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1 - Professionalism and professional identity formation: the cognitive base

from Part I - What is to be taught and learned

Published online by Cambridge University Press:  05 April 2016

Richard L. Cruess
McGill University, Montreal, Quebec, Canada
Sylvia R. Cruess
McGill University, Montreal, Quebec, Canada
Richard L. Cruess
McGill University, Montréal
Sylvia R. Cruess
McGill University, Montréal
Yvonne Steinert
McGill University, Montréal
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The task of medical education is to “shape the novice into the effective practitioner of medicine, to give him the best available knowledge and skills, and to provide him with a professional identity so that he comes to think, act, and feel like a physician.”1 (p. 5)

During the past few decades, it has become apparent that the issue of the professionalism of individual physicians and of the medical profession must be addressed explicitly at all levels of medical education. For this reason, the subjects of professionalism and professional identity are being addressed directly throughout the continuum of medical education.2–10 As is true of any significant topic that must be learned, there is a defined body of knowledge called the cognitive base that serves as the basis of the teaching, learning, and assessment of the subject. The purpose of this chapter is to outline the cognitive base that should underpin educational activities designed to support learners in medicine as they become professionals and acquire their professional identities.

As physicians, patients, and members of the general public have come to believe that medicine's professionalism is under threat, virtually all have concluded that any action to address the issue must include major initiatives throughout medical education aimed at ensuring that physicians both understand the nature of contemporary medical professionalism and live according to its precepts – that they come to “think, act, and feel like a physician.”1–6 As a result, there is now a substantial literature describing how this can best be accomplished, with a recent shift in emphasis toward supporting professional identity formation.

For centuries, professionalism as a subject was not addressed directly. There were no courses on professionalism and it was not included in the standard medical curriculum. This is not because it was deemed unimportant. The Hippocratic Oath, subsequent codes of ethics, and a host of writers addressed the values and beliefs of the medical profession, often linking them to the word “professionalism.” However, it was assumed that these values and beliefs that are the foundation of the profession would be automatically acquired during the educational process as students “acquire the complex ensemble of analytic thinking, skillful practice, and wise judgment.”

Teaching Medical Professionalism
Supporting the Development of a Professional Identity
, pp. 5 - 25
Publisher: Cambridge University Press
Print publication year: 2016

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1. Merton, RK. Some preliminaries to a sociology of medical education. In Merton, RK, Reader, LG, Kendall, PL, eds. The Student Physician: Introductory Studies in the Sociology of Medical Education. Cambridge, MA: Harvard University Press; 1957:3–79.
2. Cruess, RL, Cruess, SR. Teaching medicine as a profession in the service of healing. Acad Med. 1997; 72(11):941–52.Google Scholar
3. Cruess, SR, Cruess, RL. Professionalism must be taught. BJM. 1997; 315(7123):1674–77.Google Scholar
4. Inui, TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003.
5. Sullivan, W. Work and Integrity: The Crisis and Promise of Professionalism in North America. edition. San Francisco, CA: Jossey-Bass; 2005.
6. Cohen, JJ. Professionalism in medical education, an American perspective: from evidence to accountability. Med Educ. 2006; 40(7):607–17.Google Scholar
7. Cooke, M, Irby, DM, O'Brien, BC. Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA: Jossey-Bass; 2010.
8. Jarvis-Selinger, S, Pratt, DD, Regehr, G. Competency is not enough: integrating identity formation into the medical education discourse. Acad Med. 2012; 87(9):1185–90.Google Scholar
9. 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
10. Holden, MD, Buck, E, Luk, J, Ambriz, F, Boisaubin, EV, Clark, MA, Mihalic, AP, Sadler, JZ, Sapire, KJ, Spike, JP, Vince, A, Dalrymple, JL. Professional identity formation: creating a longitudinal framework through TIME (Transformation In Medical Education). Acad Med. 2015; 90(6):761–67.Google Scholar
11. Côté, L, Leclère, H. How clinical teachers perceive the doctor-patient relationship and themselves as role models. Acad Med. 2000; 75(11):1117–24.Google Scholar
12. Ludmerer, KM. Instilling professionalism in medical education. JAMA. 1999; 282(9):881–82.Google Scholar
13. Batalden, P, Leach, D, Swing, S, Dreyfus, H, Dreyfus, S. General competencies and accreditation in graduate medical education. Health Aff (Millwood). 2002; 21(5):103–11.Google Scholar
14. Royal College of Physicians and Surgeons of Canada. CanMEDS 2015. Ottawa, ON: RCPSC; 2015. [Accessed June 3, 2015.] Available from
