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INTRODUCTION
The concept of medical professionalism remains in constant development, without a universally accepted definition1. Understanding the phenomenon is fundamental for reaching the goals in medical education2. The parameters used for its construction are diverse and comprehensive, considering different societies and cultures. In 2020, a systematic review93) portrayed the definitions already used for medical professionalism, including the domains of clinical competence, understood as the ability for clinical reasoning and communication skills, humanistic qualities, or virtues such as altruism, and reflective capacity to self-evaluate in search of improvement. These domains derived important elements in the structuring of professionalism throughout undergraduate courses, ranging from training in interpersonal relationships, the performance of skills and work management, and reflection on the role of individual and collective medicine3.
Medical professionalism has been considered according to three major topics: interpersonal professionalism, public professionalism, and intrapersonal professionalism4. Professionalism is related to the building of the professional identity from the initial years of undergraduate medical education. Therefore, efforts must be made towards the use of tools, considering students’ training to achieve better ethical standards and medical curriculum improvement.
From this perspective, educators need tobroadentheir understanding of the hidden and formal curricula, addressing institutional barriers, and enhancing their understanding of professionalism3. Assessing professionalism represents a challenge for medical educators given the nature of its construct, which comprises diverse values, beliefs, and principles. Therefore, the importance of well-defined instruments to measure this competence.
Developed by a group of researchers from the College of Medicine of the State University of Pennsylvania, the Penn State College of Medicine (PSCOM) Professionalism Questionnaire5 is a self-applied instrument to measure attitudes about medical professionals, being the first valid and reliable tool that evaluated medical students’ perception of professionalism5,7. Its purpose is to assist in advancing medical education’s efforts to enhance professionalism at all levels, as it aims to diagnose the institutional curriculum5.
The questionnaire includes the conception of professionalism defined by the American Board of Internal Medicine (ABIM)6: altruism, accountability, excellence, duty, honor and integrity, and respect for others. The PSCOM Professionalism Questionnaire5 obtained an internal consistency value that ranged from 0.71 to 0.78, except for the Respect domain (0.51).
The PSCOM Professionalism Questionnaire was validated for Colombia7, Pakistan8 and Turkey9. To the best of our knowledge, the PSCOM Professionalism Questionnaire has not yet been validated in Brazil. The validation of the questionnaire would provide a tool to assess attitude changes during undergraduate medical education5. Translating, adapting, and validating existing scales allow the comparison of professionalism with other countries10. This study aimed to translate into Brazilian Portuguese and to validate the PSCOM Professionalism Questionnaire.
METHODS
A validation study was conducted using the PSCOM Professionalism Questionnaire in medical students. This study was conducted at a private school of medicine in Salvador, state of Bahia, Brazil. Students regularly enrolled in the Ethics and Bioethics disciplines were invited to participate in the study, given the importance of the professionalism topic in this curricular component. Of the 300 enrolled students, 249 accepted to participate in this study and signed the informed consent form.
Instrument
The PSCOM Professionalism Questionnaire was originally developed and validated by Blackall et al.5 It is a scale consisting of 36 items, distributed in seven domains: Accountability (7 items), Enrichment (6 items), Equity (4 items), Honor and integrity (8 items), Altruism (3 items), Duty (6 items), and Respect (2 items). The answers to each item are offered using a five-point Likert scale (1=never, 2=little, 3=some, 4=much, and 5=great deal).
Translation of the scale
The PSCOM Professionalism Questionnaire was translated from the original English version into Brazilian Portuguese by two independent researchers, fluent in English. Then, a third researcher, also fluent in English, synthesized the two versions. The three translators created a single consensual version. The back-translation into English was carried out by a native English speaker. The original and back-translated versions were compared by a second native English speaker, who evaluated the preservation of the content. For content validation, the final version of the translation was evaluated by an expert panel11. Ten judges, all with experience in the field of medical professionalism, participated in this validation stage. The expert committee individually analyzed the items and the overall aspects of the questionnaire. Based on the judges’ considerations, adjustments were made to the instrument.
Psychometric properties testing in the target population
This stage was conducted at a private medical school in Salvador, Bahia, Brazil. First-year students who were enrolled in the course were invited to participate in the study. Of the 300 enrolled students, 249 accepted to participate in the study and signed the Informed Consent Form.
