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Received: 29 July 2021 Revised: 9 December 2021 Accepted: 17 January 2022
DOI: 10.1111/medu.14735

RESEARCH ARTICLE
PROFESSIONALISM

Patients' perspectives on medical students' professionalism:

Blind spots and opportunities

Simon Haney1 | Paula Rowland1,2,4 | Shiphra Ginsburg1,3,4,5

1
Temerty Faculty of Medicine, University of
Toronto, Toronto, Ontario, Canada
2
Department of Occupational Science and
Occupational Medicine, Temerty Faculty of
Medicine, Toronto, Ontario, Canada
3
Department of Medicine, Temerty Faculty of
Medicine, Toronto, Ontario, Canada
4
Wilson Centre for Research in Education,
University of Toronto and University Health
Network, Toronto, Ontario, Canada
5
Mount Sinai Hospital, Toronto, Ontario,
Canada
Correspondence
Shiphra Ginsburg, Mount Sinai Hospital,
600 University Ave, Room 433, Toronto,
Ontario M5G 1X5, Canada.
Email: shiphra.ginsburg@utoronto.ca
Funding information
Temerty Faculty of Medicine, Department of
Medicine, Integrating Challenge Grant
Abstract
Background: Research has acknowledged the value of patients as essential stake-
holders in medical education, yet educators have not adequately incorporated
patients' perspectives into medical students' developing professionalism. Our
purpose was to explore patients' perceptions of professional behaviour in medical
students as a first step to considering patients' potential roles in assessing
professionalism.
Methods: Building on the existing framework of the ‘disavowed curriculum’, we used
a constructivist grounded theory approach to interview and analyse data from
19 patients (11 W, 8 M) at one urban hospital. Each participant watched five video
scenarios that depict professionally challenging situations commonly faced by medi-
cal students, after which they were asked to put themselves in the position of both
the patient and the student depicted in each scenario, and to discuss what they felt
would be appropriate or inappropriate behaviours from each perspective.
Results: Patients' responses replicated all elements of the disavowed curriculum,
including principles of professionalism, the student's affect or internal factors, and
potential implications of actions. Their responses reflected avowed, unavowed and
disavowed rationales. Participants also identified novel principles, including hide dis-
sension in the ranks, respect privacy, advocate for yourself and have trust in the sys-
tem. Patients conveyed an understanding of the multiple competing factors students
must balance (e.g., providing optimal care while maximising educational opportuni-
ties) and appeared to empathise with some of the pressures students face.
Conclusions: Our findings point to significant blind spots in previous research based
on faculty and student perspectives of professionalism. Knowing what patients per-
ceive as important will allow educational and assessment efforts to be refined to
reflect their values. Our work begins the process of understanding how best to
include patients in the assessment of medical learners.

1 | I N T RO DU CT I O N of complaints at regulatory bodies such as the College of Physicians

Professionalism in medical education remains a challenge. Despite an
1,2
abundance of teaching materials and curricula in medical schools,
ses in professionalism continue to be a persistent and frequent source
and Surgeons of Ontario.3 This suggests an ongoing need to address
how professionalism is approached in education. Often, the research
lap- and scholarship in education focuses on assessment, as it is a way of
explicitly formalising and documenting behavioural expectations.

© 2022 Association for the Study of Medical Education and John Wiley & Sons Ltd.

724 wileyonlinelibrary.com/journal/medu Med Educ. 2022;56:724–735.


