Simulation as a Tool to Promote Professional Identity Formation and Patient Ownership in Medical Students

Background

Simulation in medical education is widely considered a valuable addition to clinical training because it allows the teaching environment to be intentionally designed and controlled, thereby providing students with standardized clinical experiences that have been shown to help improve patient safety (Beal et al., 2017; Bradley, 2006; Cook et al., 2011; Maran & Glavin, 2003; McGaghie, Issenberg, Barsuk, & Wayne, 2014; Scalese, Obeso, & Issenberg, 2008). In addition to its primary uses in competency training and assessment, simulation may also be valuable in helping achieve other aims within medical education, most notably its potential for promoting students’ professional identity formation (PIF) (Cruess, Cruess, & Steinert, 2016). We propose that patient ownership is another concept that may potentially be developed within simulation because of its relationship to a physician’s professional identity (Eaton, 2005). We propose that PIF and patient ownership foster each other’s development, with simulation as a potential mediator of the two concepts. Although some researchers have proposed the value of simulation in the development of physicians’ PIF (Bradley & Postlethwaite, 2003; Rudolph, Raemer, & Simon, 2014; Wali et al., 2016), there is currently no known research into the relationship and development of both PIF and patient ownership within simulated clinical environments.

The purpose of this study was to explore the relationship between simulation and the development of PIF and patient ownership in third-year medical students who had just begun their clinical training. Specifically, this study was designed to understand which aspects of the simulation prompted students’ PIF, the extent to which simulation helped students feel ownership over their patients, and whether prior experience within the in-patient clerkships would increase students’ feelings of professional identity and patient ownership.

Research on PIF within medical education has addressed a myriad of issues related to the development of students’ professional identity. These issues range from attempting to measure the developmental trajectory of students’ PIF (Helmich et al., 2010; Kalet et al., 2016), to best practices in scaffolding reflective exercises to promote PIF (Wald, 2015), to understanding the kinds of questions students ask themselves in the midst of becoming physicians (Vivekananda-Schmidt, Crossley, & Murdoch-Eaton, 2015). However, despite the various ways in which medical educators are attempting to study and provoke the development of students’ PIF, simulation has largely remained an untapped resource. Although simulation has great potential for exploration due to its ability to provide clinical scenarios within a safe and controlled setting, researchers have yet to discover the ways in which PIF can be prompted in a simulated clinical environment.

Unlike relying on the unpredictability of training opportunities within clinical settings, simulation allows researchers to create clinical scenarios that could potentially accelerate students’ PIF (Kneebone, Scott, Darzi, & Horrocks, 2004). For example, through simulation, cases can be developed that focus on exposing students to various roles, tasks, and activities that are typically out of their reach. This practice is based on situated learning theories, particularly legitimate peripheral participation (LPP) (Bradley & Postlethwaite, 2003; Lave & Wenger, 1997; Mann, 2010). LPP is a learning theory that explains how newcomers to a community are socialized into being full members. It posits that novices, (i.e. medical students), are invited to participate on the periphery of the community first as an observer, but over time, are given access to tasks that require more responsibility as they demonstrate readiness. Simulation allows researchers to manipulate this socialization process by affording students with opportunities to take on advanced levels of responsibility within a safe environment. The result of well-developed simulation cases can thus assist students in learning how to “think, act, and feel like physicians”.⁷

In addition to the PIF, one of the other potential benefits of simulation is that it provides students with an opportunity to begin developing the skills, attitudes, and behaviors associated with taking ownership of patients (Wyatt, Bowen, Mann, Regehr, & Cianciolo, 2016). Taking ownership of patients is the central activity within the community of physicians, and is therefore deeply embedded in the professional identity of a physician. Learning to assume responsibility (i.e. “ownership” of patients) is critical in medicine, yet students rarely have the opportunity to experience this responsibility until they transition into residency. Typically, the role of third-year medical students is to interview the patients, conduct a physical exam, and communicate the information back to the healthcare team. From this perspective, students conceptualize ownership as knowing their patients inside and out (Wyatt, in press). It is not until the last year of medical school when medical students start to develop feelings of advocacy and learn to manage patient care (Wyatt, in press). Therefore, one of the benefits of clinical simulation is that it provides an environment where students can begin to “try on” these different roles as they experiment and explore what it means to be a physician.