Statistical analysis procedures
The evaluation of the psychometric properties of the PSCOM Professionalism Questionnaire was performed by exploratory factor analysis, using the FACTOR v10.10.01 software. The analysis was implemented using a polychoric matrix and the Robust Diagonally Weighted Least Squares (RDWLS) extraction method12. Initially, Kayser-Meyer-Olkin (KMO) tests were used, with values above 0.500 being accepted, and Bartlett’s test of sphericity, with values of p <0.05 being accepted. To define the number of factors to be retained, a Parallel Analysis was performed with random exchange of the observed data13 and Robust Promin rotation14. Then, the factorial loads were analyzed, adopting the following criteria as desirable: loads greater than 0.30 and absence of factorial ambiguities (that is, factorial loads close to more than one factor)11),(15.
To analyze the reliability of the scale, the indices of composite reliability were calculated, with values above 0.70 being considered satisfactory16. The adequacy of the model was assessed using the Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) adjustment indexes. RMSEA values must be less than 0.08, and CFI and TLI values must be above 0.90, or preferably, 0.9517. This study was approved by the Research Ethics Committee of the Bahiana School of Medicine and Public Health, under opinion numbers: 3,562,569 and CAEE: 17608219.3.0000.5544.
RESULTS
Table 1 depicts the original items of the scale and their respective translated versions, after the back-translation and content validation process. The final version was answered by 249 of the 300 students regularly enrolled in the Ethics and Bioethics disciplines.
Table 1 The PSCOM Professionalism Questionnaire items and their respective versions translated into Portuguese.
| Original text in English | Translation into Portuguese |
|---|---|
| Works collaboratively and respectfully within a team to the benefit of improved patient care or to the contribution of research | Trabalha de forma colaborativa e respeitosa dentro de uma equipe em benefício de um melhor atendimento ao paciente ou à contribuição de pesquisa |
| Recognizes one’s own limitations | Reconhece as próprias limitações |
| Demonstrates adaptability in responding to changing needs and priorities | Demonstra flexibilidade em resposta às necessidades de mudança e prioridades |
| Commits to implement cost-effective patient care | Compromete-se a implementar um cuidado custo-efetivo ao paciente |
| Assumes leadership in patient management | Assume a liderança no manejo de pacientes |
| Participates in activities aimed at attaining excellence in patient care | Participa de atividades que visam alcançar excelência no cuidado ao paciente |
| Responds to constructive criticism by working to improve one’s capability in the area criticized | Responde a críticas construtivas, trabalhando para melhorar a capacidade na área criticada |
| Shows a willingness to initiate and offer assistance toward a colleague’s professional and personal development | Demonstra disposição para iniciar e oferecer assistência em favor do desenvolvimento profissional e pessoal de um(a) colega |
| Takes time to review other colleagues’ work and provides meaningful and constructive comments to improve it | Disponibiliza tempo para revisar o trabalho de colegas e oferece comentários significativos e construtivos a fim de melhorá-lo |
| Attends faculty meetings, seminars, and student research presentations as a reflection of support | Participa de reuniões do corpo docente, seminários e apresentações de pesquisas de alunos como formas de apoio |
| Seeks self-improvement | Busca o autoaperfeiçoamento |
| Promotes the welfare and development of junior faculty | Promove o bem-estar e desenvolvimento de membros iniciantes do corpo docente |
| Meaningfully contributes to the teaching mission of the department and the College of Medicine | Contribui de forma significativa com a missão de ensino do Departamento e da Faculdade de Medicina |
| Adopts uniform and equitable standards for patient care | Adota padrões uniformes e com equidade no cuidado ao paciente |
| Promotes justice in the health-care delivery system by demonstrating efforts to eliminate discrimination in health care | Promove a justiça no sistema de prestação de cuidados de saúde, demonstrando esforços que visam eliminar a discriminação no sistema de saúde |
