Professionalism, Communities of Practice, and Medicine's Social Contract.

While medicine's roots lie deep in antiquity, the modern professions only arose in the middle of the 19th century after which early social scientists examined the nature of professionalism. The relationship between medicine and society received less attention until profound changes occurred in the structure and financing of health care, leading to a perception that medicine's professionalism was being threatened. Starr in 1984 proposed that the relationship was contractual with expectations and obligations on both sides. Other observers refined the concept, believing that the historic term, "social contract," could be applied to the relationship, a concept with which many agree. There was general agreement that society used the concept of the profession to organize the delivery of essential services that it required, including health care. Under the terms of the contract, the medical profession was given financial and nonfinancial rewards, autonomy, and the privilege of self regulation on the understanding that it would be trustworthy, assure the competence of its members, and be devoted to the public good. In examining how the social contract is negotiated, it has been proposed that physicians belong to a "community of practice" that they voluntarily join during their education and training. In joining the community, they accept the norms and values of community members and acquire the identity prescribed by the community. The leaders of the community are responsible for negotiating the social contract on behalf of the medical profession. In so doing, they must ensure that they recognize the importance of devotion to the public good in the maintenance of medicine's professional status.

Clinical Teachers' Perceptions of Their Role in Professional Identity Formation.

PURPOSE: A fundamental goal of medical education is supporting learners in forming a professional identity. While it is known that learners perceive clinical teachers to be critically important in this process, the latter's perspective is unknown. This study sought to understand how clinical teachers perceive their influence on the professional identity formation of learners. METHOD: In 2017, a research assistant conducted 16 semistructured interviews of clinical teachers from 8 specialties at McGill University. The research assistant audiorecorded and subsequently transcribed interviews for analysis. Following principles of qualitative description, the research team developed a coding scheme using both inductive codes (from the words of the participants) and deductive codes (based on the literature and the theory of communities of practice). Through a cross-case analysis, the team then identified salient themes. RESULTS: Participants struggled to describe their influence on learners' professional identity without first being prompted to focus on their own identity and its formation. Once prompted, clinical teachers reported viewing their personal and professional identities as integrated and believed that caring for patients was integral to forming their professional identity. They identified explicit role modeling, engaging in difficult conversations, and providing graded autonomy as ways in which they could influence the identity development of learners. However, they had difficulty discerning the magnitude of their influence. CONCLUSIONS: This study was the first to explore professional identity formation from the perspective of clinical teachers. The 2010 Carnegie Foundation report called for an increased focus on professional identity formation. Giving clinical teachers the space and guidance to reflect on this process, helping them make the implicit explicit, and supporting them in using their own experiences as learners to inform their teaching appear to be critical steps in achieving this goal.

Supporting the development of a professional identity: General principles.

While teaching medical professionalism has been an important aspect of medical education over the past two decades, the recent emergence of professional identity formation as an important concept has led to a reexamination of how best to ensure that medical graduates come to "think, act, and feel like a physician." If the recommendation that professional identity formation as an educational objective becomes a reality, curricular change to support this objective is required and the principles that guided programs designed to teach professionalism must be reexamined. It is proposed that the social learning theory communities of practice serve as the theoretical basis of the curricular revision as the theory is strongly linked to identity formation. Curricular changes that support professional identity formation include: the necessity to establish identity formation as an educational objective, include a cognitive base on the subject in the formal curriculum, to engage students in the development of their own identities, provide a welcoming community that facilitates their entry, and offer faculty development to ensure that all understand the educational objective and the means chosen to achieve it. Finally, there is a need to assist students as they chart progress towards becoming a professional.

Medicine as a Community of Practice: Implications for Medical Education.

The presence of a variety of independent learning theories makes it difficult for medical educators to construct a comprehensive theoretical framework for medical education, resulting in numerous and often unrelated curricular, instructional, and assessment practices. Linked with an understanding of identity formation, the concept of communities of practice could provide such a framework, emphasizing the social nature of learning. Individuals wish to join the community, moving from legitimate peripheral to full participation, acquiring the identity of community members and accepting the community's norms.Having communities of practice as the theoretical basis of medical education does not diminish the value of other learning theories. Communities of practice can serve as the foundational theory, and other theories can provide a theoretical basis for the multiple educational activities that take place within the community, thus helping create an integrated theoretical approach.Communities of practice can guide the development of interventions to make medical education more effective and can help both learners and educators better cope with medical education's complexity. An initial step is to acknowledge the potential of communities of practice as the foundational theory. Educational initiatives that could result from this approach include adding communities of practice to the cognitive base; actively engaging students in joining the community; creating a welcoming community; expanding the emphasis on explicitly addressing role modeling, mentoring, experiential learning, and reflection; providing faculty development to support the program; and recognizing the necessity to chart progress toward membership in the community.

