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Medical education exists to prepare the physician workforce that our nation needs, but the COVID-19 pandemic threatened to disrupt that mission. Likewise, the national increase in awareness of social justice gaps in our country pointed out significant gaps in health care, medicine, and our medical education ecosystem. Crises in all industries often present leaders with no choice but to transform-or to fail. In this perspective, the authors suggest that medical education is at such an inflection point and propose a transformational vision of the medical education ecosystem, followed by a 10-year, 10-point plan that focuses on building the workforce that will achieve that vision. Broad themes include adopting a national vision; enhancing medicine's role in social justice through broadened curricula and a focus on communities; establishing equity in learning and processes related to learning, including wellness in learners, as a baseline; and realizing the promise of competency-based, time-variable training. Ultimately, 2020 can be viewed as a strategic inflection point in medical education if those who lead and regulate it analyze and apply lessons learned from the pandemic and its associated syndemics.

In current circumstances one rightfully wonders if persistence of SARS-Cov-2 will fundamentally alter the landscape of medical education and hospital training. Absent a vaccine, the prevalence of this virus adds to annual respiratory illnesses caused by seasonal influenza, respiratory syncytial virus, rhinoviruses, and other coronaviruses. Faced with a looming new-normal, many educators are ruminating on how best to ensure rigorous medical training that produces a steady stream of competent physicians. By way of background, the umbrella of medical education covers a highly structured curriculum in a variety of pre-clinical and clinical environments whose architecture and requirements are set by the Liaison Committee for Medical Education (LCME) ( 1 ) and the Accreditation Council for Graduate Medical Education (ACGME) ( 2 ). These requirements reflect established habits for producing quality outcomes. Capricious changes to these requirements can alter the carat of each uncut gem matriculating to medical school. And for this reason, students follow inviolate course work to their doctorate. Graduates can apply for state licensure to become physicians after receiving accredited training as interns and residents. Only later when seen serving a public good are physicians fully vested professionals. Such training can last 7-10 years. Modern training encompasses a well-thought-out system of educational milestones …

This chapter addresses the key education policy consequences that derive from implementation and management of mastery learning programs in the health professions. The chapter begins with framing statements about mastery learning policy consequences taken from two scholarly reports. It proceeds to discuss the benefits and challenges of mastery learning education policies regarding four stakeholder entities: learners, education programs, sponsoring organizations, and governing bodies and the healthcare system. A brief coda provides a chapter summary.

Construct: Students entering the health professions require competency in teamwork. Background: Although many teamwork curricula and assessments exist, studies have not demonstrated robust longitudinal assessment of preclerkship students' teamwork skills and attitudes. Assessment portfolios may serve to fill this gap, but it is unknown how narrative comments within portfolios describe student teamwork behaviors. Approach: We performed a qualitative analysis of narrative data in 15 assessment portfolios. Student portfolios were randomly selected from 3 groups stratified by quantitative ratings of teamwork performance gathered from small-group and clinical preceptor assessment forms. Narrative data included peer and faculty feedback from these same forms. Data were coded for teamwork-related behaviors using a constant comparative approach combined with an identification of the valence of the coded statements as either "positive observation" or "suggestion for improvement." Results: Eight codes related to teamwork emerged: attitude and demeanor, information facilitation, leadership, preparation and dependability, professionalism, team orientation, values team member contributions, and nonspecific teamwork comments. The frequency of codes and valence varied across the 3 performance groups, with students in the low-performing group receiving more suggestions for improvement across all teamwork codes. Conclusions: Narrative data from assessment portfolios included specific descriptions of teamwork behavior, with important contributions provided by both faculty and peers. A variety of teamwork domains were represented. Such feedback as collected in an assessment portfolio can be used for longitudinal assessment of preclerkship student teamwork skills and attitudes.

Trust plays a critical role in the assessment of learners in the clinical setting. In an ideal system, learners can be vulnerable and share their limitations and areas for improvement, while faculty possess the time and skill to provide specific feedback that enables learners to achieve competency in clinical skills. For medical students, a number of threats to the establishment of trust in the learning environment exist, including the interplay between feedback and grades, the existence of bias, and competing demands for faculty time. However, several strategies can help institutions to overcome these threats and foster a culture of trust related to assessment and assessment systems: Provide ungraded environments where learners are able to be vulnerable, cocreate assessments and assessment systems with faculty and learners, acknowledge and address bias, and provide faculty with adequate time and resources to employ best practices in assessment. By intentionally employing these strategies, our institutions can support trust in assessment systems and further learner growth and achievement.

PURPOSE As part of the American Board of Internal Medicine's (ABIM's) continuing effort to update its Maintenance of Certification (MOC) program, a content validity tool was used to conduct structured reviews of MOC exam blueprints (i.e., test specification tables) by the physician community. Results from the Cardiovascular Disease MOC blueprint review are presented to illustrate the process ABIM conducted for several internal medicine disciplines. METHOD Ratings of topic frequency and importance were collected from cardiologists in 2016 using a three-point scale (low, medium, high). The web-based survey instrument presented 188 blueprint topic descriptions, each combined with five patient-related tasks (e.g., diagnosis, treatment). Descriptive statistics and chi-square analysis were employed. RESULTS Responses from 441 review participants were analyzed. Frequency and importance ratings were aggregated as a composite statistic representing clinical relevance, and exam assembly criteria were modified to select questions, or items, addressing clinically relevant content only. Specifically, ≥ 88% of exam items now address high-importance topics, including ≤ 15% on topics that are also low frequency; and ≤ 12% of exam items now address medium-importance topics, including ≤ 3% on topics that are also low frequency. The updated blueprint has been published for test takers and provides enhanced information on content that would and would not be tested in subsequent examinations. It is linked to more detailed feedback that examinees receive on items answered incorrectly. CONCLUSIONS The blueprint review garnered valuable feedback from the physician community and provided new evidence for the content validity of the Cardiovascular Disease MOC exam.

Portfolios are a powerful tool to collect and evaluate evidence of medical students' competence across time. However, comprehensive portfolio assessment systems that are implemented alongside traditional graded curricula at medical schools in the United States have not been described in the literature. This study describes the development and implementation of a longitudinal competency-based electronic portfolio system alongside a graded curriculum at a relatively large U.S. medical school.In 2009, the authors developed a portfolio system that served as a repository for all student assessments organized by competency domain. Five competencies were selected for a preclerkship summative portfolio review. Students submitted reflections on their performance. In 2014, four clinical faculty members participated in standard-setting activities and used expert judgment and holistic review to rate students' competency achievement as "progressing toward competence," "progressing toward competence with some concern," or "progressing toward competence pending remediation." Follow-up surveys measured students' and faculty members' perceptions of the process.Faculty evaluated 156 portfolios and showed high levels of agreement in their ratings. The majority of students achieved the "progressing toward competence" benchmark in all competency areas. However, 31 students received at least one concerning rating, which was not reflected in their course grades. Students' perceptions of the system's ability to foster self-assessment were mixed.The portfolio review process allowed faculty to identify students with a concerning rating in a behavioral competency who would not have been identified in a traditional grading system. Identification of these students allows for intervention and early remediation.

Purpose Over one-third of U.S. medical schools offer combined baccalaureate/MD (BA/MD) degree programs. A subset of these truncate the premedical phase, reducing total time to the MD degree. Data comparing educational outcomes of these programs with those of conventional pathways are limited. Method The authors reviewed demographic characteristics and medical school performance of all 2,583 students entering Northwestern University Feinberg School of Medicine from 1999 to 2013, comparing students in the Honors Program in Medical Education (HPME), an accelerated seven-year program, versus non-HPME medical students. They evaluated Alpha Omega Alpha (AOA) selection, quintile performance distribution from the Medical Student Performance Evaluation, United States Medical Licensing Examination (USMLE) scores, and Match outcomes. Results A total of 560 students (21.7%) entered through the HPME. HPME students were on average 2.2 years younger and less likely (15/537 [2.8%] versus 285/1,833 [15.5%]) to belong to a racial/ethnic group underrepresented in medicine. There were no significant differences in AOA selection, quintile performance distribution, or USMLE scores. More HPME students entered internal medicine (161/450 [35.8%] versus 261/1,265 [20.6%]), and fewer chose emergency medicine (25/450 [5.6%] versus 110/1,265 [8.7%]) and obstetrics-gynecology (9/450 [2.0%] versus 67/1,265 [5.3%]). Conclusions The academic performances of medical students in the two programs studied were equivalent. Accelerated BA/MD programs might play a role in ameliorating the length and cost of a medical education. The academic success of these students absent the usual emphasis on undergraduate GPA and Medical College Admission Test scores supports efforts to redefine medical student selection criteria.

