Professional Identity Formation, ProfessionaLism, Leadership And Resilience (PILLAR) in Medical Students: methodology and early results

doi:10.21203/rs.3.rs-1527305/v1

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Professional Identity Formation, ProfessionaLism, Leadership And Resilience (PILLAR) in Medical Students: methodology and early results

https://doi.org/10.21203/rs.3.rs-1527305/v1

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Background

The fundamental role of medical education is the transformation of student to doctor, through a process of education and professional identity formation (PIF), which can be informed by several educational, behavioural and emotional factors. PIF has been deemed to be of equal importance to the acquisition of clinical knowledge and skills, and includes constructs such as professionalism, leadership and resilience. We aimed to assess PIF, ProfessIonaLism, Leadership And Resilience (PILLAR) in the junior years of medical school in the 2020/2021 academic year and illustrate the potential role of quantitative assessment to demonstrate progression in these areas. In this research, we provide the methods and baseline results for the PILLAR study.

Methods

We implemented a compulsory assessment in pre-clinical years of graduate entry and direct entry medicine in the RCSI University of Medicine and Health Sciences, Dublin, Ireland. Validated scales were used to assess students’ PIF, professional behaviours, resilience and leadership. Descriptive and univariable statistical techniques were used to compare student scores between respective years.

Results

1,311 students (92% response rate) provided their consent for research. For the psychometric scales, there were no evident trends among years on these assessment measures. Results indicated significant differences in all measures however, these did not correspond to ascending year of seniority.

Conclusion

While PIF is considered difficult to assess, PILLAR may indicate a formal mechanism of quantitative assessment, while also allowing students to track their own progress over time in relation to their peers. The lack of a clear sequential pattern from junior to more senior years may indicate the need for more formal curriculum input into each of these areas.

Medical Education Research

Professionalism

Progress Testing

The fundamental role of medical education is the transformation of student to doctor, through a process of education and professional identity formation (PIF). The paradigm of PIF is complex, multi-factorial and closely linked to societal expectations, and both personal and social identity (1). It has been described as a core component of post-Flexnerian medical education (2, 3) and can be significantly impacted by university programmes (4, 5). Professional identity may be defined as “A representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting, and feeling like a physician”(3). In order to support the development of a professional identity in medical education, a cognitive base should be included as an educational objective in the formal curriculum and students should be engaged in the development of their own identities (6, 7). Specifically, experiences during clinical education have been identified as key contributors to the student’s development of their professional identity (8, 9).

The theoretical framework which underpins PIF recognizes the importance of facilitation of student engagement with communities of practice, emphasizing the social nature of learning (10). This framework proposes that learning is a social activity that takes place in communities, which are heavily influenced by history and culture (11, 12), and that full participation requires the achievement of community-determined standards of competence within the chosen domain (practice of medicine) (13). If PIF is to be a significant educational objective, robust assessment or indicators of its achievement should be established (7). Historically, the summative assessment of professional behaviours has been used as a surrogate for PIF (7), supplemented by formative methods in which learners are asked to chart their own progress over time. However, there is a dearth of literature relating to quantitative assessment of PIF, with the majority of research into professional identity conducted using qualitative methods (5). Medical schools need further information on the assessment of PIF and its subcomponents so that students are appropriately supported to develop their professional identity.

Professionalism, emotional resilience, and leadership are key elements in forming a personal and professional identity (1, 14). In addition to supporting the development of a professional identity, teaching professionalism is considered a key aspect of medical education (15, 16). Notably, unprofessional behaviors can now warrant dismissal from medical school (17). The need to strengthen the assessment of professionalism has been highlighted, and that method of assessment should match the definable elements of professionalism (18) in terms of its individual, inter-personal and societal dimensions, resulting in a need to consider multidimensional assessment (19). Along with the characteristics of professionalism, future doctors will need to have leadership capability in order to influence and manage change on the front line of healthcare (20). Concerningly, reports suggest a lack of leadership training at undergraduate level (21). For medical schools that incorporate leadership development programmes, the majority evaluate their learning through self-assessment or self-report measures (22, 23). To our knowledge, leadership has not yet been assessed as a core component of PIF, or its potential contribution to PIF identified.

