INTRODUCTION
The literature underscores the critical need to recognize and address professionalism concerns during medical education.1-3 Barry et al1 specifically linked professionalism concerns during physician assistant (PA) education to an increased risk of misconduct in clinical practice. Furthermore, Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) emphasizes professional behavior in Standards B2.19 and B4.03. We identified areas for improvement in tracking, documenting, and remediating professionalism.
We observed a tendency toward rigid, zero-tolerance policies, which often led to premature judgements about students' suitability for the profession. In response, we prioritized a growth-oriented approach to develop students professionally, fostering skills applicable to clinical practice. Our goal has been to develop a process that allows multiple touchpoints for professionalism tracking and involves diverse evaluators and settings.
In addition to traditional faculty feedback, a student peer professionalism feedback process is one that is not only beneficial for the students growth but also is advantageous for the faculty facilitating the process.4 Student peers, with more frequent contact, emerge as valuable evaluators of professionalism.4-6 Anonymous peer evaluations completed by students offer the faculty a more holistic understanding of students' competency in this area. The peer evaluations often provide confirmation of smaller suspicions faculty have that have not been fully uncovered. The multilayered approach spans admissions to the summative phase.
We have tracked the outcomes of this quality improvement initiative to assess its effectiveness in fostering professionalism.
METHODS
Literature Review
Historically, professionalism was evaluated during the admissions phase, advising sessions, or preceptor evaluations during the clinical phase. The program noted a rise in professionalism concerns that necessitated program director involvement and occasional student suspension. There was also a clear need for a delineated policy on how to manage such professionalism deficiencies.
We sought to develop a comprehensive system that reinforced professionalism throughout both didactic and clinical phases of the program, prioritizing student growth and development rather than relying solely on punitive measures.
Program faculty conducted a literature review to identify best practices for assessing professionalism in medical education. It revealed limited research specific to PA education, with most sources focused on medical school settings. Given the unique demands and compressed timeline of PA training, identifying, assessing, and remediating professionalism within the 27-month curriculum posed distinct challenges.1 However, the literature supported peer feedback as a reliable method for assessing professionalism.4-9 In addition, a focused professionalism tracking tool allows for assessment across the curriculum.10,11
This research was reviewed by the IRB #:00001338 and considered non human subject research.
Implementation of Professional Assessment Tools
Professional Development Assessment Tool
In response, our program systematically introduced several tools and processes over 2 years to enhance professionalism assessment. First, a Professional Development Assessment Tool (PDAT) was introduced to track professionalism throughout both the didactic and clinical years. This tool, accessible to all faculty, allows advisors to address concerns and reinforce positive behaviors during regular semester meetings with students.
Thus it enables the faculty to better mentor students' professionalism throughout the curriculum. The PDAT used by the program includes the following:Communicates appropriately with faculty, staff, and students in writing.Accepts feedback without defensiveness or excuses.Respectful of the perspectives of others.Precise and timely in speech and actions.Presents dressed in proper professional attire.Demonstrates adaptability to change.Submits assignments on time.Arrives on time for class, labs, and examinations.Notifies appropriate individuals if delayed or unable to attend a scheduled activity.Prepares appropriately for class.
Peer Professionalism Survey
An anonymous peer professionalism evaluation has been integrated at the conclusion of the didactic phase. Before students are given this evaluation, principal faculty and the program director conduct an orientation session, emphasizing the purpose, significance, and methodology of peer assessment while providing guidelines for delivering constructive feedback. Students are randomly assigned 5 peers to evaluate and are also required to complete a self-assessment, fostering critical self-reflection.How would you rate their overall professional decorum?How well does this person articulate their ideas and feelings?How well does this person motivate and encourage others to achieve their very best?How well does this person demonstrate a combination of confidence and humility?How well does this individual collaborate and participate in class/group activities?How well does this person receive constructive criticism and feedback?How inclusive is this person towards others regardless of differences?How well does this person listen to others?How punctual is this person to scheduled events and amenable to changes?How well does this person accept difficult situations and persevere?
The evaluation consists of 10 professionalism criteria rated on a 5-point Likert scale (with a benchmark of 3 or higher indicating sufficiency) and includes qualitative feedback. Students receive a report summarizing their peer scores and qualitative comments, allowing them to compare peer perceptions with their self-assessment. This report is distributed after multiple clinical rotations, facilitating deeper reflection on their professional growth and its impact on their clinical interactions.
