A scoping review and theory-informed conceptual model of professional identity formation in medical education.

INTRODUCTION: Professional identity formation (PIF) is a central tenet of effective medical education. However, efforts to support, assess and study PIF are hindered by unclear definitions and conceptualisations of what it means to 'think, act, and feel like a physician'. Gaps in understanding PIF, and by extension, its support mechanisms, can predispose individuals towards disengaged or unprofessional conduct and institutions towards short-sighted or reactionary responses to systemic issues. METHODS: A Systematic Evidence-Based Approach-guided systematic scoping review of PIF theories was conducted related to medical students, trainees and practising doctors, published between 1 January 2000 and 31 December 2021 in PubMed, Embase, ERIC and Scopus databases. RESULTS: A total of 2441 abstracts were reviewed, 607 full-text articles evaluated and 204 articles included. The domains identified were understanding PIF through the lens of pivotal theories and characterising PIF by delineating the underlying factors that influence it and processes that define it. CONCLUSIONS: Based on regnant theories and frameworks related to self-concepts of identity and personhood, the relationships between key PIF influences, processes and outcomes were examined. A theory-backed integrated conceptual model was proposed to delineate the interconnected relationships among these, aiming to untangle some of the complexities inherent to PIF, to shed light on existing practices and to identify shortcomings in our understanding so as to develop mechanisms in support of its multifaceted, interlinked components.

Conceptualizing Professional Identity Formation in Medicine.

THE WHAT: Professional Identity Formation (PIF) in medicine is the gradual transformation that occurs in the process of becoming a doctor, as professional values, beliefs, behaviors, relationships, roles, and responsibilities become integrated into an aggregate of existing identities. 1 Conceptually, this process may be considered as a trajectory of self-perceived identities that transpires between an individual's existing identity and an evolving, aspirational identity toward which the individual may strive. 2 This process is individualized, yet contextual, psychosocially grounded, and subject to lifelong deconstruction and reconstruction depending on how the person experiences, and thus responds to, events. 2. THE SO WHAT: Faced with key transitions, conflicts, or crises, a medical student or physician may experience dissonance between their personal values and beliefs and their professional roles and expectations.1 If left unsupported (see light blue lines in graph below), this can challenge their sense of belonging or meaning, lower self-esteem or self-efficacy, or breed distress, burnout, or attrition. When recognized and supported (see dark blue line below), defining experiences can enhance tolerance for ambiguity, enable meaning-making, foster socialization into communities of learning or practice, and deepen enculturation and commitment to the profession. 2. THE WHAT NOW: PIF is implicitly a fundamental goal of medical education, necessitating institutional support along the medical education continuum. 1-3.

The impact of death and dying on the personhood of senior nurses at the National Cancer Centre Singapore (NCCS): a qualitative study.

BACKGROUND: A nurse's role in caring for the dying is fraught with ethical, professional, and psychosocial challenges that impact how they perceive their roles as professionals. When unsupported, nurses caring for the dying experience burnout, career dissatisfaction and leave the profession. Better understanding of how caring for the dying affects the professional identity formation (PIF) of nurses will guide efforts to better support nurses. METHODS: Guided by new data on the subject, we adopt the theoretical lens of the Ring Theory of Personhood (RToP) to evaluate how caring for the dying impacts the values, beliefs, principles, professional identities and personhood of nurses. We employ Krishna's Systematic Evidence-Based Approach (SEBA) to guide the design and piloting of the semi-structured interview tool. RESULTS: Analysis of interviews with eight senior nurses in Supportive, Palliative and Oncology care revealed three domains: Identity 1) Formation; 2) Conflict and 3) Refinement. Identity Formation occurs early in a nurse's career, upon entering a new specialist field, and at the start of Supportive, Palliative and Oncology care. Identity Formation reveals significant changes to how self-concepts of professional identities are tied to individual concepts of personhood. Caring for the dying, however, resulted in Conflicts between values, beliefs, and principles within regnant concepts of personhood and their professional duties. These conflicts are captured as conflicts within ('disharmony') and/or between ('dyssynchrony') the rings of the RToP. These conflicts can result in changes to self-concepts of personhood and professional identities. Identity Refinement sees experience and timely support helping nurses attenuate the impact of difficult experiences. This reduces the risk of burnout and mitigates changes to their professional identities. Identity Refinement helps them develop a 'rooted identity' which remains relatively consistent in the face of adversity. CONCLUSIONS: Ongoing Identity Construction amongst nurses, particularly in caring for the dying, underscore the host organisation's role in ensuring structured, longitudinal, accessible, and personalised assessments and support of nurses, especially when they are prone to dyssynchrony and disharmony whilst caring for the terminally ill. Further study into assessment methods and the role of the environment is critical.

