Opinion
VIEWPOINT
Darrell G. Kirch, MD Association of American Medical Colleges, Washington, DC. Maryellen E. Gusic, MD Association of American Medical Colleges, Washington, DC. Cori Ast, MHSA Association of American Medical Colleges, Washington, DC.
Undergraduate Medical Education and the Foundation of Physician Professionalism Professionalism is the demonstrated “commitment to carrying out professional responsibilities and an adherence to ethical principles”1 and is foundational to the practice of medicine—it is expected by physicians, the health care system, and patients alike. Developing competence in professionalism is a core expectation for a physician learner,nodifferentfromdevelopingcompetenceinmedicalknowledge.Criticaltotheformationofaphysician’sprofessional identity, ensuring competence in professionalismrequirestheconcertedeffortsofmany.Althoughthere is current controversy regarding how diverse professionalorganizationsshouldensureprofessionalismamong practicing physicians, during undergraduate medical education a shared governance model, as described below, provides the framework for developing and accessing this critical competency.
The Foundation of Professionalism Begins Before Medical School
Corresponding Author: Cori Ast, MHSA, Office of the President, Association of American Medical Colleges, 655 K St NW, Ste 100, Washington, DC 20001 (cast@aamc .org).
Aspiring physicians, through many years of personal experiences prior to medical school, establish the “preprofessional” foundation for competence in professionalism, making it important to assess preprofessional attributes in medical school admissions. Providing the groundwork for these decisions, 9 core interpersonal and intrapersonal competencies have been articulated for entering medical students: ethical responsibility to self and others; reliability and dependability; service orientation; social skills; capacity for improvement; resilience and adaptability; cultural competence; oral communication; and teamwork.2 These competencies link to established competency domains for health professionals1 and go beyond expectations in knowledge and reasoning skills. Importantly, these personal competencies for entering students have been shown to be predictive of success at the majority of medical schools, both in clinical rotations and later in practice.2 The experiences that contribute to the development ofthesepreprofessionalcompetenciesoccurinitiallywithin the context of a student’s family and community and, hopefully, are reinforced by experiences in K-12, undergraduate, and (in some cases) graduate education. In addition, increasing numbers of applicants are “nontraditional,” having had work or service-oriented experiences prior to medical school that enhance preprofessional attributes.Thisnetworkoffamily,community,education,and extracurricular experiences arguably is the shared governance for professionalism among physicians.
Admission to Medical School Reinforces the Commitment to Professionalism Ensuring that matriculating medical students demonstrate preprofessional competencies is a critical next
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step, given that the overwhelming majority of those who enter medical school will not only graduate but also care for patients. The evaluation of preprofessional competencies is central to the “holistic review” of medical school applicants. Medical educators and admissions officers have been developing tools to facilitate a broad review of an applicant’s capabilities beyond academic competencies as reflected in grades and test scores. Central to the admissions process, the Medical College Admissions Test (MCAT) has recently been revised to emphasize the broader portfolio of skills required by physicians in the 21st century. The MCAT 2015 includes new test components that examine applicants’ abilities to interpret data and “think like scientists” and that require them to demonstrate understanding of the social and behavioral factors that contribute to health.3 The revised MCAT has been coupled with other changes in the admissions process, including the creation of guidelines for letters of recommendation to ensure inclusion of information about the core competencies for entering medical students and, in the standardized application form, asking applicants to document relevant personal experiences in addition to their coursework. Although many medical schools conduct personal interviews, the reliability of these relatively brief interactions in assessing an applicant’s competence may be limited. To address this challenge, an increasing number of schools are using structured multiple miniinterviews (MMIs), in which applicants rotate through a series of brief interactions assessing their response to various scenarios or questions.4 MMIs have been shown to be effective in assessing aspirants’ critical thinking and communication skills as well as their reactions to situations with ethical conflict. In early stages of implementation, MMIs appear predictive of future performance in medical school.4 Another tool currently under development in the United States is the situational judgment test (SJT), which has been shown to be effective in assessing how applicants would respond to challenging situations. Although still under assessment in the United States, an SJT has been used by Belgium for medical school admission since 1997.2 The Association of American Medical Colleges (AAMC), in partnership with the medical school admissions community and others, is engaged in examining how tools such as these can identify those applicants with the preprofessional competencies most conducive to the future development of medical professionalism. As these approaches illustrate, in the review of medical school applicants, the medical education community uses shared governance involving medical schools and their faculty, as well as the AAMC as their profes(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User on 05/17/2015
1797
Opinion Viewpoint
sional association, to develop tools and processes focused on this critical component of physician formation.