15. General Medical Council. Good Medical Practice. edition. London, UK: GMC; 2013.
16. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Washington, DC: Association of American Medical Colleges; 2008. [Accessed June 3, 2015.] Available from
17. 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
18. 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
19. Cruess, RL, Cruess, SR. Teaching professionalism: general principles. Med Teach. 2006; 28(3):205–08.Google Scholar
20. Niemi, PM. Medical students’ professional identity: self-reflection during the preclinical years. Med Educ. 1997; 31(6):408–15.Google Scholar
21. Niemi, PM, Vainiomäki, PT, Murto-Kangas, M. “My future as a physician”– professional representations and their background among first-day medical students. Teach Learn Med. 2003; 15(1): 31–39.Google Scholar
22. Beagan, BL. Everyday classism in medical school: experiencing marginality and resistance. Med Educ. 2005; 39(8):777–84.Google Scholar
23. Forsythe, GB. Identity development in professional education. Acad Med. 2005; 80(10 Suppl):S112–S117.Google Scholar
24. Bebeau, MJ. Evidence-based character development. In Kenny, N, Shelton, W, eds. Advances in Bioethics: Volume 10. Lost Virtue: Professional Character Development in Medical Education. Oxford, UK: Elsevier; 2006:47–86.
25. Hafferty, FW. Professionalism and the socialization of medical students. In Cruess, RL, Cruess, SR, Steinert, Y, eds. Teaching Medical Professionalism. New York, NY: Cambridge University Press; 2009:53–70.
26. Lempp, H. Medical-school culture. In Brosnan, C, Turner, BS, eds. Handbook of the Sociology of Medical Education. Oxon, UK: Routledge; 2009:71–88.
27. 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
28. Monrouxe, LV. Identity, identification and medical education: why should we care? Med Educ. 2010; 44(1): 40–49.Google Scholar
29. MacLeod, A. Caring, competence and professional identities in medical education. Adv Health Sci Educ Theory Pract. 2011; 16(3):375–94.Google Scholar
30. Monrouxe, LV, Rees, CE, Hu, W. Differences in medical students’ explicit discourses of professionalism: acting, representing, becoming. Med Educ. 2011; 45(6):585–602.Google Scholar
31. Weaver, R, Peters, K, Koch, J, Wilson, I. ‘Part of the team’: professional identity and social exclusivity in medical students. Med Educ. 2011; 45(12):1220–29.Google Scholar
32. White, MT, Borges, NJ, Geiger, S. Perceptions of factors contributing to professional identity development and specialty choice: a survey of third- and fourth-year medical students. Ann Behav Sci Med Educ. 2011; 17(1):18–23.Google Scholar
33. Burford, B. Group processes in medical education: learning from social identity theory. Med Educ. 2012; 46(2):143–152.Google Scholar
34. Goldie, J. The formation of professional identity in medical students: considerations for educators. Med Teach. 2012; 34(9):e641–e648.Google Scholar
35. Helmich, E, Bolhuis, S, Dornan, T, Laan, R, Koopmans, R. Entering medical practice for the very first time: emotional talk, meaning and identity development. Med Educ. 2012; 46(11):1074–86.Google Scholar
36. Helmich, E, Dornan, T. Do you really want to be a doctor? The highs and lows of identity development. Med Educ. 2012; 46(2):132–34.Google Scholar
37. Frost, HD, Regehr, G. “I am a doctor”: negotiating the discourses of standardization and diversity in professional identity construction. Acad Med. 2013; 88(10):1570–77.Google Scholar
38. Monrouxe, LV. Identities, self and medical education. In Walsh, K, ed. Oxford Textbook of Medical Education. Oxford, UK: Oxford University Press; 2013:113–23.
