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Alternative Framings, Countervailing Visions: Locating the “P” in Professional Identity Formation

Hafferty, Frederic W. PhD; Michalec, Barret PhD; Martimianakis, Maria Athina (Tina) PhD; Tilburt, Jon C. MD

doi: 10.1097/ACM.0000000000000961
Commentaries

Professional identity formation in medical education is referenced increasingly as an object for educational reform. The authors introduce core concepts from two largely untapped literatures on identity and formation, contrasting framings on occupational preparation from within the organizational socialization literature with issues of socialization and professional acculturation from a military sciences perspective.

The organizational sciences literature emphasizes socializing a workforce to “fit in,” raising questions about how organization values might clash with core professional values concerning patient primary and social justice. The military literature, in turn, advances the notions of professional identity as a collective property, and that a particular social other (the public) must participate in shaping the group’s identity as a profession.

The authors extrapolate from these reviews that the training of physicians-as-professionals, and thus issues of socialization and identity formation, require intentionality and specificity around these contrasting issues. In turn, they argue that medical educators must attend to socializing trainees to a professional group identity while at the same time producing health care professionals who retain the capacity to resist the bureaucratic application of standardized solutions to contemporary problems. Educators must thus strive to identify the skills, knowledge, and attitudes necessary that will allow physicians-qua-professionals to function as a quasi-subversive work force and to disrupt the very system that helped to shape their identity, so that they may fulfill their mission to their patients.

F.W. Hafferty is professor of medical education, Division of General Internal Medicine and Program in Professionalism and Values, Mayo Clinic, Rochester, Minnesota.

B. Michalec is associate professor, Department of Sociology, and assistant director of health research, Center for Drug & Health Studies, University of Delaware, Newark, Delaware.

M.A. Martimianakis is assistant professor and director of medical education scholarship, Department of Paediatrics, and scientist, Wilson Centre, University of Toronto, Toronto, Ontario, Canada.

J.C. Tilburt is professor of medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota.

Editor’s Note: This is a Commentary on Cruess RL, Cruess SR, Steinert Y. Amending Miller’s pyramid to include professional identity formation. Acad Med. 2016;91:180–185.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Frederic W. Hafferty, Mayo Clinic, 200 First St. SW, Rochester, MN 55901; telephone: (507) 284-8343; e-mail: fredhafferty@mac.com.

Medical education appears enraptured with the prospects and promises of professional identity formation (along with its sister concept professional identity development) as a vehicle of educational reform. Although scattered references to both terms began to surface in the 1990s (ISI Web of Science topic search “TS=professional identity formation OR TS=professional identity development”), key references to PIF* in the medical literature began to accumulate only in the past half decade. Evidence of this recent intonational cantata includes a June 2015 theme issue in Academic Medicine and a tightly interwoven trilogy of articles by Richard and Sylvia Cruess and colleagues,1,2 the third of which appears in the current issue.3 Alternative visions of profession as an object of identity formation emerged, however, in serendipitous visits to two underreferenced (within medical education) bodies of work on identity and formation: (1) issues of occupational preparation as framed within the organizational socialization literature,4 and (2) issues of socialization and professional preparation from a military sciences perspective.5 These alternative visions include whether PIF might be just another way to “on board” learners as managerial functionaries in the service of an increasingly formative (and formidable) biomedical–industrial complex,6 or whether the construction/formation of physicians-qua-professionals is about cultivating a future practice community whose collective moral vision, character, and potentially disruptive advocacy on behalf of patients may come to subvert the very structures and processes that initially gave rise to that identity.

In triangulating these three literatures (medical, military, and occupational socialization), we forefront four issues: (1) the importance of exploring alternative framings of identity formation, (2) the importance of emphasizing the unique nature of professional work and what it means to be a professional in the context of identity formation, (3) the importance of identity as a collective versus individually focused undertaking, and (4) the importance of context and of explicitly addressing forces that may be countervailing to the object in question (PIF). We consider these issues all within the broader challenge of what it might mean to intentionally embrace identity and its formation as an educational objective.

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Occupational Socialization

Our foray into alternative framings of socialization and occupational preparation began with a visit to the organizational socialization literature.4 We anticipated a discourse similar to what was appearing within the medical PIF literature. We encountered something more orthogonal. While the general object-in-question (“occupational socialization”) sounded reassuringly familiar, the lexiconal framings of “fitting in,” “onboarding” (including “effectiveness measures for onboarding”), “embeddedness,” “person–environment fit theory,” “person–organization (PO) fit,” “organizational commitment,” and “adjustment socialization” proved to be more disconcerting than affirming. Adding to our sense of disorientation was a subsequent discovery that there was zero overlap (i.e., zero hits) for a phase-specific ISI Web of Science Boolean search (“TS=professional identity formation OR TS=professional identity formation AND TS=occupational socialization”). Professionals, it seems, have an exceedingly ephemeral presence within this body of scholarship.