Promoting Professionalism Within Undergraduate Medical Education The shared governance of professionalism also is evident in the structures and processes that provide oversight for undergraduate medical education. Faculty, administrators, students, and community members sit on a variety of committees, not only those for admissions, but also for curriculum and student progression. These committees ensure the competence of trainees by following, at a minimum, the standards set by the medical school accrediting body, the Liaison Committee on Medical Education (LCME). Collectively, the schools and their accreditation process are united by the common goal of producing competent physicians who are well prepared for residency training. Increasingly, it is recognized that professionalism is not cultivated solely by role-modeling in clinical settings but rather that professionalism must be taught early, longitudinally, and deliberately using both targeted instruction and experiential learning. The LCME accreditation standards formalize the institutional responsibility by requiring that medical schools maintain a learning environment that cultivates the development of professionalism among learners.5 The medical school dean bears overall responsibility for ensuring a professional environment within the institution and in the education of students. Importantly, this responsibility for students’ professional development is shared with administrators, faculty, and students serving on various administrative committees. Curricular approaches to promote the development of professionalism include dedicated courses on ethics, embedding professionalism content within clinical clerkships, and longitudinal courses introducing students to the humanistic dimensions of caring for others. Typically, these learning opportunities are structured to reinforce and build on lessons across the entirety of the undergraduate medical education curriculum (unpublished data, AAMC Curriculum Inventory, March 18, 2015). Progression committees, which have the ultimate authority for decisions related to progress toward the awarding of a medical degree, not only must assess academic progress in knowledge and skills but also must conduct professional due diligence by certifying that those who complete undergraduate medical education demonstrate the professional attitudes and behaviors required for physi-
Shared Governance Is a Successful Model for Professional Formation The dictum that “it takes a village to raise a child” also appears to be true of educating a physician. Although the ultimate responsibility for professionalism rests with the physician aspirant, multiple parties are involved in shaping the preprofessional attributes of aspiring physicians, as well as those in the undergraduate process of training, including committees for admissions, curriculum, and progression that engage administrators, faculty, and students in the oversight, development, and assessment of professionalism. Affiliated organizations, including the LCME and AAMC, play a significant role in setting standards and providing tools related to teaching and assessing professional development. This shared governance model for undergraduate medical education lays the foundation for a lifelong commitment to professionalism in physicians, a commitment critical to both the future of the profession and the health of patients.
competencies important to entering students’ success in medical school: what are they and how could they be assessed early in the admission process? Acad Med. 2013;88(5):603-613.
a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. March 2014. http://www.lcme.org /publications.htm. Accessed March 16, 2015.
REFERENCES
3. Kirch DG, Mitchell K, Ast C. The new 2015 MCAT: testing competencies. JAMA. 2013;310(21):22432244.
1. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med. 2013;88(8):1088-1094.
4. Pau A, Jeevaratnam K, Chen YS, Fall AA, Khoo C, Nadarajah VD. The Multiple Mini-Interview (MMI) for student selection in health professions training—a systematic review. Med Teach. 2013;35 (12):1027-1041.
6. Boon K, Turner J. Ethical and professional conduct of medical students: review of current assessment measures and controversies. J Med Ethics. 2004;30(2):221-226.
2. Koenig TW, Parrish SK, Terregino CA, Williams JP, Dunleavy DM, Volsch JM. Core personal
5. Liaison Committee on Medical Education (LCME). Standard 3.5. Functions and Structure of
ARTICLE INFORMATION Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
1798
cians. To support these assessments, more than half of medical schools in the United States and Canada rely on “defined, written standards of non-cognitive behavior, [including] honesty; professional behavior; dedication to learning; professional appearance; respect for law and others; [and adherence to standards related to] confidentiality; and [lack of issues related to] substance abuse,” in addition to the academic standards for promotion established by each school.6 Although assessing competence in professionalism may be less precise than assessing competence in the knowledge of biochemistry, today there are tools to assess professionalism in students, including patient evaluations, self and peer assessments, behavioral observation, psychological testing, and even structured examinations.6 While promotion committees have formal responsibility for adherence to standards, identifying deficiencies in professionalism is a shared obligation among individual faculty educators and extends throughout medical school. The shared responsibility of teaching and assessing student professionalism is one of the most high-stakes responsibilities in undergraduate medical education, because research has identified that students who demonstrate professionalism deficiencies in medical school, including irresponsibility and diminished capacity for self-improvement, continue to display these deficiencies in residency and practice, placing patients at risk for harm.7
7. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005;353 (25):2673-2682.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User on 05/17/2015
jama.com
VIEWPOINT
Darrell G. Kirch, MD Association of American Medical Colleges, Washington, DC. Maryellen E. Gusic, MD Association of American Medical Colleges, Washington, DC. Cori Ast, MHSA Association of American Medical Colleges, Washington, DC.
