Medical students’ unprofessional behavior and educators’ support

Article information

Korean J Med Educ. 2025;37(1):47-58

Publication date (electronic) : 2025 February 26

doi : https://doi.org/10.3946/kjme.2025.322

Department of Medical Education, Tokyo Medical University, Tokyo, Japan

Corresponding Author: Ryoko Igarashi (https://orcid.org/0000-0003-0593-7364) Department of Medical Education, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan Tel: +81.3.3342.6111 Fax: +81.3.5339.3785 email: igaryo@tokyo-med.ac.jp

Received 2024 July 12; Revised 2024 November 8; Accepted 2024 December 12.

Abstract

In recent years, professionalism education has been incorporated into medical education as an important part of the curriculum. Through receiving professionalism education, most medical students gradually acquire professionalism, including a professional attitude. However, some medical students demonstrate unprofessional behavior that raises concerns among faculty and other students. There are various stages to dealing with unprofessional behavior, as follows: definition, prevention, detection, evaluation, correction, and follow-up. However, it is often difficult to identify unprofessional behavior and respond appropriately. In this study, overview of medical students’ unprofessional behavior from previous studies on medical students’ unprofessionalism behavior, and how to identify and evaluate medical students’ unprofessional behavior, and effective education that can correct medical students’ unprofessional behavior was analyzed by reviewing 52 articles. Medical students’ unprofessional behavior is classified into the following four categories: “lack of involvement,” “lack of integrity,” “lack of interaction,” and “lack of introspection.” The occurrence of unprofessional behavior was found to be attributed to personal problems, interpersonal problems, external factors, and environmental factors. Educators analyzed unprofessional behavior and its causes from four categories. Medical students should perform reflective writing to help them reflect on their unprofessional behavior. Educators should use this reflective writing to interact with medical students, and to investigate and analyze the students’ unprofessional behavior. Furthermore, educators will need to assess unprofessional behavior using a roadmap to address unprofessionalism, and to respond appropriately to each stage of the roadmap. Individualized educational interventions should be provided to help students correct their unprofessional behavior.

Keywords: Educational support; Medical student; Professionalism; Unprofessional behavior

Introduction

Professionalism education is a fundamental and important aspect of medical education [1]. Professionalism has been defined as a set of moral norms, rules, and attitudes that are considered appropriate for a particular professional practice [2,3]. According to the definition Arnold and Stern [4], professionalism is based on a foundation of clinical competence in practice, communication skills, and ethical and legal understanding, which is built on excellence, humanism, accountability, and altruism.

Physician professionalism is critical important for performing high quality medical care. It is a fundamental absolute requirement that physicians behave in a professionally desirable manner, to protecting patient safety and improve the medical conditions of patients [5]. Professionalism is an important skill that medical students who will become doctors in the future must acquire. Teaching professionalism requires strategic education that ensures the development and mastery of the learners’ knowledge, attitudes, judgments, and skills [6]. Through receiving professionalism education, most medical students gradually acquire professionalism, including a professional attitude. However, some medical students display behaviors that raise concerns with faculty and other students, referred to as unprofessional behavior [7,8]. Teachers notice and observe unprofessional student behavior in up to 20% of all students, but only 3% to 5% of teachers will actually report it [9-11]. Possible reasons for this include a lack of conceptual clarity about unprofessional behavior in medical schools, educators’ concern about the subjectivity of their judgments, fear of damaging students’ reputations, and lack of appropriate faculty educational regarding interventions, and uncertainty about the tutoring process and its outcomes to improve unprofessional student behavior [12].

Unprofessional behavior among medical students began to receive attention in the United States in about 1980, and then spread to North America, Europe, Asia, and Australia from about 2000 onward [13]. It has been reported that students who are found to have unprofessional behavior are at a higher risk of receiving official disciplinary action associated with their medical license after becoming a doctor [9,14]. Papadakis et al. [9] reported that even among doctors who had not received any disciplinary action associated with their medical license, unprofessional behavior was observed in 19.2% of doctors during their student days. It is hence important that students acquire professionalism while they are still at medical school. In addition, teachers are required to identify students who behave unprofessionally, and provide appropriate education and guidance so that students can correct their unprofessional behavior.

