How we designed and implemented teaching, training, and assessment of professional behaviour at VUmc School of Medical Sciences Amsterdam

Assessing professional identity formation (PIF) amongst medical students in Oncology and Palliative Medicine postings: a SEBA guided scoping review

BACKGROUND

Introduction to a multi-professional team who are working and caring for the dying, and facing complex moral and ethical dilemmas during Oncology and Palliative Medicine postings influence a medical student's professional identity formation (PIF). However, limited appreciation of PIF, inadequate assessments and insufficient support jeopardise this opportunity to shape how medical students think, feel and act as future physicians. To address this gap, a systematic scoping review (SSR) of PIF assessment methods is proposed.

METHODS

A Systematic Evidence-based Approach (SEBA) guided SSR of assessments of PIF in medical schools published between 1^st January 2000 and 31^st December 2021 in PubMed, Embase, ERIC and Scopus databases was carried out. Included articles were concurrently content and thematically analysed using SEBA's Split Approach and the themes and categories identified were combined using SEBA's Jigsaw Perspective. The review hinged on the following questions: "what is known about the assessment of professional identity formation amongst medical students?", "what are the theories and principles guiding the assessment of professional identity formation amongst medical students?", "what factors influence PIF in medical students?", "what are the tools used to assess PIF in medical students?", and "what considerations impact the implementation of PIF assessment tools amongst medical students?".

RESULTS

Two thousand four hundred thirty six abstracts were reviewed, 602 full-text articles were evaluated, and 88 articles were included. The 3 domains identified were 1) theories, 2) assessment, and 3) implementation in assessing PIF. Differing attention to the different aspects of the PIF process impairs evaluations, jeopardise timely and appropriate support of medical students and hinder effective implementation of PIF assessments.

CONCLUSION

The Krishna-Pisupati model combines current theories and concepts of PIF to provide a more holistic perspective of the PIF process. Under the aegis of this model, Palliative Care and Oncology postings are envisaged as Communities of Practice influencing self-concepts of personhood and identity and shaping how medical students see their roles and responsibilities as future physicians. These insights allow the forwarding of nine recommendations to improve assessments of PIF and shape the design of a PIF-specific tool that can direct timely and personalized support of medical students.

Medical student engagement in small-group active learning: A stimulated recall study

BACKGROUND

Active learning relies on students' engagement with teachers, study materials and/or each other. Although medical education has adopted active learning as a core component of medical training, teachers have difficulties recognising when and why their students engage or disengage and how to teach in ways that optimise engagement. With a better understanding of the dynamics of student engagement in small-group active learning settings, teachers could be facilitated in effectively engaging their students.

METHODS

We conducted a video-stimulated recall study to explore medical students' engagement during small-group learning activities. We recorded one teaching session of two different groups and selected critical moments of apparent (dis)engagement. These moments served as prompts for the 15 individual semi-structured interviews we held. Interview data were analysed using Template Analysis style of thematic analysis. To guide the analysis, we used a framework that describes student engagement as a dynamic and multidimensional concept, consisting of behavioural, cognitive and emotional components.

RESULTS

The analysis uncovered three main findings: (1) In-class student engagement followed a spiral-like pattern. Once students were engaged or disengaged on one dimension, other dimensions were likely to follow suit. (2) Students' willingness to engage in class was decided before class, depending on their perception of a number of personal, social and educational antecedents of engagement. (3) Distinguishing engagement from disengagement appeared to be difficult for teachers, because the intention behind student behaviour was not always identifiable.

DISCUSSION

This study adds to the literature by illuminating the dynamic process of student engagement and explaining the difficulty of recognising and influencing this process in practice. Based on the importance of discerning the intentions behind student behaviour, we advise teachers to use their observations of student (dis)engagement to initiate interaction with students with open and inviting prompts. This can help teachers to (re-)engage students in their classrooms.

