Evidence-guided approach to portfolio-guided teaching and assessing communications, ethics and professionalism for medical students and physicians: a systematic scoping review

Objectives Guiding the development of longitudinal competencies in communication, ethics and professionalism underlines the role of portfolios to capture and evaluate the multiple multisource appraisals and direct personalised support to clinicians. However, a common approach to these combined portfolios continues to elude medical practice. A systematic scoping review is proposed to map portfolio use in training and assessments of ethics, communication and professionalism competencies particularly in its inculcation of new values, beliefs and principles changes attitudes, thinking and practice while nurturing professional identity formation. It is posited that effective structuring of portfolios can promote self-directed learning, personalised assessment and appropriate support of professional identity formation. Design Krishna’s Systematic Evidence-Based Approach (SEBA) is employed to guide this systematic scoping review of portfolio use in communication, ethics and professionalism training and assessment. Data sources PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases. Eligibility criteria Articles published between 1 January 2000 and 31 December 2020 were included. Data extraction and synthesis The included articles are concurrently content and thematically analysed using the split approach. Overlapping categories and themes identified are combined using the jigsaw perspective. The themes/categories are compared with the summaries of the included articles in the funnelling process to ensure their accuracy. The domains identified form the framework for the discussion. Results 12 300 abstracts were reviewed, 946 full-text articles were evaluated and 82 articles were analysed, and the four domains identified were indications, content, design, and strengths and limitations. Conclusions This review reveals that when using a consistent framework, accepted endpoints and outcome measures, longitudinal multisource, multimodal assessment data fashions professional and personal development and enhances identity construction. Future studies into effective assessment tools and support mechanisms are required if portfolio use is to be maximised.


INTRODUCTION
Evidence for the effective embodiment of ethical and professional principles, communication skills and appropriate use of empathy in clinical practice requires a

STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ The Systematic Evidence-Based Approach methodology adopts the structure of systematic reviews and flexibility of narrative reviews to synthesise a reproducible and accountable evaluation of diverse methodological sources, settings, physician populations and specialities.⇒ This review evaluates the impact of longitudinal development of communications, ethics and professionalism competencies and their impact on professional identity formation.⇒ Given that communications, ethics and professionalism are sociocultural constructs, geopolitical sociocultural differences may raise questions as to the applicability of these findings beyond the European and North American medical education systems.⇒ As the number of articles included is limited, the review's ability to assess the long-term effectiveness of portfolios may be compromised.
on September 16, 2023  Open access longitudinal and often multisource perspective.With ethics and professionalism sharing longitudinal developmental trajectories and intimately entwined with communication skills and competencies, the three competencies are increasingly considered together.In practice longitudinal communication, ethics and professionalism (CEP) programmes appear in the curricula of the top 10 medical schools featured on the QS World University Rankings 2020. 1 Concurrent study of CEP is also underlined by their common sociocultural roots.[10][11][12] However, while previous reviews into the teaching of ethics, [13][14][15] communication [16][17][18][19][20][21][22] and professionalism [23][24][25] suggest the use of portfolios could provide a personalised, holistic and longitudinal perspective of CEP skills, knowledge and attitudes and support of developing competencies, we are aware of little progress in designing such platforms.Impetus for mapping current use of CEP portfolios also arises from the notion that developing CEP competencies shapes how medical students and physicians (henceforth clinician) 'think, act and feel like a physician' 26 or their professional identity formation (henceforth PIF). 27It is posited that the promise of CEP portfolios with better appreciation of evolving selfconcepts of professional identity will better direct support and even remediation of professional, ethical, communication and interprofessional development and PIF.This is especially pertinent at a time of increasing reports of breaches in standards, codes of conduct, and social and practice expectations. 25

METHODS
A Systematic Evidence-Based Approach (SEBA) guided Systematic Scoping Review (SSR) (henceforth SSR in SEBA) is proposed to map CEP portfolio use in medicine to guide the design, structuring and support of a proposed programme. 13-17 20-22 24 25 27-50Given space constraints, we briefly describe the six stages in the construction of SSRs in SEBA in figure 1 and more advanced details of the systematic approach, split approach, jigsaw perspective, funnelling process, reiterative process and synthesis of SSR in online supplemental appendix A. 16 27 28 35 41 48 51-56 Stage 1 of SEBA: systematic approach Determining of title and background of the review An expert team comprised of a medical librarian from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of Singapore 57 and local education experts and clinicians at the National Cancer Centre Singapore (NCCS), the Palliative Care Institute Liverpool, YLLSoM and Duke-NUS Medical School (henceforth the expert team) supported the research team in designing and overseeing the SEBA process.

