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.

The challenges of detecting progress in generic competencies in the clinical setting.

CONTEXT: Competency-based medical education has spurred the implementation of longitudinal workplace-based assessment (WBA) programmes to track learners' development of competencies. These hinge on the appropriate use of assessment instruments by assessors. This study aimed to validate our assessment programme and specifically to explore whether assessors' beliefs and behaviours rendered the detection of progress possible. METHODS: We implemented a longitudinal WBA programme in the third year of a primarily rotation-based clerkship. The programme used the professionalism mini-evaluation exercise (P-MEX) to detect progress in generic competencies. We used mixed methods: a retrospective psychometric examination of student assessment data in one academic year, and a prospective focus group and interview study of assessors' beliefs and reported behaviours related to the assessment. RESULTS: We analysed 1662 assessment forms for 186 students. We conducted interviews and focus groups with 21 assessors from different professions and disciplines. Scores were excellent from the outset (3.5-3.7/4), with no meaningful increase across blocks (average overall scores: 3.6 in block 1 versus 3.7 in blocks 2 and 3; F = 8.310, d.f. 2, p < 0.001). The main source of variance was the forms (47%) and only 1% of variance was attributable to students, which led to low generalisability across forms (Eρ2  = 0.18). Assessors reported using multiple observations to produce their assessments and were reluctant to harm students by consigning anything negative to writing. They justified the use of a consistent benchmark across time by citing the basic nature of the form or a belief that the 'competencies' assessed were in fact fixed attributes that were unlikely to change. CONCLUSIONS: Assessors may purposefully deviate from instructions in order to meet their ethical standards of good assessment. Furthermore, generic competencies may be viewed as intrinsic and fixed rather than as learnable. Implementing a longitudinal WBA programme is complex and requires careful consideration of assessors' beliefs and values.

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.

Updating the Hippocratic Oath to include medicine's social contract.

CONTEXT: It is widely understood that reciting a contemporary version of the Hippocratic Oath has two purposes. It constitutes a public commitment on the part of the prospective doctor to preserving the traditional values of the medical profession and to meeting the obligations expected of a doctor. It is also an important symbolic ritual in the process of professional identity formation. METHODS: A portion of the 1964 version of the Hippocratic Oath is examined for its relevance to the current practice of medicine. Its closing paragraph reads: 'If I do not violate this oath, may I enjoy life and art, be respected while I live and remembered with affection thereafter. May I always act to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.' This is interpreted as representing the doctor's expectations of the practice of medicine: job satisfaction; status, and prestige. It also conveys the understanding that enjoying these benefits is contingent upon the doctor's adherence to the terms of the Oath. CONCLUSIONS: Our current understanding of the relationship between medicine and society is that a social contract exists under which members of the profession are granted a privileged position in society on the understanding that they will meet society's reasonable expectations. These expectations entail obligations not only to patients and to the profession, but to wider society. The Oath under consideration, which concentrates on medicine's obligations to patients and to the profession, does not adequately reflect its obligations to society. It is suggested that versions of the Hippocratic Oath used in the future should be updated to better reflect the obligations of both individual doctors and the medical profession to society.

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.

If we assess, will they learn? Students' perspectives on the complexities of assessment-for-learning.

Introduction: Assessment can positively influence learning, however designing effective assessment-for-learning interventions has proved challenging. We implemented a mandatory assessment-for-learning system comprising a workplace-based assessment of non-medical expert competencies and a progress test in undergraduate medical education and evaluated its impact. Methods: We conducted semi-structured interviews with year-3 and 4 medical students at McGill University to explore how the assessment system had influenced their learning in year 3. We conducted theory-informed thematic analysis of the data. Results: Eleven students participated, revealing that the assessment influenced learning through several mechanisms. Some required little student engagement (i.e., feed-up, test-enhanced learning, looking things up after an exam). Others required substantial engagement (e.g., studying for tests, selecting raters for quality feedback, using feedback). Student engagement was moderated by the perceived credibility of the system and of the costs and benefits of engagement. Credibility was shaped by students' goals-in-context: becoming a good doctor, contributing to the healthcare team, succeeding in assessments. Discussion: Our assessment system failed to engage students enough to leverage its full potential. We discuss the inherent flaws and external factors that hindered student engagement. Assessment designers should leverage easy-to-control mechanisms to support assessment-for-learning and anticipate significant collaborative work to modify learning cultures.

