Medical professionalism is a core clinical competency for medical students, trainees and practice physicians; thus, modalities and best practices for teaching have become an important component of medical education [1,2,3,4]. Over the past several decades, professionalism curricula have been described in the literature and have demonstrated the need and importance of deeper ethical and humanistic reflection, rather than relying on superficial observation and assessment of behaviors alone . As a result, medical educators are tasked with designing curricula that teaches students the core elements of medical professionalism, while also effectively modeling what they teach. In 1995, the Association of American Medical Colleges (AAMC) published the Assessment of Professionalism Project, providing a resource with specific examples of behaviors that define medical professionalism for students, trainees and the practicing physician . These behavior sets have served as a guide for medical educators tasked with measuring and assessing professionalism in medical education. However, medical schools differ in their strategies of instruction and evaluation [1,2,3,4].
Recently, there has been an increasing emphasis on the process of professional identity formation (PIF) and the need to better understand students’ implicit and explicit understanding of medical professionalism . Identity formation is defined as the changing professional concept self-based on the integration of knowledge, skills, beliefs, values and experiences . Holden et al., applied the concept of identity formation in medicine as the developmental and complex process of the transformation of a lay person into a physician as one begins to establish their unique core values, morals, ethical principles and self-awareness [8, 9]. PIF in medical education has been shown to be most transformative during the transition from undergraduate education to medical education, clinical years, experience with the business of medicine and finally exposure to the practice of physicians .
The University of Central Florida College of Medicine (UCFCOM) has an integrated longitudinal curriculum that incorporates medical professionalism instruction and assessment throughout the four-year M.D. program. The UCFCOM MD Curriculum Committee charged a task force to define an evidence-based professionalism framework that incorporates the AAMC behavior sets and the work of many others [2, 11,12,13,14,15,16,17,18,19,20,21,22]. The UCFCOM professionalism framework is composed of twenty-five elements that map into six domains . During the first two years, professionalism is taught explicitly. Students participate in a course series, the Making of a Physician (MOP) Program, during which they have opportunities to work in small groups with faculty mentors and discuss topics that nurture professional growth, such as humanism, empathy, and cultural competence.
MOP begins with a session dedicated to medical professionalism and includes relevant pre-session readings, such as Swick’s Towards a Normative Definition of Medical Professionalism . During the small group session students discuss how the professional responsibilities of physicians apply to medical students. Students are also presented with scenarios of common professionalism lapses by medical students and discuss contributing factors as well as potential strategies to avoid these situations. The principles of medical professionalism are revisited throughout subsequent MOP sessions. Another integral component of the pre-clerkship curriculum is the Community of Practice (COP) Program, a longitudinal preceptorship experience, where students work side-by-side practicing physicians providing an authentic clinical context to promote deeper learning, professional identity formation, and adoption of the values of the profession.
Pre-clerkship formative and summative assessments include multiple-choice items on written exams related to knowledge of the foundational principles of medical professionalism and medical ethics, and cover topics such as patient confidentiality, maintaining appropriate relationships with patients, access to care, just distribution of finite resources, and professional responsibility. Students’ professionalism in COP sessions is assessed by their clinical preceptors using a professionalism rubric. Additionally, clinical skills encounters with standardized patients allow for professionalism assessment through direct observation of the student’s behaviors; here, students are provided feedback from the patient’s perspective, as well as from faculty and staff. Moreover, faculty emphasize with students how observed behaviors during the pre-clerkship years (interaction with patients, faculty, staff and fellow student) can be a surrogate for later behavior in patient care.
Professionalism instruction in the latter two clinical clerkship years of the MD program relies on mentoring and role modeling, where students have an opportunity to model the behaviors they observe from the practicing physicians they work with. Medical Professionalism is expected of all clinical faculty, and emphasized in UCFCOM’s faculty development program. Discussions with fellow students and clerkship directors give students an opportunity to debrief observed behaviors of clinical preceptors; egregious behaviors are reported to the Dean for Students. In addition, at the end of each rotation students complete an anonymous preceptor evaluation. Similarly, clerkship faculty assess students’ professionalism through a clerkship evaluation rubric.
In this study, we investigate how UCFCOM formal, informal and hidden curricular experiences impact student’s professional identity formation.