Introducing simulation early in medical students’ training has the potential to contribute to the early stages of students’ PIF and provide opportunities for students to explore what it feels like to take ownership of patients. Given this largely untapped potential, this study was designed to explore how a simulated clinical event supported students’ development in these two areas.

Methods

This mixed-methods study was conducted in order to determine if clinical simulation could be used the promote professional identity formation through the facilitation of patient ownership. Over the course of two days, all 192 third-year medical students from a large, public medical school in the Southeastern United States participated in individual simulations as part of a mid-year clerkship experience. Each student experienced the same case. The simulation was designed to provide the students with an opportunity to approach a patient with an urgent chief complaint of chest pain. Chest pain was chosen since it is a common complaint and one in which they would have learned about during their clerkships, regardless of the in-patient or out-patient experiences. The patient’s diagnosis was an ST-elevation acute myocardial infarction (STEMI) and the students were expected to obtain a focused history and physical examination, obtain an EKG (which demonstrated a STEMI), and then call for assistance or refer to cardiology for transfer to the catheter lab. The simulation was also specifically designed to allow students to experience feelings of patient ownership. This was achieved by placing each student into the role of the physician in an emergent case. The only other participant in the room during each simulation was a nurse actor, which eliminated opportunities for outside or collaborative assistance. The nurse actor confederates were instructed during training to refer to the student as “doctor” at all natural opportunities, as well as to remind the student that they were responsible for making decisions if the nurse was asked for their opinions. The confederates were instructed to provide assistance during the case, but not provide any clinical direction on management. This design was not intended to inflate confidence in clinical skills or abilities, and in fact many students reflected on their deficiencies during debriefing. The promotion of feelings of patient ownership allowed for a low-stakes experience of physician responsibilities without unintentionally exaggerating students’ perceived clinical competence.

Students were oriented to their role as the physician in the case during a pre-briefing session, which also included information about the purpose of the session, the resources available during the simulation, the use of the mannequin as a patient (METIman® human patient simulator from CAE Healthcare), the goal of a psychologically-safe environment, and their assigned simulation schedule. After the pre-briefing, students rotated through the simulations with the confederate acting in the role of the nurse.

Once the simulation was completed, the case facilitator took the student to another room to conduct a one-on-one debriefing. The debriefing allowed students to reflect on their experience and actions immediately after the case. The instructors had previously been taught how to use the Gather-Analyze-Summarize (GAS) model of debriefing for the session, and while PIF and ownership were not prompted explicitly, the participants were reminded that the purpose of the simulation was to provide them the opportunity to assume the role of a physician.

After the simulation and debriefing, all participants were provided with a link to an optional, anonymous, online survey instrument in Qualtrics; 76 students (40%) responded. This study approved by the Institutional Review Board, and the convenience sample of participants consented to having their responses included in this analysis. The survey instrument included demographics items, including clerkship rotation block, which can be seen in Table 1. For the purpose of analysis, the clerkship schedules were described as the primarily in-patient rotation block (Internal Medicine, Neurology, Psychiatry, Surgery) and the primarily out-patient rotation block (Family Medicine, Obstetrics/Gynecology, Pediatrics). Though the two blocks were not exclusively in-patient or out-patient, the categorization accurately represented the bulk of each block’s rotations, and described the principal difference between the two groups.

OPEN IN VIEWER

Table 1.

Demographics of the Study Population.

Age (years)
Mean	25.6
Median	25
Range	23 – 40
Gender (%)
Male	38.2
Female	60.5
Not disclosed	1.3
Race (%)
White	53.9
Black or African American	13.2
Asian	22.4
Mixed-race	3.9
Not disclosed	6.6
Ethnicity (%)
Hispanic or Latino	6.6
Not Hispanic or Latino	86.8
Not disclosed	6.6
Prior Clinical Experience (%)
Yes	36.8
No	63.2
Clerkship Block (%)
In-patient	56.6
Out-patient	43.4

Following the closed-ended items that used a Likert-type scale, students were asked three open-ended questions designed to prompt reflection on their PIF and whether the simulation had helped them take ownership of their patient. There was no word limit to the responses. The three open-ended prompts were: 1) This simulation was designed to give you the feeling of patient ownership. Describe what and where you felt you had ownership, 2) This simulation was designed to give you experience assuming the role of a physician. Describe how this experience contributed to your identity as a physician, and 3) If you did not feel like the simulation contributed to your feelings of patient ownership or identity as a physician, please explain why. Given that the simulated case was specifically designed to prompt students’ to occupy the role of a physician, we assumed that this role would invoke feelings akin to being a physician and wanted to better understand what was contributing to this invocation through qualitative analysis. These assumptions were accurate evidenced by the fact that no students answered the third open-ended question.

