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Assessing professional identity formation (PIF) amongst medical students in Oncology and Palliative Medicine postings: a SEBA guided scoping review
BMC Palliative Care volume 21, Article number: 200 (2022)
A Correction to this article was published on 26 January 2023
This article has been updated
Abstract
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 1st January 2000 and 31st 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.
Introduction
Oncology and Palliative Medicine postings help medical students understand [1,2,3], learn, practice and develop their ethics [4], empathy [5], communication [6], professionalism [7], legal [8, 9] and collaborative skills and competencies [10]. These postings also offer an opportunity for medical students to witness, discuss and participate in complex clinical decision-making [11] on matters such as end-of-life goals, best interests determinations, quality-of-life, and desired places of care and death [12]. With data suggesting that such experiences impact how medical students conceive their roles, responsibilities, competencies, and conduct within the team and the manner that they see, feel and act as future physicians, the role of Oncology and Palliative Medicine postings in influencing the professional identity formation (PIF) of medical students has come under the spotlight [13,14,15].
With potential impact on future practice, professionalism, teamworking and service orientation, the importance of shaping PIF is clear [16, 17]. Thus, the evidence that experiences in Oncology and Palliative Medicine postings influence a medical student’s PIF offers just such an opportunity to mould PIF [13,14,15]. This calls for better assessments of PIF in Oncology and Palliative Medicine postings. To be clear rather than being concerned with remediation and maintaining competencies, proposed assessments of PIF during Oncology and Palliative Medicine postings aim to direct support to medical students in a timely, personalised and appropriate manner.
Methodology
In the absence of a consistent approach to assess PIF longitudinally and holistically [16, 17], a Systematic Evidenced Based Approach guided systematic scoping review (henceforth SSR in SEBA) is proposed to map current assessments of PIF amongst medical students. This SSR in SEBA is overseen by an expert team comprised of medical librarians from the Yong Loo Lin School of Medicine (YLLSoM) and the National Cancer Centre Singapore (NCCS), and local educational experts and clinicians at NCCS, the Palliative Care Institute Liverpool, YLLSoM and Duke-NUS Medical School who guide, oversee and support all stages of SEBA in order to ensure the transparency, accountability and reproducibility of this review [5, 18,19,20,21,22,23,24,25,26,27,28]. This SSR in SEBA is also shaped by SEBA’s constructivist ontological perspective and relativist lens as well as the principles of interpretivist analysis to enhance reflexivity of the analysis and the discussions of this SSR in SEBA [29,30,31,32] Fig. 1.
The SSR in SEBA Process
Stage 1 of SEBA: systematic approach
Determining the title and research question and inclusion criteria
The PICOs format was employed (Table 1) to guide the primary research question which is “What is known about the assessment of professional identity formation amongst medical students?” and the secondary research questions are “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?”.
Searching
Independent searches of PubMed, Embase, ERIC and Scopus were conducted between 13th February 2022 and 18th April 2022. To ensure a viable and sustainable research process, the research team confined the searches to articles published between 1st January 2000 to 31st December 2021 to account for prevailing manpower and time constraints. Additional ‘snowballing’ of references of the included articles ensured a comprehensive review of articles in the field [33]. The full search strategy can be found in Appendix A.
Extracting and charting
Using an abstract screening tool, the research team independently reviewed abstracts to be included and employed ‘negotiated consensual validation’ to achieve consensus on the final list of articles to be included [34].
Stage 2 of SEBA: split approach
The Split Approach [35] employs concurrent thematic and directed content analysis of the included full-text articles as well as the creation of tabulated summaries of these articles. This process is carried out by three independent teams. The first team summarised and tabulated the included full-text articles according to recommendations set out by Wong, Greenhalgh [36]’s RAMESES publication standards and Popay, Roberts [37]’s “Guidance on the conduct of narrative synthesis in systematic reviews” (Appendix B).
Braun and Clarke [38]’s thematic analysis
Using Braun and Clarke [38]’s approach to thematic analysis, the second team ‘actively’ read the included articles to find meaning and patterns in the data [39,40,41,42,43]. In phase two, ‘codes’ were constructed from the ‘surface’ meaning for the first twenty included articles. These codes were then collated and agreed upon and used to create a codebook. The codebook was used to code and analyse the rest of the articles using an iterative step-by-step process [44]. As new codes emerged, these were associated with previous codes and concepts. In phase three, an inductive approach allowed themes to be “defined from the raw data without any predetermined classification” [42]. In phase four, the research team discussed their independent findings and employed the “negotiated consensual validation” [34] to determine the final list of themes.
Hsieh and Shannon [45]’s directed content analysis.
The third team employed Hsieh and Shannon [45]’s approach to directed content analysis to “identify and operationalize a priori coding categories” [45,46,47,48,49,50] from Cruess, Cruess [51]’s “A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators”, Barnhoorn, Houtlosser [52]’s “A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity”, and Krishna and Alsuwaigh [53]’s “Understanding the fluid nature of personhood—the ring theory of personhood”. Any data not captured by these codes were assigned a new code [54]. The choice of articles was determined by the expert team and following discussion with independent experts. These articles are seen to best capture the breadth of thinking on the subject. ‘Negotiated consensual validation’ was used to achieve consensus on the final categories [55].
Stage 3 of SEBA: Jigsaw Perspective
The Jigsaw Perspective employs Phases 4 to 6 of France, Wells [56]’s adaptation of Noblit and Hare [57]’s seven phases of meta-ethnographic approach to view the themes and categories identified in the Split Approach as pieces of a jigsaw puzzle. Overlapping or complementary elements within themes and categories are combined to create a bigger piece of the puzzle referred to as themes/ categories.
Stage 4 of SEBA: funnelling
Themes/categories were compared with tabulated summaries [56, 57], which also included quality appraisals using MERSQI and COREQ [58, 59] to ensure that the themes/categories best captured the key elements of the included articles. The domains created from this process form the basis of the discussion’s ‘line of argument’ in Stage 6 of SEBA.
Results
Two thousand four hundred thirty six abstracts were reviewed, 602 full-text articles were evaluated, and 88 articles were included (Fig. 2). The domains identified were theories, assessments, and implementation. Much of the data were drawn from lists or were presented without accompanying explications. As such, we have summarised them in a series of tables for ease of review.
PRISMA Flow chart
Domain 1. Theories
Current assessment programs are shaped by the guiding PIF theory adopted. There were eleven theories of PIF employed by current assessment programs. We summarised these in Table 2.
Of these eleven theories, there are three theories that have been especially influential to practice. One, Cruess et al.’s schematic representations of PIF and socialization [51] which touch on the notion that Oncology and Palliative Medicine postings may be both a Community of Practice (CoP) and a mechanism that facilitates the inculcation of the values, beliefs and principles and identity of the CoP or Socialisation process. Barab et al. [77] define CoPs as “a persistent, sustaining social network of individuals who share and develop an overlapping knowledge base, set of beliefs, values, history and experiences focused on a common practice and/or enterprise”. Cruess, Cruess [78] define socialisation as “a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalised, resulting in an individual thinking, acting and feeling like a physician”. The socialization process in turn is reliant upon an organised, supportive sense of community, highlighting the entwined relationships between CoPs and the socialisation process. The socialisation process is also dependent upon the CoP’s provision of personalised, timely, appropriate, holistic and longitudinal support through a combination of mentoring, role modelling, coaching, networking, advicing, supervision, tutoring, feedback, guided reflections and supervised experiential learning within a safe and structured learning environment.
Two, underscoring the interrelated nature of environmental factors and identity formation is Barnhoorn’s multi-level professionalism framework [52] that builds on Korthagen’s level of change model [64]. These theories invite the notion of environmental factors within a CoP influencing the medical student’s current beliefs, values, competencies and their identities and behaviour.
Three, Krishna’s Ring Theory of Personhood (RToP) builds on links between identity, mission and behaviour, and the impact of environmental factors on PIF (Fig. 1). The RToP also draws on Wald’s [62] and Pratt’s [61] theories on PIF to explicate the ties between the environment, experience and PIF. The RToP suggests that the medical student’s current beliefs, values, competencies and regnant identities and behaviour are shaped by their self-concepts of personhood or “what makes you, you”. Specifically, the RToP posits that the medical student’s current beliefs, values, and competencies (henceforth belief system) within the medical student’s Innate, Individual, Relational and Societal domains of personhoods shape their corresponding identities. Changes in the belief system in each domain, result in changes in their corresponding identities.
The RToP postulates that the Innate, Individual, Relational and Societal domains of personhood which may be represented as intertwined rings (Fig. 3). The Innate Identity is derived from regnant spiritual, religious, theist moral and ethical values, beliefs, and principles within the Innate Ring. The Individual Ring’s regnant belief system is derived from the medical student’s thoughts, conduct, biases, narratives, personality, decision-making processes, and other facets of conscious function which together inform the medical student’s Individual Identity. The Relational Identity is born of a belief system derived from the values, beliefs and principles governing the medical student’s personal and important relationships. The Societal Identity is shaped by regnant societal, religious, professional, and legal expectations, values, beliefs, and principles which inform their interactions with colleagues and acquaintances.
The Ring Theory of Personhood
Growing clinical, mentoring, research and personal experiences, reflections, and competencies as the medical student progresses through the Oncology and Palliative Care posting, result in changes in the belief systems and with that, changes to their corresponding identities. However, the nature of the changes in identity is determined by three considerations. One, when practical, environmental, and professional influences are consistent with the medical student’s belief system, there is ‘resonance’. When resonant values, beliefs and principles are adapted and reprioritised to better fit current practice, there is ‘synchrony’. Conversely, when there is conflict between the introduced and remnant beliefs systems in one ring, there is ‘disharmony’. Should the conflicts extend to more than one ring, there is ‘dyssynchrony’.
Two, how synchrony, resonance, disharmony, and or dyssynchrony are attended to is shaped by the medical student’s psychoemotional state, circumstances, goals, experiences, motivations, enthusiasm, idealism, abilities, competencies, virtues, expectations, knowledge, skills, and attitudes (henceforth narrative). It is also influenced by their contextual considerations including prevailing research, clinical, and organisational considerations, professional codes of conduct, societal expectations, ethical and legal standards (henceforth contextual considerations).
Three, ‘Identity work’ involves addressing the presence of synchrony, resonance, disharmony, and or dyssynchrony, in a manner that is consistent and appropriate to the medical student’s narratives, contextual considerations and available support and guidance. Pratt’s theory on PIF [61] is employed to ‘identity work’ using patching and splinting. In “patching”, the medical student adopts their perception of an ‘ideal’ identity to fill in the deficiencies in their professional identity, whereas in “splinting”, the medical student employs a former identity to protect the currently fragile professional identity. The concept of ‘identity work’ also encapsulates the decision not to act.
Domain 2. Assessment
Principles, information considered and methods of assessments
Governed by their respective guiding theories, current assessment factors and methods are summarised in Table 3.
Existing modalities of PIF assessment
Most evaluations focus upon character traits, conduct and the cognitive base. Whilst we discuss the key approaches, we summarise the tools identified in Table 4.
Reflections (11/88, 12.5%)
Reflective practice plays a critical role in PIF [63, 86]. Current assessments of reflections are guided by Kegan’s constructive-developmental theory [63], Gibb’s reflective circle [95], Schon’s theory of the reflective practitioner [124], or Boud’s models of reflective thinking [116].
Guided Feedback (8/88, 9.1%)
Guided, multi-sourced [63, 109, 111] and competency-based [102] feedback influence the socialization process [100, 102], guides role modelling of good behaviour [126], shapes critical thinking [122], addresses bad professional behaviour [126], reinforces commitment to the professional role [81] and builds emotional resilience [122].
Portfolio (11/88, 12.5%)
Portfolios serve as a powerful tool for reflection and reinforce professional and organizational values [127]. To achieve these objectives, portfolio includes a mix of generalised assessment methods [28], longitudinal assessment data [63, 104, 110], self-assessments [104] of work and accomplishments [127] and reflections [28, 99, 104, 116, 127, 128] on ethical issues [128], professional breaches [128], and moral dilemmas [128]. Other contents of portfolios are highlighted in Table 5.
Tools contextualised to the nature of PIF
Assessments of PIF are often stage-based.
Stage-based nature of PIF
Assessments often reflect the notion of a stage-specific development of PIF exemplified by Cruess, Cruess [17]’s amendment of Miller’s pyramid. Figure 4 stratifies the assessment tools in accordance with these stages. The included articles for each stage are also found in Appendix C.
Tools used in the assessment of PIF grouped according to the stages of Miller’s pyramid
“Knows”/ Knows How” (10/88, 11.4%)
‘Know’ considers the medical student’s level of knowledge [17]. ‘Know how’ determines if the medical student knows how to analyse, interpret, synthesise, and apply the knowledge [17]. These elements inform behaviour [52], and reflect attitudes [113].
“Shows how”/ “Does” (34/88, 38.6%)
“Shows how” considers the demonstration of skills and interpersonal and individual behaviour [17]. Behaviour is assessed by teachers/ tutors [103, 114, 129], supervising physicians [102, 114], patients [128], peers [63, 100, 103, 106, 114, 126] and or may be self-assessed [114]. However, it is peer assessments that are considered the most reliable and authentic means of assessing this aspect [126].
