Microsoft Word - ProfessionalIdentityFormationArticle.docx Published by University of Minnesota Libraries Publishing Professional Identity Formation Among College Premedical Students: A Glimpse into the Looking Glass Using a Career Eulogy Reflective Exercise William J. Crump, MD, R. Steve Fricker, MPA, Allison M. Crump, MD DOI: https://doi.org/10.24926/jrmc.v2i1.1683 Journal of Regional Medical Campuses, Vol. 2, Issue 2 (2019) z.umn.edu/JRMC All work in JRMC is licensed under CC BY-NC Dr. William Crump; Associate dean, University of Louisville School of Medicine Trover Campus at Baptist Health Madisonville, Madisonville, Kentucky. Mr. Fricker; Director of rural health/student affairs, University of Louisville School of Medicine Trover Campus at Baptist Health Madisonville, Madisonville, Kentucky. Dr. Allison Crump; Research assistant at the time of this study, University of Louisville School of Medicine Trover Campus at Baptist Health Madisonville, Madisonville, Kentucky. Corresponding Author: Dr. Crump, ULSOM Trover Campus at Baptist Health Madisonville, 200 Clinic Drive - 3rd North, Madisonville, KY 42431; email: bill.crump@bhsi.com; telephone: (270) 824-3515; fax: (270) 824-3590. All work in JRMC is licensed under CC BY-NC Volume 1, Issue 6 (2019) Journal of Regional Medical Campuses Original Reports Professional Identity Formation Among College Premedical Students: A Glimpse into the Looking Glass Using a Career Eulogy Reflective Exercise William J. Crump, MD; R. Steve Fricker, MPA; Allison M. Crump, MD Abstract Introduction Pre-medical students are at the very beginning of their formation of a professional identity as a physician. Working with these students early in their education can help them appreciate the importance of professional identity formation as well as inform educators on best methods to understand this process. Methods A reflective exercise was used at the beginning of sessions with pre-medical students at their home campus who attended a medical school presentation on the admissions process. Students were asked to reflect on what they wished to be said about them at the end of their career in the form of a “Career Eulogy.” A simple form was developed and administered to the students to capture their reflective writing and their basic demographics anonymously. Qualitative data were blinded and then coded into clusters by the authors using an iterative process. Results Reflections from 79 pre-medical students indicated a preference to be remembered for quality and excellence in care, especially among upper level students and students from small towns. Compassion, patient relationships, and the doctor as teacher terms were more likely to be written by Juniors and Seniors while Freshmen and Sophomores tended to focus on terms related to enjoyment of life and service. Discussion This reflective exercise provided useful insight into professional identity formation among these college pre-meds and could be used with larger, more diverse groups to determine its value and clarify true differences among the demographic characteristics. Involving similar pre-medical students in focus group settings could also further assist with interpretation of the meaning of these reflections. Introduction As a more holistic approach to choosing students for medical school has developed, much has been written about the best premedical curriculum and the role of the new MCAT.1,2 Some have suggested more study of a broader view of the premedical college experience that includes the hidden curriculum and identity formation outside of the classroom.3 Core pre-professional competencies have also been suggested.4 Most previous publications on this issue have either focused on attrition or study of student attitudes about the caricature of the “premedical syndrome” of “cut throat” behavior by overachieving, selfish college students who see everything about their college experience as a competition.5,6 However, some have found in surveys that pre-meds both perceive themselves and are perceived by other students and faculty as altruistic and interested in making a difference in their future patients’ lives.7,8 In our 12-year experience of working with selected pre-meds in summer pathways rural immersion experiences we found some validity to both views. In group discussions of clinical cases and practical ethical dilemmas found in everyday practice, we observed college students at various levels of professional identity formation and could watch their development across the 2-3 summers we worked with them.9 We found that simple reflective exercises at the beginning of DOI: https://doi.org/10.24926/jrmc.ADDHERE Journal of Regional Medical Campuses, Vol. 1, Issue 6 Original Reports each session greatly facilitated their discussion of the deeper aspects of their hopes and dreams. We found a simple exercise recently published as it was used with interns in a university hospital environment10 and field testing with our small selected group of pre-meds went well. In this exercise, the participants reflect and then record what they would like to be said about them at a retirement event far in the future. Our goal in this study was to use the exercise in a larger group of less selected pre-meds to develop an understanding of the important components of professional identity formation. Secondarily, we were interested in differences by gender, rural upbringing, and level in school. The study protocol was reviewed by the Baptist Health Madisonville IRB and approved as exempt. Methods The career eulogy form was modified from a similar effort used with hospital-based interns.10 There were lines for demographics followed by the statement: “Imagine that you are ready to retire from medicine in the distant future. Write a short speech