After de-identifying the data, we created a priori codes adapted from the amended version of Miller’s Pyramid in Figure 1 (Cruess et al., 2016). The original version of Miller’s Pyramid (Miller, 1990) described the layers of assessing clinical competence, but the amended version included an additional peak called “IS (Identity)”: “thinking like a physician”, “acting like a physician”, and “feeling like a physician.” This study used these descriptors as a priori codes, asserting that combined, these three aspects contribute to the development of a student’s PIF. A systematic approach was done to construct additional a priori codes to identify the context of the simulation. These codes capture how students perceive the fidelity of the simulation that may affect their PIF. These codes include: 1) people acting in the simulation, 2) the material environment within the simulation, 3) time (i.e., commenting on specific moments), 4) place (e.g., room, hospital, catheter lab), and 5) language use or conversation. During the content analysis, an additional in-vivo code was created to capture another aspect of students’ experience not adequately captured in the a priori codes. This emergent code was “metacognition,” defined as a reflection on one’s own thinking or development.

OPEN IN VIEWER

Figure 1.

The a priori and emergent codes from the content analysis.

Latent content analysis (Potter & Levine-Donnerstein, 1999) was used to identify and interpret deeper levels of meaning that existed in the textual data collected. This involves immersion in the students’ responses and contextualizing the meaning of the text into its respective code. The constant comparative method was employed to refine and organize codes into over-arching categories (Glaser, 1965; Hewitt-Taylor, 2001). This analysis was done in the cloud-based program, Dedoose version 8.0.35, which allows multiple individuals to collaborate on qualitative research.

To ensure coding reliability between researchers, an objective measure of interrater reliability (IRR) was assessed. The IRR between the first and second author was established using a randomly-selected 10% subset of the data. The first author coded the all of the data, while the second author reviewed the code development intermittently over the three-week process. Establishing IRR helped ensure that the primary coder within the study met the standards of the expert coder (McHugh, 2012). A Cohen’s Kappa was calculated to account for units of meaning that were assigned multiple codes. All quantitative analyses were performed using SPSS, version 25. After the Cohen’s Kappa was calculated for each of the nine codes, an average was produced from all nine values, which served as the estimate of IRR (k = 0.84). Once IRR was established, the subsequent qualitative analysis of students’ responses was conducted exclusively by the first author. Discussion between the authors continued throughout the analysis to ensure trustworthiness in the interpretation of the results.

As illustrated in Figure 1, the codes were organized into two categories: individual elements and contextual elements. A summation score for each category was calculated for the number of times a student mentioned any of the identified codes in their open-ended responses. These scores are referred to as their Individual Element Score (IES) and Contextual Element Score (CES). A higher IES describes a more introspective attitude that is built on students’ personal motivations and internal processes. A higher CES describes a student who referred more to the environmental aspects of the simulation, which is interpreted as an extrospective practice wherein students are more engaged with the fidelity of the simulation. The purpose of having two scores is to discern differences in how students grapple with their PIF and whether independent variables such as clerkship block or prior clinical experience had an effect on how students scored.

After the content analysis was complete, a two-way MANOVA was performed to explore any possible relationships between the independent variables of clerkship block and prior clinical experience, and the dependent variables of students’ individual element score (IES) and contextual element score (CES). Post-hoc analysis was conducted using two independent samples t-tests to determine which clerkship block (in-patient vs. out-patient) had an effect on IES and whether the presence or absence of prior clinical experience had an effect on students’ IES.

Results

The content analysis of students’ open-ended responses revealed that the simulation prompted students to think about their role as a physician and to contemplate the prospects of an emerging professional identity. In the analysis, “feeling like a physician” had the highest frequency of use (n = 86) within its individual element category, as well as, when all the codes were compared to each other. “People in the simulation” was the most frequently used code within the contextual element category (n = 46). As illustrated in Figure 2, in descending order, the remaining codes were ranked: metacognition (n = 61), thinking like a physician (n = 49), acting like a physician (n = 43), material environment within the simulation (n = 24), time (n = 20), language use or conversation (n = 14), and place (n = 6).