Redefining scholarship for health professions education: AMEE Guide No. 142

Scholarship is an integral aspect of academia. It shapes the practice of individuals and the field and is often used to inform career progression decisions and policies. This makes it high stakes. Yet it is complex, and ambiguous. Definitions vary and the term does not necessarily translate well across contexts. In this AMEE guide, our aim is to establish a contemporary definition of scholarship which is appropriate to health professions education (HPE). Our specific objectives are to provide guidance to support colleagues in their career development as professional educators and to challenge biases and assumptions about scholarship which may still exist in educational systems and structures. Ultimately, we hope that this work will advance the stature/standing of scholarship in the field. We provide a general definition of scholarship and how this relates to the scholarship of teaching (and learning) (SoT[L]) and scholarly teaching. Drawing on Boyer's seminal work, we describe different types of scholarship and reflect on how these apply to HPE, before moving on to describe different types of engagement with scholarship in HPE, including scope of contribution and influence. Using cases and examples, we illustrate differences in scholarly engagement across stages of a career, contexts, and ways of engaging. We provide guidance on how to assess 'quality' of scholarship. We offer practical advice for health professions' educators seeking academic advancement. We advocate that institutional leaders consider their systems and structures, so that these align with faculty work patterns, and judge teaching and professional practice appropriately. We conclude by offering a new definition of scholarship in HPE.

Are all LGBTQI+ patients white and male? Good practices and curriculum gaps in sexual and gender minority health issues in a Dutch medical curriculum

Objectives: People marginalized based on their sexual and gender identity face specific health risks and experience barriers to culturally competent care. Insight into how Dutch medical schools address LGBTQI+ health-related learning objectives is scarce. We therefore examined how LGBTQI+ health issues are integrated in the Amsterdam UMC-VUmc medical curriculum by evaluating the year-two course 'Sex, Sexuality and Relationships' for LGBTQI+ content. Methods/Design: We examined written course content (course syllabus, lecture notes, and course literature) of the 2016-2017 course. We used a framework for essential LGBTQI+ content in medical education and an intersectional approach to examine which LGBTQI+ themes and subthemes were addressed. Results: Several essential LGBTQI+ health issues were adequately addressed and integrated into the Amsterdam UMC-VUmc curriculum, but we also identified curriculum gaps. The needs of patients with lesbian, bisexual, or gender non-conforming identities were marginally addressed, and issues related to intersections of minoritized sexual and gender identities with other aspects of diversity such as ethnicity, age and class remained unexplored. The course discussed gender and sexuality as fixed and mainly binary constructs, and only addressed biomedical explanatory models of sex, gender and sexuality. Discussion and conclusion: The absence of complex patient identities in relation to sex, gender and sexuality does not adequately prepare students to provide LGBTQI+ responsive care. If not designed and taught competently, LGBTQI+-related curriculum content may reproduce bias and stereotypes, and contribute to a medical climate where both LGBTQI+ patients, students, and doctors conceal their identities. Further implementation of LGBTQI+ health issues is required in (continuing) medical education to secure culturally competent clinical environments. Educational research is needed to understand how medical education contributes to marginalization of LGBTQI+ identities and thus, to health disparities.

Professional practice behaviour: Identification and validation of key indicators

Introduction

Professional behaviour is regarded as an important competency for occupational therapy practice, yet little guidance exists for indicators underpinning development or remediation in the educational or practice settings. This study sought to confirm the content validity of observable professional behaviour indicators from an existing evaluation framework for representativeness and relevance for occupational therapy practice.

Methods

A modified Delphi approach was conducted with expert panellists ( n = 30) consisting of regulators, administrators, faculty members, practitioners, and students for professional behaviour indicator consensus, together with a cross-sectional survey of practitioners ( n = 119). Fleiss’ κ and χ2 contingency tables were completed for agreement across panellists, and between panellist and survey groups. Cross-case qualitative analyses identified facilitators and barriers for professional behaviour practice.

Results

Content validity of 17 professional behaviour indicators was achieved, with >85% agreement from the expert panellists and the cross-sectional survey group. Main professional behaviour reporting issues in practice included fear of reprisal, lack of formal policies, and an unsupportive culture. Support from others, documented workplace policies, and self-regulation/duty to monitor were the critical facilitators for supporting professional behaviour in practice.

