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RIME

“I AM a Doctor”

Negotiating the Discourses of Standardization and Diversity in Professional Identity Construction

Frost, Heather D., PhD; Regehr, Glenn, PhD

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doi: 10.1097/ACM.0b013e3182a34b05
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Abstract

As gatekeepers to the medical profession, medical educators are responsible for producing the right kind of physicians. Increasingly, the medical education community has recognized that doing so means ensuring not only that medical students acquire the technical skills and knowledge required for safe and competent practice but also that they graduate conceiving of and identifying themselves as professional physicians. Leading medical educators have promoted this view, including Cooke and colleagues,1 who, in their call for the reform of medical school and residency, maintained that “the formation of an appropriate professional identity” should be “one of four key curricular goals.” While recognizing its importance, medical educators also have come to realize that we have not been as effective in this realm as we might like. Many faculty have expressed dissatisfaction with the type of physicians their students are becoming. They are concerned and disheartened by students’ diminished interest in primary care and generalist specialties2–4; unwillingness to practice in rural and underserved areas5–8; reluctance to assume academic positions9,10; lifestyle priorities and poor work ethic11,12; lack of professionalism13–15; and declining empathy, compassion, and humanism.16–18 Put differently, faculty are wondering why their medical students are not constructing professional identities either that are congruent with faculty’s expectations and standards or that the medical profession recognizes as appropriate and desirable.

No longer part of the lay world of patients yet still on the margins of the medical profession, generations of medical students have been challenged to make sense of who they are in the context of their training and who they will be in the context of the profession. However, in the discussion that follows, we propose that the process of constructing an appropriate professional identity has become more complicated for contemporary medical students because of three converging factors. The first factor is the increasing diversity of medical school classes. The second factor is the presence of two dominant, yet competing discourses within medical education: one promoting this diversity and the other emphasizing greater standardization and uniformity. And the third is the fact that the tension between these two discourses remains largely unacknowledged and unaddressed by medical educators.

In this article, we begin by presenting a critical review of the discourses of diversity and standardization as they have been articulated in seminal publications from the medical education literature, demonstrating the tension between them. We then survey the social sciences literature to describe the tenets of a social constructionist theory of identity. We draw on this theory to explore what the tension between the discourses of diversity and standardization might mean for medical students and the ways in which they are constructing their professional identities. We subsequently return to the medical education literature for examples of how students might resolve this tension when constructing their own professional identities. Finally, we conclude by highlighting the implications of a social constructionist interpretation of professional identity for medical educators, medical education researchers, and the medical profession more generally.

Method

Between March and May 2012, the first author (H.D.F.) scanned a subset of prominent medical education journals, including Academic Medicine, Medical Education, Advances in Health Sciences Education, Medical Teacher, and Teaching and Learning in Medicine, in search of articles related to the concept of professional identity construction within the context of undergraduate medical training. We limited this search to articles written in English and published within the past 20 years (1992–2012). During this preliminary scan, the discourses of diversity and standardization emerged as particularly salient. This discovery led to a targeted search through online databases, including MEDLINE, GoogleScholar, ERIC, and Web of Science, for articles that focused on the issues and concepts identified in the preliminary scan—the discourses of standardization and diversity (such as competency frameworks, professionalism, and admissions) as well as various aspects of student diversity (race, gender, ethnicity, sexuality) within undergraduate medical education. We also hand-searched the reference lists and conducted citation analyses of heavily cited and significant articles. This secondary search was iterative and informed by our ongoing discussions and analysis of the literature. Given the breadth of our search, we cannot specify a simple list of key words. We, however, made no effort to be comprehensive. Rather, our intention was to critically review publications that we identified as representative of the discourses of diversity and standardization, to highlight their assumptions, premises, and logic, to understand the potential role of these discourses in identity construction. This critical analysis was guided by an earlier comprehensive review of the social sciences literature relating to theories of identity construction in the context of immigration, completed by the first author (H.D.F.) as part of her doctoral dissertation.19 The brief survey of the social sciences literature that we present in this article is similarly based on this earlier review.