Learning the key skills of emotional resilience is also core to the development of PIF. Resilience is defined as the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioural flexibility and adjustment to external and internal demands (24). Medical school is challenging and educators have recognised that the stress of medical school can be significant, including impact from academic pressures, educational debt, personal life events, gender identity, learning environment, and exposure to human suffering (25, 26). There is an increasing recognition of the importance of self-awareness and self-care for the health and well-being of healthcare professionals (27), brought into sharper focus by the COVID-19 pandemic (28). It has been suggested that robust professional identity development could also prove protective against medical burnout (29) by making physicians more resilient. However, assessment of resilience in medical students and the potential correlation with PIF has yet to be determined.

Aim

The study aimed to develop a method for the assessment of PIF, ProfessionaLism, Leadership And Resilience – the PILLAR assessment. We aim to report this method and explore differences among years on the outline constructs.

Our main objectives were to descriptively examine PIF, ProfessionaLism, Leadership And Resilience across a cohort of medical students. Our second objective was to examine if there was a relationship between these measures and the year of medical training of the students. Ethical approval was sought and obtained from the Research Ethics Committee of the RCSI prior to conducting the study (REC202005016).

All methods were carried out in accordance with relevant guidelines and methodology approved by the RCSI Research Ethics Committee. The methods are reported in accordance with the STROBE checklist for reporting results of cross-sectional observational studies (30).

Design

The study was a baseline cross-sectional assessment of the entire cohort of medical students in the RCSI University of Medicine and Health Sciences, Dublin, using established quantitative measures. At the RCSI, there is a five-year Direct Entry Medicine (DEM) programme, along with a four-year Graduate Entry Medicine (GEM) programme. DEM and GEM classes combine for the final two senior years. Furthermore, there is a Foundation Year programme completed by a proportion of students (approximately 50%) prior to commencing the DEM programme. Due to the involvement of a large cohort of students (entire years), it was decided that an online assessment would be the optimal method for data collection.

In selecting measures to ensure a comprehensive assessment was performed, selected scales were required to have appropriate content and psychometric validity. Length of each measure was also a key concern to be mindful and respectful of students’ time, especially to facilitate future longitudinal study, and to ensure satisfactory completion rates. A 76-item questionnaire (Appendix A) was compiled, combining four validated scales along with a selection of demographic questions.

Following completion of a pilot study (n = nine participants), where it was identified that no major changes to the format were required, the PILLAR study assessment was embedded within modules in each pre-clinical year as a core element of the professionalism curriculum. While completion of PILLAR was compulsory, students gave voluntary, fully informed consent (or not) for their data to be used for research purposes, as per previous research (31, 32). The assessment responses were anonymised. Akin to progress testing, we incorporated a student feedback loop providing students with their individual responses to each question along with general feedback on the results (class averages).

Data Collection

PILLAR was administered by the RCSI Quality Enhancement Office (QEO), who acted as the study’s independent data controllers, using online survey software. PILLAR was pseudonymised in order to assign respective credits to students for completion. On receipt of responses, the QEO fully anonymised the results so that any identifiable data had been erased prior to transfer of data to study research team.

In advance of the administration of PILLAR and invitations to participate being sent to students, the study investigators gave brief presentations to each year introducing the assessment. At those class times, the QEO sent out an automated, personalised email to every eligible student with an individualised link to complete the assessment as part of the assigned module, followed by two weekly reminders. The individualised link took participants to an online participant information leaflet and consent form where they consented or declined that their information may be used for the purposes of research.

Sample

During September 2020 and February 2021 all students in Foundation Year (pre-medicine; FY) and Years 1–3 of direct-entry undergraduate medicine and Years 1 and 2 of graduate-entry medicine (GEM) completed the assessment and were invited to participate in this study (n = 1,427).

