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Professional Identity Formation: Creating a Longitudinal Framework Through TIME (Transformation in Medical Education)

Holden, Mark D. MD; Buck, Era PhD; Luk, John MD; Ambriz, Frank MPAS, PA-C; Boisaubin, Eugene V. MD; Clark, Mark A. PhD; Mihalic, Angela P. MD; Sadler, John Z. MD; Sapire, Kenneth J. MD; Spike, Jeffrey P. PhD; Vince, Alan PhD; Dalrymple, John L. MD

doi: 10.1097/ACM.0000000000000719
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The University of Texas System established the Transformation in Medical Education (TIME) initiative to reconfigure and shorten medical education from college matriculation through medical school graduation. One of the key changes proposed as part of the TIME initiative was to begin emphasizing professional identity formation (PIF) at the premedical level. The TIME Steering Committee appointed an interdisciplinary task force to explore the fundamentals of PIF and to formulate strategies that would help students develop their professional identity as they transform into physicians. In this article, the authors describe the task force’s process for defining PIF and developing a framework, which includes 10 key aspects, 6 domains, and 30 subdomains to characterize the complexity of physician identity. The task force mapped this framework onto three developmental phases of medical education typified by the undergraduate student, the clerkship-level medical student, and the graduating medical student. The task force provided strategies for the promotion and assessment of PIF for each subdomain at each of the three phases, in addition to references and resources. Assessments were suggested for student feedback, curriculum evaluation, and theoretical development. The authors emphasize the importance of longitudinal, formative assessment using a combination of existing assessment methods. Though not unique to the medical profession, PIF is critical to the practice of exemplary medicine and the well-being of patients and physicians.

M.D. Holden is vice chair, Undergraduate and Continuing Medical Education, and professor and director, General Internal Medicine, University of Texas Medical Branch, Galveston, Texas.

E. Buck is senior medical educator, Office of Educational Development, University of Texas Medical Branch, Galveston, Texas.

J. Luk is assistant professor of medicine and assistant dean for interprofessional integration, University of Texas Dell Medical School, Austin, and clinical associate professor of pediatrics and assistant dean for regional medical education, University of Texas Medical Branch, Galveston, Texas.

F. Ambriz is clinical assistant professor and chair, Physician Assistant Department, University of Texas Pan American, Edinburg, Texas.

E.V. Boisaubin is distinguished teaching professor of medicine, University of Texas Medical School at Houston, Houston, Texas.

M.A. Clark is visiting scholar, Lincoln Center for Applied Ethics, Arizona State University, Tempe, Arizona.

A.P. Mihalic is associate dean for student affairs and professor of pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.

J.Z. Sadler is professor of psychiatry and clinical sciences and Daniel W. Foster, MD Professor of Medical Ethics, University of Texas Southwestern Medical Center, Dallas, Texas.

K.J. Sapire is professor of anesthesiology and perioperative medicine, University of Texas MD Anderson Cancer Center, Houston, Texas.

J.P. Spike is professor, McGovern Center for Humanities and Ethics, University of Texas Medical School at Houston, Houston, Texas.

A. Vince is medical anthropologist and director, University Health Professions Office, University of Texas at San Antonio, San Antonio, Texas.

J.L. Dalrymple is assistant dean for clinical integration, and associate professor and division director of gynecologic oncology, Department of Obstetrics and Gynecology, University of Texas Dell Medical School, Austin, Texas.

Funding/Support: The University of Texas System supported this work.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Previous presentations: Parts of this work have been presented at the Generalists in Medical Education Annual Conference, Chicago, Illinois, November 8, 2014; the Council on Resident Education in Obstetrics and Gynecology/Association of Professors of Gynecology and Obstetrics Annual Meeting, Atlanta, Georgia, February 2014; the Generalists in Medical Education Annual Conference, Philadelphia, Pennsylvania, November 1, 2013; the Southern Group on Educational Affairs Annual Conference, Savannah, Georgia, April 18–20, 2013; the Innovations in Health Science Education Conference, Austin, Texas, February 21, 2013; the Generalists in Medical Education Annual Conference, San Francisco, California, November 2–3, 2012; the UTMB (University of Texas Medical Branch) Academy of Master Teachers Spring Symposium, Galveston, Texas, May 18, 2012; and the Southern Group on Educational Affairs Annual Meeting, Lexington, Kentucky, April 2012.

Correspondence should be addressed to Mark D. Holden, General Internal Medicine, University of Texas Medical Branch, 301 University Blvd., Route 0566, Galveston, TX 77555-0566; telephone: (409) 772-4182; e-mail: mholden@utmb.edu.

