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June 2018 SEA-Q


Which of the following statements BEST describes professional identity formation in the recently proposed amendment to Miller’s pyramid for assessment of clinical competence?

  • A.) Knows when individual behaviors are appropriate.
  • B.) Consciously demonstrates behaviors expected of a physician.
  • C.) Demonstrates attitudes, values and behaviors expected of one who has come to think, act and feel like a physician.
  • D.) Knows the behavioral norms expected of a physician.


C.): Demonstrates attitudes, values and behaviors expected of one who has come to think, act and feel like a physician.


Since the publication of Miller’s landmark article (1990) on assessment of clinical skills and competence almost 30 years ago, his framework has served as a template for design and development of numerous teaching and evaluation systems in medical education. His pyramid places “knowledge” at the base, with “competence”, “performance” and “action” as successive levels of development in this learning process.
More recently, a growing understanding of the significance of professionalism and professional identity formation has led to the suggestion that this pyramidal structure should be re-evaluated. Cruess et al (2016) have postulated a fifth level - “Identity” - at the apex of the pyramid (Figure). This level signifies incorporation of attitudes and behaviors that is consistent with “thinking, acting and feeling like a physician”, a concept of professional identity first described by Merton (1957) in a classic study of the sociology of medical education.
Over the past decade, professional identity formation (PIF) has gained prominence as a result of the report generated from the Carnegie Foundation for the Advancement of Teaching in 2010. The authors posited that medical education is fundamentally about becoming a dedicated physician – they defined PIF as the development of professional values, actions, and aspirations – and recommended that this should serve as a major focus for the learning process in medical education.
Cruess et al theorize that PIF is developed gradually, is a dynamic process, and that occurs over time through experiences and social interactions within medicine’s community. As a result, an environment of good role models and faculty mentors are essential to this teaching and learning process.

Figure: The amended version of Miller’s pyramid with the addition of “Is” and an outline of what is to be assessed at each level. Sources: Adapted with permission from Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65(9 suppl):s63–s67. (From Cruess et al)
These authors suggest that the assessment of “Is” should be primarily formative, since PIF is a gradual progression in the individual’s development within the medical community of practice.


  1. Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990 Sep;65(9 Suppl):S63-7.
  2. Cruess RL1, Cruess SR, Steinert Y. Amending Miller's Pyramid to Include Professional Identity Formation. Acad Med. 2016 Feb;91(2):180-5.
  3. Irby DM1, Cooke M, O'Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010 Feb;85(2):220-7.

Author Information:

Swapna Chaudhuri, MD, PhD
Professor & Vice-Chair for Administration
Associate Program Director – Curriculum & Assessment
Department of Anesthesiology
Texas Tech University Health Sciences Center, Lubbock, Texas


The SEA is proud to be a member-driven organization, dedicated to the teaching and development of future anesthesiologists, and to the advancement of those who educate them.

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