional. Thus, the relationship between (specialised) professionals, fellow (other)

professionals and non-professionals has become increasingly more democratic, and the

relationship has formed a hybrid partnership-oriented association whereby each team

member needs to take both his/her specific but shared responsibility [Fainzang, 2005]. In

this regard, the team for medical practice (in which healthcare team members share the goal

to attain the best patient-care and safety) may now include patients. This role of patient

means not only the Sir William Osler’s notion of the “patient is the best teacher” but it also

signifies the partnership as an active player in medical practice.

A team for an enterprise with this partnership-oriented relationships (especially of multi-

disciplinary members) can be viewed as ‘communities of practice [Wenger, 1998]’ where

every member shares goals and ‘culture [Bruner, 1996]’ by taking part in social interactions

with various other members. In this view, the process of negotiation and re-conciliations of

problems, which can sometimes comprise contradictions within team members, may be a

key activity leading to a new type of professional expertise labelled as the ‘knot-working

[Engeström, 2004]’:
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… a new generation of expertise … not based on ‘supreme and stable individual

knowledge and ability’ but on ‘the capacity to cross boundaries and to negotiate and

improvise “knots” of collaborations in meeting constantly changing challenges ...’


This ‘knot-working’ expertise may be supplemental to traditional expertise domains, which

focus mainly on specialised knowledge and skills. In this regard, Bernstein [1999] made a

distinction with labelling two types of discourses in (horizontal and vertical) knowledge

describing the new horizontal type as a form of knowledge that “… has a group of well-

known features: it is likely to be oral, local, context dependent and specific, tacit, multi-

layered, and contradictory across but not within contexts.” This can be differentiated from a

traditional vertical type of knowledge that “… takes the form of a coherent, explicit, and

systematically principled structure, hierarchically organised, as in the sciences, or … a series

of specialised languages with specialised modes of interrogation and specialised criteria for

the production and circulation of texts as in the social sciences and humanities [Bernstein,

1999; p.4].”

The current shifts in the relationships between professionals and clients/customers and in

the expanded view of expertise to include a horizontal discourse, together with an increased

number of specialities and an improved accessibility to specialised information, all

contribute to the changes in the concept of the profession, specifically professionalism. The

definition of professionalism, therefore, differs as a function of one’s perspective in view of

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each socio-cultural standpoint. Medical professionalism is not an exception, of course, but a

significant exemplar.

Medical professionalism in the UK

The General-Medical-Council (GMC), the regulating body which all clinicians must register in

order to practise medicine in the UK, published the Tomorrow’s-Doctor [1993, and a revision

in 2003] to provide a guideline of the principles of professionalism for pre-register medical

students and apprentices. More recently, the GMC published the Good-Medical-Practice

[1995, and a revision in 2006] to provide specific examples of medical professionalism in

individual situations. This Good-Medical-Practice [General-Medical-Council, 2006] guideline

is now utilised to help determine whether or not doctors act in a professional manner,

namely performance or health through fitness to practise procedures. At this point,

assessment systems (to be used throughout one’s clinical career from undergraduate

education to revalidation) that allow individual doctors to continue their registrations to the

GMC are now required to be consistent with the principles and values stated in the


The Royal-College-of-Physicians [2005] also recently conducted a research programme to

develop a definition of medical professionalism in the Doctors-in-society document. The

Working-Party of the Doctors-in-society, which consisted of representative members

Medical professionalism and assessment systems

nominated from both professional clinicians and non-professional citizens, agreed on the

statements of the Doctors-in-society, and provided a description of the need for a clear

definition of professionalism:

The practice of medicine is distinguished by the need for judgement in the face of

uncertainty. Doctors take responsibility for these judgements and their consequences. A

doctor’s up-to-date knowledge and skill provide the explicit scientific and often tacit

experiential basis for such judgements. But because so much of medicine’s

unpredictability calls for wisdom as well as technical ability, doctors are vulnerable to

the charge that their decisions are neither transparent nor accountable. In an age

where deference is dead and league tables are the norm, doctors must be clearer about

what they do, and how and why they do it. [p. xi]

The present essay investigates the contemporary concept of medical professionalism by

examining the Doctor-in-society [Royal-College-of-Physicians, 2005], Good-Medical-Practice

[General-Medical-Council, 2006] and the assessment instruments currently implemented in

the UK. The two primary questions that are addressed in this essay are:

(1) What is the professionalism in medicine at the present time? and

(2) What are the actual procedures currently in place to assess and develop professional

standards in relation to the defined professionalism?

