Moving Beyond the Dichotomous Assessment of Professionalism in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors

Purpose This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics.Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students.Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.Professionalism is a core competency of medicine and medical education, grounded in the intentional daily commitments that physicians make to their patients and society.1 Students acquire and practice professional values, attitudes, and behaviors developmentally and in parallel with their increasing medical knowledge and clinical skills.2 Within clerkships, the domains of medical knowledge and clinical skills have widely accepted definitions with standardized assessment metrics and tools to develop students' knowledge and skills.3-5 The same is not true for professionalism, the definition and assessment of which are often implicit and unstandardized and the developmental progression of which is often uncharted.6,7 Although medical knowledge and clinical skills improve demonstrably throughout undergraduate training, anecdotal and qualitative evidence has shown that professional behaviors can diminish in clinical learning environments.8-10 This can lead to problems with professional conduct in postgraduate training11 and clinical practice, where complaints to medical boards stem primarily from deficiencies in professional behavior.12In the absence of standardized assessment metrics that define aspirational professional attitudes and behaviors, medical educators can identify and respond only to behavioral lapses. This deficit framework perpetuates a rigid dichotomous characterization of behavior as either unprofessional or professional rather than a spectrum of behaviors. As a result, educators and education systems are limited in their ability to foster the growth-oriented framework that supports the development of professional behaviors over time.The current literature on professionalism assessment within clinical clerkships is sparse. Existing studies recapitulate the deficit framework of professionalism assessment and focus primarily on how faculty identify, characterize, and report lapses in behavior13-15 and barriers to doing so.16 One framework for the assessment of behaviors describes lapses in involvement, integrity, communication, and introspection.14 Select studies describe the utility of specific assessment strategies, including faculty, peer, and self-evaluations, and objective structured clinical examinations focused on individual components of professionalism17 or combined formative and summative behavioral assessments.18 No existing studies offer a comprehensive approach to professionalism assessment or provide recent data on the policies and procedures used by clerkship directors (CDs) nationally. This study addresses this significant gap by identifying the extent to which current educators use shared definitions and assessment metrics to accurately and reliably evaluate professionalism in clerkships.In this study, we present a comprehensive depiction of professionalism and assessment from the direct reports of a nationally representative survey of U.S. internal medicine (IM) CDs. Our first aim was to examine how IM clerkship faculty and leadership conceptualize current professionalism and professional behaviors and attitudes. The second aim was to identify whether and how faculty use metrics to assess professionalism and factor it into clerkship grades. The third aim was to describe the barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.Purpose This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics.Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students. Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.Professionalism is a core competency of medicine and medical education, grounded in the intentional daily commitments that physicians make to their patients and society.1 Students acquire and practice professional values, attitudes, and behaviors developmentally and in parallel with their increasing medical knowledge and clinical skills.2 Within clerkships, the domains of medical knowledge and clinical skills have widely accepted definitions with standardized assessment metrics and tools to develop students' knowledge and skills.3-5 The same is not true for professionalism, the definition and assessment of which are often implicit and unstandardized and the developmental progression of which is often uncharted.6,7 Although medical knowledge and clinical skills improve demonstrably throughout undergraduate training, anecdotal and qualitative evidence has shown that professional behaviors can diminish in clinical learning environments.8-10 This can lead to problems with professional conduct in postgraduate training11 and clinical practice, where complaints to medical boards stem primarily from deficiencies in professional behavior.12In the absence of standardized assessment metrics that define aspirational professional attitudes and behaviors, medical educators can identify and respond only to behavioral lapses. This deficit framework perpetuates a rigid dichotomous characterization of behavior as either unprofessional or professional rather than a spectrum of behaviors. As a result, educators and education systems are limited in their ability to foster the growth-oriented framework that supports the development of professional behaviors over time.The current literature on professionalism assessment within clinical clerkships is sparse. Existing studies recapitulate the deficit framework of professionalism