In 2012, the Northwestern University Feinberg School of Medicine launched a redesigned curriculum addressing the four primary recommendations in the 2010 Carnegie Foundation for the Advancement of Teaching report on reforming medical education. This new curriculum provides a more standardized evaluation of students' competency achievement through a robust portfolio review process coupled with standard evaluations of medical knowledge and clinical skills. It individualizes learning processes through curriculum flexibility, enabling students to take electives earlier and complete clerkships in their preferred order. The new curriculum is integrated both horizontally and vertically, combining disciplines within organ-based modules and deliberately linking elements (science in medicine, clinical medicine, health and society, professional development) and threads (medical decision making, quality and safety, teamwork and leadership, lifestyle medicine, advocacy and equity) across the three phases that replaced the traditional four-year timeline. It encourages students to conduct research in an area of interest and commit to lifelong learning and self-improvement. The curriculum formalizes the process of professional identity formation and requires students to reflect on their experiences with the informal and hidden curricula, which strongly shape their identities.The authors describe the new curriculum structure, explain their approach to each Carnegie report recommendation, describe early outcomes and challenges, and propose areas for further work. Early data from the first cohort to progress through the curriculum show unchanged United States Medical Licensing Examination Step 1 and 2 scores, enhanced student research engagement and career exploration, and improved student confidence in the patient care and professional development domains.

PURPOSE Medical educators struggle to find effective ways to assess essential competencies such as communication, professionalism, and teamwork. Portfolio-based assessment provides one method of addressing this problem by allowing faculty reviewers to judge performance, as based on a longitudinal record of student behavior. At the Feinberg School of Medicine, the portfolio system measures behavioral competence using multiple assessments collected over time. This study examines whether a preclerkship portfolio review is a valid method of identifying problematic student behavior affecting later performance in clerkships. METHOD The authors divided students into two groups based on a summative preclerkship portfolio review in 2014: students who had concerning behavior in one or more competencies and students progressing satisfactorily. They compared how students in these groups later performed on two clerkship outcomes as of October 2015: final grades in required clerkships, and performance on a clerkship clinical composite score. They used Mann-Whitney tests and multiple linear regression to examine the relationship between portfolio review results and clerkship outcomes. They used USMLE Step 1 to control for knowledge acquisition. RESULTS Students with concerning behavior preclerkship received significantly lower clerkship grades than students progressing satisfactorily (P = .002). They also scored significantly lower on the clinical composite score (P < .001). Regression analysis indicated concerning behavior was associated with lower clinical composite scores, even after controlling for knowledge acquisition. CONCLUSIONS The results show a preclerkship portfolio review can identify behaviors that impact clerkship performance. A comprehensive portfolio system is a valid way to measure behavioral competencies.