This sense of disconnectedness and estrangement, in turn, prompted questions about what kind of a physician workforce would be required to address 21st-century patient care needs and whether an approach to organizational socialization that stressed “fitting in” might effectively deliver on such needs. Perhaps the increasing number of physicians seeking employment at large health care corporations demands (at least from the organization’s perspective) a more “person–organization (PO) fit” model?7 Alternatively, we speculated that physicians might not be all that enthusiastic, either for themselves directly or for their trainees, to discover that the PIF machinery operating within their medical school or residency program was being structured to deliver learners who were better poised (identity-wise) to “fit in” than to disruptively advocate on behalf of their patients. Continuing, we wondered whether patients might be served better by an alternative (identity-wise) provider—the physician-as-resister/subversive, and thus someone who was purposefully trained (i.e., socialized) to be a proactive alternative to the bureaucratic or market-based models of organizing medical work.8 Without coming to a conclusion (yet), we wondered how different training structures and processes might produce different types of practitioner identities. With these emergent questions in mind, we left a land of organizational acquiescence for some (possible) alternative framings.

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The Military

Our trek into the military sciences literature, although certainly not preordained, was far from adventitious. Social scientists, particularly those with a comparative bent, have long favored exploring how the study of other occupations might facilitate insights into physician training—the Carnegie Foundation’s Preparation for the Professions Program, with its symbiotic focus on clergy, law, engineering, nursing, and medicine being a case in point.9 Nonetheless, the military has not been a “usual suspect” in these comparative forays. Thus, what we encountered5,10,11 was equally strange. In contrast to the organizational sciences’ virtual nontreatment of the professional, along with its thematic emphasis on “fitting in,” we encountered a historically grounded set of concerns that the military had become “too bureaucratized,” that its members had lost a sense of “shared identity,” and that the military’s collective identity as a “public servant” was in jeopardy, all reflecting a “stressed institution whose professional culture was in peril.”5 In contrast to our broad readings of the organizational socialization and physician PIF literatures, we were struck by the Army’s rather pointed concerns that its officer corps had accepted “the pervasiveness of bureaucratic norms and behaviors as natural and appropriate.”5 Additionally, we were struck by how this concern was bracketed by an explicitly sociological recognition that professions were different from other organizational forms in terms of how work is organized and carried out, particularly with respect to issues of autonomy and discretionary decision making, a selfless orientation toward work on behalf of others, and the application of expert knowledge and skills to an ever-changing array of occupation-specific challenges.12,13

Reflecting these forebodings, and somewhat in contrast to medicine, the Army chose to frame identity issues by focusing (1) on the threat of bureaucratization (as opposed to medicine’s focus on commercialization), (2) on identity as a collective property (as opposed to medicine’s focus on identity at the level of the individual practitioner), and (3) on the Army’s explicit framing of its occupational identity as a “public servant” (as opposed to medicine’s focus on altruism at the individual practitioner level and medical–societal relations as involving a “social contract”). All three of these differential framings warrant additional explication.

First, and core to the Army’s concerns about identity, is its belief that bureaucratic work, by its very nature, involves the routine application of standardized knowledge and skills. Although the Army recognized standardization as a necessary part of military work, it also deemed standardization to be an insufficient and dysfunctional response to conflicts the Army saw as “inherently existing” within both rules and their consequences. As such, the Army concluded that it needed to train “professionals” given the complexities and uncertainties that were an implicit part of all military decision making and for those times when the standard application of generic knowledge breaks down or reaches a dead end.

Second, and leaving aside any pedagogical particulars, the Army explicitly understood that any response to the above deficits and threats needed to take place both at the individual as well as collective levels. This meant attending not only to the officer-as-professional but also to the Army-as-profession. Moreover, and appealing to our own hidden curriculum leanings, the Army recognized that its current organizational practices ethos and cultural underpinnings were sending messages to its members (what the Army referred to as “unwritten norms”) as to how the Army was devaluing the professional over other forms of identity, such as the “bureaucratic functionary.” Taken as a whole, the Army concluded that “there is institutional value in a shared professional identity.”5

Third, this sense of self and group as professional was foundationally tied not only to the Army’s view of itself as a “public servant” but also to the view that this identity was something that had to be negotiated between internal leadership and the public. In short, the Army explicitly disavowed any claim to being the sole arbiter of its identity, along with recognizing that a particular social other (the public) must participate in shaping its identity as a profession.

Finally, the theoretical model of professions and professionalism embraced by the Army was linked more to the writings of the sociologist Andrew Abbott14 than to medicine’s long-time sociological favorite, Eliot Freidson.8 As such, and now turning more to medicine, Abbott’s focus on jurisdictional disputes and boundary maintenance is more in keeping with issues of professions in the context of teamwork, interprofessional education,15 and relations with the public than in “finding soul in a medical profession of one.”16

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The Physician-as-Professional