Results

Discourse of diversity

The discourse of diversity in medical education emphasizes respect for and the value of individual students and their unique life experiences, educational backgrounds, and identities (such as gender, race, religion, ethnicity, and socioeconomic status). The discourse includes policies relating to medical schools’ admissions processes, which intentionally seek to enroll broadly diverse student populations. The Liaison Committee on Medical Education mandates that all accredited medical schools in the United States “have policies and procedures to achieve appropriate diversity among its students, faculty, staff, and other members of its academic community.”16 Diversity has been an issue for North American medical schools since the 1960s when civil rights activists brought public attention to the severe underrepresentation of racial and ethnic minorities in the health care professions.17,18 However, the nature of this discourse within medical education has shifted considerably since that era.18,20,21 Whereas early attempts to increase minority student enrollment were morally justified and framed in the interests of social equity and racial justice, the contemporary discourse focuses on the outcomes realized through greater student diversity.18,20,21 Central to this discourse is the notion that a diverse student body yields unique “educational dividends,” which are ultimately advantageous to health care.18 Diverse students bring to their training a multitude of different talents, unique outlooks, and distinct experiences, which enhance the educational experiences of all medical students, and thus serve to engender more culturally competent, empathic, and service-oriented graduates who are better prepared to care for society’s increasingly heterogeneous patient population.22–24 Increasing student diversity is thus seen as the mechanism for improving access to and quality of care for underserved and disadvantaged populations and, ultimately, ameliorating inveterate health disparities.22,25,26

Discourse of standardization

In contrast to the discourse of diversity, the discourse of standardization emphasizes the importance of uniformity, consistency, and the commonalities both amongst trainees and physicians and across the profession. Inherent in this discourse is a drive to concretely define what is core or essential to being a physician—what every physician should be, what each should be able to do, and what knowledge and skills each should master.

Although embedded within many areas of medical education, the push for standardization is particularly evident within discussions of competency-based education (CBE), which explicitly seeks to educate students towards specific standards as they are articulated in core competencies. Representing the promise of a more standardized output (graduates and physicians), CBE is touted as a means for making medical education more transparent, socially accountable, and responsive to patients’ needs.27–30 Rather than emphasizing time, as has been the tradition in the “tea bag” model of medical education, in CBE models31,32 teaching and assessment are organized around a set of predetermined, progressive, standard competencies.27,33,34 Medical educators thus suggest that CBE has the potential to be more learner-centered, individualized, and accommodating to diverse learners than traditional programs, allowing trainees to set the pace of their learning.34,35 However, given that what students must learn (the “exit competencies”) and that the sequence in which they must learn it (the “milestones”) are fixed and predetermined, the extent to which students may stray from the path is restricted. Further, the value of CBE is understood to hinge largely on the precision and clarity with which the medical education community is able to define and codify the core competencies we hope to see in graduates.

Not surprisingly, much of the discussion around CBE has focused on what competency is, what distinguishes a core competency, and the process for identifying, defining, and delineating these competencies.35–38 These discussions serve to tie the achievement of more standardized physicians to the specification of core competencies and to equate greater standardization with improved patient care.28,39,40 The Royal College of Physicians and Surgeons of Canada unambiguously conveys this logic in its description of the competency-based CanMEDS framework that appears on its Web site: “CanMEDS: Better standards. Better physicians. Better care.”41 Thus, regardless of the flexibility of the paths that they follow through training, the end point of a student’s journey might well be considered more explicitly constrained and inviolable than ever before. Although the competency movement most clearly represents the discourse of standardization, this discourse also undergirds other discussions within the field, such as those around professionalism and professional development.42–44

Discourses in tension

The discourses of diversity and standardization are individually sensible, and each confers important benefits to the medical profession. However, although both are directed towards producing better physicians and improving patient care, the pathways they propose to achieve that goal diverge. They are built on different assumptions, entail different ways of thinking about medical education and the profession, and support very different pedagogical strategies, objectives, and solutions.

The discourse of diversity emphasizes individuality, difference, and a plurality of possibilities. It advances the notion that heterogeneity and multiplicity are beneficial to medical education and, by extension, to patients. It explicitly suggests that admitting more diverse students leads to educational outcomes that benefit public health and patient care. This reasoning in turn implies that medical education should be organized and delivered in ways that encourage the incorporation, preservation, and leveraging of students’ idiosyncrasies. If differences are effaced or negated through medical training then the benefits of admitting diverse students fail to be realized.