Measures

Measures incorporated in the assessment included a measure of each of the core PILLAR constructs of professional identity formation, professionalism, resilience, leadership, as follows:

Professional Identity Formation (PIF)

PIF was assessed using a 9-item questionnaire with nine themes, which included common domains of professional activity for healthcare professionals (33). The themes were team working, communication, patient or client assessment, cultural awareness, ethical awareness, using patient or client records, dealing with emergencies, reflective practice and teaching. Participants were asked to indicate on a scale of 0 (indicating 1st day student doctor) to 6 (indicating a newly qualified doctor) how they would feel at present undertaking a list of nine activities, with each activity reflecting one of the nine themes. A higher mean score reflected a higher professional self-identity score.

Through feedback from our pilot study, it was decided to include one further item relating to PIF: ‘I feel like a member of the medical profession’ to which participants were given five response options from strongly disagree to strongly agree, with lower scores indicating lower levels of PIF.

Professionalism

The scale for professionalism examined both student perceptions of and participation in unprofessional behaviours (34). Participants were asked to consider twenty-five statements and then answer if they have observed the behaviour, participated in the behaviour and state whether they felt the behaviour was professional or not. For each behaviour listed, descriptive statistics were used to describe student observation of, participation in, and perception of the behavior as unprofessional.

Leadership

We used the Medical Leadership Competency Framework (MLCF), which outlines the competencies expected of practicing clinicians (20). The MLCF has been demonstrated to aid curriculum design, highlight individual strengths and development areas through self-assessment, and assist with personal development planning and career progression (20). Participants were asked to self-assess in two areas only – demonstrating personal qualities and working with others, totaling 15 items. We assigned a scoring system to identify the average for each domain where A Lot of the Time = 2, Some of the Time = 1 and Very Little /None of the Time = 0, with higher total scores indicating higher levels of leadership.

Resilience and wellbeing

Two measures were chosen to investigate resilience and wellbeing - the Brief Resilience Scale (BRS) and the EPOCH Measure of Adolescent Well-Being (35, 36). The BRS was chosen to measure resilience because it is a short, validated measure that is simple and widely used (37, 38). Participants are asked to self-assess on a 5-point Likert scale of agreeableness against six specific statements describing their typical response in relation to bouncing back or recovering from stress, with higher scores indicating greater resilience (35). EPOCH measures five positive psychological characteristics which together support higher levels of well-being: engagement, perseverance, optimism, connectedness and happiness. This measure is composed of 20 items, with item responses rated on a 5-point scale ranging from 1 for ‘never’ to 5 for ‘always’. Scores are calculated for each domain as the average of the four items (36).

Data analysis

Stata v.16 was used for cleaning and statistical analyses (39). Descriptive statistics were used to profile demographic characteristics of participants. Means and standard deviations were calculated for continuous variables and total scale scores. Linear regression analysis was carried out to explore potential differences across years.

1,427 students were invited to complete the PILLAR assessment, with n = 1,331 (93%) students responding and n = 1,311 (92%) consenting to their data being used for research. Sample descriptive statistics are presented in Table 1. Mean age was 22 ± 3.0 years with just over half of participants being female. In terms of country of origin, the majority of students were from four individual regions/countries, the Middle East (29%), North America (21.3%), Ireland (16.5%) and Malaysia (11.5%), reflecting the diversity of our student population.

