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Renewing Professionalism in Dental Education: Overcoming the Market Environment

Key words: assessment, faculty exemplars, moral reasoning, portfolio, professionalism, service-learning, social contract

Submitted for publication 07/19/06; accepted 10/12/06

	Abstract

Top Abstract Professionalism's moral... Defining professionalism Student moral character: fixed... Educational research in... Renewing professionalism Conclusions References

 
The most important mission of dental education is development of student professionalism. It is only within the context of professionalism that specialized knowledge and technical expertise find meaning. Altruism, integrity, caring, community focus, and commitment to excellence are attributes of professionalism. Its backbone is the obligation of service to people before service to self—a social contract. Professionalism can and should be acquired by targeted interventions, not as an assumed by-product of dental education. Top-down, rule-based professionalism is contrasted with its experience-based, mentor-mediated, socially driven counterpart. Moral principles are inherent in professional development and the professional way of life. Unfortunately, American society, including higher education, glorifies a market mentality centered on expansion and profit. Through formal and hidden curricula, dental schools send mixed messages to students about the importance of professionalism. Institutional consensus on professionalism should be developed among faculty, administration, and students through passionate advocacy and careful analysis of dentistry’s moral convictions. The consensus message should communicate to stakeholders that morality and ethics "really count." Maximum student exposure to faculty exemplars, substantial service-learning experiences, and portfolio use are likely to enhance professionalism, which should be measured for every student, every semester, along with faculty and institutional assessment. Research reveals a significant relationship between levels of student moral reasoning and measures of clinical performance and shows that moral reasoning ability can be enhanced in dental students. Valid and reliable surveys exist to assess student moral reasoning. Documented student unprofessional behavior is a predictor of future state professional board disciplinary action against practitioners, along with low admissions test scores and course failures in the first two professional school years. ADEA Policy Statements recognize the importance of professionalism in student development. From day 1 of dental school, faculty and students should have no doubt as to what constitutes acceptable and unacceptable behavior in academic and clinical settings. With education and experience, dental students and dentists are likely to elevate their standards of professionalism.

Professionalism may be envisioned as more than the absence of unprofessional actions, to include "a set of identifiable positive qualities or behaviors."⁴ Part of professional development entails recognizing, "adopting, and upholding a code of conduct."¹ Indeed, much of the published literature on professionalism describes "a set of values, virtues, or characteristics—overarching principles to which doctors are held."¹

Given its importance, most beginning dental students have "little understanding why [dentistry] is a profession, or why [dentists] are professionals. Most instruction about professionalism takes place within the hidden curriculum [‘relationships between and among students and faculty, rituals, and forms of socialization’⁵], which practically ensures that student-generated conceptions of professionalism will be different from those of faculty and administrators."⁴ Alton Fisher further reminded us nearly fifty years ago that "it can’t be assumed that every student will strive automatically to develop [professional] attitudes."⁶ Personal background, needs, and expectations may influence acquisition of professional traits.

Unfortunately, numerous studies in contemporary health professions education confirm a high incidence of unprofessional conduct by students.⁴ Charles Bertolami observed that "cheating is common" in dental schools and that ethics curricula are generally ineffective in modifying student or practitioner behavior.⁷ A recent survey of AEGD and GPR directors revealed that inadequate resident professionalism was a major program issue.⁸ David Chambers stated that "we have underestimated the extent to which dentists are the victims of commercialism," giving as one example emphasis on "high-profit services while ignoring comprehensive care."⁹ Henry Chalfin prescribed "more in-depth training in [ethics and professionalism] in our schools and postgraduate programs" as necessary to re-establish dentistry’s altruistic professional obligation to patients.¹⁰

Professionalism has for too long been considered a natural by-product of dental education,⁴ akin to presumed possession of teaching ability that attends award of doctoral degrees. In the "acquisition-by- osmosis" fantasy, "one becomes ‘professional’ by virtue of completing the curriculum and qualifying for the [D.D.S./D.M.D.] degree," not by virtue of targeted instruction.⁴ Lack of analytical study of the development of professionalism contributes to this faith, rather than evidence-based conception! As dedicated educators attest, optimal student attainment of professionalism is "problematic, not automatic."⁴

Two basic mechanisms are used to develop dental student professionalism. "Rule-based professionalism," a top-down, list-driven, often abstract approach, contrasts with a more recent "developmental professionalism,"⁴ a "bottom-up, behavior-based" philosophy emphasizing early student clinical and community experiences coupled with mentor-assisted moral development.¹ Classes in professional ethics and morality featuring teacher-centered detailing of desirable attributes may convey professionalism as a static, "conceptual mass at rest," and result in shallow learning and diminished student enthusiasm.⁴ Bottom-up experiences incorporating professional responsibilities may portray professionalism as "an action system, residing within a social context,"⁴ engendering serious reflection, deeper learning, and budding interest.

