Jichi Medical University (JMU) is a private medical university founded in 1972 in Japan. The curriculum of JMU complies with the standardized model core curriculum outlining fundamental learning contents for undergraduate medical education in Japan . While the preclinical curriculum is partly integrated, it remains mostly stepwise. In JMU, students mainly learn clinical medicine in traditional didactic lectures before Year 4 to 6 (Y4-6) clinical clerkship. JMU students study liberal arts in the first and second trimesters of Y1. Lectures and experiments in basic medicine also begin in Y1 second trimester. Clinical medicine lectures start from Y2 second trimester. Before Y3 end, students finish almost all subject lectures in basic and clinical medicine. Each basic and clinical medicine class is capped by end-of-unit tests where lecturers create test items based on lecture content.
Y3 has seven sessions of one-day hybrid problem-based learning (PBL), each divided into four segments: morning case discussion for the formulation of self-study objectives, self-study period for research on objectives and preparation for afternoon discussion, afternoon discussion including within-group information sharing, and a 60-minute wrap-up lecture from a specialist.
Currently, students read the introductory part of a clinical scenario before PBL and preview morning discussion content. For example:
‘A 56-year-old man came to your hospital because he had 20-min anterior chest oppression after breakfast this morning. Please find clinical problems or possible differential diagnoses as best you can.’
The full story containing clinical history and findings is provided on the date of the PBL session.
PIF-oriented intervention platform
The core component of the PIF-oriented platform is composed of an online instruction video and an essay format. The instruction video aimed at encouraging students to articulate their future image as an independent medical professional tackling patient problems via life-long learning. The essay format meant to provide pre-PBL in-depth communication between students and their role models (Figure 1).
After watching the instruction video and reading the PBL scenario introductory, students were asked to answer the following essay questions:
Q1: Please formulate your future professional images, and articulate how useful this PBL case-study would be to you as a doctor responsible for this case.
Q2. Based on your answer for Q1, please articulate how you will optimize your self-study for this case to make this opportunity most meaningful.
Aside from these questions, students were asked to submit the professional identity essay (PIE)  three times during the research period. PIE is useful for helping learners articulate their values and norms about medical professionalism, and role model doctors provide feedback by referring to rubrics based on Kegan’s constructive developmental theory [21-23]. This study used a Japanese version of PIE (PIE-J) as a reference for role models’ feedback on Q1 and 2 and as an assessment tool for students’ professionalism levels (see also Instruments). The professional identity essay-based feedback was also aimed at the remediation of self-images with underdeveloped professionalism (low developmental stages in PIE) in the intervention group.
Those materials were provided on a Moodle online learning management system. Through the Moodle platform, eligible JMU-graduate doctors provided feedback on Q1 and Q2 by simultaneously referring to each student’s PIE. As a rule, the feedback did not contain hints for the PBL scenario in order to avoid teacher-centered instruction. In this study, six JMU graduates with clinical experience of 18-37 years were chosen as role models and feedback providers. Students were allowed to continue communicating with their role models via the Moodle platform until they were satisfied. Before the study, all role models received intensive training for appropriate PIE use and feedback on Q1 and 2.
We hypothesized the online pre-PBL platform would raise student awareness of their future professional image and relevance of PBL scenarios for their future professional selves. We also proposed that a clearer image of their future professional selves and relevance of PBL contents would encourage preclinical year students to acquire learning strategies encouraged by thoughtful role models’ comments. Overall, we expected that the pre-PBL PIF-oriented platform would promote PIF and SRL in a parallel manner.
Participants and design
A randomized controlled trial was designed. All JMU 2019 Y3 students (n = 124) were invited to participate in this research. Eventually, 112 agreed were randomly divided into two groups: Group A (n = 56, female=18, male=38, mean age 21.5y±0.7) and Group B (n = 56, female=11, male=45, mean age 21.7y±1.0). Group A used Moodle-based PIF-oriented platform before the second to fourth PBL, while group B did before the fifth to seventh PBLs in 2019. Both groups conducted the six one-day PBLs in the same manner on PBL dates, and SRL and PIF levels were compared between the two groups (Figure 2). Group A and B did not mix in the PBL group session.
We conducted the randomized controlled trial in a crossover manner to ensure all students had the same overall learning experience , even though the effects of the PIF-oriented intervention had remained unclear.
We hypothesized that PIF and SRL levels should improve in parallel, i.e., Group A in the first half of the research period, with Group B becoming equivalent to Group A in the second half.
1) PIF data collection
The PIF levels for norms and values of professionalism were measured using PIE, an essay-based measurement tool with 9 question items. Referring to Dr. Kalet and colleagues’ rubric based on Kegan’s identity stage , assessors chose learners’ professional identity levels from Stage II to II/III, III, III/IV, IV, IV/V, and V. The PIF measurement by PIE has been validated in undergraduate settings [23, 30]. In this study, we used a Japanese version of the PIE form and rubric (PIE-J) originally in English. Back translation between English and Japanese was conducted by the main author (YM, Japanese) and an American professor living in Japan literate in both English and Japanese (AJL). PIE stages from all students were assessed by two authors (YM & MN) by in-depth discussions following the rubric until full agreement was reached.
2) SRL data collection
Learners’ SRL levels were measured by a Japanese-language version of the Motivated Strategies for Learning Questionnaire (MSLQ-J)  reported to be useful in measuring SRL in undergraduate medical education [18, 32, 33]. MSLQ is composed of 81 items with seven-point Likert scales which quantify levels of nine types of learning strategies (rehearsal: R, elaboration: ELA, organization: O, critical thinking: CT, metacognitive self-regulation: MSR, time and study environment: TaSE, effort regulation: ER, peer learning: PL, and help-seeking: HS), and six variables of motivation states (intrinsic goal orientation: IGO, extrinsic goal orientation: EGO, task value: TV, control of learning beliefs: CBaL, self-efficacy for learning and performance: SEfLaP, and test anxiety: TA). All 81 items were translated into Japanese and back-translated by the main author (YM) and an American professor (AJL).
Effects of treatment and time (fixed effects) on MSLQ-J scores and PIE-J stages were tested and estimated using two-level regression analysis (upper level: participants; lower level: occasion) in the Open Source statistical package jamovi (version 1.2.9) . Treatment and time were treated as fixed effects (estimated with full informed maximum likelihood), and participant-level random intercept served as a random effect (estimated with restricted maximum likelihood). For the first measurement of all scales, the two groups were treated as one because the first measurement took place before any treatment (see Chapter 15 in  for a detailed explanation of this model and the rationale behind it). Marginal R2, a multilevel equivalent of the R2-statistic commonly used for traditional linear regression models, was used to estimate the effects of time and treatment (values of around 0.01, 0.06 and 0.14 represented small, medium and large effects). The Bayesian Information Criterion (BIC) was used to determine which of the time-effect-only and the time-and-treatment-effect model is to be preferred (i.e., the model with the smallest BIC) . Correlations between MSLQ-J scores and PIF-J stages (RQ2) were analyzed and visualized using network analysis in the Open Source statistical package JASP (version 0.12.1.0) .