Professionalism in the Gray Zone: Comparing Medical Student and Preceptor Judgments of Ambiguous Clinical Scenarios

Abstract Background: Professionalism is a core competency in medical education, yet many challenges encountered during clinical training occur in ambiguous situations where expectations depend on clinical context, role responsibilities, and workplace norms. These “gray-zone” situations may be particularly challenging for students transitioning into clerkships. This study examined whether medical students and physician clinical preceptors differed in their judgments of professionalism across gray-zone clinical scenarios and in their confidence in those judgments. Methods: A cross-sectional survey was administered to second-year osteopathic medical students and physician clinical preceptors. Participants classified behaviors depicted in 20 standardized professionalism vignettes as professional or unprofessional and rated their confidence in each judgment. Responses from 75 students and 185 preceptors (N = 260) were analyzed. Vignette-level classifications were compared using Pearson’s chi-square or Fisher’s exact tests with Benjamini-Hochberg false discovery rate correction. Domain-level misalignment was summarized using mean absolute percentage-point differences. Participant-level mean confidence scores were also compared between groups. Results: Seven of 20 vignettes demonstrated student–preceptor differences at the unadjusted significance threshold, and four remained significant after correction for multiple comparisons. The largest difference involved accessing a patient’s medical record after direct clinical involvement had ended, classified as professional by 10.7% of students compared with 61.6% of preceptors. Differences also remained for follow-up of imaging results, phone use during rounds, and use of the term “noncompliant” without contextual framing. The greatest domain-level misalignment occurred among vignettes involving integrity, honesty, and trustworthiness (20.0 percentage points), with additional differences involving patient-centered language, scope and role clarity, and accountability. Students demonstrated lower overall confidence than preceptors (2.43± 0.24 vs. 2.62 ± 0.27; Hedges’ g = 0.72; p < .000001); however, confidence differences did not consistently parallel differences in professionalism judgments. Conclusions: Medical students and physician preceptors frequently agreed about professionalism but differed substantially in selected ambiguous clinical situations. These differences were not consistently attributable to lower student confidence, suggesting that students and preceptors may apply different contextual assumptions when interpreting the same behavior. Explicitly addressing gray-zone scenarios and the reasoning underlying different professional judgments may help make implicit clinical expectations more visible and better prepare students to navigate context-dependent professionalism during clinical training.