Introduction: L'évaluation peut influencer positivement l'apprentissage mais la conception de dispositifs d'évaluation pour l'apprentissage efficaces s'avère difficile. Nous avons implanté en formation prédoctorale un système obligatoire d'évaluation pour l'apprentissage comprenant une évaluation en milieu clinique des compétences transversales et un test de rendement progressif, puis évalué ses effets. Méthodes: Nous avons mené des entretiens semi-dirigés avec des étudiants en troisième et quatrième années de médecine à l'Université McGill pour explorer la manière dont le système d'évaluation avait influencé leur apprentissage au cours de la troisième année. Nous avons effectué une analyse thématique, informée par la théorie, des données. Résultats: Onze étudiants ont participé. Les résultats indiquent que l'évaluation a influencé leur apprentissage par le biais de plusieurs mécanismes différents. Certains d'entre eux nécessitaient une implication faible de la part de l'étudiant, comme l'identification des objectifs à atteindre (feed-up), l'apprentissage amélioré par les tests, la recherche d'informations après un examen. D'autres exigeaient une implication importante (par exemple, étudier pour les tests, sélectionner les évaluateurs pour obtenir une rétroaction de qualité, mettre à profit la rétroaction). L'implication des étudiants était modulée par leur perception des avantages et des inconvénients de s'impliquer, et de la crédibilité du système. Cette dernière était influencée par les objectifs-en-contexte des étudiants: devenir un bon médecin, contribuer à l'équipe soignante, réussir les épreuves d'évaluation. Discussion: Notre système d'évaluation n'a pas réussi à impliquer suffisamment les étudiants que pour réaliser son potentiel. Nous abordons les défauts inhérents au système ainsi que les facteurs externes qui ont entravé l'implication des apprenants. Pour implanter efficacement un dispositif d'évaluation pour l'apprentissage, les concepteurs d'évaluations devraient optimiser les mécanismes qui sont faciles à contrôler et être prêts à s'investir dans un important travail de collaboration pour changer les cultures d'apprentissage.

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.

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.

Assessment of professionalism: recommendations from the Ottawa 2010 Conference.

Over the past 25 years, professionalism has emerged as a substantive and sustained theme, the operationalization and measurement of which has become a major concern for those involved in medical education. However, how to go about establishing the elements that constitute appropriate professionalism in order to assess them is difficult. Using a discourse analysis approach, the International Ottawa Conference Working Group on Professionalism studied some of the dominant notions of professionalism, and in particular the implications for its assessment. The results presented here reveal different ways of thinking about professionalism that can lead towards a multi-dimensional, multi-paradigmatic approach to assessing professionalism at different levels: individual, inter-personal, societal-institutional. Recommendations for research about professionalism assessment are also presented.

Linking the teaching of professionalism to the social contract: a call for cultural humility.

Professionalism, which is fundamental to medical practice, must be taught explicitly. It is the basis of medicine's relationship to society, which most observers call a "social contract." The social contract serves as the basis for society's expectations of medicine and medicine's of society. It therefore directly influences professionalism. The role of the healer is universal, but how professionalism is expressed will differ between countries and cultures due to differences in their social contracts. When professionalism is taught, it should be related to the different cultures and social contracts, respecting local customs and values.

Teaching professionalism across cultural and national borders: lessons learned from an AMEE workshop.

BACKGROUND: At the 2009 AMEE meeting in Malaga, Spain, a workshop was held entitled "Medicine's Social Contract with Society - An International Perspective." AIMS: One of the objectives of this workshop was to explore the international differences in medicine's social contract with society, which is linked to the nature of professionalism. METHODS: Nineteen individuals from 11 countries participated. They were asked to compare the expectations of the patients and the general public as well as those of the medical profession with those outlined in a recent publication addressing the issue from a North American perspective. RESULTS: The results indicated that the role of the healer appears to be universal, with only minor differences being found in different cultures and countries. However, there were differences noted in the role of the professional, which of course must reflect national differences in the social contract in health care. CONCLUSION: These differences must be respected by those teaching professionalism.

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.

Professionalism Mini-Evaluation Exercise for medical residents in Japan: a pilot study.

CONTEXT: Assessing medical professionalism among medical residents is of great importance. The Professionalism Mini-Evaluation Exercise (P-MEX) is a tool for assessing professionalism that was developed, tested for reliability and validated in Canada. Prior to the present study, no Japanese version of the P-MEX had been tested. METHODS: We modified the P-MEX for use in Japan and tested it on medical residents in a Japanese teaching hospital. For each resident, eight evaluators completed the P-MEX forms. A total of 184 P-MEX forms were completed on 23 senior residents. The construct validity of the P-MEX was analysed by confirmatory factor analysis through structural equation modelling. The reliability of the P-MEX was tested using generalisability theory and a decision study. After performing the assessment and providing feedback to the residents, we conducted a survey on the residents' perceptions of the assessment. RESULTS: Results indicate content and construct validity. A confirmatory factor analysis revealed that factor loadings ranged from 0.58 to 0.96, indicating good construct validity except for one item (P12: Maintained appropriate boundaries with patients and colleagues). Structural equation modelling showed that adding new items developed in Japan to the P-MEX provided adequate factor validity. A decision study showed confidence intervals sufficiently narrow with as few as 10 evaluations, slightly more than the eight forms verified in Canada. Most residents stated that the items were reasonable and appropriate, the results of the assessment were consistent with their own self-evaluation and the assessment enhanced their motivation. CONCLUSIONS: Our study demonstrated good evidence of adequate reliability and validity of the P-MEX for the assessment of professionalism among Japanese residents. Moreover, the addition of new items developed in Japan provided adequate factor validity.

