Perceptions of Medical Students’ Unprofessional Behaviors Among Faculty Members and Medical Students: A Cross-Sectional Study at a Japanese Medical School

Introduction

Physicians are expected to have a certain degree of professionalism. This includes accountability, altruism, excellence, and humanism (compassion, empathy, or integrity) based on excellent clinical skills, communication skills, and sound ethics.¹ Patients expect physicians to be professional,² and creating trusting relationships between patients and physicians can contribute to improving patient outcomes and increasing patient satisfaction.^3,4 Medical students should be educated on what constitutes unprofessional behavior during their graduation itself, as it can be a risk factor for disciplinary measures after graduation.⁵ Unprofessional behavior is generally categorized into four behaviors: lack of engagement, dishonesty, disrespect, and poor self-awareness.⁶ In Pakistan, 65% of medical students reported that their peers had involved in such behaviors,⁷ indicating the need to instill professionalism in students.⁸ However, evaluating medical students’ and physicians’ professionalism is rather complicated as it encompasses multiple aspects such as individual, interpersonal, social, organizational, and cultural values.^6,9,10

Medical educators do not always instruct or report on observed unprofessional behaviors.¹¹ Although they observe such behaviors in 20% of the medical students, these are reported in only 3–5% of the cases.¹² This may happen due to various reasons, including the fear that reported students may give faculty members a low evaluation, lack of clarity regarding what constitutes unprofessional behavior, concerns that decisions regarding unprofessional behaviors may be subjective, or the time constraint of educating students.¹³ Therefore, education on professionalism and standardization methods to improve unprofessional behaviors remains insufficient worldwide.^4,14,15 However, failing to address unprofessional behaviors may undermine patient safety.

To appropriately educate and report medical students’ unprofessional behavior, it is important to assess and realign their perceptions regarding such behaviors. In particular, the concerns of educators’ subjective evaluations and fears of negative evaluations by students may be resolved by understanding what behaviors medical students and faculty members perceive as unprofessional and the differences in their perceptions.¹⁶ However, to the best of our knowledge, there are only two existing quantitative studies on such differences, which are cross-sectional studies performed in England and Saudi Arabia.^14,17 In these studies, faculty members judged medical students’ misconduct more severely than the medical students. In the England study, the public gave the harshest evaluations.¹⁷ In England, the Good Medical Practice framework established by the General Medical Council, which serves as a global standard for medical professionalism, is likely embedded in the professional consciousness of healthcare providers.¹⁸ In Saudi Arabia, professionalism is evaluated based on medical standards, as well as religious and cultural concepts.¹⁹ These may have influenced the difference in perceptions observed in England and Saudi Arabia. Although these studies have clarified differences in perceptions regarding academic integrity, unethical conduct, and clinical behaviors, they have not addressed perceptions related to interpersonal issues or personal characteristics. In England, clinical behaviors related to patient interactions and unethical actions are emphasized.¹⁸ In contrast, in Japan, actions that cause discomfort to others or disrupt one-on-one relationships, as well as clinical behaviors, are emphasized.¹⁸ Given these differences, the findings from England and Saudi Arabia may not necessarily be applicable to the Japanese context.

Hence, this study was conducted based on the hypothesis that perceptions of unprofessional behaviors in clinical settings differ between Japanese medical students and faculty members. Investigating these differences may allow for improvements in faculty training and curriculum design, potentially contributing to patient safety in the future.

Materials and Methods

Study Design and Setting

This single-center cross-sectional study was conducted at the Faculty of Medicine, Saga University, Japan. Saga Prefecture is a regional city in northern Kyushu, southern Japan, with a population of 830,000 people. Saga University is the only medical school in the Saga Prefecture. Medical education in Japan spans six years, and after graduating from high school, students enroll in medical schools to become doctors. Medical students with qualifications as student doctors can start clinical practice. These qualifications can be obtained by passing a public test (computer-based testing and an objective structured clinical examination) in the fourth year.⁵ After 1.5 years of clinical practice and passing the national medical examination, they can work as medical residents in Japan. At the time of this study, there were 186 faculty members and 101 fourth-year medical students at this medical school. All fourth-year students were scheduled to take public tests within one month. Though they had several lectures on professionalism, none were specifically conducted on medical students’ unprofessional behavior.