outlining what you would like to be said about you at the retirement ceremony. In about 50 words, write the speech below.” These were distributed in the Fall of 2015 at the beginning of a one-hour session of a pre-medical club meeting hosting the Trover Campus Associate Dean for his annual presentation concerning the medical school admission process. Anonymity was assured as was voluntary participation. The writings were completed in 5-7 minutes and were collected by the club officers and placed in a sealed envelope. Two regional state universities in western Kentucky were included, each about 90 miles in opposite directions from the Trover Campus. One had an enrollment of 11,000 based in a town of 18,000 (34 completed forms) and the other had an enrollment of 20,000 based in a town of 62,000 (45 completed forms). All 79 completed forms were included and legible enough to be coded. These had all demographics removed and were then classified and coded by the authors. One coder (AMC) is a recent Trover Campus medical school graduate and also graduated from one of the included universities. One (RSF), has training as a medical anthropologist and 16 years in medical education including summer pre-med programs. The other (WJC) is the Trover Campus Associate Dean with 35 years of experience with both pre-med pathway programs and medical education. The authors used an iterative process where a rubric of terms was developed from reading the eulogies and then the text coded by each author individually and then reviewed by the group. During this process, the authors met and agreed by consensus on the correct coding for ambiguous or overlapping terms. Table 1 shows the 10 clusters of terms the authors identified as recurring themes in the student eulogies. When the exact term did not occur, the synonyms shown were typical of those included in that cluster. Table 1. Terms used by students to describe themselves in their Career Eulogies Terms used by students Cluster Seeking excellence; knowledgeable; seeking improvement; the best; quality of care; great doctor; contributed to medical knowledge; left a legacy Quality Vigor; excitement; love of medicine; impact on care; persistence; never gave up; never backed away from a challenge Passion Empathy; kind heart; sentimental; understanding; sympathetic; every patient mattered; gave patients hope; truly cared Compassion Connected with patients; puts patients’ needs first; made personal connections; personable Patient relationships Always happy; my life was a gift; the journey was fun; the joy of practice; always had a smile; positive attitude Enjoy life Brought better care to my town; legacy in my town; very involved in community; educated the community Community Taught colleagues; taught community members about their health; hosted medical students Teacher Genuinely sought to help others; payment not required Service Blessed to serve; faith is central; servant of God; displayed faith through care Calling Loyal to family; puts energy into relationship with spouse; love of family Family Results As shown in Table 2, this group of pre-med students most frequently hoped they would be remembered for quality and excellence in clinical care. Among upper level students (junior or senior) and those from small towns, this term was even more frequently used, with little difference by gender. Juniors and seniors also included more frequent terms under the compassion, patient relationship, and doctor as teacher clusters. Freshmen and sophomores more frequently included terms in the enjoy life and service clusters. DOI: https://doi.org/10.24926/jrmc.ADDHERE Journal of Regional Medical Campuses, Vol. 1, Issue 6 Original Reports Table 2. Demographic characteristics of students completing Career Eulogies aOne student self-identified as a graduate student b5 students did not answer this question cRural defined as coming from a hometown with a population <30,000 Women more frequently included terms under the passion, compassion, and patient relationship clusters than did the men in the study population. In addition to terms under the quality cluster, rural students more frequently chose terms in the community and family clusters. Discussion Studying this larger group of less selected premeds enlarged our understanding of their professional identity and validated what we had perceived in our smaller more selected summer pathways groups. Use of the career eulogy in larger more diverse groups will be needed to determine if the differences among school level, gender, and rurality are generalizable. The only studies available for comparison are much older and were survey-driven. McCranie, reporting 253 students attending 13 “more selective” liberal arts colleges in the Midwest, found more “type A” behavior among students seeking any kind of doctoral degree, medical or not, than in those planning a Masters or Bachelors. They also found this negative stereotype more frequently in women, which is very different from our findings.5 Conrad reported 30 student surveys from Brandeis University weighted towards upperclassmen and found more agreement with the “cut-throat” stereotype among underclassmen while upperclassmen were less concerned about competition and felt more balanced in their lives.6 Hackman reported 317 Yale sophomores and seniors that included some non-pre-med students for comparison. The pre-meds more frequently reported interest in being helpful and making a contribution to society, but also selected job security and prestige as important to them. Non-pre-med women indicated more interest in enjoying life and generally more optimism than the men in the study. Pre-med women, however, chose answers much like the pre-med men.7 Sade reported 498 students from 13 undergraduate campuses in