Teaching professionalism in a formal curriculum is so much different than demonstrating professionalism in the Emergency Department. So much of what students and residents learn about professionalism are from observed behaviors of the attending physicians — that is, the hidden curriculum.

In a qualitative study assessing medical student reflection essays during an EM clerkship, the authors (my friends Dr. Sally Santen and Dr. Robin Hemphill) found some startling results. The instructions to the medical students were to “think about an aspect of professionalism that has troubled you this month. Write a minimum of one half-page reflection describing what was concerning and how you might handle it.”


  • 61 of 150 reflection essays discussed professionalism themes.
  • Using a grounded theory approach, the authors first looked at the data and then created categorical themes. 

 Analytic Domains

1. Demonstration of positive professional behavior

  • Demonstration of compassion and empathy
  • Tension between respecting diversity and respecting other core values
  • Balance between patient-centered care and effective care 
  • Commitment to ethical principles

2. Observation of unprofessional behavior 

  • Lack of compassion 
  • Not telling the truth 
  • Lack of teamwork 
  • Inappropriate medical care

3. Personal improvement and learning

  • Whether to speak up because they are subordinate in a hierarchy 
  • Plans for their own future personal professional behavior through reflection on observed professional and unprofessional behavior and their own behavior

The take-home point is that unprofessional behavior definitely occurs in the ED to varying degrees, and medical students are astute at identifying these. There were examples of lack of compassion, struggles in prescribing opiates to apparently drug-seeking patients, and not telling patients the truth.

As residents and faculty, we must maintain an open-mind and set high standards for professionalism. Even if you aren’t being called out on it, learners are noticing. They just might not be vocalizing their concerns because of their role as “subordinates” in a hierarchy who depend on evaluations to secure a good grade on their rotation.

Especially with young, impressionable new medical students and interns in the ED soon to start in the new academic year, remember to lead by example.

Santen SA, Hemphill RR. A Window on Professionalism in the Emergency Department Through Medical Student Narratives. Annals of emergency medicine. 2011 – in early press. PMID: 21624702.

Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD