Reflections in Internal Medicine Approaches to professional behaviour assessment: Tools in the professionalism toolbox Walther N.K.A. van Mook a,b, ⁎, Simone L. Gorter c , Helen O'Sullivan d , Valerie Wass e , Lambert W. Schuwirth b , Cees P.M. van der Vleuten b a Departments of Intensive Care and Internal Medicine, Maastricht University Medical Centre, P. Debeyelaan 25, 6202 AZ Maastricht, The Netherlands b Department of Medical Education Development and Research, Maastricht University, Faculty of Health, Medicine, and Life Sciences, Maastricht, The Netherlands c Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre, Maastricht, The Netherlands d Centre for Excellence in Developing Professionalism, School of Medical Education, University of Liverpool, Liverpool, United Kingdom e Manchester Medical School, University of Manchester, Manchester, United Kingdom abstract article info Article history: Received 23 December 2008 Received in revised form 22 July 2009 Accepted 25 July 2009 Available online 20 September 2009 Keywords: Problem based learning Professional behaviour Professionalism Tutorial group Assessment Tools There is general agreement that professionalism and professional behaviour should be (formatively and summatively) assessed, but consensus on how this should be done is still lacking. After discussing some of the remaining issues and questions regarding professionalism assessment, this article discusses the importance of qualitative comments to the assessment of professional behaviour, focuses on the currently most frequently used tools, as well as stresses the need for triangulation (combining) of these tools. © 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. 1. Introduction Assessing professionalism as an outcome measure of medical education mirrors the trend to measure outcomes of patient care as indicators of health care quality. Tools have been developed for measuring professionalism and professional behaviour to identify, counsel, and remediate students demonstrating poor professional behaviour [1]. Assessing professionalism during (internal medicine) specialist training programmes serves comparable purposes [2]. The challenge of assessing professionalism can be summarised by two statements: “If it can't be measured, it can't be improved,” and “They don't respect what you expect, whereas they respect what you inspect” [3]. Assessment motivates students to learn what is important and informs teachers whether programme expectations are clear and whether students have learnt from these experiences. Lack of formal assessment may send a conflicting message to students. Assessment of professional behaviour serves a clear forma- tive purpose (‘no feedback, no learning’ or ‘assessment drives learning’), as well as a summative purpose (‘no learning, no pass,’ or ‘go/no-go decision’). To date the focus has largely been on the summative aspects, and identifying the few ‘bad apples.’ However the formative aspect is obviously essential and should benefit all students. Many other issues and questions fuel the ongoing debate. Some debate whether professionalism or professional behaviour should be assessed. Should one global measure be used (as a comprehensive and integrated entity), or should professionalism be broken down into specific elements, which are measured independently? [4–7] Addi- tional areas of discussion centre on: (i) how many observers are needed to make a reliable assessment? (ii) Who should perform it; faculty, peers, patients or even others? (iii) Where to perform assessments; only in authentic contexts or are simulated circumstances acceptable? And (iv) how often should assessments be done; frequently after short observations or less often after intensive observation? The perfect measure for professionalism lies most certainly in Utopia! Any one single measure alone is not sufficient [8]. A combination (triangulation) of currently available instruments is necessary [9]. With any unstructured assessment tool, the quality of the information gathered is dependent on the user. Contemporary professionalism assessment methods, however, tend to be mildly structured. They include self and peer assessment, the objective structured clinical examination (OSCE), direct observation by faculty during regular educational sessions, critical incidents reports and learner maintained portfolios [3,10–12]. Often standardised checklists are used [13,14]. European Journal of Internal Medicine 20 (2009) e153–e157 ⁎ Corresponding author. Departments of Intensive Care and Internal Medicine, Maastricht University Medical Centre, P. Debeyelaan 25, 6202 AZ Maastricht, The Netherlands. Tel.: +31 43 3876385; fax: +31 43 3874330. E-mail address: w.van.mook@mumc.nl (W.N.K.A. van Mook). 0953-6205/$ – see front matter © 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2009.07.012 Contents lists available at ScienceDirect European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim