Longitudinal Effects of Early Clinical Experiences on Medical Students' Professional Identity Formation.

Purpose: To support and explore medical students’ professional identity formation1 as a physician through experiential learning in authentic clinical environments, which occurs during their preclinical years, allowing for earlier association of preclinical knowledge to patient-specific contexts and earlier engagement with threshold concepts2 essential to becoming a physician. Approach: Innovation: Throughout phase 1 of Washington University School of Medicine’s (WUSM’s) new Gateway Curriculum, preclinical students complete three, 3-week clinical immersions. There are 3 types of immersions—ambulatory/emergency department, procedural/surgical, and inpatient, across a variety of specialties. Incorporating experiential learning theory,3 students perform clinical activities like those of clerkships—taking medical histories, performing physical exams, presenting patients, calling consults, writing notes, and participating in the operating room, as well as activities focused on course objectives such as incorporation within an interprofessional team, talking with patients about their lived experiences, and discussing the impact of health systems on patients. Furthermore, activity cards have students record clinical practice activities related to course objectives. Assessment of students within each immersion occurs via direct observation and longitudinal clinical performance assessments, evidence-based medicine critical appraisals, and analytic writing assignments. These writing assignments require students to demonstrate understanding of rotation objectives based on their lived clinical experiences. Writing prompts for these assignments ask students to discuss course content related to objectives, such as interprofessional care teams, systems-based care, social determinants of health, and personal learning goals developed through reflective use of feedback. Evaluation: Students evaluate immersions through satisfaction ratings and open-text comments on end-of-immersion questionnaires. WUSM’s Program Evaluation/Continuous Quality Improvement Unit (PECQI) summarized ratings and categorized open-text comments on the questionnaires. A separate team of 3 evaluators, who were not part of PECQI and not involved in planning or implementing the immersions, analyzed a sample of the analytic writing assignments from all 3 types of immersions using conventional content analysis.4 Outcomes: The first cohort in the Gateway Curriculum includes 105 students, all of whom completed all 3 immersions and associated assignments. Qualitative analysis of a sample of data, obtained at completion of the students’ third immersion, shows that students consistently describe their role as a liminal state from a passive observer—self-identified as a student trait—to an increasingly active care provider—a trait associated with the physician’s role. Students comment on discomfort and growth of this transitional stage, noticing, for example, the benefits and flaws of health care systems as they interact with social determinants of health, the interprofessional care team, patients, and their patients’ families. Students identify the value of communication, partnering with patients, and learning from interprofessional team members. In aspirational statements, students begin to self-identify threshold concepts central to their future identity as a physician such as patient-centeredness, the importance of equitable care, comfort with ambiguity, and need for lifelong learning. Quantitative data show that students feel that critical elements of immersions occur and that students self-identified “working in interprofessional teams” and “opportunities to practice clinical care” as well-executed aspects of the immersions. The analytic writing assignment prompts provide a lens for professional development, encouraging the student to reflect on their transition from student to physician in multiple contexts. Qualitative data from the written assignments show that these intentionally designed clinical immersions coupled with longitudinal, guided self-reflection expose medical students to key threshold concepts of physician professional identity formation. Significance: As a direct result of their participation within clinical interprofessional teams, combined with the directed learning of clinical immersions, preclinical students begin to frame their remaining preclinical activities through the lens of their identity as a future physician. Therefore, students enter their clerkship years having already begun their development of a professional identity as a physician.