| Appreciates and respects the diverse nature of research subjects and/or patients, and honors these differences in one’s work with them | Aprecia e respeita a natureza diversa de participantes de pesquisa e/ou pacientes e respeita essas diferenças no trabalho com os mesmos |
| Respects the rights, individuality, and diversity of thought of colleagues and students | Respeita os direitos, individualidade e diversidade de pensamento dos colegas e estudantes |
| Upholds scientific standards and bases decisions on scientific evidence and experience | Defende os padrões científicos e baseia as decisões em evidências e experiências científicas |
| Assumes personal responsibility for decisions regarding patient care | Assume responsabilidade pessoal pelas decisões relacionadas ao atendimento ao paciente |
| Represents information and actions in a truthful way | Representa informações e ações de maneira verdadeira |
| Maintains patient/physician relationships that do not exploit personal financial gain, privacy, or sexual advantages | Mantém relações médico-paciente que não exploram ganhos financeiros pessoais, privacidade ou vantagens sexuais |
| Advocates a patient’s or research subject’s interest over one’s own interest | Defende o interesse de um paciente ou participante de pesquisa sobre seu próprio interesse |
| Reports data consistently, accurately and honestly | Relata dados de forma consistente, precisa e honesta |
| Refusal to violate one’s personal and professional code of conduct | Recusa-se a violar o código de conduta pessoal e profissional |
| Meets commitments and obligations in a conscientious manner | Cumpre compromissos e obrigações de maneira consciente |
| Shows compassion | Demonstra compaixão |
| Demonstrates empathy | Demonstra empatia |
| Volunteers one’s skills and expertise for the welfare of the community | Oferece voluntariamente suas habilidades e conhecimentos para o bem-estar da comunidade |
| Participates in corrective action processes toward those who fail to meet professional standards of conduct | Participa de processos de ações corretivas sobre àqueles que não cumprem os padrões profissionais de conduta |
| Does not seek to advance one’s career at the expense of another’s career | Não busca avançar na carreira às custas da carreira de outra pessoa |
| Reports medical or research errors | Relata erros médicos ou de pesquisa |
| Discloses conflicts of interest in the course of professional duties and activities | Declara conflitos de interesse no exercício de deveres e atividades profissionais |
| Respects patient autonomy and helps them make informed decisions | Respeita a autonomia do paciente e o ajuda a tomar decisões informadas |
| Acts in ways that show a commitment to confidentiality | Age de forma a demonstrar comprometimento com a confidencialidade |
| Avoids offensive speech that offers unkind comments and unfair criticisms to others | Evita fala ofensiva que contenha comentários indelicados e críticas injustas aos outros |
| Is professionally attired in a manner that is respectful of others | Veste-se profissionalmente de maneira respeitosa para com os outros |
Source: Prepared by the authors.
The exploratory factor analysis obtained a KMO = 0.920 and Bartlett’s test of sphericity was significant (2719.0, gl = 630; P <0.001). As shown in Table 2, the parallel analysis recommended a three-factor solution.
Table 2 Parallel Analysis of the PSCOM Professionalism Questionnaire in 249 medical students. Salvador, Bahia, Brazil.
| Real Data % Variance | Mean of Randoma % Variance | |
| 1 | 31.7949* | 6.0016 |
| 2 | 6.8598* | 5.5780 |
| 3 | 5.3198* | 5.2877 |
| 4 | 4.2209 | 5.0385 |
| 5 | 3.8961 | 4.8195 |
| 6 | 3.5312 | 4.6177 |
| 7 | 3.2838 | 4.4284 |
| 8 | 3.0527 | 4.2552 |
| 9 | 2.9797 | 4.0886 |
| 10 | 2.7497 | 3.9269 |
| 11 | 2.5992 | 3.7778 |
| 12 | 2.3818 | 3.6256 |
| 13 | 2.2564 | 3.4786 |
| 14 | 2.1738 | 3.3381 |
| 15 | 2.1212 | 3.1943 |
| 16 | 2.0601 | 3.0575 |
| 17 | 1.9115 | 2.9154 |
| 18 | 1.7870 | 2.7740 |
| 19 | 1.7413 | 2.6352 |
| 20 | 1.6055 | 2.5020 |
| 21 | 1.4696 | 2.3640 |
| 22 | 1.3516 | 2.2344 |
| 23 | 1.3424 | 2.1003 |
| 24 | 1.2293 | 1.9624 |
| 25 | 1.0739 | 1.8286 |
| 26 | 0.9437 | 1.6915 |
| 27 | 0.9116 | 1.5503 |
| 28 | 0.7193 | 1.4062 |
| 29 | 0.6398 | 1.2649 |
| 30 | 0.5769 | 1.1177 |
| 31 | 0.4567 | 0.9663 |
| 32 | 0.4082 | 0.8058 |
| 33 | 0.3051 | 0.6418 |
| 34 | 0.2162 | 0.4566 |
| 35 | 0.0291 | 0.2684 |
*the number of factors to be retained is three, as three factors of the actual data have explained variance greater than the random data.