Participants

Participants included faculty members of the Faculty of Medicine, Saga University, who had participated in the faculty development (FD) on “Responding to unprofessional behaviors of medical students” in December 2024, and fourth-year medical students of the same institution who participated in the lecture on “unprofessional behaviors of medical students” in January 2025. One month prior to the FD program, the theme and outline were sent to all faculty members via e-mail, encouraging them to attend the program. The lecture was also announced to all medical students, encouraging them to attend. Medical students and faculty members who did not consent to participate in this study were excluded from the analysis.

Sample Size

In a previous report, which investigated the differences in perceptions of student misconduct between medical students and faculty members, the recognition scores for “attending ward teaching whilst drunk (alcohol misuse and lack of insight)” were 3.1 and 3.9, respectively (6-point scale).¹⁷ Based on the results of the previous study, an alpha error of 0.05, and a beta error of 0.20, we calculated a sample size of 26 participants in each group for this study.

Data Collection

To collect data, this study employed a Google Forms questionnaire, the items for which were determined by the faculty members of the Education and Research Center for Community Medicine, who are the core members of medical education. The types of unprofessional behaviors of medical students and the categorization proposed in a previous study were used for the final determination.⁶ This questionnaire was used on a pilot basis. The uniform resource locator of the questionnaire was sent to the faculty members and fourth-year medical students (using a QR code) prior to the commencement of the respective FD program and lecture. All responses were obtained before the sessions began.

Variables

Respondents’ identification numbers or names, gender, and age or year of graduation were obtained. In addition, the respondents were asked to choose all applicable medical students’ unprofessional behaviors from the following list that they believed should be taught and reported: lack of active participation or minimal effort during clinical training; disruptive behavior during clinical training; unexcused absence or tardiness; acting without obtaining the necessary consent; avoiding communication with others; being uncooperative; improper dressing and personal hygiene; failure to comply with rules and regulations; false statements or misrepresentation; fabrication or falsification of data; inappropriate use of social networking services (SNS); bullying, discrimination, and sexual harassment; violation of privacy or confidentiality obligations; rejection of feedback or refusal to accept feedback content; resistance to change; failure to reflect on oneself and blaming others or external factors; and complaining about early start times or late end times of clinical training. Details of the questionnaire are provided in Supplementary Materials 1 and 2.

Statistical Analysis

Categorical variables are expressed as percentages and were compared using the χ² test. Continuous variables are expressed as medians, and interquartile ranges were compared using the Mann–Whitney U-test. Missing data were excluded from the analysis, and statistical significance was set at p < 0.05. Univariate logistic regression analysis was used to assess the odds ratios (OR) and 95% confidence intervals (CI) for the perceptions of unprofessional behaviors among medical students and faculty members. To complement the OR, Cohen’s h was calculated to quantify the magnitude of differences in proportions between the two groups. Multivariate logistic regression with stepwise reduction was used to identify variables that differentiated the two groups, and the OR and 95% CI were assessed. Considering multicollinearity, among the variables that showed statistical significance in the univariate analysis, one variable from each pair with a Spearman correlation coefficient of 0.7 or higher was selected, and the other was excluded. The internal consistency of the questionnaire was assessed using Cronbach’s α coefficient. SPSS (version 29; IBM Corp., Armonk, NY, USA) was used for statistical analyses.

Ethical Considerations

This study was approved by the Ethics Committee of the Faculty of Medicine at Saga University (approval number R6-58), and the content is disclosed on the website of the Faculty of Medicine, Saga University. Participant consent was obtained using the opt-out method, and participants’ anonymity was ensured. The study was performed in accordance with the 1975 Declaration of Helsinki and approved by the Medical Ethics Committee of the Faculty of Medicine.

Results

Participant Characteristics

A total of 42 faculty members attended the FD, of which 40 agreed to participate in this study (response rate 21.5%) and were included in analyses (faculty group). The median number of years since their graduation was 22. A total of 65 fourth-year medical students attended the lecture on unprofessional behaviors without agreements to participate in this study (response rate 64.4%). The median age of medical students was 22 (22–23) years (student group). Among the participants, 20 of the 40 (50%) faculty members were men, and 27 of the 65 (42%) medical students were men (p=0.556).