HANEY ET AL.
The vast majority of research on the assessment of professional-
ism has been approached from the faculty's perspective,4–6 although
many studies have incorporated the views of other health care profes-
7–10
sionals or peers. Notably lacking is a robust body of research from
patients' perspectives. In 2010, an international working group on the
assessment of professionalism recommended that future research
should ‘develop and evaluate means of incorporating patients' per-
spectives into the assessment of professionalism.’6 These recommen-
dations were revisited in 2019 through a bibliometric study, which
found that while progress was made in some areas, such as an
increase in studies from linguistic and culturally diverse contexts,
research on patient perspectives of professionalism ‘remained largely
absent.’11
In non-education health care settings, several studies have
explored patients' perspectives of practicing physicians' professional-
ism. For example, some studies have asked patients to define profes-
sionalism7,12 or to describe, which aspects are most important.9,13,14
Yet few studies have looked within the education setting to under-
stand patients' views of professionalism in medical students and resi-
dents. One survey study involving parents of paediatric patients
reported that members of the public judge ‘unprofessionalism’ in
medical students harsher than doctors do, and recommend more puni-
tive sanctions, with the most lenient judges being medical students
themselves.15 This suggests that patients and the public may hold
medical students to higher standards than educators do. Given the
limited work involving patients' perspectives, this gap is important to
investigate. If patients understand professionalism in a way that is dif-
ferent from how it is understood, taught and assessed by insiders
(doctors, educators and learners), it may be one reason why profes-
sionalism complaints persist despite more and better education. This
is important during medical school as students' professionalism may
have meaningful impacts on current patients' care. Furthermore, the
habits that students form in medical school can have lasting effects
once they are in independent practice.16 Therefore, we need to better
understand the role that patients can play in students' developing
professionalism.
To achieve these goals, we purposely aimed to build on existing
research and knowledge focused on challenges to professionalism
that medical students commonly face. For this study, we drew on the
framework of the ‘disavowed curriculum’, first developed in 2003.17
Based on studies of medical students and faculty, researchers found
that in the face of a professional dilemma, individuals were motivated
to act by referencing a principle of professionalism, by their affect or
instincts, or by considering implications of their actions. Some of these
considerations were considered openly avowed, such as the principle
to provide comfort to patients. Others, such as the pressure to obey
or defer to one's supervisors, even if that is not desirable, are consid-
ered ‘unavowed’, because while they are not openly encouraged, they
are not discouraged either; they are often tacitly condoned. The third
category, disavowed, refers to motivations and actions which are
openly discouraged, such as a student being more concerned about
their evaluations than about what is best for a patient.17 This
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725
framework has been refined in studies of medical students and prac-
ticing physicians in multiple settings, yet it has never been used to
understand patients' perspectives.4,18,19
Our purpose was therefore to understand patients' perspectives
of medical students' professionalism, by building on the disavowed
curriculum framework. Specifically, we asked patients how they think
medical students should respond to standardised professional
dilemmas, to determine whether important gaps exist between what
medical students are traditionally taught and assessed on and what is
expected by patients.
2 | METHODS
2.1 | Design
Underpinned by a constructivist grounded theory (CGT) approach,20
we interviewed 20 patients to explore their responses to five previ-
ously developed video scenarios that depict medical learners in pro-
fessionally challenging situations. The video scenarios have been used
in studies with medical students in three countries and with faculty in
Canada.8,17–19,21 A brief overview of each video can be seen in Box 1.
CGT was employed as we wished to build on an existing framework
(the DC) that was developed using CGT, and to theorise new insights
where this was not a good fit. Additionally, a constructivist perspec-
tive was essential when working with patients to ensure any data or
new theory generated is co-constructed between participants and
researchers. CGT allows researchers to adopt a reflexive viewpoint to
their own values, life experiences, situations and relationship with
research participants and requires investigators to situate their
research in the social and historical conditions of its production.22,23
Box 1. A summary of the videos used in
interviews with patient participants. Source:
Ginsburg et al.17
Video 1:
A clinical clerk (senior medical student) is walking down the
hall with the attending surgeon, at the end of ward rounds.
She is telling the surgeon that the patient they are about to
see wants to know her test results. The patient is post–liver
transplant, and on a postop film they discovered a large lung
mass and no one has told her. Every day, the patient asks
about the results, and the student feels awkward not dis-
closing the information. The surgeon tells the student that
that is up to the other team (medicine) and not up to them,
as they are just responsible for the surgery and postop care.
The surgeon then gets paged away, and the student enters
the patient's room. The patient is in good spirits, and wants
to go home soon, but again asks for her test results.
Scene ends.
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726 HANEY ET AL.

Video 2: the room, turns to the resident, and in a friendly voice, says
A medical team is thrilled that they are done by 5 pm on a ‘Hmm—she must be pretty good for you to not even be
Friday afternoon, and they all decide to go out for drinks. scrubbed in!’ Then she asks the student: ‘How many of
The medical student arrives, and they invite him along, as these have you done before?’ Scene ends.
it's his last day. However, the student has not quite finished
his work—he has a patient that he's worried about, who has
high blood sugars and may need insulin over the weekend.
The resident tells the student that it's no big deal, it can wait
2.2 | Procedure
until Monday. When the student protests, the resident tells
him again not to worry, that there's an on-call team that can
After obtaining research ethics board approval, participants were rec-
deal with it, and then asks if he's coming for drinks.
ruited from the patient population of a large teaching hospital in
Scene ends.
Toronto, Canada, using poster advertisements. We excluded patients
Video 3:
who were not fluent in English and those who were themselves medi-
A medical student is about to go into a patient's room,
cal professionals. After providing informed consent, each participant
when an intern (PGY1) interrupts to tell her that they are
completed a 60–90-min semi-structured interview where they were
about to do a bone marrow in emergency, and that she
shown the five videos. The first Interview was conducted jointly by
should go see it. The student, frustrated, tells him she
two authors (S. G. and S. H.), following which the remainder were con-
cannot go and watch, because she promised to see one
ducted by S. H. alone. During the interviews, participants were asked
of her chronic patients, who ‘takes forever.’ She explains
to take on two different perspectives. First, we asked them to put
to him that this patient is quite demented, and although
themselves in the position of the patient and answer what they
he's been told every day that he's going to a nursing
thought the medical student(s) should do in each video, listing all
home, he forgets and keeps asking when he can go
acceptable actions and additionally to comment on what they
home. When he realizes he's being ‘placed,’ he gets very
thought a student should absolutely not do. Following this, participants
confused and angry, and then he cries. It takes a long
were asked to reconsider the situation if they were in the position of
time to calm him down, and it's distressing for the stu-
the medical student (and to again consider all possible, best, and unac-
dent to go through this with him every day. The intern
ceptable actions). Participants were asked to consider what factors
hints that ‘Well, if he doesn't remember anyway…’ but
may be at play in each scenario that might influence a student's behav-
then trails off and leaves. The scene ends with the stu-
iour. This was done to illuminate the extent to which participants could
dent entering the patient's room.
perceive the tensions and competing interests that the medical stu-
Video 4: dents were negotiating in the different contexts of each video. All
A group of medical students (male and female) are in a interviews were transcribed by a third party service and entered into
fertility clinic. The staff doctor enters with a male patient, NVivo for analysis.
and begins enthusiastically teaching them about infertility.
He asks the patient to undress, and although uncomfort-
able, he does. The doctor continues teaching, and asks 2.3 | Patient stakeholder engagement
one of the (female) students to come over and palpate
the genitalia. No one is wearing gloves, and no one has It is important to value the experiential knowledge of patients during
spoken to the patient, who is obviously uncomfortable. the research process.24 During the initial phase of design, a patient
After they are done with the exam, the doctor leaves advocate with a strong foundational understanding of research
with the patient, and says ‘I'll be back in a couple of methods was invited to help craft the interview guide. This individual
minutes with the next patient.’ Once they leave, the stu- was shown written descriptions of each video case and the interview
dents express their horror and discomfort with the situa- guide. Potential problem areas were noted, such as the use of medical
tion, but realize that he's coming back in a minute with a jargon that may not be understandable, as well as noting that in two
new patient. Scene ends. of the scenarios, there is no patient that appears (rather, patients are
Video 5: being discussed). This input proved invaluable as it allowed close mon-
A medical student and her resident are outside a patient's itoring of potentially problematic areas of the interview guide.
room, discussing the thoracentesis they are about to per-
form (the student's first), and he tells her they are pretty
easy if you know what you are doing. In the next scene, 2.4 | Analysis
they are all set to do the procedure—the patient is draped,
the student is gloved with needle in hand, and the resident Two approaches were used in parallel during analysis. We began cod-
is behind her. Just as the freezing is going in, a nurse enters ing deductively using the disavowed curriculum framework; at the
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HANEY ET AL. 727