OPEN IN VIEWER

Figure 2.

The frequency of individual and contextual element codes.

The frequency in which metacognition was coded demonstrates that students were actively monitoring themselves and their development as they engaged with the patient. In some cases, the simulation prompted students to think like physicians, whereas others experienced the simulation in ways that prompted them to feel like physicians. Regardless of what triggered students’ PIF, the results of the content analysis clearly showed that the simulation allowed students to take on the perspective of a physician in ways they may not have had the opportunity to experience in their clerkships prior to the simulation.

For example, several students indicated that occupying a physician’s role helped them move from being a student shadowing on the sideline, to being the person who is primarily responsible for a patient. This felt like a major shift for many students, particularly in terms of decision-making. One student described it this way:

This simulation allowed me to be the one making the decisions. As a medical student, this can often be lacking, as most decisions, especially major ones, are often deferred to more senior members of medical teams. This experience helped to put me in the driver’s seat.

Other students commented that the simulation helped them feel more confident that one day, they may be able to effectively manage patient care. While there is a substantial level of variability among the tasks assigned to students across their various clerkship rotations, typically, the role of third-year medical students is limited because they rarely get the opportunity to make decisions for the diagnosis and treatment of the patient. Most students’ duties are limited to collecting pertinent information from patients and then presenting to more senior members of the team who ultimately make the decisions. One student described the role they typically occupy, saying, “We are frequently asked questions about ‘next steps’ in management, but are rarely required to navigate through entire patient encounters on our own.” Participating in the simulation allowed students to conceptualize their professional development, and appreciate the impending responsibilities they would soon be assuming.

Many students realized through their reflections that they would not be medical students for much longer, and that in a short period of time they would be managing patient care. The simulation helped students visualize the quickly-approaching end of medical school, which in turn allowed students to reflect on what they would experience when they fully assumed the identity of a physician. One student described the realization this way: “The complete responsibility and ownership of the scenario reminded me of how soon I would have to step into the shoes of a physician. I still feel like a student, but graduation definitely feels a little bit closer now.” Others remarked on the fact that soon a team of healthcare providers would be looking to them to make decisions. A student described this realization, writing, “[I had] a sort of weird realization that in a shorter amount of time than I can grasp, people will actually look to me to make decisions about the patient’s management.” The simulation prompted students to look at their timeline from an extracted perspective, where they were able to see themselves within a developmental process. Students reflected on the consequences of nearing the end of medical school, and what that would mean for their PIF.

The simulation seemed to bi-directionally prompt students’ feelings of wanting to own their patients and contemplation of their role as a physician. It allowed students to experience feelings associated with the performance of the role of a physician, as well as, feelings of patient ownership; two feelings they are not often given the opportunity to experience as third-year students. These two concepts (professional identity and patient ownership) appear to be inextricably linked, with one prompting the other. By taking ownership of the simulated patient, students began to contemplate their PIF, and by having the opportunity to experience the role of a physician, students felt greater patient ownership. One student discussed the relationship this way, “I think the moment the patient asked me ‘What’s wrong with me doc?’ was when that feeling of ownership kicked in.” Another student described the relationship between ownership and PIF as an inverse process: “I felt ownership when I was the one in the room with the patient. . . and I had to consult [other] physicians to help me.” By placing students in the role of a physician, the students began to feel a sense of responsibility and ownership for the patient. Likewise, when they experienced the feeling of ownership over a patient, they also felt more like a physician.

The qualitative data show active reflections on the students’ part and it is important to discern if different factors (clerkship block and prior clinical experience) impacted how students expressed these reflections, especially since students’ responses were coded for individual elements more frequently. The quantitative results indicated there was no statistically significant interaction between clerkship block and prior clinical experience on the combined dependent variables of IES and CES (F(2,71) = 0.309, p = 0.735; Wilks’ Λ = 0.991). However, there were significant between-subject effects between clerkship block and IES (p = 0.038), and prior clinical experience status and IES (p = 0.036). Results of the two independent samples t-tests showed that students who had just completed the in-patient clerkship block had significantly higher IES (2.65, + 0.897) compared to students who had completed the out-patient clerkship block (2.18 + 0.727) at p = 0.017. Students who did not have prior clinical experience before their clerkships had statistically significant higher IES (2.63 + 0.761) compared to students who did have prior clinical experience (2.14 + 0.932), at p = 0.017.