In contrast, the discourse of standardization strives for homogeneity, fundamental sameness, and a limited range of possibilities. It conveys the sense that there is a single uniform way of being a competent, professional physician. This discourse in turn works to support a simplified approach to medical education whereby curricula and assessments are designed to capture and translate for trainees the essence of the physician by way of, for instance, professionalism standards or core competencies. This discourse promotes the understanding that students will develop in a more standard fashion if their training, although not wholly uniform, is tailored to curb and eliminate variability.

These discourses, therefore, are not simply heterogeneous—they are in tension. This tension, however, remains largely unacknowledged by medical educators. With few exceptions,33 scholarly discussions have been framed such that they align with one discourse or the other, which has served to divide the discourses into separate literatures so that the two seldom collide. As a result, scholars and researchers have not experienced this discursive tension, nor have they had to grapple with its implications. For medical students, however, this tension is troublesome because, as social constructionists would contend, students rely and draw on these discourses as they attempt to figure out how to become a physician, what it means to be a physician, what it means to belong to a profession, how they will fit in to the profession, and their own sense of who they will be as physicians when they finally emerge from their training.45–49 Put simply, students use the discourses of standardization and diversity to construct their professional identities.

The social construction of professional identities

Identity is one of the most significant dimensions of contemporary social sciences analysis.50–52 In the 1960s, scholars from a range of social science disciplines, including sociology, anthropology, human geography, and cultural studies, began to abandon the traditional notion that human beings have stable biologically grounded identities in favor of an understanding of identities as multiple, dynamic, and socially constructed.49–55 Although the literature in this field is vast and varied, we review here some of the main tenets of a social constructionist stance on identity as espoused by social sciences theorists.

Social scientists generally agree that we are not born with our identities (such as gender, race, ethnicity, religion, and socioeconomic class), nor can they be passively assigned and adopted. Rather, they are social constructions.45,56–62 We construct and reconstruct our identities out of the various sociocultural materials and resources that are available to us in our everyday lives. Social construction broadly describes the process whereby we draw on, engage with, and adopt existing discourses, norms, practices, and processes to make sense of and give meaning to our own experiences and lives. Through this process, we define ourselves. Thus, though socially and culturally derived, identities also are deeply personal.54 Medical students’ professional identities can be conceptualized similarly as both socially constructed and deeply personal. For the purposes of our discussion, such an approach implies that (1) medical students construct professional identities out of the competing discourses of diversity and standardization; (2) they use and negotiate these discourses differently and experience the process of construction differently depending on their unique social identities; and, as a result, (3) they construct different types of professional identities.

Social constructionists would maintain that medical students construct their professional identities within the context of the medical profession and its associated institutions. The discourses, practices, norms, and expectations of the medical school and the profession serve as the raw materials and resources that medical students use to construct their identities.47,48,63,64 Although the discourses of diversity and standardization are by no means the only raw materials to which students are exposed, given their recent prominence in medical education, we can expect these discourses to be significant resources within the available sociocultural repertoire. Thus, the discourses of standardization and diversity convey important and powerful messages, cues, and directions to students about what it means to be a physician and how they should become one.

Unlike in the scholarly literature, however, these discourses are not packaged and delivered in medical education to students as cleanly teased apart and logically separate entities. Medical students are more likely to experience them as coexistent, overlapping, and messy discourses. They are thus likely to be very aware of the inherent tensions and contradictions. During the admissions process, for instance, prospective medical students encounter the discourse of diversity as they are urged to illustrate what makes them unique and sets them apart from the other applicants with a 4.0 grade point average who are inspired to help people. They hear that what makes them different is important and that the medical school values their distinctiveness. However, applicants also confront the push for standardization in that they are required to demonstrate their uniqueness in a way that conforms to admission standards. They need to fit a relatively standard applicant profile and be able to demonstrate how, if admitted, they have the potential to become like their peers and colleagues, and eventually indistinguishable members of the profession. In these ways, the discourses of standardization and diversity send conflicting messages to medical students about what it means to be a physician and how to become one. Navigating and negotiating these mixed messages is part of the process of professional identity construction. The professional identities that medical students construct are shaped by and reflect how they come to terms with and personally reconcile the contradictions and tensions between these discourses. How students undertake this reconciliation depends to a large extent on who they are.