Assessment of the “Does” aspect involves the demonstration of skill and behaviour even when not being formally assessed [17]. This aspect too is best reflected in peer assessments [17]. Skills are assessed by supervising physicians [102] or peers [63, 102, 106], using workplace-based assessments (e.g. actual patient encounters [114], simulation (e.g. simulated patients [114]) and OSCEs [63, 95, 106, 120].
“Is” (18/88, 20.5%)
At the “Is” stage, self-concepts of identity are evaluated by questionnaires [94, 130], and moral reasoning [87].
We summarise the prevailing tools in Table 6.
Assessing socialization (13/88, 14.8%)
Socialization can be assessed through reflections [81, 82, 86, 90, 98, 100, 101, 112, 115, 116, 127], longitudinal assessments in portfolios [63, 98, 100, 104, 127], and guided feedback.
Domain 3. Implementation
Who assesses PIF?
PIF can be self-evaluated, or assessed by peers [100], faculty [100, 127, 132], clinical supervisors [133], patients [133] and other healthcare professionals [133, 136]. Elliot et al. [100], suggests that peer assessments are a reliable evaluation method, particularly in a group setting or when involving facets of communications, self-awareness, self-care and growth. Peer assessments, however, are vulnerable to misrepresentation and collusive agreements [134]. Self-assessments are useful, particularly when triangulated with other source material [132]. Van Mook et al. [132] suggests that faculty assessments are dependent on individual attitudes, motivation and instructional skills of faculty members.
Administrative Considerations/Role of host organisation (4/88, 4.5%)
Assessments should be explicit, confidential [126], and accompanied by accessible feedback and results [88, 131]. These considerations underline the importance of faculty training and emphasize the need for clearly stipulated assessment guidelines to safeguard fair assessments [90, 103].
Remediation (11/88, 12.5%)
Remediation is increasingly acknowledged as an elemental aspect of any training process that must be informed by a thorough assessment [87, 133]. To remain transparent, confidential and personalised, the remediation programme must be robust and longitudinal, involving goal setting [89], provide feedback [107] evidence of the completion of modules [87, 89], and the inclusion of reflections [87, 89, 133]. Remedial processes should be supported by accessible mentoring, coaching and counselling support [87, 103, 115, 131] and personalised and timely follow-up and monitoring of progress [135].
The procedures including warnings [79, 135], suspension, dismissal/ expulsion [79, 118] after appropriate discussions and escalation to senior faculty, dean’s office and directors [79, 127, 133], must be clearly delineated.
Stage 5 of SEBA: analysis of evidence-based and non-data driven literature
The themes drawn from evidenced-based publications were compared with those from non-data-based articles (grey literature, opinion, perspectives, editorial, letters). The themes from both groups were similar and non-data-based articles did not bias the analysis untowardly.
The reiterative stage of SEBA
As part of the SEBA process, the expert team evaluated the initial data found in this review. This process drew attention to several recent reviews that were subsequently considered in the analysis of the data to ensure an evidence-based, clinically relevant synthesis of the data.
Recent reviews on the use of portfolios [137] amongst medical students as a means of mapping longitudinal development and identity formation underscore the key elements within a portfolio and highlight the efficacy of e-portfolios.
Similarly, reviews of how medical students, physicians and nurses caring for dying patients [13], coped and its impact on their PIF suggest that Krishna et al. (2020)’s [53] Ring Theory of Personhood (RToP) provides an effective means of capturing changes in identity over time and in the face of crises. The RToP was subsequently added to the list of current guiding theories (Table 3). These insights helped frame the discussion.
Discussion
Stage 6 of SEBA: synthesis of SSR in SEBA
To answer its primary research question which was “What is known about assessments of PIF amongst medical students?”, this SSR in SEBA forwards the Krishna-Pisupati’s model (Fig. 5) of current concepts of PIF amongst medical students. Drawn from included articles and based on regnant theories and practices, the Krishna-Pisupati’s model provides insights into the rationale for the various assessments employed to direct timely support of PIF amongst medical students.
Krishna-Pisupati model
Summarising and contextualising the findings of this SSR in SEBA, the Krishna-Pisupati’s model is constructed around the key themes of leading PIF theories. These are the structural and individual aspects of PIF theories. Simply put, the structural aspects may be encapsulated by the notion of Oncology and Palliative Care postings functioning as CoPs. The individual aspects on the other hand highlight the role each medical students plays in shaping their professional identity.
Structural
The notion that Oncology and Palliative Care postings may be considered as CoPs, pivots on three postulations. One, Oncology and Palliative Care postings offer a safe and structured learning, organizational, professional, clinical, practice, academic and research environment for medical students (henceforth learning environment). The notion of the interactions extending beyond the dyadic relationship between tutor and student and embracing the influences of the learning structure and culture, resonates with Korthagen’s level of change model and Barnhoorn’s multi-level professionalism framework.