The concept of professionalism has gained traction in medical education over the past few decades but does not fully capture the depth and complexity of what it means to be a physician. As Cooke and colleagues1 noted, “Students typically enter medical school with only a superficial understanding of the values underpinning the medical profession and how these values inform every step of the educational process.” Instruction in medical professionalism has focused on understanding and applying ethical principles, observable behaviors, and medicine’s contract with society.2 Over the last decade, the concept of physician professional identity formation (PIF) has emerged to identify the process through which a student transforms into a physician,3 and an increasing number of authors have emphasized the importance of an intentional focus on PIF in medical education.4,5 Sklar6 expressed concern about the challenges to PIF that result from “the commodification of health care and the deterioration of the health care environment,” in which medical services become products bought and sold in the health care marketplace. Despite the collective emphasis on PIF in medicine, however, no detailed conceptual framework exists on which to scaffold curricular pedagogies or assessment strategies.

The University of Texas System (UTS) established the Transformation in Medical Education (TIME) initiative to reconfigure, enhance, and shorten undergraduate medical education (UME) from college matriculation through medical school graduation. TIME uses competency-based education, incorporates nontraditional topics from the humanities and social sciences, and emphasizes PIF. Given TIME’s accelerated education time frame, the TIME Steering Committee and initiative partners were significantly concerned with the impact of bringing students into medical education who were younger and less emotionally mature. To address this concern, the TIME Steering Committee established PIF as a cornerstone of the initiative, with the goal that early, deliberate focus on PIF would foster its development in students. The TIME competencies and PIF are foundational elements of four UTS-wide premedical and medical education partnerships that include four medical schools and eight undergraduate campuses.

This article summarizes the relevant literature and describes the process of defining PIF and creating its framework. We will then elaborate on the framework and examine its applications and implications for medical education.

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Background

Much of the work on personal identity development derives from Erikson’s7 identity theory and Marcia’s8 identity status paradigm expanded by social development theory9 and social learning theory.10 Wilson et al11 described professional identity as “the integration of personal values, morals, and attributes with the norms of the profession.” Kegan’s constructive-developmental theory12 has been applied to identity development in several professions, including with military trainees and officers,13 law students and lawyers early in their careers,14 and dental students.15

Consideration of professional identity development within the health professions16–18 acknowledges the dynamic nature of professional identities that are “assembled” and “disassembled,” socially defined and influenced, and intertwined with one’s self-concept and one’s multiple personal identities. The role of the learning environment has been highlighted,19 and Phillips et al20 emphasized the importance of experiences and self-reflection. Johnson et al18 noted the potential for conflict between personal values and developing professional values, as well as dissonance between idealized expectations and the reality of the profession.

Much of the PIF literature in medicine parallels that of other health professions. Jarvis-Selinger et al21 emphasized the dynamic nature of PIF in medical students as they construct and deconstruct identities from rotation to rotation. Littlewood et al22 highlighted the importance of the social environment of early clinical experiences. Monrouxe23 described the complexity of balancing several subidentities with one’s professional identity. Pratt et al24 identified adaptive patterns to discrepancies between idealized and actual work activities in postgraduate medical education.

Additional PIF literature in medicine highlights the importance of experiential learning, early clinical experiences, role models, discourse, socialization, and relationships.25–28 Students’ level of developing expertise may also impact PIF,29 as reflected in their understanding and approach to professional dilemmas.30 The literature further underscores the importance of self-reflection in identity development.31–35

Gold et al36 described factors to consider in designing a framework for personal and professional development in medical students. Boudreau et al37 recently published on a four-year apprenticeship in UME that focused on PIF. Building on this background literature from multiple disciplines and perspectives, the UTS TIME partners sought to develop a structural framework that would define PIF components and scaffold curricular strategies to enhance and assess PIF across the longitudinal continuum from college matriculation to medical school graduation.

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Framework Development

In 2012, the TIME Steering Committee established a task force to define PIF, explicate its key aspects, and identify strategies for its promotion and assessment. After selecting a task force chair, the TIME Steering Committee issued an invitation to all UTS institution faculties to apply for the interdisciplinary PIF task force. Thirteen faculty members were selected on the basis of their expressed interest, academic and geographic diversity, and health science education experience. Designated as UTS Health Professionalism Scholars, the task force members included educators and practitioners from three academic undergraduate and five health science campuses representing psychology, anthropology, philosophy, humanities, ethics, student affairs, education, physician assistant studies, anesthesiology, obstetrics–gynecology, pediatrics, psychiatry, and internal medicine.