Which pedagogical principles should clinical teachers know? Teachers and education experts disagree. Disagreement on important pedagogical principles.

BACKGROUND: In a previous study, a group of non-clinician medical education experts identified 30 pedagogical principles, knowledge of which might enhance clinical teaching effectiveness. AIMS: To assess expert teachers? perceptions of which basic pedagogical principles, if known and understood, would enhance their teaching effectiveness. METHOD: We conducted an on-line Delphi consensus-building study with 25 expert clinical teachers who rated the importance to teaching effectiveness of each of the 30 principles. RESULTS: There was agreement between clinicians and PhD education experts on the importance of several of the principles but there was major disagreement between the 2 groups for many principles, including those related to assessment and those relevant to clinical teachers? day to day teaching activities. CONCLUSIONS: The lack of concordance between clinical teachers and education experts with respect to how the 30 principles rank in importance may have serious implications for faculty development and for the design, development, and assessment of educational programs. Program directors and curriculum designers should exploit the strengths of both clinician and non-clinician educators to assure the success of educational programs.

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.

Faculty development as an instrument of change: a case study on teaching professionalism.

Faculty development includes those activities that are designed to renew or assist faculty in their different roles. As such, it encompasses a wide variety of interventions to help individual faculty members improve their skills. However, it can also be used as a tool to engage faculty in the process of institutional change. The Faculty of Medicine at McGill University determined that such a change was necessary to effectively teach and evaluate professionalism at the undergraduate level, and a faculty development program on professionalism helped to bring about the desired curricular change. The authors describe that program to illustrate how faculty development can serve as a useful instrument in the process of change. The ongoing program, established in 1997, consists of medical education rounds and "think tanks" to promote faculty consensus and buy-in, and diverse faculty-wide and departmental workshops to convey core content, examine teaching and evaluation strategies, and promote reflection and self-awareness. To analyze the approach used and the results achieved, the authors applied a well-known model by J.P. Kotter for implementing change that consists of the following phases: establishing a sense of urgency, forming a powerful guiding coalition, creating a vision, communicating the vision, empowering others to act on the vision, generating short-term wins, consolidating gains and producing more change, and anchoring new approaches in the culture. The authors hope that their school's experience will be useful to others who seek institutional change via faculty development.

The Professionalism Mini-evaluation Exercise: a preliminary investigation.

BACKGROUND: As the evaluation of professional behaviors has been identified as an area for development, the Professionalism Mini-Evaluation Exercise (P-MEX) was developed using the mini-Clinical Examination Exercise (mini-CEX) format. METHOD: From a set of 142 observable behaviors reflective of professionalism identified at a McGill workshop, 24 were converted into an evaluation instrument modeled on the mini-CEX. This instrument, designed for use in multiple settings, was tested on clinical clerks in medicine, surgery, obstetrics and gynecology, psychiatry, and pediatrics. In all, 211 forms were completed on 74 students by 47 evaluators. RESULTS: Results indicate content and construct validity. Exploratory factor analysis yielded 4 factors: doctor-patient relationship skills, reflective skills, time management, and interprofessional relationship skills. A decision study showed confidence intervals sufficiently narrow for many measurement purposes with as few as 8 observations. Four items frequently marked below expectations may be identifiers for "problem" students. CONCLUSION: This preliminary study suggests that the P-MEX is a feasible format for evaluating professionalism in clinical training.

Teaching professionalism: general principles.

There are educational principles that apply to the teaching of professionalism during undergraduate education and postgraduate training. It is axiomatic that there is a single cognitive base that applies with increasing moral force as students enter medical school, progress to residency or registrar training, and enter practice. While parts of this body of knowledge are easier to teach and learn at different stages of an individual's career, it remains a definable whole at all times and should be taught as such. While the principle that self-reflection on theoretical and real issues encountered in the life of a student, resident or practitioner is essential to the acquisition of experiential learning and the incorporation of the values and behaviors of the professional, the opportunities to provide situations where this can take place will change as an individual progresses through the system, as will the sophistication of the level of learning. Teaching the cognitive base of professionalism and providing opportunities for the internalization of its values and behaviors are the cornerstones of the organization of the teaching of professionalism at all levels. Situated learning theory appears to provide practical guidance as to how this may be implemented. While the application of this theory will vary with the type of curriculum, the institutional culture and the resources available, the principles outlined should remain constant.