Medical Students’ and Faculty Members’ Perceptions of Unprofessional Behavior

The Cronbach’s α coefficient for the items assessing perceptions of unprofessional behaviors was 0.877 overall, with 0.871 for the faculty group and 0.883 for the student group. Table 1 shows the comparison of perceptions of unprofessional behaviors between faculty members and medical students. More than 80% of the participants in both groups recognized the following behaviors as unprofessional behaviors, the highest being “disruptive behavior during clinical training” followed by “violation of privacy or confidentiality obligations”, “false statements or misrepresentation”, “inappropriate use of SNS”, “fabrication or falsification of data”, “acting without obtaining the necessary consent”, and “unexcused absence or tardiness” (Figure 1). Behaviors that were recognized by less than 50% of the students and faculty members were “lack of active participation or making minimal effort during clinical training”, “failure to reflect on oneself and blaming others or external factors”, “avoiding communication with others”, “complaining about early start times or late end times of clinical training”, and “resistance to the change”. Among all unprofessional behaviors, the faculty group was significantly less likely than medical students to recognize the following behaviors as unprofessional: “violation of privacy or confidentiality obligations (85% vs 98%, p=0.007)”, “false statements or misrepresentation (85% vs 97%, p=0.025)”, “inappropriate use of SNS (83% vs 98%, p=0.010)”, “fabrication or falsification of data (83% vs 95%, p=0.029)”, and “bullying, discrimination, and sexual harassment (75% vs 98%, p<0.001)”. The ORs (95% CI) for these unprofessional behaviors in the univariate logistic regression analysis were 0.089 (0.010–0.766), 0.180 (0.034–0.940), 0.150 (0.029–0.762), 0.228 (0.005–0.941), 0.047 (0.006–0.383), respectively.

Table 1 Comparison of Faculty and Student Perceptions of Medical Students’ Unprofessional Behaviors

Figure 1 The seven unprofessional behaviors with the highest agreement between faculty members and medical students. More than 80% of the participants in both faculty members and medical students recognized the following behaviors as unprofessional behaviors, the highest being “disruptive behavior during clinical training” followed by “violation of privacy or confidentiality obligations”, “false statements or misrepresentation”, “inappropriate use of SNS”, “fabrication or falsification of data”, “acting without obtaining the necessary consent”, and “unexcused absence or tardiness”.

Unprofessional Behavior Perceptions That Differed Between Medical Students and Faculty Members

The results of the multivariate logistic regression analysis are shown in Table 2. Stepwise reduction identified “bullying, discrimination, and sexual harassment” (OR 0.058, 95% CI 0.007–0.487) as the only significant factor that differed in terms of perceptions between medical students and faculty members.

Table 2 The Findings of Multivariable Logistic Regression Analysis with Stepwise Reduction on the Perceptions of Unprofessional Behaviors in Medical Students and Faculty Members

Discussion

In the present study, 80% or more of both the medical students and faculty members of the studied university recognized the following behaviors as unprofessional behaviors: “disruptive behavior during clinical training”; “violation of privacy or confidentiality obligations”; “false statements or misrepresentation”; “inappropriate use of SNS”; “fabrication or falsification of data”; “acting without obtaining the necessary consent”; and “unexcused absence or tardiness”. Among these, disruptive behavior, false statements or misrepresentations, inappropriate use of SNS, and unexcused absence or tardiness were consistent with a previous study conducted in Saudi Arabia.¹⁴ Violations of privacy and confidentiality, as well as acting without necessary consent, suggest a diminished sense of responsibility as a physician, and medical students who engage in such behaviors are likely to be subject to disciplinary action after graduation.^5,20 Therefore, students should be educated about such behaviors before graduation, which highlights the need for developing a curriculum that facilitates effective professionalism education. However, only 43% of the faculty members and 54% of the medical students in our study perceived a lack of active participation or minimal effort during clinical training as unprofessional. Previous reports in Saudi Arabia showed that 100% of faculty members and 85% of medical students recognized reduced initiative, such as dereliction of the allocated duty in group work, as unprofessional.¹⁴ Given that medical students who exhibit such a lack of positivity and motivation are more likely to be subject to disciplinary action after graduation,^5,20 it is important to recognize this behavior as unprofessional among both educators and medical students.