In order to address the first question, the next section begins with a summary of the

Doctors-in-society document, in order to provide an overview of the current discourses

Medical professionalism and assessment systems

regarding medical professionalism. Next, this discourse is compared with the Good-Medical-

Practice guideline to develop a working definition and description of medical professionalism

in the UK. To address the second question, the essay then discusses contemporary concepts

of the assessment process, particularly with regards to competence-based assessment [Wolf,

1995] and in the context of the lifelong learning in post-compulsory education and training

[Boud and Falchikov, 2007; Ecclestone, 2005; Knight and Yorke, 2003]. Finally, the current

assessment systems used in the UK [Postgraduate-Medical-Education-and-Training-Board,

2007; The-Foundation-Programme, 2007] are analysed. As will be seen, this analysis

indicates that the modern notion of professionalism emphasises the aspect of mutually

interacting and socially constructed integrated network. This is in contrast to a generation

ago where authoritative definitions of professionalism might have been taken for granted.

Terminology of medical professionalism in the UK

Because the definition of medical professionalism varies as a function of context, any

discussion of this concept should begin with a working definition to specify what it means in

the current context. The Doctors-in-society document described the specific terms, that

would be used for their definition of the medical professionalism. Table 1 shows a list of all

of the words specified in the document that are labelled as the abandoned, restricted and

retained terms.
Medical professionalism and assessment systems


Table 1: Terminology for description of professionalism in the “Doctors in society”

Abandoned words Restricted words Retained words to use

Terms mastery, autonomy, competence, art, morality, excellence, judgement,

privilege, self-regulation, altruism, vocation, social- moral-contract, practice,
power, superiority, contract and appropriate- profession, knowledge,
control, independency accountability skills, science, society,
and personal-authority service, commitment and

The words of ‘mastery,’ ‘autonomy,’ ‘privilege’ and ‘self-regulation’ were abandoned due to

their ambiguous and potentially misleading connotations. The unfavourable connotations of

these are ‘control,’ ‘personal authority,’ ‘power,’ ‘superiority’ and ‘independency from the

patient and preponderance of medical evidence’ for example. These decisions, together with

the notions of ‘shared decision-making’ and ‘shared practice,’ is consistent with a shift in

focus from a paternalistic and therapeutic style in hierarchical relationships to a supporting

and empowering style in mutually respecting partnerships between healthcare-providers

and clients.

Also the traditional use of the terms ‘competence,’ ‘art’ and ‘social contract and morality’

was identified as potentially confusing and restricting. The term of ‘competence’ in modern

educational discourses often connotes a ‘minimum competency’ particularly for the purpose

of passing a mark of tick-box (pass-or-fail) criteria in a summative assessment [Wolf, 1995].

The ‘art’ and ‘social contract and morality’ may indicate to letting ambiguity in decision-

makings survive in doctor’s mind without an explicit explanation. These connotations may
Medical professionalism and assessment systems


signify a separation, between doctor(s) and patient(s) and even a separation between

doctors (that is, between one who is assessed and the other who assesses), rather than

teamwork with the shared aim and goal, namely for the public good. Thus, ‘excellence,’

‘judgement’ and ‘moral contract,’ respectively, were recommended to use as alternative

terms useful for reflecting current medical professionalism, since these terms better place

an emphasis more on mutual agreement [Royal-College-of-Physicians, 2005].