same time, we inductively analysed and coded to capture what did TABLE 1 Participant demographics
not fit into the existing framework. Analysis began after the first inter- Gender
view was transcribed and continued in an iterative process through-
Female 11
out data collection. Deductive coding was conducted by SH with
Male 8
frequent checks by SG, in which we identified and coded all instances
Age category
of previously identified principles, affect and implications from the
0–17 1
disavowed curriculum. At the same time, we inductively coded each
18–34 8
transcript to identify concepts that were not represented in the exis-
ting framework, using principles of CGT. Analysis started with open 35–44 0

coding followed by axial coding to group codes into themes and look 45–54 4
25 55–64 2
for relationships between them, followed by selective coding. We
then selectively coded for newly identified concepts using a process ≥65 2
of constant comparison, in which we repeatedly went back to the Average age 37
transcripts as new codes were developed, compared and refined. As
Note: Age missing for two participants.
this process continued, similarities between annotated text emerged
and were refined into themes that were added as new nodes in
NVivo. Throughout the analysis, memos were created to serve as a discussion provided reassurance about the value of these scenarios as
record of our reflections as the coding progressed. We paused data a prompt, demonstrating the utility of these tools beyond the medical
collection initially after 12 interviews and discussed our coding with insider community for which they were originally designed. Our par-
the larger research team, following which we determined that we ticipants were also able to respond to the scenarios from the two per-
required several more interviews to achieve theoretical sufficiency.26 spectives asked of them: that of the patient and that of the student,
as indicated in the results below.

2.5 | Reflexivity
Throughout the entirety of the study, all members of the research
team remained reflexive of how their previous experiences as health
care professionals, researchers, students and educators could influ-
ence data collection and analysis processes. S. H. was a Master's stu-
dent at the time of data collection, with experience conducting face
to face surveys with patients at hospital discharge. P. R. is a social sci-
entist with expertise in qualitative research and an interest in patient
engagement programmes. S. G. is an education researcher and practic-
ing clinician, who teaches and assesses professionalism in medical
learners. The disavowed curriculum was developed by S. G. As analy-
sis progressed, we took care to not be constrained by the existing
framework and to remain open and vigilant in identifying new codes
and themes.
3 | RESULTS
3.1 | The framework
To organise our findings, we added new themes to the original
‘disavowed curriculum’ framework as outlined in the introduction (see
Figure 1). We coded text as a reference to principles (also sometimes
called imperatives) when a participant referred to an idealised or
abstract concept or apparent guideline when describing their
reason(s) for suggesting an action. Reference to affect was used to
code instances in which participants' emotions or feelings were identi-
fied as the motivating factor for proposing their actions. Text was
coded as a reference to implications if participants justified their deci-
sion by referring to the potential implications the proposed actions
would have on the people involved in the situation. The black boxes
in the figure represent the original framework, while the grey boxes
represent the newly identified themes from the current study
(Table 2).

Twenty patients completed interviews, but one was excluded after he
self-disclosed that he had undergone medical training. We enrolled
9 men and 11 women, with an average age of 37; 9 participants were
between 18 and 34 years old, and many were in University (See
Table 1 for details).
All five video scenarios were readily understood by patients and
were successful at sparking discussion. This was an important finding,
as the scenarios were created for a medical insider audience. Prior to
this study, it was not clear that scenarios scripted for a medical insider
community would have both salience and relevance beyond that
particular community. The ease with which participants engaged in
3.2 | Previously identified themes
Of note, our participants referred to all of the existing elements of the
original framework in discussing the scenarios, suggesting that they
considered a comparable range of rationales and motivations for action
as did previous groups of medical students and faculty. For example,
participants often made reference to the principle to ‘take care of
patients’ as they responded to the videos. One summed it up nicely by
stating that, ‘The medical student's first duty is to the patient.’
(P9) Similarly, participants recognised that medical students should pro-
vide comfort, behave with integrity and to know their limitations.

