Document Type : Original Article


1 Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Department of Medical Ethics, School of Medicine, University of Medical Sciences

2 Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences

3 Department of Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences

4 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Knowledge Utilization Research Center, Tehran University of Medical Sciences

5 Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran


INTRODUCTION: Despite all efforts that have been made to promote professional behavior among
medical trainees, unfortunately, reports from medical schools around the world confirm the prevalence
of nonprofessional behaviors by medical students. Experts in the field of medical ethics and medical
education in different countries have suggested several reasons for failing to minimize unprofessional
performance among medical students.
MATERIALS AND METHODS: This qualitative study aimed to promote our understanding from the
challenges faced by Iranian medical students in providing professional behavior. The study was first
conducted in the form of a semi‑structured face‑to‑face interview with medical students and then
completed with a focus group discussion (FGD) session. Forty‑nine medical students participated
in the interviews and 11 students participated in the FGD session. Qualitative conventional content
analysis was used for examining the data.
RESULTS: The participants classified the obstacles of professional behavior into the following
three main categories: problems related to educational system, problems related to the society, and
problems related to students themselves.
CONCLUSION: Regarding the impact of various personal, social, and educational factors on the
creation and expansion of unprofessional behaviors among medical students, it is essential to have
a comprehensive approach for solving the problem.


1. Levinston W, Ginsburg S, Hafferty F, Lucey C. Understanding
Medical Professionalism. 1st ed. China: McGraw‑Hill Education/
Medical; 2014.
2. Ellaway RH, Chou CL, Kalet AL. Situating remediation:
Accommodating success and failure in medical education
systems. Acad Med 2018;93:391‑8.
3. Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld‑JaegerJ,
Bost P. Patient complaints and malpractice risk. JAMA
4. Rosenstein AH. The quality and economic impact of disruptive
behaviors on clinical outcomes of patient care. Am J Med Qual
5. RosensteinAH. Physician disruptive behaviors: Five year progress
report. World J Clin Cases 2015;3:930‑4.
6. Allinson M, Chaar B. How to build and maintain trust with
patients. Pharma J November 2016;297:7895. Available
from: https://www.pharmaceutical‑‑care/
article?firstPass=false. [Last accessed on 2018 Oct 10].
7. ABIM Foundation, American Board of Internal Medicine,
ACP‑ASIM Foundation. American College of Physicians‑American
Society of Internal Medicine, European Federation of Internal
Medicine. Medical professionalism in the new millennium:
A physician charter. Ann Intern Med 2002;136:243‑6.
8. Blank L, Kimball H, McDonald W, Merino J; ABIM Foundation,
ACP Foundation. Medical professionalism in the new
millennium: A physician charter 15 months later. Ann Intern
Med 2003;138:839‑41.
9. de Oliveira Vidal EI, Silva Vdos S, Santos MF, Jacinto AF, Boas PJ,
Fukushima FB, et al. Why medical schools are tolerant of unethical
behavior. Ann Fam Med 2015;13:176‑80.
10. Byszewski A, Hendelman W, McGuinty C, Moineau G. Wanted:
Role models – medical students’ perceptions of professionalism.
BMC Med Educ 2012;12:115.
11. Silveira GL, Campos LK, Schweller M, Turato ER, Helmich E,
Antoniode Carvalho-Filho M. "Speed up”! The influences of the
hidden curriculum on the professional identity development of
medical students. Health Prof Educ 2019;5:198-209.
12. Ozolins I, Hall H, Peterson R. The student voice: Recognising
the hidden and informal curriculum in medicine. Med Teach
13. Hafler JP, Ownby AR, Thompson BM, Fasser CE, Grigsby K,
Haidet P, et al. Decoding the learning environment of medical
education: A hidden curriculum perspective for faculty
development. Acad Med 2011;86:440‑4.
14. Caldicott CV, Faber‑Langendoen K. Deception, discrimination,
and fear of reprisal: Lessons in ethics from third‑year medical
students. Acad Med 2005;80:866‑73.
15. Shapiro J. The feeling physician: Educating the emotions in
medical training. Eur J Person Cent Healthc 2013;1:310‑6.
16. Doulougeri K, Panagopoulou E, Montgomery A. (How) do
medical students regulate their emotions? BMC Med Educ
17. Strauss A, Corbin J. Basics of Qualitative Research: Techniques
and Procedures for Developing Grounded Theory. 4th ed. United
States of America: SAGE Publications, Inc.; 2014.
18. Neutens J. The Hidden Curriculum: What are you teaching?
Association of Professors of Gynecology and Obstetrics (APGO);
2008. Available from: [Last accessed on
2017 Oct 10].
19. Roberts LW, Warner TD, Hammond KA, Geppert CM, Heinrich T.
Becoming a good doctor: Perceived need for ethics training
focused on practical and professional development topics. Acad
Psychiatry 2005;29:301‑9.
20. Yamey G, Roach J. Witnessing unethical conduct: The effects.
West J Med 2001;174:355‑6.
21. Shapiro J. Walking a mile in their patients’ shoes: Empathy and
othering in medical students’ education. Philos Ethics Humanit
Med 2008;3:10.
22. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK,
Isenberg GA, et al. The devil is in the third year: A longitudinal
study of erosion of empathy in medical school. Acad Med
23. Ofri D. What Doctors Feel: How Emotions Affect the Practice of
Medicine. 1st ed. United States of America: Beacon Press; 2014.