Discussion

The qualitative results of this study demonstrate that professional identity formation (PIF) and patient ownership are two interrelated concepts, and that both can be facilitated through simulation. Because PIF and patient ownership are such integral and complex developmental processes for medical students, having a safe, controlled, and standardized modality through which to facilitate growth is of enormous importance. This finding is a significant contribution the field of simulation research, as well as to educators and administrators who seek to leverage the maximum value that simulation has to offer.

The quantitative analysis conducted on the results of the content analysis further contribute to the understanding of how PIF and patient ownership are facilitated through simulation specifically. Students who completed the in-patient clerkship rotation block scored higher in IES after the in-patient high-fidelity simulation case. Medical students on in-patient clerkship rotations participate on the periphery of the medical team. However, during the simulation activity, while the setting was familiar, students were forced to transition from providing perfunctory contributions to directly managing patient care in their assumed role of the physician. This resulted in the more students processing the change more consciously and in terms of individual change (i.e., thinking, acting, and feeling like a physician). Students who had just completed their out-patient clerkship rotations may have experienced similar cognitive dissonance, but in an unfamiliar context, the change was not expressed through the frame of individual elements.

Another quantitative result identified the effect of students’ clinical experiences prior to beginning their clerkships. The prior clinical experiences students cited in the survey instrument included roles such as shadowing or scribing. These activities are primarily observational in nature, and as a result, the students who previously shadowed or scribed developed a limited mental model of the role of a physician without active participation in the medical team. This superficial level of familiarity gave students an awareness of the context of a medical setting, but not the experience in a participatory role. Examined along with the higher IES for students who completed the in-patient clerkship block, one might conclude that prior observation provides a cursory understanding of care management without the more fully-developed framework that comes from assuming a role on the medical team. A potential explanation is that superficial exposure of prior clinical observations and the resulting illusion of deep understanding may have prevented the necessary and transformative cognitive dissonance of transitioning from peripheral to central participation, which may be what led to the higher expression of IES for students on the in-patient block.

The most coded individual element was “feeling like a physician” While this higher frequency cannot result in prescriptive simulation practices by itself, it is further evidence that PIF can be facilitated through simulation by the promotion of patient ownership. The most common contextual element was “people in the simulation.” This higher frequency could inform the design of simulations intended to promote PIF, as the presence of confederates in the case facilitated students’ experience of “feeling like a physician.” However, regardless of whether patient ownership and PIF are explicit goals of a simulation for medical students, awareness of the developmental process experienced by participants can lead to more intentional, responsive case design.

Debriefing is an area with potential design implications. The current model of simulation debriefing guides participants through initial reactions and questions about the clinical components of the case, focusing on reflection on performance and how to improve in the future (Cheng et al., 2014; Fanning & Gaba, 2007). In light of this study, debriefing could be well-suited to purposeful explorations of the ways in which the simulation affected participants’ views of themselves and their roles within the context of PIF.

Conclusion

When medical students felt like a physician, they took ownership of their patients. When they took ownership of their patients, they felt like a physician. Simulation has long been recognized as a valuable tool for developing clinical skills and teamwork behaviors, but it also fosters PIF and a sense of patient ownership. By introducing simulation activities earlier in medical education, students will be provided with opportunities to develop patient ownership earlier, allowing for a fuller, more mature development process.

The topics of patient ownership and PIF in simulation is an area of great importance and an opportunity for future research. Presently, patient ownership is largely studied only in residency (Eaton, 2005; Hamstra, Woodrow, & Mangrulkar, 2007) with only occasional of studies of medical students in their clerkships (Wyatt et al., 2016; Wyatt, Egan, & Wood, 2018). Future research should more deeply examine student experiences of patient ownership and PIF in simulation, as well as the relationships of observational and participatory clinical experiences on these development processes.

Simulations may allow medical students to monitor their progress through the internal development of patient ownership and professional identity formation. These processes are imperative to the success of a practicing physician (Cruess et al., 2016; Wyatt, in press). Of course, not all simulations are created equal, which makes it imperative that the quality of the simulation design and debriefing process be standardized and crafted with reflective questions. By designing simulation activities with this in mind, educators and administrators can better facilitate the productive transition of student to physician.