728
F I G U R E 1 The disavowed curriculum framework—expanded. The guiding framework, the disavowed curriculum,17 expanded to include
themes newly identified in transcripts from patient participants [Color figure can be viewed at wileyonlinelibrary.com]
Participants also recognised and referenced ‘unavowed’ principles such
as ‘do what you're told’, as seen in this quote from one patient, who
said that medical students ‘are not the lead in the team that's looking
after the patient. They're very much a subsidiary.’ (P17).
In addition to the avowed and unavowed, our participants also
recognised several disavowed motivations, such as students being
concerned about their evaluations and their futures. One participant,
for example, seemed to understand that a student may not wish to
speak up even if a supervisor did something wrong, noting that ‘… stu-
dents are afraid to say something just in case, like to jeopardize their
placement or whatever. I feel like a student would just be afraid to say
something…’ (P16). Another recognised the tensions that students
have to navigate, such as wanting to ‘maintain a good relationship
with anyone who's higher in the hierarchy than you are’ (P11) and not
wanting to be labelled as ‘a complainer’ by reporting other people's
behaviour (P19).
Further examples can be seen in Table 2.
3.3 | Newly identified themes
Our open coding and analysis identified four new themes that were
not previously reported: hide dissension in the ranks, respect privacy,
advocate for yourself and trust in the system. All new patient identi-
fied themes map on to the disavowed curriculum as principles/imper-
atives. The first two principles are directed at learners, while the latter
two are directed at fellow patients.
3.4 | Hide dissension in the ranks
Many of our participants referred to an idea or principle that patients
should not be aware of disagreements between their care providers.
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HANEY ET AL.
This includes disagreements about the plan of care being provided as
well as disagreements about the actions of colleagues. One example is
demonstrated by the following comment in response to Video 1, in
which test results have been withheld from a patient. The participant
is speaking as if they were the medical student in the scenario:
Well, I would not state to the patient what the doctor's
thoughts are …. I would not say that we have the
results but the doctor does not want us to disclose
them. Because the patient should not see any different
views between the students and the doctors. (P7)
Here, the participant is concerned that the patient might learn that
the medical student and her supervisor have differing opinions on
how to proceed with the patient's test results. Participants' sensitivity
to being aware of dissension also extended to witnessing disagree-
ments between care providers, as explained by one participant in
response to Video 4: ‘I wouldn't really argue with my superior because
I think it's not right, in front of the patient… for the patient's well-
being …’ (P16).
Disagreements between colleagues at the same level
(e.g., physician–physician) and at different levels (physician-student)
were both seen as undesirable—the outcome of either is that they can
plant seeds of doubt in patients regarding their care, as seen in the
following response to Video 4:
… if the medical student has to speak publicly like that,
it would convey the message that, ‘Oh, there's an argu-
ment between the two.’ And then… as the patient I
would think, ‘Oh, that means that there's different per-
spective on my health and so who should I believe
then?’ It would make me feel fearful in a way, ‘cause
then that means the healthcare providers… do not all

HANEY ET AL.
T A B L E 2 Themes derived from interviews with 19 patients in which participants watched 5 videotaped scenarios of medical students in
professionally challenging situations
Principle
theme Theme Description
Reference to previously identified principles
Avowed Provide appropriate clinical care Comments relating to medical care or
principles procedures.
Provide comfort and relieve patient Comments related to relieving a patient's
anxiety anxiety, providing comfort, or acting to
avoid worsening a patient's anxiety/
discomfort.
Disclose the truth Comments specifically about a patient's
right to know information (diagnosis,
who's doing a procedure, etc.).
Behave with integrity Comments relating to the principle of
honesty in general, for honesty's sake;
also integrity, keeping one's word.
Know your limitations Comments about being aware of your
level of knowledge and experience. Do
not go beyond the limits.
Report bad eggs Comments about the duty to report
offences/lapses.
Be efficient with resources Comments relating to a principle of using
resources, including other people,
efficiently. Also efficacy in the use of
one's own time.
Unavowed Obey Comments about obeying for the sake of
principles obeying.
Defer Comments relating to trust and a sense of
a supervisor's better judgement or
knowledge.
Step up to the plate Comments about filling any voids in care.
Taking responsibility for gaps or lapses
of others.
Know the system Comments about having an awareness of
the hierarchy. Understanding different
roles within the hierarchy and use
people for this purpose.
Get an education Comments relating to the principle of
getting a good education, including to
help future patients.
Disavowed Know when to fudge the truth Comments related to avoiding the truth
principles or fudging the truth; protecting oneself
or getting out of difficult situations.
Reference to newly identified principles
Avowed Respect privacy/be respectful Comments relating to respecting patients'
principles privacy and confidentiality.
Advocate for yourself—patient- Comments relating to patients voicing
directed imperative their concerns without being prompted
as well as comments about patients'
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729
Example quote
‘You cannot leave the patient without
insulin for a weekend. That's just not
right. I cannot think of another option,
actually.’
‘I think they should have asked the
patient if he was comfortable…‘
‘I'd want to know what stage of learning
she's at. So if she's in training at least
say that that's her status but there's
someone supervising the action she's
doing.’
‘I would probably go in to the patient
actually. That's what I would do
because I have made that commitment.’
‘That's going, I think, above and beyond
the responsibility of the medical
student.’
‘I just think… the protocol is followed…
But if it's not followed… The students
should report on the supervisor.’
‘I do not really think it has to be… the
medical student that goes and always
does the talking… it's not like any
medical information that's being passed
down to that patient.’
‘I would take the direction from the
supervisor. I think you have to do that.’
‘I would leave the decision of her
diagnosis to somebody who is higher
than me like an actual medical doctor.’
‘Is it something that I can let go once?
Yes, I can let it go once. Could I let it go
as a medical student twice? Never.’
‘I would probably see if there was
anybody else on-call that I could ask if
the doctors really intend on going out
and leaving right at that moment.’
‘… you should be trying your best to learn
as much as you can.’
‘As I've been talking… I think transparency
is always good. But I think, in this
situation, she should not have
answered…‘
‘… not talk so openly about the patient.
Anyone could have been overhearing
that…’
‘I mean I've seen people go from patient
to patient With not changing gloves,
that's an issue. You've got to call that
(Continues)
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730 HANEY ET AL.

TABLE 2 (Continued)

Principle
theme Theme Description
responsibility to self-advocate and the
barriers to doing that.
Trust in the system—patient-directed Comments about the trust patients put in
imperative the healthcare and medical education
systems.
Unavowed Hide dissension Comments relating to how patients
principles should not be aware of disagreements
between physicians and/or other
healthcare professionals.
Reference to affect
Affect, personality, inner feelings Comments about actions being
dependent on the type of person.
Comments about students acting on
their feelings in the moment.
Reference to implications
Implications for patients Comments about what might happen to a
patient if the student did/did not act.
Implications for students—external Comments about what might happen to
the student as a result of action/
inaction—including concern for grades,
evaluation, reputation, having the
resident still like them or teach them,
etc.; also includes social implications.
Implications for students—internal Comments about how the participants
thinks the students would feel as a
consequence of a particular action or
failure to act.
Implications for others Comments about what might happen to
others—including team, attending,
residents, etc.—if a student did/not act.
Example quote
out… I would call that out as the
patient.’
‘… when you are the patient, you are
trusting your doctor and you are hoping
that they are acting in your best
interest.’
‘The student questioning at that point
would not go down well in front of the
patient.’
If I was a medical student, given my
personality… I would make sure that I
really understood what to do…‘ … so I
guess it really depends on you as a
person', like if… you are comfortable to
just say, “Oh, I do not have a lot of
experience,”… or if you are the type of
person who cannot…’
‘… delivering the message to the patient
without the education around it… is
even worse than not telling the patient.
The wrong information is worse.’
‘… it's also [about] repercussions… if you
went ahead to say something, and… the
whole situation sort of unfolded and
exploded that way, would that get back
to the supervisor, and then you already
know that he did not want you to say
anything in the first place? That could
be an issue or a problem.’
‘But I have a feeling that if it was to me
and I was in that situation, I would not
be able to cope… Yeah. I would not be
able to walk away.’
‘It was totally inappropriate on her part to
do that… I would like you to speak to
her.’

go with the same answers so then who would I trust? I
would lose that trust that I'm supposed to develop in
that patient-doctor relationship. So if anything, the
two people should say it not in front of my face, so
that I do not feel that fear going on behind my head.
(P20).
3.5 | Be respectful/respect privacy
Participants repeatedly discussed the importance of respecting
patients' privacy and treating patients with respect, as demonstrated
in the following quote in which concerns are raised about conversa-
tions being overheard:

When patients are cognisant of a lack of consensus amongst their
care providers, they may lose confidence in the decision-making pro-
cess about their care. This doubt erodes and undermines the patient–
doctor relationship and illustrates the importance of minimising the
display of dissension.
I find that there is no privacy around conversations in a
hospital between doctors whether students or not you
can hear everybody's business. I think there needs to
be an acknowledgement of when you talk about
patients and who can hear you. (P2).

HANEY ET AL.
Participants also discussed issues relating to privacy by referring to
the principle of patient confidentiality and how important it is to main-
tain while providing care. In Video 3, in which the student and resident
are discussing a patient in the hallway, one participant stated that
‘[Students should have] training prior to going into the
clinic, because there's always patient confidentiality,
and other coworkers may not necessarily have the
right to know about a patient's condition,… so there's
the confidentiality aspect, which I feel is lacking in this
video.’ (P7).
In addition to discussing the importance of maintaining a patient's pri-
vacy, many participants also made comments about the importance of
being respectful towards patients and their families. Participants per-
ceived some depicted actions of care providers to be disrespectful.
For example, in Video 5, in which a nurse speaks to the student in
front of the patient, one participant said, ‘it's very inconsiderate of the
other person to talk above the patient as if that person wasn't there.’
(P17). Through the exploration of this theme it became evident that
while appropriate care is important, sometimes it is ‘even more impor-
tant… that you treat [the] patient with dignity and respect …’ (P19).
3.6 | Advocate for yourself
Several of our participants referred to a guiding principle that patients
must actively advocate for themselves. We included comments under
this theme if participants discussed a patient's responsibility to advo-
cate for themselves or if they noted barriers to patients speaking
up. Consider the following quote in response to video 4 and how the
participant described how they would act if they were the patient in
the fertility clinic:
… you'd ask the doctor or the supervisor in question
that the students leave or stay, depending on whether
you would consent to it or not… You should have been
consented beforehand, you'd ask why were you not
consented beforehand. (P12).
For this participant, it seems that patients should feel comfortable to
speak up and ask questions to advocate for themselves while they are
receiving care. A few participants felt even more strongly, expressing
that ‘… ultimately it comes down to the patient. They should ask
questions, should be responsible for their own health as far as
enquiring.’ (P15). This sentiment was echoed by another participant
who thought patients need to ‘Take control. It's your body, it's your
life. You need to know what's going on…‘ (Participant 13). Words like
‘should’ and ‘take control’ reflect a strong belief that patients should
not be passive recipients of care.
Some participants noted that speaking up relied on a shared
responsibility with health care providers, including medical students.
This suggests that participants' conceptualization of professionalism
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731
was not only about the behaviour of the health care professional
towards the patient, but also about the capacity of the health care
professional to create the conditions necessary for patients to be able
to speak up. Yet participants also noted barriers that sometimes
prevented patients from being able to advocate for themselves. For
example, not all patients may want or be able to challenge authority,
due to the power imbalance between patients and care providers, or
because they may not be aware that they can speak up due to their
unfamiliarity with the health care system:
‘… the patient should have said something but maybe,
because he felt submissive to the higher ups because
these people are the medical [educators] he might feel
like, ‘Oh, they know what they're doing so why should
I bother?’ (P20)
While P20 recognises that a patient may feel submissive and reluctant
to speak up, however, P2 voiced their belief that that should not mat-
ter, that ‘if the patient is feeling uncomfortable, the patient needs to
speak up for themselves. This is not a timid patient, this is not an
elderly patient and… they should know those rights and speak up …’
This belief that the patient should speak up, that it is their responsibil-
ity, was echoed by a different participant, who stated that in case of
an error,
‘… if a step was missed, the initial responsibility lies on
whoever missed that step. But if it's going to be
corrected, then the patient's going to have to do some-
thing about it.’ (P12).
While the theme of advocacy was relevant across our dataset of par-
ticipant responses, there was clearly a fair amount of diversity in their
responses and expectations about self-advocacy. While participants
disagreed on how self-advocacy might be pursued by the patient,
there was consistency in their opinions that health care professionals
should create the conditions for patient self-advocacy to be both
expressed and appropriately received.
3.7 | Trust in the system
The final theme refers to a guiding principle that patients should have
trust in the healthcare and medical education systems, and includes
comments about trusting a medical learner's level of training, the edu-
cational process, and the judgement of healthcare providers. This is
demonstrated in the following response to video 5, where the partici-
pant is sharing their thoughts on having a medical student perform a
procedure on them:
‘… at the same time, I think I would… deep down know
that she is a medical student and she obviously knows
a lot. She's practicing in a hospital… this is where all of
the doctors that get experience started out… I would