In contrast, the notions of ‘knowledge,’ ‘skills,’ ‘science,’ ‘practice,’ ‘profession,’ ‘society,’

‘service,’ ‘commitment’ and ‘integrity’ were retained as descriptors for professionalism

because they have less ambiguity and a neutral connotation with regards to equality and

dignity. The terms ‘vocation,’ ‘appropriate accountability’ and ‘altruism’ were also retained

but with some qualifications. The qualifications again emphasise the equal and co-operative

associations between doctor(s) and patient(s) as opposed to any connotations implying a

separated/dichotomised hierarchical relationship such as one in which doctors have a ‘God-

given status’ or a ‘managerial accountability’ and that a doctor should ‘sacrifice’ oneself

entirely for the profession of medicine, respectively [Table 1].

In summary, the terms applied in the Doctors-in-society document were selected for the

purposes of (1) decreasing ambiguity with particular connotations of hierarchical

(paternalistic) relationship, and (2) increasing an acknowledgement of equality (agreements)

and human dignity which is thought to enhance effective teamwork and a mutual respecting

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The working definition of the medical professionalism

The final definition of medical professionalism presented in the Doctors-in-society document

is: “… a set of values, behaviours and relationships that underpin the trust the public has in

doctor.” The specific descriptions of medical professionalism provided include:

In their day-to-day practice, doctors are committed to: integrity, compassion, altruism,

continuous improvement, excellence, working in partnership with members of the

wider healthcare team. These values, which underpin the science and practice of

medicine, form the basis for a moral contract between the medical profession and

society. Each party has a duty to work to strengthen the system of healthcare on which

our collective human dignity depends.

These statements have marked a shift towards mutual respecting partnerships in a day-to-

day practice between doctors, and other healthcare professionals, and also include patients

and their families as members of an integrated team. The specific implementation of the

concept of professionalism is made for two levels of operation [Royal-College-of-Physicians,


(1) Institutional level as a profession:

a. Partnership and mutual respect in patient-doctor interaction; and

Medical professionalism and assessment systems


b. Value and purpose of the profession in the context of a healthcare system.

(2) Individual level as a professional:

a. Respect and care for well-being and human dignity in patient; and

b. Compassion and continuous improvement in doctor.

In the institutional level of operation, the Doctors-in-society document identified six themes

where the concept has important implications: (1) leadership, (2) teams, (3) education, (4)

appraisal, (5) careers and (6) research [Royal-College-of-Physicians, 2005]. At the individual

level, the Good-Medical-Practice guideline lists seven areas of applications: (1) Good

professional practice, (2) Maintaining good medical practice, (3) Relationships with patients,

(4) Working with colleagues, (5) Teaching and training, (6) Probity, and (7) Health. A list of

specific duties associated with each principle serves as a practical guideline for

implementation, with a rationale that “… patients must be able to trust doctors with their

lives and health.” These principles and the associated rationale are consistent with the major

principle of the definition of the medical professionalism presented in the Doctors-in-society

document, which itself was the result of a nationwide survey and subsequent discussions.

For the purpose of this essay, the above definition and description of professionalism

provided in the Doctors-in-society document is used.

Medical professionalism and assessment systems


Assessment systems for the medical professionalism as a practical implementation

The assessment systems and instruments used in the workplace (both in individual and

institutional levels of operation) may have a significant influence on ultimate performance.

Consistent with this idea, Boud [1988] argued that “... assessment methods and

requirements probably have a greater influence on how and what students learn than any

other single factor [quoted by Pickford and Brown, 2006].” One of the explanations for this

influence comes from behavioural theory. Specifically, this theory argues that the

assessment process, including both preparative and implementing courses of action, can

provide external (and also introjected/internalised at times) motivation (whether with or

without intrinsic incentives) for change in behaviour. That is, results of the assessment

process can provide rewards (which increase specific behaviours) or punishers (which

decrease specific behaviours). This is also consistent with some network theories such as the

theories of ‘reciprocity [Kiyonari et al., 2000; Siegrist, 2005]’ and ‘indirect reciprocity [Nowak

and Sigmund, 2005].’ Hence, designing effective workplace based assessment systems

should be one of the key strategies to ensure effective and practical implementation of

medical professionalism.

For the implementation of medical professionalism in the UK, the primary goal has been

described as one that will serve “… to underpin the ‘trust’ the public has in doctors [Royal-

College-of-Physicians, 2005].” Although quantifying the degree of quality is recognised as a

difficult challenge [Epstein, 2007], the trust in individual level of operation can be said to

comprise three different practical domains of capabilities, namely knowledge, skills and
Medical professionalism and assessment systems


attitudes. The attitudinal facet further consists of (1) suitable manners and etiquettes as

explicit behaviours [Kahn, 2008] and (2) proper (value) judgement in each situation invisibly

nurtured and embedded in a culture of their communities of practice.

Professional standards for assessment of professionalism, in the institutional level of

operation, are described [Postgraduate-Medical-Education-and-Training-Board, 2008] as a

series of statements under the five headings:

(1) Planning:

(i) Curriculum purpose and development; (ii) Assessment system must be fit for

the purpose;

(2) Contents:

(iii) Content of the curriculum; (iv) Content of the assessment will be referenced to

all of the areas of the Good-Medical-Practice;

(3) Delivery:

(v) Managing curriculum implementation; (vi) Model of learning; (vii) Learning

experiences; (viii) Assessment system methods;

(4) Outcomes:
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(ix) Supervision of the trainee; (x) Role of the Assessor; (x-i) Assessment feedback;

(x-ii) Standards for classification of performance and/or competence; (x-iii)

Documentation will be standardised and accessible nationally;

(5) Review:

(x-iv) Curriculum review and updating; (x-v) Resources; (x-vi) Lay and patient

involvement; (x-vii) Equality and diversity.

Three of these five categories (designing contents, delivery of assessment system, and

utilising outcomes of assessment data) are particularly associated with a practical

implementation of the medical professionalism in a workplace-based assessment. Hence,

the following sections utilise these categories in order to investigate the potentials and

limitations of assessment for professionalism.

Designing contents for effective assessment systems in the workplace

Many aspects of assessment (including validity, reliability, feasibility, cost-efficiency,

acceptability, authenticity, manageability, consistency, transparency, fairness and

educational-impact) have been suggested as important to take into account in order to

maximise the efficacy of assessment instruments [Epstein, 2007; Pickford and Brown, 2006;

Swanwick and Chana, 2005]. One assessment instrument may be strong in one aspect but

weak in others, and these individual aspects can sometimes conflict with each other,
Medical professionalism and assessment systems


requiring appropriate balance and adequate levels of triangulation [Postgraduate-Medical-

Education-and-Training-Board, 2007]. One attempt to integrate those aspects is the creation

of the ‘utility index,’ which adopts what can be viewed as the six most important aspects

from the above list, and is calculated by the equation of: ‘utility index = educational-impact x

validity x reliability x cost-efficiency x acceptability x feasibility [Postgraduate-Medical-

Education-and-Training-Board, 2007; p.7-12. for further detailed descriptions].’ The

usefulness of this index, however, has yet to be determined.

Theoretically, the more tests and clearer the list of objectives in the measures, the better the

capabilities can be assessed. However, there needs also to be a balance ‘… between

aggregation and specificity [Wolf, 1995; p.73].’ Despite the clear benefit in terms of

transparency for both assessors and assessees, well-articulated outcomes can become

‘(minimum) competencies [Wolf, 1995]’ and may have a possibility to promote the ‘surface

learning’ rather than the ‘deep learning [Brown and Knight, 1994]’ in professional

development due to a large amount of workloads for the mere purpose of recording in their

assessment [Ecclestone, 2005]:

… the pressure of external targets can make teachers and students adopt a low-risk

approach, thereby minimising engagement in order to ‘get through’ the requirements.