Identification of research question
The research and expert team determined the primary research question: 'What is known about CEP portfolios?'.The secondary research questions were 'what role do CEP portfolios have in teaching and assessing CEP development?'.

Inclusion criteria
A population, intervention, comparison and outcome (PICOs) format, outlined in table 1, was used to guide the research process. 58 59entification of relevant studies The research team developed search strategies and carried out independent reviews for relevant publications in the PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases (search strategy enclosed in online supplemental appendix B).Keeping with Pham et al's 60 approach of ensuring a feasible and sustainable research process, the team contained the search to articles published between 1st January 2000 and 31st December 2020 to accommodate existing human resource and time constraints and ensure a sustainable review process.

Selection of studies included in review
Six members of the research team created individual lists of titles to be included, while three other members of the research team carried out hand searches and ancestry searches of seven leading journals in medical education (Academic Medicine, Medical Education, Medical Teacher, Advances Health Sciences Education, BMC Medical Education, Teaching and Learning in Medicine and Perspectives on Medical Education) accessed through the National

Open access
University of Singapore (NUS) library portal.These individual lists of titles were discussed online and Sandelowski and Barroso 61 's 'negotiated consensual validation' approach to 'articulate, defend, and persuade others of the "cogency" or "incisiveness" of their points of view or show their willingness to abandon views that are no longer tenable' was applied to achieve consensus on the final list of titles to be scrutinised.

Assessing the quality of articles
Eight research team members individually appraised the quality of the quantitative and qualitative studies using the Medical Education Research Study Quality Instrument 62 and Consolidated Criteria for Reporting Qualitative Studies. 63age 2 of SEBA: split approach Two teams carried independent and concurrent thematic and content analysis of the included articles while a third team created tabulated summaries based on recommendations drawn from Wong et al's 64   24: Portfolios as a method of student assessment' was then used to contextualise their use in portfolios.

Stage 3 of SEBA: the jigsaw perspective
The jigsaw perspective sees the themes and categories identified compared and combined where overlaps and similarities exist.

Stage 4 of SEBA: the funnelling process
The funnelling process sees the themes/categories created from the jigsaw approach compared with the tabulated summaries to determine their consistency.

Patient and public involvement
Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

RESULTS
A total of 12 300 abstracts were reviewed, 946 full-text articles were evaluated and 82 articles were analysed (figure 2).The funnelled domains identified are: (1) indications, (2) portfolio content, (3) portfolio design and implementation and (4) strengths and limitations.In keeping with its goals of transparency and accountability, these tables are enclosed in online supplemental appendix C.
Funneled domain 1: indications CEP portfolios curate longitudinal multisource, multimodal assessment data taken at different settings and contexts allowing it to serve two main roles: teaching and assessment 70 71 (table 2).However, few span undergraduate and postgraduate education. 69 72 73As assessment tool CEP portfolios assist in the identification of areas of weakness and guide the provision of a comprehensive, targeted feedback, support and remediation. 72 74 75Most CEP assessment portfolios in postgraduate education focus on evidencing the attainment of required competencies, [76][77][78][79][80] capturing reflections and indications of PIF. 78 81-83CEP portfolios in the postgraduate setting have also been used for revalidation purposes. 81s a teaching tool, CEP portfolios encourage selfdirected learning, 75 84-86 self-improvements, 71 reflective practice, 72 73 75 79 81 85-95 motivate practitioners to achieve desired competencies 90 96 and bolster overall professional and personal development. 72