A Scoping Review of Professional Identity Formation in Undergraduate Medical Education.

BACKGROUND: Professional identity formation (PIF) in medical students is a multifactorial phenomenon, shaped by ways that clinical and non-clinical experiences, expectations and environmental factors merge with individual values, beliefs and obligations. The relationship between students' evolving professional identity and self-identity or personhood remains ill-defined, making it challenging for medical schools to support PIF systematically and strategically. Primarily, to capture prevailing literature on PIF in medical school education, and secondarily, to ascertain how PIF influences on medical students may be viewed through the lens of the ring theory of personhood (RToP) and to identify ways that medical schools support PIF. METHODS: A systematic scoping review was conducted using the systematic evidence-based approach. Articles published between 1 January 2000 and 1 July 2020 related to PIF in medical students were searched using PubMed, Embase, PsycINFO, ERIC and Scopus. Articles of all study designs (quantitative and qualitative), published or translated into English, were included. Concurrent thematic and directed content analyses were used to evaluate the data. RESULTS: A total of 10443 abstracts were identified, 272 full-text articles evaluated, and 76 articles included. Thematic and directed content analyses revealed similar themes and categories as follows: characteristics of PIF in relation to professionalism, role of socialization in PIF, PIF enablers and barriers, and medical school approaches to supporting PIF. DISCUSSION: PIF involves iterative construction, deconstruction and inculcation of professional beliefs, values and behaviours into a pre-existent identity. Through the lens of RToP, factors were elucidated that promote or hinder students' identity development on individual, relational or societal levels. If inadequately or inappropriately supported, enabling factors become barriers to PIF. Medical schools employ an all-encompassing approach to support PIF, illuminating the need for distinct and deliberate longitudinal monitoring and mentoring to foster students' balanced integration of personal and professional identities over time.

Medical students' preference for returning to the clinical setting during the COVID-19 pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has led to widespread disruptions in the clinical education of medical students. In managing students' return to the clinical setting, medical schools face the challenge of balancing education, service and risk considerations. To compound this challenge, medical students may prefer not to re-enter during a period of great uncertainty, leading to substantive downstream sequelae on individual, institutional and national levels. Understanding students' views on resuming clinical experiences, therefore, is an important consideration. The purpose of this study was to assess medical students' preference for re-entering the clinical setting during the COVID-19 pandemic and to explore personal and environmental characteristics associated with that preference. METHODS: We conducted an electronic survey of currently enrolled medical students at the Duke-NUS Medical School, less than a month into the COVID-19 pandemic. Survey items were aligned with a conceptual framework related to medical students' preference for returning to the clinical setting. The framework consisted of three domains: (a) non-modifiable demographic information; (b) factors thought to be modifiable through the course of medical education, including burnout, tolerance for ambiguity, motivation and professionalism, and (c) students' perception of COVID-19 infection risk to self. RESULTS: Approximately one-third (n=63) of 179 students preferred not to return to the clinical setting. Results of a multivariable analysis indicated that compared to this group, the two-thirds (n=116) of students favouring return showed evidence of greater autonomous (or internal) motivation, a greater sense of professional responsibility and a lower self-perception of harbouring risk to patients. CONCLUSIONS: Students' preference on returning to the clinical environment stems from the interplay of several key factors, and is substantively associated with perceptions of professional responsibility and their own potential risk to the health care system. Mindfully considering and addressing these issues may help medical schools in their preparation for returning students to the clinical setting.

