Karen Szauter

Professional Identity Formation in Medical Education: The Convergence of Multiple Domains

There has been increasing emphasis on professionalism in medical education over the past several decades, initially focusing on bioethical principles, communication skills, and behaviors of medical students and practitioners. Authors have begun to discuss professional identity formation (PIF), distinguishing it as the foundational process one experiences during the transformation from lay person to physician. This integrative developmental process involves the establishment of core values, moral principles, and self-awareness. The literature has approached PIF from various paradigms—professionalism, psychological ego development, social interactions, and various learning theories. Similarities have been identified between the formation process of clergy and that of physicians. PIF reflects a very complex process, or series of processes, best understood by applying aspects of overlapping domains: professionalism, psychosocial identity development, and formation. In this study, the authors review essential elements of these three domains, identify features relevant to medical PIF, and describe strategies reported in the medical education literature that may influence PIF.

Quality of standardised patient research reports in the medical education literature: review and recommendations

Context  In order to assess or replicate the research findings of published reports, authors must provide adequate and transparent descriptions of their methods. We conducted 2 consecutive studies, the first to define reporting standards relating to the use of standardised patients (SPs) in research, and the second to evaluate the current literature according to these standards.

The rhetoric of rationalization: how students grapple with professional dilemmas.

Medical educators are facing a critical problem: How do we accurately assess professionalism? Currently, we are beginning to understand professionalism; however, we have been relatively unsuccessful in attempts to evaluate it, and we have been unable to predict professional behavior in our students. Professionalism has been described not only as the ability to uphold the principles and values of the profession, but also as the ability to negotiate between competing values in a specific context. Understanding the nature of such negotiations requires asking more than ‘‘What did the student do?’’ or ‘‘What choice did the student make?’’ We must also ask, ‘‘Why did the student choose that action?’’ or ‘‘How did the student justify the action?’’ 4,5 The science of rhetoric provides formal analytic tools for excavating and analyzing students’ reasoning strategies. The particular rhetorical approach used in this study is ‘‘social constructivism,’’ which emphasizes how language embodies strategies for action. Social constructivist rhetoric suggests that language both reflects and shapes our reality. Students’ stories of professional dilemmas, therefore, provide a window onto their perceptions—and constructions —of their roles in the medical world. The structure of the language used in these stories reflects the structure of students’ applied logic, and therefore reflects their growing phronesis—practical wisdom and the ability to make decisions in complex situations—as they talk themselves into, and out of, professional actions. Such an examination of logic does not entail predicting students’ intentions. Rather, looking at both how students act and their understandings of why they act provides a richer understanding of their professional development and a framework for shaping it.

Medical Students' Perspectives on and Responses to Abuse During the Internal Medicine Clerkship

Background: The abuse of medical students on clinical rotations is a recognized problem, but the effects on students and their responses warrant further study. Purpose: To determine the severity of student abuse and the effects of abuse on students during the internal medicine clerkship. Methods: Internal medicine clerks at 11 medical schools (N = 1,072) completed an exit survey. Students were asked whether they had been abused. If they had, they were asked about the severity of the abuse, whether they reported it, and its effects on them. Results: Of the responding students, 123 (11%) believed they had been abused. Only 31% of the students who felt abused reported the episodes to someone. The most common consequences of the events included poor learning environments, lack of confidence, and feelings of depression, anger, and humiliation. Conclusion: Students described a variety of personal and educational effects of abuse. They generally did not report abuse because of fear of retaliation and the belief that reporting is pointless.

Internal Medicine Clerkship Directors' Use of and Opinions About Clerkship Examinations

Background: For years, quantifiable examinations have been a core component of assessing medical student competence during the internal medicine clerkship. Purpose: To determine how internal medicine clerkship directors use and view examinations and how uses of examinations have changed. Methods: In 1999, the Clerkship Directors in Internal Medicine conducted a confidential survey of its 123 institutional members. Results: Survey response rate was 89% (109/123). The National Board of Medical Examiners subject examination was used by 83%, alone (49%) or in combination with a faculty developed examination or a standardized patient examination (34%). Minimum passing scores were required for the subject exam by 80%, for faculty-developed examinations by 65%, and for the standardized patient exam by 63%. Examinations contribute approximately 25% toward a students final grade. Students with acceptable clerkship performances but who fail an exam typically retest after self-study. Students who fail a retest receive unsatisfactory grades and require additional medicine experience. Of the clerkship directors who reported using the National Board of Medical Examiners subject examination, 45 (50%) provided comments on ways to improve the examination. Comments focused on examination content, reporting results, basing the exam on a published core curriculum, and general administrative issues. Over the past decade, use of the National Board of Medical Examiners subject examination has increased (66% to 83%), use of faculty-developed examinations has declined (46% to 27%), and the use of a clerkship standardized patient examination increased sharply (2% to 27%). Conclusions: Internal medicine clerkship directors commonly require students to pass standardized or locally developed exams and use test results to make academic decisions. The use of standardized patient examinations has increased significantly and likely reflects a broadening of competency assessment. Our results can serve as a basis for individual programmatic evaluation, for internal medicine and other clerkship directors.

Student Perceptions of the Professional Behavior of Faculty Physicians

Abstract This study was conducted to obtain a baseline understanding of the professional behavior of clinical faculty physicians from the medical students’ perspective. Students completed a professionalism evaluation of supervising faculty at the end of each required third-year clerkship over a one year period. Results were analyzed by specific behaviors and across clerkships. Differences were noted in the frequency of the types of problems seen, and varied by clerkship discipline. The most common transgressions of professional behavior reported were the use of derogatory language towards other services or patients and the disrespectful treatment of others. Our study served to provide objective feedback to the faculty about student perceptions of faculty as role models for professionalism while on clinical rotations.