After reviewing relevant literature on theoretical constructs of identity development and PIF in medicine and other professions, the task force developed a consensus definition of PIF through a series of in-person meetings, conference calls, and e-mails. Clarification of the distinction between professionalism and PIF was essential to the task force’s work. Both the process of defining PIF and the definition itself facilitated the task force’s group formation and aligned its language and understanding of PIF:

Professional Identity Formation is the transformative journey through which one integrates the knowledge, skills, values, and behaviors of a competent, humanistic physician with one’s own unique identity and core values. This continuous process fosters personal and professional growth through mentorship, self-reflection, and experiences that affirm the best practices, traditions, and ethics of the medical profession. The education of all medical students is founded on PIF.38

To identify key aspects of PIF, the task force developed a candidate list of 17 characteristics. Using a modified Delphi technique,39 the task force reached consensus on 10 key characteristics that the group considered foundational to professional identity: adaptable, altruistic, curious, empathic, ethical, honest, reflective, responsible, self-aware, and trustworthy. These characteristics align well with those in the Association of American Medical Colleges’ report on students’ core personal competencies for medical school success.40 Although these key aspects provide a glimpse into PIF, they do not fully capture the richness, depth, and range necessary to describe the complexity of physician identity or to bridge the concept and its application. To further explicate the complex identity intrinsic to a practicing physician’s multiple roles and activities, the task force used an iterative process to delineate domains and subdomains incorporating the key aspects and more completely characterizing physician PIF.

To facilitate longitudinal application (from college matriculation through medical school graduation) of these domains and subdomains, the PIF task force adapted three developmental stages from the Pediatrics Milestone Project.41 Phase 1 (Transition) represents the introduction of PIF, in which students’ curiosity and passive observations inform their nascent professional identity. Students in Phase 1, typically undergraduates, exhibit an interest in medicine but are not yet engaged with the field as professionals. Phase 2 (Early Developing Professional Identity) describes the maturing professional identity of students engaged in medical school education and early clinical experiences. These students appreciate the delivery of patient care and the concept of being professional but have yet to assume primary responsibility. Medical students early in their clerkship rotations typify this phase. Phase 3 (Developed Professional Identity) describes students who understand the gravity and rigor of being responsible health care providers demonstrating a sense of duty and service. Attaining Phase 3 may be an appropriate goal for graduating medical students. Additionally, the Pediatrics Milestones Project describes two further stages of PIF: Mature Professional Identity and Broadened Professional Identity, which would be relevant to graduate medical education (GME) and professional practice.

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PIF Framework

Structure

The PIF task force constructed a framework that tangibly formats the 6 domains and 30 subdomains (Table 1) across the three developmental phases. Each domain section begins with definitions and terminal objectives. Within the domain sections, each subdomain is defined and outlines the objectives, activities, and assessment strategies that translate the concepts into proposed curricular applications for all three phases of development. Where appropriate, the framework identifies relevant components of the TIME competencies. Each developmental phase of the subdomains features a set of objectives for students at that phase. Terminal objectives for each domain mark the goals for medical school graduation. Resources and/or references for faculty and students conclude each subdomain section. For an example of a subdomain in the PIF framework, see Chart 1.

Table 1

Table 1

Chart 1 Example of One Subdomain From the Professional Identity Formation (PIF) Framework Developed by the TIME (Transformation in Medical Education) Initiative PIF Task Force at the University of Texas System, 2012a

Chart 1 Example of One Subdomain From the Professional Identity Formation (PIF) Framework Developed by the TIME (Transformation in Medical Education) Initiative PIF Task Force at the University of Texas System, 2012a

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Suggested activities

Consistent with the literature, activities suggested within the framework include a variety of formal courses, personal development workshops, reflective writing, community service learning, clerkships and electives, mentorship, cultural immersion experiences, and learning communities. These opportunities provide rich experiences to facilitate the development of students’ professional identities. For example, volunteerism is often cited as a desirable attribute of premedical students, medical students, and professionals. Early interest in volunteering has demonstrated associations with exploration of opportunities; gateway experiences; greater quality, depth, and leadership in service; and, ultimately, an enduring commitment and joy in serving others.42–44 Leming’s45 study of high school students revealed that community service with ethical reasoning and self-reflection components had a greater effect on students’ identity formation than community service alone.

In the PIF framework, volunteering in different contexts and roles spans all three phases and crosses all domains: attitudes; habits; perceptions and recognition; relationships; duties and responsibilities; and personal characteristics. While similar activities may span developmental phases, the activity’s level of challenge or sophistication should be modified and increase as the students advance and gain expertise.