A 9-Year retrospective review of antibiotic cycling in a surgical intensive care unit.

BACKGROUND: Six years after initiating a monthly antibiotic cycling protocol in the surgical intensive care unit (SICU), we retrospectively reviewed antibiogram-derived sensitivities of predominant gram-negative pathogens before and after antibiotic cycling. We also examined susceptibility patterns in the medical intensive care unit (MICU) where antibiotic cycling is not practiced. MATERIALS AND METHODS: Antibiotic cycling protocol was implemented in the SICU starting in 2003, with monthly rotation of piperacillin/tazobactam, imipenem/cilastin, and ceftazidime. SICU antibiogram data from positive clinical cultures for years 2000 and 2002 were included in the pre-cycling period, and those from 2004 to 2009 in the cycling period. RESULTS: Profiles of SICU pseudomonal isolates before (n = 116) and after (n = 205) implementing antibiotic cycling showed statistically significant improvements in susceptibility to ceftazidime (66% versus 81%; P = 0.003) and piperacillin/tazobactam (75% versus 85%; P = 0.021), while susceptibility to imipenem remained unaltered (70% in each case; P = 0.989). Susceptibility of E. coli isolates to piperacillin/tazobactam improved significantly (46% versus 83%; P < 0.0005), trend analysis showing this improvement to persist over the study period (P = 0.025). Similar findings were not observed in the MICU. Review of 2004-2009 antibiotic prescription practices showed monthly heterogeneity in the SICU, and a 2-fold higher prescribing of piperacillin/tazobactam in the MICU (P < 0.0001). CONCLUSIONS: Six years into antibiotic cycling, we found either steady or improved susceptibilities of clinically relevant gram-negative organisms in the SICU. How much of this effect is from cycling is unknown, but the antibiotic heterogeneity provided by this practice justifies its ongoing use.

Inhibition of in vivo tumor angiogenesis and growth via systemic delivery of an angiopoietin 2-specific RNA aptamer.

BACKGROUND: Cellular events mediated by the Tie2 receptor are important to tumor neovascularization. Despite the complex interplay of the best-characterized Tie2 ligands, angiopoietins 1 and 2, Ang2 is purportedly "proangiogenic" in the presence of vascular endothelial growth factor. We examined whether in vivo administration of an RNA aptamer that specifically blocks Ang 2 would inhibit tumor angiogenesis and growth. METHODS: Ang2-mediated Tie2 receptor phosphorylation was assessed in vitro in the absence and presence of aptamer coupled to polyethylene glycol. IN VIVO ANGIOGENESIS ASSAY: CT26 murine colon carcinoma cells expressing green fluorescent protein were delivered into mouse dorsal skinfold window chambers. Animals received daily intraperitoneal injections of phosphate-buffered saline, low-dose (Ang2 aptamer-LD; 1 mg/kg/d), or high-dose aptamer (Ang2 aptamer-HD; 10 mg/kg/d). Vascular length density was measured under fluorescence microscopy. PRIMARY TUMOR GROWTH: CT26 cells expressing luciferase were injected into flanks of BALB/c mice to allow tumor growth monitoring by bioluminescence imaging. Animals received continuous phosphate-buffered saline or aptamer (1 mg/kg/d) via ALZET pumps. Tumors were assessed for CD31/PECAM-1 immunostaining and Hoechst dye uptake. RESULTS: Pegylated aptamer inhibited Tie2 phosphorylation. Systemic aptamer administration reduced vascular length density (P < or = 0.03) and decreased bioluminescence emission (P < 0.04), corresponding to 50% decrease in tumor volume (P = 0.04). Control tumors displayed abundant vascular marker staining, in contrast to tumors from aptamer-treated animals. CONCLUSIONS: in vivo administration of a clinically relevant, pegylated RNA aptamer specifically designed against Ang2 inhibited tumor angiogenesis and growth. These findings support targeted Ang2 inhibition as a relevant anti-angiogenic, anti-neoplastic strategy.