	Professionalism’s Moral Imperative

Top Abstract Professionalism's moral... Defining professionalism Student moral character: fixed... Educational research in... Renewing professionalism Conclusions References

 
Professional life is a cooperative endeavor. Dental practice is intensely personal. The way of professional life entails considerate and close interactions with people founded on a "blending of moral dispositions and professional expertise."¹¹ Moral principles are integral to professional strength.¹² Basic to human nature, however, are self-interest and conflict between "me" and "us." The "lure of self-interest" easily displaces the patient as first concern, deflates trustworthiness, and compromises professional integrity. A market-centered professional succumbs to pressure to behave competitively toward peers and to place demands of profit ahead of professional standards of excellence.²

Morality may be defined as keeping "me" in check, self-interest as the "antithesis of professionalism."⁴ The distinguished scholar and diplomat George Kennan believed that humanity requires "a moral order, founded on an appreciation of the dilemmas of birth and death and of the requirements of social living . . . , drawn up by those who are wiser and more experienced than the masses of humanity. . . . It is always better that there should be some moral law, even an imperfect or entirely arbitrary one, than . . . none at all; for the human being who recognizes no moral restrictions and has no sense of humility is worse than the foulest and most savage beast" (emphasis added).¹²

Much of current American public and higher education rejects moral teaching. But until the mid-twentieth century, moral education was a regular element of American education. Character education in those times meant "the business of schools to help students appreciate the importance of basic virtues essential for responsible citizenship" in a democratic society.¹¹ Yet the recent statement of Robert Brown, professor emeritus of educational psychology at the University of Nebraska, proves that the spark of morality and common sense still burns in contemporary education: "Learning outcomes should include moral development, good citizenship, leadership skills, interpersonal competencies, and multicultural awareness."¹³ These outcomes describe attributes of professionalism.

	Defining Professionalism

Top Abstract Professionalism's moral... Defining professionalism Student moral character: fixed... Educational research in... Renewing professionalism Conclusions References

 
Educational literature states that professionalism is either well defined and commonly understood or vague in meaning and not well known.^4,11 The dictionary definition is simple: "the conduct, aims, or qualities that mark a profession or professional person."¹⁴ Adding a health care slant, we may further define it as a life characterized by display of high intellectual, technical, and moral qualities and abilities, in service to patients and community. Traditional references commonly identify altruism as a core principle of professionalism.⁴

Health care professionalism has been concisely described as "medical morality."¹⁵ Essential professional qualities include "integrity, honesty, civic-mindedness, courage, self-sacrifice, ability to communicate clearly, thorough and clear work documentation, and commitment to quality."² Professional activities confer the "highest sense of responsibility" on their practitioners.² A contemporary feature of professionalism is the concept of community service,⁴ detailed below.

While the term "professional" has a long history in health education scholarship, "professionalism" is a newer word, appearing first in this scholarly literature in the text of a 1968 Journal of Dental Education article by J.R. Parrish, "Professional Conduct in Dental School and After."¹⁶ This reference preceded by over ten years the appearance of "professionalism" in medical education literature.⁴ First use of the word in a published dental education article title was in A.P. Shefrin’s "The Use of Role-Playing for Teaching Professionalism and Ethics," in the 1978 Journal of Dental Education.¹⁷

In educational research, professionalism is discussed in three contexts: "as a comprehensive construct[;] as one facet of clinical competence[; and] as an array of separate elements."¹⁸ In the ideal learning environment, dental students serve a three-leveled apprenticeship in professionalism, beginning with the intellectual or cognitive, moving to a grounding in "the body of skills shared by competent practitioners," and finally being introduced to "the values and attitudes shared by the professional community."² Much research confirms the hidden curriculum’s critical role in the third apprenticeship, as students learn what it means to be a professional.²

Sullivan stated that "even in the contemporary climate of moral relativism, few speak of professional behavior as existing only in the eye of the beholder."² Given serious moral and religious disparities among people, there remains a "widespread consensus [on] a set of virtues that cuts across these differences."¹¹ Bestowing the descriptor "professionalism" on observed actions is noteworthy praise; charging "unprofessionalism" is profound condemnation.²

Excellence in professionalism does not connote practical perfection. Seasoned doctors affirm Michael Pritchard’s statement that "even competent, dedicated professionals sometimes fail. Honest mistakes are made and unexpected complications can arise."¹¹

Social Contract
Unquestioned is society’s total dependence on the specialized knowledge, skills, and services provided by professionals. As compared to a generation ago, many of today’s patients are more knowledgeable about health care and may question a doctor’s advice, yet personal and community well-being still depends on an array of professionals. The public expects that professionals provide their services not only competently, but as experts worthy of trust. Without trust, professionalism is gravely wounded, for "professionals need to be trusted in order to perform well."¹¹ This holds for dentists, physicians, clergy, educators, and other professionals. Trust is earned in large measure through truthfulness and also from exercise of caring, dependability, and sound judgment.¹¹

Sullivan links the essence of professionalism with a social contract: the obligation of service to people before service to self.² He states that the social contract occupies the heart and moral foundation of professionalism and serves as the basis for the honored position of professionals in society.

