Pathology, professionalism, portfolios and progress

Abstract

Abstract Community-driven standards of professionalism must be addressed, worldwide, at all levels of medical education. The imperative to implement robust strategies to ensure that doctors embrace these standards to justify the autonomy afforded to the medical profession has been a key concern of specialist medical colleges in recent years. Pathologists face unique challenges. Rapid technological change and increasing commercialisation have distanced them further than ever before from patients and other clinicians, resulting in negative stereotypes that impede understanding of professional roles that may have adverse consequences for interdisciplinary communication and patient care. This study explores the socio-cultural and educational factors impacting on the development of professional identity in pathology specialist training in Australia and New Zealand, with the aim of recommending an educational model for the attainment of professionalism. Theories of social identity and education relating to self-regulated and situated learning informed the study and model. Textual data from interviews, surveys and discussions were captured over the course of a professional, college-led intervention that included a new curriculum addressing standards of professionalism in pathology, and an associated portfolio designed as a formative assessment tool. Based on these texts, hermeneutic phenomenological strategies were used to explore the experiences of pathology trainees, their supervisors, educators and clinicians. A pathologist’s professional identity is a self-constructed schema involving value orientations and commitment to goals that reflect beliefs about what it means to be a good pathologist. For many, these values do not correspond to the ideals of professionalism constructed by the community at large. In the face of many social and political pressures, pathologists have developed an identity that conforms to a stereotype in which technical knowledge and skills are strong values that may be detached from the need for competence in the broader, non-technical areas. This identity may be partly founded in career selection, but is perpetuated through interdisciplinary discourse, internalisation, role modelling, work practice and a curriculum and assessment structure that de-emphasises non-technical roles. Trainees are strongly influenced by the values displayed and feedback provided by supervisors who themselves may be subject to the influences of a negative culture. Conflicts between goals and values in technical and non-technical aspects of training can be de-motivating and may constrain the development of a reflective identity that embraces professionalism. Whilst competency-based frameworks such as CanMEDS have been invaluable in drawing attention to the place of non-technical competencies in formal curricula, they do not necessarily take account of the complex and powerful hidden curriculum that lies behind the formal curriculum and exists at the level of role-modelling, stereotyping, work practice and institutional policies. Developing a model of professionalism fit for the purpose of pathology training has involved deconstruction of the CanMEDS model and self-regulated learning processes to carefully examine their parts. The new model reassembles these elements in the situated learning environment and broader cultural and organisational structures applying to pathology. It emphasises alignment of goals, values and processes at all levels of the curriculum, both formal and hidden. The curriculum should integrate and operationalise technical and non-technical competencies with concretely-defined outcomes that are meaningful in the context of pathologists’ roles. Learning portfolios should be simple and flexible, requiring of more than tick-boxes to facilitate reflection. Formative assessment and guided self-assessment from supervisors are critical for the trainee to identify learning needs and to support development of capacity for self-regulation. Onerous formal assessments that devalue professionalism should be reviewed. The College and training institutions must demonstrate commitment to professional values through policy and provision of resources. The approach in this study, which strongly links professional identity development to the attainment of professionalism in medical specialty training, has implications for educators in understanding the many social and educational factors that must be considered in developing curricula for medical professionalism relevant to other disciplines and settings.