In previous studies, faculty members were more severe in their ratings of almost all unprofessional behaviors than medical students.^14,17 However, in the present study, faculty members rated the following unprofessional behaviors significantly lower than the medical students: “violation of privacy or confidentiality obligations”, “false statements or misrepresentation”, “inappropriate use of SNS”, “fabrication or falsification of data”, and “bullying, discrimination, and sexual harassment”. Among them, it is possible that false statements or misrepresentation and fabrication, or falsification of data are more frequently encountered by faculty members. It has been reported that faculty members tend to analyze professionalism in multiple aspects.¹⁷ As they may consider the reasons for and motivations behind some of these behaviors, these may be more permissible,²¹ and may lead them to make ambiguous and inconsistent decisions. It is also believed that physicians may ignore misconduct by medical students as they consider that they have little or no clinical responsibility.¹⁷ This may have affected the results of this study. Moreover, 5–15% of the medical residents tend to indulge in plagiarism, misconduct during exams, and fraudulent description of publications, and 40–50% tend to report inaccurate results of patient tests and false work hours.²² Faculty members’ memories of their own experiences as residents may have also influenced the results.

In the present study, faculty members were less likely to recognize “bullying, discrimination, and sexual harassment” as an unprofessional behavior than medical students, which was the only significant factor that differed significantly between the groups in the multivariate analysis. Unprofessional and destructive behaviors are often seen in physicians, and 95% of them routinely face insults, angry voices, rude attitudes, or abuse from other physicians.²³ In addition, female physicians are more likely to be seen as contributing less to their work, experience economic inequality and lose opportunities for career advancement,^24,25 and may consider bullying, discrimination, and sexual harassment common; therefore, they may no longer recognize it as unprofessional behavior. In fact, the proportion of female physicians at Japanese medical schools decreases in accordance with the increase in academic ranks.²⁶ Moreover, female leaders are highly underrepresented and report feeling undervalued in their positions as leaders.²⁷ However, if faculty members do not address these unprofessional behaviors, medical students would begin to feel that these are acceptable.¹² Therefore, despite commonly encountering these behaviors, faculty members should not overlook such dishonest, inappropriate, and unacceptable behaviors. Institutionalizing professionalism training, regularly conducting FD workshops, and offering lectures on gender inequality are important strategies to help faculty members recognize such behaviors as unprofessional and provide appropriate guidance to medical students.

Study Limitations

This study had some limitations that must be considered. First, this study may have had a selection bias because it was a single-center cross-sectional study. Therefore, the generalizability of the results is limited. Second, the results may not reflect the perceptions of the entire institution because only the data obtained from faculty members and medical students who participated in the FD and lecture, respectively, were analyzed. Especially, the response rate of faculty members was low, and it is possible that those who participated ware more interested in unprofessional behaviors. Therefore, the perception of faculty members toward unprofessional behaviors may be more lenient than the results of this study. Third, obtained data may be influenced by social desirability bias and response bias. As a result, medical students’ recognition of unprofessional behaviors may be overestimated. Fourth, this study did not investigate the grade of perceptions for each unprofessional behavior, willingness to report it, confidence in handling it, and the barriers and facilitators to reporting. Therefore, even though faculty members are less likely to perceive the behaviors as unprofessional, they may choose to take harsher measures when sanctions are applied. Additionally, even when these behaviors were observed, whether they were actually reported remains unclear. Fifth, this study investigated the recognition of unprofessional behaviors to be taught and reported. Therefore, whether faculty members and medical students believe such behaviors should be addressed through guidance or reporting remains unclear. Finally, different results may be observed if globalization increases the number of faculty members or medical students from abroad, as cultural aspects can influence the perceptions of unprofessional behaviors.

Conclusions

The perceptions of unprofessional behaviors among faculty members and medical students were generally in agreement. However, faculty members were significantly less likely than medical students to consider some behaviors, particularly bullying, discrimination, and sexual harassment, as unprofessional. Hence, faculty members’ perceptions of these behaviors could be improved through the institutionalization of faculty development programs on professionalism, thereby facilitating the effective education of medical students in professional ethics and contributing to the advancement of patient outcomes. To ensure the generalizability pf these findings, multi-center and multi-cultural studies are required to capture the influence of cultural aspects on perceptions of unprofessional behaviors.