In Pearl S. Buck’s Pulitzer Prize–winning novel The Good Earth,1 a Chinese peasant farmer, Wang Lung, overcomes poverty, lack of education, and famine and, through perseverance, hard work, and luck, ultimately becomes a prosperous landowner. He marries, has children, temporarily moves to the city during a famine and learns to pull a rickshaw, returns to his village, buys land, and eventually becomes successful and wealthy. As he experiences these events, his conception of who he is and what he can do changes. He creates a succession of identities to fit his changing circumstances, evolving from an uneducated farmer to a man of substance and respectability to whom others come for advice. All of these identities are superimposed upon a core personality and set of values forged during his upbringing with his family.
As I read this novel recently, the changes that Wang Lung experienced reminded me of some of the changes that physicians undergo during medical training and practice. Jarvis-Selinger et al2 describe the process of physicians’ professional identity formation (PIF) during education as a series of stages in which trainees construct new identities and abandon old ones “at the level of the individual, which involves the psychological development of the person, and at the collective level, which involves a socialization of the person into appropriate roles and forms of participation in the community’s work.” The authors argue that medical education should expand beyond an exclusive focus on achieving competencies (“doing the work of a doctor”) toward understanding and nurturing the process of identity development (“being a doctor”).
I was reminded of the importance of PIF during a recent conversation with one of my student mentees. She (identifying characteristics changed) was halfway through her third year of medical school and trying to select a residency. She asked my advice, and I posed a few questions to her to get to know her a bit better.
“What specialties are you considering?” I asked.
“Well, that’s the problem,” she said. “What I want to do does not really seem to exist, at least as a residency. I want to do women’s health and work on prevention and sports medicine for women as well as work on older women’s health issues. I also want to work on African Americans’ health issues because that is my background. But I don’t think I want to do ob–gyn because I am not very interested in surgery.”
“Okay, well, how about internal medicine?” I said. “That will give you a lot of options as far as subspecialties, and it is a great foundation regardless of what you do. You could also get extra training in health disparities and public health during your residency.”
“I thought of internal medicine, but I really did not like my internal medicine rotation very much. We had all of these patients with chronic illnesses awaiting nursing home placement. They were generally so impaired and confused that I could hardly talk to any of them. They seemed to need a social worker more than a doctor. I spent most of my time doing paperwork. The residents did not seem very happy, and I never got to know my attendings. They changed every week.”
“Well,” I answered, “that can be a problem on the wards. How about family medicine? There are many directions you could go in a family medicine residency. The patients might be younger than in internal medicine. You would learn a lot about obstetrics and gynecology but not so much surgery. We really need more people to go into primary care, particularly in the rural areas.”
“I know. But I am a single mom with a three-year-old. I need a program that would be supportive of my situation. I don’t think I could go to a rural area,” she said.
Her responses raised many questions for me about balancing professional identity and personal identity. I realized that I needed to know more about the importance of PIF. One useful source was the landmark study of medical education by Cooke et al.3 These authors, like Jarvis-Selinger et al, identified PIF as an essential priority for medical education. Unfortunately, PIF often is an afterthought in the education process, far behind the accumulation of knowledge and the achievement of competencies needed for clinical rotations. And yet if a student cannot visualize his or her future identity in medicine, the student may select the wrong specialty and risk burnout and wasted effort.
To show the importance of PIF in medical education, almost the entire content of this issue of Academic Medicine focuses on this topic. Hedy S. Wald, PhD, provided invaluable assistance by identifying some of the topics and authors featured in this issue, helping to ensure that it provides a rich mix of perspectives. This issue’s authors describe programs, teachers, and the educational environment that create opportunities for personal and professional growth for trainees. These authors suggest that in the development of a medical student, programs in PIF can be equal partners with programs that emphasize acquisition of procedural skills and medical knowledge. As I review some highlights from this issue, I hope our readers will find the topic as useful for themselves as it was for me in understanding PIF, including understanding the challenges facing my student.
Cruess et al4 provide an excellent overview of and orientation to the key concepts of PIF as well as some historical context. They describe how students integrate their unique personal characteristics and life experiences gained prior to medical school with the health care learning environment, and how they progress through various stages from peripheral roles to more central roles in the health care team.
Wald et al5 present three pedagogic innovations contributing to the PIF process within undergraduate and graduate medical education at their institutions. These strategies aim to help students create new and resilient identities as medical professionals, by embodying and integrating elements such as guided reflection, the significant role of relationships (faculty and peers), mindfulness, adequate feedback, use of e-portfolios, faculty development, and creating collaborative learning environments.
Meyer et al6 investigated PIF in a collaborative program in which new nurse practitioner graduates and internal medicine residents progress through their training together in a primary care clinic at a VA hospital. This qualitative study demonstrated initial differences in the identities of nurse practitioners (expertise in education, prevention, and advocacy) and physicians (expertise in disease, pathophysiology, and pharmacology). These changed over time as the trainees created new individual identities and a team identity, learned more about each other’s skills and interests, and found ways to maximize their joint capabilities for the best quality care for their patients.
Wiltse Nicely and Fairman,7 in a Commentary on the report by Meyer et al,6 describe some of the controversies surrounding nurse practitioner fellowships and recommend that fellowships not become a requirement. They suggest that the fellowships be provided as an option for new graduates or those changing their focus of practice.
Langendyk et al8 discuss in a Perspective the critical importance of changing the medical education of physicians and nurses so that current hierarchical relationships can be reconfigured to facilitate a more team-based practice environment. They explore the gap between what is taught to students about professional roles and the actual clinical roles that exist in practice, and emphasize the importance of creating more fluid identities for both physicians and nurses to bridge current silos and create support for team identities.
Finally, Onyura et al9 examine the risks to physicians’ professional identity during the process of retirement. In this qualitative study, the authors, using focus groups, interviewed academic physicians interested in late-career and retirement planning issues and found that for many, their occupational and personal identities were so intimately intertwined that retirement represented a significant threat to their conception of who they were and what they could do of value after retirement. Indeed, most of us who are physicians and other caregivers cherish our professional identity and find that it absorbs most of our time and energy, leaving us fearful at the end of our careers that retirement will leave us with no residual identity at all. Onyura et al provide a view of professional identity during late-career transitions, including retirement, that could be valuable in assisting physicians during times of change. And if current projections concerning future physician workforce shortages materialize, the information about physicians’ professional identity may be helpful in designing programs to retain and support the continued practice of physicians nearing retirement.
In my reading of The Good Earth, I found another link to medical education and practice, one we have not always recognized and honored: the narrative of a hero overcoming obstacles and in the process forging an identity. In medical education, the heroes and heroines of these sometimes-overlooked narratives are our colleagues and students. In Academic Medicine, examples of such narratives can be found in the “Teaching and Learning Moments” feature; we have two such examples this month.10,11 These stories provide authentic descriptions of how our students and colleagues reflect on their experiences and share them with our community and, in so doing, form their identities and contribute to our shared identity as medical professionals.
I hope the various contributions in this issue of Academic Medicine that discuss PIF will help you, as they have helped me, in seeing the need to make the changes necessary to give PIF a much larger role in medical education and practice. Ideally, our medical schools could play a more active and positive role in the longitudinal support of students and graduates and their changing identities. Such support could lead to more opportunities for graduates to mentor students and junior faculty and could foster more volunteerism and philanthropic giving by graduates as part of an ongoing relationship. The connections between generations have long been a source of strength and wisdom for human society, illustrated in the rituals of religion, in art, and in literature like The Good Earth. Perhaps a focus on PIF, growth, and change across the entire continuum of medical education and practice could help us create and maintain such important connections in our medical community.
David P. Sklar, MD
1. Buck PS The Good Earth. 1931 New York, NY Washington Square Press
2. Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough: Integrating identity formation into the medical education discourse. Acad Med. 2012;87:1185–1190
3. Cooke M, Irby D, O’Brien B Educating Physicians: A Call for Reform of Medical School and Residency. 2010 San Francisco, Calif Jossey-Bass
4. Cruess RL, Cruess SR, Boudreau JD, et al. A schematic representation of the professional identity formation and socialization of medical students and residents: A guide for medical educators. Acad Med. 2015;90:718–725
5. Wald HS, Anthony D, Hutchinson TA, Liben S, Smilovitch M, Donato AA. Professional identity formation in medical education for humanistic, resilient physicians: Pedagogic strategies for bridging theory to practice Acad Med. 2015;90:753–760
6. Meyer EM, Zapatka S, Brienza RS. The development of professional identity and the formation of teams in the Veterans Affairs Connecticut Healthcare System’s Center of Excellence in Primary Care Education Program (CoEPCE). Acad Med. 2015;90:802–809
7. Wiltse Nicely KL, Fairman J. Postgraduate nurse practitioner residency programs: Supporting transition to practice. Acad Med. 2015;90:707–709
8. Langendyk V, Hegazi I, Cowin L, et al. Imagining alternative professional identities: Reconfiguring professional boundaries between nursing students and medical students. Acad Med. 2015;90:732–737
9. Onyura B, Bohnen J, Wasylenki D, et al. Reimaging the self at late-career transitions: How identity threat influences academic physicians’ retirement considerations. Acad Med. 2015;90:794–801
10. Liu J. Keeping my humanity. Acad Med. 2015;90:731
11. Negrete L. All the small things. Acad Med. 2015;90:712