Professional ethical competence for medical students : a qualitative study

Introduction: Regarding the great responsibility maintained by medical students, it is required to qualify ethical competence in addition to clinical competence. There is no consensus on professional ethics competence characteristics of medical students as this notion relies upon the context and may go under the influence of several cultural, religious, and social factors. Purpose: This research is conducted focusing on educators’ realization of professional ethics competence qualifications in medical students. Methodology: This is a qualitative study. In this regard, semi-structured in-depth interviews were conducted by 15 medical educators. Research data were analyzed using qualitative content analysis through Graneheim and Lundmen method. Findings: Data analysis showed three main classes: belief and respect for values, beneficence, and moral character (integrity, altruism and (self) discipline. Discussion and Conclusion: Professional ethics competence of medical students is not only defined by professional values, but also by respecting cultural and religious values and beliefs in community and patients. In addition, cooperation and teamwork, as well as Moral character are of characteristics of a medical student with ethical competence. Thus, it is recommended that medical curriculums focus on training professional values, enhancing teamwork, and moral character.


INTRODUCTION
Professional ethics is of critical issues in medical ethics domain.Compliance with professional ethics may offer abundant advantages for both doctors and patients and result in improved interaction with patients and colleagues (1,2) Though, professional ethics is generally accepted, it is characterized with a wide range of different definitions (3).The discord stems from three different frameworks of professional ethics including virtue oriented, conduct oriented, and professional identity, which has been recently interested (4) .Medical education not only leads to learning and technical skills, but also creates a new identity to the physician within education process distinguishing him from others as a physician.The identity contains different commitments to patients, colleagues, and even community.Various internal and external factors may contribute in generating the identity.Wilson et al. (2013) investigated the factors such as communities of practice, role model, and narrative reflection with curricula (5).Cruess et al. (2015) believe that medical educators play the role of supporter and advisor to form professional identity in students (6).On the other hand, gaining experience in different conditions is an important factor.Indeed, professional identity is a social and relational process, which requires helping students to successfully role model in the face of various conditions (7) .In this regard, in a study, sophomores were taken to a children camp.At the end of a week, students were convinced that consultations for patients largely influenced developing professional identity (8).
However, medical curricula often consider technical educations rather than ethical aspects.While, regarding medical students shouldered the great responsibility, it is critically required that ethical competence is obtained in addition to, and even more than, clinical competence.Since educating medical students largely contributes in developing and strengthening ethical competences in the current and prospective doctors, and regarding the significance of professional ethics, this issue still calls for more work in the area of medical education.In Iran, despite activities on the area of medical ethics, especially, several recent publications, professional ethics of medical students lack adequate literature.On the other side, as the issue of ethics competence depends upon the society and culture requiring entry into the experience world of participants; thus, the present paper indicates experimental results of qualitative studies conducted in Iranian context through exploring participants experiences.In addition, research data also present an indigenous image of professional ethics competence for medical students.

RESEARCH METHOD
The study is conducted through a qualitative research method.A qualitative study enables the researcher to gain insight into the internal experiences of participants and to find out how meanings are internally implied through culture.Therefore, 15 medical educators conducted an in-depth semi-structured interview.Research participants were medical educators with clinical work and teaching experience of Shahid Beheshti University of Medical Sciences in Tehran (10 individuals) and Qom (5 individuals).Duration of interviews varied from 25-45 minutes.
Research objective was initially explained to the participants and they were assured of collected data confidentiality; in addition, they were allowed to leave at any time of the study.Interview items include: how do you develop and enhance ethical features in medical students?What are ethical competence inclusion criteria for a medical students?Based on personal experience, what ethical aspects must be considered in educating medical students?Research data were analyzed using qualitative content analysis method through Graneheim and Lundmen approach (9).Therefore, semantic units were initially specified following interviews during analysis, scripting, and providing a proper text of participants' experiences.Next, codes were grouped and classified by a constant comparative analysis approach.Subclasses were placed in larger classes in terms of the relationships.Then, class common themes were abstracted and named through using thematic analysis.
For data strength, research results were examined using two qualitative researchers.Further, data credibility was also obtained by long-term relationship, data constant comparison, and participants' review.Data generalizability was also attained through describing field study and participants quotations.

