RESEARCH REPORT Validation of a Method for Measuring Medical Studentsâ Critical Reflections on Professionalism in Gross Anatomy Christopher M. Wittich,1* Wojciech Pawlina,2,3 Richard L. Drake,4 Jason H. Szostek,1 Darcy A. Reed,3,5 Nirusha Lachman,2 Jennifer M. McBride,4 Jayawant N. Mandrekar,6 Thomas J. Beckman1 1Department of Internal Medicine, Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota 2Department of Anatomy, College of Medicine, Mayo Clinic, Rochester, Minnesota 3Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota 4Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio 5Department of Internal Medicine, Division of Primary Care Internal Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota 6Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, College of Medicine, Mayo Clinic, Rochester, Minnesota Improving professional attitudes and behaviors requires critical self reflection. Research on reflection is necessary to understand professionalism among medical students. The aims of this prospective validation study at the Mayo Medical School and Cleveland Clinic Lerner College of Medicine were: (1) to develop and validate a new instrument for measuring reflection on professionalism, and (2) determine whether learner variables are associated with reflection on the gross anatomy experience. An instrument for assessing reflections on gross anatomy, which was comprised of 12 items structured on five-point scales, was developed. Factor analysis revealed a three-dimensional model including low reflection (four items), moderate reflection (five items), and high reflection (three items). Item mean scores ranged from 3.05 to 4.50. The overall mean for all 12 items was 3.91 (SD 5 0.52). Internal consistency reliability (Cronbachâs a) was satisfactory for individ- ual factors and overall (Factor 1 a 5 0.78; Factor 2 a 5 0.69; Factor 3 a 5 0.70; Over- all a 5 0.75). Simple linear regression analysis indicated that reflection scores were nega- tively associated with teamwork peer scores (P 5 0.018). The authors report the first validated measurement of medical student reflection on professionalism in gross anatomy. Critical reflection is a recognized component of professionalism and may be important for behavior change. This instrument may be used in future research on professionalism among medical students. Anat Sci Educ 6: 232â238. © 2012 American Association of Anatomists. Key words: critical reflection; gross anatomy education; validation study; professional- ism; undergraduate medical education INTRODUCTION Professionalism is an essential competency to develop in medical students (Baernstein et al., 2009). Gross anatomy has been iden- tified as a rich educational experience for learning the funda- mental aspects of professionalism (Escobar-Poni and Poni, 2006, Swartz, 2006; Sugand et al., 2010), which should be emphasized throughout a physicianâs career (Pangaro, 2006). Indeed, the cost of neglecting professionalism has been demonstrated by studies showing that unprofessional behaviors during medical school are associated with later disciplinary action against prac- ticing physicians (Papadakis et al., 2005; Stern et al., 2005). Medical professionalismâa required component of being a physician (ABIM, 2002; GMC, 1993, 2003, 2009)âis a *Correspondence to: Dr. Christopher M. Wittich, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA. E-mail:
[email protected] Grant sponsor: Mayo Clinic Program on Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota. Received 20 July 2012; Revised 19 September 2012; Accepted 4 October 2012. Published online 4 December 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/ase.1329 © 2012 American Association of Anatomists Anat Sci Educ 6:232â238 (2013) JULY/AUGUST 2013 Anatomical Sciences Education multifaceted construct that includes respect, accountability, dutifulness, and excellence (ABIM, 2002; Arnold et al., 2007; Reed et al., 2008). It has been argued that improving profes- sional attitudes and behaviors requires critical self reflection (Wittich et al., 2010c), which is defined as ââa meta-cognitive process that develops greater understanding of both the self and the situation, so that future encounters with the situation are informed from the previous encountersââ (Sandars, 2009). Mezirowâs transformative learning theory reveals how uncomfortable ââdisorienting dilemmasââ expose personal limi- tations, stimulate reflection, and reveal falsely-held assump- tions (Mezirow, 1997). To advance Mezirowâs theory, Kember and colleagues described levels of thought including habitual action, understanding, reflection and critical reflection (Kember et al., 2000; Mann et al., 2009). This process involves testing new perspectives in order to change attitudes and behaviors (Wittich et al., 2010c). Ultimately, research on reflection will be necessary to understand and promote pro- fessional behavior among medical students. This study builds upon our previous research on the case- based learning system (CBLS), which measures faculty physi- ciansâ reflections on adverse patient events (Wittich et al., 2010b). The CBLS reflection study showed that physicians could be stratified into low and high levels of reflection on adverse events, and that physician reflection was associated with rele- vance and generalizability of the adverse event (Wittich et al., 2010b). Although critical self-reflection is vital for ensuring com- petence (Lachman and Pawlina, 2006) and medical professional- ism (Epstein, 1999; Epstein and Hundert, 2002) there have been no validated methods for measuring reflection on professionalism among medical students in gross anatomy laboratories. We hypothesized that a medical student reflection on pro- fessionalism in gross anatomy would be associated with char- acteristics of the learner, such as gender, teamwork ratings, and standardized test scores. The aims of this study were: (1) to develop and validate a new instrument for measuring reflection on professionalism among medical students, and (2) determine whether medical studentsâ characteristics are asso- ciated with reflection on the gross anatomy experience. METHODS Study Design and Population This was a prospective validation study involving medical stu- dents at the Mayo Medical School and Cleveland Clinic Lerner College of Medicine. Gross anatomy at Mayo Medical School is a first-year, six-week modified team-based learning didactic block (120 hours) that involves briefing sessions, team-based learning exercises, and dissections completed by the students using embalmed cadavers (Gregory et al., 2009). Gross anat- omy at the Cleveland Clinic Lerner College of Medicine is a first- and second-year course that occurs periodically as part of a systems curriculum and involves case-based presentations stressing relevant anatomy and observations of prosected fresh cadaveric regions (Drake, 2007). This study was deemed exempt by the Mayo Clinic Institutional Review Board and approved by the Cleveland Clinic Institutional Review Board. Reflection Instrument Development The instrument for assessing studentsâ reflections on gross anatomy was developed based on the previously validated instrument (Kember et al., 2000; Mann et al., 2009) and was modified by experts with experience in medical education and scale development (authors C.M.W., W.P., R.L.D., J.H.S, D.A.R., N.L., J.N.M., T.J.B.). Kemberâs instrument comprised four levels of reflection: habitual action, understanding, reflec- tion, and critical reflection (Kember et al., 2000; Mann et al., 2009). Habitual action is a perfunctory feat that through repe- tition has become automatic (Kember et al., 2000; Mann et al., 2009). Understanding is using existing knowledge without crit- ically appraising that knowledge (Kember et al., 2000; Mann et al., 2009). Reflection is exploring past experiences to de- velop new understandings (Boud et al., 1985; Kember et al., 2000; Mann et al., 2009). Critical reflection is a deeper form of reflection where a personâs perspective is changed (Kember et al., 2000; Mann et al., 2009). Critical reflection involves an examination of current attitudes or behaviors in a new context. We adapted Kemberâs tool to be used by medical students in gross anatomy laboratories by creating 12 items (three for each level of reflection) structured on a five-point Likert scale (1 5 disagree, 2 5 disagree with reservation, 3 5 neutral, 4 5 agree with reservation, and 5 5 agree). Data Collection and Analysis All Mayo Clinic 2009 first-year (N 5 49) and second-year students (N 5 54), Mayo Clinic 2010 first-year students (N 5 48), and Cleveland Clinic 2011 second-year students (N 5 27) were invited to complete the reflection on professionalism form after their anatomy experience. The reflection instru- ment was distributed using an online survey tool. Reminders to complete the reflection instrument were sent weekly for two weeks after the initial invitation to participate. Partici- pantsâ responses comprised the data for internal structure val- idation and measurements of association. Factor analysis with orthogonal rotation was completed to explore the dimensionality of assessment instrument scores. Since the instrument items were based on Kemberâs levels of reflection, we anticipated that the items would cluster into four categories (Kember et al., 2000; Mann et al., 2009). In basic terms, a factor loading might be described as a measure of the strength of association between an itemâs scores and the factor that an item loads on. In this study, items with fac- tor loadings >0.4 were retained (DeVellis, 1991). Internal consistency reliability for each factor and overall were calcu- lated using Cronbachâs a. Cronbachâs a coefficients >0.7 were considered acceptable (DeVellis, 1991; Beckman, 