Funneled domain 2: characteristics
The contents of portfolios were shaped by their overall function 77 80 83 98 99 (table 3).Postgraduate CEP assessment portfolios inject more details on undergraduate portfolios.2][103] Greater detail in postgraduate CEP assessment portfolios sees the addition of modified essay questions, 79 polypharmacy journal/audits, 70 95 99 104 105 professional workshops and training sessions, 98 104 106-108 Table 2 Benefits of CEP teaching and assessment portfolios

CEP teaching portfolios CEP assessment portfolios
Enhancing learning Promotion of life-long learning 104 106 Promotion of self-directed learning ► Formulation of learning plans. 90 96 126 Facilitates outcome-oriented learning. 89 90 118 120 ► Personalised learning. 109 129lance of structure and freeform learning 69 76 92 128 130 131 Adaptable to goals 77 98 132 Alignment of learning outcomes and assessment methods 90 91 97 112 118 Allows personalised assessments 77 Allows assessment over time 84 92 and stages of development 69 and that facilitate evaluation of: ► Learning and progress over time. 77 101 Learning curve. 115► In different settings. 70 98 Complex behaviours. 72 74 77 84 90 104 122 133► Outcomes/competencies. 128 133 Self-assessment. 77 112 132 Complex skills. 98 Professionalism. 132 Cultural competence. 132 Communication skills. 132 Clinical ethics. 134 Problem solving abilities. 77 132Longitudinal data ► Possess good predictive value of subsequent clinical competency. 74 135► Enhances validity of portfolio grading. 69 Guides better decisions. 74 122 136 Provides authentic assessment is a key principle of it. 92 104 109► Provides insights in the various core competencies. 106 Fair mode of assessment 104 and allows student to defend positions/work. 69► Provides students with direction and clarity. 130 131llows the combination of summative and formative assessment 69 91 and multisource assessments 818797129109 and triangulation 77 109 Facilitates personalised feedback 122 that can be informed by understanding of the individual setting and context 98 104 126 Personal and professional development Promotes self-understanding 79 114 115 ► Understanding feelings and thoughts. 126 129 Understanding of one's values. 92 Understanding activity/experience. 69 88 123 ► Understanding of how one functions in a team.122 ► Fears and stressors feelings of inadequacy. 123 137 Cates evidence of skills 106 ► Skills to compile a portfolio. 88 120 123 129 140 ► Clinical skills.104 Organises information 120 128 ► Documentation of progress.9 Cross-sectional view of one's competence 69 77 101 109 Personalisation Allows for personalisation 69 90 104 113 132 ► Personal experiences.69 Choice over the contents 69 104 132 Benefits to faculty Improvement of curriculum 83 92 ► Identify areas of weakness in curriculum. 83 Provide insights into mentoring, teaching, etc. 141 Facilitates design of the programme.83

Faculty development
► Understand more about how students acquire competencies. 104 Insight into the impact of their interventions. 136 141nsight into their professional conduct, role modelling and pastoral care 115

E-portfolios
Ease of use: ► Easier use. 90 Accessible. 73issemination and editing of information 113 CEP, communication, ethics and professionalism.Open access health service meeting reports 79 and reviews by medical regulatory authorities. 95A detailed summary is provided in online supplemental appendix D.