39. Wilson, I, Cowin, LS, Johnson, M, Young, H. Professional identity in medical students: pedagogical challenges to medical education. Teach Learn Med. 2013; 25(4):369–73.Google Scholar
40. Boudreau, JD, Macdonald, ME, Steinert, Y. Affirming professional identities through an apprenticeship: insights from a four-year longitudinal case study. Acad Med. 2014; 89(7):1038–45.Google Scholar
41. Hill, E, Bowman, K, Stalmeijer, R, Hart, J. You've got to know the rules to play the game: how medical students negotiate the hidden curriculum of surgical careers. Med Educ. 2014; 48(9):884–94.Google Scholar
42. Mavor, KI, McNeill, KG, Anderson, K, Kerr, A, O'Reilly, E, Platow, MJ. Beyond prevalence to process: the role of self and identity in medical student well-being. Med Educ. 2014; 48(4):351–60.Google Scholar
43. McNeill, KG, Kerr, A, Mavor, KI. Identity and norms: the role of group membership in medical student wellbeing. Perspect Med Educ. 2014; 3(2):101–12.Google Scholar
44. Monrouxe, LV, Rees, CE, Endacott, R, Ternan, E. ‘Even now it makes me angry’: health care students’ professionalism dilemma narratives. Med Educ. 2014; 48(5):502–17.Google Scholar
45. Dornan, T, Pearson, E, Carson, P, Helmich, E, Bundy, C. Emotions and identity in the figured world of becoming a doctor. Med Educ. 2015; 49(2):174–85.Google Scholar
46. Cruess, RL, Cruess, SR, Boudreau, JD, Snell, L, Steinert, Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med. 2015; 90(6):718–25.Google Scholar
47. Sharpless, J, Baldwin, N, Cook, R, Kofman, A, Morley-Fletcher, A, Slotkin, R, Wald, HS. The becoming: students’ reflections on the process of professional identity formation in medical education. Acad Med. 2015; 90(6):713–17.Google Scholar
48. Lave, J, Wenger, E. Situated Learning: Legitimate Peripheral Participation. Cambridge, UK: Cambridge University Press; 1991.
49. Wenger, E. Communities of Practice: Learning, Meaning, and Identity. Cambridge, UK: Cambridge University Press; 1998.
50. Ihara, CK. Collegiality as a professional virtue. In Flores, A, ed. Professional Ideals. Belmont, CA: Wadsworth; 1988:56–65.
51. Vignoles, VL, Schwartz, SJ, Luyckx, K. Introduction: toward an integrative view of identity. In Schwartz, SJ, Luyckx, K, Vignoles, VL, eds. Handbook of Identity Theory and Research. New York, NY: Springer; 2011:1–27.
52. Skorikov, VB, Vondracek, FW. Occupational identity. In Schwartz, SJ, Luyckx, K, Vignoles, VL, eds. Handbook of Identity Theory and Research. New York, NY: Springer; 2011:693–714.
53. Wenger, E, McDermott, R, Snyder, WM. Cultivating Communities of Practice: A Guide to Managing Knowledge. Cambridge, MA: Harvard Business Press; 2002.
54. Cruess, RL, Cruess, SR. Expectations and obligations: professionalism and medicine's social contract with society. Perspect Biol Med. 2008; 51(4):579–98.Google Scholar
55. Birden, H, Glass, N, Wilson, I, Harrison, M, Usherwood, T, Nass, D. Defining professionalism in medical education: a systematic review. Med Teach. 2014; 36(1):47–61.Google Scholar
56. Oxford English Dictionary. edition. Oxford, UK: Clarendon Press; 1989.
57. Piaget, J, Inhelder, B. The Psychology of the Child. New York, NY: Basic Books; 1969.
58. Kohlberg, L. The Psychology of Moral Development: Moral Stages and the Life Cycle. San Francisco, CA: Harper & Row; 1984.
59. Erikson, EH. The Life Cycle Completed. New York, NY: WW Norton; 1982.
60. Kegan, R. The Evolving Self: Problem and Process in Human Development. Cambridge, MA: Harvard University Press; 1982.
61. Marcia, JE. Identity in adolescence. In Adelson, J, ed. Handbook of Adolescent Psychology. New York, NY: Wiley; 1980:159–87.
