Professionalism is defined by various scientists and researchers over the period of time. In 2002, Epstein and Hundert defined professional competence as "the habitual and judicious use of

communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served’’.[1] The Royal College of Physicians, United Kingdom defined professionalism as “a set of values, behaviours, and relationships that underpin the trust the public has in doctors”. The American Board of Internal Medicine identified the key elements of professionalism as: altruism, accountability, duty, excellence, honour, integrity and respect for others. The medical educationists from Netherlands defined professionalism in terms of observable behaviours to make assessment feasible.[2] A faculty development initiative tried to build consensus by defining some of the core attributes of professionalism in an effort to make these elements more comprehensive.[3] Elements in initial definitions are easy to identify but difficult to measure as learning outcomes. Subsequent definitions evolved which included behaviours that are observable and to some extent measurable. Hence, it is amenable to assessment and inclusion as a core curricular component. while everyone agrees on the core elements of professionalism, a consensus on a culturally appropriate global definition appears to be lacking. Therefore, it is important for each country and every institution to develop its own definition of professionalism, according to the societal norms of the times and identify its core elements.[4]

Doctors are expected to consistently exhibit professional attitudes, behaviour, values and ethics in their practice. Professionalism is an important component of medicine's contract with society. The concept of the profession of a doctor has changed considerably with the times. Previously, doctors were granted autonomy by the community, with the belief that they would place the welfare of their patients before their own. However, in contemporary society,

This autonomy has been jeopardised by the altered public perception about the role of the doctor. Their behaviour is now observed and scrutinized more closely by the media. Doctors' own attitudes towards their vocation have also changed.[5]

Medical professionalism is one of the core accreditations by National Medical Commission for Graduate Medical Education competencies. Studies have shown that students who demonstrate unprofessional behaviour during their undergraduate and postgraduate education are more likely to be found guilty of unprofessional actions by the monitoring boards after they graduate. Thus, the need to include teaching and assessment of professionalism in the formal curricula for undergraduate and postgraduate medical training has been globally acknowledged. The P-MEX instrument developed by Richard L. Cruess, MD is an evaluation instrument used to assess professionalism in clinical training through a faculty-observed encounter of trainee's behavior either with or without patients. Utilizing a 4-point Likert-type scale, the trainee is evaluated on 24 different directly observable items of medical professionalism which assess skills related to: the doctor-patient relationship, reflection, time management, and interprofessional relationships [6]. Transmitting professionalism and professional values by role modelling is no longer recognised as sufficient. As this occurred, it became apparent that the evaluation of professionalism needed improvement and there have been calls for new methods to be developed. Assessment of professionalism not only allows for timely feedback to residents to help them improve, but also allows for development of better curriculum to prevent lapses in medical professionalism.[7]

This study is done with an aim to establish PMEX as a competent scoring system for the assessment of professionalism among medical students with the following objectives: to analyse the relevance of PMEX in current health scenario, to analyse the feasibility of PMEX in Competency Based Medical Education curriculum, to analyse the comprehensiveness of PMEX scoring system for practical application and to assess the efficacy of PMEX as a formative assessment tool for improvement of professional competency in medical students.

AIM AND OBJECTIVES

The aim of this project is to establish PMEX as a competent scoring system for the assessment of professionalism among medical students.

Objectives of the project:

• To analyse the relevance of PMEX in current health scenario.
• To analyse the feasibility of PMEX in Competency Based Medical Education curriculum.
• To analyse the comprehensiveness of PMEX scoring system for practical application
• To assess the efficacy of PMEX as a formative assessment tool for improvement of professional competency in medical students

Study setting-

Department of Surgery, Jorhat Medical College & Hospital Study duration- 6 months (February 2024 to July 2024)

Study design-

Cross sectional study

Study participants-Faculty and Post graduate residents of Surgery Inclusion criteria–

➢Those who gave written and informed consent for the study.

Exclusion criteria-

➢Post graduate residents on District Residency Program.

➢Faculty and Residents who do not give consent for the study.

Sampling method- Purposive sampling

Sample size- 6 Faculty and 33 Post graduate residents of Surgery. Data Collection Tool- Pre-validated Questionnaire[6] and Interview.