Source: Prepared by the authors.
The matrix of factorial loads is shown in Table 3. The first factor grouped 14 items and was related to the Professional-Patient Relationship. The second factor grouped five items, being defined as Professional Development. The third factor grouped 10 items, concerning Ethical Commitment. In total, seven items were excluded. Five did not show factorial loads greater than 0.30, and two showed factorial ambiguity.
Table 3. Exploratory factor analysis of the PSCOM Professionalism Questionnaire in 249 medical students. Salvador, Bahia, Brazil.
| Items | Factorsa | ||
|---|---|---|---|
| F1 | F2 | F3 | |
| Demonstrates empathy | 0.982 | -0.342 | |
| Respects the rights, individuality, and diversity of thought of colleagues and students | 0.824 | ||
| Respects patient autonomy and helps them make informed decisions | 0.812 | ||
| Shows compassion | 0.693 | ||
| Avoids offensive speech that offers unkind comments and unfair criticisms to others | 0.680 | 0.331 | |
| Appreciates and respects the diverse nature of research subjects and/or patients, and honors these differences in one’s work with them | 0.627 | ||
| Recognizes one’s own limitations | 0.545 | ||
| Represents information and actions in a truthful way | 0.517 | 0.357 | |
| Meets commitments and obligations in a conscientious manner | 0.489 | ||
| Volunteers one’s skills and expertise for the welfare of the community b | 0.485 | 0.330 | |
| Is professionally attired in a manner that is respectful of others | 0.476 | ||
| Demonstrates adaptability in responding to changing needs and priorities | 0.462 | ||
| Maintains patient/physician relationships that do not exploit personal, financial gain, privacy, or sexual advantages | 0.385 | ||
| Promotes justice in the health-care delivery system by demonstrating efforts to eliminate discrimination in health care | 0.356 | ||
| Acts in ways that show a commitment to confidentiality | 0.545 | ||
| Takes time to review other colleagues’ work and provides meaningful and constructive comments to improve it | 0.675 | ||
| Shows a willingness to initiate and offer assistance toward a colleague’s professional and personal development | 0.606 | ||
| Seeks self-improvement | 0.560 | ||
| Promotes the welfare and development of junior faculty | 0.486 | ||
| Attends faculty meetings, seminars, and student research presentations as a reflection of support | 0.411 | ||
| Upholds scientific standards and bases decisions on scientific evidence and experience | -0.501 | 0.785 | |
| Advocates a patient’s or research subject’s interest over one’s own interest | 0.646 | ||
| Adopts uniform and equitable standards for patient care | 0.635 | ||
| Discloses conflicts of interest in the course of professional duties and activities | 0.635 | ||
| Reports medical or research errors | 0.626 | ||
| Assumes personal responsibility for decisions regarding patient care | 0.582 | ||
| Participates in corrective action processes toward those who fail to meet professional standards of conduct | 0.548 | ||
| Commits to implement cost-effective patient care | 0.507 | ||
| Refusal to violate one’s personal and professional code of conduct | 0.427 | ||
| Meaningfully contributes to the teaching mission of the department and the College of Medicine b | 0.310 | 0.417 | |
| Assumes leadership in patient management | 0.319 | ||
| Reports data consistently, accurately and honestly c | |||
| Works collaboratively and respectfully within a team to the benefit of improved patient care or to the contribution of researchc | |||
| Does not seek to advance one’s career at the expense of another’s careerc | |||
| Participates in activities aimed at attaining excellence in patient care c | |||
| Responds to constructive criticism by working to improve one’s capability in the area criticizedc | |||
a Robust Promin Rotation. Factor loads above 0.30 are shown.
b Items excluded due to factorial ambiguity.
c Items excluded due to the absence of a factor load greater than 0.30.
Source: Prepared by the authors.
Finally, the Composite Reliability indices for each factor were calculated. Professional-Patient Relationship (14 items) obtained 0.892, Professional Development (5 items) attained 0.684, and Ethical Commitment (10 items) was 0.832. The factorial structure showed adequate adjustment indexes (χ2 = 326.813, gl = 525; p < 0,05; RMSEA = 0,030; CFI = 0,992; TLI = 0,990).
DISCUSSION
In undergraduate medical courses, the formal curricula should include teaching tools that will encourage ethical and professional behaviors by the graduates. Given its multidimensional aspect, the construction of medical professionalism is complex and difficult to understand1. Professionalism is a competence that should be acquired during the medical undergraduate period. Therefore, teaching professionalism and applying a tool for evaluating the degree to which medical students should meet the established understanding criteria for professionalism is essential.
Several scales have already been developed for medical professionalism evaluation18),(19. A literature review described the PSCOM Professionalism Questionnaire with good internal consistency and content validity; however, its structural validity was undetermined19. In our study, Parallel Analysis pointed to a three-factor solution13, differing from developers, who suggested seven factors5.
The solution with three factors (domains) was the best attained one, with good psychometric properties11),(20. The number of domains present in a scale does not seem to change its scope18. Analogous to that proposed by Van De Camp et al.4, the Professional-Patient Relationship domain can be understood as interpersonal professionalism, that is, when the doctor interacts with the patient or with another health professional. For example, avoiding offensive speech that contains rude comments and unfair criticism of others and maintaining doctor-patient relationships that do not exploit personal financial gains, privacy, or sexual advantages. The Professional Development domain would be contained in intrapersonal professionalism, which according to the referred author is the way through which the doctor meets the demands of the profession as an individual and therefore involves personal characteristics4.
In Ethical Commitment there is public professionalism, in which the doctor needs to be able to assume standards prescribed in their code of ethics, being, therefore, the requirement that society expects4. Likewise, it can be observed in the study by Klemenc-Ketis and Vrecko18, in which only three conceptually close factors (domains) were found: empathy / humanism, professional relationship / development and responsibility.
The present study applied rigorous methodological approaches for the translation, cross-cultural adaptation, and validation of the original English version of the PSCOM Professionalism Questionnaire. The psychometric behavior of the translated version of the questionnaire was tested by exploratory factor analyses, using polychoric matrix and the Robust Diagonally Weighted Least Squares (RDWLS)12. The factorial structure of the present study showed adequate adjustment in all indexes.
Concerning the internal consistency of the instrument, the reliability of two factors (Professional-Patient Relationship and Ethical Commitment) was > 0.70, and for the factor entitled Professional Development, the reliability was satisfactory (0.684). As for the development of the PSICOM, the internal consistency reliability for each factor ranged from 0.51 to 0.785.
It is noteworthy that the elements described by ABIM21 can be used to build consensus on the domains of professionalism, but cultural differences must be considered. The ABIM structure has been considered reliable in Western and Eastern societies to portray and evaluate attitudes towards professionalism and that is why countless studies have already used the ABIM structure using different instruments8.
The PSCOM Professionalism Questionnaire was also validated for Spanish and after the factor analysis, four new domains were found, namely patient care, ethical attitude, partnership and relationship with health systems7. In a recent study to assess the reliability of the PSCOM Professionalism Questionnaire for Pakistan, it showed that despite the seven-factor solution found, it occurred with a factorial structure that was different from the one observed in the original instrument, as in the respect domain, which now has five items instead of two8. The validation study of the Turkish version of PSCOM revealed consistency with the factors of the original scale, with the exception of only one item in the commitment domain9.
The PSCOM Professionalism Questionnaire may help psychologists and medical educators in medical curriculum implementation and intervention for medical professionalism teaching in Brazil. The difficulty in defining professionalism can be partly understood, since the topic is not clinical, and it may be hidden in the medical school curriculum18. Validating and adapting tools for subjective measurements such as professionalism in different cultures allows comparisons of undergraduate medical students’ perceptions between countries.
This study showed some limitations, as all participants were from the second period of medical undergraduate school, and it was conducted at a single Brazilian medical school. However, there is a limited number of studies concerning the performance of professionalism questionnaires. Despite these limitations, the PSCOM Professionalism Questionnaire is one tool that contributes to the efforts to enhance professionalism at all levels in medical education.
CONCLUSION
In this study, the three-factor solution was the best one found to represent the data. The questionnaire evidenced good psychometric properties and appropriateness to evaluate medical students’ professionalism. It is necessary to use appropriate and validated scales to evaluate students in relation to professionalism and from that point it is possible to propose the restructuring of the curriculum, or even greater integration of this framework, to reach more desirable ethical standards in medical education. An important next step would be to administer the instrument to all periods of medical undergraduate course and residency.