Table 1

Participant demographics
Demographics	Foundation Year	Year 1	Year 2	Year 3	GEM 1	GEM 2	Overall
Consented Responses /Recipients Response Rate	158 /182 87%	362 /388 93%	329/353 93%	293/ 327 89%	81/87 93%	88 /90 98%	1311/1427 92%
Age (years) Mean (SD)	19 (± 1.7)	21 (± 2.9)	22 (± 2.8)	22 (± 2.5)	24 (± 2.1)	26 (+ 3.4)	22 (± 3.0)
Gender Male Female Non-Binary /Prefer to self-describe / Prefer not to say	n = 78 (44%) n = 71 (46%) n = 5 (4%)	n = 156 (44%) n = 199 (55%) n = 4 (1%)	n = 133 (40%) n = 191 (58%) n = 5 (2%)	n = 116 (40%) n = 166 (58%) n = 5 (2%)	n = 39 (48%) n = 42 (52%) --	n = 34 (38%) n = 52 (59%) n = 3 (3%)	n = 556 (43%) n = 721 (56%) n = 21 (1%)
Nationality /Region of Origin Ireland North America Malaysia Middle East Other	n = 5 (3%) n = 30 (20%) n = 2 (1%) n = 92 (60%) n = 24 (16%)	n = 49(13%) n = 38(11%) n = 53 (15%) n = 128(36%) n = 90 (25%)	n = 46(14%) n = 53(16%) n = 65(20%) n = 84(25%) n = 81(25%)	n = 48(17%) n = 51(18%) n = 39(14%) n = 91(31%) n = 58(20%)	n = 28(35%) n = 41(51%) n = 1(1%) n = 1(1%) n = 10(12%)	n = 20(23%) n = 52(58%) n = 0 n = 2 (2%) n = 15(17%)	n = 230(16.5%) n = 297(21.3%) n = 162(11.5%) n = 411(29.4%) n = 297(21.3%)
Total	n = 158	n = 362	n = 329	n = 293	n = 81	n = 88	n = 1,311
GEM: Graduate Entry Medicine; SD: Standard Deviation

Table 2 provides means and standard deviations of each scale by year of medical training. Table 3 provides results of the regression analysis by year of intake, using Foundation Year (FY) as the comparator group. In comparison to FY, GEM1, GEM2 and Year 1 had significantly higher resilience scores, but this pattern was not seen for Year 2 or Year 3. GEM2, Year 2 and Year 3 had significantly lower engagement scores, with Year 2 and Year 3 also having significantly lower perseverance and optimism scores than FY. Only GEM1 had higher connectedness scores, while only Year1 had higher happiness scores. In terms of leadership (working with others), there were no significant differences from FY, except that Year 3 had lower scores. GEM1 and GEM2 had higher leadership (personal qualities) scores, but there were no differences among DEM years compared to FY. The PIF results indicated that GEM1 were less likely to report feeling like a member of the medical profession than FY. They were also less likely to rate themselves as feeling like a qualified doctor than FY, whereas GEM2 and Year 3 scored higher than FY on this scale. Overall, there was no clear consistent evidence of increasing or decreasing scores by cohort.

Table 2

Means and standard deviations for each variable of interest when stratified by year of assessment.
Mean (SD)	BRS	EPOCH Engagement	EPOCH Perseverance	EPOCH Optimism	EPOCH Connectedness	EPOCH Happiness	Leadership Working with others	Leadership Personal Qualities	PIF 1 Member of Medical Profession	PIF 2 1st day student Dr – Qualified Dr
FY	3.16 (± 0.68)	3.00 (± 0.77)	3.57 (± 0.88)	3.48 (± 0.95)	4.04 (± 0.88)	3.31 (± 0.97)	1.63 (± 0.30)	1.48 (± 0.28)	3.44 (± 1.03)	1.64 (± 1.55)
Year 1	3.36 (± 0.80)	2.89 (± 0.77)	3.63 (± 0.77)	3.51(± 0.85)	4.14 (± 0.85)	3.50 (± 0.85)	1.60 (± 0.33)	1.50 (± 0.33)	3.66 (± 0.99)	1.61 (± 1.38)
Year 2	3.23 (± 0.75)	2.81 (± 0.88)	3.29 (± 0.88)	3.19 (± 0.95)	3.92 (± 0.93)	3.18 (± 0.97)	1.60 (± 0.33)	1.46 (± 0.32)	3.53 (± 0.93)	1.90 (± 1.31)
Year 3	3.10 (± 0.8)	2.79 (± 0.88)	3.38 (± 0.89)	3.22 (± 0.95)	3.92 (± 0.97)	3.18 (± 0.96)	1.53 (± 0.36)	1.45 (± 0.33)	3.49 (± 1.01)	1.81 (± 1.31)
GEM 1	3.57 (± 0.68)	2.98 (± 0.74)	3.71 (± 0.76)	3.43 (± 0.80)	4.41 (± 0.66)	3.47 (± 0.85)	1.60 (± 0.29)	1.57 (± 0.56)	3.01 (± 0.98)	0.91 (± 0.80)
GEM 2	3.51 (± 0.72)	2.64 (± 0.78)	3.40 (± 0.83)	3.39 (± 0.87)	4.16 (± 0.85)	3.30 (± 0.90)	1.61 (± 0.34)	1.55 (± 0.27)	3.46 (± 0.84)	2.11 (± 0.88)
Com-bined Total	3.27 (± 0.75)	2.84 (± 0.83)	3.47 (± 0.85)	3.34 (± 0.92)	4.06 (± 0.90)	3.30 (± 0.94)	1.60 (± 0.33)	1.49 (± 0.31)	3.51 (± 0.98)	1.81 (± 1.36)
BRS: Brief Resilience Scale; PIF: Professional Identity Formation; FY: Foundation Year; GEM Graduate Entry Medicine

