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11 - Assessment of professionalism and progress in the development of a professional identity

from Part III - Principles

Published online by Cambridge University Press:  05 April 2016

John J. Norcini
Research (FAIMER), Philadelphia, Pennsylvania, USA
Judy A. Shea
University of Pennsylvania, Philadelphia, Pennsylvania, USA
Richard L. Cruess
McGill University, Montréal
Sylvia R. Cruess
McGill University, Montréal
Yvonne Steinert
McGill University, Montréal
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Over the past few decades, the focus on professionalism has increased dramatically throughout the continuum of medical education. It is now considered an essential component of competence in a variety of countries including Canada (CanMEDS roles), India (Medical Council of India Regulations on Graduate Medical Education, 2012), the United Kingdom (Good Medical Practice), and the United States (ACGME competencies).1–4 The emphasis on competencies such as professionalism reflects a shift to a model that starts with the desired educational outcomes and works backward to define the educational process.

Assessment is central to outcomes-based education. It constitutes the means by which stakeholders are assured that learners have achieved the competencies necessary to meet the needs of the community. For students, it offers guidance regarding milestones in their development.5 In addition, there is a growing appreciation of the critical role of formative assessment and feedback in both learning and identity formation.6 This chapter will address the assessment of professionalism by (1) outlining the challenges, (2) citing reasons for assessing it, (3) using Miller's pyramid as a framework for describing some of the methods of assessing professionalism and the research that supports them, and (4) suggesting some principles for developing an assessment system for professionalism. We conclude with brief consideration of lessons learned and future directions.

At the outset we note that many chapters in this book are focused on professional identity formation, rather than professionalism. Identity formation as a process has been studied for decades.7,8 Recently, the literature has explicitly addressed the question of how the process of medical education supports and enhances professional and clinical identity formation.9–11 We see professionalism and professional identity formation as two largely overlapping bodies of work. Because our task in this chapter is to address assessment, and there is a rich literature in the area, we chose that body of work for our focus. The goals and methods of assessment generally align with how students perform – as of yet they are not well developed (and perhaps they should not be?) for judging what a person is. Nevertheless, many of the tools and processes we review and the ideas behind them are readily adaptable to the concerns underlying professional identity formation, such as reflections, attitudes, and behaviors.

Teaching Medical Professionalism
Supporting the Development of a Professional Identity
, pp. 155 - 168
Publisher: Cambridge University Press
Print publication year: 2016