Importance Success on the internal medicine (IM) examination is a central requirement of the American Board of Internal Medicine’s (ABIM’s) Maintenance of Certification program (MOC). Therefore, it is important to understand the degree to which this examination reflects conditions seen in practice, one dimension of content validity, which focuses on the match between content in the discipline and the topics on the examination questions. Objective To assess whether the frequency of questions on IM-MOC examinations were concordant with the frequency of conditions seen in practice. Design, Setting, and Participants The 2010-2013 IM-MOC examinations were used to calculate the percentage of questions for 186 medical condition categories from the examination blueprint, which balances examination content by considering importance and frequency of conditions seen in practice. Nationally representative estimates of conditions seen in practice by general internists were estimated from the primary diagnosis for 13 832 office visits (2010-2013 National Ambulatory Medical Care Surveys) and 108 472 hospital stays (2010 National Hospital Discharge Survey). Exposures Prevalence of conditions included on the IM-MOC examination questions. Main Outcomes and Measures The outcome measure was the concordance between the percentages of IM-MOC examination questions and the percentages of conditions seen in practice during either office visits or hospital stays for each of 186 condition categories (eg, diabetes mellitus, ischemic heart disease, liver disease). The concordance thresholds were 0.5 SD of the weighted mean percentages of the applicable 186 conditions seen in practice (0.74% for office visits; 0.51% for hospital stays). If the absolute differences between the percentages of examination questions and the percentages of office visit conditions or hospital stay conditions seen were less than the applicable concordance threshold, then the condition category was judged to be concordant. Results During the 2010-2013 IM-MOC examination periods, 3600 questions (180 questions per examination form) were administered and 3461 questions (96.1%) were mapped into the 186 study conditions (mean, 18.6 questions per condition). Comparison of the percentages of 186 categories of medical conditions seen in 13 832 office visits and 108 472 hospital stays with the percentages of 3461 questions on IM-MOC examinations revealed that 2389 examination questions (69.0%; 95% CI, 67.5%-70.6% involving 158 conditions) were categorized as concordant. For concordance between questions and office visits only, 2010 questions (58.08%; 95% CI, 56.43%-59.72% of all examination questions) involving 145 conditions were categorized as concordant. For concordance between questions and hospital stays only, 1456 questions (42.07%; 95% CI, 40.42%-43.71% of all examination questions) involving 122 conditions were categorized as concordant. Conclusions and Relevance Among questions on IM-MOC examinations from 2010-2013, 69% were concordant with conditions seen in general internal medicine practices, although some areas of discordance were identified.

For the dean's letter to be valuable, it should be an objective and unabridged summary of the student's performance without obscuring or eliminating the very information that might predict difficulty in residency.

The landscape of combined baccalaureate-MD programs has changed substantially in the last two decades but has not been documented in detail. The authors review the current state of these programs and discuss opportunities for future study of their evolving role and potential impact.In 2011, using a definition of baccalaureate-MD program built on prior research, the authors reviewed Association of American Medical Colleges sources and medical school Web sites to identify and characterize 81 active programs. In addition, they surveyed the 57 medical schools offering those programs; 31 schools with 39 programs responded. The resulting database inventories the number and distribution of programs; institutional affiliations; missions or goals; length; size; admissions criteria; curricula; and retention requirements.Since the inception of combined programs in 1961, their number and curricular length have increased. Pressures that spurred earlier programs remain evident in the goals of today's programs: attract talented high school or early college students, especially from diverse backgrounds; prepare physicians to meet societal needs; and offer an enriched premedical environment. Baccalaureate educational activities achieve program goals through special courses, medical experiences, community service, and learning communities tailored to students' needs. Admission and retention criteria are comparable to those of traditional medical schools.Combined baccalaureate-MD programs have evolved along several paths during the last half century and have enriched the baccalaureate experiences of medical students. Shifting expectations for the selection and education of future physicians warrant focused research on these programs to document their effectiveness in addressing those expectations.

Goals in resident training ambulatory clinics include providing quality clinical care, research, and teaching. Achieving these goals is challenging. Our objective was to explore whether patients, r...