In contrast to their aims of empowering learners, competence-based and outcome-

based models appear often to create a tedious paper chase as part of accumulating

evidence of achievement [p.59].

Medical professionalism and assessment systems


Using multi-methods and longitudinal assessment systems has been suggested as a way to

overcome the limitations and conflicts. Such methods can also avoid excessive burden to

assessees at one point in time [Epstein, 2007; Swanwick and Chana, 2005]. For example, the

use of a portfolio as a longitudinal learning record with multiple assessment data has been

introduced in medical education worldwide, although the efficacy of such a portfolio as

assessment for both formative (developmental) and summative (judgemental) purposes has

also yet to be studied and determined.

Formative and summative roles for delivery of assessment systems

Since 1970’s, a dominant trend in designing assessment systems, particularly for

postgraduate qualifications and workplace-based assessment, has shifted its focus

[Ecclestone, 2005] from systems that create norm-referencing examination data (for

summative purpose) to systems that develop ‘criterion-referencing’ or ‘competence-based’

data (for formative purpose) [Carless et al., 2006; Ecclestone, 2005; Kirkwood, 2007]. The

norm-referencing ranking systems basically attempt to compare learners in order to select

the better achievers who have relatively higher scores, while the criterion-referencing

systems aim to recognise areas of relative weakness in order to foster trainee’s ability and to

promote further development. This latter approach is based on the notion of ‘scaffolding’

based and developed on the concept of ‘zone of proximal development [Vygotsky and Cole,

Medical professionalism and assessment systems


It is the distance between the actual development level, determined by independent

problem solving, and the level of potential development, as determined through problem

solving under adult guidance or in collaboration with more able peers. … The zone of

proximal development defines those functions that have not yet matured but are in the

process of maturation, functions that will mature tomorrow but are currently in an

embryonic state [p.86].

The key component of the formative assessment, therefore, is to provide effective feedback

(or ‘feed-forward [Pickford and Brown, 2006: p.13]’) that can help the learner to have

scaffolds so that his/her independent, self-directed [Knowles, 1975], and ‘reflective [Schön,

1987]’ learning can be further promoted and enhanced.

In addition, the notions of ‘outcome-based’ and/or ‘performance-based’ assessment systems

have also been introduced to the concept of ‘competence-based’ assessment particularly in

workplace-based assessment systems because of their different connotations [Postgraduate-

Medical-Education-and-Training-Board, 2008]:

… [Assessment systems] may comprise different methods, and be implemented either

as national examinations, or as assessments in the workplace. The balance between

these two approaches principally relates to the relationship between competence and

performance. Competence (can do) is necessary but not sufficient for performance

(does do), and as trainees’ experience increases so performance-based assessment in

the workplace becomes more important [p.3].

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Workplace-based assessment of medical professionalism, therefore, should apply this

performance-based assessment system, and the following series of instruments have been

introduced in the UK [Postgraduate-Medical-Education-and-Training-Board, 2007; The-

Foundation-Programme, 2007] to achieve this goal:

 Direct observations using the ‘Direct-Observation-of-Procedural-Skills (DOPS)’ for

practical skill performances, ‘mini-clinical-evaluation-exercise (mini-CEX)’ for clinical

problem-solving manners, and ‘Case-Based-Discussion (CBD)’ for decision-making

and clinical reasoning procedures in the workplace context assessed by supervisors;

 ‘Multi-Source-Feedback (MSF)’ or the ‘360-degree’ assessments by peers, fellow

professionals (in other specialities), other members of team (co-medical

professionals), and patients, using:

o Mini-Peer-Assessment-Tool (mini-PAT),

o Team-Assessment-of-Behaviours (TAB); and

 ‘Portfolio’ which includes self-reflective log notes on one’s practice and on the

feedbacks of above assessment as a practical record of one’s own development.