Table 3

Beta coefficients and 95%ile confidence intervals for the relationship between year of assessment and each variable of interest.
	BRS	EPOCH Engagement	EPOCH Perseverance	EPOCH Optimism	EPOCH Connectedness	EPOCH Happiness	Leadership Working with others	Leadership Personal Qualities	PIF Member of Medical Profession	PIF 1st day student Dr – Qualified Dr
FY	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Year 1	0.206* (.066, .345) 0.004	− .105 (-.260, .0503) 0.185	.058 (-.104, .217) 0.488	.038 (-.135, .211) 0.666	.137 (-.0324, .306) 0.113	.184† (.009, .359) 0.040	− .028 (-.092, .035) 0.380	.0256 (-.033, .085) 0.394	.218† (.032, .405) 0.022	− .024 (-.290, .243) 0.862
Year 2	0.0694 (-.072, .211) 0.337	− .180† (-.338, − .023) 0.025	− .282* (-.444, − .119) 0.001	− .284* (-.459, − .109) 0.001	− .114 (-.286, .057) 0.191	− .135 (-.313, .043) 0.136	− .030 (-.094, .035) 0.368	− .021 (-.080, .039) 0.493	.092 (-.097, .280) 0.342	.263‡ (-.006, .533) 0.056
Year 3	-0.0592 (-.204, .086) 0.423	− .197† (-.358, − .037) 0.016	− .185† (-.351,-.019) 0.029	− .259* (-.439,-.080) 0.005	− .0932 (-.268, .082) 0.296	− .129 (-.310, .053) 0.165	− .097† (-.170, − .031) 0.004	− .025 (-.086, .036) 0.414	.049 (-.144, .242) 0.620	.175 (-.099, .448) 0.210
GEM 1	0.417* (.219, .615) < 0.001	− .0198 (-.241, .201) 0.860	.132 (-.097, .362) 0.259	− .045 (-.290, .200) 0.718	.380* (.138, .621) 0.002	.153 (-.097, .402) 0.230	− .035 (-.126, .056) 0.450	.090* (.007, .174) 0.007	− .428* (-.693, − .164) 0.002	− .730* (-1.104, − .356) 0.000
GEM 2	0.352* (.159, .545) 0.000	− .346† (-.561, − .132) 0.002	− .175 (-.396, .046) 0.121	− .087 (-.325, .151) 0.473	.129 (-.105, .363) 0.280	− .0183 (-.261, .224) 0.883	− .0190 (-.107, .069) 0.673	.0758‡ (-.005, .156) 0.065	.020 (-.237, .276) 0.879	.476† (.102, .850) 0.013
* p < 0.01, † p < 0.05, ‡ p < 0.1