RESULTS
Three main classes included belief and respect for values, beneficence, and professional manner.Belief and respect for values consists of secondary classes of cultural values recognition and observing dos and don'ts.Beneficence maintain subclasses of sincere service delivery to the patient/ client, and generous behavior with colleagues.And finally, moral character embraces secondary class of medical virtues.In the following, main and secondary classes, as well as subclasses are explained in detail: a.According to the participants experiences, belief and respect for community values are regarded as one of the essential characteristics of a medical student's ethical competence.Values composed of two secondary classes of religious values and observing dos and don'ts.Religious values are respected when a medical students first of all recognizes religious values; and secondly, believes in moral values.Then, observes necessary dos and don'ts to adhere the values.Recognition of values in Islamic culture forms life basics and objective; furthermore, it controls on human thought and activity.Respecting recognition of values, research attendees expressed that "value perspective, relating to the origin of universe, and viewing public servicing as excellence steps toward lord are professional ethics requirements".In addition to recognition, belief in values is also important to medical students.One of the participants said that, "the ideal human values prescribed by the religion are professional ethics prerequisites . . .if the individual believes in god supervision, he would often try to satisfy god".Devotion (commitment) and adhering value dos and don'ts are considerably regarded in religious values.The participants mentioned that the Muslim physician must avoid the illegal deeds.In this case, an educator remarked that, "abortion has been prohibited by Islam; otherwise, it is legally provided by law.Unfortunately, some students ignore this issue advising some patients for abortion."Another educator referred to the conducts forbidden by Islam, "students should devote to piety; in a better word, they are obliged to take care of themselves.For instance, not only alcoholic drinks are prohibited, but also negatively influence individual function and career future.Or in sexual matters, they are avoided of any relationships with clients.That is why Islam advises to get married and students should marry sooner".
b.According to the participants, sincere service delivery to the patient and generous behavior to colleagues in achieving ethics competence through beneficence are expressed in the following subclasses: Respecting patient reverence, a participant uncovered that, "respect for autonomy is one of critical principles of medical ethics.Adequate information provided to the patients for making clinical decision is of the respect elements." "Misusing patients to educate prospective physicians violates the patient's rights", another educator told "informed consent is necessary for any measures including visit or medical treatments.Importantly, no deception, reluctance or coercion is permitted." Respecting avoiding any injury to the patient, a participant added that "a medical students must be aware that the first step in medicine is not to cause damage.""Any physical, mental, and financial kind of injuries to the patient is avoided", another educator declared, "for instance, although, truth is regarded as code of ethics; the conditions for patient and companions must be regarded, too.In some cases, the issue is cautiously and gradually raised so that any mental harm is avoided."Patient privacy is another important factor visiting patients.One of the educators noted that "male physicians must be accompanied by female nurses and try minimal contact with female patients.On the other side, it is recommended that, for the sake of trust, physicians avoided visiting alone opposite genders."Respecting proper relationship, participants emphasized that, "the patient must be assured that he is being listened and redundant words are directed by medical art.The patient facial expressions and body language are also paid attention to."Or "physicians are not expected to hurt patient in words or crudeness."To achieve ethic competence, a medical students must approach to the fact that health care services are teamwork and generous conduct to colleagues is of professional ethics requirements.Regarding cooperation and collaboration with health care team, one participant indicated that "a medical students is obliged to cooperate with other health team members and avoids any unnecessary controversy."Similarly, another attendee also pointed out that "a medical students may ask for the aid of instructors in clinical work if needed without any embarrassment as patient care necessarily demands teamwork."Respecting medical students' accountability, a research attendee expressed that "educators always highlight that any misconduct threatening a patient health must be observed and revised", for instance, they have noted that "in the medical community, any drug addiction or mental difficulties must be immediately reported to himself or authorities to be corrected.They would be removed if misconduct continues."Another educator hints to cyberspace, "Students must be careful to avoid any Unprofessional behavior in cyberspace in relation to patient or colleagues.In addition, they must care for unethical websites."In term of respect for colleagues, one participant claimed that, "a friendly-working relationship is demanded; further, any backbiting and accusation is prohibited.""An individual who majors in medicine must be ethics oriented; in other word, one should treat others as one would like others to treat oneself", said by an educator.c.
To attain moral character, a medical students needs a virtues.the components and subclasses are as follows: Medical personality is closely affiliated to academic integrity.As stated by one of the attendees, "students must abstain from any cheating or copying during education years.""A physician must hold a comprehensive view to its patient considering all aspects and provide the required conditions to approach the person closer to the health as much as possible", propositioned by a research participant.Respecting honesty of medical students, one participant asserted that, "a medical student must follow medical standards and guidelines under educator supervision to get expertise."Educators in term of altruism have announced that, "students must always serve for the benefit of patient rather than higher revenues.Unfortunately, some physicians intend for unnecessary costly works."Students participating in charity Performance or freely visiting deprived regions may benefit stronger virtue of altruism", as an educator cited.A physician proper personality only emerges through discipline.As educators emphasized, "a student must be disciplined maximally enjoying the opportunities and trying to avoid any absence or delay" or "discipline is necessary for goal attainment as all tries may go astray lacking discipline."