Implicit in the social contract is that professionals are expected to do what is right, even if it means personal sacrifice.¹¹ A "9-to-5" mentality, for example, diminishes the sense of duty to patients. People of integrity, such as professionals, are furthermore known to practice at least a degree of reflection and critical thinking: "There are times when it is important for professionals to pause reflectively and ask whether what they are contemplating doing is ethically justifiable."¹¹ Sullivan notes that "integrity is never a given, but always a quest that must be renewed . . . demand[ing] considerable individual self-awareness and self-command."² Professional integrity entails adherence to "the fundamental role and character of one’s profession—to its principles, values, ideals, goals, and standards."²

Dentistry’s social contract is clearly embodied in published American Dental Education Association (ADEA) Policy Statements serving as "recommendations and guidelines for dental education institutions, programs, and personnel."¹⁹ These encourage faculty and student awareness of the profession’s social obligation through "formal instruction and faculty role models," so that students understand the dependence of professional education and self-regulated practice on the "implicit contract to serve the public good."¹⁹

Aspiring professionals may envision integrity as more than the absence of wrongdoing: "right- doing" describes the limitless opportunities for positive acts during daily professional practice.¹¹ A vibrant professional culture emphasizes a mix of good works and basic practice as the right course.

Morality and the Market Environment
In its possession and display of moral values, the dental school student body is a microcosm of society. It is fair to state that major elements of early twenty-first-century society are hostile to propagation of professionalism and moral standards. De Freitas et al. noted the "emergence of a secular morality that allows for some disconnection between morals, ethics, and theological tradition."⁵ Bertolami mentioned the declining influence of religion, family, and local community in conveying moral standards.⁷ In much of Western culture, man has displaced God as the supreme creative intelligence.²⁰ Where it exists, a philosophy of "no right or wrong, just differences of opinion" is naturally at odds with exercise of professional responsibilities.

It is no exaggeration that professional prestige is under siege. Cynicism abounds on professional performance, motives, and even claims to distinct expertise. The professional mandate to "serve the public’s interest" is viewed with increasing skepticism.^2,7

Realistic assessment of modern society reveals the inherent struggle of professionalism in a culture that "links [professional] skills less with public purposes than with market advantage."² The 2006 Ethics Summit on Commercialism cosponsored by the American Dental Association and the American College of Dentists identified the damaging effect on professionalism of "pervasive, rising, and multifactorial" commercialism.²¹ The danger of commercialism lies not in use of business-based management tools, but in adopting "its core ideology, self-interest."⁴ As it is, professionalism as social trusteeship is fast yielding to the "notion of the professional as a purveyor of expert services," and worse: "Today’s market triumphalism exalts economic enterprise to a position of commanding social value and highest individual virtue. Is the notion of a calling simply indigestible within our increasingly competitive, unequal, and market-driven society?"²

The related socioeconomic phenomenon of entrepreneurism is an enemy of professionalism. The entrepreneurial whiz is a charismatic, media-glorified figure, drawing young talent toward the flame of high income and hot markets. Large organizations employing professionals may also be toxic to professionalism in their focus on financial bottom lines to the detriment of patient interests and doctor autonomy. As only one example, managed care corporations may "pressure doctors into emphasizing economic efficiency at the expense of clinical judgment, . . . recast[ing] the doctor’s practice as a profit center rather than a healing enterprise."²

Search for Grandeur: Immorality in Higher Education
Unfortunately for professional students and faculties, a blatant contributor to the social decline of professionalism is the major American university. Former Harvard president Derek Bok noted the academy’s "increasing embrace of the business model, with its overriding concern for profit and expansion."² Bok bemoaned the "entrepreneurial emphasis and definition of organizational purpose based on profit" of leading American universities. Specifically, as Bok says, the admissions arena has evolved into "the key academic profit center. The entire enrollment process is driven by the imperative to improve the institution’s market position."

The academy’s financial big league features nine- and ten-figure fundraising drives and the building of $600 million hospitals. A university president’s recent exhortation to move "beyond excellence to eminence"²² conveys the quest for expanding greatness and its facilitation by huge infusions of money.

Another academic issue receiving considerable attention and deeply harming the public’s trust in professions is dishonesty by "professional" educators. Recent allegations that an academic dean at a large eastern health education center falsified medical clinic financial statements were connected to prospects for a personal bonus.²³ At the same university, a trustee and prominent political figure made hiring demands and threatened retaliation were they not met. Cronyism, nepotism, and sweetheart deals on real estate were so widely practiced at this institution that the immediate university past-president "established a formal rating system that assigned numerical rankings to job candidates based on their political connections."²³

Similar facts helped lead de Freitas et al. to conclude that "the university does not provide the climate to develop moral and ethical values and principles."⁵

Political Realism
Political support is necessary for professional function in society. In the words of a top academic health center administrator, "Politics is everything." Through laws, administrative edicts, and purse string control, political input determines the nature of professional practice and its economic prospects.² Sadly, "improvement" in health care is typically associated with creation of more laws, rules, and regulations to "protect" the public and control professional behavior. Some legal remedies have a repressive and even nasty tone, as evidenced by a reading of the failed "Health Security Act" pitched by the Clintons in 1993–94. While dental and specialty associations are effective political and legislative advocates, it bears repeating to political leaders and the public that "nothing can substitute for having a trustworthy [dentist] to safeguard a patient’s interest: not laws, regulations, not a patient’s bill of rights, not watchdog federal and state agencies, not fine print in an insurance contract."⁴

	Student Moral Character: Fixed or Variable?

