title: An investigation of professionalism reflected by student comments on formative virtual patient encounters.
abstract: BACKGROUND
  This study explored the use of virtual patient generated data by investigating the association between students' unprofessional patient summary statements, which they entered during an on-line virtual patient case, and detection of their future unprofessional behavior.
  
  
  METHODS
  At the USUHS, students complete a number of virtual patient encounters, including a patient summary, to meet the clerkship requirements of Internal Medicine, Family Medicine, and Pediatrics. We reviewed the summary statements of 343 students who graduated in 2012 and 2013. Each statement was rated with regard to four features: Unprofessional, Professional, Equivocal (could be construed as unprofessional), and Unanswered (students did not enter a statement). We also combined Unprofessional and Equivocal into a new category to indicate a statement receiving either rating. We then examined the associations of students' scores on these categories (i.e. whether received a particular rating or not) and Expertise score and Professionalism score reflected by a post-graduate year one (PGY-1) program director (PD) evaluation form. The PD forms contained 58 Likert-scale items designed to measure the two constructs (Expertise and Professionalism).
  
  
  RESULTS
  The inter-rater reliability of statements coding was high (Cohen's Kappa = .97). The measure of receiving an Unprofessional or Equivocal rating was significantly correlated with lower Expertise score (r = -.19, P < .05) as well as lower Professionalism score (r = -.17, P < .05) during PGY-1.
  
  
  CONCLUSIONS
  Incident reports and review of routine student evaluations are what most schools rely on to identify the majority of professionalism lapses. Unprofessionalism reflected in student entries may provide additional markers foreshadowing subsequent unprofessional behavior.
authors.affiliation: Uniformed Services University of the Health Sciences (USUHS), Bethesda, USA. ting.dong.ctr@usuhs.edu.|Department of Medicine (A3068), USUHS, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA. ting.dong.ctr@usuhs.edu.
authors.forename: Ting
authors.identifier: http://orcid.org/0000-0002-4939-6865
authors.initials: T
authors.lastname: Dong
authors.affiliation: Uniformed Services University of the Health Sciences (USUHS), Bethesda, USA.
authors.forename: William
authors.initials: W
authors.lastname: Kelly
authors.affiliation: Uniformed Services University of the Health Sciences (USUHS), Bethesda, USA.
authors.forename: Meredith
authors.initials: M
authors.lastname: Hays
authors.affiliation: Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
authors.forename: Norman B
authors.initials: NB
authors.lastname: Berman
authors.affiliation: Uniformed Services University of the Health Sciences (USUHS), Bethesda, USA.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Durning
mesh_terms: D001291:Attitude of Health Personnel; D002982:Clinical Clerkship / Q000592:standards; D002983:Clinical Competence / Q000592:standards; D004503:Education, Medical, Graduate / Q000592:standards; D004521:Educational Measurement / Q000379:methods*; D006801:Humans; D007388:Internal Medicine / Q000193:education* / Q000592:standards; D016544:Patient Simulation; D028743:Professional Misconduct; D000068616:Professionalism / Q000592:standards; D015203:Reproducibility of Results; D013337:Students, Medical; D014481:United States
keywords: Professionalism; Residency evaluation; Virtual patient encounter