Funnelled domain 3: strengths and limitations
The strengths and limitations of portfolios are outlined in table 5.
9 Use of multisource assessments at multiple timepoints 80 in clinical settings 81 104 see postgraduate portfolios provide good inter-rater reliability. 77 109Postgraduate portfolios also detect stress and burnout. 107age 5 of SEBA: analysis of data and non-data driven literature Findings from the different stages of SEBA were discussed with members of the expert team and relevant stakeholders.There were concerns from the expert team about the impact of grey literature on the narrative, given that they were neither peer reviewed nor necessarily evidence based.As a result, the research team differentiated correspondence, letters, editorials and perspective pieces from ► Use of portfolio. 69 88 Portfolio content -determining competencies to assess. 69 91 Promotional decisions. 69 71 89 115 142tandard-setting exercises 75 Provision of sample portfolios for reference 112 116 121 ► Roles for assessors. 69 71 74 114 115 117 142 Expectations of students. 131 Duration spanning across preclinical and clinical years. 139ell-defined structure with room for flexibility 69 86 88 90 112 Student-centred 90 Appropriate student to mentor ratio 71 138 Sufficient curricular experience for reflection and feedback 71 Protected time for reflection, feedback and regular meetings with mentors 71 74 87 129 Faculty Good faculty support. 115 139nsure culture is supportive of portfolio system. 71 139lexible and enthusiastic tutors passionate and experienced mentors. 85 88rricular integration Early introduction of portfolio 88 113 129 143 Easing portfolio into curriculum 69 72 86 88 90 -including orientation, training and introductory sessions 69 72 88 90 112 115 116 for learners and staff training 69 71 72 75 84 85 88 Implementation of portfolios throughout curriculum 115 Portfolio content aligning with phase of medical journey and competencies required 69 71 90 97 116 142 Assessments Clear scoring rubrics 69 139 Alignment between assessments and outcomes 86 87 90 Transparent assessment criteria and outcomes to maintain fairness 71 72 113 121 Standardisation of portfolio use and content, 86 87 assessors training 72 and increased number of assessors 86 87 143 to improve assessment reliability 86 87 143 Separate processes and reviewers for summative and formative portfolio 71 summative assessments to specify clear pass/fail requirements 69 Incorporation of student feedback into portfolio development 69 72 90 Assessors External examiners 69 Faculty members 69 71 74 114 117 142 Mentors 128 Senior staff to be paired with new examiners 69 Mentors should not assess own student 86 92 Assessment frequency Formative assessments to monitor and guide student learning -conducted throughout the year 86 88 91 Summative assessments to evaluate learner performance -conducted annually, 69 71 75 122 thrice 88 or multiple times a year 77 79 Oversight and delegation Establishment of portfolio oversight committee 71 75 Regular programme evaluation 71 Clear division of support roles -for example, pedagogical and technical support 113 Open access academic databases and grey literature from data-driven or research-based peer-reviewed data.Both groups were then independently analysed.The themes/categories identified were then compared with enhance further the accountability and the reproducibility of stage 5 of SEBA.Evidence-based data from bibliographic databases (henceforth evidence-based publications) were separated from grey literature, perspectives, editorials, letters and non-data-based articles drawn from bibliographic databases (henceforth non-data driven).These two groups were separately thematically analysed.

Stage 6 of SEBA: synthesis of the discussion
The Best Evidence Medical Education Collaboration Guide 110 and the Structured approach to the Reporting In healthcare education of Evidence Synthesis 111 were used to guide the discussion.

DISCUSSION
This SSR in SEBA suggest that overlaps in ethics, professionalism and communication skills, knowledge, attitudes and competencies reaffirm the concurrent training and assessments of CEP competencies in portfolios. 72 74 75To be effective CEP teaching and longitudinal assessment portfolios require a consistent framework replete with clearly delineated goals, 112 aligned expectations, predetermined assessment criteria for specified competencies, 69 71 72 77 83 85 87 96 97 102 103 106 112-117 agreed on endpoints and outcome measures and the curation, structuring and organisation of longitudinal multisource, multimodal assessment data. 70 71The combination of these data facilitate training, assessment, feedback and holistic and longitudinal support, 75 84-86 101-103 118 119 guide reflection 72 73 75 79 81 85-95 and bolster professional and personal  72 88 96 97 Critically, the employ of consistent and agreed on structure, goals, purpose, role, learning objectives, content and assessment guidelines also affords users with a personalised perspective of their CEP development on which they can reflect on and glean insights and feedback. 86 120 121et to be effective, CEP portfolios require policing and underscore the need for trained 70 and dedicated faculty 88 capable of effective role modelling, 115 support 69 79 88 92 97 and providing feedback 122 and who appreciate the individual's current concepts, narratives, motivations, abilities and availabilities and contextual considerations.Furthermore, the efficacy of portfolios and their ability to meet the stated objectives stated in table 2 and realise their stated benefits in table 5 are reliant on the appropriate mix of assessment methods employed, the frequency of assessments, the efficacy of analysis and the quality of the feedback, support and remediation provided should it be required.It should not be forgotten that CEP portfolios reflect the development of an individual and such changes should be measured and contextualised within the wider education, training, practice, professional, research, clinical, interprofessional team based and organisational perspective.This further underlines the importance of the host organisation's role in assessing and guiding development of CEP competencies.
With these requisites met, evidence of changes in CEP knowledge, skills and competencies suggests a shift in the thinking, attitudes and conduct of clinicians.The Krishna-Pisupati model posits that sustained changes in practice, beliefs, values and principles will result in changes in the clinician's belief systems which, in turn, inform their selfconcepts of identity and shape their PIF.