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1. Frank, JR, Jabbour, M, Tugwell, P, Boyd, D, Labrosse, J, MacFadyen, J. Skills for the new millennium: report of the societal needs working group, CanMEDS 2000 Project. Ann R Coll Physicians Surg Can. 1996; 29(4):206–16.Google Scholar
2. Medical Council of India. Salient Features of Regulations on Graduate Medical Education. New Delhi, IN: Medical Council of India; 2012. [Accessed Jan. 2, 2015.] Available from
3. General Medical Council. Good Medical Practice. London, UK: General Medical Council; 2001.
4. Leach, DC. A model for GME: shifting from process to outcomes. A progress report from the Accreditation Council for Graduate Medical Education. Med Educ. 2004; 38(1):12–14.Google Scholar
5. Tekian, A, Hodges, BD, Roberts, TE, Schuwirth, L, Norcini, J. Assessing competencies using milestones along the way. Med Teach. 2015; 37(4):399–402.Google Scholar
6. Norcini, J, Burch, V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach. 2007; 29(9):855–71.Google Scholar
7. Marcia, JE. Development and validation of ego-identity status. J Pers Soc Psychol. 1966; 3(5):551–58.Google Scholar
8. Erikson, EH. The Life Cycle Completed. New York, NY: WW Norton; 1982.
9. Bosk, CL. Forgive and Remember. Chicago, IL: University of Chicago Press; 1979.
10. Monrouxe, LV. Identity, identification and medical education: why should we care? Med Educ. 2010; 44(1):40–49.Google Scholar
11. Cruess, RL, Cruess, SR, Boudreau, JD, Snell, L, Steinert, Y. Reframing medical education to support professional identity formation. Acad Med. 2014; 89(11):1446–51.Google Scholar
12. Stern, DT. A framework for measuring professionalism. In Stern, DT, ed. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006:3–14.
13. Hodges, BD, Ginsburg, S, Cruess, R, Cruess, S, Delport, R, Hafferty, F, Ho, MJ, Holmboe, E, Holtman, M, Ohbu, S, Rees, C, Ten Cate, O, Tsugawa, Y, Van Mook, W, Wass, V, Wilkinson, T, Wade, W. Assessment of professionalism: recommendations from the Ottawa 2010 Conference. Med Teach. 2011; 33(5):354–63.Google Scholar
14. Miller, GE. The assessment of clinical skills/competence/performance. Acad Med. 1990; 65(9 Suppl):S63–S67.Google Scholar
15. Cruess, RL, Cruess, SR, Steinert, Y. Amending Miller's pyramid to include professional identity formation. Acad Med. 2015. Sept. 1, 2015. [‘Online First’: DOI 10.1097/ACM.0000000000000913].
16. Norcini, JJ, Swanson, DB, Grosso, LJ, Shea, JA, Webster, GD. A comparison of knowledge, synthesis, and clinical judgment. Multiple-choice questions in the assessment of physician competence. Eval Health Prof. 1984; 7(4):485–499.Google Scholar
17. Cruess, RL, Cruess, SR. Teaching professionalism: general principles. Med Teach. 2006; 28(3):205–08.Google Scholar
18. Veloski, JJ, Fields, SK, Boex, JR, Blank, LL. Measuring professionalism: a review of studies with instruments reported in the literature between 1982 and 2002. Acad Med. 2005; 80(4):366–70.Google Scholar
19. Kao, A. Ethics, law, and professionalism: what physicians need to know. In Stern, DT, ed. Measuring Medical Professionalism. Oxford, UK: Oxford University Press; 2006:39–52.
20. CITI Program. Collaborative Institutional Training at the University of Miami. [Accessed Dec. 26, 2014.] Available from
21. Nunnally, JC, Bernstein, IH. Psychometric Theory. edition. New York, NY: McGraw-Hill; 1994.
22. Streiner, DL, Norman, GR. Health Measurement Scales: A Practical Guide to their Development and Use. edition. Oxford, UK: Oxford University Press; 2008.
23. Barry, D, Cyran, E, Anderson, RJ. Common issues in medical professionalism: room to grow. Am J Med. 2000; 108(2):136–42.Google Scholar
24. Stobo, JD, Blank, LL. ABIM's project professionalism: staying ahead of the wave. Am J Med. 1994; 97:1–3.Google Scholar
25. Kesselheim, JC, McMahon, GT, Joffe, S. Development of a Test of Residents’ Ethics Knowledge for Pediatrics (TREK-P). J Grad Med Educ. 2012; 4(2):242–45.Google Scholar
26. Blue, AV, Crandall, S, Nowacek, G, Luecht, R, Chauvin, S, Swick, H. Assessment of matriculating medical students’ knowledge and attitudes towards professionalism. Med Teach. 2009; 31(10):928–32.Google Scholar
27. Swick, HM. Toward a normative definition of medical professionalism. Acad Med. 2000; 75(6):612–16.Google Scholar
28. Niemi, PM. Medical students’ professional identity: self-reflection during the preclinical years. Med Educ. 1997; 31(6):408–15.Google Scholar
29. Rademacher, R, Simpson, D, Marcdante, K. Critical incidents as a technique for teaching professionalism. Med Teach. 2010; 32(3):244–49.Google Scholar