Two, the structure afforded Oncology and Palliative Care postings with clearly established roles, responsibilities, codes of practice and expectations, clearly signposted trajectories, training methods, communication processes, interactive and context-rich content, expectations, assessments, and support mechanisms. The structure provides guided immersion into the Oncology and Palliative Care work environment and mentored progress; from a peripheral role in the team to being a part of the care team which are at the heart of CoPs. It is also supported by the provision of timely and personalised coaching, counselling, supervision, role modelling, mentoring and guided reflection (henceforth mentoring umbrella), an inherent aspect [138] of an Oncology and Palliative Care posting as an interactive developmental process.
Three, CoPs also structure effective evaluation, longitudinal support and follow-up of the medical student. This holistic and longitudinal assessment process considers the medical student’s narrative, their contextual considerations, self-awareness, and willingness to engage. Also integrated into guiding assessments aimed at directing timely and personalised support, within this personalised developmental process are the medical student’s maturing cognition, developing resilience and competencies, emotional growth, changing narratives, evolving character and motivations, growing ability to engage support networks, participation in reflective practices and seeking support and guidance and in taking on feedback. This highlights the importance of the mentoring umbrella [139] and perhaps just as significantly, the need for faculty training and support to apply the appropriate assessments and provide timely, personalised, and appropriate feedback and support.
The combination of a mapped training program, the mentoring umbrella, trained faculty, structured assessments, guided reflections and supervised experiential learning within the curated learning environment aspects support a structured, and personalised Socialisation Process. The Socialisation Process also thrives in the presence of a congruence between the medical student’s characteristics, goals, expectations, and stages of development and the training and experiences being offered in the Oncology and Palliative Care postings. Peh et al. [138] noted that when pitched at a level appropriate for their training, competencies and experience, medical students better relate to the value of Palliative Care postings and recognise the experiences afforded (Congruence). Similarly, the content, standards, roles and responsibilities expected of medical students and the approaches used to train and support the medical student must be consistent with the practice settings, program culture and academic structure as well as regnant sociocultural considerations (Social Validation).
Individual influences
The individual aspects of current PIF theories are virtually encapsulated by a combination of the RToP and Wald’s [62] and Pratt’s [61] theories on PIF. The RToP sketches the influence of the prevailing belief system, the particular medical student’s narratives, contextual and environmental considerations and their developing competencies on their maturing self-concept of identity and personhood. Wald’s [62] and Pratt’s [61] theories on PIF offers to explain the consequent changes in the medical student’s RToP during their Oncology and Palliative Care postings [11, 12, 140, 141]. Concurrently, the combination of the RToP and Wald’s [62] and Pratt’s [61] theories on PIF provide new insights into key elements of the CoP’s Socialisation Process.
The concept of ‘sensitivity’ describes the medical student’s awareness of resonance, synchrony, disharmony and or dyssynchrony when transitioning to different roles, responsibilities, practice settings, cultures, and structures and goals; and or exposure to death [142, 143] and dying [18, 20], moral distress [144,145,146] and the demands of dignity-based patient [147] centred care [148,149,150,151,152,153,154,155,156,157,158,159], ubiquitous with Oncology and Palliative Care postings [11, 12, 140, 141] (henceforth events). The medical student’s ‘judgement’ attributes significance to these ‘events’. ‘Judgement’ determines if the event has resulted in resonance, synchrony, disharmony and or dyssynchrony and if these effects warrant attention. “Willingness’ refers to the motivation of the medical student to attend to the effects of events and the resonance, synchrony, disharmony and or dyssynchrony caused. With events likely to cause a mix of resonance, synchrony, disharmony and or dyssynchrony, ‘balance’ sees that the medical student prioritise adaptations to maintain their overall identity. ‘Sensitivity’, ‘events’, “willingness’, ‘judgement’ and ‘balance’ are influenced by the medical student’s narratives, contextual considerations, competencies, stage of development and how their changing narratives, contextual and belief systems are supported.
Housed within a structured and supported CoP, Oncology and Palliative Care postings [11, 12, 140, 141] can modulate the influence of environmental and contextual considerations, and their effects upon ‘sensitivity’, ‘events’, “willingness’, ‘judgement’ and ‘balance’. It is also able to tailor timely, personalised, and appropriate support to attend to the medical student’s narratives, contextual considerations, competencies, and stage of development. The provision of support is also influenced by the CoP’s access to trained mentors who are able to offer timely, appropriate, personalised and holistic guidance and longitudinal support.