There are stages to dealing with unprofessional behavior, as follows: definition, prevention, detection, evaluation, correction, and follow-up. However, it is difficult to define and determine unprofessional behavior, such as why the act occurred, and to respond in an appropriate manner [15,16].

Therefore, in this paper, an overview of medical students’ unprofessional behavior based on previous studies will be provided and what defines unprofessional behavior, as well as how unprofessional behavior can be accurately identified, assessed, and evaluated will be investigated.

The purpose of this study was to conduct a literature review on the reality of unprofessional behavior among medical students, and clarify effective education methods that enables students to correct their unprofessional behavior.

Methods

A literature search was conducted using a database. The method was carried out following the general technique advocated for medical education research [17,18]. PubMed, which includes most medical articles, was used as the database. The keywords “Medical student,” “Attitude Education,” “Professionalism,” “Unprofessionalism,” “Assessment of unprofessionalism,” “Re-education,” and “Educator response” were used in the search. The search was conducted for 23 years’ worth of articles, from 2000 to 2023. As a result, “Medical student” AND “Attitude education” AND “Unprofessionalism” were found in 602 articles. “Medical student” AND “Attitude education” AND “Unprofessionalism” in 87 articles, “Medical student” AND “Professionalism” AND “Unprofessionalism” in 236 articles, and “Medical student” AND “Assessment of unprofessionalism” in 106 articles. “Medical student” AND “Unprofessionalism” AND “Re-education” in 197 articles, “Medical students” AND “Unprofessionalism” AND “Educator response” in 53 articles, and“ Medical students” AND “Unprofessionalism” in 266 articles. In the end, duplicate articles were omitted and 52 articles that focused on the actual state of unprofessional behavior, factors behind unprofessional behavior, educators’ responses to students showing unprofessional behavior, evaluation of unprofessional students, and re-education were selected for analysis (Fig. 1).

Fig. 1.

Study Flowchart

Definition of unprofessional behavior

There are various definitions of medical professionalism, but its essence is that doctors should adhere to high ethical and moral standards to gain the trust of their patients. The concept of medical professionalism is based on both the nature of the profession and the nature of doctors’ work. The attributes of medical professionalism reflect societal expectations, as they are associated with the responsibility of doctors, not only to individual patients but also to the wider community [19]. As patients cannot evaluate the knowledge, skill, and virtue of the doctor, the doctor has an ethical responsibility to assure the patient of these, and the doctor has an internal and social responsibility not to betray the trust of people. In this sense, those who accept the responsibility of having their knowledge, skills, and humanity trusted by patients and society, and those who implement these are considered professional doctors and professional medical professionals [20].

Professionalism for medical students is therefore described as“ being fully aware of the doctor’s duties to be deeply involved in human life and to protect the health of patients, and to pursue a career as a doctor while practicing patient-centered medicine” in the medical education model curriculum. Professionalism is the values, attitudes, and behaviors expected of doctors. In particular, it emphasizes the ethical aspects of life and death, and the importance of taking a patient-centered position [21].

Therefore, unprofessional behaviors of medical students include acting, behaving, or speaking in an inappropriate manner. Lack of common sense and social and ethical issues are considered to be unprofessional. Furthermore, those who are not considered fit to become doctors in the future may be considered to be students with unprofessional behavior.

Characteristics of the unprofessional behavior of medical students

Mak-van der Vossen et al. [13] classified medical students’ unprofessional behavior into four categories. These four categories of unprofessional behavior of medical students were further classified as“ Lack of the 4 Is”: lack of involvement, lack of integrity, lack of interaction, and lack of introspection [16] (Fig. 2). The definitions of each are as follows: (1) Lack of involvement: tardiness or absence, noncompliance with deadlines, and so forth; (2) Lack of integrity: cheating, plagiarism, data fabrication, alteration, and so forth; (3) Lack of interaction: poor communication, inappropriate handling of social media personal information, and so forth; and (4) Lack of introspection: avoiding feedback, shifting responsibility, and so forth.

Fig. 2.

The 4 I’s of Unprofessional Behaviors in Medical Students

From Mak-van der Vossen M, et al. Med Teach. 2020;42(4):372-379 [16].

Unprofessional behavior is thought to be a result of personal problems, interpersonal problems, and external and environmental factors [7,22]. Furthermore, unprofessional behavior can affect classmates, teachers, medical teams, and patients [23].