30. Stark, P, Roberts, C, Newble, D, Bax, N. Discovering professionalism through guided reflection. Med Teach. 2006; 28(1):e25–e31.Google Scholar
31. Jha, V, Bekker, HL, Duffy, SR, Roberts, TE. A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine. Med Educ. 2007; 41(8):822–29.Google Scholar
32. Veloski, J, Hojat, M. Measuring specific elements of professionalism: empathy, teamwork, and lifelong learning. In Stern, DT, ed. Measuring Medical Professionalism. Oxford, UK: Oxford University Press; 2006:117–46.
33. Kohlberg, L. The Meaning and Measurement of Moral Development (Volume 13). Worcester, MA: Clark University Press; 1981.
34. Gibbs, JC, Arnold, KD, Morgan, RL, Schwartz, ES, Gavaghan, MP, Tappan, MB. Construction and validation of a multiple-choice measure of moral reasoning. Child Dev. 1984; 55(2):527–36.Google Scholar
35. Rest, JR. Longitudinal study of the defining issues test of moral judgment: a strategy for analyzing developmental change. Dev Psychobiol. 1975; 11(6):738–48.Google Scholar
36. Rees, CE, Knight, LV. The trouble with assessing students’ professionalism: theoretical insights from sociocognitive psychology. Acad Med. 2007; 82(1):46–50.Google Scholar
37. Hojat, M, Mangione, S, Nasca, TJ, Cohen, MJM, Gonnella, JS, Erdmann, JB, Veloski, J, Magee, M. The Jefferson scale of physician empathy: development and preliminary psychometric data. Educ Psychol Meas. 2001; 61(2):349–65.Google Scholar
38. Hojat, M, Fields, SK, Veloski, JJ, Griffiths, M, Cohen, MJ, Plumb, JD. Psychometric properties of an attitude scale measuring physician-nurse collaboration. Eval Health Prof. 1999; 22(2):208–20.Google Scholar
39. Hojat, M, Veloski, J, Nasca, TJ, Erdmann, JB, Gonnella, JS. Assessing physicians’ orientation toward lifelong learning. J Gen Intern Med. 2006; 21(9):931–36.Google Scholar
40. Hojat, M, Gonnella, JS, Nasca, TJ, Fields, SK, Cicchetti, A, Lo Scalzo, A, Taroni, F, Amicosante, AM, Macinati, M, Tangucci, M, Liva, C, Ricciardi, G, Eidelman, S, Admi, H, Geva, H, Mashiach, T, Alroy, G, Alcorta-Gonzalez, A, Ibarra, D, Torres-Ruiz, A. Comparisons of American, Israeli, Italian and Mexican physicians and nurses on the total and factor scores of the Jefferson scale of attitudes toward physician–nurse collaborative relationships. Int J Nurs Stud. 2003; 40(4):427–35.Google Scholar
41. Kohlberg, L. The Development of Modes of Moral Thinking and Choice in the Years 10 to 16. Unpublished doctoral dissertation. Chicago, IL: University of Chicago; 1958.
42. Kohlberg, L. Stage and sequence: the cognitive-developmental approach to socialization. In Goslin, DA, ed. Handbook of Socialization Theory and Research. Chicago, IL: Rand McNally; 1969:347–480.
43. Kohlberg, L, Candee, D. The relationship of moral judgment to moral action. In Kurtines, WM, Gewirtz, JL, eds. Morality, Moral Behavior and Moral Development. New York, NY: Wiley; 1984:52–73.
44. Baldwin, DC Jr, Self, DJ. The assessment of moral reasoning and professionalism in medical education and practice. In Stern, DT, ed. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006:75–93.
45. McDaniel, MA, Hartman, NS, Whetzel, DL, Grubb, WL III. Situational judgment tests, response instructions, and validity: a meta‐analysis. Personnel Psychology. 2007; 60(1):63–91.Google Scholar
46. Lievens, F, Buyse, T, Sackett, PR. The operational validity of a video-based situational judgment test for medical college admissions: illustrating the importance of matching predictor and criterion construct domains. J Appl Psychol. 2005; 90(3):442–52.Google Scholar
47. Aukes, LC, Geertsma, J, Cohen-Schotanus, J, Zwierstra, RP, Slaets, JP. The development of a scale to measure personal reflection in medical practice and education. Med Teach. 2007; 29(2–3):177–82.Google Scholar
48. Crossley, J, Vivekananda-Schmidt, P. The development and evaluation of a Professional Self Identity Questionnaire to measure evolving professional self-identity in health and social care students. Med Teach. 2009; 31(12):e603–e607.Google Scholar
49. Norcini, JJ, McKinley, DW. Assessment methods in medical education. Teaching and Teacher Education. 2007; 23(3):239–50.Google Scholar
50. Swanson, DB, Clauser, BE, Case, SM. Clinical skills assessment with standardized patients in high-stakes tests: a framework for thinking about score precision, equating, and security. Adv Health Sci Educ Theory Pract. 1999; 4(1):67–106.Google Scholar
51. Barrows, HS, Abrahamson, S. The programmed patient: a technique for appraising student performance in clinical neurology. J Med Educ. 1964; 39:802–05.Google Scholar
