Amending Miller’s Pyramid to Include Professional Identity Formation

Abstract

In 1990, George Miller published an article entitled "The Assessment of Clinical Skills/Competence/Performance" that had an immediate and lasting impact on medical education. In his classic article, he stated that no single method of assessment could encompass the intricacies and complexities of medical practice. To provide a structured approach to the assessment of medical competence, he proposed a pyramidal structure with four levels, each of which required specific methods of assessment. As is well known, the layers are "Knows," "Knows How," "Shows How," and "Does." Miller's pyramid has guided assessment since its introduction; it has also been used to assist in the assessment of professionalism.The recent emphasis on professional identity formation has raised questions about the appropriateness of "Does" as the highest level of aspiration. It is believed that a more reliable indicator of professional behavior is the incorporation of the values and attitudes of the professional into the identity of the aspiring physician. It is therefore proposed that a fifth level be added at the apex of the pyramid. This level, reflecting the presence of a professional identity, should be "Is," and methods of assessing progress toward a professional identity and the nature of the identity in formation should be guided by currently available methods.

Social support in the workplace for physicians in specialization training

“…Professional identity can be seen as a representation of one’s self, which is formed over time in stages through an internalization of the norms, values, and characteristics of one’s medical profession [32]. Professional medical identity is dynamic, and it changes throughout one’s life and career [33]. When beginning one’s postgraduate medical studies, the process of positioning oneself as both a specialist and a future leader in the complex context of a healthcare organization becomes active [34].…”

Professionalism in Pathology: A Case-Based Approach as a Potential Educational Tool

“…12,13 Professional identity, which encompasses professional values and behavior, is developed gradually and continuously through the various life stages, adapting and changing over time. 14 For others, professionalism is more than a checklist of desirable behaviors, and is more attuned to a comprehensive ''belief system'' about how we (physicians practicing pathology) ensure that our members are worthy of the public's trust and how we hold each other accountable. 15 In this context, despite changes within and outside of the practice of medicine, physician organizations and groups act as ''moral agents'' by repeatedly and consistently reinforcing their mission and providing guidance in carefully crafted ethics and professionalism statements, policies, and position papers that set their moral tone.…”

O Ensino da Psicologia em Medicina: Contexto, Metodologias e Identidade do Médico

“…37 However, according to these authors, these levels are insufficient to describe a coherent integration of values and personal and professional attitudes, proposing the structure to conclude in a fifth level, called 'is' and that accurately translates 'self' or professional identity. 36 This identity includes behavioural knowledge and norms, taught and learned, but also values, attitudes, expectations of others and social norms in relation to the role of a doctor which, although flexible, varies according to his or her self, but also through external demands, the weight of the social organization and the health system in which he or she works. Due to the importance it plays in medical training, the development of identity should be considered a priority in teaching, leading therefore to the restructuring of objectives and goals to be achieved.…”

“…Students felt more attached to the concept of 'good doctor' perceiving professionalism as an external construct which was imposed on them, pointing out the need to address the link between what is taught on a formal level and what is experienced in the complexity of medical practice. 35 A particularly relevant issue for medical training within a sociocultural approach, is the construction of a professional identity that, according to Cruess et al 36 is structured in a pyramidal way integrating knowledge, skills, performance and actions. This is proposed by Miller in the sequence 'know' -'knows how' -'shows how' -'does' in regard to the evaluation of the doctor's competencies.…”