Educators’ responses to unprofessional students

Educators have noticed unprofessional behavior in up to 20% of all students, but only 3% to 5% are actually reported [9-11]. This low rate of reporting reflects the difficulty of assessing professionalism [12]. Moreover, this also suggests that many educators will pretend not to see unprofessionalism. Possible reasons for this include lack of conceptual clarity regarding unprofessional behavior in medical schools, concern about the subjectivity of their judgments, fear of harming students’ reputations, lack of appropriate faculty education, and uncertainty regarding the corrective process and its outcomes.

Students may not realize that their own behavior is unprofessional [24]. When students are faced with situations that challenge their professionalism, they may not have the skills or attitudes to deal with them, or may not be in a situation that encourages or promotes professionalism. Therefore, it is important for educators to respond with this perspective. It is also important not to focus excessively on the individual who demonstrated unprofessional behavior. Educators should keep in mind that they should not label students as being unprofessional [25].

Evaluation to identify unprofessional students

Mak-van der Vossen et al. [26] created a roadmap for educators that addresses the lack of professionalism among medical students. They then presented an assessment of unprofessional behavior and how to respond to unprofessional students. The roadmap for handling unprofessionalism includes the following three phases: (1) Explore and understand, (2) Remediate, and (3) Gather evidence for dismissal [26].

1. Explore and understand

In the“ Explore and understand” phase, students who have performed unprofessional behavior have discussions with their educators. There are often complex and hidden factors underlying students’ unprofessional behavior, including personal attitudes, social norms, and interpersonal relationships. Therefore, educators need to utilize the“ theory of planned behavior” to identify and determine the factors that led to the unprofessional behavior, from their interactions with students, and understand the behavior more deeply [27]. In addition, there is the“ onion model” for analyzing student behavior (Fig. 3). This model is a multilevel professionalism framework, in which what happens on the outer level of the model is considered to affect the inner level, and vice versa [28]. What happens in the outer level of environment (work environment, personal family environment, physical and mental condition, and so forth) affects the inner levels, namely, behavior (observable behaviors), competency (general knowledge, skills, and attitudes), beliefs and values (beliefs and values of the ideal doctor image), identity (the identity formed upon thinking about oneself), and mission (the identity that one has formed), and vice versa.

Fig. 3.

The Multi-Level Professionalism Framework (Onion Model)

From Barnhoorn PC, et al. Med Teach. 2019;41(3):303-308 [28].

It is structured so that a step-by-step approach can be taken from the outer situation to the individual’s inner self. Educators can ask questions and analyze unprofessional behavior based on this model.

2. Remediate by individualized education

In this stage, if unprofessional behavior does not improve even after repeated discussion, and if serious unprofessional behavior is confirmed, individualized guidance based on the student’s situation is provided to prevent recurrence. The purpose of individualized education is to support students in reaching their academic goals through individualized methods, improve their knowledge of professionalism and interpersonal relationshipbuilding skills, and develop insights into the values of professionalism. The educational content consists of a curriculum involving the preparation of assignments, focusing on role models chosen by the learner, mentoring and coaching of individual learners, counseling, simulating situations that are challenging and require professionalism, and providing feedback [22,29-31]. It is important for educators to evaluate the effectiveness of individualized education re-education for learners, and to monitor their progress over time [31,32].

3. Gather evidence for dismissal

This stage is the phase to proceed to when there is no improvement in the student’s unprofessional behavior after taking the measures in stage 1 and stage 2. In addition, at this stage, in accordance with the rules and policies of the university, the collection of clear evidence of the student’s previous unprofessional behavior is required, to consider the student’s management (suspension/expulsion). It is important to carefully document the evaluation results and ensure transparency. To avoid conflicts of interest in the responsibility for final decisions, the responsibility should be transferred from the educators involved in the student’s re-education to a third party or committee within the university organization, for example, to the Professionalism Promotion Committee [33].

Need for medical educators to have academic knowledge and skills

It has been suggested that students’ unprofessional behavior may subsequently lead to more serious unprofessional behavior after becoming a doctor [9,14,34-37]. Moreover, lack of professionalism can also reduce the quality of patient care, and negatively affect the working environment and relationships within the workplace [38-40].

Addressing professionalism in medical education is an important issue. Kalet et al. [41] discussed that what constitutes unprofessional or un-doctor-like behavior should be part of the curriculum for educators to address.

Therefore, there is an urgent need for educators to take measures regarding how to address the issue of professionalism. Reflection is a form of professionalism education in medical education [42]. Reflective practice aims to raise awareness of professionalism and the development of a professional identity to become a doctor [42-44]. Reflective practice aims to raise awareness of professionalism and the development of a professional identity to become a doctor [42-44]. In particular, reflective writing is an educational intervention that focuses on the following three areas of professionalism: “professional responsibility,” “altruism, and responsibility to patients and society,” and “self-regulated learning about professional ethics and codes of conduct” [41,45]. Reflective writing is used as a learning tool to develop medical students’ reflective thinking and professional identity [46-48]. In other words, for medical students, writing is a process that enables reflection, to understand and make sense of their experiences. The process then leads to the development of reflective skills and insight [49].

Introspection through reflective writing is important for the students’ behavior repair process. The sharing and detailed exploration of what is written in the text between students and educators allows enable students to reflect on the written experiences [50]. In addition, discussion with students is important for educators to encourage the development of professionalism through students’ reflective practice [50,51]. When educators interact with students, it is necessary to combine them with the “10 questions to explore a student’s unprofessional behavior” proposed by Mak-van der Vossen et al. [16] (Table 1).

Table 1.

Ten Questions to Explore a Student’s Unprofessional Behavior

Educators can explore the meaning of what is written in the students’ reflective writing by interacting with the students. Allowing time for discussion can build trust between educators and students, and it is consistent with the student’s behavior remediation process. Students become more positive about sharing reflective writing with educators and receiving feedback from educators. In addition, students become more aware of their own strengths and shortcomings in professionalism [52]. Lucey and Souba [25] reported that discussion of unprofessional behavior between educators and students can effectively strengthen students’ professional identity formation.

Here are some specific educational examples using reflective writing.

1. Case 1

After completing clinical training in palliative care and hospice care, a medical student reflected on his interactions with patients and wrote some reflective writing. The students reflected, as follows.

“I felt emotional when the patient described the conversation in which she decided to stop all treatments and seek hospice care.” “I thought crying would be unprofessional or improper in some way.” “Prior to the palliative care experience, I had not given dying patients any thought.” “Having never really experienced a dying patient, I have actually been terrified about having to deal with one.” “The patient was still hoping for another doctor to come and fix him; it was difficult to listen to him. [because] the hope in his voice was unmistakable and heartbreaking.” “Being exposed for the first time to difficult, emotionally charged issues, I find it challenging to know exactly how to approach patients with the appropriate balance of compassion and respect while still exploring these issues.”

From the student’s reflective writing, teachers were able to recognize the student’s “fear of facing dying people, especially not knowing how to communicate well” and “empathy toward patients, and the student’s own biases toward patients.” Additionally, clinical training in palliative care medicine was found to be effective for enhancing introspection to enable self-awareness of students’ emotional responses to the clinical training experience. Teachers can use the information on what the students experience and learn during the clinical training, including the students’ internal emotional responses and self-transformation, to develop educational interventions that will help students to provide appropriate supportive care to patients receiving palliative care or hospice care. In addition, students’ experiences in clinical training in palliative care medicine are not only suitable for reflective practice and reflective writing, but also contribute towards efficient education in teaching professionalism [53].

2. Case 2

Third year medical student A’s attitude in clinical training was regarded as a problem. The student reflected on his attitude, as follows.

“I had been an excellent student in school, but medical school was very difficult and I lost a lot of my selfconfidence. Therefore, I was afraid to acknowledge my shortcomings, and became very defensive in my interactions with the teachers. I was also trying to hide my weaknesses.”

The teacher talked about how the purpose of clinical training was to learn what both patients and society as a whole expect from doctors, and how to achieve this through clinical training. The teacher and student discussed the situation of the student’s clinical training.

In the process, the student’s defensive attitude gradually decreased. The student began to understand the moral obligations of become a doctor, and to acknowledge his own shortcomings and weaknesses. The student became more open about his weaknesses, and more receptive to constructive opinions and feedback. The student accepted the teacher’s help in becoming a good doctor, and finished his clinical training, which had become a meaningful experience [41].

