Exploring Medical Professionalism amongst Postgraduate Trainees of Bolan Medical Complex Hospital Quetta

Introduction: The traditional educational system has concentrated on cognition acquisition and skills essential for physician practice. However, medical educationists are focusing more on good professional doctors now, having a cognitive foundation to work alongside their social roles as a physician-to-be. Aims and Objectives: To assess medical professionalism amongst postgraduate trainees at Bolan Medical Complex Hospital, Quetta.

enormous recognition in medical education 3 .Medical professionalism exhibits a social commitment between doctors, patients, and the society they serve.For being a good professional moral and intellectual traits are needed.Altruistic, trustworthiness, empathy, lifelong learning, teamwork, emotional intelligence and patient care are the main ingredients of these traits 4 .Researchers in Western countries use different tools to assess the professional behavior of medical students 3, 4, 5, 6 .The same is observed in Pakistan, Razaq A, assessed professionalism amongst PGs through mini evaluation exercise (P-MEX), 7 while, Naureen K in her study developed and validated psychomotor analysis of the Professional Assessment Tool (PAT) 8 .Though professionalism at the undergraduate level has been assessed by other researchers 9,10,11,12,13 , no study has ever been conducted to assess professional behavior at PG levels such as responsibilities, reliability and accountability, self-assessment, humanism, integrity, empathy and compassion, honesty, and

INTRODUCTION
Globally, acute generalized peritonitis ranks among the top surgical emergencies 1 .It is more common in Third World nations.The prevalence of perforation is low (0.6% -4.9%) in developed nations but high (33% -63%) in West Africa 2 .554 persons were discovered to have peritonitis in a study that took place over three years in India 3 .Researchers in Pakistan have conducted studies with similar methods, with one study reporting 650 cases in a just 9 months 4 .Most cases of peritonitis are caused by a gastrointestinal perforation or anastomotic leak 5 .In the case of peritonitis, anaerobes and gramnegative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade brought on by the release of endotoxins 5 .Clinical evidence is used to identify peritonitis.Diagnosis can be achieved via upright plain x-ray of the abdomen, USG, or CT scan.This is often done through diagnostic laparoscopy nowadays 6 .Resuscitation, diagnosis, prompt exploration, treatment of the underlying cause, and extensive surgical peritoneal lavage have always been the cornerstones of peritonitis therapy regimens (IOPL) 7,8 .Regular IOPL is performed to lessen bacterial contamination and burden.Even though large volumes of normal saline are used in IOPL, the rates of sepsis, wound infection, and mortality remain alarmingly high.Another method ethical behavior, as well as professional engagement with the community.The rationale of the study: The assessment of PG's professional behavior is a crucial element of development as a physician.Medical educators accept that professionalism is an inner skill and performance as a professional is very important for being a good clinician.Identification of deficiencies in medical professionalism is crucial in career development.This study highlights the core deficiencies in the professional behavior of PGs.Therefore, by using PAT we checked PG's professional level of three different specialties of Bolan Medical Complex Hospital (BMCH), Quetta.This shall assist in achieving the goal of formally integrating professionalism in the postgraduate curriculum to transmit the attributes, principles, and beliefs of the health profession and introduce new strategies to enhance professionalism amongst postgraduate trainees.In the current study item 1 of Domain 1 "Fulfill responsibilities in quality manner" and item 5 of Domain 3 "Establishing and maintaining appropriate boundaries in work and learning situations" scored the highest percentage (n=22/47, 46.8%).In a contrary study conducted on pharmacy students, Eukel H 14 in his study recognizes all items of Domain 4 as crucial in the health profession, (84-91%), whereas in our study very low scores (38.1%) were obtained at item 1 of Domain-4 14 .Absence or deficiency of this domain may lead to ineligibility for the licensure certification.On the other hand, PGs of the current study were keen to perform their duties, aware of what the public, patients' families, and patients themselves expected.The healthcare system introduces professional development initiatives including short courses and seminars and others to remain updated with the need for the professionalization of medical education 15 .