LIMITATIONS
The generalisability of the results of this study is limited by the identified studies selected for review.First, the majority of the papers included originate from Europe and North America.Given that CEP is a sociocultural construct, these geopolitical sociocultural differences raise questions as to the applicability of these findings beyond the European and North American medical education systems.Second, as the number of articles included is limited, the SSR in SEBA's ability to assess the long-term effectiveness of portfolios may be compromised.

CONCLUSIONS
The suggestion that CEP portfolios can capture, instruct and assess PIF requires further study.While there have been posits on how such evaluations could be made, such Appreciation of effective communication, 88 143 148 ethical issues 92 and fosters critical professional attitudes. 87 1495 129 Facilitates preparation for postgraduate medical training. 88 128 130or faculty Identification of areas of concern and allows for early, timely intervention. 74 75nhances interaction between students and teachers. 69 88 92acilitates reiterative reassessment of teaching strategies. 69ssessments Longitudinal 122 Good validity. 74eliable assessment tool -allows for triangulation of information and evidence from multiple sources and contexts. 71bility to assess a wide range of competencies. 90 97llows for more authentic assessments. 74ives faculty greater insight into students' achievement of behaviourally oriented competencies that traditional methods do not. 75valuates achievement during clinical attachment/clerkship. 97 Provides a basis for the judgement of a student's professional fitness to practice. 72

Figure 2
Figure 2 PRISMA flow chart.PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Table 1
PICOS inclusion and exclusion criteria Does not include personal intellectual engagement with the content and associated learning (for instance, curriculum vitae, logbooks and the use of personal digital assistants).BMJ Open: first published as 10.1136/bmjopen-2022-067048 on 28 March 2023.Downloaded from ► Portfolios with input from students and/or residents and/or doctors and/or input from faculty members and other individuals.► Portfolios with different structures: extent by which the structure has been prescribed and/or left to individual discretion.Other documentation methods or learning tools that are: ► Not longitudinal or single timepoint.► ► Effectiveness of the use of portfolios to assess and teach communication, ethics and professionalism.► Impact of the use of portfolios on medical students (both undergraduate and postgraduate).► Impact of the use of portfolios on the faculty.NA Study design ► Articles in English or translated to English.► Articles published from 1st January 2000 to 31st December 2020.► Databases: PsycINFO, Embase, PubMed, ERIC, Scopus and Google Scholar.► All study designs including: NA PICOS, population, intervention, comparison and outcome.on September 16, 2023 by guest.Protected by copyright.http://bmjopen.bmj.com/ RAMESES publication standards: meta-narrative reviews, and Popay et al's 65 'Guidance on the conduct of narrative synthesis in systematic reviews'.The categories employed in the content analysis for undergraduate communications were Rider et al's 66 'A model for communication skills assessment across the undergraduate curriculum', Goldie's 67 'Review of ethics curricula in undergraduate medical education', Duffy et al's 68 'Assessing Competence in Communication and Interpersonal Skills: The Kalamazoo II Report' and Hong et al's 13 'Postgraduate Ethics Training Programs: A Systematic Scoping Review'.Tay et al's 24 'Assessing Professionalism in Medicine -A Scoping Review of Assessment Tools from 1990 to 2018' was employed for codes for professionalism, and Friedman Ben David et al's 69 article 'AMEE Medical Education Guide No.

Table 4
Portfolio content (competencies assessed and assessment modalities)