Amending Miller's Pyramid to Include Professional Identity Formation.

In 1990, George Miller published an article entitled "The Assessment of Clinical Skills/Competence/Performance" that had an immediate and lasting impact on medical education. In his classic article, he stated that no single method of assessment could encompass the intricacies and complexities of medical practice. To provide a structured approach to the assessment of medical competence, he proposed a pyramidal structure with four levels, each of which required specific methods of assessment. As is well known, the layers are "Knows," "Knows How," "Shows How," and "Does." Miller's pyramid has guided assessment since its introduction; it has also been used to assist in the assessment of professionalism.The recent emphasis on professional identity formation has raised questions about the appropriateness of "Does" as the highest level of aspiration. It is believed that a more reliable indicator of professional behavior is the incorporation of the values and attitudes of the professional into the identity of the aspiring physician. It is therefore proposed that a fifth level be added at the apex of the pyramid. This level, reflecting the presence of a professional identity, should be "Is," and methods of assessing progress toward a professional identity and the nature of the identity in formation should be guided by currently available methods.

A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators.

Recent calls to focus on identity formation in medicine propose that educators establish as a goal of medical education the support and guidance of students and residents as they develop their professional identity. Those entering medical school arrive with a personal identity formed since birth. As they proceed through the educational continuum, they successively develop the identity of a medical student, a resident, and a physician. Each individual's journey from layperson to skilled professional is unique and is affected by "who they are" at the beginning and "who they wish to become."Identity formation is a dynamic process achieved through socialization; it results in individuals joining the medical community of practice. Multiple factors within and outside of the educational system affect the formation of an individual's professional identity. Each learner reacts to different factors in her or his own fashion, with the anticipated outcome being the emergence of a professional identity. However, the inherent logic in the related processes of professional identity formation and socialization may be obscured by their complexity and the large number of factors involved.Drawing on the identity formation and socialization literature, as well as experience gained in teaching professionalism, the authors developed schematic representations of these processes. They adapted them to the medical context to guide educators as they initiate educational interventions, which aim to explicitly support professional identity formation and the ultimate goal of medical education-to ensure that medical students and residents come to "think, act, and feel like a physician."

How we made professionalism relevant to twenty-first century residents.

The complexity of the current medical trainee work environment, including the impact of social media participation, is underappreciated. Despite rapid adoption of social media by residents and the introduction of social media guidelines targeted at medical professionals, there is a paucity of data evaluating practical methods to incorporate social media into professionalism teaching curricula. We developed a flipped classroom program, focusing on the application of professionalism principles to challenging real-life scenarios including social media-related issues. The pre-workshop evaluation showed that the participants had a good understanding of basic professionalism concepts. A post-workshop survey assessed residents' comfort level with professionalism concepts. The post-workshop survey revealed that the postgraduate trainees perceived significant improvement in their understanding of professionalism (p < 0.05). Resident responses also exposed some challenges of real-life clinical settings. There was an apparent contradiction between placing a high value on personal health and believing that physicians ought to be available to patients at any time. Participants' satisfaction with the course bodes well for continual modification of such courses. Innovative flipped classroom format in combination with simulation-based sessions allows easy incorporation of contemporary professionalism issues surrounding social media.

Reframing medical education to support professional identity formation.

Teaching medical professionalism is a fundamental component of medical education. The objective is to ensure that students understand the nature of professionalism and its obligations and internalize the value system of the medical profession. The recent emergence of interest in the medical literature on professional identity formation gives reason to reexamine this objective. The unstated aim of teaching professionalism has been to ensure the development of practitioners who possess a professional identity. The teaching of medical professionalism therefore represents a means to an end.The principles of identity formation that have been articulated in educational psychology and other fields have recently been used to examine the process through which physicians acquire their professional identities. Socialization-with its complex networks of social interaction, role models and mentors, experiential learning, and explicit and tacit knowledge acquisition-influences each learner, causing them to gradually "think, act, and feel like a physician."The authors propose that a principal goal of medical education be the development of a professional identity and that educational strategies be developed to support this new objective. The explicit teaching of professionalism and emphasis on professional behaviors will remain important. However, expanding knowledge of identity formation in medicine and of socialization in the medical environment should lend greater logic and clarity to the educational activities devoted to ensuring that the medical practitioners of the future will possess and demonstrate the qualities of the "good physician."

The Professionalism Assessment of Clinical Teachers (PACT): the reliability and validity of a novel tool to evaluate professional and clinical teaching behaviors.