A comparison of antiangiogenic therapies for the prevention of liver metastases.

Angiogenesis is essential for solid tumor growth. Although successful antiangiogenic therapies have been demonstrated in animal models, a systematic comparison of the efficacy of different antiangiogenic factors has not been described in the hepatic environment. To address this issue, CT26 murine colon carcinoma cells were transfected with retroviral vectors encoding murine endostatin (mEndostatin), human angiostatin (hAngiostatin), murine-soluble vascular endothelial growth factor receptor-2, (msFlk-1), or murine-soluble Tie2 (msTie2). The transfected cells were then subjected to another round of transfection with a luciferase cDNA-encoding retroviral vector. Expression of these putative antiangiogenic proteins inhibited the proliferation of human umbilical vein endothelial cells in vitro but not tumor cells. To examine effects on tumor growth in vivo, modified cells were delivered via intrasplenic injection into BALB/c mice to induce liver metastases. Tumor burden was measured weekly by bioluminescence. Growth of hepatic metastases in vivo was significantly reduced in mice that were administered cells expressing msTie2 (76% reduction compared with control cells 21 days after intrasplenic inoculation; P < 0.05). Similar results were observed with cells that expressed msFlk-1 and hAngiostatin. However, expression of mEndostatin had no significant effect on the growth of liver metastases compared with control animals. These findings indicate that multiple antiangiogenic pathways are necessary for the growth of hepatic metastases, and each of these pathways is a potential clinically relevant antiangiogenic target for the treatment of this disease.

Targeted inhibition of alphavbeta3 integrin with an RNA aptamer impairs endothelial cell growth and survival.

Alphavbeta3 integrin is a crucial factor involved in a variety of physiological processes, such as cell growth and migration, tumor invasion and metastasis, angiogenesis, and wound healing. Alphavbeta3 integrin exerts its effect by regulating endothelial cell (EC) migration, proliferation, and survival. Inhibiting the function of alphavbeta3 integrin, therefore, represents a potential anti-cancer, anti-thrombotic, and anti-inflammatory strategy. In this study, we tested an RNA aptamer, Apt-alphavbeta3 that binds recombinant alphavbeta3 integrin, for its ability to bind endogenous alphavbeta3 integrin on the surface of cells in culture and to subsequently affect cellular response. Our data illustrate that Apt-alphavbeta3 binds alphavbeta3 integrin expressed on the surface of live HUVECs. This interaction significantly decreases both basal and PDGF-induced cell proliferation as well as inhibition of cell adhesion. Apt-alphavbeta3 can also reduce PDGF-stimulated tube formation and increase HUVEC apoptosis through inhibition of FAK phosphorylation pathway. Our results demonstrate that by binding to its target, Apt-alphavbeta3 can efficiently inhibit human EC proliferation and survival, resulting in reduced angiogenesis. It predicts that Apt-alphavbeta3 could become useful in both tumor imaging and the treatment of tumor growth, atherosclerosis, thrombosis, and inflammation.

Hepatic tumor growth: target for angiogenesis inhibition?

Pathologic angiogenesis induced by a tumor is essential for its survival. The promise of tumor inhibition by targeting angiogenesis over the past several years has translated into numerous ongoing clinical trials. Recently, in a phase III trial involving patients with metastatic colorectal cancer, Bevacizumab (Genentech, Inc, San Francisco, CA), a recombinant humanized monoclonal antibody against vascular endothelial growth factor used in conjunction with standard chemotherapy was shown to increase survival, progression-free survival, response rate, and duration of response compared to chemotherapy alone. Thus far, duration of the increased response remains less than 6 months. The majority of deaths in patients with colorectal cancer are related to hepatic metastases. It is hoped that novel approaches directed at the complex interactions between tumor and microenvironment in the angiogenic process will strengthen the therapeutic armamentarium against hepatic malignancies.

Osteopontin silencing by small interfering RNA suppresses in vitro and in vivo CT26 murine colon adenocarcinoma metastasis.