DISCUSSION
According to the objective of the present research, which is explaining professional ethics competence in medical students, research results demonstrated that belief and respect for values, beneficence and moral character are of critical elements of professional ethics competence in medical students.Research findings are consistent with the results of other studies; however, there are some inconsistencies, too.Major studies have been carried out to present professional moral characteristics in physicians and medical students.
The research has emphasized on belief and respect for values in professional ethics competence of medical students.Community cultural values, belief in values, observing dos and don'ts certainly influence attaining ethics competence in medical students.It appears that admitting values of others is one of significant features of a medical ethically competent student as it makes the student to consider patients' different aspects and treat them not an object or thing.To lessen cultural differences, cultural competence is emphasized in curriculum as an international education approach (10).and some evaluation measurements have been planned .In this regard, it is suggested that some curriculum is designed so that prospective doctors are granted the required knowledge, attitude, and expertise to work with different cultures (11).
Participants of the present study have acknowledged respecting for patients religious values; regarding the religiosity of the majority of people in Iran, it is critically significant that Iranian medical students pay adequate attention to it.Ignoring or disrespecting patients values may cause public distrust to physicians and destroy sympathetic relationships between patient and doctor.
In this study, beneficence and sincere servicing have been determined as professional ethics competence requirements.Therefore, in addition to reverence and sincere servicing, beneficence and avoiding patient injury, proper interaction is of critical professional ethics characteristics.The first thing to do is to listen to the patient and to care for its emotions, which is known as empathy.Empathy significantly contributes in the relationship with patient and results in positive outcomes for both patient and medical practitioners (12) .In a similar study conducted on medical students, interpersonal communication skill was provided as the most important feature of a good physician followed by knowledge and expertise in the second and third ranks (13).Norcini et al. (2010) highlighted that the ability to properly communicate with patients, considering patient oriented treatments, as well as communication skills are of a good doctor criteria (14).Steiner-Hofbauer (2017), in a review study, uncovered that in the literature patients describing a good physician have mostly focused on communication skills; whereas, physicians have taken medical skills necessary for being a good practitioner (15).communication skills must be critically considered in medicine curricula to improve medicine professionalism (16).Since medical services are delivered as teamwork, medical services would be provided more effective and better if all team members are cooperatively collaborated.Research participants have also stressed on the significance of generous behavior to colleagues.Rogers and Ballantyne (2013) declared that medicine curriculum must move toward teamwork education.Care level improves by respect and cooperation and medical error level decreases (17).
Results of the current study reveal that medical students are accountable for individual behaviors and must be familiar with social responsibilities.Competence is a context-dependent notion; hence, medical educations are supposed to learn social responsibilities and accountability in the real world (17) Enjoying moral character may lead medical students to professional ethics competence.Carey et al, in a study in 2015, underlined that today medical education must direct toward character-based approaches (18).Majority of the research samples claimed that medical educators are committed to improve professional manner in the students and give proper feedbacks to the students about their conducts (19,20) .It may be stated that professional virtues and values rooted in virtue-oriented medical ethics, which is historically older than other ethical theories, discussing the characteristics of a good