Top Abstract Professionalism's moral... Defining professionalism Student moral character: fixed... Educational research in... Renewing professionalism Conclusions References

 
It is generally agreed that new students bring to dental school a genuine desire to learn, along with a set of moral values. It is certain that the moral origins of professionalism precede entry into professional education. Components of professional attitude were long ago noted as "acquired during the total educational process commencing at birth."⁶ As Pritchard observed, "How a child’s understanding of the moral importance of truthfulness might come into play as he or she becomes a professional suggests that a more complete account of what is needed to become a responsible professional should begin in childhood."¹¹ Most children entering elementary education indeed have "strong ideas about what is fair and unfair, kind and cruel, honest and dishonest."¹¹

Historically, owing to early moral development, intentional change in dental student moral status has been viewed as unattainable.²⁴ However, while current research indicates that moral reasoning ability is modifiable in professional students, it also documents the tendency for stasis or decline of student moral attitudes in pre- and postdoctoral curricula.^3,4,15,25,26 David Stern discovered "a failure of progression of moral reasoning during professional education," with unchanged "moral reasoning scores of 488 medical students at one institution over the four years of medical education," and the same result for veterinary medical students.⁴ "Ethical erosion" has been noted as students "progress" through predoctoral dental and medical programs.^3,4,15,25,26 Hutton surveyed 644 students from forty-six American dental schools and found a progressive decline "in student attitudes about dental education and dentistry . . . as students advance in the curriculum."²⁵ Bertolami referenced "the mal-adaptive cynicism" that can develop in dental students.⁷ On the postdoctoral level, a sample of medical residents failed to make age-expected gains in moral reasoning ability.⁴ Literature "suggests that [student] moral development is profoundly influenced"⁶ and often inhibited by dental education.^3,4,24,25

These disturbing findings demand the attention of dental educators. How are common practices of dental schools "shaping the consciousness as well as character of students, faculty, and leadership?"² One answer is found in the quality of the daily routines, practices, and attitudes of the school, the forementioned hidden curriculum. Acknowledged are its powerful socializing experiences, which "shape apprentices to the practices of the professional school" and to which "future practitioners owe a great deal of their own assumptions about what really matters for the professional."^2,27

A powerful and negative message may be found in dental school clinical requirements. Within this system, students may perceive professional responsibility as centering on numbers of procedures instead of caring for people. The stressful search for patients may foster an attitude of "patient as stepping-stone." Continuation of this misplaced idea in practice would be disastrous for patients and dental professionalism.

An institutional culture that promotes opportunism is hostile to development of vocational integrity and "produces cynicism and demoralization."² If student and faculty experience validates a context of distrust and threat, defensive self-interest seems the reasonable stance toward life. On the other hand, "if student [and faculty] experience rewards cooperation and trust, the individual comes to accept these attitudes as normal and rational."²

Mixed Messages
Granting that dental school faculty and administrators are usually well intentioned, critical analysis of institutional culture is indicated. Lynn Paine of the Harvard Business School stated that "behavior is affected by the culture and context an organization creates."²⁸ As such, personal character may be malleable, not cast in stone. Professional schools send clear positive or negative messages to stakeholders about the valuation of professionalism. In Fisher’s words, "dental education exerts its initial influence on the character of its students in the first course of the curriculum."⁶

What are formal and hidden curricula communicating to students about the place of professionalism in dental education?²⁹ Certainly, that allocation of formal curricular hours speaks volumes about "what counts and what doesn’t count." And for many dental schools, memorizing and spewing forth biomedical science facts are critically important to success; mass exposure to preclinical dental sciences and practical examinations is monumentally important; high grades are essential to postgraduate program acceptance; and, in their paucity of hours, pass-fail grades, and lack of formal student assessment, professionalism is the least important and most expendable element in the curriculum. In short, knowledge and skills "count"; professionalism doesn’t.