We sought to investigate the number of US medical schools utilizing portfolios, the format of portfolios, information technology (IT) innovations, purpose of portfolios and their ability to engage faculty and students.A 21-question survey regarding portfolios was sent to the 141 LCME-accredited, US medical schools. The response rate was 50% (71/141); 47% of respondents (33/71) reported that their medical school used portfolios in some form. Of those, 7% reported the use of paper-based portfolios and 76% use electronic portfolios. Forty-five percent reported portfolio use for formative evaluation only; 48% for both formative and summative evaluation, and 3% for summative evaluation alone.Seventy-two percent developed a longitudinal, competency-based portfolio. The most common feature of portfolios was reflective writing (79%). Seventy-three percent allow access to the portfolio off-campus, 58% allow usage of tablets and mobile devices, and 9% involve social media within the portfolio. Eighty percent and 69% agreed that the portfolio engaged students and faculty, respectively. Ninety-seven percent reported that the portfolios used at their institution have room for improvement.While there is significant variation in the purpose and structure of portfolios in the medical schools surveyed, most schools using portfolios reported a high level of engagement with students and faculty.

I believe that I am a competent physician. While I suppose that many people have an inflated sense of their own competence (and this is certainly true of physicians who consistently overestimate their performance on clinical quality indicators), this assessment is based, at least in part, on information from three reliable sources. First, our university-based internal medicine practice provides quarterly feedback to individual physicians on a number of quality measures. My results, compared both to my peers as well as to national standards, are comfortably above the mean. Second, the medical center provides us with patient satisfaction scores based on patient surveys. My scores have been consistently near the top. Third, as an active clinical teacher and preceptor, I have a thick portfolio of relatively decent teaching evaluations. I believe that they too provide insight into my clinical competence; certainly, physician-teachers with a poor grasp of medical reasoning or who have not kept up with the medical literature are unlikely to be assessed favorably. All of these measures are flawed and subject to one bias or another, but collectively, they give a consistently positive view of my competence as a general internist. What brings about this moment of self-reflection? Not anything as profound or potentially life altering as a mid-life crisis; instead, it was the more prosaic experience of taking the Maintenance of Certification (MOC) in Internal Medicine board exam. Every 10 years all internal medicine physicians who were board certified in 1990 or later must complete requirements for the MOC, including passing a comprehensive multiple-choice exam, in order to maintain their certification. I last had to re-certify about 10 years ago and had high hopes that there had been substantial improvement in the process in the intervening years; alas, I was disappointed to discover that not much has changed. I can now tell you what the ideal tidal volume is for an intubated patient with Acute Respiratory Distress Syndrome (ARDS). No doubt this is crucial clinical information—just not for me or for most other physicians like me. As a general internist who practices entirely in the ambulatory setting, I will never be responsible for ventilator settings, and in fact, I never was. Likewise, shortly before the test, on the advice of a colleague, I committed to memory the formula for calculating serum osmolality. While it was no great feat to re-install this formula back into my short-term memory bank (though I do find memorization a bit more challenging than I did 20 years ago), with the easy availability of formulas, clinical algorithms and guidelines on smartphones and tablets, having to commit these sorts of facts to memory for a multiple choice test is just plain dumb. My disappointment with the MOC exam extends beyond what we are expected to know, though I found much of it to be either irrelevant to my clinical practice or consisting of information that could be easily looked up. I was even more disappointed with the absence of what I consider to be the true core competencies of a general internist, the essential knowledge and skills required to take good care of medical outpatients. As a primarily outpatient-based general medicine physician, I spend much of my time working with patients to change their behavior—assessing and improving their adherence to medication, increasing their exercise, modifying their diet, etc. Of the 180 questions I had to answer in the daylong exam, not one tested my competency on that topic—or on any one of a dozen other topics essential to my clinical practice. Of the handful of questions on mental and behavioral health topics, there was not one that asked about the diagnosis and management of common depression or anxiety disorders, also core skills of a competent outpatient general internist. I suspect that my generalist colleagues who practice primarily in the inpatient setting also felt that much of the material to be mastered was not relevant to their clinical practice. This is one of the challenges that the American Board of Internal Medicine (ABIM) faces in trying to develop a ‘one size fits