assessment and focus primarily on how faculty identify, characterize, and report lapses in behavior13-15 and barriers to doing so.16 One framework for the assessment of behaviors describes lapses in involvement, integrity, communication, and introspection.14 Select studies describe the utility of specific assessment strategies, including faculty, peer, and self-evaluations, and objective structured clinical examinations focused on individual components of professionalism17 or combined formative and summative behavioral assessments.18 No existing studies offer a comprehensive approach to professionalism assessment or provide recent data on the policies and procedures used by clerkship directors (CDs) nationally. This study addresses this significant gap by identifying the extent to which current educators use shared definitions and assessment metrics to accurately and reliably evaluate professionalism in clerkships.In this study, we present a comprehensive depiction of professionalism and assessment from the direct reports of a nationally representative survey of U.S. internal medicine (IM) CDs. Our first aim was to examine how IM clerkship faculty and leadership conceptualize current professionalism and professional behaviors and attitudes. The second aim was to identify whether and how faculty use metrics to assess professionalism and factor it into clerkship grades. The third aim was to describe the barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.Purpose This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics.Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students.Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.Professionalism is a core competency of medicine and medical education, grounded in the intentional daily commitments that physicians make to their patients and society.1 Students acquire and practice professional values, attitudes, and behaviors developmentally and in parallel with their increasing medical knowledge and clinical skills.2 Within clerkships, the domains of medical knowledge and clinical skills have widely accepted definitions with standardized assessment metrics and tools to develop students' knowledge and skills.3-5 The same is not true for professionalism, the definition and assessment of which are often implicit and unstandardized and the developmental progression of which is often uncharted.6,7 Although medical knowledge and clinical skills improve demonstrably throughout undergraduate training, anecdotal and qualitative evidence has shown that professional behaviors can diminish in clinical learning environments. 8-10 This can lead to problems with professional conduct in postgraduate training11 and clinical practice, where complaints to medical boards stem primarily from deficiencies in professional behavior.12In the absence of standardized assessment metrics that define aspirational professional attitudes and behaviors, medical educators can identify and respond only to behavioral lapses. This deficit framework perpetuates a rigid dichotomous characterization of behavior as either unprofessional or professional rather than a spectrum of behaviors. As a result, educators and education systems are limited in their ability to foster the growth-oriented framework that supports the development of professional behaviors over time.The current literature on professionalism assessment within clinical clerkships is sparse. Existing studies recapitulate the deficit framework of professionalism assessment and focus primarily on how faculty identify, characterize, and report lapses in behavior13-15 and barriers to doing so.16 One framework for the assessment of behaviors describes lapses in involvement, integrity, communication, and introspection.14 Select studies describe the utility of specific assessment strategies, including faculty, peer, and self-evaluations, and objective structured clinical examinations focused on individual components of professionalism17 or combined formative and summative behavioral assessments.18 No existing studies offer a comprehensive approach to professionalism assessment or provide recent data on the policies and procedures used by clerkship directors (CDs) nationally. This study addresses this significant gap by identifying the extent to which current educators use shared definitions and assessment metrics to accurately and reliably evaluate professionalism in clerkships.In this study, we present a comprehensive depiction of professionalism and assessment from the direct reports of a nationally representative survey of U.S. internal medicine (IM) CDs. Our first aim was to examine how IM clerkship faculty and leadership conceptualize current professionalism and professional behaviors and attitudes. The second aim was to identify whether and how faculty use metrics to assess professionalism and factor it into clerkship grades. The third aim was to describe the barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.Purpose This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics.Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94. 2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students.Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.Professionalism is a core competency of medicine and medical education, grounded in the intentional daily commitments that physicians make to their patients and society.1 Students acquire and practice professional values, attitudes, and behaviors developmentally and in parallel with their increasing medical knowledge and clinical skills.2 Within clerkships, the domains of medical knowledge and clinical skills have widely accepted definitions with standardized assessment metrics and tools to develop students' knowledge and skills.3-5 The same is not true for professionalism, the definition and assessment of which are often implicit and unstandardized and the developmental progression of which is often uncharted.6,7 Although medical knowledge and clinical skills improve demonstrably throughout undergraduate training, anecdotal and qualitative evidence has shown that professional behaviors can diminish in clinical learning environments.8-10 This can lead to problems with professional conduct in postgraduate training11 and clinical practice, where complaints to medical boards stem primarily from deficiencies in professional behavior.12In the absence of standardized assessment metrics that define aspirational professional attitudes and behaviors, medical educators can identify and respond only to behavioral lapses. This deficit framework perpetuates a rigid dichotomous characterization of behavior as either unprofessional or professional rather than a spectrum of behaviors. As a result, educators and education systems are limited in their ability to foster the growth-oriented framework that supports the development of professional behaviors over time.The current literature on professionalism assessment within clinical clerkships is sparse. Existing studies recapitulate the deficit framework of professionalism assessment and focus primarily on how faculty identify, characterize, and report lapses in behavior13-15 and barriers to doing so.16 One framework for the assessment of behaviors describes lapses in involvement, integrity, communication, and introspection.14 Select studies describe the utility of specific assessment strategies, including faculty, peer, and self-evaluations, and objective structured clinical examinations focused on individual components of professionalism17 or combined formative and summative behavioral assessments.18 No existing studies offer a comprehensive approach to professionalism assessment or provide recent data on the policies and procedures used by clerkship directors (CDs) nationally. This study addresses this significant gap by identifying the extent to which current educators use shared definitions and assessment metrics to accurately and reliably evaluate professionalism in clerkships.In this study, we present a comprehensive depiction of professionalism and assessment from the direct reports of a nationally representative survey of U.S. internal medicine (IM) CDs. Our first aim was to examine how IM clerkship faculty and leadership conceptualize current professionalism and professional behaviors and attitudes. The second aim was to identify whether and how faculty use metrics to assess professionalism and factor it into clerkship grades. The third aim was to describe the barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.Purpose This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics.Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students.Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.Professionalism is a core competency of medicine and medical education, grounded in the intentional daily commitments that physicians make to their patients and society.1 Students acquire and practice professional values, attitudes, and behaviors developmentally and in parallel with their increasing medical knowledge and clinical skills.2 Within clerkships, the domains of medical knowledge and clinical skills have widely accepted definitions with standardized assessment metrics and tools to develop students' knowledge and skills. 3-5 The same is not true for professionalism, the definition and assessment of which are often implicit and unstandardized and the developmental progression of which is often uncharted.6,7 Although medical knowledge and clinical skills improve demonstrably throughout undergraduate training, anecdotal and qualitative evidence has shown that professional behaviors can diminish in clinical learning environments.8-10 This can lead to problems with professional conduct in postgraduate training11 and clinical practice, where complaints to medical boards stem primarily from deficiencies in professional behavior.12In the absence of standardized assessment metrics that define aspirational professional attitudes and behaviors, medical educators can identify and respond only to behavioral lapses. This deficit framework perpetuates a rigid dichotomous characterization of behavior as either unprofessional or professional rather than a spectrum of behaviors. As a result, educators and education systems are limited in their ability to foster the growth-oriented framework that supports the development of professional behaviors over time.The current literature on professionalism assessment within clinical clerkships is sparse. Existing studies recapitulate the deficit framework of professionalism assessment and focus primarily on how faculty identify, characterize, and report lapses in behavior13-15 and barriers to doing so.16 One framework for the assessment of behaviors describes lapses in involvement, integrity, communication, and introspection.14 Select studies describe the utility of specific assessment strategies, including faculty, peer, and self-evaluations, and objective structured clinical examinations focused on individual components of professionalism17 or combined formative and summative behavioral assessments.18 No existing studies offer a comprehensive approach to professionalism assessment or provide recent data on the policies and procedures used by clerkship directors (CDs) nationally. This study addresses this significant gap by identifying the extent to which current educators use shared definitions and assessment metrics to accurately and reliably evaluate professionalism in clerkships.In this study, we present a comprehensive depiction of professionalism and assessment from the direct reports of a nationally representative survey of U.S. internal medicine (IM) CDs. Our first aim was to examine how IM clerkship faculty and leadership conceptualize current professionalism and professional behaviors and attitudes. The second aim was to identify whether and how faculty use metrics to assess professionalism and factor it into clerkship grades. The third aim was to describe the barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.Purpose This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics.Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students.Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.Professionalism is a core competency of medicine and medical education, grounded in the intentional daily commitments that physicians make to their patients and society.1 Students acquire and practice professional values, attitudes, and behaviors developmentally and in parallel with their increasing medical knowledge and clinical skills.2 Within clerkships, the domains of medical knowledge and clinical skills have widely accepted definitions with standardized assessment metrics and tools to develop students' knowledge and skills.3-5 The same is not true for professionalism, the definition and assessment of which are often implicit and unstandardized and the developmental progression of which is often uncharted.6,7 Although medical knowledge and clinical skills improve demonstrably throughout undergraduate training, anecdotal and qualitative evidence has shown that professional behaviors can diminish in clinical learning environments.8-10 This can lead to problems with professional conduct in postgraduate training11 and clinical practice, where complaints to medical boards stem primarily from deficiencies in professional behavior.12In the absence of standardized assessment metrics that define aspirational professional attitudes and behaviors, medical educators can identify and respond only to behavioral lapses. This deficit framework perpetuates a rigid dichotomous characterization of behavior as either unprofessional or professional rather than a spectrum of behaviors. As a result, educators and education systems are limited in their ability to foster the growth-oriented framework that supports the development of professional behaviors over time.The current literature on professionalism assessment within clinical clerkships is sparse. Existing studies recapitulate the deficit framework of professionalism assessment and focus primarily on how faculty identify, characterize, and report lapses in behavior13-15 and barriers to doing so.16 One framework for the assessment of behaviors describes lapses in involvement, integrity, communication, and introspection. 14 Select studies describe the utility of specific assessment strategies, including faculty, peer, and self-evaluations, and objective structured clinical examinations focused on individual components of professionalism17 or combined formative and summative behavioral assessments.18 No existing studies offer a comprehensive approach to professionalism assessment or provide recent data on the policies and procedures used by clerkship directors (CDs) nationally. This study addresses this significant gap by identifying the extent to which current educators use shared definitions and assessment metrics to accurately and reliably evaluate professionalism in clerkships.In this study, we present a comprehensive depiction of professionalism and assessment from the direct reports of a nationally representative survey of U.S. internal medicine (IM) CDs. Our first aim was to examine how IM clerkship faculty and leadership conceptualize current professionalism and professional behaviors and attitudes. The second aim was to identify whether and how faculty use metrics to assess professionalism and factor it into clerkship grades. The third aim was to describe the barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.Purpose This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics.Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students.Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.Professionalism is a core competency of medicine and medical education, grounded in the intentional daily commitments that physicians make to their patients and society. 1 Students acquire and practice professional values, attitudes, and behaviors developmentally and in parallel with their increasing medical knowledge and clinical skills.2 Within clerkships, the domains of medical knowledge and clinical skills have widely accepted definitions with standardized assessment metrics and tools to develop students' knowledge and skills.3-5 The same is not true for professionalism, the definition and assessment of which are often implicit and unstandardized and the developmental progression of which is often uncharted.6,7 Although medical knowledge and clinical skills improve demonstrably throughout undergraduate training, anecdotal and qualitative evidence has shown that professional behaviors can diminish in clinical learning environments.8-10 This can lead to problems with professional conduct in postgraduate training11 and clinical practice, where complaints to medical boards stem primarily from deficiencies in professional behavior.12In the absence of standardized assessment