732
just let her do her job because I would sort of trust…
the supervisor…’ (P1).
This participant would be willing to be treated by a student because
she trusts the supervising physician. The concept of trust arose
repeatedly in the interviews, with many participants reflecting that
while they understand the role patients play in the training of learners,
they trust the education system to treat them safely and to not place
them in the hands of someone who is not competent.
‘Well, in a perfect world where no one has to train,
you would not want someone who's never done some-
thing before practicing on you, especially if they do not
disclose that they are in training… But as a patient, you
have to understand that the medical students have to
undergo training and they have to do it on humans.’
(P7).
Embedded within these comments relating to trust is the acknowledg-
ment by participants of the risk associated with having trainees learn-
ing on patients. In most instances, participants believed this risk is
properly managed and worth the reward of playing a role in preparing
future care providers:
… I would be forgiving and understand that, ‘Oh, the
student here is going to be the future medical care pro-
vider, so I understand that they need the experience
and the practical procedures in order to get to know
the environment and the procedures like that.’ (P20).
This was echoed by another participant who remarked that they
‘don't want a fourth-year student doing anything that they shouldn't
be doing. But I'm trusting the system…’ (P5). Some participants also
noted that the need to trust is essentially unavoidable, because of the
imbalance of knowledge and power between patients and providers:
There might be this imbalanced relationship because
the patient has so much trust and the doctor's so
knowledgeable… that whatever they say they cannot
argue because they just simply believe… And I would
too because they have so much past history, past
experience and studies to be where they are right now.
Their qualification says a lot, so I would not really
question it. (P20).
The above quote was also coded as a barrier to patients speaking up
and demonstrates the conflict that can occur between different prin-
ciples in the disavowed curriculum framework. Here, there is tension
between the two patient identified principles of ‘trust in the system’
and ‘advocate for yourself’. Participants trust the healthcare and med-
ical education systems to look out for their best interests while also
serving the interests of medical trainees by advancing their level of
training without compromising patient safety.
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HANEY ET AL.
4 | DI SCU SSION
The purpose of this study was to explore patients' perceptions of how
medical students should behave in the face of ‘professionally chal-
lenging situations.’ We also aimed to determine whether a gap exists
between what medical students are taught and assessed on and what
is expected by patients. We found that patients' responses to the
standardised scenarios replicated the themes previously reported in
the disavowed curriculum, which was generated based on student and
faculty data, suggesting these themes are important to patients. How-
ever, we also confirmed that our previous research had significant
blind spots, as seen by the novel themes patients identified in the cur-
rent study. This should serve as a reminder of the enormous value of
having patients engaged in medical education research, not just as
subjects but as co-producers.27
Of the ‘blind spots’ patients exposed, two (‘trust in the system’
and ‘advocate for yourself’) were, unexpectedly, imperatives directed
not at medical professionals but at fellow patients. While these imper-
atives were novel additions to the disavowed curriculum framework,
they link to other literature. For example, ‘trust in the system’ has par-
allels with the concept of ‘impersonal trust’, the idea that trust is not
established through an individual but through the profession the indi-
vidual is embedded in.28 The factors that influence the level of trust
patients have in their physicians is only partially understood,29 with
insufficient evidence to conclude what types of interventions might
increase trust.30 One potential explanation for this is a ceiling effect,
given that patients' trust in physicians is already high, although race
and socio-economic status have been shown to influence the level of
trust patients have in their healthcare professionals.31 Our findings
also suggest that patients' trust in the system is not absolute, and
indeed can be somewhat tenuous, subject to erosion by largely habit-
ual practices such as providing reports to professional colleagues
without consideration of patient presence during those conversations.
Practices of this nature have previously been identified by medical
students as ‘objectification of patients’, a common characteristic of
professional lapses students witness.32 Therefore, although trust in
physicians may be relatively high, it is easily eroded by students and
professionals and deserves further attention in medical school
curricula.
The theme that patients should advocate for themselves has res-
onance in the broader literature on patient self-advocacy. Concepts of
patient self-advocacy are complex and diverse, claiming roots in social
movement theories, social activism and anti-colonial practices.33 The
conceptual, social, and political complexity of patient self-advocacy is
beyond the scope of this paper. However, what is particularly inter-
esting in this study is the way patient self-advocacy is being posi-
tioned in relationship to concepts of professionalism. While advocacy
is included in constructs of professional work, frameworks such as
CanMEDS tend to focus on health professionals using ‘their expertise
and influence’ to work ‘with those they serve’ and to ‘speak on behalf
of others when required’.34 In this study, we see participants calling
not only for health professionals to speak on behalf of patients, but to
actively create and sustain the conditions for patients to speak for