The support provided by the combination of a mapped training program, the mentoring umbrella, trained faculty, structured assessments, guided reflections and supervised experiential learning within the curated learning environment galvanises the medical student’s ‘willingness’ to address ‘events’ and the resultant is resonance, synchrony, disharmony and or dyssynchrony. This will encourage and assist efforts to carry out the required ‘identity work’. ‘Identity work’ refers to efforts by the medical student to adapt their identity to their current situation (Context-specific self-concept of identity). This may include ‘inaction’, ‘patching’, ‘splinting’ or ‘enriching’ which is the strengthening of the medical student’s current value system and reinforcement of their regnant professional identity [61]. Kuek et al. [27] and Ho et al. [25] suggest that if the medical student determines that their present identity fits the role, responsibility, circumstances, setting and or practice, there is synchrony, and the prevailing identity is ‘enriched’. If there are differences between the inculcated and regnant values, beliefs and principles that cannot be easily addressed, the medical student may adopt Pratt’s concepts of patching or splinting their current identity [61]. Lacking experience, knowledge, skills and the appropriate competencies, novices start by drawing on their previous identities to ‘splint’ their current identities [79]. As they develop experience, insights, and inculcate their reflections, the appropriate values, beliefs and principles, a medical student may sequester the identity of a ‘senior’ or experienced clinician to ‘patch’ their new identities as they grow and adapt to their new roles [61]. With greater experience, reflection, feedback, mentoring and role modelling, a customised sense of identity that is more robust is created [79]. Identity work on the customised self-concept of identity often simply involves ‘fine tuning’.
Appreciation of the cycle of ‘sensitivity’, ‘judgement’, ‘balance’, ‘willingness’, and the capacity and ability to carry out ‘identity work’ affords insights into the development of the medical student’s PIF. This is important as medical students move from an individualised sense of identity that is focused upon their own needs, to an interpersonal sense of identity that considers the needs of others and finally, to an institutional identity that considers, espouses and role models the program’s shared identity. These considerations underline the importance of faculty training and support within the CoP.
Based on the structural and individual considerations, Krishna-Pisupati’s model is presented as three concentric rings. The outer ring underlines the notion of Oncology and Palliative Care postings existing as CoPs. The second ring recognises the medical student’s narratives which influence the medical student’s ‘sensitivity’, ‘judgement’, ‘balance’, ‘willingness’, and capacity and ability to carry out ‘identity work’. The narratives and the structure of the CoP shape the lens through which the medical student interprets the contextual considerations represented by the third ring.
Krishna-Pisupati’s model maintains that assessments of PIF should be seen as a means of guiding medical students as they develop their PIF and as a means of directing timely and appropriate support to them when they need it. In using the Krishna-Pisupati model to address the secondary research question “What are the tools used to assess PIF in medical students?”, Table 7 reveals a wide variety of context-specific largely ‘unidimensional assessments’ focused on self-assessments, reflective practice, single time point identity assessments and competency evaluations.
Similarly in answering the research question “What considerations impact the implementation of PIF assessment tools amongst medical students?” the Krishna-Pisupati model (Fig. 5) reveals the variability in who assesses, supports, and remediates PIF related issues. Aside from the variety of tools employed, there is also significant inconsistencies amongst current approaches adopted to assess self-concepts of identity.
Based on these findings, the Krishna-Pisupati model forwards a set of observations that could provide a framework for more effective assessments of PIF processes.
A framework for the assessment of PIF
The insights garnered from addressing its primary and secondary research questions highlight the need to underline the goals of assessments of PIF. This is to direct timely and personalised mentoring support, and appropriate feedback and guide longitudinal communication between the host organization, mentors and tutors and medical students in their Oncology and Palliative Care postings. The goal of this process is to nurture a balanced and effective professional identity.
We set out a framework to guide assessments of PIF.
One, the assessment of PIF must be a personalised process. A personalised assessment program [28] recognises the influence of the medical student’s pre-existing identities, personal histories, demographics, professional, social, personal, academic, research, clinical and practice circumstances which shape their beliefs, values and principles and inform their thinking, decision making, actions, conduct and clinical practice. These considerations represent the foundational aspects of PIF.