Appendix B shows the results of the professionalism scale and indicates in each year what percentage of students perceive the respective statements as unprofessional behaviour. This Table also includes the percentages of students who have A) Observed and or B) Participated in the behaviour statements. Overall, ≥ 75% of the entire cohort deemed that 19 out of the 25 behaviours were unprofessional. 90% of FY students responded being Intoxicated at school events as being unprofessional in comparison with 73% of Year 3 students. There was a similar difference between Year 1 and Year 3, with 90% DEM 1 and 75% of Year 3 participants identifying Using workrooms for nonclinical activities as being unprofessional behaviour; 52% of Year 3 students reported being absent from mandatory lectures as unprofessional in contrast with 24% of Year 1 students.

This study presents the development of a method for the quantitative assessment of PIF, professionalism, leadership and resilience in a large group of medical students. 1,311 (92%) eligible participants consented to their data being used for research. Results indicate that student engagement, connectedness and happiness may decrease as student’s progress through medical school. In addition, results suggest that students’ opinion of their leadership skills decrease in relation to ascending year of seniority. Regression analysis demonstrated significance amongst years on certain variables, however, there was no clear consistent evidence of increasing or decreasing scores by cohort.

Strengths and Limitations

To our knowledge this is the first time PIF, professionalism, leadership, and resilience have been assessed in combination across a large cohort (n = 1,427) of medical students and thus a range of perspectives attained. A strength of our cohort was that it included a wide range of nationalities (n = 52). Through our methodology, we ensured an excellent response rate (93%), reducing the study’s non-response bias and strengthening the results. A further strength of this study is that most other research in this area is purely qualitative (5). This study establishes PILLAR as a method to quantitatively assess the four areas of interest and has demonstrated the feasibility of administering a combination of validated scales. It also shows PILLAR’s future potential to test the effectiveness of curricular interventions in these areas as part of formative feedback and summative assessment. The longer-term aim will be to assess each of the areas of interest over time, akin to progress testing.

A limitation of this research is that a cross-sectional study of this kind can only imply association, not causation. However, future work will demonstrate the longitudinal progress of students in these areas. It is important to note that the assessment was not carried out at the same time or place for all participants, which may have affected results. We have identified that the validated scales do not seem to discriminate consistently among the years. It is unclear as to why this is but it could be attributed to cohort effects, changing curriculum or a lack of formalised curricular input on each of these concepts. Future iterations of PILLAR, with longitudinal data for each student, will shed light on these issues.

In the years 2020 and 2021, when this research was carried out, the fundamental principles of professionalism, leadership and resilience have all been tested as never before. The emergence of COVID-19 has had an impact on global health and society that is unprecedented in modern times. In addition, it has significantly disrupted medical education and demanded rapid attention from medical educators (40, 41). Furthermore, the ‘hidden’ medical learning environment has changed with the learning opportunities from interactions with faculty, peers, patients and university staff being modified or limited. PILLAR was conducted in this context, so it may have influenced the results. This will become clearer in future iterations of the assessment.

Despite the limitations outlined above PILLAR can offer important insights. Evidence from other research indicates that attitudes to professionalism can worsen over medical school training and some of our results are supportive of this (16, 42). A key assessment theme found across medical school institutions is the ability of the student to be self-reflective (42) and the PILLAR assessment does facilitate student’s self-reflection, which will be strengthened when PILLAR is repeated in upcoming years. Therefore, while there is an extensive literature on the teaching and assessment of PIF, there is a significant need to explore its quantitative assessment and its subcomponents, over time. This process of assessing students repeatedly and combining their results on these assessments, referred to as “progress testing”, has been demonstrated to be a valuable way of making predictions about future competence and/or performance (43). The next iteration of this study plans to explore whether the principles of progress testing can also be applied to quantitative PIF assessment.