HANEY ET AL.
themselves. These findings have implications for medical students'
developing professionalism. Not only should students develop capac-
ity as advocates, but they should recognise the difficulties inherent in
patients' capacity to self-advocate. These difficulties may be transient,
reflecting the complexities of variable trajectories of health and ill-
ness.35,36 However, they may be more deep set, reflecting entrenched
37
institutions that have systematically perpetuated power imbalances.
Further, to support patient self-advocacy requires a capacity for
critical reflection, recognising one's own actions may be inadvertently
creating the very conditions that promote silence.38 This expectation
that health care professionals and learners have a responsibility to
nurture patient self-advocacy is an elaboration on existing conceptual
models of professionalism, and deserves attention in medical
curricula.
Most of the newly identified themes in our data were categorised
as avowed principles in the disavowed curriculum framework, that is,
they are principles that align with values publicly stated by the profes-
sion. In contrast, the theme ‘hide dissension in the ranks’, is
unavowed, because it is not explicitly avowed that patients should not
be made aware of disagreements, although it seems to be tacitly
understood. Certainly, openly arguing in front of patients would be
seen as disrespectful and rude. But what about other, milder types of
disagreements, for example, those that may occur during teaching
rounds? During case presentations, for example, medical students
may be questioned or challenged about their interpretations and find-
ings, or team members may disagree about an approach to diagnosis.
One recent study found that bedside rounds that included case pre-
sentations in the room, in front of patients, were more likely to lead
to patient confusion than when presentations occurred outside the
room.39 In-room presentations were also more likely to avoid sensi-
tive topics, although they had other positive effects as well. Combined
with our findings, this suggests that the movement to be more
patient-centred by teaching at the bedside with patients may there-
fore have unintended consequences, both for patient care and for
professionalism. It may be difficult indeed for students to learn how
(and when) to engage in disagreements about patient care, especially
when attempting to advocate for a patient, without inadvertently
adding to patient anxiety.
This tension noted between otherwise equally important themes
is consistent with prior research.40 For example, the patient impera-
tives of ‘trust in the system’ and ‘advocate for yourself’ tell patients
that they need to speak up for themselves and take control of the sit-
uation while also trusting that the systems in place will look after
them. These types of tensions and conflicts were previously identified
in research on the disavowed curriculum, in which it was reported that
‘disclose the truth’ can often conflict with ‘know when to fudge the
truth’; and know when to ‘obey’ can conflict with ‘step up to the
plate’.4 In studies of medical and surgical faculty, these conflicts were
resolved in inconsistent ways and led to significant variability in how
students' actions were judged.4 The standardised dilemmas we used
were designed to have no one clear, right answer, so these tensions
were not unexpected and reinforce the critical importance of under-
standing the context surrounding professional dilemmas. Interpreting
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733
and judging the appropriateness of a behaviour depends on the
specifics of the particular situation, including the training level of the
individuals involved and the principles that are in tension.
Our participants' abilities to understand the student perspective
can be taken as evidence that patients may understand some of the
difficulties that come with being a student, and the tensions students
face in the clinical learning environment. This suggests that patients
may be able to consider and account for the pressures students face if
they were to be engaged to provide feedback or assessments. While
this could appear to challenge earlier findings by Brockbank et al.,
who reported that the public may actually be harsher than staff doc-
tors in their judgements of students' behaviours, there are key meth-
odologic differences that should be considered. In Brockbank's study,
researchers wrote scenarios depicting medical student misconduct,
which were deliberately written to represent ‘unambiguous contexts,
and not professionally challenging situations’. In our study, not only
were the situations deliberately challenging, with no obvious correct
response, we also did not provide participants with specific medical
student responses; that is, participants first hypothesised potential
responses by students and then judged them. It has yet to be seen if
these findings of understanding and potential leniency in patients'
judgements would translate to clinical practice. Further, it is important
to emphasise that while there may be benefits to patients understand-
ing the pressure that medical students are under, it is also a critical
reminder that patients can see the flaws in the medical education sys-
tem, as illustrated by their frequent references to the unavowed and
disavowed themes. This should remind educators that these elements
of the hidden and disavowed curriculum are not invisible and that
work is still required to address them.
While all decisions about this research study were made carefully
and reflexively, it is not without limitations. Participants were self-
selected from a large, urban hospital, with multiple factors influencing
ability to participate. They were required to have sufficient time to
participate as well as the ability to communicate fluently in English.
Our volunteers were also relatively young. These factors affect the
transferability of our findings to other settings. Further, many of our
participants were university educated, and may not reflect other,
more diverse populations in terms of their ability to understand the
scenarios as portrayed. While our study is necessarily limited, the find-
ings do identify potential blind spots in dominant models of profes-
sionalism and associated concepts of assessment. These findings
warrant further exploration. This study also relied on an existing
framework and a combination of inductive and deductive coding.
Even though a rigorous analytic process was used, other researchers
using different sensitising concepts may interpret the data in
other ways.
The implications of this research are useful for both medical edu-
cators and researchers. Educators should focus on teaching and rein-
forcing the themes patients identified in this study as blind spots in
the disavowed curriculum. This could include instruction on how to
minimise barriers to patient self-advocacy, how to communicate
respectfully and honour the trust patients place in the medical educa-
tion and care systems. Given the push towards multi-source feedback

734
and assessment, both for learners and practicing physicians, it is likely
that patients will become future contributors to the assessment of
professionalism. This will require educators to more fully understand
and consider patients' unique and varied perspectives of medical
students' professionalism.
Researchers should use these findings to further consider how to
best engage patients in teaching and assessing professionalism in
medical education. Research that aims to build on the disavowed cur-
riculum should focus on replicating results in differing yet specific
contexts, in order to enhance its relevance and utility for other
groups. Future studies that seek to incorporate patient perspectives
on constructs of professionalism should invite a wide range of patient
perspectives, recognising the historical, cultural, political, and personal
standpoints that influence interpretations of professionalism. Further
thought should also be given to what is meant by patient perspec-
tives, how those perspectives are represented, and by whom.41,42 This
programmatic approach to understanding patient perspectives can
help us reconfigure the way we think about equitable representation
in patient engagement programmes and help unlock ways in which
patients can be better engaged in shaping the teaching and assess-
ment of professionalism.
ACKNOWLEDGEMEN TS
We gratefully acknowledge Dr Ryan Brydges and Dr Ayelet Kuper
who both served on Simon Haney's MSc thesis committee and who
helped shape this project.
We also gratefully acknowledge our patient participants.
FUND ING
The study has been funded by the Temerty Faculty of Medicine,
Department of Medicine, Integrating Challenge Grant.
CONF LICT S OF INTE R ES T
We have no competing interests to declare.
E TH I CAL AP PR O V AL
Ethical approval for this study was granted by the REB committee,
University of Toronto.
AUTHOR CONTRIBUTIONS
S. H. made contributions to the conception or design of the work;
acquired, analysed and interpreted all data; drafted the paper and
critically revised it; gives final approval; and agrees to be accountable.
P. R. made contributions to the conception or design of the work;
analysed and interpreted all data; revised the paper critically; gives
final approval; and agrees to be accountable.
S. G. made contributions to the conception or design of the work;
analysed and interpreted all data; drafted the paper and critically
revised it; gives final approval; and agrees to be accountable.
ORCID
Paula Rowland https://orcid.org/0000-0001-8054-7142
Shiphra Ginsburg https://orcid.org/0000-0002-4595-6650
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How to cite this article: Haney S, Rowland P, Ginsburg S.
Patients' perspectives on medical students' professionalism:
Blind spots and opportunities. Med Educ. 2022;56(7):724-735.
doi:10.1111/medu.14735