David Stern reported that "students are socialized across [formal and hidden] curricula to be acutely sensitive to ‘what faculty want,’ and this fact demands that we pay particular attention to the presence of power and social hierarchies within the structure of [dental] education. Students spend an inordinate amount of time ‘scoping out’ their learning environments to determine what they are status-wise, what they will be held responsible for, and who has the power to hold their noses to the pedagogical grindstone."⁴

Stern observed ironically that faculty members "expect entering students to behave as professionals and to adopt the expected norms of the profession. When faculty propose professionalism assessments for students, one of students’ first reactions will be to ask about the professionalism assessments in place for faculty!"⁴ It comes as no surprise that faculty recalcitrance is a great obstacle to assessment of institutional professionalism. Where it exists, such close-minded and self-protective behavior is a terrible example of professional responsibility.

What Predicts Professional Behavior?
The current numbers-driven system of dental school acceptance does not select applicants based on professionalism potential. Dental and medical school admissions studies show that while required admissions data (overall GPA, science GPA, admissions test score, references, personal essay) are fairly successful in predicting academic performance, they have no predictive power relative to professional behavior in pre- and postdoctoral studies and practice.¹ Also nonpredictive of professional behavior outcomes in medical school were "parental education level, age at admission, extracurricular activities, sports participation, and advanced degrees."¹

On the other hand, a retrospective cohort study at an American medical school revealed that student failure to complete professional school immunization and course evaluation requirements is a "significant predictor of unprofessional behavior in clinical years," along with inaccurate student self-assessment of performance on standardized patient exercises. Students who overestimated their performance had significantly lower clinical professionalism ratings than students demonstrating humility in self-assessment.¹ As the authors postulate, this may "reflect the value of humility, seen as a virtue in most doctors."¹ Positive faculty assessment of "conscientious behavior" by students is another predictor of clinical professionalism.²⁴

Sustained Unprofessionalism
Dental educators may assume that professional dental students become professional dentists.³⁰ Educators are naturally concerned about students who exploit the trust invested in them and act unprofessionally, intuitively fearing repetition of the misconduct in practice. Recent research findings validate these concerns.³⁰ Notwithstanding anecdotal foreknowledge of clinical faculty in predicting problematic practitioners, little evidence has supported student professionalism as an important competence in dental education and lifetime ethical dental practice. The 2005 Papadakis et al. study in the New England Journal of Medicine reveals that specific types of unprofessional student behavior are predictive of state professional board disciplinary action against practitioners.³⁰ Professional board disciplinary action is strongly associated with formerly documented student noncompliance, irresponsibility, impaired relationships with peers, faculty, and staff, unreliable attendance at clinic, argumentativeness, rudeness, and diminished capacity for self-improvement.³⁰ Professional board action against practitioners is also associated with low student admissions test scores and failing courses in the first two professional school years. Students having three or more instances of recorded unprofessional behavior had eight times greater risk of later disciplinary action in practice (drug- or alcohol-related offenses, conviction for a crime, negligence, inappropriate prescribing, violation of a board order, and sexual misconduct) compared to control students.³⁰ A chilling study conclusion was that "among some students, unprofessional behavior is sustained over decades." This article also reported that male gender was not a disciplinary action risk factor, a finding at odds with other studies.

	Educational Research in Professionalism

Top Abstract Professionalism's moral... Defining professionalism Student moral character: fixed... Educational research in... Renewing professionalism Conclusions References

 
Muriel Bebeau’s 2002 review of thirty-three studies from dentistry, medicine, veterinary medicine, nursing, and law found that professional education generally does not promote development of moral judgment.³¹ Bebeau confirmed differences in development of moral judgment based on "maturity, region, culture, and gender." Other studies measuring moral reasoning consistently documented higher scores for women than men.⁴ Bebeau noted that inclusion of carefully designed ethics instruction could improve dental student moral reasoning ability^31–34 and emphasized the need to explicitly measure moral reasoning outcomes in evaluating instructional effectiveness.³³ Her studies of dental and nursing students further revealed "a significant relationship between moral reasoning and clinical performance."^31–34 Bebeau cautioned against relying on ethical development "quick-fixes" such as white coat ceremonies, favoring experience-based, student reflective thinking, and echoed Chalfin’s call for in-depth predoctoral and postgraduate ethics education.³⁵

Self and Baldwin reported a significant relationship between "levels of moral reasoning and measures of clinical performance of medical students, residents, and physicians."⁴ They concluded that "assessment of moral reasoning is important in assessment and teaching of professionalism."

Given the hidden curriculum’s key role in developing student professionalism, assessing only the formal curriculum is inadequate. Measurement of professionalism should reflect the "multidimensionality of student learning."⁴

While health professional literature reports curricular innovations designed to promote student professionalism, very few studies evaluate criteria for predicting professional behavior in dental school applicants, students, and practitioners.³⁶ Assessment of the efficacy of professionalism education in turn depends on valid and reliable faculty, student, and patient surveys.