all’ approach to the MOC exam. Over the past decade, the algorithmic growth in medical information and the huge increase in patients with multiple, complex chronic medical problems, coupled with the increasing specialization of general internists as hospital medicine specialists or ambulatory medicine specialists, has made it more difficult to identify one common internal medicine knowledge base. Instead of sticking with an old paradigm that no longer reflects the current practice of internal medicine, the ABIM should continue to develop new ways of promoting and assessing engagement in clinical practice, such as it has done with the Practice Improvement Modules, Point of Care Clinical Question Module and a few others. While imperfect, these modules are more effective in engaging adult learners and in making the MOC relevant to their clinical practice than the current process. The ABIM states on their website that MOC “promotes lifelong learning and the enhancement of the clinical judgment and skills essential for high quality patient care.” While I (and others1) agree with the importance of lifelong learning for physicians and with the imperative of having an objective process by which a physician’s knowledge and skills are periodically assessed, it seems clear that the current MOC system, and the multiple choice exam in particular, fall far short of this goal. Multiple-choice questions are the wrong instrument to use for the assessment of diagnostic reasoning and other higher-level cognitive skills essential for competent patient care. Several articles in this issue of JGIM focus on physician education and clinical competence. One such paper, authored by Colla et al.2, examines clinical practice through the lens of the ABIM Foundation’s successful Choosing Wisely campaign. Using Medicare data from 2006 to 2011, they attempt to estimate the prevalence of 11 Choosing Wisely services by creating claims-based algorithms to identify low value services and in the context of geographic variation across regions. Perhaps not surprisingly, they found significant overuse of low-value services and substantial variation across different hospital systems. Low-value care was overused by both generalists and specialists in clinical services, such as the use of antipsychotics in patients with dementia and overuse of preoperative cardiac evaluation (a favorite topic, by the way, of the MOC exam). Many professional societies participated in the Choosing Wisely initiative, and in this issue, Riggs and Ubel3 reflect on the role of professional societies in limiting indication creep. In their provocative Perspective, they state that indication creep occurs when an intervention meant to benefit patients with a specific health condition is expanded to encompass either a new condition or a new population of patients. They go on to argue that, similar to the efforts of organized medicine to reduce waste through the Choosing Wisely campaign, professional societies should take the lead in preventing indication creep, either by not recommending interventions that go beyond existing evidence or by advocating for and facilitating new clinical trials when feasible. Perhaps the best strategy to get physicians to practice competent, high-value care is to train them earlier in the educational pipeline. One important aspect of quality of care in residency education has to do with patient ‘handoffs,’ either in the hospital or in the clinic. In this issue of JGIM, Pincavage et al.4 address the issue of handoffs in the outpatient setting. They describe an intervention conducted at an academic medicine residency clinic to improve the process for patients when they transition to a new resident physician. Two months prior to the transfer of care, they gave patients a packet of information that included a welcome letter and a photograph from their new primary care provider, as well as a visit preparation tool to help facilitate communication with their new doctor. The second phase of the intervention included a hand drawn “comic” titled “Mrs. B. Changes Doctors,” which they found more effectively captured patient’s attention and engaged them in the hand-off process. In an accompanying editorial, Bump5 points out that patient handoffs between residents in the clinic or on the wards may be detrimental to patient care. What remains to be seen, however, is whether this sort of ‘comic’ intervention can lead to a decrease in errors and adverse events. But perhaps the most important leverage point to improve patient care in the 21st century is described by Lin, Schillinger and Irby6 in a short piece on “value-added” medical education. They assert that value-added education has the potential to transform our approach to medical education by adhering to a set of five principles, including early integrated workplace learning for all medical students and the fusion of robust experiential learning experiences with the delivery of high-performing, patient-centered primary care. This is a bold approach to medical education that has the potential to transform our concept of what it means to be a competent physician in the 21st century. With this concept of “value added” education in mind, perhaps some day soon we will be assessing the competence of ambulatory-based general internists with a process that examines their ability to function effectively as members of a multi-disciplinary team in a patient-centered medical home. But for now, if asked about the tidal volume for a patient with ARDS, I’d go with 6–8 mL/kg of ideal body weight. Break a leg.