This contrast between an occupational socialization perspective on fitting in and a military science view of identity formation as a collectively oriented bureaucratic resister brings us to the hub of our concerns: the physician-qua-professional as an object of identity formation. If PIF means what it says—namely, that we are talking about the identity of a particular type of worker (professional)—then any PIF movement needs to be intentional about how it uses the term “professional” as a prefictorial adjective for a process (identity formation) when applied to a particular occupational type (in our case, physician). If the objective is to train physicians-qua-professionals, and to do so in ways different from physicians as technical experts, bureaucratic functionaries, and/or market mavens,8 then we must address three additional pedagogical challenges. If we agree that there is something particular about identity formation when the object in question is a professional (as opposed to some other type of worker), then our first challenge is how pedagogy will reflect this object in question, which we define as a group of highly skilled workers who possess a shared identity, a collective sense of selfless service, and the inclination and ability to apply their skills and expertise in a discretionary manner. We emphasize identity as a shared property (given its necessary role in any effective system of peer review); altruism, given its necessary role in shaping work on behalf of others (a rather remarkable, if controversial,17 property of professionals and professions); and discretionary decision making, both at the group and individual levels (because of the ongoing need to collectively resist applying traditional/routinized solutions to new and novel challenges).

Our second challenge, and one recognized by the Army, is that the identity formation of professionals is not merely a matter of addressing the thesis but also in confronting the presence of, and proactively countering, possible antitheses. If there are inherent threats to profession as a way of organizing work, then it is necessary that PIF specifically attend to those threats. The Army’s concerns (with leaders becoming bureaucratic functionaries) need not be medicine’s, but whatever the countervailing challenges, they must be formally identified and addressed as a key element in PIF.

Third, and perhaps most important, any process of PIF needs to be intentional in addressing identity formation as a collective activity, both in terms of the formative process itself and in terms of outcome. A profession is a collective enterprise, with professionalism a shared “belief system about how best to organize and deliver health care.”18 It is not the sum product of like-minded individuals.

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PIF: Toward a Submission–Subversion Dialectic

All social groups must continuously navigate the tensions that exist between the demands of external adaptation and the stressors of internal integration.19 On the one hand, groups seek to reaffirm and reproduce their core beliefs and ways of being. On the other, they must be adaptive in the face of emergent challenges and environmental turmoil. Too little integration and groups fragment; too much and they stagnate or implode. Threats of fit aside, stability through reproduction is the proximal and stronger force—even as group members recognize (usually in principle, and often in hindsight) how easily stability can turn into stagnation and ultimately cultural decay.

From this sociological vantage point we see the foundational (even if ultimately avoidable) challenge for PIF being to produce a community of practitioners who have been steeped in learning environments that promote the identification and internalization of core occupational values (thus addressing the issue of PIF at a collective level) while remaining willing to resist the application of entrenched assumptions about the structures and solutions necessary to perpetuate the practice of that profession in the face of emergent uncertainties and disruptions. Even more paradoxical, PIF must seek an identity equilibrium in which graduates not only resist ritualistically applying routine solutions to complex problems but also seek to disrupt the very systems that gave rise to that identity to begin with. Moreover, and now when functioning as role models and cultural brokers for the next generation of trainees, these physicians-as-professionals will possess the cultural humility and relativism necessary to simultaneously preserve that core while simultaneously jettisoning the peripheral. In these respects, and extending the Army’s concerns with bureaucratic strictures, we see identity-as-professional, when applied to medicine, being forged more within a crucible of ferment, resistance, and metamorphosis than stability, compliance, and clonal reproduction. Similarly, we see medicine’s future as a profession being defined within an ongoing (and necessary) tension between the siren calls of system controls and bureaucratic stability, and a more collective sense of physicianhood as a disruptive and quasi-subversive work force—in the service of patients. For these reasons, PIF is best viewed as a structure and process that fosters disruption and dialectic over compliance and certitudes.

There are other ways of framing the above challenges and thus alternative ways of thinking about PIF. Nonetheless, we remain resolute in our conviction that the training of physicians-as-professionals, and thus issues of socialization and identity formation, require a certain intentionality and specificity. Our specificity is tied to the object in question (professionals) and thus to a collective that will resist applying standard solutions to contemporary problems. Our intentionality is grounded in identifying the skills, knowledge, and attitudes necessary that will allow professionals-qua-professionals to disrupt the very system that helped to shape that identity. This juxtaposition is something quite different from leadership training as well as something different from a vision of identity formation that calls for learning environments to be “nurturing” and (consequentially) for individuals to “be all that they can be” and/or to “find their own path.”

In our 30,000-foot sampling of the organizational sciences, military sciences, and medical PIF literatures, we have chosen to paint our arguments with a broad brush. As such, we have been purposefully blind to the nuances that exist within these three domains, such as issues of agency in the case of the organizational socialization literature or issues of conformity in the case of the military sciences. Although the cottage industry of PIF in medicine is producing some notable prototypes to help us iterate on, innovate in, or at least innervate debate toward important discussions of what we are aiming for when we say we want to “form” physicians in training, we believe that any lasting scalable contribution of the PIF movement to undergraduate and graduate medical education crucially hinges on the extent to which the framers of the movement can forefront the “P” in PIF to ask: In whose interest? To what ends?

* We employ two different conventions when referencing the term “professional identity formation.” We use the acronym PIF when referring to the literature as a whole. Alternatively, we use an italicized P in PIF when advancing arguments that identity formation of professionals as a special subtype.
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© 2016 by the Association of American Medical Colleges