Conceptualizing a class of medical students as an undifferentiated body, as Becker and colleagues65 did in 1961 in Boys in White, is no longer sensible. Though still less diverse than North American society as a whole, we have seen a sharp rise in student diversity—more women, more openly gay and lesbian students, more students from nonscience backgrounds, and so forth. Each of these diverse students arrives as a complicated person with multiple intersecting identities, which means that they define themselves according to a range of social categories.19,48,66–71 For instance, a student may identify as a woman but also as gay, middle class, and Jewish. How medical students conceive of themselves in terms of their social identities informs and influences how they use available cultural materials, reconcile conflicting messages, and, ultimately, construct professional identities.

Thus, although students encounter the same discourses and are all seeking to figure out if and how these two discourses work together, no single formula or standard approach to the negotiation and reconciliation process exists. Educational researchers examining identity construction amongst secondary school students, for example, found that students who were exposed to the same educational discourses interpreted, used, and negotiated those materials differently.19,72–75 Students resolved and reconciled tensions in ways that made sense to them personally and that resonated and worked with their respective social identities. Similarly, we can expect medical students’ social identities to be influenced by how they engage with and resolve the tensions between the discourses of standardization and diversity. Given this multiplicity and variability, we are likely to encounter many different versions of professional identity within any given medical school class.

Complicating this process further, researchers have demonstrated that, even when students desire to be transformed, the process of identity construction entails struggle and brings with it confusion, anxiety, conflict, costs, and compromises.47,75,76 The manner in which individual students experience the process is, however, likely to be highly individualized and more complicated for some students than others, depending on the extent of the perceived compatibility between their social identities and that of the standardized physician. Nonetheless, we should not expect the process of remaking oneself into a physician to be uncomplicated or angst-free for any student.

Examples of identity struggles from the medical education literature

In this section, we examine examples from the medical education literature to demonstrate how both the nature and the degree of students’ struggles vary in relation to their unique social identities.

Evidence from the existing literature supports the theory that medical students are wrestling with and negotiating the discourses of standardization and diversity in different ways, are constructing a variety of professional identities, and are experiencing different kinds of struggles as they construct those identities. For the purpose of our discussion, we refer to the different types of identities that we have extracted from the literature as standards, alternatives, and hybrids.

Some students appear to resolve the conflict between the discourses of diversity and standardization by focusing on the messages associated with standardization to construct a standard version of identity. These students are heavily influenced by the pressure towards homogeneity and compelled by the fears of standing out and not being accepted.77–80 They attempt to fit into a mold77 and have come to believe that the well-trodden road is the only road.80 Constructing a standard identity may require students to shift their social identities or let go of certain aspects of who they are to align with the perceived norm. Students describe making trade-offs, deemphasizing parts of who they really are (e.g. particular social identities), and stifling their individuality to identify with the standard.77,79 For example, in a personal essay entitled “Normal white female,” a medical student describes how she deemphasized her sexual identity when she was applying for admission to medical school to fit in.81 She recalls that she often “could not show those parts of [herself] that distinguish [her], those parts that show strength, resilience, and character.”81 Her narrative suggests that, although disconcerting, constructing a standard identity was a possibility for her because her other social identities aligned reasonably well with the standard: She is white with a “good middle-class suburban education.”81 Comments from students scattered throughout the literature reinforce that such an approach is not uncommon. They report, for example, that by the end of medical school, they “become narrower people,”79 their individual talents and interests are overshadowed and “forgotten,79 and their personal flair78 is so dampened that they graduate more alike than when they entered.77 The discourse of standardization is more dominant for these students—they want to be like “them”—and they construct a standard identity by downplaying or suppressing facets of themselves that do not seem compatible with their evolving professional identity.