metrics that define aspirational professional attitudes and behaviors, medical educators can identify and respond only to behavioral lapses. This deficit framework perpetuates a rigid dichotomous characterization of behavior as either unprofessional or professional rather than a spectrum of behaviors. As a result, educators and education systems are limited in their ability to foster the growth-oriented framework that supports the development of professional behaviors over time.The current literature on professionalism assessment within clinical clerkships is sparse. Existing studies recapitulate the deficit framework of professionalism assessment and focus primarily on how faculty identify, characterize, and report lapses in behavior13-15 and barriers to doing so.16 One framework for the assessment of behaviors describes lapses in involvement, integrity, communication, and introspection.14 Select studies describe the utility of specific assessment strategies, including faculty, peer, and self-evaluations, and objective structured clinical examinations focused on individual components of professionalism17 or combined formative and summative behavioral assessments.18 No existing studies offer a comprehensive approach to professionalism assessment or provide recent data on the policies and procedures used by clerkship directors (CDs) nationally. This study addresses this significant gap by identifying the extent to which current educators use shared definitions and assessment metrics to accurately and reliably evaluate professionalism in clerkships.In this study, we present a comprehensive depiction of professionalism and assessment from the direct reports of a nationally representative survey of U.S. internal medicine (IM) CDs. Our first aim was to examine how IM clerkship faculty and leadership conceptualize current professionalism and professional behaviors and attitudes. The second aim was to identify whether and how faculty use metrics to assess professionalism and factor it into clerkship grades. The third aim was to describe the barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students. Purpose This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics.Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students.Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.Professionalism is a core competency of medicine and medical education, grounded in the intentional daily commitments that physicians make to their patients and society.1 Students acquire and practice professional values, attitudes, and behaviors developmentally and in parallel with their increasing medical knowledge and clinical skills.2 Within clerkships, the domains of medical knowledge and clinical skills have widely accepted definitions with standardized assessment metrics and tools to develop students' knowledge and skills.3-5 The same is not true for professionalism, the definition and assessment of which are often implicit and unstandardized and the developmental progression of which is often uncharted.6,7 Although medical knowledge and clinical skills improve demonstrably throughout undergraduate training, anecdotal and qualitative evidence has shown that professional behaviors can diminish in clinical learning environments.8-10 This can lead to problems with professional conduct in postgraduate training11 and clinical practice, where complaints to medical boards stem primarily from deficiencies in professional behavior.12In the absence of standardized assessment metrics that define aspirational professional attitudes and behaviors, medical educators can identify and respond only to behavioral lapses. This deficit framework perpetuates a rigid dichotomous characterization of behavior as either unprofessional or professional rather than a spectrum of behaviors. As a result, educators and education systems are limited in their ability to foster the growth-oriented framework that supports the development of professional behaviors over time.The current literature on professionalism assessment within clinical clerkships is sparse. Existing studies recapitulate the deficit framework of professionalism assessment and focus primarily on how faculty identify, characterize, and report lapses in behavior13-15 and barriers to doing so.16 One framework for the assessment of behaviors describes lapses in involvement, integrity, communication, and introspection.14 Select studies describe the utility of specific assessment strategies, including faculty, peer, and self-evaluations, and objective structured clinical examinations focused on individual components of professionalism17 or combined formative and summative behavioral assessments.18 No existing studies offer a comprehensive approach to professionalism assessment or provide recent data on the policies and procedures used by clerkship directors (CDs) nationally. This study addresses this significant gap by identifying the extent to which current educators use shared definitions and assessment metrics to accurately and reliably evaluate professionalism in clerkships.In this study, we present a comprehensive depiction of professionalism and assessment from the direct reports of a nationally representative survey of U.S. internal medicine (IM) CDs. Our first aim was to examine how IM clerkship faculty and leadership conceptualize current professionalism and professional behaviors and attitudes. The second aim was to identify whether and how faculty use metrics to assess professionalism and factor it into clerkship grades. The third aim was to describe the barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students.