Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on global health professions education—how ideas, experiences, approaches, and even resources can be shared across borders and across cultures to advance health professions education around the globe.
Amany (her name is Arabic for “wishes”) graduated with the highest grades from a medical school in Syria; she trained as a pulmonary physician but had to flee the country at the outbreak of the war. Together with her daughter, she has found asylum in the Netherlands, where she is now trying to rebuild her life. After having completed language and citizen courses, she worked as an assistant nurse but still wished to pursue a career as a physician. She successfully applied for an elderly care medicine residency training program and is now training to become an elderly care physician. After two months of postgraduate training, a female patient living in the nursing home with end-stage Parkinson disease suddenly becomes severely dyspneic because of an aspiration pneumonia. The patient refuses referral to the hospital for intravenous antibiotic treatment and wants to be allowed to die, asking for symptomatic treatment only. The nurses empathize and agree with the patient, and insist on starting morphine treatment to relieve the dyspnea. Amany does not know how to respond to this situation because the approach the nurses are supporting challenges Amany’s understanding of what a good doctor would do in this circumstance.
Stories like Amany’s are becoming increasingly common: A medical trainee moves from one cultural context to another and is challenged with navigating the resulting shifts in his or her professional identify. Amany’s professionalism will be judged on how she behaves in this situation, and her behavior will be influenced by how well she understands her new cultural context and manages to shift her professional identity. Medical educators can play a critical role in supporting a resident like Amany, but it is complex because such stories raise many questions: How do medical professional values vary around the globe? How do medical trainees in different parts of the world develop their professional identities? How can we, as medical educators, support medical trainees in this process, in particular, when facing cross-cultural differences?
In the last few years, there has been a discourse shift in the medical education literature from teaching professionalism to fostering professional identity formation as the ultimate goal of medical education,1–4 resulting in a wave of publications addressing professional identity formation.5–7 In a recent paper, Cruess and colleagues,4 some of the foremost thinkers of the professionalism movement in medicine, have explicitly connected teaching professionalism with professional identity formation. They describe how, 15 years ago, it seemed appropriate to emphasize the importance of teaching and assessing professionalism in medicine, making sure that learners understood the cognitive base of professionalism, internalized a professional value system, and demonstrated appropriate professional behaviors. Now though, they and others argue that teaching professionalism is no longer an end but a means to professional identity formation, through which educators help their future graduates to gradually think, act, and feel like physicians.4,8
In this Article, we aim to address this nascent concept of professional identity formation from a polyvocal (not a single viewpoint or consensus but an expression of multiple opinions), multidisciplinary, cross-cultural perspective. In doing so, we aim to ensure that the developing professional identity formation discourse avoids the past pitfalls of the professionalism movement that has been dominated by Western notions for a long time.9 To do this, we will deliberately open up the professional identity formation discourse to include different non-Western approaches right from the beginning, by delineating the different cultural approaches to medical professionalism, reflecting on professional identity formation in different cultures and on different theories of identity development, and advocating for a context-specific approach to professional identity formation.
Medical professionalism is based on the notion that there exists a social contract between medicine and society from which the expectations of both patients and physicians are derived. This social contract changes over time and differs across countries and societies, reflecting social, cultural, and individual norms and values. Societal expectations depend on the cultural context; different cultures or societies expect different behaviors and attitudes from and extend different privileges to patients and physicians.9 In most contexts, the professional autonomy of physicians is a privilege that is not enjoyed by many other professions. In the Arabian and Eastern contexts, physicians have more authority in decision-making processes than patients,10 while the balance is oriented more toward patient autonomy in Western contexts. Another example of cross-cultural differences may be that being accessible to patients seems essential to Asian and North American doctors but not to UK doctors.11
Patients’ privileges and confidentiality issues are also interpreted differently in various cultures. For instance, physicians in Saudi Arabia have to obtain consent to interact with female patients from their “Wali Amr” (their male guardian—a husband, father, brother, or son).12 In contrast, in some European countries (e.g., the Netherlands), children younger than 18 years old are allowed to request physician-assisted suicide. These differences are socially acceptable and legally sound in their respective countries, demonstrating the context-specificity of professionalism and implying that medical educators should avoid a black-and-white dualist approach to being professional (“white”) or not (“black”) and instead favor a broad spectrum of professionalism “colors.”13
As a consequence, in the last decade, authors from different cultures have not only tried to validate and adapt Western professionalism frameworks, such as the American Board of Internal Medicine’s Physician Charter framework, but have also developed new, context-specific professionalism frameworks, resulting in frameworks based on Confucian values for China14 and Taiwan,15 Bushido concepts for Japan,16 and the concept of Divine accountability for the Arab world.13
These professionalism frameworks reflect the different social contracts found in these different countries. And the professional identities desired and proscribed both by physicians in these societies and by the societies themselves are based on these contracts, making the process of becoming a doctor dependent on context and country. As representatives of cultures in which a context-specific understanding of professionalism has emerged (Europe [E.H.], Asia [H.-M.Y.], North America [A.K.], and the Arab world [M.A.-E.]), we aim to reflect on professional identity formation in different cultures, addressing different questions and issues. In doing so, we will return to the story of Amany and explore the following questions: What are the culture-specific elements pertaining to identity development in her story? How would these culture-specific elements be understood differently in other cultures? Do we, as medical educators, need to conceptualize identities as context-specific, as we have learned from the professionalism movement?9 Or does identity imply a notion of self that remains constant across different contexts? What implications does this have for health professionals being trained in one place but moving to another place where they need to adjust to different societal expectations? Does this mean that they need to change their professional identity, as was recently suggested?17
What Is Identity?
Identity is the answer to the question “Who am I?” And professional identity is the answer to the question “Who am I as a professional?” Developing a professional identity involves the process of learning to integrate different positions, roles, and expectations within a coherent sense of self.18 In the scientific debate around identities, there are different discourses that relate to one another but build on different psychological and sociological theories.
From one point of view, individuals have a single identity, developed during childhood or early adolescence and remaining more or less stable, being knowable as such, while other conceptions use the language of multiple identities, referring to the notion that a person always has to play different roles, depending on time and context. Next, a distinction is made between identity as a psychological process on an individual level, leading to a coherent sense of self which remains constant in different circumstances, and identity as a social process, in which identity depends on group membership and participation in different and changing communities. Another set of discourses is related to the distinction between identity as an attribute or as something you can possess, which thus can be measured, and identity as a construction or as something you are doing or performing (e.g., how one dresses or uses language).1
Moreover, there are three varying levels (personal, role, and group) from which one can answer the question “Who am I?”19 From the first (personal), identity is about understanding yourself in light of your personal life history and in relation to your personal values. In the second (role), identity is about understanding yourself in relation to others and identifying with specific roles in relation to others (e.g., identifying as a teacher in relation to a student or as a doctor in relation to a patient). And from the third (group), identity is about relating to or categorizing yourself as part of a group or community (e.g., identifying as part of an interprofessional rehabilitation team or as part of the medical profession).
In the first level, identity is considered to be a mirror of the deepest and most authentic parts of a person. Personal identity is a sense of self that is consistent over a longer period of time and is built around core values that are at the same time intensely personal and socially and culturally influenced.20 Additionally, one may develop multiple personal identities, all pertaining to different core values.
Amany always wanted to become a doctor to help build her country, contribute to society, and decrease injustice and inequality. Fostering love and caring for others are core values that contribute to the ideal portrayal of the person Amany wants to be. As a doctor, Amany has been trained to cure patients and never withdraw active treatment if there is still anything that can be done. Being a mother herself, she does not understand how another mother may not want to live as long as possible for her children. As a daughter, on the other hand, she saw her own mother dying years ago and vividly remembers how her mother was struggling toward the end of her life and how she silently wished her mother would die quickly to prevent her from further suffering.
Core values and conceptions of what constitutes good behavior serve as a basis for moral identity but, even if they are found in multiple cultures, do not necessarily correlate to fixed attributes or absolute notions of personal identity. For example, one of the core cultural values of most medical students, physicians, and patients in Arab countries is faith in God (Allah) and the hereafter (Day of Judgment). In the recently developed four-gates model of Arabian medical professionalism,13 the notion of self-accountability for one’s own behaviors, referred to as “taqwa,” is therefore strongly related to accountability to God, which is also expressed by the notion of “ehtesab” or self-motivation, which refers to expecting reward from God, not from other people. Although a similar divine accountability has historically been part of the Western tradition as well, this seems to be less prominent in current Western understandings of professionalism (at least in parts of Europe). Thus, even core values that are universally acknowledged, such as accountability, may be interpreted or expressed differently in various cultures.
When Amany discusses the case of the patient with pneumonia wanting symptomatic treatment only with her colleagues, they strongly emphasize patient autonomy, stating that a doctor should follow the patient’s wish to die. Amany feels confused and anxious. Why would doctors even think about letting patients die? These doctors are playing God! Amany strongly feels she could never make such a decision, believing that ultimately her accountability will not be to other people but to God. When asking for help from her attending physician, this supervisor criticizes Amany for a lack of flexibility and moral reasoning, explicitly doubting her fitness for practice in the Dutch health care system.
Personal or moral identities are core and therefore can be highly emotional.21 While emotions are individually felt and interpreted, medical students learn which emotions are acceptable to experience and express, and to what extent, in different specific medical contexts, each of which has its own norms and rules. Understanding oneself from a professional standpoint, reflecting on possible identities, and trying to resolve professional dilemmas may lead to strong emotions.21,22 Descriptions in the literature of the role of emotions in medicine, however, are largely grounded in Western (e.g., North American and Northwest European) conceptualizations of learning and identity development, which apply an individualist perspective. There may be important differences in Eastern cultures, with a stronger emphasis on social relationships,23 or in the Arab world, with its reference to Divine accountability.13 For example, Western cultures emphasize emotions and identities as part of an independent self, an autonomous and self-directed being. Emotions and identities in Eastern and Arabian cultures, in contrast, can be best understood in terms of an interdependent self, embedded in relationships with other people or with God.24 While a Western medical student asks, “Who am I?” an Eastern one may ask, “Who am I in relation to others?” and an Arabian one may ask, “Who am I in relation to God?” Generally speaking, we hypothesize that Western identity is mainly absolute with a stronger focus on the personal values of individuals, while in the East and the Arab world it is mainly relative and social as it considers relations with others.
By the time of her death, Amany’s mother had not been involved in the major decisions regarding her treatment. In her current situation, Amany is not sure about discussing a hospital referral with the patient herself but instead wants to get consent from the patient’s son (the person Amany thinks of as her patient’s Wali Amr). The patient, however, gets angry when she overhears Amany calling her son and asking him for his opinion—she insists on making this decision on her own.
In the second level, understanding yourself in relation to others is a social and psychological process, in which identification with salient roles takes place. In the course of medical training, students or professionals will increasingly identify with the roles of medical student, resident or house officer, consultant, or clinical supervisor.4 The identification with a specific role and with the meanings and expectations attached to this role, as well as the internalization of social positions accorded to this role, is a socialization process. Ideally, a strong and stable sense of self develops through this process.25,26
The process of role socialization is context-specific. For example, in a paper on the cultural construction of emotion in Chinese rural life, Potter27 addressed the question of whether emotional metaphors were necessary or relevant for understanding role socialization or role performance. The author cogently argued that relationships in the West are derived from, and symbolized and affirmed by, feelings, which are direct expressions of the self and as such are considered legitimate bases for social action. According to the same author, in China, a person derives social meaning primarily from social context, which refers to a continuous social order that does not need any affirmation by inner or individual emotional responses. For medical education, in a study comparing medical students from Canada and Taiwan, the Taiwanese medical students seemed to be far more concerned about the influence of their behavior on their social relationships.23 The Taiwanese students, for example, more frequently mentioned the implications of their behaviors for their patients and their patients’ families, and referred to their place in hierarchies and the possible consequences of their behavior for more senior trainees than the Canadian medical students did. It seemed that Taiwanese students, more than their Canadian colleagues, tried to understand professional dilemmas in accordance with their positions or roles within their relationships, and thus considering their identities within multiple relationships.