doctor.Pellegrino has accentuated on benevolence, empathy, honesty, courage, and truthfulness as medicine fundamental virtues (7) Other scholars including Beauchamp and Childress, in the book "Principles of biomedical ethics", referring significance of ethical virtues, mentioned to six moral virtues as the main medicine virtues as follows: the virtue of care, compassion, discernment, trustworthiness, integrity, and conscientious.However, medical disciplines may vary such that some virtues are necessary for some disciplines.For instance, in surgery, in addition to other virtues, courage, compassion, and tolerance are essential (19).Or four virtues of integrity, compassion, self-effacement, and self-sacrifice are Fundamental for medical students (7).
In the present study, three major virtues of integrity, altruism, and (self) discipline have been attained.Integrity is one of major virtues in medicine, which is ethical character requirement (3).Integrity implies constant observance of high behavioral standards and avoiding personal and professional codes violation emphasized in medical education (Shrank, 2004).Thus, it is necessary to adhere to the integrity both in the clinical practice and education.Academic integrity signifies copy and cheating prevention; however, it may be widely defined.In a qualitative study, students referred to other factors including being honest with oneself and others, fulfilling group work commitments, reporting ethical violations, and etc (21).Academic integrity as well as learning technical aspects of medicine along with honesty and no cheating cause sincere service delivery of graduated students and avoid patients injuries.Furthermore, the physician keeps away from any nonprofessional relationships.Adhering would result in a typical ethical commitment in the career and in an obligation to continue ethical practice.A morally obliged individual is not easily influenced by illegal environments; and is committed to ethical deeds even in the absence of no assessment.
Altruism is another significant factor, which has been interested in this study.It has been always a critical feature for medical practitioners (4).Although, recently expressed, altruism has been ignored in the current century; (22) it still significantly contributes in students motivations and improves the relationship with patients.According to a study, altruism may protect individuals from burnout (23).
A physician must try to be disciplined.Today, universities, in professional ethics guideline, highlight on the proper appearance of the medical students and practitioners.For instance, they are banned from wearing unpleasant dressing and unusual makeup (24).According to the findings of Del-Ben et al. (2013), it is observed that it is critically significant that students may attain self-control and professional manner, and internalize professional values for medical practitioners; further, it is necessarily required that medical students are internally motivated for learning and to be active and disciplined in the process of learning (25).In this study, issues of integrity, altruism and (self) discipline, which are Moral character requirements, may largely handle stress factors in prospective medical practitioners.
Regarding that the present research only enjoyed experiences of medical educators; thus, it is recommended that further studies are conducted interviewing medical students.

CONCLUSION
The present research findings contribute in developing a medical student into a professional individual.A medical students needs to first recognize cultural values to attain belief and respect for values.In addition, the student is expected to stick to clear beliefs, observe moral dos and don'ts, and particularly consider community religious values.A medical students must be pioneer in beneficence respect to the patient, and avoid any injury.Moreover, he should be devoted to cooperation-based generous behavior with colleagues.Hence, it is necessary that medical education curriculum largely focuses on teamwork and cooperation.
Moral character is ethics competence requirement.An honest, altruistic and disciplined individual would enjoy ethical manner.Thus, it is suggested that curriculum planners consider developing professional ethics competence in medical education curriculum.

Table 1 :
Codes, sub categories, and main categories of medical student's professional ethical competency