Clinical Team Survey
In the summative phase the clinical committee implemented a Clinical Faculty and Staff Professionalism Survey, specifically designed for the final 4 months of training. An aggregate of the responses (scored on a Likert scale) on the following topics is assessed for each student.Composure under difficult circumstances.Adaptability/flexibility.Timeliness with assignment deadlines.Communication and listening skills.Attendance and participation with class activities.
Summative Strengths, Weaknesses, Opportunities, and Threats Analysis
In conjunction with this, students complete a comprehensive strengths, weaknesses, opportunities, and threats (SWOT) analysis evaluating their medical knowledge, clinical competencies, and professionalism. This SWOT analysis integrates feedback from preceptors, peers, and faculty, ensuring a holistic assessment of each student's professional development, providing insight as they prepare for their post-graduate careers.
The phased rollout of these professionalism tracking tools, including faculty training, evolved over 2 years and was fully implemented for the Class of 2023. This structured, multisource evaluation framework reinforces professionalism as an ongoing developmental process.
Remediation
Throughout the curriculum, when professionalism concerns arise, we are able to more effectively remediate those concerns. When an issue is recognized in one of the professionalism assessment tools, the designated advisor or faculty administrator responsible for that tool will meet with the individual student to review the concern and initiate appropriate remediation. Remediation of a professionalism concern is a very individualized approach, recognizing that each situation may require tailored mentorship to facilitate professional growth.
Program director involvement is reserved for cases involving repeat concerns or significant violations. The goal of these early remediation opportunities is to correct behaviors in a formative way, allowing students time to mature in this area.
Evaluation of Effectiveness
To evaluate the impact of our multilayered professionalism assessment process, we conducted 2 primary assessments. The first was a preimplementation and postimplementation review of professionalism outcomes, specifically examining the number of students requiring major remediation involving program director intervention. The preimplementation cohort included the Classes of 2021 and 2022, while the postimplementation cohort encompassed the Classes of 2023 to 2025.
In addition, students from the Classes of 2024 to 2025 participated in a feedback survey to assess the perceived value of the peer professionalism evaluation tool. This survey consisted of 2 Likert-scale questions and one open-ended question:How helpful did you perceive the information gathered from the peer professionalism survey (1–5)?How valuable did you find the experience of participating in the survey and providing professional feedback (1–5)?Please provide any additional feedback on the peer professionalism survey.
The Likert-scale responses ranged from 5 (extremely beneficial) to 1 (not beneficial at all), a benchmark score of 3 or higher was established as an indicator of sufficient perceived value.
RESULTS
Analysis of Preimplementation and Postimplementation Remediation Findings
In the Classes of 2021 and 2022, 5 students per cohort required major professionalism remediation, defined as cases necessitating program director involvement and, in some instances, suspension. There was insufficient data tracking prior to the Class of 2021. Following the full implementation of our professionalism assessment tools, there was a marked decline in major remediation cases, demonstrating the effectiveness of early intervention and faculty empowerment in addressing professionalism concerns.
The Class of 2025 remains in training with one semester left, and ongoing monitoring will provide further insight into the long-term impact of these tools. However, current data already suggest a substantial reduction in major professionalism issues postimplementation.
The data in Figure 1 enable a direct comparison between preimplementation (Classes of 2021–2022) and postimplementation (Classes of 2023–2025) cohorts. Across all 5 cohorts (totaling 300 students), 180 students from the postimplementation period completed training under the fully integrated professionalism process.
Before full implementation, 8.3% (Class of 2021) and 8.3% (Class of 2022) required major professionalism remediation. Following implementation, remediation rates dropped to 0% in 2023, 1.7% in 2024, and remain at 0% thus far for 2025.
When averaging preimplementation and postimplementation groups, the major professionalism remediation rate decreased from 8.3% preimplementation to 0.6% postimplementation, reinforcing the effectiveness of this structured, multisource evaluation approach in fostering professional growth among students.
Student Feedback
Over the past 2 years, student feedback on the peer professionalism survey was collected to assess its effectiveness and students' perceptions of giving and receiving professional feedback. A total of 113 students were invited to participate in a voluntary, anonymous survey, with 31 responses, yielding a 27.4% response rate.
Regarding the perceived helpfulness of the peer professionalism survey (Figure 2), 87% of respondents rated it a 3 or higher on the Likert scale, indicating a moderate to high level of perceived benefit. The remaining 13% found it slightly beneficial. Similarly, when asked about the value of participating in the evaluation and providing professional praise and constructive feedback, all but one respondent rated it a 3 or higher (Figure 2).