For other students, constructing a standard identity does not seem feasible. They consider the trade-offs and compromises that such an approach entails to be too great. These students see the professional standard as being so at odds with their other social identities that they feel as if they are losing who they are. For them, resolving the standardization/diversity conflict might mean prioritizing the messages of diversity. These students view their individuality and distinctiveness as assets that need to be protected, so they construct an alternative identity based on being different from the norm. For instance, in a study conducted at an American medical school, American Indian and Alaskan Native medical students expressed their concern that becoming a physician “might mean relinquishing their American Indian identities.”82 Several of these students responded to what they saw as a normalizing pressure by distancing themselves from the norm and resisting and rejecting messages associated with the discourse of standardization. One student “disdained the pressure to become like other physicians” and, as she explained, did not want to “play that game.”82 In clinging tighter to their cultural identities as American Indian and Alaskan Native, students constructed an alternative professional identity that served to accentuate their separateness from “mainstream” students and physicians. Similarly, at a Canadian medical school, a student from a working class background repeatedly insisted that because of her identity as someone from “the other side of the tracks,” she “would never become one of them.”83 For such students, the discourse of diversity is most important, and the alternative identities they construct serve to play up, rather than mute, their differences.

Still other students construct what social scientists refer to as hybrid identities.76,83,84 They selectively borrow aspects from each discourse to construct an identity that allows them to (mostly) fit the standard while retaining enough of themselves that they do not feel lost. Although far less prevalent within the medical education literature, this approach is exemplified by an openly gay male student who, in a personal essay, wrote about his decision to remove the earring he had worn for the first two years of medical school. He recounted the doubt surrounding his decision, his fear that he had “committed the cardinal sin” and “crawled back into the closet” as one of his gay peers expressed disgust that he was ashamed to wear his earrings.85 The young man defended his decision, reasoning that although “homosexuality is a state of being” and he permits his “feminine side to be expressed as freely at the hospital as in the company of other gays,” wearing an earring is “not professional attire for the medical floors.”85 He suggested that although wearing an earring had been a manifestation of his identity as a gay man, it was not an expression of his identity as a professional gay physician. Rather than prioritizing one discourse over the other, this student acknowledged messages from both discourses to construct a hybrid identity that is based on both standards and individuality.

These examples are not representative of all students’ pathways to becoming professional. Nor are we arguing for the appropriateness of one over the other. Rather, we intended to demonstrate some of the ways in which medical students might interpret the discourses of standardization and diversity, some of the personal struggles they are experiencing, and the various identities they might create as a result. When faculty observe that their medical students are not turning out the way they had envisioned or desired, it is likely that they are running up against these discordant discourses and are being challenged by those identities that at times appear incongruent or inconsistent with professional norms, standards, and expectations of what it means to be a physician.

Discussion

Implications for medical educators

The social constructionist understanding of professional identity that we laid out above focuses on the student as the active agent engaged in the hard work of identity construction. Medical educators then must assume the role of facilitator in that process. As facilitators, educators might consider not only how to assist students in constructing their professional identities but also how to help them do so in ways that the profession recognizes as legitimate and appropriate. If this is our goal, we cannot continue to leave students to their own devices as they attempt to reconcile competing discourses, whether they be the two we have highlighted here or the many others that likely are part of the hidden curriculum.86 Educators might become explicitly and intentionally involved in this process by providing, for instance, ongoing mentorship, guidance, and support to students as they struggle to interpret and make sense of these discourses within medical education. Rather than insisting that students become like “us,” we should help to inform and structure their negotiations in a more sophisticated way so that all students are able to construct identities as physicians that will allow them to retain and take advantage of their individuality while respecting and honoring professional values and norms.

An attendant concern in this effort is determining how to best provide and create pedagogical spaces87 and opportunities within the curriculum to facilitate students’ identity construction. Shepherding students through their personal journeys and struggles will require opportunities for small-group and one-on-one faculty–student interactions, whereby faculty learn about who their students are, initiate and lead explicit conversations about identity construction, dedicate time to explaining what construction entails both for educators and students, share their own experiences and struggles, and clarify the goals of medical education.

