Have you ever experienced your doctor behaving unprofessionally? Perhaps you have felt uncomfortable, or worse, have questioned your safety? Did you wonder if doctors are taught how to behave professionally during their training?

Well, patient safety can indeed be threatened by the unprofessional behavior of physicians. Research has shown that this can be predicted by a physician’s behavior as a medical student. It’s no surprise then, that medical schools all over the world are increasingly paying attention to teaching and assessing professionalism.

Unfortunately, medical teachers often show a reluctance to fail students behaving unprofessionally, mainly because they do not know what to document or are afraid to be subjective, and therefore hesitate to take action. Professionalism guidelines describe what is expected regarding professional behavior, but do not always specifically describe what constitutes the unprofessional behavior of undergraduate medical students.

Professionalism guidelines describe what is expected regarding professional behavior, but do not always specifically describe what constitutes the unprofessional behavior of undergraduate medical students.

For example, an educational guideline could mention the importance of accountability, but does not make clear what would be the specific manifestation of a lack of accountability by a medical student. Although the General Medical Council has recently updated their guideline (previously known as ‘Tomorrow’s doctors’) to now indicate normative domains of concern, an overview of real-life behaviors that are actually seen by teachers and peer students at medical school, or in the hospital, did not yet exist.

My co-authors and I, all teachers in medical professionalism, are often consulted by colleagues who seek confirmation before denominating certain student behavior as unprofessional. We also notice that medical teachers often use indirect language while describing unprofessional behaviors in assessment forms such as: ‘professional attitude has to improve’ or ‘needs to read more’. Such remarks do not make clear what the teacher actually saw, and what aspect he/she thinks that the student must pay attention to.

Clear descriptors providing a common language for unprofessional behavior could offer teachers a tool for recognizing and denominating unprofessional behavior, and could support them in acknowledging it.

That’s why we set up a literature search to find descriptors of medical students’ unprofessional behaviors that were actually experienced by medical teachers or students themselves. Findings of this research project have recently been published in BMC Medical Education.

The 4 I’s of unprofessionalism

We compiled evidence from 46 research papers and found that medical students can behave unprofessionally in at least 205 different ways. We grouped these 205 descriptions into 30 descriptors, and organized them into 4 main themes. These four themes are indicated as The 4 I’s:

• Involvement (failure to engage: e.g. being late, poor initiative, avoiding patient contact),
• Integrity (dishonest behaviors: lying, fraud in exams, data falsification),
• Interaction (disrespectful behavior: discrimination, poor communication, lack of sensitivity to another person’s needs) and
• Insight (poor self-awareness: not accepting feedback, lack of awareness of another person’s needs, blaming external factors rather than one’s own inadequacies).

An early transparent discussion among teacher and student about the teacher’s observations can make medical students aware of their (often unintended) unprofessional behaviors.

Interestingly, the 4 I’s seemed to appear fairly consistently in research papers coming out of different continents: similar themes of concern exist globally. However, attention for them did not arise everywhere at the same time.

The temporal trend we found is that, around 1980, North-American researchers started studying unprofessional behavior of medical students, firstly emphasizing Integrity, followed by attention for Interaction and Involvement. From 2000 on, researchers in other parts of the world also started to investigate Integrity problems. Around 2000, North-American researchers moved forward to study Insight, quickly followed by their colleagues in Europe and Australia.

It will be interesting to see if a similar trend will arise in the rapidly growing body of literature on this topic coming from South America, Africa and Asia.

Medical teachers should care about their students’ unprofessional behavior. They should not be afraid to be subjective, but take action by openly discussing their observations with the student. The framework of The 4 I’s can help them, as it serves as a tool providing a common language for describing students’ unprofessional behavior.

An early transparent discussion among teacher and student about the teacher’s observations can make medical students aware of their (often unintended) unprofessional behaviors, and could inform teachers about underlying personal, interpersonal or institutional causes for the behavior. By discussing such behaviors, without blaming the student, but with the goal of offering help, teachers can contribute to the prevention of future professionalism lapses.

With this research article we hope to help medical students and teachers alike in creating a culture of professionalism in medical school, which is not only beneficial for the aspiring doctors, but ultimately for the safety of their future patients.