Hepatic metastasis is a primary cause for failure of locoregional therapy in colorectal cancer. Increased expression of osteopontin (OPN), a ligand for alpha(v)beta3 integrin and CD44 receptors, is associated with metastasis in several types of cancer. However, the mechanism by which OPN mediates metastasis in colorectal cancer remains unknown. We hypothesized that OPN mediates invasion of colon cancer cells through basement membrane and migration through extracellular matrix (ECM). In this study, we used CT26 murine colon adenocarcinoma cells syngeneic to BALB/c mice to generate cell lines (pS-OPN) in which OPN expression was suppressed through small interfering RNA (siRNA) plasmids. CT26 wild-type cells (WT) and CT26 cells stably expressing murine-mismatch siRNA (pS-MM) served as controls. Western blotting quantified OPN protein levels and our most downregulated clone, pS-OPN-A4, demonstrated a mean 3.0-fold decrease in OPN protein expression versus WT. In vitro cell motility and invasiveness were decreased in pS-OPN-A4 by 3.6-fold (P = 0.004 versus WT) and 4.1-fold (P = 0.01 versus WT), but proliferation was similar amongst cell lines. We demonstrated that OPN suppression significantly correlates with MMP-2 downregulation. In vivo hepatic metastasis was assessed by quantifying liver weights and surface tumor nodules in 33 BALB/c mice (11/group) subjected to intrasplenic injection of tumor cells. pS-OPN-A4 resulted in a 50.4% decrease in mean liver weight compared with WT (3.79 +/- 1.49 g versus 1.88 +/- 1.34 g, P = 0.009). Only 18% of pS-OPN-A4 livers had >20 metastatic surface nodules compared with 89% for WT and 75% for pS-MM-V6. This study demonstrates that RNA interference stably reduces CT26 tumor expression of OPN and significantly attenuates CT26 colon cancer metastasis by diminishing tumor cell motility and invasiveness.

Use of in vivo bioluminescence imaging to predict hepatic tumor burden in mice.

BACKGROUND: We used bioluminescence imaging (BLI) to validate serial assessment of neoplastic growth within the murine liver. We hypothesized that, in mice bearing luciferase-expressing liver metastases, bioluminescence would reflect neoplastic burden estimated by liver weight. MATERIALS AND METHODS: Murine colon carcinoma cells were infected with a retroviral vector encoding luciferase. Bioluminescence was measured in vitro, and in vivo following intrasplenic tumor cell inoculation into Balb/C mice. At varying time intervals, mice were imaged and immediately killed to determine correlation of in vivo and ex vivo BL with liver weight. To examine sensitivity in vivo, we performed direct intrahepatic inoculation. RESULTS: In vitro, photon emission correlated with increasing cell numbers. In the metastatic model, a statistically significant increase was depicted in both liver weight and bioluminescence 20 days after tumor inoculation compared with earlier time points (P < 0.0001). With progressively increasing tumor burden, however, a poor correlation between in vivo BL and liver weight was observed. When livers with very large tumors were excluded, R(2) = 0.90. In contrast, correlation between ex vivo BL and liver weight remained high throughout the study period (R(2) = 0.94). CONCLUSIONS: When imaging tumors at end-stages of disease, in vivo BL underestimates actual tumor burden. If context-specific limitations are recognized, however, BLI is a sensitive approach to temporal monitoring of tumor progression in preclinical models.

European surgical survey of acute pancreatitis--union of diversity.

The widely variable nature of acute pancreatitis renders it a challenging disease to manage via standardized approaches. King and Siriwardena present their findings from a survey of European surgical approaches to diagnostic and therapeutic management of severe acute pancreatitis in an attempt to delineate areas of discordance that may help direct future studies. An erratic trend in the management of severe acute pancreatitis is evident despite growing evidence to support several diagnostic and therapeutic procedures as standards of care. On the other hand, areas of discordance largely characterize those currently lacking in adequate literature support underscoring the need to generate randomized studies that will address them.