2007). Overall reflection scores were reported as the mean and standard deviation (6 SD) of each of the 12 instrument items. For all calculations of association, values for items cor- responding to habitual action were reverse-scored due to the negative phrasing of these items. Associations between reflection scores and learner variables were determined. The learner variables were selected a priori based on published definitions of professionalism including respect, accountability, dutifulness, and excellence (ABIM, 2002; Arnold et al., 2007; Reed et al., 2008), as well as multi- ple validated methods and multi-source assessments used in leading professionalism assessment strategies (ABIM, 2002; Arnold et al., 2007; Reed et al., 2008). Specifically, learner var- iables included student gender (female, male), anatomy faculty professionalism score (1 5 needs improvement, 2â4 5 meets expectations, 5 5 exceeds expectations), reflection duration (minutes), National Board of Medical Examiners1 (NBME1) Gross Anatomy and Embryology Subject Examination scores, teamwork peer score (ranging from 0 to 180) (Levine, 2008), modified professional associate rating score (PAR; Likert scale 1 5 low to 9 5 high), (Ramsey and Wenrich, 1999; Chen et al., 2009; Camp et al., 2010) and Medical College Admis- sion Test1 (MCAT1) score (ranging from 0 to 45). Anatomical Sciences Education JULY/AUGUST 2013 233 The anatomy faculty professionalism score was an item on the studentâs final gross anatomy course evaluation and was determined jointly by course faculty. The item reads ââConsis- tently demonstrates professional and ethical behaviorââ with anchors including ââtreats faculty and colleagues with respect, respects and honors the gift of the human body, shows commit- ment to honesty, attends course exercises, and demonstrates a commitment to the pursuit of excellence and continuous quality improvement.ââ Professional behavior was an objective provided to the students in a written document prior to the course. The reflection duration was determined using the online survey tool and included the time required for both instrument completion and an optional typed narrative reflection. The teamwork peer score is a previously described method to assess team-work (Levine, 2008). Using this method, students in a dissection group distributed a total of 60 points to team members. Scores were based on their judgment of the team membersâ preparation for laboratory dissection, contribution to dissection, attendance, flexibility, personal commitment, responsibility, and overall pro- fessionalism (Levine, 2008). The previously validated PAR score was determined from an average of all assessments completed by the anatomy dissection group of four members (Ramsey and Wenrich, 1999; Chen et al., 2009; Camp et al., 2010). The PAR score contained items including respect, integrity, responsibility, compassion, problem-solving, commitment to excellence, and overall professionalism. Cleveland Clinic students had data available only for gender and reflection duration. Associations between mean reflection scores from all 12 items as an outcome variable and categorical or continuous variables were assessed using univariate and multivariate lin- ear regression. The Cleveland Clinic students were not included in the multivariate analysis because data for all vari- ables was not available. Statistical significance was set at P < 0.05. Statistical analyses were performed using SAS, version 9.2 (SAS Institute, Cary, NC). RESULTS Reflection Instrument Validation The reflection on professionalism instrument was completed by 45/49 (91.8%) of Mayo Clinic 2009 first-year, 43/54 (79.6%) of Mayo Clinic 2009 second-year, 47/48 (97.9%) of Mayo Clinic 2010 first-year, and 26/27 (96.3%) of Cleveland Clinic 2011 first-year medical students. Factor analysis (Table 1) Table 1. Gross Anatomy Student Reflection on Professionalism Instrument: Item Loadings Item loadings Item Reflection levela Factor 1 Factor 2 Factor 3 1. When working with my cadaver, I performed/viewed the dissections without thinking about them. Habitual action 0.662 0.069 20.039 2. When working with my cadaver, I was able to dissect/view the dissections without thinking about what I was doing. Habitual action 0.854 0.045 0.070 3. When dissecting/working with my/the cadaver, I did tasks without having to think about them. Habitual action 0.756 0.116 0.022 4. When working with my/the cadaver, I continually thought about the material with which I was working. Understanding 0.433 0.235 0.108 5. To know anatomy, I needed to understand the dissection I was performing/viewing. Understanding 0.100 0.491 0.077 6. Working with my cadaver required me to understand the techniques/ educational value of dissection. Understanding 20.020 0.587 0.020 7. When working with my/the cadaver, I often reflected on my activity to see whether I could have improved