62. Hafferty, FW, Castellani, B. A sociological framing of medicine's modern-day professionalism movement. Med Educ. 2009; 43(9):826–28.Google Scholar
63. Ross, S, Lai, K, Walton, JM, Kirwan, P, White, JS. “I have the right to a private life”: medical students’ views about professionalism in a digital world. Med Teach. 2013; 35(10):826–31.Google Scholar
64. Bosk, C. Forgive and Remember: Remembering Medical Failure. Chicago, IL: University of Chicago Press; 1979.
65. Becker, HS, Geer, B, Hughes, EC, Strauss, AL. Boys in White: Student Culture in Medical School. Chicago, IL: University of Chicago Press; 1961.
66. Daniels, N. Just Health: Meeting Health Needs Fairly. Cambridge, UK: Cambridge University Press; 2008.
67. Cassell, EJ. The changing concept of the ideal physician. Daedalus. 1986; 115(2):185–208.Google Scholar
68. Pellegrino, ED. Character formation and the making of good physicians. In Kenny, N, Shelton, W, eds. Advances in Bioethics: Vol. 10. Lost Virtue: Professional Character Development in Medical Education. Oxford, UK: Elsevier; 2006:1–15.
69. Birden, H, Glass, N, Wilson, I, Harrison, M, Usherwood, T, Nass, D. Defining professionalism in medical education: a systematic review. Med Teach. 2014; 36(1):47–61.Google Scholar
70. Hafferty, FW. Definitions of professionalism: a search for meaning and identity. Clin Orthop Relat Res. 2006; 449:193–204.Google Scholar
71. Castellani, B, Hafferty, FW. The complexities of medical professionalism: a preliminary investigation. In Wear, D, Aultman, JM, eds. Professionalism in Medicine: Critical Perspectives. New York, NY: Springer; 2006:3–23.
72. Freidson, E. Professionalism: The Third Logic. Cambridge, UK: Polity Press; 2001.
73. Fuchs, VR, Cullen, MR. The transformation of U.S. physicians. JAMA. 2015; 313(18):1821–22.Google Scholar
74. Starr, P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982.
75. Cruess, SR, Johnston, S, Cruess, RL. “Profession”: a working definition for medical educators. Teach Learn Med. 2004; 16(1):74–76.Google Scholar
76. ABIM Foundation, American Board of Internal Medicine; ACP-ASIM Foundation, American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002; 136(3):243–46.
77. Swick, HM. Toward a normative definition of medical professionalism. Acad Med. 2000; 75(6):612–16.Google Scholar
78. Working Party of the Royal College of Physicians. Doctors in society. Medical professionalism in a changing world. Clin Med (Lond). 2005; 5(6 Suppl 1):S5–S40.
79. Hafferty, FW, McKinlay, JB, eds. The Changing Medical Profession: An International Perspective. New York, NY: Oxford University Press; 1993.
80. Ho, MJ, Yu, KH, Hirsh, D, Huang, TS, Yang, PC. Does one size fit all? Building a framework for medical professionalism. Acad Med. 2011; 86(11):1407–14.Google Scholar
81. Al-Eraky, MM, Chandratilake, M. How medical professionalism is conceptualised in Arabian context: a validation study. Med Teach. 2012; 34(Suppl 1):S90–S95.Google Scholar
82. Dixon, DM, Sweeney, KG, Gray, DJ. The physician healer: ancient magic or modern science? Br J Gen Pract. 1999; 49(441):309–12.Google Scholar
83. Kearney, M. A Place of Healing: Working with Suffering in Living and Dying. Oxford, UK: Oxford University Press; 2000.
84. Emanuel, EJ, Emanuel, LL. Four models of the physician-patient relationship. JAMA. 1992; 267(16):2221–26.Google Scholar
85. Coulter, A. Patients’ views of the good doctor. BMJ. 2002; 325(7366):668–69.Google Scholar
86. Emanuel, EJ, Emanuel, LL. What is accountability in health care? Ann Intern Med. 1996; 124(2):229–39.Google Scholar
87. Broadbent, J, Laughlin, R. “Accounting logic” and controlling professionals: the case of the public sector. In Broadbent, J, Dietrich, M, Roberts, J, eds. The End of the Professions? The Restructuring of Professional Work. London, UK: Routledge; 1997:34–49.