For quality management and quality assurance purposes, two important considerations have

been suggested for applying these workplace-based assessment in practice, namely the

number of assessments regarding both (1) assessment time points and (2) assessors

performances [Postgraduate-Medical-Education-and-Training-Board, 2007]:

Medical professionalism and assessment systems


Extensive sampling for borderline trainees may be needed to precisely identify the

problems behind their difficulties so that a plan can be formed to find remedial

solutions where possible. The main value of workplace based assessments is that they

provide immediate feedback. The information acquired during a workplace based

assessment can also provide evidence of progression of a trainee and therefore

contribute evidence suitable for recording in their learning portfolio [p.21].

With regard to the aspect of assessors’ performance, the next section explores some specific

limitations as well as potential solutions for these limitations.

Interpretation of outcomes in the workplace and assessors’ performance

Various assessment systems have been developed on the basis of the fundamental

assumption of “… transparent ‘benchmark’ of the performance criteria [Wolf, 1995; p.24].”

This assumption often generates “… philosophical tension between what we know and can

express, and what we know but cannot express in words [Ecclestone, 2005; p.29].” The area

of this philosophical tension becomes the space where the ‘compensation’ would operate

[Wolf, 1995]:

... [Assessors] compensate, make allowances, interpret, and explain away. The more

experienced the assessor, the more they are operating in a familiar field, and the more

they have internalised a model of competence (which may or may not be the same as
Medical professionalism and assessment systems


other people’s), the more ‘active’ their judgemental aggregation becomes. … People

are often unaware of the degree to which they are operating in this way [p.71].

Those internalised and unaware models of competence may be heterogeneous and

distributed within all individuals in the communities of practice as parts of the whole culture

or as the ‘distributed cognition [Salomon, 1993]’:

There is no doubt that culture is patterned, but there is also no doubt that it is far from

uniform, because it is experienced in local, face-to-face interactions that are locally

constrained and, hence, heterogeneous with respect to both “culture as a whole” and

the parts of the entire cultural toolkit experienced by any given individual [p.15].

Any assessment procedures inevitably involve cultural adjustments to a certain degree:

… Assessors do not simply ‘match’ candidates’ behaviour to assessment instructions in

a mechanistic fashion. On the contrary: they operate in terms of an internalised,

holistic set of concepts about what an assessment ‘ought’ to show, and about how, and

how far, they can take account of the context of the performance, make allowances,

refer to other evidence about the candidate in deciding what they ‘really meant,’ and

so on. [Wolf, 1995; p.67]

This statement emphasises the importance of an implicit/unarticulated culture in order to

maintain a coherence/reliability within a community of practice by filling the gaps between

the content of instructions and the context of the performance. Wolf continued to argue
Medical professionalism and assessment systems


that this maintenance of coherence (or an increase of reliabilities) can be achieved by

keeping effective networks in the process of implementing the explicit rules in each real


The key requirements are exemplars and networks of assessors – plus a good deal of

realism about what can be claimed and achieved. … Different users read the same

exemplars differently: you cannot assume that the aspects which you consider ‘key’ will

be the ones which others identify and generalise from. … The finding underlines how

important and, potentially, how effective assessor networks are. They are, in fact, the

key element in ensuring consistency of judgement [ibid.; p.76-77].

This type of network activity, labelled as the ‘knot-working [Engeström, 2008]’ activity, often

emerges and evolves sporadically (in time and location) and informally within an

organisation or system. Although there may be a limit in articulation, a series of

considerations for measures has been suggested as a check-list to reduce the level of

heterogeneity in each local knot-working activity [Baker et al., 1994; quoted in Swanwick and

Chana, 2005]:

 Specification — of standards, criteria, and scoring guides;

 Calibration — of assessors and moderators;

 Moderation — of results, particularly those on the borderline;

 Training — of assessors, with retraining where necessary; and

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 Verification and audit — through quality assurance measures and the collection of

reliability data [p.465].