Two, an assessment program must adopt a multi-source [63] and multidimensional [97] assessment process involving a variety of tools. Recognizing the primary role of the assessment process is to provide holistic support mix of tools that will capture the inputs of patients [133], peers [100], tutors and the interprofessional team and is a practical solution for the absence of a singular tool to assess PIF. A mix of regnant tools also allows for a more considered assessment of the medical student’s progress, needs and identity formation. It also accounts for their individual levels of knowledge, skills, attitudes, and competencies; conduct, decision-making processes, interprofessional and collaborative practice; patient interactions; and their coping and needs. This personalised time-specific, context-dependent [129] evaluation also considers the practice environment and support mechanisms available to the medical student. This is especially important in Oncology and Palliative Medicine postings where medical students are especially affected by exposure to death and the care of dying patients (henceforth death and dying) [25].
Three, the program must be longitudinal [63, 78] and capable of capturing the medical student’s needs and progress along their development trajectories. As a result, assessments at different time points [78, 81, 85] are encouraged as are due consideration of the medical student’s reflections, perspectives, and positions on a variety of matters. This is especially important when experiences with death and dying in settings associated with Oncology and Palliative Medicine such as Intensive Care and Paediatrics are affected by growing experiences, resilience, knowledge, skills, attitudes, competencies, and insights [13,14,15, 20, 25, 160].
Four, the use of a variety of assessment methods, involving input from different assessors [87] at different time points [78, 81, 85] and setting in tandem with self-assessments, reflections, and feedback; underlines the need for the assessment program to be capable of contending with different data sources. This assessment process must also be able to blend the data to provide a sketch of the medical student’s progress at a specific time point. At the heart of this must be clarity on what is being assessed, particularly when these assessments can contain significant data.
Five, the assessment program must be accessible, robust [161] and institutionally supported [162]. Influenced by our recent review of portfolio use amongst medical students [137], this SSR in SEBA proposes the use of e-portfolios to enhance accessibility of the data. E-portfolios provide medical students with easy access to entries, promote reviewing and reflecting upon their experiences and feedback, make adding corroborative evidence from a variety of sources and formats including videos or website links easier, and facilitate the employ of multi-source and longitudinal assessments and feedback [163,164,165,166,167]. An e-portfolio’s accessibility also provides supervisors with easy access to holistic and longitudinal data to effectively appraise a medical student’s progress and coping, evaluate their personal needs, and provide timely and appropriate feedback and support [163,164,165,166,167].
Six, the inclusion of written, electronic, audio and video data, drawings, paintings, poetry, reflections, and assessments in e-portfolios underline the need for a structured approach [168, 169]. This structure is delineated by clearly stipulated learning objectives and contents, professional standards and expected roles and activities [163,164,165,166,167].
Seven, the structure of the e-portfolios must be sufficiently flexible [170,171,172] to contend with different practice settings and program goals; guide reflections and feedback, and include a “choice of materials by the student” [168] and “individualised selection of evidence” [173].
Eight, assessments of PIF must be overseen by the host organization. This is especially important given that assessments of PIF are carried out over time and in different settings involving different team members, peers, and tutors. As a result, team members, peers and tutors need to be trained to evaluate and even provide feedback in a personalised, appropriate, timely, specific manner. Those assessing PIF should exemplify the traits that they are assessing others for, and students should be safe-guarded from unfair evaluations [174].
Nine, students must see the value in these assessments [174] for there to be meaningful growth in PIF. There is an inherent risk of turning PIF into “deliverables” which can add further stress and anxiety to the process of PIF and cause genuine assessments to be masked by attempts to manage others’ impressions. PIF must be made an explicit goal of medical education with avenues for students to reach out for support.
Future additions
Considering the growing data on PIF, portfolio use and assessment methods, there are several potential facets that ought to be considered in the future including the employ of e-portfolio-based assessments, feedback, reflective and support mechanism to appraise and support PIF [144].
Ngiam et al. [20], Kuek et al. [27] and Ho et al. [25]’s reviews of how medical students and physicians cope with confronting death and caring for dying patients raise the notion of an RToP-based tool. Ngiam et al. [20], Kuek et al. [27] and Ho et al. [25] posit that a better understanding of changes in concepts of personhood will provide insights into the medical student’s evolving identity, and their decision making processes, thinking, actions, conduct and clinical practice. Furthermore, these authors suggest that an RToP based tool populated with data drawn from the e-portfolio or directly from the regular application of the RToP could provide insights into the medical student’s personal experiences, coping and needs. Such insights could help direct timely, personalised, and appropriate support to medical students in need.