88. Gruen, RL, Pearson, SD, Brennan, TA. Physician-citizens – public roles and professional obligations. JAMA. 2004; 291(1):94–98.Google Scholar
89. Bloche, MG. Clinical loyalties and the social purposes of medicine. JAMA. 1999; 281(3):268–74.Google Scholar
90. Irvine, D. The Doctors’ Tale: Professionalism and Public Trust. Abingdon, UK: Radcliffe Medical Press; 2003.
91. DeAngelis, CD. Medical professionalism. JAMA. 2015; 313(18):1837–38.Google Scholar
92. Cohen, JJ. Tasking the “self” in self-governance of medicine. JAMA. 2015; 313(18):1839–40.Google Scholar
93. Marcovitch, H. Governance and professionalism in medicine: a UK perspective. JAMA. 2015; 313(18):1823–24.Google Scholar
94. Baker, DP, Day, R, Salas, E. Teamwork as an essential component of high-reliability organizations. Health Serv Res. 2006; 41 (4 Pt 2):1576–98.Google Scholar
95. Teirstein, PS, Topol, EJ. The role of maintenance of certification programs in governance and professionalism. JAMA. 2015; 313(18):1809–10.Google Scholar
96. Pellegrino, ED. The medical profession as a moral community. Bull N Y Acad Med. 1990; 66(3):221–32.Google Scholar
97. Coulehan, J. Viewpoint: today's professionalism: engaging the mind but not the heart. Acad Med. 2005; 80(10):892–98.Google Scholar
98. McGaghie, WC, Mytko, JJ, Brown, WN, Cameron, JR. Altruism and compassion in the health professions: a search for clarity and precision. Med Teach. 2002; 24(4):374–78.Google Scholar
99. Borges, NJ, Manuel, RS, Elam, CL, Jones, BJ. Comparing millennial and generation X medical students at one medical school. Acad Med. 2006; 81(6):571–76.Google Scholar
100. Watson, DE, Slade, S, Buske, L, Tepper, J. Intergenerational differences in workloads among primary care physicians: a ten-year, population-based study. Health Aff (Millwood). 2006; 25(6):1620–28.Google Scholar
101. Brennan, TA, Rothman, DJ, Blank, L, Blumenthal, D, Chimonas, SC, Cohen, JJ, Goldman, J, Kassirer, JP, Kimball, H, Naughton, J, Smelser, N. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA. 2006; 295(4):429–33.Google Scholar
102. Relman, AS. Medical professionalism in a commercialized health care market. JAMA. 2007; 298(22):2668–70.Google Scholar
103. Sambunjak, D, Straus, SE, Marusić, A. Mentoring in academic medicine: a systematic review. JAMA. 2006; 296(9):1103–15.Google Scholar
104. 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
105. Mann, KV. Reflection: understanding its influence on practice. Med Educ. 2008; 42(5):449–51.Google Scholar
106. Cruess, SR, Cruess, RL, Steinert, Y. Role modelling – making the most of a powerful teaching strategy. BMJ. 2008; 336(7646):718–21.Google Scholar
107. Kolb, DA. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice-Hall; 1984.
108. Epstein, RM. Reflection, perception and the acquisition of wisdom. Med Educ. 2008; 42(11):1048–50.Google Scholar
109. Wald, HS, Reis, SP, Monroe, AD, Borkan, JM. ‘The Loss of My Elderly Patient’: interactive reflective writing to support medical students’ rites of passage. Med Teach. 2010; 32(4):e178–e184.Google Scholar
110. Wald, HS. Professional identity (trans)formation in medical education: reflection, relationship, resilience. Acad Med. 2015; 90(6):701–06.Google Scholar
111. Polanyi, M. Personal Knowledge: Towards a Post-Critical Philosophy. Chicago, IL: University of Chicago Press; 1958.
112. Steinert, Y, Cruess, S, Cruess, R, Snell, L. Faculty development for teaching and evaluating professionalism: from programme design to curriculum change. Acad Med. 2005; 39(2):127–36.Google Scholar
113. Steinert, Y, Cruess, RL, Cruess, SR, Boudreau, JD, Fuks, A. Faculty development as an instrument of change: a case study on teaching professionalism. Acad Med. 2007; 82(11):1057–64.Google Scholar
114. Cruess, RL, Cruess, SR. Professionalism, professional identity, and the hidden curriculum: do as we say and as we do. In Hafferty, FW, O'Donnell, JF, eds. The Hidden Curriculum in Health Professional Education. Lebanon, NH: Dartmouth College Press; 2014:171–81.