A number of existing surveys may assist in development of solid, institution-specific assessment vehicles. Two questionnaires developed to measure student professionalism as assessed by residents and faculty are the Baldwin Survey of Resident Reports of Unethical and Unprofessional Conduct and the Scale to Measure Professional Attitudes and Behaviors in Medical Education.⁴ The Defining Issues Test assesses moral reasoning in pre- and postdoctoral students.^4,31

Patient-reported assessment of student professionalism is provided by the Wake Forest Physician Trust Scale.³⁷ The Amsterdam Attitudes and Communication Scale uses faculty assessment of observed student management of patients.⁴ A simple Professionalism Evaluation Form used by course directors and faculty at a U.S. medical school assesses student attributes.²⁹ A Student Professionalism Scale, based on personality-related professionalism competencies identified as essential to successful practice, was employed by Chamberlain et al. to assess dental student professional behavior.³⁸

	Renewing Professionalism

Top Abstract Professionalism's moral... Defining professionalism Student moral character: fixed... Educational research in... Renewing professionalism Conclusions References

 
Despite formidable obstacles, all is not lost with dental professionalism. At least three factors provide egress from the swamp. One is dentistry’s deep-rooted professional culture, still a potent force for social and professional good. The dentist’s ability to contribute to and participate in this culture, the daunting educational and licensure efforts necessary for entrée, and the important benefits for patients and society create a powerful professional bond. Opportunities for leadership, high social position, and substantial income add to the attraction, plus the "promise of a satisfying sense of identity and personal achievement." Professionalism "as a means of livelihood that is also an attractive way of life is still a reality."²

The second key lies in addressing the problems of contemporary society: provision of quality education, access to and costs of health care, relief of human suffering, recurring war and terrorism, and neglect of children and the elderly. Only professionals can solve these problems. As Marten Ten Hoor emphasized in the 1960 Journal of Dental Education, "Solution of problems of common welfare can’t be left to the uneducated, or to dictators, or bureaucrats, or politicians."³⁹

Sullivan rightly stated that "professionalism opposes the misplaced concept that consumer demand is the unfailing answer to social [and physical] ills, taking us beyond the simplistic idea that a market framework can solve the most important issues of social and political life." While successful professional services depend on "firm relationships, continuity, and stability, these are problematic in the culture of the ‘terrific deal.’"²

The third step in remediation of the professionalism dilemma is realizing that salvation lies in well-planned and sustained education. As Papadakis et al. noted, "Professionalism can and must be taught and modeled."³⁰ With education and experience, dental students and dentists are likely to elevate their standards of professionalism.³⁰ This contention is not universal, as some educational leaders question the "staying power" or value of ethics instruction in effecting behavioral change.^7,40

In addition, educational emphasis on "patient-focused, socially orienting practice" is vital to renewal of professionalism’s social bond. This entails teaching and modeling of the patient’s interest as the highest priority in dentistry, defining and maintaining "standards of competence and integrity," and provision of "expert advice to society" on health issues.² The social contract is the moral spine of professionalism; without it, the professional body withers.

Vigilant action by state dental boards in identifying and disciplining unprofessional dentists is another essential factor in reenergizing dental professionalism.⁴⁰

Setting the Institutional Course
Since dental schools radiate unmistakable messages about the importance, or lack thereof, of professionalism, school leadership must first align institutional culture with maximum professionalism. Dental school leadership is responsible for developing institutional consensus on foundational issues of professionalism, then practicing the principles that result and communicating them to constituents. The job includes continual assessment of student and faculty professionalism and mission adjustment.

Strengthening professionalism in dental schools is far more than a committee assignment. It demands passionate advocacy for institution-wide behavioral standards of excellence that set dentistry apart in its social responsibility, stakeholder buy-in, and challenge of attainment. It includes recruitment of multiple exemplars of professionalism who live and practice the special qualities and duties inherent in professional life. It mandates love of people and the dental profession, and substantially elevates institutional esprit de corps.

Successful reinvigoration of professionalism in dental education is a systemic response to a critical need, analogous to the total quality management concept in Japanese manufacturing. It is not an add-on to a sick curriculum or the "quality control" approach that so miserably failed American industry. Professionalism is not something that students and practitioners can put on and take off, like a white coat. It exists deeply as part of personal identity.⁴

Whether part of strategic planning or as a separate exercise, leadership, faculty, and students must develop a concise and readily understandable definition of professionalism. Perhaps this responsibility is best exercised by the dental profession as a whole. Answers to a number of vital questions will provide background for consensus:

1. What is dentistry’s moral core: the core commitments that define the profession? As Coulehan put it, "A profession without its own distinctive moral convictions has nothing to profess."⁴⁰ There is a distinct lack of student integration with the moral core of dentistry.²
   
2. What social roles does the dental profession serve?
   
3. How does the dental school demonstrate to students, faculty, university, practitioners, and society the importance it places on development of professionalism?
   
4. What are the daily responsibilities of dental professionalism to faculty, students, and practitioners? What constitutes exemplary professionalism to these groups?
   
5. Given the teaching and learning provided by the school’s formal and hidden curricula, how do students, faculty, and administration actually behave in daily practice? How does the school evaluate professionalism in students and faculty?
   