In Vitro Stability of Ranitidine Hydrochloride in Enteral Nutrient Formulas

Objective: To determine the chemical stability and physical compatibility of ranitidine in enteral nutrient formulas. Measurements: A stability-indicating HPLC assay was used to measure the recovery of ranitidine from tablet (dissolved in water) or syrup after up to 24 hours of in vitro incubation in a variety of enteral nutrient formulas. Ranitidine binding to components of the formulas was measured after ultrafiltration. Results: Eight enteral nutrient formulas were studied, and more than 90% of added ranitidine was recovered from each formula after 24 hours. The amount of ranitidine bound to components of the formulas varied between 8% and 29%. No gross physical incompatibilities were seen and the pH of each formula changed by less than 0.1 pH units over 24 hours. Conclusions: Ranitidine from either tablet or syrup was stable in the enteral nutrient formulas studied. Administration of ranitidine by admixture into these enteral formulas may be feasible.

Adding the human dimension to simulation scenarios.

The relatively recent widespread acceptance of simulation methodology has stimulated creative development of simulation-based activities across health care disciplines. Descriptions of educational programs, projects, and research using simulation have appeared in hundreds of journals. Historically, simulation-based activities have been grouped in 2 broad categories: model-based simulation (technologyenhanced simulation) and simulation programs employing actual people (simulated or standardized patients or participants). The divide between these 2 simulation applications remains evident in our administrative structures, with many facilities sustaining 2 geographically separate simulation centers supported by staff specifically dedicated to either technology-based simulation or simulated patient (SP)Ybased activities. Until recently, much of our literature has been separate, and experts working in one area had a limited understanding of the potential educational contributions of the other. The added benefit blending of technology-based simulations with people (participating in roles from patients or family members to health care providers) is increasingly recognized as a valuable educational tool. Each simulation methodology requires careful planning, preparation, and refinement. Now more than ever, sharing descriptions of best practices and innovations is essential to keep simulation methodology moving forward. Two articles in the August 2013 and April 2014 issues of Simulation in Healthcare address issues related to the inclusion of SPs in technology-based simulation activities. These articles share the authors’ experiences and practical recommendations regarding recruitment and training of SPs. Both articles contribute interesting perspectives to the limited literature on how to choose and train the human participants for their roles in simulations. Dr Pascucci et al posit that professional actors provide important dimensions to simulations and that formal theatrical training is essential for SPs participating in complex, emotionally charged scenarios. The article describes their program, supported by a performing arts consultant, to select and prepare their SPs. Their processes involve techniques familiar to the acting community: audition, casting, rehearsal, performance, and critique. The authors strongly support the need for formal acting training to ensure that the SP can quickly and realistically adapt during evolving scenarios. The article by Ms Sanko et al provides a more theorybased approach to preparing participants for their role as a health care provider during a simulation scenario. They describe a variety of formal theatrical techniques, which can be applied during the training of SPs. Their article also touches on the contributions of the visual cues of the scenariosVthe costumes, props, and settingVand how purposeful inclusion adds realism to the scenario. Although simulated patient methodology has a long history, optimal techniques for recruitment and training of SPs remains open for discussion. Published recommendations have largely served as guidelines to individual programs, with processes being created locally based on available resources. Recommendation on how to integrate SPs into scenarios into technology-based simulations have been limited. The current articles serve as a reminder that the addition of SPs to a simulation scenario requires careful preparation and planning to ensure that the SP enhances, rather than derails, the scenario. Is an acting background essential for simulated patients or participants in complex scenarios? The benefits of employing actors are highlighted by Pascucci et al and Sanko et al. Characteristics including the ability to effectively portray the emotional depth of the role, skills in improvisation, and the ability to separate from Karen Szauter, MD, FACP Editorial

A Methodological Review of the Assessment of Humanism in Medical Students.

Background Humanism is a complex construct that defies simplistic measurement. How educators measure humanism shapes understanding and implications for learners. This systematic review sought to address the following questions: How do medical educators assess humanism in medical students, and how does the measurement impact the understanding of humanism in undergraduate medical education (UME)? Method Using the IECARES (integrity, excellence, compassion, altruism, respect, empathy, and service) Gold Foundation framework, a search of English literature databases from 2000 to 2013 on assessment of humanism in medical students revealed more than 900 articles, of which 155 met criteria for analysis. Using descriptive statistics, articles and assessments were analyzed for construct measured, study design, assessment method, instrument type, perspective/source of assessment, student level, validity evidence, and national context. Results Of 202 assessments reported in 155 articles, 162 (80%) used surveys; 164 (81%) used student self-reports. One hundred nine articles (70%) included only one humanism construct. Empathy was the most prevalent construct present in 96 (62%); 49 (51%) of those used a single instrument. One hundred fifteen (74%) used exclusively quantitative data; only 48 (31%) used a longitudinal design. Construct underrepresentation was identified as a threat to validity in half of the assessments. Articles included 34 countries; 87 (56%) were from North America. Conclusions Assessment of humanism in UME incorporates a limited scope of a complex construct, often relying on single quantitative measures from self-reported survey instruments. This highlights the need for multiple methods, perspectives, and longitudinal designs to strengthen the validity of humanism assessments.

Use of standardised patients with actual findings.

Overall, GEMS has positively affected participants’ delivery of emergency medicine (5.7 ⁄ 7) and willingness to continue rural emergency medicine (5.5 ⁄ 7). Feedback has initiated minor changes to facilitate participant follow-up and completion. GEMS can help rural doctors to not only learn and practise emergency medicine skills, but to do so with confidence. Interactive training can be delivered at the rural site.