The maturation and coordination of sucking, swallowing, and respiration in preterm infants.

A fundamental goal of medical education is the active, constructive, transformative process of professional identity formation (PIF). Medical educators are thus charged with designing standardized and personalized curricula for guiding, supporting, and challenging learners on the developmental professional identity pathway, including the process of socialization. The author of this Commentary provides an overview of foundational principles and key drivers of PIF supporting the being, relating, and doing the work of a compassionate and competent physician. Key elements of PIF including guided reflection, use of personal narratives, integral role of relationships and role modeling, and community of practice are viewed through various lenses of PIF theory and pedagogy. Questions informing the PIF discourse are raised, including interprofessional identity considerations. Central emergent themes of reflective practice, relationships, and resilience are described as supporting and reciprocally enhancing PIF. Overarching lessons include attending to learners' and faculty's PIF within a developmental trajectory of the professional life cycle; process and content within PIF curricula as well as learners' individual and collective voices; curricular/extracurricular factors contributing to socialization, self-awareness, development of core values, and moral leadership; integrating PIF domains within pedagogy; faculty development for skilled mentoring and reflective coaching; and implementing resilience-promoting skill sets as "protective" within PIF. Outcomes assessment including the impact of curricula on learners and on patient-centered care can be challenging, and potential next steps toward this goal are discussed.

Professional identity (trans)formation in medical education: reflection, relationship, resilience.

Recent calls for an expanded perspective on medical education and training include focusing on complexities of professional identity formation (PIF). Medical educators are challenged to facilitate the active constructive, integrative developmental process of PIF within standardized and personalized and/or formal and informal curricular approaches. How can we best support the complex iterative PIF process for a humanistic, resilient health care professional? How can we effectively scaffold the necessary critical reflective learning and practice skill set for our learners to support the shaping of a professional identity?The authors present three pedagogic innovations contributing to the PIF process within undergraduate and graduate medical education (GME) at their institutions. These are (1) interactive reflective writing fostering reflective capacity, emotional awareness, and resiliency (as complexities within physician-patient interactions are explored) for personal and professional development; (2) synergistic teaching modules about mindful clinical practice and resilient responses to difficult interactions, to foster clinician resilience and enhanced well-being for effective professional functioning; and (3) strategies for effective use of a professional development e-portfolio and faculty development of reflective coaching skills in GME.These strategies as "bridges from theory to practice" embody and integrate key elements of promoting and enriching PIF, including guided reflection, the significant role of relationships (faculty and peers), mindfulness, adequate feedback, and creating collaborative learning environments. Ideally, such pedagogic innovations can make a significant contribution toward enhancing quality of care and caring with resilience for the being, relating, and doing of a humanistic health care professional.

Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice.

Preterm infants develop the skills necessary to begin oral feeding as their health stabilizes and as they reach a postconceptional age that supports coordination of breathing and swallowing with oral-motor functioning. The time from initiation of oral feeding to full oral feedings (with adequate intake for growth and maintenance of physiologic stability) can vary from days to months for the preterm infant. The approach to feeding the infant during this transition period must be developmentally supportive and tailored to meet the needs of the individual. To accomplish this, caregivers--notably nurses and parents--need to communicate about the specific skills that the infant has gained, about skills that are emerging, and about skills that the infant has not yet developed. The Early Feeding Skills (EFS) Assessment is a checklist for assessing infant readiness for and tolerance of feeding and for profiling the infant's developmental stage regarding specific feeding skills: the abilities to remain engaged in feeding, organize oral-motor functioning, coordinate swallowing with breathing, and maintain physiologic stability. This article introduces the EFS.

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The early feeding skills assessment for preterm infants.

Gastroesophageal reflux and respiratory disease in children

There has been increasing emphasis on professionalism in medical education over the past several decades, initially focusing on bioethical principles, communication skills, and behaviors of medical students and practitioners. Authors have begun to discuss professional identity formation (PIF), distinguishing it as the foundational process one experiences during the transformation from lay person to physician. This integrative developmental process involves the establishment of core values, moral principles, and self-awareness. The literature has approached PIF from various paradigms-professionalism, psychological ego development, social interactions, and various learning theories. Similarities have been identified between the formation process of clergy and that of physicians. PIF reflects a very complex process, or series of processes, best understood by applying aspects of overlapping domains: professionalism, psychosocial identity development, and formation. In this study, the authors review essential elements of these three domains, identify features relevant to medical PIF, and describe strategies reported in the medical education literature that may influence PIF.

Professional identity formation in medical education: The convergence of multiple domains

Breathing pattern and ventilation during oral feeding in term newborn infants.

Apnea, bradycardia, and cyanosis during oral feeding in term neonates

Changes in the relative contribution of ribcage and abdomen during augmented breaths were assessed in two groups of infants (less than 2 weeks and 4-12 weeks old). In both groups ribcage and abdominal movements increased during augmented breaths in quiet sleep. In the older infants the relative increase was greater for the ribcage (P less than 0.05) when expressed either as a ribcage to abdominal movement ratio or as a percent of the respective movements during control breaths. In contrast, no significant change of the relative contribution was observed in the younger age group. During active sleep paradoxical movement of the ribcage, observed during tidal breaths, continued during the first phase of the augmented breath; however, during the second phase of inspiration, the ribcage moved outward in all but one infant. Our results show that marked increases in tidal volume are associated with greater increases in ribcage contribution in infants beyond the neonatal period. This may reflect differences in recruitment patterns of intercostal muscles during development.

Relative contribution of ribcage and abdomen during augmented breaths in infants.

Recent studies in infants have demonstrated substantial reduction in minute ventilation during oral feeding. The aim of the present study was to determine the incidence of cyanosis and bradycardia during oral feeding as a result of the reduction in minute ventilation or apnea. Heart rate, sucking pressure, respiratory efforts and airflow were monitored continuously during feeding in 50 term neonates (mean birth weight 3.5 kg, gestational age 39.7 weeks) in the first week of life. Bradycardia (≤100/min) occurred in 9 (18%) infants during the continuous sucking phase of oral feeding. Six of these episodes were preceded by apnea and the remaining 3 episodes were associated with hypopnea (marked reduction in minute ventilation). Airway obstruction occurred during most of the apneic episodes (5/6) and two resulted in cyanosis. The apnea and bradycardia resolved spontaneously with continued feeding in all except one infant. The only intervention performed was discontinuation of feeding in this infant. No episodes of isolated bradycardia or aspiration (associated with coughing and/or choking) was seen in any of the infants monitored. Our results suggest that apnea and transient bradycardia occur more frequently than previously recognized in term infants during oral feeding. This presumably reflects the inability of some infants in coordinating the feeding and breathing patterns during the first week of life and should be considered normal unless it persists beyond the neonatal period. Supported by grants by NIH (HL-01156) and March of Dimes (5-426).

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Mark L. Clark

Papers

Professional identity formation in medical education: The convergence of multiple domains

Breathing pattern and ventilation during oral feeding in term newborn infants.

Apnea, bradycardia, and cyanosis during oral feeding in term neonates

Relative contribution of ribcage and abdomen during augmented breaths in infants.

1453 apnea and bradycardia during oral feeding in term neonates