Besides exploration of foundational issues, the process of assessing and enhancing professionalism in dental education includes identifying assessment criteria, developing faculty and student awareness, collecting data on interventions, and providing feedback.⁴

While culturally, ethnically, and economically diverse students and faculty are highly desirable for dental education, differences in languages and customs may pose communication challenges to attainment of consensus on professionalism.⁷ Great care, talented people, sense of mission, and considerable work will enable creation and effective communication of the consensus message, the standard for all dental school interpersonal activities. Consensus-developed, explicit standards of professionalism will infuse dental school admissions materials, dental student handbooks, faculty handbooks, predoctoral orientation presentations, all clinical experiences, faculty, student, and patient interactions, dental fraternity operations, and expected outcomes for graduation. Faculty handbooks should contain clear language about the importance of daily modeling of professionalism, its evaluation in faculty performance reviews and promotion decisions, and the responsibility to assess student professionalism. Continuing, evidence-based faculty development programs are also essential to building and maintaining a strong core of professionalism.^40–42

Part of the consensus message to students is their need to learn, from day one of dental school, that cheating does matter: to students, future practitioners, patients, and professions. Perhaps more importantly, the same applies to faculty. Dental faculty and administrators, as well as government and corporate dentists, need to know, and practice, that employee status does not excuse unprofessional conduct.¹¹

Need for Heroes
Stellar faculty modeling of professionalism "continue[s] to remind [students] of what professionals could be, or could be imagined as being. . . . By just such visions men [and women] live through the low moments,"¹² and aspire to excellence.

With profound influence on the practice of student and future doctor professionalism,^{3,6,15,40,44,45} faculty exemplars deserve a place of honor within dental schools. Leadership is advised to identify, organize, encourage, and reward these heroes. This is a daunting task at dental schools whose definition of faculty support is a yearly award by students to their favorite educator. Physical space can be devoted to honoring exemplary faculty in a "hall of champions," with a school website link performing the same function. Bonuses can be given. The investment will be returned manyfold.

If an upsurge of professionalism occurs in dental education, these faculty, and others inspired by them, will lead the charge. By their example, an evidence-based, countercultural movement will form to elevate ethical and moral standards and combat negative messages of the formal and hidden curricula.

Service-Learning
Pritchard welcomed the current "marked increase in student volunteerism,"¹¹ which dovetails with dental education’s need for major student service-learning.⁴⁰ Service-oriented learning projects are necessary student community experiences that, when highly structured and combined with carefully designed learning objectives, "encourage understanding and appreciation of the health needs of the underprivileged."¹¹

Because clinically oriented community service gives students a strong taste of practice, "[these] experiences can stimulate reflection on directions [students] want their careers to take and on the values and ethical ideals they hope to sustain."^11,43,44 School clinics alone do not provide sufficient student interdisciplinary learning and opportunities for social responsibility.⁴⁰ Through service-learning, students may also discover the influence of insurance companies and pharmaceutical firms on patient care and the importance of doctor advocacy on behalf of patients.⁴⁴

As Jack Coulehan advised, "The minimal required ‘dose’ of community service must be sufficiently large for students to view it as integral to the culture of [dental] education and practice, rather than an unconnected add-on."⁴⁰ Four months of predoctoral service-learning appears to fit this bill.^40,43,44

Within service projects, guided teaching enables students to appreciate moral components of patient care and apply moral principles clinically. As in dental practice, student "mastery can only be achieved by participation in assessing and responding to moral situations under the guidance of mentors."¹⁵

The system of student selection could benefit from inclusion of formal predental service-learning requirements.² Applicants with a service project history reflect at least a degree of social awareness. Furthermore, dental school applicants should know the school’s culture of professionalism: its defining role in the school’s mission, how it is practiced and assessed, and the rigors of professional responsibility. Does the applicant commit to assume these responsibilities?

Student Portfolios
Student-generated written, oral, and shared reflections on class and clinical experiences are invaluable learning and motivational aids.^4,40,45,46 Student portfolios may contain written professionalism goals, patient and self-evaluations, faculty and peer comments, videos of class presentations, descriptions of critical incidents, and reflective comments on clinical practice.^4,40,45,46 Not only a record of personal progress and achievement, the reflection on performance encouraged by portfolios helps "translate the experience of clinical practice into learning."⁴ With the demands of a packed curriculum, reflective time is a rare commodity in health professions education.⁴

When applied consistently, portfolio work develops key aspects of professionalism such as self- assessment, effective written and oral communication, and increased awareness of developing professional identity.^4,40 As Stern noted, "the developmental and longitudinal nature of the portfolio allows students and faculty to observe progress over time."⁴

As ADEA Policy Statements advise, students should be encouraged to participate in dental associations and dental fraternities.¹⁹ Hidden curricular learning resources for professionalism, they provide healthy venues for sharing experiences, developing personal awareness, and alleviating anxiety, frustration, and depression.⁴⁰ Small-group, informal student-faculty meetings perform the same function.