Ethical approval was taken from
For PGs proper time management between work demands and learning requires commitment, good performance at work and being successful in their academics 16 .The same was reflected in our research work as PGs were aware of their boundaries and managed time between their work and learning facilitating their academic success (n=22/47, 47%).Teamwork is the crucial and detectable work design of this advanced era 17 .Most of the PGs of the current study (n=20/47, 42.5%) were cognizant that collaborative work enhances creativity, and innovation and assists in resolving unsolved issues and therefore they preferred teamwork.Individuals due to financial strains, academics, job, and family issues may experience interpersonal problems and stress on the other hand, individuals with good mental health are emotionally intelligent (EI), demonstrate constructive behavior process emotional information accurately, and gather social support 18 .Our PGs demonstrated good emotional control in stressful conditions (n=19/47, 40.4%).In past decades there were deficient transdisciplinary and evidence-based strategies for patient safety and insufficient risk management schemes in Pakistan.However, institutions as well as PGs have attempted to upgrade healthcare 19 .Participants in the current work were aware of patients' needs and alert to the needs of their peers.(n=18/47), 38.2% score for patient and peer need respectively).Sequenced educational standards and assessment policies produce standards-based education.Constructive feedback is crucial for students because that stimulates, motivates and engages students in the required direction producing desired results in learning 20 .Our research participants were cognizant of constructive feedback and utilized it properly (n=17/47, 36%).This study was the first in its kind that was conducted to assess professionalism at PGs of three different specialties (General medicine, Psychiatry, Neurosurgery) in the most well reknowned and largest medical teaching institution of Balochistan, Pakistan.Though other researchers have assessed professional level but utilization of different tools makes it difficult to compare the results of the current study with others' work.There may be a bias in answering the questions as well as in data collection.In future, the different domains of physician competency should be developed and evaluated separately.Also, further studies should be carried out to implement this questionnaire (PAT) to a larger cohort of PGs to validate its use and for longitudinal assessment of the professionalism behaviors of PGs.
To attain the benefits of professionalism properly we should follow the following steps to confirm the effective integration of professional education into our curriculum: Step I: Acquiesce the definition of professionalism that is acceptable to the institution.
Step II: Develop a curriculum frameworkby setting expectations.
Step III: Models for learning/teaching professionalism.

How to teach professionalism:
The best way to teach professionalism is reflective work.Reflection before action and reflection on action are the forms of the Kolb's Learning Cycle (The Kolb'smodel points out two divergent methods of learning through acquaintance (concrete experience)' and 'perceptions.'These methods of acquaintance follow 'reflective observation' and 'active experimentation) 21 .Kolb's defines experiential learning theory as where reflectors construct knowledge through their experience and nurture reflective thinking 22 .

How to measure professionalism:
1. Measure PG's professionalism by collecting data on their attendance, tasks completed and being submitted on time, regular and active participation in evaluation and research.After completing each task adequately on time, they should be awarded points/scores/grades based on their observed professional behavior 21 .2. Peer assessment process based on communication skills, task performance, and personal performance should be employed.In peer assessment colleagues' views on the strengths and weaknesses of their peers improves student professional behaviors.

360-degree professionalism appraisal for PGs during their training.
A team assessment of behavior (TAB) consisted of a 3-point scale (pass, borderline, and fail) along with a comment box on four domains including Professional relationship with patients, Verbal communication skills, Teamwork, and Accessibility should be done.Each rater (doctor, cosupervisor, nurse) fills in the TAB and confidentially returns it to the student's clinical supervisor who summarizes a report to decide whether the student requires further training or his/her professionalism development in a particular domain of professionalism is adequate 21 .

Fig
Fig-1: The Bar Chart presents the Highly Statistically Significant Correlation between Professional Years and Items DISCUSSION Highly statistically significant results (p-<.001) were observed when professional years were correlated with item no 4 of Domain 2 (Selfassessment to identify strengths and weaknesses), and items no 1, 2, and 3 of Domain 3 ("Establish Rapport, Sensitive to the need of Patients and Sensitive to the need of Peers," respectively) The highest percentage score (n=22, 46.8%) was obtained at item 1 of Domain 1 and item 5 of Domain 3. Secondly (n=20, 42.5%) item 8 and item 9 were second and third positions in this category (n=19, 40.4%) from Domain 3. Other items no 2 and 3 (Domain 3) and items no 4 (Domain2) attained 43% score.Whereas item no. 4 from Domain 2 gained a 40.5% score.In the current study item 1 of Domain 1 "Fulfill responsibilities in quality manner" and item 5 of Domain 3 "Establishing and maintaining appropriate boundaries in work and learning situations" scored the highest percentage (n=22/47, 46.8%).In a contrary study conducted on pharmacy students, Eukel H 14 in his study recognizes all items of Domain 4 as crucial in the health profession, (84-91%), whereas in our study very low scores (38.1%) were obtained at item 1 of Domain-414 .Absence or deficiency of this domain may lead to ineligibility for the licensure certification.On the other hand, PGs of the current study were keen to perform their duties, aware of what the public, patients' families, and patients themselves expected.The healthcare system introduces professional development initiatives including short courses and seminars and others to remain updated with the need for the professionalization of medical education15 .

Mean Age 21.4SD±.658 Table1: Displays Demographic Data Sr. No Domain Items Miller Level of Performan ce N (%age) 1
Participants' demographics (age, gender, professional year, medical experience, other degrees, and specialty) were collected.There were five domains in PAT consisting of 33 items.