A long-standing ethos surrounds the practice of medicine. In that ethos physicians cannot fulfill their healing purpose without showing a high level of professionalism toward patients. It is part of medicine’s social contract, a contract through which scrutiny by public interest typically tells physicians how well they are doing and how well they have been taught. Medical educators within the span of modern memory still believe the careful selection of students maximizes the likelihood new learners, in addition to acquiring medical knowledge and skills, can understand and adopt traditional values of professionalism. Matriculating students harboring some sense of social responsibility are thought to be more inclined to embrace these values, particularly if they are shared by likeminded peers. Such principles include service, competency, altruism, integrity, promoting the public good, transparency, and accountability.

In this issue, Brenner and colleagues report a correlation between the frequency of negative comments in the "dean's letter" and future problems during a psychiatry residency program. Their study makes an important contribution to the body of literature on factors that predict professionalism-related performance issues during residency and suggests the importance of dependable data that can be used to predict and hopefully intervene early in the training of future physicians across all specialties. As we think about the implications of this study, important issues involving the standardization of medical student performance evaluations (MSPEs) and the assessment of professionalism are raised. Despite the Association of American Medical Colleges' 2002 guidelines for MSPEs, subsequent studies have revealed that considerable inconsistencies among the evaluations still remain. To enhance the accuracy and usefulness of the MSPEs in predicting "problem residents," improved standardization is necessary. Moreover, Brenner's findings call for the development of more vigorous assessment of professionalism in undergraduate medical education, as well as more accurate reporting of these assessments to residency programs. Longitudinal assessment of professionalism with robust tools allows for the identification and possible remediation of students early in their undergraduate training. Insofar as unprofessional behavior in medical school is predictive not only of problems during residency but also of later disciplinary action against the practicing physician by state medical boards, it is the obligation of the medical school to the residency program and to society to identify and report these behaviors.

Although professionalism has always been a core value in medicine, it has received increasingly explicit attention over the past several years. Unfortunately, the terms used to explain this competency have been rather abstract. This study was designed to identify and prioritize behaviorally based signs of medical professionalism that are relevant to patients, physicians, and nurses.The qualitative portion of this project began in 2004 with a series of 22 focus groups held to explore behavioral signs of professionalism in medicine. Separate groups were held with patients, inpatient nurses, outpatient nurses, resident physicians, and attending physicians from different specialties, generating a total of 68 behaviorally based items. In 2004-2006, quantitative data were collected through national patient (n = 415) and physician leader (n = 214) surveys and a statewide nurse (n = 237) survey that gauged the importance these groups attach to the behaviors as signs of professionalism and determined whether they are in a position to observe these behaviors in the clinical setting.The surveys of patients, physician leaders, and nurses provided different perspectives on the importance and visibility of behavioral signs of professionalism. Most of the behaviors were deemed very important signs of professionalism by at least 75% of patients, physicians, and/or nurses; far fewer were considered observable in the clinical setting.This study demonstrates that it is possible and instructive to define professionalism in terms of tangible behaviors. Focusing on behaviors rather than attributes may facilitate discussion, assessment, and modeling of professionalism in both medical education and clinical care.

Background Widely used models for teaching and assessing communication skills highlight the importance of greeting patients appropriately, but there is little evidence regarding what constitutes an appropriate greeting. Methods To obtain data on patient expectations for greetings, we asked closed-ended questions about preferences for shaking hands, use of patient names, and use of physician names in a computer-assisted telephone survey of adults in the 48 contiguous United States. We also analyzed an existing sample of 123 videotaped new patient visits to characterize patterns of greeting behavior in everyday clinical practice. Results Most (78.1%) of the 415 survey respondents reported that they want the physician to shake their hand, 50.4% want their first name to be used when physicians greet them, and 56.4% want physicians to introduce themselves using their first and last names; these expectations vary somewhat with patient sex, age, and race. Videotapes revealed that physicians and patients shook hands in 82.9% of visits. In 50.4% of the initial encounters, physicians did not mention the patient's name at all. Physicians tended to use their first and last names when introducing themselves. Conclusions Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names.