Conclusion

The professional behaviour indicators in this study offer observable behaviours from which assessment rubrics or tools may be developed. Further study is warranted.

Failure of faculty to fail failing medical students: Fiction or an actual erosion of professional standards?

OBJECTIVES

Literature has shown that some assessors assign passing grades to medical students who, in fact, should not have passed. This inability of the faculty to fail underperforming students can jeopardise the reputation of professional programs, be it in the medical field or beyond. Simultaneously, weak students become incompetent physicians and, thus, endanger the community they serve. The impetus for conducting this systematic review was to identify barriers to faculty in failing struggling medical students.

METHODS

The databases of MEDLINE, Scopus, Wiley online library, Cochrane library, OVID, Taylor and Francis, CINAHL, Springer link, ProQuest, and ISI Web of knowledge were searched using Medical Subject Headings (MeSH) terms 'Faculty failure' AND 'Failing students' AND 'Failure to fail' OR 'Assessment'. The data were synthesised, and the results were analysed.

RESULTS

This search showed a wealth of barriers to faculty contributing to a 'failure to fail' such as their concerns about legal action and an appeals process; the stress of failing students; a lack of knowledge about proper documentation; unavailability of support, resources, and offices for faculty; absence of administrative guidelines; and complex dismissal procedures discouraging the faculty from failing students.

CONCLUSION

Institutional faculty development programs and training workshops should facilitate the education of supervisors and assessors for timely evaluation and regular documentation of trainee assessment. The provision of legal advice in cases of appeal and professional support by the resource and support office is emphasised.

A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity

The relatively new term "Professional Identity Formation" (PIF) complements behavior-based and attitude-based perspectives on professionalism. Unprofessional behavior and its remediation should also be addressed from this perspective. However, a framework is needed to guide discussion and remediation of unprofessional behavior, which can encompass behavior-based, attitude-based, and identity-based perspectives on professionalism. To this end, the authors propose a multi-level professionalism framework which describes, apart from professional behavior, more levels which influence professional performance: environment, competencies, beliefs, values, identity, and mission. The different levels can provide tools for educators to address and discuss unprofessional behavior with their students in a comprehensive way. By reflecting on all the different levels of the framework, educators guard themselves against narrowing the discussion to either professional behavior or professional identity. The multi-level professionalism framework can help educators and students to gain a better understanding of the root of unprofessional behavior, and of remediation strategies that would be appropriate. For despite the recent emphasis on PIF, unprofessional behavior and its remediation will remain important issues in medical education.

Motivation and academic performance of medical students from ethnic minorities and majority: a comparative study

BACKGROUND

Medical students from ethnic minorities underperform in knowledge and skills assessments both in pre-clinical and clinical education compared to the ethnic majority group. Motivation, which influences learning and academic performance of medical students, might play an important role in explaining these differences, but is under-investigated. This study aimed to compare two types of motivation (autonomous and controlled) of ethnic minority (Western and non-Western) and majority (Dutch) students, and their association with academic performance.

METHODS

In a cross-sectional study, all students of a Dutch medical school were invited to complete a survey including the Academic Self-Regulation Questionnaire, measuring autonomous and controlled motivation, in the academic year 2015-2016. Motivation was compared using Kruskal-Wallis test and performance was compared using One-Way ANOVA. Linear regression analysis was used to determine the association between motivation and performance (grade point average; GPA).

RESULTS

The response rate was 38.6% (n = 947). Autonomous motivation (AM) of non-Western students was higher than that of Dutch students in pre-clinical and clinical education (p < 0.05). Controlled motivation was higher in Western students than in Dutch students (pre-clinical education; p < 0.05). AM was associated with a higher GPA for Dutch (pre-clinical education; β = 0.33, p < 0.05) and Western students (clinical education; β = 0.57, p < 0.05) only.