Recipe Tried and True
At the final graduation ceremony of Northwestern University’s dental school, Dr. Harold T. Perry offered this "prize-winning" formula for professionalism: "Gather all ingredients together so that they are close at hand. Get a clean cloth and wipe the bowl clean of any lingering bad habits. Take maturity, respect, experience, and stir gently. Add unlimited amounts of compassion and kindness. Mix well with responsibility. To this add caring by the handful, and fold in trust. Continue to stir gently, adding listening, honesty, and generous amounts of communication. Slip in ethics and treatment goals and pieces of keeping promises. Bake in an office filled with compassion, respect, and self-esteem. Before serving, sprinkle over with patience and a lot of understanding. Serve with imagination, good humor, and, on the side, a big smile."⁴⁷

	Conclusions

Top Abstract Professionalism's moral... Defining professionalism Student moral character: fixed... Educational research in... Renewing professionalism Conclusions References

 
Professionalism is "a caring and humanitarian activity that respects patients and colleagues and strives to give something back to community and profession."⁴⁸ Bertolami accurately described professionalism as truly "a whole-life project."⁷

Flowering of dental professionalism requires that educational leaders passionately advocate for high standards of practice, including a clear conception of the importance of professionalism, "while inviting public response and involvement in the profession’s effort to clarify its mission and responsibilities."²

"Professional integrity should be an explicitly common educational objective in dental education,"² its measurement a top priority.⁴ Yet it appears that "while we profess and encourage professionalism, we do little to ensure its presence."⁴ Stern warned that "failure to assess for professionalism sends a conflicting message to both students and practicing dentists"⁴ about the reality of its status in dentistry. It is inconsistent and self-serving for dentistry to proclaim reverence for professionalism "while willing to settle for graduates who manifest it only as a surface phenomenon."⁴ The question must then be asked, "Just how ‘core’ is professionalism to dentistry’s nature and identity?" Dental education must show that morality and ethics "really count."⁵

An institution’s moral tone is set from the top.¹⁵ Dental school and university cultures send clear messages to students on the importance of professionalism in daily life. For good or ill, faculty attitudes and behaviors powerfully determine student attitudes and behaviors.¹⁵

Avenues offering favorable prospects for renewing dental professionalism include "greater student exposure to professional role models, deep experience in community service, and reflective written and oral portfolio development."⁴⁰ At the heart of these efforts is "helping young people examine what’s often unexamined about their worldview and sense of purpose."²⁸

Research shows that moral reasoning ability is strongly associated with "qualities and attributes of professionalism."⁴ Formal educational programs can enhance student moral reasoning, a foundational step in promoting professionalism.¹ Likewise, early patient contact promotes student self-confidence and development of professional attributes.⁴⁹

Valid and reliable surveys exist for pre- and postdoctoral student assessment of moral reasoning. Such assessment is likely useful in evaluating student professionalism and curricular programs designed to develop professionalism. Moral reasoning tests have been advocated as part of health professions student evaluation.⁴ Measurement of moral reasoning should also be effective in assessing institutional professionalism.

Current dental school admission requirements do not predict student outcomes in professionalism.¹ Moral reasoning assessment may be useful in screening applicants. The strongest predictor of unprofessional practice is documented unprofessional student behavior.²⁴ Low DAT scores and course failures in the first or second dental school years are predictors of unprofessional practice. Faculty-documented conscientious student behavior and accurate student self-assessment of performance on standardized patient encounters, on the other hand, predict future professionalism.^1,31 Student humility may be another predictor of professional behavior.

As evidenced by its policy statements, ADEA has helped lead efforts at recognizing the importance of professionalism in the development of dentists.¹⁹ These words of wisdom beg familiarity at all levels of dental education and practice. As per ADEA Competencies for the New Dentist, student professional development should begin on day one of dental school.⁵⁰ Expectations and responsibilities of professionalism should be crystal clear, with faculty and students having no doubt as to what constitutes acceptable and unacceptable professional behavior in academic and clinical settings. Elimination of mixed messages to students about professionalism is a dental school responsibility.

Finally, as ADEA Policy Statements advise, "Market forces, societal pressures, and professional self-interest should not compromise the professional objective of equitable and adequate health care for all Americans."¹⁹

	Footnotes

 
Dr. Masella is Associate Professor, Department of Orthodontics, Nova Southeastern University College of Dental Medicine. Direct correspondence and requests for reprints to him at Department of Orthodontics, College of Dental Medicine, Nova Southeastern University, 3200 S. University Drive, Fort Lauderdale, FL 33328; 954-262-7397 phone; 954-262-1782 fax; rmasella{at}nova.edu.

This article is followed by two reaction articles—the first by Dr. Ronald Botto, University of Illinois at Chicago, and the second by Dr. Donald Patthoff, Member of the Ethics Committee of the American College of Dentists.

Exchange ideas and ask questions about this article in an online chat with Dr. Richard Masella, Wednesday, April 11, 2007, noon-12:45 p.m. Eastern time. For complete details, visit www.adea.org.

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