As educators, however, we are not only facilitators of this process but also providers of the raw materials that students need to construct their identities. How students craft their professional identities is heavily determined and constrained by the materials to which they are exposed during their training. If we hope to affect the process of identity construction, addressing how we talk about becoming a professional is important. For example, educators should emphasize that medical training is necessarily transformative—students should expect to change—but that professional identity construction is not meant to be a process of erasure whereby students feel as if they have lost who they are. Similarly, educators should articulate that professional identity construction is not intended to be a top-down process whereby educators dictate to students who they should be, but, rather, it is a personal journey throughout which students derive their own meanings and construct their own identities. In addition, faculty should convey that, as educators and professionals, we want them to construct an identity that intersects with and builds on who they are and that, hopefully, allows them to experience identity integration and alignment. Educators have the opportunity to provide medical students with a new lens for understanding what is happening to them during their training and what it means to be a physician. More fundamental and perhaps most important, we can provide new discursive material that students can bring to the task of identity construction. Thus, educators may begin to confront the tensions between the discourses of standardization and diversity to create a new discourse that, while appreciating the need for standardization, common values, and a shared sense of what it means to be a physician, also recognizes the value that individuals and their respective differences bring to the profession and to practice.

Implications for medical education researchers

The body of literature on medical students and professional identity is expanding rapidly and has provided us with valuable information about important aspects of identity construction.88–93 However, in emphasizing the importance of students’ social identities, the social constructionist approach suggests new research questions and lines of inquiry. At present, our understanding of who students are in terms of their own self-conceptualizations and multiple intersecting social identities is underdeveloped. To gain a better sense of how students’ social identities inform their professional identities, researchers might ask different questions of medical students to explore how they really see themselves; what messages they are taking from the discourses of diversity and standardization; what they are doing with these clearly competing discourses; how they determine which discursive messages to adopt, adapt, or reject; and the extent to which their social identities influence their interpretation and use of discursive material.

More fully exploring and uncovering the dynamics and nuances of professional identity construction also requires that we address the extent to which students are constructing different identities, how those different identities are being manifested, and under what conditions and out of what materials they are being constructed. In this regard, we should explore the implications of medical students’ different professional identities. Research conducted in other educational settings and in business and management suggests that how people identify has implications for their educational and career trajectories19,73,74 and their performance and creativity at work.94 This evidence suggests that medical education researchers would do well to explore the relationship between identity construction and educational and career outcomes to address such questions as, Does the way that students identify affect how they learn, what they learn, or why they learn it? Do different identities support different career choices or ways of practicing?

Implications for the medical profession

Finally, if our objective as educators is to assist our students as they construct identities that the profession deems appropriate, then, in our best interest and in the interest of our students, we should initiate a new discourse, at the level of the profession, that brings together the discourses of standardization and diversity to harness the existing tension and to pose some broad but important questions. These questions include, How much diversity and individuality can be accommodated within the boundaries that define medicine as a profession? Must there be a limit to diversity? If so, what is it and who will define it? How do we capitalize on individual strengths while maintaining medicine’s identity as a profession? We recognize that these questions are not easy to answer, but we propose that, in grappling with them, and bringing them into the professional discourse, we can better help our students to not only understand, but also appropriately resolve, the tensions they face as they attempt to construct their own identities as physicians within the context of the profession.

Conclusions

Becoming a physician is necessarily challenging and transformative. As medical educators, faculty, and researchers, we cannot hope to render this journey entirely without obstacles. Our review of seminal articles from the medical literature, however, suggests that, at present, we may be, albeit inadvertently, further complicating the process of professional identity construction for medical students by failing to address the tension that students face as they are torn between the competing influences of the discourses of diversity and standardization. If we are to take seriously the call from leaders in medical education to prioritize professional identity construction in medical training, we must begin to grapple with these tensions in our teaching, curricula, and research. The social constructionist approach informs us that the discourses circulating within, and produced by, the medical profession are key resources for medical students’ identity construction. Thus, to influence professional identity construction, we must seek change across the profession. To achieve this goal, the medical profession must acknowledge and take advantage of the tension between the discourses of standardization and diversity and generate a new discourse to shape the identities of future physicians.

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