Undergraduate Medical Education and the Foundation of Physician Professionalism Professionalism is the demonstrated “commitment to carrying out professional responsibilities and an adherence to ethical principles”1 and is foundational to the practice of medicine—it is expected by physicians, the health care system, and patients alike. Developing competence in professionalism is a core expectation for a physician learner,nodifferentfromdevelopingcompetenceinmedicalknowledge.Criticaltotheformationofaphysician’sprofessional identity, ensuring competence in professionalismrequirestheconcertedeffortsofmany.Althoughthere is current controversy regarding how diverse professionalorganizationsshouldensureprofessionalismamong practicing physicians, during undergraduate medical education a shared governance model, as described below, provides the framework for developing and accessing this critical competency.
The Foundation of Professionalism Begins Before Medical School
Corresponding Author: Cori Ast, MHSA, Office of the President, Association of American Medical Colleges, 655 K St NW, Ste 100, Washington, DC 20001 (cast@aamc .org).
Aspiring physicians, through many years of personal experiences prior to medical school, establish the “preprofessional” foundation for competence in professionalism, making it important to assess preprofessional attributes in medical school admissions. Providing the groundwork for these decisions, 9 core interpersonal and intrapersonal competencies have been articulated for entering medical students: ethical responsibility to self and others; reliability and dependability; service orientation; social skills; capacity for improvement; resilience and adaptability; cultural competence; oral communication; and teamwork.2 These competencies link to established competency domains for health professionals1 and go beyond expectations in knowledge and reasoning skills. Importantly, these personal competencies for entering students have been shown to be predictive of success at the majority of medical schools, both in clinical rotations and later in practice.2 The experiences that contribute to the development ofthesepreprofessionalcompetenciesoccurinitiallywithin the context of a student’s family and community and, hopefully, are reinforced by experiences in K-12, undergraduate, and (in some cases) graduate education. In addition, increasing numbers of applicants are “nontraditional,” having had work or service-oriented experiences prior to medical school that enhance preprofessional attributes.Thisnetworkoffamily,community,education,and extracurricular experiences arguably is the shared governance for professionalism among physicians.
Admission to Medical School Reinforces the Commitment to Professionalism Ensuring that matriculating medical students demonstrate preprofessional competencies is a critical next
jama.com
step, given that the overwhelming majority of those who enter medical school will not only graduate but also care for patients. The evaluation of preprofessional competencies is central to the “holistic review” of medical school applicants. Medical educators and admissions officers have been developing tools to facilitate a broad review of an applicant’s capabilities beyond academic competencies as reflected in grades and test scores. Central to the admissions process, the Medical College Admissions Test (MCAT) has recently been revised to emphasize the broader portfolio of skills required by physicians in the 21st century. The MCAT 2015 includes new test components that examine applicants’ abilities to interpret data and “think like scientists” and that require them to demonstrate understanding of the social and behavioral factors that contribute to health.3 The revised MCAT has been coupled with other changes in the admissions process, including the creation of guidelines for letters of recommendation to ensure inclusion of information about the core competencies for entering medical students and, in the standardized application form, asking applicants to document relevant personal experiences in addition to their coursework. Although many medical schools conduct personal interviews, the reliability of these relatively brief interactions in assessing an applicant’s competence may be limited. To address this challenge, an increasing number of schools are using structured multiple miniinterviews (MMIs), in which applicants rotate through a series of brief interactions assessing their response to various scenarios or questions.4 MMIs have been shown to be effective in assessing aspirants’ critical thinking and communication skills as well as their reactions to situations with ethical conflict. In early stages of implementation, MMIs appear predictive of future performance in medical school.4 Another tool currently under development in the United States is the situational judgment test (SJT), which has been shown to be effective in assessing how applicants would respond to challenging situations. Although still under assessment in the United States, an SJT has been used by Belgium for medical school admission since 1997.2 The Association of American Medical Colleges (AAMC), in partnership with the medical school admissions community and others, is engaged in examining how tools such as these can identify those applicants with the preprofessional competencies most conducive to the future development of medical professionalism. As these approaches illustrate, in the review of medical school applicants, the medical education community uses shared governance involving medical schools and their faculty, as well as the AAMC as their profes(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User on 05/17/2015
1797
Opinion Viewpoint
sional association, to develop tools and processes focused on this critical component of physician formation.