on what I did. Reflection 0.160 0.520 0.166 8. When working with my/the cadaver, I contemplated what I was doing and considered alternative ways of doing it. Reflection 0.189 0.588 0.122 9. Working with my/the cadaver caused me to question other peoples/ habits, and consider ways to improve my own work. Reflection 0.042 0.444 0.300 10. As a result of working with my/the cadaver, I have changed my normal way of thinking about things. Critical Reflection 0.175 0.194 0.581 11. Working with my/the cadaver had challenged some of my firmly held ideas. Critical reflection 0.041 0.049 0.702 12. When working with my/the cadaver, I discovered faults in what I have previously believed to be correct. Critical reflection 20.083 0.159 0.571 aColumn 2 shows each of the original Kember levels of reflection (Kember et al., 2000; Mann et al., 2009), and reveals how these cor- respond to the levels of low (Factor 1), moderate (Factor 2), and high (Factor 3) reflection found in the current study. 234 Wittich et al. revealed a three-dimensional model for measuring medical student reflection on professionalism during gross anatomy. The factors were: low reflection (four items), moderate reflec- tion (five items), and high reflection (three items). Specifically, the low reflection factor was comprised of the three items that corresponded to Kemberâs lowest level (habitual action) and one understanding level item. The moderate reflection factor comprised two items from Kemberâs understanding level and all three items from the Reflection level. The high reflection factor corresponded with the three items from Kemberâs Critical Reflection level. Item mean scores (Table 2) ranged from 3.05 to 4.50. The overall mean for all 12 items was 3.91 (SD 5 0.52). Internal consistency reliability (Cronbachâs a) was satisfactory for individual factors and overall (Factor 1 a 5 0.78; Factor 2 a 5 0.69; Factor 3 a 5 0.70; Overall a 5 0.75). Reflection Score Associations Simple linear regression analysis (Table 3) indicated that reflection scores were negatively associated with the team- work peer scores (mean teamwork score 5 99.2 6 9.3; P 5 0.018). A one-point increase in reflection score was associ- ated with a 0.011 decrease in teamwork peer score (b 5 20.011 6 0.0048; P 5 0.018). There were no statistically significant associations between studentsâ reflection scores and gender, faculty professionalism score, reflection duration, NBME subject examination score, teamwork peer score, pro- fessional associate rating, or MCAT score. No other variables were statistically significant when using a multivariate linear regression model. DISCUSSION We report the first validated instrument for measuring medi- cal student reflection on professionalism during gross anat- omy. The instrument had reliable scores and stratified student reflection on professionalism into minimal, moderate and high levels. Also, reflection scores were negatively associated with dissection group teamwork scores. Table 2. Gross Anatomy Student Reflection on Professionalism Instrument: Factors, Mean Scores, and Reliability Items Meana Standard deviation Factor 1âMinimal reflection Cronbachâs a 5 0.78 When working with my cadaver, I performed/viewed the dissections without thinking about them. 3.85 1.15 When working with my cadaver, I was able to dissect/view the dissections without thinking about what I was doing. 3.62 1.22 When dissecting/working with my/the cadaver, I did tasks without having to think about them. 3.51 1.21 When working with my/the cadaver, I continually thought about the material with which I was working. 3.96 1.08 Factor 2âModerate reflection Cronbachâs a 5 0.69 To know anatomy, I needed to understand the dissection I was performing/viewing. 4.45 0.80 Working with my cadaver required me to understand the techniques/educational value of dissection. 4.50 0.65 When working with my/the cadaver, I often reflected on my activity to see whether I could have improved on what I did. 4.18 0.88 When working with my/the cadaver, I contemplated what I was doing and considered alternative ways of doing it. 3.89 0.95 Working with my/the cadaver caused me to question other peoples/habits, and consider ways to improve my own work. 4.14 0.88 Factor 3âHigh reflection Cronbachâs a 5 0.70 As a result of working with my/the cadaver, I have changed my normal way of thinking about things. 4.07 0.91 Working with my/the cadaver had challenged some of my firmly held ideas. 3.03 1.19 When working with my/the cadaver, I discovered faults in what I have previously believed to be correct. 