Professional identity formation: creating a longitudinal framework through TIME (Transformation in Medical Education).

The University of Texas System established the Transformation in Medical Education (TIME) initiative to reconfigure and shorten medical education from college matriculation through medical school graduation. One of the key changes proposed as part of the TIME initiative was to begin emphasizing professional identity formation (PIF) at the premedical level. The TIME Steering Committee appointed an interdisciplinary task force to explore the fundamentals of PIF and to formulate strategies that would help students develop their professional identity as they transform into physicians. In this article, the authors describe the task force's process for defining PIF and developing a framework, which includes 10 key aspects, 6 domains, and 30 subdomains to characterize the complexity of physician identity. The task force mapped this framework onto three developmental phases of medical education typified by the undergraduate student, the clerkship-level medical student, and the graduating medical student. The task force provided strategies for the promotion and assessment of PIF for each subdomain at each of the three phases, in addition to references and resources. Assessments were suggested for student feedback, curriculum evaluation, and theoretical development. The authors emphasize the importance of longitudinal, formative assessment using a combination of existing assessment methods. Though not unique to the medical profession, PIF is critical to the practice of exemplary medicine and the well-being of patients and physicians.

Do students do what they write and write what they do? The match between the patient encounter and patient note.

BACKGROUND: Patient notes are used for a variety of purposes in health care. Medical students are taught the structure of patient notes early in training. Review of patient notes are then used to assess synthesis and integration of patient information. It is critical that the information in the note accurately and completely represents the student-patient encounter. METHOD: The authors reviewed videotapes of students in three standardized-patient based scenarios and compared what occurred during the physical examination with the subsequent documentation in the patient note. RESULTS: In all, 207 encounter-note pairs were reviewed. Only 8 (4%) of the notes completely and accurately represented what occurred during the encounter. Problems with underdocumentation, overdocumentation, and inaccurate documentation of physical findings were seen for all three patient scenarios. CONCLUSIONS: These findings highlight the need to teach and assess both data gathering skills and written documentation of findings in medical training.

A comparison of faculty-led small group learning in combination with computer-based instruction versus computer-based instruction alone on identifying simulated pulmonary sounds.

BACKGROUND: Computer-based learning has gained widespread acceptance in medical curricula, but can it replace faculty-led teaching. PURPOSE: To investigate the effectiveness of independent computer-based learning of pulmonary auscultation alone and in combination with faculty-led teaching. METHODS: The first method involved independent computer-based instruction (CBI; Group 1) of 113 second-year medical students. The second method involved a combination of faculty-led instruction and independent CBI (Group 2) of 79 second-year medical students. A pretest-posttest method of assessment was used. RESULTS: The pretest showed recognition rates of 48% for Group 1 and 46% for Group 2, whereas the posttest showed recognition rates of 81% for Group 1 and 88% for Group 2. The posttest clinical correlation scores were identical with both groups scoring 93 percent. CONCLUSIONS: The study demonstrates that student learning of pulmonary auscultation is similar whether a computer-based independent instructional approach is used alone or in combination with faculty-led sessions.

Incorporating simulators in a standardized patient exam.

OBJECTIVE: Using simulated patients during a clinical skills exam that involves many students has the advantage of standardizing the delivery of historical data. One major disadvantage is the inability to standardize the physical exam findings. We designed a simulated patient exam that incorporates simulated abnormal physical exam findings. DESCRIPTION: The simulated patient exam case was divided into three separate stations: (1) the simulated patient's history, (2) the simulated physical exam, and (3) the presentation station. Dyspnea was chosen as the chief complaint because of the broad differential of possible cardiac and pulmonary auscultatory findings. In the first station, students obtained historical data from the standardized simulated patient. Students were graded on their ability to ask appropriate historical questions. Trained observers were used to verify the numbers of historical cues obtained by the students. The second station consisted of simulated physical exam findings. Students first measured the blood pressure on a commercially available blood pressure simulator arm from the Medical Plastics Laboratory, Inc., Gatesville, TX. Students then auscultated an abnormal digital heart sound and pulmonary sound from a small auscultation transducer developed by Andries Acoustics, Spicewood, TX. Students also palpated a simulated pulse from a newly developed pulse transducer. Digital cardiopulmonary sounds and pulse data were recorded onto a CD-ROM disc and transmitted to the small transducers via a CD-ROM disc player. Students used their own stethoscopes to auscultate cardiopulmonary sounds from the small transducers. The students were graded in the second station on their ability to accurately measure a blood pressure, identify abnormal cardiopulmonary digital sounds, and finally describe a peripheral pulse. In the third station, students presented the historical data and physical exam findings to a faculty member, and then provided a differential diagnosis list based on their key findings from the other two stations. A total of 171 students (n = 171) completed the simulated patient exam. Each student completed the exam in 45 minutes. DISCUSSION: In our simulated patient exam, students were evaluated not only on their data-gathering skills for key historical findings but also on the ability to correctly identify key physical exam findings such as abnormal cardiopulmonary sounds. Key physical exam findings were then integrated into the clinical decision-making process, which was presented in the faculty presentation station. Simulated patients with abnormal cardiopulmonary findings can be used for testing purposes. However, cardiac auscultatory abnormalities such as the ventricular S3 gallop are difficult to find and usually occur in a decompensated state such as heart failure. Other physical exam findings such as pulmonary crackles and wheezes also occur in decompensated conditions. Therefore, the use of simulators during a simulated patient exam offers the possibility of introducing several abnormal physical exam findings without having an unstable patient present in an exam setting. Further, the use of simulated physical exam findings allows for complete standardization of a clinical-simulated patient exam.