CONCLUSIONS

Our results show significant differences in the type of motivation between the ethnic majority and minority groups. The association of motivation with performance also differs between ethnic groups. We found that AM has a positive influence on GPA. Further research is needed to uncover the underlying mechanisms.

Implementation of Competency-Based Pharmacy Education (CBPE)

Implementation of competency-based pharmacy education (CBPE) is a time-consuming, complicated process, which requires agreement on the tasks of a pharmacist, commitment, institutional stability, and a goal-directed developmental perspective of all stakeholders involved. In this article the main steps in the development of a fully-developed competency-based pharmacy curriculum (bachelor, master) are described and tips are given for a successful implementation. After the choice for entering into CBPE is made and a competency framework is adopted (step 1), intended learning outcomes are defined (step 2), followed by analyzing the required developmental trajectory (step 3) and the selection of appropriate assessment methods (step 4). Designing the teaching-learning environment involves the selection of learning activities, student experiences, and instructional methods (step 5). Finally, an iterative process of evaluation and adjustment of individual courses, and the curriculum as a whole, is entered (step 6). Successful implementation of CBPE requires a system of effective quality management and continuous professional development as a teacher. In this article suggestions for the organization of CBPE and references to more detailed literature are given, hoping to facilitate the implementation of CBPE.

Distinguishing Three Unprofessional Behavior Profiles of Medical Students Using Latent Class Analysis

PURPOSE

Because unprofessional behavior of physicians is associated with unprofessional behavior in medical school, identifying unprofessional behavior in medical school is critical. Research has noted the difficulty in assessing professional behavior. Instead of identifying isolated behaviors, it could be more helpful to recognize behavioral patterns to evaluate students' professional behavior. The authors aimed to identify patterns in the unprofessional behaviors of medical students and to construct descriptions based on these patterns.

METHOD

Content analysis of research articles yielded a template of unprofessional behaviors for coding student evaluation forms indicating unsatisfactory professional behavior, collected from 2012 to 2014 at the VUmc School of Medical Sciences, Amsterdam, the Netherlands. Latent class analysis was used to identify classes of students with a high chance of displaying comparable unprofessional behaviors. Teachers' feedback of prototype students was summarized to generate profile descriptions.

RESULTS

A template of 109 behaviors was used to code 232 evaluation forms of 194 students (3.9% students/year). Latent class analysis identified three hypothetical classes of students: Class 1 (43%) was labeled as "Poor reliability," class 2 (20%) was labeled as "Poor reliability and poor insight," and class 3 (37%) was labeled as "Poor reliability, poor insight, and poor adaptability."

CONCLUSIONS

These profiles of unprofessional behavior might help to improve the evaluation of unprofessional behavior in medical school. Further research should provide evidence for confidently accepting or rejecting the profiles as an instrument to identify which students are expected to benefit from remediation trajectories.

Toward diversity-responsive medical education: taking an intersectionality-based approach to a curriculum evaluation

Recent years have seen a rise in the efforts to implement diversity topics into medical education, using either a 'narrow' or a 'broad' definition of culture. These developments urge that outcomes of such efforts are systematically evaluated by mapping the curriculum for diversity-responsive content. This study was aimed at using an intersectionality-based approach to define diversity-related learning objectives and to evaluate how biomedical and sociocultural aspects of diversity were integrated into a medical curriculum in the Netherlands. We took a three-phase mixed methods approach. In phase one and two, we defined essential learning objectives based on qualitative interviews with school stakeholders and diversity literature. In phase three, we screened the written curriculum for diversity content (culture, sex/gender and class) and related the results to learning objectives defined in phase two. We identified learning objectives in three areas of education (medical knowledge and skills, patient-physician communication, and reflexivity). Most diversity content pertained to biomedical knowledge and skills. Limited attention was paid to sociocultural issues as determinants of health and healthcare use. Intersections of culture, sex/gender and class remained mostly unaddressed. The curriculum's diversity-responsiveness could be improved by an operationalization of diversity that goes beyond biomedical traits of assumed homogeneous social groups. Future efforts to take an intersectionality-based approach to curriculum evaluations should include categories of difference other than culture, sex/gender and class as separate, equally important patient identities or groups.