Coaching builds reflective skills among learners, and is the key to sustained behavior change and continued professional growth [50,54]. Kaslow et al. [51] proposed that “coaching and deliberate practice with feedback and monitoring are likely to be more effective strategies for addressing lapses in professionalism” [25]. These reports indicate that it is necessary for educators to use students’ reflective writing to understand and introspect on situations in which unprofessional behavior occurred, and to intervene educationally so that students can develop their insights [52].

In addition, educators are required to understand the situation of the students through the students’ reflective writing, and plan educational programs for individual students, to enable them to change their behavior. In other words, the role of the educator is to analyze the content of the reflective writing and integrate it with feedback and coaching to respond to students. Moreover, it is important for educators to use the students’ reflective writing and interaction with students to develop their own knowledge and skills to enable students to set individualized learning development goals that can lead to the correction of their unprofessional behavior, and to design ongoing educational intervention programs.

This means that it is important for educators to acquire a high level of academic knowledge and skills that enable them to identify and analyze, communicate, provide feedback, and coach on the factors that contribute to unprofessional behavior by appropriate educational interventions and roles. Therefore, we believe that it is necessary to establish a program development structure that enables medical educators to acquire the necessary knowledge and skills.

Discussion

Students are immature, and they are trying to obtain and acquire the qualities and abilities required as a doctor, while still in the process of growing up. Therefore, students often do not have a sufficient understanding of professionalism, which will lead to unprofessional behavior. Professionalism is the values, attitudes, and behaviors required of doctors. In particular, it emphasizes the ethical aspects of life and death, and the importance of taking a patient-centered stance. If unprofessional students fail to correct their behavior, when they become doctors in the future, it could affect patients, the medical team, multidisciplinary collaboration, and even their own career development. Therefore, it is very important to provide professionalism education from as early as the first year of medical school, and develop the competencies necessary for professionalism.

It is also urgently necessary to establish a system to visualize unprofessional behavior. When educators notice unprofessional behavior in students, they should not turn a blind eye to it, and they should listen to what the student has to say about why they acted that way, and to determine the factors that contribute to their behavior from the content of the conversation.

In addition, educators should have students with unprofessional behavior perform reflective writing, so they can reflect on their own behavior. Educators can then integrate the content of the discussions with the student and the reflective writing to analyze factors contributing to the student’s unprofessional behavior, using the four categories of medical students’ unprofessional behavior proposed by Mak-van der Vossen et al. [13,16]. Then, educators are required to use the roadmap to address medical student unprofessionalism developed by Mak-van der Vossen et al. [26] to assess the unprofessional behavior, decide on how to handle the unprofessional student, and provide feedback to the student.

Therefore, educators need to provide individualized responses, education, and guidance to help students with unprofessional behavior understand professionalism and correct their own behavior. It is hence important that educators acquire the academic knowledge and high levels of skills (communication, feedback, coaching, and monitoring) to properly identify and analyze the factors that contribute to unprofessional behavior.

Educators should help students to deepen their learning and grow, so that by the time the students graduate from medical school, they will have acquired the skills necessary for professionalism, be able to respond to the demands of society, medical care, and patients, and become trusted doctors.

Conclusion

It is important for educators to identify and analyze the unprofessional behavior of students, and provide individualized responses and educational interventions to help students correct their unprofessional behavior. Furthermore, educators need to incorporate professionalism education into the curriculum so that students can acquire the necessary competencies for professionalism and form their professional identities by the time they graduate from medical school.

Notes

Acknowledgements

None.

Funding

No financial support was received for this study.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Author contributions

All work was done by Ryoko Igarashi.

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To be explored	Question
1. Student’s perspective about the facts	What happened?
2. Alignment with assessment outcome	Do you agree with the unprofessional behavior judgment?
3. Intentions	What did you intend to do?
4. Beliefs	What did you expect to happen?
5. Context	What circumstances influenced your behavior?
6. Power	Were you able to influence the circumstances?
7. Effect on others	What do you think your behavior did to others?
8. Emotions	How do you feel about it now?
9. Causes	Are there any circumstances that make it more difficult for you than for other students to comply with the professionalism expectations?
10. Plans	How would you act in a similar situation next time?