Physicians function as clinicians, teachers, and role models within the clinical environment. Negative learning environments have been shown to be due to many factors, including the presence of unprofessional behaviors among clinical teachers. Reliable and valid assessments of clinical teacher performance, including professional behaviors, may provide a foundation for evidence-based feedback to clinical teachers, enable targeted remediation or recognition, and help to improve the learning environment. However, few tools exist for the evaluation of clinical teachers that include a focus on both professional and clinical teaching behaviors. The Professionalism Assessment of Clinical Teachers (PACT) was developed and implemented at one Canadian institution and was assessed for evidence of reliability and validity. Following each clerkship rotation, students in the 2009-2010 third-year undergraduate clerkship cohort (n = 178) anonymously evaluated a minimum of two clinical teachers using the PACT. 4,715 forms on 567 faculty members were completed. Reliability, validity, and free text comments (present in 45 % of the forms) were examined. An average of 8.6 PACT forms were completed per faculty (range 1-60), with a reliability of 0.31 for 2.9 forms (harmonic mean); 12 forms were necessary for a reliability of 0.65. Global evaluations of teachers aligned with ratings of free-text comments (r = 0.77, p < 0.001). Comment length related negatively with overall rating (r = -0.19, p < 0.001). Mean performance related negatively with variability of performance (r = -0.72, p < 0.001), although this may be related to a ceiling effect. Most faculty members were rated highly; however 'provided constructive feedback' was the least well-rated item. Respectful interactions with students appeared to be the most influential item in the global rating of faculty performance. The PACT is a moderately reliable tool for the assessment of professional behaviors of clinical teachers, with evidence supporting its validity.

Commentary: professionalism, unionization, and physicians' strikes.

Professionalism is the basis of medicine's social contract with society. The details of that contract are influenced by the presence or absence of a national health plan. In countries with such a plan, unlike in the United States, negotiations are dictated by the nature of medicine's contract with society and take place between the medical profession and society directly. This system has required that medicine be represented at the negotiating table, and, in most instances, it has resulted in the unionization of physicians. To influence these negotiations, the medical profession has used various forms of collective action, including strikes. As the United States continues on the path toward health care reform, it seems likely that the American medical profession will also require an organization to represent it at the negotiating table and will be under the same pressures to strike as are physicians in other countries. Because both unionization and strikes pose potential threats to the professionalism of students, residents and practicing physicians, such issues should be a part of the medical education curriculum at both the undergraduate and postgraduate levels. The authors briefly review the literature on strikes and job actions and share personal experiences to support this discussion. Students and residents should have an opportunity to consider these issues in a safe environment, both to understand the potential impact of a strike on patients and the profession and to determine their own personal course of action should such a situation arise.

Physicianship: Educating for professionalism in the post-Flexnarian era.

Although he did not write extensively about professionalism, Abraham Flexner clearly understood its critical role in medical practice. In discerning the basics of medical education he characterized scientific methodology as the instrumental minimum. He left open to future generations the task of defining its necessary complement, the "noble behaviors and fine feelings" required of the medical practitioner. Situated within the current professionalism movement, and informed by previous commentary on the enduring attributes of medicine, a curriculum based on "Physicianship"--the physician as healer and professional--can serve as a logical post-Flexnerian curriculum. The conceptual armature of Physicianship and the attributes necessary for the fulfillment of both the professional and healer role can assist in the selection of students and constitute the educational blueprint for medical teaching. The critically important concepts of identity formation and the requirements for the valid and reliable assessment of professional behaviors of students and faculty are essential components. A Physicianship curriculum, as conceived and deployed at the McGill University Faculty of Medicine, might resonate with Flexner.

Developing and piloting a form for student assessment of faculty professionalism.

One of the impediments to teaching professionalism is unprofessional behavior amongst clinical teachers. No method of reliably assessing the professional behavior of clinical teachers has yet been reported. The aim of this project was to develop and pilot such a tool. Thirty-four desirable professional behaviors in clinical teachers were identified. Medical students (n = 13) and medical educators (n = 30) rated their importance and validity. Based on the ratings, 16 behaviors in 4 dimensions were included in an assessment form that was piloted in the Department of Pediatrics at McGill University, with medical students (n = 94) rating the professionalism of their clinical faculty (n = 20). One hundred and ninety forms were returned with between 1 and 22 evaluations per faculty member. Scores ranged from 25 to 48 (maximum rating = 48, mean score = 42.7, SD = 6.29). A generalizability analysis was conducted; internal consistency was 0.89, and reliability for a mean of 8.23 ratings per faculty member was 0.53. Inter-rater reliability for one item was 0.11, potentially due to the context specificity of behavior or low frequency of unprofessional behaviors. Exploratory factor analysis revealed 3 factors with eigen values over 1. Assessment of the professionalism of clinical teaching faculty appears to be feasible, acceptable and reasonably reliable. The explicit evaluation of professional conduct in clinical faculty could encourage the maintenance of professional behaviors and potentially decrease the effects of negative role modeling and positively affect the hidden and informal curricula.