For example, during Phase 1, students could volunteer in a community service center, thus promoting the attitude of service orientation, the habit of displaying empathy, and the responsibility of honoring commitments. For students in Phase 2, volunteering in a student-led free clinic could further enhance service orientation with greater levels of responsibility arising from increased clinical competence. A student in Phase 3 might become director of a student-led free clinic, which would help develop the personal characteristic of leadership. Students could compile these volunteering activities, related reflective essays, and formative feedback in portfolios as an educational strategy to demonstrate longitudinal development.46–48

The first TIME student cohorts matriculated at undergraduate campuses in 2012 and 2013, with anticipated transition to one of the four partner medical schools three years later and to GME beginning in 2019. TIME partners have used the PIF framework to develop activities and structure courses for inaugural cohorts at undergraduate and medical campuses. Initial programs include community service learning, reflective writing, small-group learning, portfolios, mentoring, and seminars on professional development. TIME student feedback received so far from across multiple partnerships indicates initial success and supports the development of more complex integrated programs that will expand as these students transition to the medical campuses.49,50

Existing medical school curricular and extracurricular activities provide sustainable platforms for students’ exploration and development of PIF. When mapped to the PIF framework, either by students or schools, students’ experiences and performance outcomes could be used to track their PIF development. For example, critical self-reflection and journaling could enhance students’ self-awareness of their PIF development, especially if journaling is undertaken after academic or professionalism challenges and emotionally charged experiences.51,52

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Assessment of PIF Within the Framework

Assessing PIF is essential to the evolution of our understanding of this multifaceted, developmental process. Three important purposes for assessments are (1) providing feedback to learners, (2) evaluating curricular and extracurricular strategies to promote PIF, and (3) advancing theoretical development. Cooke et al1 recommended three general strategies for PIF assessment: observations as part of clinical assessments, developmental benchmarks, and assessment of learning environments. They also emphasized “aspirational” elements outside the arena of competencies. Jarvis-Selinger et al21 expanded the idea of aspirational elements and highlighted assessment of PIF as different and complementary to competency-based assessment, framing PIF as a way of being rather than a way of doing.

Hafferty53 referred to this construct as internalized socialization and contrasted it with the predominant focus on observable behavior in assessments of professionalism. The relationship between professionalism and PIF is bidirectional, each influencing the other.54 Thus, performance of professional behaviors may foster PIF. Inconsistent use of the terms professionalism and PIF in the literature results in a need for clear and explicit assessment goals.

Because PIF is a complex, nonlinear, developmental process influenced by personal characteristics, experiences, and sociocultural factors, assessment strategies must be longitudinal and embrace complexity.55 No single assessment activity can provide definitive information about an individual or a group. A strategy of multiple complementary and overlapping assessments provides the necessary pluralistic approach without adding substantially to the global assessment burden for learners.56

We use the term assessment broadly, referring to documenting knowledge, skills, attitudes, and beliefs, and include both formal and informal assessments. The nonlinear construct of PIF is not suitable for establishing standards through the assessment process. Rather, the task force recommends descriptive, formative assessments using mixed methods to provide feedback, evaluate curricular programs, and guide theoretical development.

Monitoring students’ development provides information that can, in turn, be used when mentoring, encouraging, and supporting identity development. It also allows us to examine the effects of educational interventions. Although we do not advocate comparing individuals with one another on the basis of assessments, there is value in comparing relative impacts of educational programs and activities. Identifying individual developmental trajectories may highlight commonalities among students as well as educational interventions to support students’ development. It may become possible, with continued development of the construct and improvement of assessment methods, to establish benchmarks to monitor progress and identify opportunities for support or intervention. As assessment work progresses, the aggregated information may confirm or disconfirm theoretical assumptions about PIF. An iterative process of conceptual development alternating with data gathering can advance both assessment methods and theory.

Common assessment strategies can be adapted to assess PIF, including objective structured clinical examinations (OSCE), reflective writing, multisource feedback, surveys, and portfolios. In the absence of well-developed approaches to PIF in the gestalt, assessment of PIF components may continue its explication. Combining assessment strategies and perspectives can yield more robust assessment.