3.77 1.05 Overall (12 items) Cronbachâs a 5 0.75 3.91 0.52 bBased on a five-point Likert scale (1 5 disagree, 2 5 disagree with reservation, 3 5 neutral, 4 5 agree with reservation, and 5 5 agree). Anatomical Sciences Education JULY/AUGUST 2013 235 The medical student reflection on professionalism instru- ment has validity evidence that includes content, internal structure, and criterion (associations with other variables) (Messick, 1995). Instrument item content was based on edu- cational theories about critical reflection (Mezirow, 1997), prior instruments (Kember et al., 2000; Wittich et al., 2010a), and revision by medical education experts. Internal structure validity was supported by internal consistency cal- culations and factor analysis that identified minimal, moder- ate and high levels of reflection (Kember et al., 2000). Finally, criterion validity was found in the association between reflec- tion and teamwork scores. Previously reported reflection instruments have measured studentâs written reflections on case write-ups (Wald et al., 2009), pathology course work (Kanthan and Sengerm, 2011), case vignettes (Boenink et al., 2004), and video recordings of simulated patient interactions (Hulsman et al., 2009). Sobral validated the reflection-in-learning scale regarding studentsâ thoughts about reflective learning (Sobral, 2005). Roberts and Stark (2008) reported the self- regulation and insight scale that measures studentsâ self-regu- lation of their professionalism. However, the reflection instrument described in the current study is, to our knowl- edge, the first scale that specifically targets professionalism in the anatomy laboratory, which is arguably a medical stu- dentâs first clinical encounter. We found that medical student reflection and dissection group teamwork scores were inversely related. Studies in the business and psychology literature have shown that the traits of extroversion, emotional stability and agreeableness are related to team effectiveness (Barrick et al., 1998; Stewart et al., 2005). The negative correlation between reflection and teamwork scores observed in this study may suggest that highly reflective team members are perceived as introverted and less agreeable, thus leading to lower teamwork assess- ment scores. Further research is needed to confirm and fully explore this association. We found no association between studentsâ reflection scores and gender or assessments of knowledge. Prior investi- gation has also shown no association between reflective learn- ing and medical student gender or measures of student knowledge (Sobral, 2005). Additionally, we found no associa- tion between reflection scores and the duration of the stu- dentsâ reflection. Although we are unaware of prior studies in medical education to explore this relationship, one might anticipate that the quality of a reflection is at least partly de- pendent upon the amount of time that is dedicated to the act of reflecting. Associations with other important variables Table 3. Associations Between Reflection Scores and Student Characteristics Variables N (%) b 6 SE P valuea Gender Male 73 (45.3) 20.14 6 0.081 0.093 Female 88 (54.7) Professionalism scoreb 1 (needs improvement) 2 (1.5) 20.068 6 0.055 0.22 2 (meets expectations) 2 (1.5) 3 (meets expectations) 11 (8.3) 4 (meets expectations) 16 (12.1) 5 (exceeds expectations) 101 (76.5) Mean 6 SD Reflection duration (minutes) 9.4 6 8.5 0.0036 6 0.0048 0.45 NBME Gross Anatomy and Embryology Subject Examinationb 593.4 6 84.1 0.00035 6 0.00054 0.52 Teamwork peer scoreb 99.2 6 9.3 20.011 6 0.0048 0.018 Professional associate ratingb 8.4 6 0.6 20.046 6 0.079 0.56 MCATb 32.7 6 3.7 20.021 6 0.012 0.094 aSimple linear regression. bVariables including professionalism score, NBME Gross Anatomy and Embryology Subject Examination score, teamwork peer score, professional associate rating, and MCAT score and were available for Mayo Medical Students only. N, number; SE, standard error; SD, standard deviation; NBME, National Board of Medical Examiners; MCAT, Medical College Admission Test. 236 Wittich et al. such as the students experience or age would be important to explore in future studies. Our new instrument for measuring medical student reflec- tion on professionalism during gross anatomy could be used to explore important research questions, such as whether stu- dent reflectiveness remains stable or improves over time. Related to this, prior work has shown that resident physi- ciansâ reflection is unchanged over the course of residency training (Wittich et al., 2011). Additionally, more could be learned about how various teaching methods, dissection teams, and student personality traits contribute to critical reflection. This study has limitations. First, not all students provided complete data for the calculations of association. Nonethe- less, the item-to-assessment ratio was greater than 1:10, which is generally sufficient for meaningful factor analysis (DeVellis, 1991). Additionally, our power calculation suggests that with as few as 100 observations we had 80% power to detect correlations of 0.3 or larger. Also, for associations of reflection scores with categorical variables such as gender, we would have 