The PILLAR methodology provides important information on the challenges of quantitatively assessing medical students in the four key areas of professionalism, leadership, resilience and professional identity formation, serving as a “progress test”. In medical education, we have an obligation to ensure that the next generation of clinicians have the resilience, leadership skills and professional behaviours to deliver/ provide safe and high quality health care. In addition to this, there is a curriculum need to identify a method to quantitatively assess these key areas. PILLAR presents one mechanism to illustrate student progression in these areas in a quantitative manner.

PILLAR: Professional Identity Formation, ProfessionaLism, Leadership And Resilience

PIF: Professional Identity Formation

STROBE: Strengthening the Reporting of Observational Studies in Epidemiology

DEM: Direct Entry Medicine

GEM: Graduate Entry Medicine

QEO: Quality Enhancement Office

FY: Foundation Year

MCLF: Medical Leadership Competency Framework

BRS: Brief Resilience Scale

EPOCH:

SD: Standard Deviation

RCSI: Royal College of Surgeons in Ireland, University of Medicine and Health Sciences.

Ethics Approval and Consent to Participate

Ethical approval was sought and obtained from the Research Ethics Committee of the RCSI prior to conducting the study (REC202005016). Fully informed consent was obtained from all subjects.

Consent for publication

Not applicable

Availability Data Materials

The data that support the findings of this study are available from the corresponding author but restrictions apply to the availability of these data, which were used with permission for the current study, and so are not publicly available. Data is however available from the authors upon reasonable request and with permission of RCSI Research Ethics Committee.

Competing Interest

The authors declare that they have no competing interests.

Funding

Dr Ryan’s role is supported by the Bons Secours Health System. The Bons Secours Health System had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors’ Contributions

AR, AH, and FD conceived the idea and study design. AR completed acquisition and cleaning of the data, conducted analysis, interpreted the data, drafted and revised the manuscript. AH and DWH advised on interpretation of the data along with contributing to drafting and revising the manuscript. FB gave specific advice on Stata and statistical analysis along with contributing to drafting and reviewing the manuscript. MEC gave specific advice on Leadership along with reviewing the manuscript. FD oversaw all aspects of the study and specifically advised on study design, analysis and write-up. All authors were involved in writing and approved the final manuscript.

Acknowledgements

We acknowledge our pilot participants who provided very valuable feedback on the data collection materials. We are very grateful to all our student participants in the study along with the RCSI Quality Enhancement Office who acted as independent data controllers. We would also like to acknowledge the advice from Dr Colm Healy (RCSI) and Dr Catherine Nora Moran (RCSI) on the development of this paper.

Notes on Contributors

Aine Ryan, BSc (Physio), MSc, PhD, PGDip HPE, MISCP. is a Postdoctoral Fellow in Professionalism & Honorary Lecturer at RCSI University of Medicine and Health Sciences, Dublin. ORCID: https://orcid.org/0000-0002-9259-9799

Anne Hickey PhD, AFPsSI, Reg.Psychol.PsSI is a Professor of Psychology and Deputy Dean for Positive Education at RCSI University of Medicine and Health Sciences, Dublin ORCID: https://orcid.org/0000-0003-0008-3195

Denis W.Harkin MB BCh BAO MD PGCHET FRCSI FRCS(Gen.Surg) FEBVS is a Consultant Vascular Surgeon & Chair of Medical Professionalism at RCSI University of Medicine and Health Sciences, Dublin. ORCID: https://orcid.org/0000-0002-4701-8350

Fiona Boland is Lecturer in Biostatistics and Research Methods at the RCSI Data Science Centre, Dublin. ORCID: https://orcid.org/0000-0003-3228-0046

Mary E. Collins, CPsychol, EdD. MSc. BA. AC. is a Senior Executive Development Specialist at the RCSI Graduate School of Healthcare Management, Dublin.

Frank Doyle, F. Ps.S.I is a Senior Lecturer at the Division of Population Health Sciences in RCSI University of Medicine and Health Sciences, Dublin. ORCID: https://orcid.org/0000-0002-3785-7433

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No competing interests reported.

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Professional Identity Formation, ProfessionaLism, Leadership And Resilience (PILLAR) in Medical Students: methodology and early results

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