Data collection method:

1. Preparation of survey questionnaire of P-MEX consisting of four domains: Doctor- patient relationship skills, Reflective skills, Time management and Inter- professional relationship skills. Each behaviour was assessed in 5 Grades:1=Unacceptable 2=Below expectations 3=Meet expectations 4=Above expectations 5=Not applicable in this case.
2. The Faculty of Surgery who gave consent to participate in the project were sensitized about the project and the P-MEX session questionnaire were peer reviewed among the selected 6 faculty of Department of Surgery Jorhat Medical College and Hospital, who acted as assessors of PMEX. The pre validated questionnaire was placed in a Google form.
3. The Surgery residents who gave consent to participate in the project were notified the date time and venue of P-MEX sessions.
4. PMEX SESSIONS: Each Resident was assessed by 6 assessors in 8 different clinical settings- Out-patient department (OPD), In-patient department (IPD), Pre- operative ward, post-operative ward, Major operation theatre (Major OT), Minor operation theatre (Minor OT), Casualty and Intensive care unit/ Intensive Therapy Unit (ICU/ ITU). 4 Residents were assessed in all settings per week. Assessment of 33 Residents were completed by 8 weeks. The assessors observed the interaction of the Resident with a patient in a given clinical setting at the pre fixed date time and venue. Feedback to the residents were given by the assessors after every assessment. Students wrote reflections at the end of the session.
5. PMEX sessions scoring were done by assessors in the pre- designed Google form.
6. Assessor were interviewed to rate the relevance, feasibility and comprehensiveness of each item in P-MEX using a 1-10 numerical rating scale (1strongly not relevant, 10 completely relevant) and also any comment or suggestion for improvement of PMEX were recorded.
7. The entire study was conducted after obtaining due permission from the Institution Ethics Committee, Jorhat Medical College and Hospital.
8. Data Analysis Plan

• Descriptive analysis of post assessment interview of assessors
• Thematic analysis of PMEX scores of residents

2. The collected data is placed in a master chart using MS EXCEL. Statistical analysis is done using IBM-SPSS Version 2.0.Patients were positioned in the sniffing position, and preoxygenation was carried out for three minutes.

In Group A, FOI was performed using a flexible fiberoptic bronchoscope with an appropriately sized endotracheal tube preloaded. In Group B, VL was performed using a standard video laryngoscope. All procedures were performed by anesthesiologists with at least five years of experience.

Based on the statistical analysis, the following results are obtained in our study:

Relevance has a mean of 7.34 and range 4-9 (Table1 and Figure 1) which is very relevant as per the scoring system

Table 1: Relevance of P-MEX

Figure 1: Relevance of P-MEX

Feasibility has a mean of 7.34 with a range of 4-9 (Table 2 and Figure 2) which is very relevant as per the scoring system in the study.

Table 2: Feasibility of P-MEX

Figure 2: Feasibility of P-MEX

Comprehensiveness having a mean of 7.71 with a range of 5-9 (Table 3 and Figure 3) which is extremely relevant as per the scoring system

Table 3: Comprehensiveness of P-MEX

Figure 3: Comprehensiveness of P-MEX

Table 4: Efficacy of P-MEX

Figure 4: Efficacy of P-MEX

Table 5: Analysis of domains of P-MEX tool with respect to Relevance, Feasibility and Comprehensiveness

Majority of the faculties found the questionnaire and method of evaluation satisfactory. One faculty expressed the opinion that the process is a bit lengthy and another one noted inconvenience in some patients, especially in critical care environments like casualty department and ICU.

The effectiveness of the study is evident from the results as with the progress of each session of each assessment of P-MEX session, the individual post graduate students showed an improvement of score in all domains of skills with an overall average lowest score of 1.75 and average highest score of 2.5 in the assessment no.1, which improved to average lowest score of 3.0 and average highest score of 4.0 in the assessment no.8.

In our study, in settings like OPD, Wards and Minor OT where relatively systematic patient inflow is there and by virtue of the patients’ condition, the scores with regards to relevance and feasibility are higher as proper assessment is possible in comparison to critical care settings.

In this study done at our setting, the data shows that in the critical settings like Casualty and ICU, there is a trend of lower scores in terms of 

The study conducted by F Jahan et al showed that professionalism includes personal behaviours, knowledge, and competency. It also includes the attitudes and values one holds and that run through the profession as a whole. Medical students learn professionalism during the course by either direct teaching or experiential learning.[8] Another study conducted by Y Hur et alon core elements of medical professionalism for medical school aspirants.[9] Our study also aims to impart these core values of professionalism during the formative years of a medical student through a scientific and analytical assessment method.