80% power to detect a difference of 0.57 standard deviations or higher, based on a two sample t-test. Second, students of first and second years may have had dif- ferent degrees of reflection on the gross anatomy experience, and grouping them together for the statistical analysis may have influenced the study results. Finally, although the gross anatomy experience was different between the two medical schools (preserved versus unembalmed cadavers), this vari- ability should enhance the generalizability of the validity find- ings, which incorporated survey results from both medical schools, to other medical school anatomy courses. CONCLUSION In conclusion, we report the first validated measure medical student reflection on professionalism in gross anatomy. Criti- cal reflection is a recognized component of professionalism (ABIM, 2002) and is believed to be an important step for physician behavior change (Wittich et al., 2010c). We antici- pate that this new instrument may serve as a cornerstone for future research on professionalism among medical students working in anatomy laboratories and during their early clini- cal encounters. NOTES ON CONTRIBUTORS CHRISTOPHER M. WITTICH, M.D., Pharm.D., is an assist- ant professor of medicine in the Department of Internal Medi- cine, Division of General Internal Medicine at College of Med- icine, Mayo Clinic, Rochester, Minnesota. He is a practicing internist and his research interest is in medical education. WOJCIECH PAWLINA, M.D., is a professor of anatomy and medical education and chair of the Department of Anat- omy at the College of Medicine, Mayo Clinic, Rochester, Minnesota. He teaches anatomy and histology to first-year medical students and serves as an assistant dean for curricu- lum development and innovation at Mayo Medical School. His research interest is in medical education. RICHARD L. DRAKE, Ph.D., is a professor in the Department of Surgery and Director of Anatomy at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio. He teaches gross anatomy, embryology, and neuroanatomy to first-year and second-year medical students. JASON H. SZOSTEK, M.D., is an assistant professor of medicine in the Department of Internal Medicine, Division of General Internal Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota. He is a practicing internist and his research interest is in medical education. DARCY A. REED, M.D., M.P.H., is an assistant professor of medicine in the Department of Internal Medicine, Division of Primary Care Internal Medicine at the College of Medi- cine, Mayo Clinic, Rochester, Minnesota. She is Chair of Stu- dent Assessment Committee at Mayo Medical School, Associ- ate Director of the Mayo Clinic Program in Professionalism and Ethics, and Deputy Editor of the Journal of General In- ternal Medicine. She is a practicing internist and her research interest is in medical education. NIRUSHA LACHMAN, Ph.D., is an associate professor in the Department of Anatomy at the College of Medicine, Mayo Clinic, Rochester, Minnesota. She teaches anatomy and histology to first year medical students. Her research interest is in medical education. JENNIFER M. MCBRIDE, Ph.D., is an assistant professor in the Department of Surgery and Director of Histology at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio. She teaches his- tology, gross anatomy, and neuroanatomy to first-year and second-year medical students. JAYAWANT N. MANDREKAR, Ph.D., is an associate pro- fessor of biostatistics in the Department of Health Sciences Research, Division of Biomedical Statistics and Informatics at the College of Medicine, Mayo Clinic, Rochester, Minnesota. He is a biostatistician and his research interest is in the appli- cation and extension of statistical methods for the evaluation of the quality and domains of clinical teaching, neurologic dis- eases, prosthetic joint infections, and assays for viral detection. THOMAS J. BECKMAN, M.D., is a professor of medi- cine and medical education in the Department of Internal Medicine, and chair for education in the Division of General Internal Medicine at the College of Medicine, Mayo Clinic, Rochester, Minnesota. He serves as an Associate Editor for the Mayo Clinic Proceedings journal. He is a practicing inter- nist and his research interest is in medical education. ACKNOWLEDGMENTS This study was deemed exempt by the Mayo Clinic Institu- tional Review Board and approved by the Cleveland Clinic Institutional Review Board. LITERATURE CITED ABIM. 2002. ABIM Foundation. American Board of Internal Medicine; ACP- ASIM Foundation. American College of Physicians-American Society of Inter- nal Medicine; European Federation of Internal Medicine. Medical professional- ism in the new millennium: A physician charter. Ann Intern Med 136:243â246. Arnold L, Shue CK, Kalishman S, Prislin M, Pohl C, Pohl H, Stern DT. 2007. 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