What difficulties do faculty members face when conducting workplace-based assessments in undergraduate clerkships?

OBJECTIVE

Workplace-based assessments are based on the principle of providing feedback to medical students on clinical performance in authentic settings. In practice, however, the assessment often overshadows the feedback. The aim of this study was to determine what problems faculty perceived when performing workplace-based assessments and what solutions they suggested to overcome these difficulties.

METHODS

Discussion meetings were conducted with education coordinators and faculty (n=55) from 11 peripheral hospitals concerning the difficulties encountered when conducting workplace-based assessments. We analysed the reports from these discussion meetings using an integrated approach guided by our research questions to code the data. Two researchers analysed the data independently and resolved differences of opinion through consensus.

RESULTS

The problems perceived by faculty in workplace-based assessments (difficulties) and suggestions for improvement formed the overarching themes. Problems included the short duration of clerkships, students choosing the assessment moments, the use of grades for the mini-Clinical Evaluation Exercise, the difficulty in combining teacher and assessor roles and the difficulty in giving fail judgements. Suggestions for improvement included longer clerkship duration, faculty choosing the assessment moments, using a pass/fail system for the mini-Clinical Evaluation Exercise and forward feeding of performance from earlier clerkships following a fail judgement.

CONCLUSIONS

Our study indicates that faculty perceive difficulties when conducting workplace-based assessments. These assessments need periodical review to understand the difficulties faculty experience using them; they also require periodical feedback to ensure their proper and effective use.

Socialization to professionalism in medical schools: a Canadian experience

BACKGROUND

Accrediting bodies now recognize the importance of developing the professionalism competency, by setting standards that require medical schools to identify where professionalism is addressed and how it is evaluated within the formal curriculum. The objective of this study was to compare how professionalism competency is formally addressed in the curricula of Canadian medical schools, and to better understand the Canadian approach to reporting and remediation of lapses.

METHODS

A literature review was performed and with the input of the AFMC(Association of Faculties of Medicine of Canada) Professionalism group, questionnaires were generated. An electronic survey was circulated to key leaders across the country at all the medical schools. In-depth telephone interviews were used to further explore themes, and a subsequent focus group was held to discuss challenges, particularly related to reporting and remediation.

RESULTS

The preponderance of formal professionalism teaching remains in the form of lectures and small group sessions in the preclinical years. Formal teaching declines significantly in the clerkship/clinical years. Evaluation is usually performed by a clinical supervisor, but OSCE, portfolio, and concern notes are increasingly used. Role modeling is heavily relied upon in clinical years, suggesting faculty training can help ensure clinical teachers recognize their influence on trainees. Formal remediation strategies are in place at most schools, and often involve essay writing, reflection exercises, or completion of learning modules about professionalism. Lack of clarity on what defines a lapse and fear of reprisal (for both trainees and faculty) limits reporting.

CONCLUSIONS

This study provides an overview of how professional identity formation is supported in the Canadian context, guided by the standards set out by CanMEDS. Despite a rich literature that describes the definition, program design and evaluation methods for professionalism, in some areas of the curriculum there is still an opportunity to ensure programs embrace the suggested framework. Examples of teaching and evaluation methods, deficiencies in the clinical years of study (clerkship) and challenges in addressing lapses and organizational structure are identified. The results help identify the gaps that need to be addressed and some solutions that can be modeled at other academic institutions.

The 'missing person' in roles-based competency models: a historical, cross-national, contrastive case study

CONTEXT

The use of roles such as medical expert, advocate or communicator to define competencies is currently popular in health professions education. CanMEDS is one framework that has been subject to great uptake across multiple countries and professions. The examination of the historical and cultural choices of names for roles generates insight into the nature and construction of roles. One role that has appeared in and disappeared from roles-based frameworks is that of the 'person'.

