UIC PROFESSIONALISM EVALUATION FORM FOR MEDICAL STUDENTS

Medicine is a profession that requires high standards of behavior in addition to the mastery of a large body of knowledge and clinical skills. In addition to fulfilling all academic requirements, students are required to display behaviors consistent with accepted standards of professional conduct.

The professionalism evaluation is designed to be used in two ways:

Exemplary Professionalism

Although all students are expected to master the professionalism levels that are detailed in these pages, there are instances of exemplary student professionalism that we feel should be singled out for recognition. A faculty or staff member who directly observes such instances is encouraged to fill out this form (checking the box at the beginning noting that this student has performed in an exemplary manner). A resident directly observing such behavior may also fill out this form, but must have it co-signed by the attending physician before forwarding the form to Student Affairs. The faculty, resident or staff member would first discuss the form with the student and then forward it to the Office of Student Affairs. Students receiving two or more exemplary forms will have their performance noted in the Dean's letter.

Deficient Professionalism

Some students will be found deficient in professionalism skills and may need more intensive help in developing these skills. A faculty member who is concerned about a student's behavior will give feedback to the student and make suggestions for improvement. If the behavior is repeated or is initially serious enough, then the Professionalism Evaluation Form noting the deficiency will be completed; reviewed with the student; and forwarded to the Associate Dean of Student Affairs. (As above, this form can be filled out by a faculty member, staff member, or resident, though the form will need to be co-signed by an attending physician if it is filled out by a resident.) If a first or second-year student receives one or more professionalism evaluations noting deficient behavior, he/she will meet with the Associate Dean for Student Affairs for counseling and remediation. Reference to these sessions will not be made in the Dean's letter. However, if a student receives two or more professionalism evaluations noting deficiencies in the first two years and receives a subsequent form noting deficiencies in the third or fourth year, then these evaluations and issues will be mentioned in the Dean's letter and the student may be referred to the Student Advancement Committee for their consideration including dismissal from medical school.

Please note that this form is not to supersede or replace one-to-one faculty to student feedback, which is the cornerstone of clinical learning. This form is to be reserved for those instances in which feedback has been unsuccessfully attempted, and for those instances in which the behavior being displayed is either substantially exemplary, or grossly deficient.

If you have any questions about the performance criteria, please call Assistant Dean James Mendez at 312.996.2450

UIC COLLEGE OF MEDICINE

MEDICAL STUDENT PROFESSIONALISM EVALUATION FORM

EXEMPLARY BEHAVIOR

____________________________ __________________________________

Student Name (type or print legibly) Date this form was discussed with student

THIS STUDENT HAS EXHIBITED EXEMPLARY BEHAVIOR IN ONE OR MORE OF THE FOLLOWING AREAS (CIRCLE ALL THAT APPLY)

I. Self improvement and adaptability

a. Maintains professional composure in highly stressful situations

b. Exhibits exemplary personal clinical judgment in stressful situations

2. Relationships with students, faculty, staff and patients

a. Consistently demonstrates skill in establishing rapport with students, faculty, staff and patients

b. Demonstrates exemplary sensitivity to the needs of the patient, the patient's family and the health care team

c. Maintains exemplary sensitivity, courtesy and respect for fellow students, staff, and faculty in a learning environment

3. Upholding the UIC College of Medicine Statement on Professional Behavior

a. Consistently contributes to an atmosphere conducive to learning

b. Respects the diversity of race, gender, religion, sexual orientation, age,

disability or socioeconomic status of fellow students, members of the health care team, and patients.

c. Resolves conflicts in an unusually skillful manner that respects the dignity of every person involved.

Comments (please explain why you checked what you checked)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_______________________ ____________________ _____________________

Faculty signature Printed Name Contact # (Phone/email)

THIS SECTION TO BE COMPLETED BY THE STUDENT

My comments are: (optional)

I have read this evaluation and discussed it with the faculty member.

_____________________________ _________________

Student Signature Date

UIC COLLEGE OF MEDICINE

MEDICAL STUDENT PROFESSIONALISM EVALUATION FORM

DEFICIENT BEHAVIOR

____________________________ __________________________________

Student Name (type or print legibly) Date this form was discussed with student

THIS STUDENT HAS EXHIBITED DEFICIENCIES IN THE BEHAVIOR OF NOTE IN

THE FOLLOWING AREAS (CIRCLE ALL THAT APPLY)

I. Reliability and responsibility

a. Fulfilling responsibilities in a reliable manner

b. Completing assigned tasks promptly

c. Attendance as required (which includes:)

i. Appearing on time as scheduled

ii. Remaining until the end of the activity as required

d. Notifying appropriate persons prior to missing required activities

2. Self-improvement and adaptability

a. Accepting constructive feedback

b. Recognizing limitations and seeking help

c. Incorporating feedback in order to make needed changes in behavior

d. Maintaining professional composure in stressful situations

e. Exhibiting good personal clinical judgment in stressful situations

3. Relationships with students, faculty, staff and patients

a. Establishing rapport

b. Placing the needs of the patient ahead of personal needs

c. Being sensitive to the needs of the patient, the patient's family and the health care team

d. Establishing and maintaining appropriate boundaries in work and learning situations

e. Maintaining an appropriately sensitive, courteous and respectful manner with fellow students, faculty, staff and patients in a learning environment

4. Upholding the UIC College of Medicine Statement on Professional Behavior

a. Maintaining honesty and integrity

b. Contributing to an atmosphere conducive to learning

c. Respecting the diversity of race, gender, religion, sexual orientation, age, disability or socioeconomic status of fellow students, members of the health care team, and patients.

d. Resolving conflicts in a manner that respects the dignity of every person involved.

e. Using professional language and being mindful of the environment.

f. Putting the needs of the patient ahead of one’s personal needs

g. Protecting patient confidentiality

h. Dressing in a professional manner as appropriate to the learning environment.

Comments (please explain the circled items)

__________________________________________________________________________________________________________________________________________________________________________________________