The study conducted by V Passi et al explains in details about the importance of professionalism among doctors and also elaborates the importance of assessment methods for the proper development of curriculum design and teaching and learning methods for supporting professionalism.[10] The study conducted by P Wagner et al on defining medical professionalism also concluded similar findings.[11]. Our study also has the aim and objectives of finding a comprehensive assessment method of professionalism.

The study conducted by KT Tay et al depicts various accreditation frameworks by different regulatory agencies across the globe which includes Accreditation Council for Graduate Medical Education (United States),Canadian Medical Education Directives for Specialists Roles for Family Medicine, European Federation for Internal Medicine’s Physician Charter for Medical Professionalism, General Medical Council Professionalism Capabilities Framework (United Kingdom) and Indian Medical Council Professional Conduct, Etiquette and Ethics and analyses existing different methods for assessment which includes Miller’s Pyramid, Kirkpatrick’s model etc. The pointed time consuming and longitudinal nature of assessment of these methods which tends to lose the core objective of imparting professionalism in medical students many a times.[12]

The meta-analysis conducted by H Li et al analysed 74 instruments of assessment of professionalism from 80 existing studies which included P-MEX as well. The study concluded that although instruments measuring medical professionalism are diverse, only a limited number of studies were methodologically sound. Future studies should give priority to systematically improving the performance of existing instruments and to longitudinal studies.[13] The study conducted by J Goldie et al on assessment of professionalism also has similar findings.[14]

Professionalism Mini Evaluation Exercise (P-MEX) has been recently incorporated a tool for assessment of professionalism among various medical and allied professionals among different countries as shown in the studies conducted by Y Tsuwaga et al in Japan[15], M Karukiwi et al in Finland[16], W Fong et al in multi-ethnic society of Singapore[17], M Kazemipoor et al among dental professionals[18],L Amirhajlou et al among Emergency Medicine residents[19], AL Tusci et al in Turkey[20], T Kaur et al among dental students in India[21], N Jaffari et al in Iran[22], N Abenova et al in Kazakhstan[23] and BK Arai in Brazil[24].

The studies showed a consensus conclusion that P-MEX shows evidence of adequate validity, reliability, and generalizability of findings show evidence of adequate validity, reliability, and generalizability of the P-MEX and confirmed the four areas of medical professionalism reflected in P-MEX: doctor-patient relationship, reflective skills, time management, and inter-professional relationship skills. The studies also agreed that P- MEX is the only evaluation tool for medical professionalism verified in both a Western and East Asian cultural context but commented that subjective evaluations should be complemented with external assessments or feedback in order to take individual and cultural aspects into account. Our study on P-MEX has similar results in comparison to all these studies with a relevance of mean 7.34, feasibility of mean 7.34 and comprehensiveness of 7.71 in a scale of 1-10 which is very relevant as per the scoring system in the study. The average improvement of the results of post-graduates starting from assessment 1 to assessment 8 shows that this tool is efficacious in formative assessment of professionalism among students.

Based on the results, it is concluded that P-MEX is a competent scoring system for the assessment of professionalism among medical students. This method shall enforce induction of professionalism skill teaching, learning and assessment module in under graduate and post graduate curriculum. Students and residents shall have improved proficiency of medical professionalism and faculty shall be motivated to conduct further research in professional skill. The data collected could be easily studied and the deficits were clearly recognised with regards to skills assessed in a particular setting. Moreover, the data helps us understand

Whether the study conducted in a particular setting for a particular skill is relevant and feasible enough. The questionnaire is comprehensive enough to gauge the efficacy of the study in limited setting. The feedback given to the students at the end of each session showed improvement in results in the subsequent sessions, which shows that P-MEX is a competent tool to assess, deliver feedback and help in improving the proficiency of the post graduate students. The system of assessment via P-MEX questionnaire can be further modified based on the feedback with regards to critical settings like ICU, Casualty and Major OT. Overall, the P-MEX tool is comprehensive, the study shows that the assessment by a compact questionnaire which is able to touch on all four domains of professionalism: doctor – patient relationship, time management skill, reflective skills and inter-personal skills is an effective way.

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