115. Bebeau, MJ, Faber-Langendoen, K. Remediating lapses in professionalism. In Kalet, A, Chou, CL, eds. Remediation in Medical Education: A Mid-Course Correction. New York, NY: Springer; 2014:103–27.
116. Brainard, AH, Brislen, HC. Viewpoint: learning professionalism: a view from the trenches. Acad Med. 2007; 82(11):1010–14.Google Scholar
117. Benbassat, J. Undesirable features of the medical learning environment: a narrative review of the literature. Adv Health Sci Educ Theory Pract. 2013; 18(3):527–36.Google Scholar
118. Lesser, CS, Lucey, CR, Egener, B, Braddock, CH III, Linas, SL, Levinson, W. A behavioral and systems view of professionalism. JAMA. 2010; 304(24):2732–37.Google Scholar
119. Gaufberg, EH, Batalden, M, Sands, R, Bell, SK. The hidden curriculum: what can we learn from third-year medical student narrative reflections? Acad Med. 2010; 85(11):1709–16.Google Scholar
120. Benbassat, J. Changes in wellbeing and professional values among medical undergraduate students: a narrative review of the literature. Adv Health Sci Educ Theory Pract. 2014; 19(4):597–610.Google Scholar
121. Fox, RC. Medical uncertainty revisited. In Albrecht, GL, Fitzpatrick, R, Scrimshaw, SC, eds. The Handbook of Social Studies in Health & Medicine. London, UK: SAGE; 2002; 409–25.
122. Janss, R, Rispens, S, Segers, M, Jehn, KA. What is happening under the surface? Power, conflict and the performance of medical teams. Med Educ. 2012; 46(9):838–49.Google Scholar
123. van der Zwet, J, de la Croix, A, de Jonge, LPJWM, Stalmeijer, RE, Scherpbier, AJJA, Teunissen, PW. The power of questions: a discourse analysis about doctor-student interaction. Med Educ. 2014; 48(8):806–19.Google Scholar
124. Bynum, WE IV, Goodie, JL. Shame, guilt, and the medical learner: ignored connections and why we should care. Med Educ. 2014; 48(11):1045–54.Google Scholar
125. LeBlanc, VR. The effects of acute stress on performance: implications for health professions education. Acad Med. 2009; 84(10 Suppl):S25–S33.Google Scholar
126. Yerkes, RM, Dodson, JD. The relation of strength of stimulus to rapidity of habit-formation. J Comp Neurol. 1908; 18(5):459–82.Google Scholar
127. Wear, D, Aultman, JM, Varley, JD, Zarconi, J. Making fun of patients: medical students’ perceptions and use of derogatory and cynical humor in clinical settings. Acad Med. 2006; 81(5):454–62.Google Scholar
128. Lingard, L. Language matters: towards an understanding of silence and humour in medical education. Med Educ. 2013; 47(1):40–48.Google Scholar
129. Feudtner, C, Christakis, DA, Christakis, NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med. 1994; 69(8):670–79.Google Scholar
130. Krause, EA. Death of the Guilds: Professions, States, and the Advance of Capitalism, 1930 to the Present. New Haven, CT: Yale University Press; 1996.
131. Dunning, AJ. Status of the doctor–present and future. Lancet. 1999; 354 Suppl:SIV18.Google Scholar
132. Stevens, RA. Public roles for the medical profession in the United States: beyond theories of decline and fall. Milbank Q. 2001; 79(3):327–53.Google Scholar
133. Oxford Dictionary of Philosophy. Oxford, UK: Oxford University Press; 1996.
134. Wynia, MK. The short and tenuous future of medical professionalism: the erosion of medicine's social contract. Perspect Biol Med. 2008; 51(4):565–78.Google Scholar

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