South Carolina, a population more likely to be similar in some ways to ours, as the other 3 reports were from ivy league schools or campuses described as “more selective” but unnamed. Sade included faculty and non-pre- med students in the survey along with premeds. The most prevalent picture of premeds was one of altruism but also excessively competitive with narrow interests, and the student respondents did not differ in their perceptions by level in school.8 Limitations Our study is limited by population size and inclusion of two regional campuses with more rural students than a national sample would include. The study population is also racially homogeneous. The population of the region only has about 6% non-white citizens, and the pre-med groups are even more homogeneous. Most of the clusters were easy to differentiate, but two groups were more difficult. Ultimately, the coders agreed that service was an activity that occurred outside of the doctor’s workplace and was generally not revenue producing. “Going the extra mile” was clustered with passion and “putting patients’ needs first” was clustered with patient relationships rather than either being included as service. Likewise, the line between compassion and patient relationships was difficult to code with some wording used by the students. The terms clustered under patient relationships were seen as more bidirectional while empathy and kind heartedness were seen more as residing in the physician and were clustered with compassion. It would be interesting to compare students’ results who are from generation birth dates designated as millennials with those from birth dates designated as generation Z, but we did not capture birth date or age on the anonymous eulogy forms. From talking with the pre-med advisors and surveying the audience, it did seem that almost all were in the typical college age of 18-23. As a rough estimate, there would have been more millennials in the upper class students and more generation Z among the freshmen and sophomores, but any more precise comparison is not possible with these results. Perhaps inferential statistics would be helpful with data like these. When we did that, only 2 clusters were significant, and 3 more were close. Ultimately it seemed that given our group sizes and qualitative nature of the responses, Chi-square and Fisher Exact tests did not add much to our understanding of the students’ responses. The use of focus groups might also shed light on the meaning of these clusters to the pre- medical students and help in our interpretation of these data. For example, a single focus group we conducted with a small group of summer program college pre-medical students who DOI: https://doi.org/10.24926/jrmc.ADDHERE Journal of Regional Medical Campuses, Vol. 1, Issue 6 Original Reports had experienced additional reflective exercises tended to emphasize patient relationships and compassion easily. They also were comfortable broaching sensitive issues, such as the doctor’s role with discussing spirituality with the patient. This issue was something they entered our program thinking was off limits in the doctor’s office. In anonymous evaluations of summer programs, the reflective exercises were often listed as a favorite part of the program, with a typical quote: “I like the Friday morning reflections because they pushed me … to pause ... think like a physician ... and treat the patient as a whole.” Conclusion Perhaps more important than precise classification is the value of the exercise as a reflection that forces the task- focused, sometimes distracted pre-med to practice a moment of mindfulness. We have continued to use this exercise with pre-meds, medical students in all 4 years, and medical residents as an introduction to a session addressing professional identity development and personal health. The 5-7 minutes of silent, focused reflection seems to be welcomed by all. We continue to gather more responses, including focus groups de-briefing the process, and hope that others will begin to use this exercise and share their findings. References 1. Dienstag JL. Relevance and rigor in premedical education. NEJM. 2008;359:221-224. doi: 10.1056/NEJMp0803098. 2. Kirch DG, Gusic ME, Ast C. Undergraduate medical education and the foundation of physician professionalism. JAMA. 2015;313:1797-1798. doi: 10.1001/jama.2015.4019. 3. Gross JP, Mommaerts CD, Earl D, Devries RG. After a century of criticizing premedical education, are we missing the point? Acad Med. 2008;83:516-520. doi: 10.1097/ACM.0b013e31816bdb58. 4. Koenig TW, Parrish SK, Terregino CA, Williams JP, Volsch JM. Core personal competencies important to entering students’ success in medical school: What are they and how could they be assessed early in the admission process? Acad Med. 2013;88:603-613. doi: 10.1097/ACM.0b013e31828b3389. 5. McCranie EW, Lewis GL. Prevalence of type A behavior among undergraduates with medical and nonmedical career plans. J Med Educ. 1987;62:926- 928. 6. Conrad P. The myth of cut-throats among premedical students: On the role of stereotypes in justifying failure and success. J Health Soc Behav. 1986;27:150-160. 7. Hackman JD, Low-Beer JR, Wugmeister S, Wilhelm RC, Rosenbaum JE. The premed stereotype. J Med Educ. 1979;54:308-313. 8. Sade RM, Fleming GA, Ross GR. A survey on the “Premedical Syndrome”. J Med Educ. 1984;59:386- 391. 9. Whittington CP, Crump WJ, Fricker, RS. An invitation to walk a mile in their shoes: a rural immersion experience for college pre-medical students. Journal of Regional Medical School Campuses. 2019;1(5). doi:10.24926/jrmc.v1i5.1565. 10. Yu E, Wright SM. “Beginning with the end in mind”: Imagining personal retirement speeches to promote professionalism. Acad Med. 2015;90:790-793. doi: 10.1097/ACM.0000000000000690.