Qualitative responses were analyzed using thematic coding, with a 20% frequency threshold set to identify significant themes. Two positive themes emerged: “overall good experience and value” (22%) and “peer feedback and self-reflection contributing to professional growth” (42%). While no negative themes met the benchmark, 13% of respondents mentioned challenges providing feedback due to limited familiarity with their peers.
DISCUSSION
Impact
This real-world application of our multilayered professionalism tracking and remediation approach has shown promising results in improving student professionalism within our PA program. This process has been refined, guided both by literature and internal feedback, enabling us to align with accreditation standards more effectively while fostering professional growth among students. Our process allowed us to observe clear trends in the reduction of major professionalism concerns, as reflected by the drop in program director-level remediation in the Classes of 2023 and 2024 compared with previous cohorts.
First Cohort Analysis
The Classes of 2021 and 2022 did not experience the full benefits of the professionalism assessment tools, as faculty onboarding and implementation were still in progress. The Class of 2023 was the first cohort to begin training with all professionalism evaluation measures in place. This allowed faculty to identify and address professionalism concerns proactively, ensuring early intervention before issues escalated to the level of program director involvement.
Importance of Peer Evaluation and Feedback on its Effectiveness
A key component of the multilayered approach was peer evaluation, which diversified feedback sources and provided insights that faculty or preceptor assessments might not capture. To maximize the effectiveness of the peer evaluation process, structured orientation sessions were implemented to educate students on delivering constructive, professional feedback; an area highlighted as essential in previous studies.4 This orientation also serves as preparation for peer feedback in clinical practice. While some students expressed concerns about not knowing their peers well enough to provide detailed feedback, the survey was administered after 4 semesters of the didactic phase and overall student response indicated that they found the evaluation process beneficial.
Given the significant time a cohort spends together during the didactic phase, peer evaluation remains a valuable tool for professional development.
Evaluation of Multilayered Approach
Before the implementation of our professionalism assessment model, professionalism was evaluated at discrete points, including admissions, letters of recommendation, advising meetings, and preceptor evaluations. However, these assessments did not prioritize early identification of concerns or provide structured support for students to develop skills better aligned with professionalism. A key objective of our revised process was to shift from a reactive, punitive approach to a proactive model that fosters continuous professional growth and self-reflection.
Our findings indicate a measurable reduction in professionalism remediation cases requiring program director intervention, suggesting an increase in student accountability and improved professional conduct. By embedding professionalism assessment across multiple layers of training, we have reframed the focus from disciplinary action to professional development, equipping students with structured opportunities to reflect, receive feedback, and refine their behaviors before issues escalate.
Limitations
While our results demonstrate positive trends, several limitations must be acknowledged. The absence of a control group limits our ability to establish a direct causal relationship between the intervention and observed improvements. Withholding professionalism assessment tools from a subset of students would have been ethically and pedagogically inappropriate, given ARC-PA accreditation standards requiring professionalism tracking for all learners.
In addition, our findings are specific to a single PA program, which may limit the generalizability of the results to other institutions with different curricular structures. The relatively small sample size further restricts the statistical power of our findings, and future research with larger cohorts would be beneficial for confirming these trends.
Another limitation involves potential variability in professionalism assessments. Despite standardized evaluation tools, differences in faculty and student perceptions of professionalism may introduce inconsistencies. Furthermore, because faculty onboarding and implementation were ongoing during the transition period, students in the preimplementation group may have been indirectly exposed to elements of the new model.
However, despite this potential overlap, a clear decline in major professionalism remediation cases was observed in postimplementation cohorts.
These limitations underscore the need for further investigation, ideally through multiinstitutional studies with larger sample sizes to better assess the long-term impact of a multi-tiered professionalism process.
Next Steps and Future Research
To further refine our approach, future efforts could focus on enhancing peer evaluation training and embedding structured feedback mechanisms earlier in the curriculum to normalize the process of professional self-reflection. Faculty calibration sessions could also be expanded to improve consistency in professionalism assessments. In addition, implementing this model in other PA programs or broader health professional education contexts could provide valuable insight into its adaptability and effectiveness.
Finally, longitudinal studies tracking graduates into clinical practice could offer further evidence of the sustained impact of multilayered professionalism training on long-term professional behavior.