Promoting Professionalism Within Undergraduate Medical Education The shared governance of professionalism also is evident in the structures and processes that provide oversight for undergraduate medical education. Faculty, administrators, students, and community members sit on a variety of committees, not only those for admissions, but also for curriculum and student progression. These committees ensure the competence of trainees by following, at a minimum, the standards set by the medical school accrediting body, the Liaison Committee on Medical Education (LCME). Collectively, the schools and their accreditation process are united by the common goal of producing competent physicians who are well prepared for residency training. Increasingly, it is recognized that professionalism is not cultivated solely by role-modeling in clinical settings but rather that professionalism must be taught early, longitudinally, and deliberately using both targeted instruction and experiential learning. The LCME accreditation standards formalize the institutional responsibility by requiring that medical schools maintain a learning environment that cultivates the development of professionalism among learners.5 The medical school dean bears overall responsibility for ensuring a professional environment within the institution and in the education of students. Importantly, this responsibility for students’ professional development is shared with administrators, faculty, and students serving on various administrative committees. Curricular approaches to promote the development of professionalism include dedicated courses on ethics, embedding professionalism content within clinical clerkships, and longitudinal courses introducing students to the humanistic dimensions of caring for others. Typically, these learning opportunities are structured to reinforce and build on lessons across the entirety of the undergraduate medical education curriculum (unpublished data, AAMC Curriculum Inventory, March 18, 2015). Progression committees, which have the ultimate authority for decisions related to progress toward the awarding of a medical degree, not only must assess academic progress in knowledge and skills but also must conduct professional due diligence by certifying that those who complete undergraduate medical education demonstrate the professional attitudes and behaviors required for physi-
Shared Governance Is a Successful Model for Professional Formation The dictum that “it takes a village to raise a child” also appears to be true of educating a physician. Although the ultimate responsibility for professionalism rests with the physician aspirant, multiple parties are involved in shaping the preprofessional attributes of aspiring physicians, as well as those in the undergraduate process of training, including committees for admissions, curriculum, and progression that engage administrators, faculty, and students in the oversight, development, and assessment of professionalism. Affiliated organizations, including the LCME and AAMC, play a significant role in setting standards and providing tools related to teaching and assessing professional development. This shared governance model for undergraduate medical education lays the foundation for a lifelong commitment to professionalism in physicians, a commitment critical to both the future of the profession and the health of patients.
competencies important to entering students’ success in medical school: what are they and how could they be assessed early in the admission process? Acad Med. 2013;88(5):603-613.
a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. March 2014. http://www.lcme.org /publications.htm. Accessed March 16, 2015.
REFERENCES
3. Kirch DG, Mitchell K, Ast C. The new 2015 MCAT: testing competencies. JAMA. 2013;310(21):22432244.
1. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med. 2013;88(8):1088-1094.
4. Pau A, Jeevaratnam K, Chen YS, Fall AA, Khoo C, Nadarajah VD. The Multiple Mini-Interview (MMI) for student selection in health professions training—a systematic review. Med Teach. 2013;35 (12):1027-1041.
6. Boon K, Turner J. Ethical and professional conduct of medical students: review of current assessment measures and controversies. J Med Ethics. 2004;30(2):221-226.
2. Koenig TW, Parrish SK, Terregino CA, Williams JP, Dunleavy DM, Volsch JM. Core personal
5. Liaison Committee on Medical Education (LCME). Standard 3.5. Functions and Structure of
ARTICLE INFORMATION Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
1798
cians. To support these assessments, more than half of medical schools in the United States and Canada rely on “defined, written standards of non-cognitive behavior, [including] honesty; professional behavior; dedication to learning; professional appearance; respect for law and others; [and adherence to standards related to] confidentiality; and [lack of issues related to] substance abuse,” in addition to the academic standards for promotion established by each school.6 Although assessing competence in professionalism may be less precise than assessing competence in the knowledge of biochemistry, today there are tools to assess professionalism in students, including patient evaluations, self and peer assessments, behavioral observation, psychological testing, and even structured examinations.6 While promotion committees have formal responsibility for adherence to standards, identifying deficiencies in professionalism is a shared obligation among individual faculty educators and extends throughout medical school. The shared responsibility of teaching and assessing student professionalism is one of the most high-stakes responsibilities in undergraduate medical education, because research has identified that students who demonstrate professionalism deficiencies in medical school, including irresponsibility and diminished capacity for self-improvement, continue to display these deficiencies in residency and practice, placing patients at risk for harm.7
7. Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005;353 (25):2673-2682.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User on 05/17/2015
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