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Professional Identity Formation and the Clinician–Scientist: A Paradigm for a Clinical Career Combining Two Distinct Disciplines

Rosenblum, Norman D. MD; Kluijtmans, Manon PhD; ten Cate, Olle PhD

doi: 10.1097/ACM.0000000000001252
Perspectives
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SDC

The clinician–scientist role is critical to the future of health care, and in 2010, the Carnegie Report on Educating Physicians focused attention on the professional identity of practicing clinicians. Although limited in number, published studies on the topic suggest that professional identity is likely a critical factor that determines career sustainability. In contrast to clinicians with a singular focus on clinical practice, clinician–scientists combine two major disciplines, clinical medicine and scientific research, to bridge discovery and clinical care. Despite its importance to advancing medical practice, the clinician–scientist career faced a variety of threats, which have been identified recently by the 2014 National Institutes of Health Physician Scientist Workforce. Yet, professional identity development in this career pathway is poorly understood. This Perspective focuses on the challenges to the clinician–scientist’s professional identity and its development. First, the authors identify the particular challenges that arise from the different cultures of clinical care and science and the implications for clinician–scientist professional identity formation. Next, the authors synthesize insights about professional identity development within a dual-discipline career and apply their analysis to a discussion about the implications for clinician–scientist identity formation. Although not purposely developed to address identity formation, the authors highlight those elements within clinician–scientist training and career development programs that may implicitly support identity development. Finally, the authors highlight a need to identify empirically the elements that compose and determine clinician–scientist professional identity and the processes that shape its formation and sustainability.

N.D. Rosenblum is professor and Canada Research Chair in Developmental Nephrology, Department of Paediatrics, and associate dean, Physician Scientist Training, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

M. Kluijtmans is program director, Master of Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands.

O. ten Cate is professor and director, Center for Research and Development of Education, University Medical Center Utrecht, Utrecht, The Netherlands.

Funding/Support: This work was supported, in part, via professional development support provided by the Undergraduate and Postgraduate Medical Education and the Department of Paediatrics, Faculty of Medicine, University of Toronto, and the Centre for Research and Development of Education, University Medical Centre Utrecht (to N.D. Rosenblum).

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Norman D. Rosenblum, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, 686 Bay St., Toronto, Ontario, Canada M5G 0A4; telephone: (416) 813-5667; e-mail: norman.rosenblum@sickkids.ca.

Professional identity has become a major focus of attention in medical education.1,2 The 2010 Carnegie Report on Educating Physicians, which called for a focus on professional identity formation in medical education, defined professional identity as a composite of the values, beliefs, sense of affiliation, aspirations, and synchrony with the norms of the medical profession.2 The large increase in the literature on professional identity suggests that the Carnegie recommendations have stimulated considerable scholarly activity.3 For most practicing health care professionals, professional identity is established in the context of a career that has a singular focus on clinical practice. However, in academia, many practicing clinicians are engaged in scientific research and/or the education of future clinicians. If performed at a high level of proficiency, both endeavors—health care and medical education or scientific research—require considerable invest ment in two disciplines simultaneously, potentially presenting challenges to identity formation. This Perspective, therefore, focuses on professional identity formation in clinician–scientists. We consider the challenges to professional identity in a clinician–scientist career that is informed by the two distinct but related disciplines. The clinician–scientist career may be defined by training in both a health profession as well as a research track, and a professional focus on the interface of clinical care and research.

The 2014 National Institutes of Health (NIH) Physician Scientist Workforce (PSW) Working Group argued that the capacity of clinicians trained in medicine and the allied health professions to combine clinical practice and scientific research is critical, even indispensable, to the strategy of advancing medical practice. This is particularly the case in academic health science centers that value interdisciplinary and team-based collaboration.4 Yet, evidence suggests that the physician scientist pipeline is threatened and that the career track for allied health clinician–scientists, far less developed than that for physician scientists, still requires major development.4 Previous analyses of the clinician–scientist career have focused on formative curricula, career development strategies, funding to sustain research, and institutional forces that affect the interaction between clinical activity and research.5–8 In contrast, little attention has been paid to the fundamental issue of professional identity formation. Defining the nature of clinician–scientist professional identity is critical to understanding the fundamental beliefs, motivations, and actions that underlie the decision to enter this career track and to remain a clinician–scientist in the face of unique and sometimes-onerous pressures.