METHODS

In order to examine the implications of explicitly including or excluding the role of the 'physician as person' in a competency framework, we conducted a contrastive analysis of the development of frameworks in Canada and the Netherlands. We drew upon critical social science theoretical understandings of the power of language in our analysis.

RESULTS

In Canada, the 'person' role was a late addition to the precursory work that informed CanMEDS, and was then excluded from the final set of CanMEDS role names. In the Netherlands, a 'reflector' role was added in some Dutch schools and programmes when CanMEDS was adopted. This was done in order to explicitly emphasise the importance of the 'person' of the trainee.

CONCLUSIONS

In analysing choices of names for roles, we have the opportunity to see how cultural and historical contexts affect conceptions of the roles of doctors. The taking up and discarding of the 'person' role in Canada and the Netherlands suggest that as medical educators we may need to further consider the ways in which we wish the trainee as a person to be made visible in the curriculum and in assessment tools.

Assessing professional behaviour: Overcoming teachers' reluctance to fail students

Background

Developing professional behaviour is an important goal of medical education in which teachers play a significant part. Many teachers can be reluctant to fail students demonstrating unprofessional behaviour. We hypothesize that supporting teachers in teaching and assessing professional behaviour and involving them in remediation will reduce this reluctance.

Findings

In 2010, VUmc School of Medical Sciences Amsterdam introduced an educational theme on professional behaviour for the bachelor's and master's programmes in medicine with a special emphasis on supporting teachers in teaching and assessing professional behaviour and involving them in the remediation process. Information was extracted from the student database on the number of unprofessional behaviour judgments awarded over 2008-2010 (before the intervention), and 2010-2013 (after introducing the intervention), which was compared. To find out if teachers' reluctance to fail had decreased, qualitative feedback from the teachers was gathered and analysed. Since the implementation of the educational theme, the number of unprofessional behaviour judgments has risen. The teachers are positive about the implemented system of teaching and assessing professional behaviour, and feel less reluctant to award an unsatisfactory professional behaviour judgment.

Conclusions

Supporting teachers in teaching and assessing professional behaviour and involving them in students' remediation appears to reduce their reluctance to fail students demonstrating unprofessional behaviour.

Attitudes of Pakistani and Pakistani heritage medical students regarding professionalism at a medical college in Karachi, Pakistan

BACKGROUND

An increased interest in professionalism has been reported in the field of medical education due to concerns regarding deterioration of humanism and professional values in the teaching and practice of medicine. The primary aim of this study was to assess attitudes of Pakistani and Pakistani heritage students at a medical college in Pakistan about important elements of professionalism that an ideal medical doctor should possess. A further objective of the study was to determine students' preferred ways of learning professionalism.

METHODS

A written survey was distributed to undergraduate medical students at a public sector medical college at Karachi, Pakistan in 2011. Using the Penn State College of Medicine (PSCOM) Professionalism Questionnaire, attitudes of medical students of semester 1, 5, and 8 regarding professionalism were assessed anonymously.

RESULTS

The mean age of the students was 21.11 ± 2.72 years. Forty-three percent of the respondents were male. Forty percent of the students held Pakistani citizenship. Thirty-five percent students were US citizens with Pakistani parents and twenty-five percent were Pakistani heritage students that had dual citizenships. No significant differences in the elements of professionalism (Accountability, Altruism, Duty, Excellence, Honesty & Integrity and Respect) mean scores or in the overall mean score of professionalism among the various classes were found. The total overall Cronbach alpha value for all elements of the professionalism in the selected classes was above 0.9. The most preferred methods for learning professionalism were role modeling by faculty, case based scenarios and role plays.

CONCLUSION

The students rated all the attributes of professionalism as important and there was no difference across the study years. The overall internal consistency of each element of professionalism was high in different classes. Faculty role models, case based scenarios and role plays may be used to teach professionalism. As a great majority of students were having a Pakistani heritage rather than complete Pakistani born and bred background, hence findings of the survey may not be taken as representative of typical Pakistani medical students.