52. Harden, RM, Gleeson, FA. Assessment of clinical competence using an objective structured clinical examination (OSCE). Med Educ. 1979; 13(1):41–54.Google Scholar
53. van Zanten, M, Boulet, JR, Norcini, JJ, McKinley, D. Using a standardised patient assessment to measure professional attributes. Med Educ. 2005; 39(1):20–29.Google Scholar
54. Klamen, D, Williams, R. Using standardized clinical encounters to assess physician communication. In Stern, DT, ed. Measuring Medical Professionalism. Oxford, UK: Oxford University Press; 2006:53–74.
55. Norcini, JJ, Blank, LL, Arnold, GK, Kimball, HR. The mini-CEX (clinical evaluation exercise): a preliminary investigation. Ann Intern Med. 1995; 123(10):795–99.Google Scholar
56. Cruess, R, McIlroy, JH, Cruess, S, Ginsburg, S, Steinert, Y. The Professionalism Mini-evaluation Exercise: a preliminary investigation. Acad Med. 2006; 81(10 Suppl):S74–S78.Google Scholar
57. Kogan, JR, Holmboe, ES, Hauer, KE. Tools for direct observation and assessment of clinical skills of medical trainees: a systematic review. JAMA. 2009; 302(12):1316–26.Google Scholar
58. Al Ansari, A, Ali, SK, Donnon, T. The construct and criterion validity of the mini-CEX: a meta-analysis of the published research. Acad Med. 2013; 88(3):413–20.Google Scholar
59. Hawkins, RE, Margolis, MJ, Durning, SJ, Norcini, JJ. Constructing a validity argument for the mini-Clinical Evaluation Exercise: a review of the research. Acad Med. 2010; 85(9):1453–61.Google Scholar
60. Tsugawa, Y, Ohbu, S, Cruess, R, Cruess, S, Okubo, T, Takahashi, O, Tokuda, Y, Heist, BS, Bito, S, Itoh, T, Aoki, A, Chiba, T, Fukui, T. Introducing the Professionalism Mini-Evaluation Exercise (P-MEX) in Japan: results from a multicenter, cross-sectional study. Acad Med. 2011; 86(8):1026–31.Google Scholar
61. Wilkinson, TJ, Wade, WB, Knock, LD. A blueprint to assess professionalism: results of a systematic review. Acad Med. 2009; 84(5):551–58.Google Scholar
62. Papadakis, MA, Teherani, A, Banach, MA, Knettler, TR, Rattner, SL, Stern, DT, Veloski, JJ, Hodgson, CS. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005; 353(25):2673–82.Google Scholar
63. Papadakis, MA, Arnold, GK, Blank, LL, Holmboe, ES, Lipner, RS. Performance during internal medicine residency training and subsequent disciplinary action by state licensing boards. Ann Intern Med. 2008; 148(11):869–76.Google Scholar
64. Arnold, L. Assessing professional behavior: yesterday, today, and tomorrow. Acad Med. 2002; 77(6):502–15.Google Scholar
65. Norcini, JJ. Peer assessment of competence. Med Educ. 2003; 37(6):539–43.Google Scholar
66. Consumer Assessment of Healthcare Providers and Systems. CAHPS Clinician & Group Surveys. Rockville, MD: Agency for Healthcare Research & Quality; 2011. [Accessed Dec. 30, 2014.] Available from
67. Donnon, T, Al Ansari, A, Al Alawi, S, Violato, C. The reliability, validity, and feasibility of multisource feedback physician assessment: a systematic review. Acad Med. 2014; 89(3):511–16.Google Scholar
68. Eva, KW, Regehr, G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med. 2005; 80(10 Suppl):S46–S54.Google Scholar
69. Mann, K, Gordon, J, MacLeod, A. Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2009; 14(4):595–621.Google Scholar
70. McLachlan, JC, Finn, G, Macnaughton, J. The conscientiousness index: a novel tool to explore students’ professionalism. Acad Med. 2009; 84(5):559–65.Google Scholar
71. Stern, DT, Frohna, AZ, Gruppen, LD. The prediction of professional behavior. Med Educ. 2005; 39(1):75–82.Google Scholar
72. Shumway, JM, Harden, RM. AMEE Guide No. 25: The assessment of learning outcomes for the competent and reflective physician. Med Teach. 2003; 25(6):569–84.Google Scholar
73. Birenbaum, M, Breuer, K, Cascallar, E, Dochy, F, Dori, Y, Ridgway, J, Wiesemes, R. A learning integrated assessment system. Educational Research Review. 2006; 1(1):61–67.Google Scholar
74. van der Vleuten, CP, Schuwirth, LW, Driessen, EW, Dijkstra, J, Tigelaar, D, Baartman, LK, van Tartwijk, J. A model for programmatic assessment fit for purpose. Med Teach. 2012; 34(3):205–14.Google Scholar
75. Lynch, DC, Surdyk, PM, Eiser, AR. Assessing professionalism: a review of the literature. Med Teach. 2004; 26(4):366–73.Google Scholar
76. Pellegrino, JW, Chudowsky, N, Glaser, R, eds. Knowing What Students Know: The Science and Design of Educational Assessment. Committee on the Foundations of Assessment Report: National Research Council. Washington, DC: National Academy Press; 2001.

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