Further, we expect that identifying the elements of clinician–scientist professional identity development will be critical to generating the principles that inform selection, education, and career development strategies to improve recruitment and retention into the clinician–scientist workforce. As we discuss below, professional identity is likely threatened at one or more stages during the educational and career development pathway, when clinical and scientific knowledge has not been sufficiently integrated to generate a professional niche, in which the values and skills from both domains complement rather than compete with each other. Such domain synergy for the emerging clinician–scientist would offset the forces that negatively impact career development. Here, we review elements of professional identity development that apply to a dual-discipline career and identify program elements within clinician–scientist training and career development programs that can be mobilized to explicitly support identity development.

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The Clinician–Scientist Career Track: Current Status

The tradition of combining scientific investigation with clinical care reaches as far back as the Greco-Roman period and involves the breadth of health professionals.5,9 Despite the demonstrated value of the clinician–scientist role, the 2014 NIH PSW highlighted major threats to this career path,4 including lack of growth in the U.S. physician scientist workforce since 1980; lack of recruitment of young clinician–scientists to offset the effect of an aging cohort; inadequate synergy between clinical and research phases in educational curricula; increasing complexity of research and clinical care, potentially limiting the ability to perform at the desired level within each of these domains; and a decreasing availability of role models and mentors in academia.4,10 The magnitude of these concerns is greater for health professions (i.e., nursing and allied health professions, rather than physicians) for which the clinician–scientist pipeline is far less developed.4,11

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The Clinician–Scientist: Reconciling Clinical and Scientific Professional Identities

Similarities between clinical and scientific practice

In forming a professional identity, the clinician–scientist must generate an interface between clinical practice and research. Because the scientific method is fundamental to clinical practice, it seems that the cultures of clinical practice and science are readily reconciled. Indeed, the values and professional practices that inform both clinical practice and research are similar in many respects and are interconnected. In Western medicine, the scientific method drives the clinical approach to disease pathogenesis, diagnosis, and treatment. The scientific method, which employs hypothesis formation and experimentation using controlled data collection and objective analysis as its central quantitative methodologies, is foundational both to science and to clinical education and practice. Moreover, both qualitative methodologies and clinical approaches rely on rigorous descriptive and analytic techniques. Finally, clinical medicine and science highly value honesty, integrity, self-reflection, and continuous learning as fundamental to their professional standards of practice and ethics.

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Differences between clinical and scientific practice

The professional worlds of the scientist and the clinician differ in fundamental respects.12 Clinical care is delivered with strong adherence to standards of practice and respect for expert opinion, despite the recognition that uncertainty often underlies diagnosis and therapeutic management. Although the clinical world seeks to apply scientific knowledge to clinical care, the desired scientific evidence often does not exist. Thus, clinical care is necessarily delivered using a combination of perspectives incorporating scientific evidence, clinical experience, and patients’ individual circumstances. Clinical practice values inquiry into what is unknown; however, certainty in diagnosis and management is valued more and therefore takes precedence.

In contrast, the scientist embraces uncertainty as a means to discover what is true; variance and error are integral and informative to scientific practice. In medical practice, error is a threat. During their education and identity formation, clinicians are educated in the value of and need to adhere to established standards of professional practice, reinforced through the application of detailed national and international competency frameworks. In contrast, scientists are rewarded for investigating gaps in knowledge, challenging current hypotheses, and interrogating accepted truths. In this sense, physicians are valued for their conformity with their colleagues, while scientists are valued for their lack of conformity. Thus, there exists a tension between the identity values and practices in clinical care and scientific research.

The absence of professional credentialing that formally recognizes the clinician–scientist role is a further threat to professional identity. Credentialing occurs in the clinical and scientific domains separately. Moreover, credentialing at the level of clinical practice is based only on the individual’s clinical expertise, without relation to their expected role as a clinician–scientist. Affiliation is crucial to establishing a professional identity; a community of professionals with a common purpose provides internal guidance, role models, and a community of practice—all of which facilitates a narrative construction of one’s identity and a demonstration of value to external communities. Thus, the absence of formal recognition for the clinician–scientist career track may impede a sense of belonging to a like-minded group.

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Professional Identity Formation in a Dual-Discipline Career: Applying Theory to Empiric Evidence

Facilitating professional identity formation in health professionals

Although there are few studies that directly investigate the nature and development of clinician–scientist professional identity, we can draw principles from analyses of identity development in other professional contexts and apply them to the clinician–scientist career track. Professional identity forms through a socialization process in which a new professional identity is integrated with one’s personal identity.13 List 1 shows the factors that facilitate identity formation in health professional trainees and include (1) a tolerance for ambiguity and complexity; (2) the capacity to manage both ambiguity and complexity; (3) personal resilience; and (4) a socialization process that fosters a reconciliation between personal and professional identities, self-reflection, and a collaborative learning environment. This process of socialization is supported by systems of role modeling and mentorship.13–19 We suggest that these factors also can be related to developing and sustaining personal identity, integrating personal and professional identities, and growing and establishing professional identity.

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List 1Factors That Support Development of Health Professional Identity

Personal

  • Certainty of personal values, ambitions, abilities, affinities, self-esteem
  • Self-perceived competence
  • Tolerance for ambiguity and complexity
  • Ability to manage complexity
  • Resilience

Program Design

  • Socialization process that facilitates reconciliation of personal and professional identities
  • Guided reflection and feedback
  • Collaborative and experiential learning environments
  • Role modeling
  • Mentorship
  • Identification with a particular professional role
  • Perception of formal status of professional role in society
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Integrating professional identities: possible models

Compared with health professionals with a singular focus on clinical practice, clinician–scientist professional identity formation represents a more complex socialization process incorporating both clinical practice and scientific research. Although the relevant factors for health professional identity (summarized above and in List 1) seem to apply to the clinician–scientist (though not yet with empirical support), the ways in which clinician–scientists represent their professional identities have, to our knowledge, not been defined. Roccas and Brewer14 theorized four possible models—intersection, dominance, compartmentalization, and merger—by which individuals maintain a single representation of identity in the face of multiple nonconvergent group identities (such as clinician and scientist). In “intersection,” an individual forms a single unique identity with properties that make it distinct from any of the individual group memberships. With the “dominance” model, the individual adopts a primary identity to which other group memberships are subordinate. The “compartmentalization” identity is context or situation specific, thus, compartmentalized. In the fourth model, “merger,” noncongruent identities are combined to generate an identity that is the sum of the individual identities. Roccas and Brewer proposed that individuals choose identity models in accordance with their tolerance for complexity, which is determined by a tolerance for ambiguity, a balance of personal values including power and achievement versus benevolence, self-direction versus conformity, the need to fit within traditional frameworks, and the cognitive effort needed to manage degrees of complexity. How clinician–scientists view themselves may impact their professional focus. To our knowledge, there is an absence of published literature on the interrelationship between area of research (biomedical-bench versus clinical versus population-based) chosen by clinician–scientists and their professional identities. Roccas and Brewer’s theoretical paradigm could be used as a framework to generate insight into how clinician–scientists choose different areas of research, what “models” they use to interface between research and clinical arenas, how they reconcile the cultures of clinical practice with their areas of research, and how such choices influence the construction and sustainability of their professional identities.

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Evolution of professional identity: From single to complex role

Clinician–scientists often begin their educational and professional careers in a single disciplinary role and then develop a more complex clinician–scientist role over time. How is identity shaped in the face of this complexity? Identity formation while adapting to new roles has been informed by Ibarra20 in a qualitative inquiry of professionals in business and management transitioning to more senior roles. Ibarra identified three important tasks relevant to new identity formation: (1) observing role models to identify potential identities; (2) experimenting with intermediate forms of a redefined image of self, which Ibarra terms the “provisional self”; and (3) evaluating experiments projecting one’s self against internal standards and external feedback. “Provisional selves” serve as benchmarks for interpreting and judging one’s own behavior, functioning as standards against which people calibrate external feedback and their own affective reactions, thus helping them decide what to accept, reject, or try again. Individuals who observed a greater number and diversity of role models created a broader set of possible selves; added more variety to their repertoire of attitudes, behaviors, and presentation styles; and demonstrated greater capacity to combine these elements in provisional selves that supported self-development.20

Ibarra’s findings are consistent with dialogical self theory,21 which posits that the self has multiple internal voices, termed “I” states, which are shaped by internal voices and external influences to form a unified self-concept. Using dialogical self theory as a foundation, McIlveen and Patton22 suggested that successful career development stems from the opportunity to express various identity positions in different situations while simultaneously being able to articulate the added value of a corresponding professional identity position (e.g., the value of research while working in a clinical context). These perspectives align with observations of health professional students in which professional identity development was viewed as a dynamic process of “assembling” and “disassembling” professional identity and with the observed roles of experience and self-reflection in shaping this iterative process.16,23–26 In the following section, we describe a study of clinician–scientist trainees and consider how these ideas, particularly Ibarra’s “provisional self” theory, are applicable.