Concurrently, Tan et al. [137]’s review of portfolio use amongst medical students suggests that the employ of Hong et al. [26]’s and Zhou et al. [5]’s adaptation of Norcini et al.’s concept of micro-credentialling and micro-certification in medical education [175] will allow benchmarking of their progress. Inspired by Wald et al.’s [62] notion that PIF is shaped by developing clinical competencies, ‘general micro-competencies’ facilitate appraisal of the medical student’s progress from one competency-based stage to another within the posting [176, 177]. Tan et al. [137] suggest that ‘personalised micro-competencies’ account for the medical student’s particular contextual considerations, knowledge, skills, experiences, and attitudes, allowing for individualised and contextualised assessment of progress and development. The combination of ‘general micro-competencies’ and ‘personalised micro-competencies’ could be used to alert tutors and host organisations to possible frailties in how the medical student addresses resonance, synchrony, disharmony and or dyssynchrony. This is based on the notion that ‘general micro-competencies’ and ‘personalised micro-competencies’ shape identity work. Appreciation of these gaps then could not only mould the nature of the support but also help with remediation of the issues. This could direct timely and appropriate support that can be directed to medical students, particularly when PIF exhibits a nonlinear [63], longitudinal development [63, 78] process [178]. These insights will also help guide remediation, direct individualized [179] support, counselling [87, 89, 110] and guided reflections [87, 110, 180] in and beyond present postings.
Whilst the use of Tan et al.’s notion of general and personalised ‘micro-competencies’ [175] to benchmark progress underscores the intertwined nature of developing clinical competencies and PIF, program organisers should be mindful of distinguishing the goals and roles of these assessments in supporting PIF longitudinally from assessments of skills, knowledge and attitudes [176, 177].
Limitations
One of the main limitations of this review has been its overly focused approach that excluded residents and junior doctors in training. This is especially concerning given the longitudinal nature of PIF and the limitations to the number of articles included.
In addition, the nature of PIF also makes comparisons of PIF assessments across different cultures, settings, undergraduate and postgraduate medical student populations. This can be problematic given the differences in levels of experience, competencies, roles, responsibilities and needs and the educational and healthcare programs involved.
Moreover, whilst this study was intended to analyse the wide range of current literature on PIF assessment programs, our review was limited by our specific focus and a lack of consistent reporting of current programs. Furthermore, most of the included papers were largely drawn from North American and European practices, potentially limiting the applicability of these findings in other healthcare settings.
Other limitations include our focus on articles that were published in English which may have compounded concerns over the applicability of these findings beyond the North American and European settings. Whilst taking into account the limited resources and availability of the research and expert teams and limiting the review to the specified dates to increase the chances of completing the review, this too could have seen important articles excluded.
Conclusion
In mapping current thinking on PIF using the Krishna-Pisupati model, positing the use of general and personalised ‘micro-competencies’ and e-portfolios and proposing the design and employ of a RToP-based tool, this SSR in SEBA proffers unique insights into PIF in Oncology and Palliative Care postings. In doing so, it highlights new areas for study and a chance for stock taking. Even with the possibility of these findings being employed in other postings such as Accident and Emergency and Surgical postings and postgraduate Oncology and Palliative Care training, program designers, administrators and faculty must ensure that their programs do possess the structure, support and means of assessing medical students facing intense clinical, ethical and moral issues in a timely and personalised manner.
Concurrently, further study into the experiences of medical students during their Oncology and Palliative Care postings, the RToP-based tool, the employ of general and personalised ‘micro-competencies’ in tandem with e-portfolios will be the focus of our coming efforts as we look forward to further engagement in this exciting aspect of education in Oncology and Palliative Care.
Availability of data and materials
All data generated or analysed during this review are included in this published article and its supplementary files.
Change history
26 January 2023
A Correction to this paper has been published: https://doi.org/10.1186/s12904-022-01120-1
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Acknowledgements
The authors would like to dedicate this paper to the late Dr. S Radha Krishna and A/Prof Cynthia Goh whose advice and ideas were integral to the success of this review and Thondy and Maia Olivia whose lives continue to inspire us. The authors would also like to thank the anonymous reviewers, Dr Ruaraidh Hill and Dr Stephen Mason for their help comments which greatly enhanced this manuscript. The authors would also like to thank Alexia Sze Inn Lee and Nur Diana Abdul Rahman for their help in searching and coding the articles.
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Supplementary Information
Additional file 1: Appendix A.
Full Search Strategy.
Additional file 2:
Appendix B. Tabulated summaries.
Additional file 3: Appendix C.
Stage-based nature of PIF.
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Teo, K.J.H., Teo, M.Y.K., Pisupati, A. et al. Assessing professional identity formation (PIF) amongst medical students in Oncology and Palliative Medicine postings: a SEBA guided scoping review. BMC Palliat Care 21, 200 (2022). https://doi.org/10.1186/s12904-022-01090-4
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DOI: https://doi.org/10.1186/s12904-022-01090-4