OSCEs can assess PIF domains and subdomains, including humanism, empathy,57 integrity, rapport building,58,59 and ethical decision making.57,58,60–62 Reflective writing provides rich qualitative information that is valuable in delineating trajectories and aspects of personal and professional growth.51 Application of Kegan’s constructive-developmental theory may provide a framework for assessing students’ identity formation through evaluation of their reflective writing.13,15,63 Although the literature is inconclusive about the value of using standard multisource feedback formats with medical trainees,64–71 the opportunity for learners to compare multiple perspectives with their own self-assessments may prove to be a powerful PIF tool. Surveys offer additional means to collect valuable information about the natural history of PIF and how it develops and relates to other attributes and experiences of the individual, such as personality traits or demographic variables.72–75 Portfolios offer longitudinal data for assessment, synthesized from multiple methods and perspectives.76,77

Within the TIME initiative, assessments may be used to inform program evaluation at three levels: the individual curricular element, the campus program, and the total initiative. Data and outcomes from the inaugural TIME cohorts will be collected and analyzed through students’ entry into GME in 2019. This process is facilitated by a structure that includes campus-level PIF coordinators and a system-level PIF director.

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Other Applications of the PIF Framework

We envision using the framework to develop educational programs that would promote PIF and explore the potential of prospective medical students, especially as it relates to the characteristics critical to withstanding the rigors of studying and practicing medicine; significant resilience and self-care are required for the journey. For example, applicants’ volunteering portfolios, as revealed through their applications, secondary essays, and interviews, would provide initial data for the PIF framework. The depth, context, and personal impact of volunteer experiences combined with critical self-reflection would demonstrate applicants’ development along relevant phases of the PIF domains and subdomains.78,79 The PIF framework could also be used as a practical rubric to evaluate existing and emerging curricular innovations. A proactive application of the PIF framework as part of curriculum design would enhance integration of educational pathways and desired outcomes.

The PIF task force anticipates that additional tools and resources will be identified and expanded by TIME partners and other users. The TIME-PIF Web site allows users to view the entire document80 using tabs or filters to select certain domains, subdomains, and elements. Users may also search by key word and can print or save in a variety of formats. Users are encouraged to provide feedback to the Web site administrators and suggest additional resources.

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Implications of the PIF Framework

Development of a PIF framework for medical education is a critical step for curriculum design, program evaluation, and student assessment. This framework is derived from real-life professional activities and expectations of a physician. Identity is developed over time with cumulative experiences but not necessarily in a linear or predictable fashion. The framework incorporates a developmental trajectory spanning medical education from college matriculation through medical school graduation. The three phases are defined not by time, but by the depth of a student’s commitment and responsibility. Students might demonstrate variable progress in each domain and subdomain because of their diverse cultural, personal, education, and experiential backgrounds. Although this framework is focused on UME, expansion into subsequent phases would be appropriate for GME and professional practice, as PIF continues to develop.24

Real-life activities of physicians require integration of multiple combinations of knowledge, skills, and attitudes, as reflected in ten Cate’s81 description of entrustable professional activities, which include multiple competencies. Some educational activities promote integration across multiple domains and subdomains of the PIF framework, as they are not independent components. For example, The Brewsters,82 an interactive fictional story that intertwines professionalism, clinical ethics, and research ethics, has been used with Phase 1 and Phase 2 students in formal course work and extracurricular seminars. Students engage in perspective taking, challenge their ethical decision making, and build self-awareness, aiming to enhance empathic understanding.83 This experience traverses many domains: duties and responsibilities, perception and recognition, relationships, habits, and personal characteristics. Reflective writing and small-group discussions encourage integration of these components relevant to students’ experiences and perspectives. The Brewsters’ materials include assessments of cognitive mastery of ethical principles. These may be augmented with assessments of PIF through reflective writing about the integration of ethical principles with personal values.

Although the PIF task force developed this framework for UME, the diverse background of the team provided the framework with a broad perspective on professional development. The background literature used for the framework spans multiple professions and highlights significant similarities across professions. The approach for framework development may be applicable to other health professions, though specific domains, subdomains, and delineations of developmental phases would vary.

The training of future physicians demands greater attention to the complex dynamics found in the confluence of the scientific, cultural, humanistic, and social dimensions that constitute medical education, medical practice, and health care delivery. PIF reflects a continuum of formative development that serves to instill the essence of professional values and a sense of physicianship.55,84,85 Becoming a compassionate and competent physician has as much to do with the process of developing and understanding one’s individual professional identity as with the integration of learned core medical knowledge, skills, and attitudes.86

Acknowledgments: The authors wish to thank other members of the University of Texas Transformation in Medical Education Professional Identity Formation Task Force who contributed to the development of the framework: David Henzi, EdD, and Scott Wright, EdD. The authors also wish to thank Jill Delsigne, PhD, and Diane Hackett for their editorial assistance and the University of Texas System for financial and administrative support.

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