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Evidence in favor of an evolutionary model of professional identity

The results of a study on graduates of the Canadian Child Health Clinician–Scientist Program (CCHCSP) align with and illustrate Ibarra and McIlveen’s findings. CCHCSP trainees begin their training to become a clinician–scientist with a health profession identity already formed. They reported that they began to experiment with a clinician–scientist identity through a variety of curricular experiences, including intensive research in their chosen subject, interdisciplinary research exercises, longitudinal knowledge translation and team research mentorship programs, symposia focused on the intersection of the clinician–scientist career and health research, and interaction with role models and mentors. In so doing, they compared their newly developed roles against their existing personal and professional identities and tested out their new roles in their particular professional context. To CCHCSP trainees, these developmental stages were critical to their final decisions on whether or not to continue as a clinician–scientist during and after training.27 Together, these theoretical and empirical analyses highlight the importance of role models, as well as multiple educational and professional practice environments. Further, they demonstrate the value of reflective and adaptive competencies to professional identity formation during the transition from novice to expert clinician–scientist. In so doing, they provide important clues on how clinician–scientists form their professional identities.

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Clinician–Scientist Training Programs: Unexplored Elements That May Support Professional Identity Development

It is important to consider how factors related to professional identity development align with the diverse programs that constitute the pipeline for clinician–scientists. Indeed, programs focused on the educational and career development of clinician–scientists exist at the undergraduate medical (e.g., MD/PhD)28,29; postgraduate (physician residency research tracks, nursing and allied health graduate research studies)11,27,29–31; and faculty development (e.g., NIH K Programs, Institutional Faculty Development Programs)32,33 levels. A recent analysis, however, highlighted the gaps in knowledge about their impact on professional identity development.34 Literature describing these programs and their outcomes has generally focused on employment as a clinician–scientist, professional time dedicated to research, research funding, and research productivity. However, some studies provide a rich description of program-specific curricular elements in the MD/PhD, Clinical Translational Science Awards, CCHCSP, Vanderbilt University Career Development Program, and the Toronto Hospital for Sick Children Scientist Track Investigator Program.27,31–33,35,36 As summarized in List 2, some or all of these programs feature experiences whereby trainees and early-stage clinician–scientists learn how to maintain clinical skills during a period of intense research activity, develop a professional niche with complementary clinical and research activities, and implement clinical knowledge to drive research questions and studies to innovate within clinical activity. These programs also feature curricula that focus on time management, organizational, and collaborative skills among a larger set of professional, non-research-specific skills needed to operate within research and clinical medicine. They also focus on strategies for converting potential feelings of inferiority over being less expert in either clinical medicine or research than peers focused solely on either domain into a consciousness of unique added value for those straddling both disciplines.6 These curriculum components are supported by community building (peer-to-peer support) and by a diversity of role models and mentors.

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List 2Program Elements Commonly Found in Clinician–Scientist Training and Career Development Programs

  • Unique integration of clinical medicine and research and the clinician–scientist role
  • Maintenance or restoration of clinical skills during research-intensive periods
  • Structured research experience
  • Problem solving and critical analysis
  • Professional skills (non-research-specific)
  • Management skills
  • Team-based research and collaboration
  • Role modeling
  • Mentorship
  • Interdisciplinary and transdisciplinary research
  • Community (network) of health researchers

Comparing the factors that support professional identity development for health professionals (List 1) with clinician–scientist training program elements (List 2) reveals that some clinician–scientist training programs may exert positive effects on professional identity formation, facilitating the process of socialization in addition to engendering the knowledge and skills needed to succeed as a clinician–scientist. Further analysis could determine whether trainee success is due only to skill development, or whether bolstered professional identity, developed and strengthened by these programs, results in superior performance.

