In Reply to Barnhoorn

We thank Dr. Barnhoorn for having entered into a discussion of professional identity formation and Miller’s pyramid. We are pleased to see that he is concerned about issues of professional behaviors and professionalism. However, we take exception with some elements of his letter. First, we did not suggest that professional identity formation replace the concepts of professional behavior and professionalism. In earlier publications, we indicated our belief that making the acquisition of a professional identity an educational objective builds upon experience gained from teaching professionalism.1,2 Furthermore, in acquiring a professional identity, the norms of behavior expected of a future physician are those traditionally associated with professionalism. The explicit teaching of professionalism will thus remain necessary. Second, we remind Dr. Barnhoorn that our purpose in amending Miller’s pyramid was not to clarify the nature of professional identity formation but, rather, to broaden the scope of assessment in this emerging field. Miller’s pyramid has become a widely used framework within which the multiple levels of mastery over the art and science of medicine can be assessed.3 It was not meant to assist in the understanding of the educational process, nor have we used it for that purpose. If the development of a professional identity is to be an educational objective, some method of determining whether individuals have achieved this objective becomes necessary. While this may be “idealistic,” it has been shown to be feasible in medicine and other professions.3 As Miller’s pyramid has been used extensively to develop programs for the assessment of professionalism and professional behaviors, our intention is to expand upon this framework to accommodate the concept of professional identity formation. The “onion model” invoked by Dr. Barnhoorn may or may not be helpful in understanding professional identity formation. However, it does not appear to be useful in assessing progress towards the development of a professional identity. Richard L. Cruess, MD Professor of surgery and core faculty member, Centre for Medical Education, McGill University, Montréal, Québec, Canada; [email protected] Sylvia R. Cruess, MD Professor of medicine and core faculty member, Centre for Medical Education, McGill University, Montréal, Québec, Canada. Yvonne Steinert, PhD Professor of family medicine and director, Centre for Medical Education, McGill University, Montréal, Québec, Canada.

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