Specifically, the anchored rating scales (1: very poor, 2: poor, 3: fails to reach the required

standards, 4: fair, 5: good, to 6: excellent, for example) and the borderline methods for

grading in assessment systems (pass, borderline, and fail) were introduced to apply in the

current workplace-based assessment in order to decrease a possibility of inevitable

measurement-errors as well as to increase opportunities to provide assessees with a second

chance [Postgraduate-Medical-Education-and-Training-Board, 2007].

Summary and conclusions

This present essay has investigated and attempted to answer two questions:

(1) What is the current view of medical professionalism in the UK? and

(2) What are the procedures currently in place for assessing medical professionalism?

To address the first question, the modern concept of medical professionalism in the UK, was

discussed with respect to how key documents (the Doctors-in-society and Good-Medical-

Practice guidelines), and a working definition of medical professionalism was given as “… a

set of values, behaviours and relationships that underpin the trust the public has in doctors.”
Medical professionalism and assessment systems


Medical professionalism has increasingly emphasised a ‘mutual respecting partnership’

between doctors, other healthcare professionals, and patients and their families, with a

focus on human dignity. In other words, medical professionalism has increasingly

emphasised the concept of teamwork, particularly the ‘knot-working’ activity among multi-

disciplinary members that aims to attain public good, including the best patient care.

To address the second question, the essay reviewed current systems of assessment,

particularly workplace-based assessment systems. Assessment systems typically assess three

specific practical domains of capability at the individual level; namely knowledge, skills and

attitudes. The third domain, attitude, was suggested to be influenced by the culture of

institution. Therefore, a practical implementation of medical professionalism in the current

workplace-based assessment system was examined in the individual level, but the some of

the categories in the institutional level were also reviewed in relation to the individual level

of operation, specifically contents, delivery and outcomes.

For designing ‘contents’ and ‘delivery’ of assessment instruments, educational-impact,

validity, reliability, cost-efficiency, acceptability, and feasibility were highlighted to be

important to take into account, and use of combination of multi-methods and longitudinal

assessment systems, a learning portfolio for example, was introduced as a recommendation.

The importance of feedbacks in the performance-based assessment system was also

emphasised in the use of effective delivery of assessment system.

Medical professionalism and assessment systems


In interpreting the ‘outcomes’ of workplace based assessment, the influence of culture as

‘knot-working’ activity of assessors was signified as to minimise the effect of inevitable

measurement-errors. The anchored-rating-scales and the-borderline-method have been

introduced in many workplace-based assessment systems as potential methods to help to

enhance ‘knot-working’ so as to reduce the error.

These recommendations and potential solutions must be studied further to determine their

utility and efficacy. However, there appears to be a consistent message in current thinking.

Specifically, these attempts should be conducted by not separate individual professionals or

institutions, but by an integrated team of communities of practice including professionals,

fellow professionals, other professionals and the public/patients as a ‘society [Bauman,


‘Society’ is increasingly viewed and treated as a ‘network’ rather than a ‘structure’:

it is perceived and treated as a matrix of random connections and disconnections

and of an essentially infinite volume of possible permutations [p.3].

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The actual recommendations in the Doctors-in-society made to the governing organisations


(1) To strengthen clinical leadership and managerial skills as key competencies of

professional practice; and to create a national group to define the requirements for a

common forum, in order to speak out on behalf of medicine with a unified voice.

(2) To review how doctors can best be supported in their contributions to multi-

professional teams; and to explore ways of strengthening common learning to enable

better inter-professional education and training.

(3) To review selection procedures (to include lay members in the panels, for example)

to identify students with the potential to develop qualities of medical

professionalism; and to ensure time for professional engagement with students,

including raising managerial and organisational awareness.

(4) To review professional content of appraisal, with a view to incorporating professional

values as key components in evaluating a doctor’s performance and development.

(5) To establish a mechanism to examine how best to improve the management of

medical careers. The goal is to create career paths that meet the present and future

needs of patients, reflecting demographic changes in both society and medicine.

(6) To establish a forum as the funders to call for and consider research proposals into

how medical professionalism might best be studied as part of an overall goal to

improve health outcomes.