The common elements between professional identity development in health professionals and clinician–scientist program training features, considered together with the findings of Ibarra and McIlveen, provide a basis for approaches in clinician–scientist programs that would promote professional identity development. Curricular elements that deserve attention include guided reflection, team-based and collaborative learning environments in which trainees can experiment with different roles as a clinician–scientist, peer-to-peer support within a community of practice, and role modeling and mentorship. The literature reviewed in this Perspective offers a variety of methods for realizing these curricular elements and includes the use of reflective journals, mentorship strategies using mentoring teams with diverse types of expertise, team-based learning combined with case studies and reflective essays, interdisciplinary and transdisciplinary research exercises, experiential workshops highlighting non-research-specific skills critical to the clinician–scientist career, community building among students and clinician alumni, and multidisciplinary advisory teams.

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Moving Forward: An Agenda to Elucidate Clinician–Scientist Professional Identity Formation

Although the analyses described above do not specifically address professional identity formation of clinician–scientists or other interdisciplinary careers, they do highlight questions that are no doubt relevant to continued inquiry of professional identity formation in the health sciences. We suggest the following research to address current gaps in understanding clinician–scientists’ professional identity. It may be crucial to foster a distinctive professional identity that enables a synergy, rather than a tension, between the values and skills of clinical practice and scientific research. With this disciplinary synergy, the clinician–scientist would be able to more easily offset the forces that threaten the career development pathway. To that end, studies of clinician–scientist trainees and established clinician–scientists should more fully probe the nature of professional identity construction during and after training, the impact of identity formation on career sustainability, and training and career development programs’ contributions to professional identity. These studies should aim to elucidate how clinician–scientists formulate their professional identity, to pinpoint critical determinants of success or failure, and to define the effects of curricular paradigms in training and retaining clinician–scientists. Study participants should include both clinician–scientists engaged in programs with strong mentorship and role models as well as clinician–scientists who are not thus engaged. Finally, studies also should be conducted in countries with different and diverse practices for training and employing clinician–scientists (e.g., North America versus Europe). Analyses of this type can be cross-sectional or prospective in nature.

To aid in and perpetuate these kinds of research inquiries, a professional identity survey tool should be developed that measures clinician–scientist identity formation across programs, research fields, clinical fields, and nations. This tool should be informed by experts in the fields of psychology and health professions education, with strong contributions by clinician–scientist program leaders through a consensus-seeking framework based on published literature, including that summarized in this Perspective, and expert opinion. Additionally, the developed survey tool should allow for open-ended evolution of questions in keeping with ethnographic methodology to capture findings that might not be anticipated. Questions to include should address the following: whether a unique clinician–scientist identity exists or if it is instead dominated by either identity as a clinician or a scientist; is it a merger of both, or is a particular identity (clinical versus research) context specific? Inquiries should further define the process by which clinician–scientists develop and sustain their professional identity, with specific reference to how the dialogical self and provisional self theoretical frameworks contribute to this process. Finally, studies should determine how clinician–scientists assess the influence of professional identity on their performance, engagement, and sustainability in their respective roles.

What can programs do now to foster professional identity in clinician–scientists? As discussed above, socialization plays an important role in professional development. Findings suggest that clinician–scientist training and career development programs should pay particular attention to establishing communities of practice in which clinician–scientists can engage in collaborative learning environments as they progress from novice to expert; doing this within the context of a cohort should help clinician–scientists navigate an interdisciplinary career track and find a productive synergy between clinical practice and scientific research.

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In Sum

Professional identity formation in clinician–scientists, a paradigm for a clinical career that incorporates more than one major discipline, is undefined. Yet, professional identity is likely a critical determinant of career sustainability. This Perspective identifies numerous forces that shape the clinician–scientist professional identity. The interrelationship between factors that promote professional identity formation and program elements in clinician–scientist programs provides a basis to recommend curricular elements that can promote the clinician–scientist identity. At the same time, there is currently a lack of evidence about the specific determinants of clinician–scientist professional identity development. This gap in knowledge encourages further studies that examine professional identity development, in order to inform educational and career strategies to support clinician–scientist career tracks as well as enhance our understanding of other clinical careers that combine multiple disciplines of practice.

Acknowledgments: The authors thank Dr. Anita Small for critical review of the manuscript and Dr. Sjoukje van den Broek for helpful discussions regarding professional identity formation.

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