Additionally, the role we as individuals play is not always the same. We may actively construct different identities by identifying with different roles. And we adjust our behavior and presentation of ourselves depending on the audience.28 In a study on hospice workers, for example, health care professionals presented themselves frontstage (i.e., when they were in direct interactions with patients) as caring and compassionate, but backstage (i.e., when they were not in direct interactions with patients) engaged in dark humor and morbid conversations.29 They needed this safe backstage area to prepare or revitalize for better frontstage performances. Similarly, in a recent study on emotional support in undergraduate medical education, we found that medical students adjusted their presentation of themselves, navigating different contexts and deliberately choosing where to share their emotional experiences.30
Although Amany tries to stay calm and act professionally, her notions about being a good doctor are strongly challenged by this case. She feels insecure but at the same time highly responsible for what is going to happen with this patient. Her supervisor, however, forbids Amany to send the patient to the hospital, emphasizing that they should follow the patient’s wishes, and takes over the care of the patient. At the end of the day, when Amany goes home, she urgently needs to “blow off steam.” She most wishes to go shopping with a friend, to talk a bit about what happened with someone from whom she expects support, and to temporarily refrain from her responsibilities as a doctor.
In the third level, developing a specific identity, or different identities, often includes membership in one or more social groups. Physicians generally belong to multiple professional groups, with medicine being the largest and their specialty grouping probably being the most influential; however, the different communities within which they work may also have a large impact. Being a member of a group is associated with positive attitudes toward the group you belong to (the in-group) and with negative or even stereotypical perceptions of other people (the out-group).31 From a cross-cultural perspective, having grown up and being socialized as a doctor in one country and moving to a new country with different cultural norms and values may lead to feeling like an outsider, making fitting in with the social or professional group challenging. These doctors may have to adapt their previous understandings of being a doctor in order to be accepted by medical professionals in their new country.17
The next day, when discussing the case again, her colleagues also criticize Amany for calling the son without asking the patient’s permission, judging this to be unprofessional. Amany feels very much like an “outsider” among her peers and is highly frustrated. She is uncertain about her and others’ professional behavior, and, on a deeper level, her understanding of what it means to be a good doctor has been strongly challenged.
An alternative to thinking about identity as fixed, permanent, and stable group membership can be offered by the theory of communities of practice,32 in which health care professionals are related to one another by working together in given social practices that are shifting and dynamic. Identity emerges from collaboratively negotiating meaning within these communities of practice. From a cross-cultural perspective, leaving one set of communities of practice to join others can cause tensions. Thinking about group membership as being constructed in social practice, however, may offer a promising avenue for bridging these tensions, as identity in this case is not about being a member of a fixed group but is instead about collaboratively giving meaning to joint experiences in practice.33 Whereas self-categorization as a member of a group may be rather absolute, the continuous negotiation of meaning and identity in interactions with other individuals working in practice takes time and is a process that allows for the exchange of preexisting values or beliefs for new, shared understandings and practices. Identity here is not a fixed label or a given right by a certain profession but, instead, is a dynamic process of construction among collaborators.
Initially, Amany was worried about the nurses asking for morphine treatment, perceiving the active role nurses play in decision making in Dutch nursing homes as a threat to her position as a doctor. Back home in Syria, she had developed an identity as a doctor as the one who leads the team and who is not supposed to show any doubt to patients or colleagues. This difference made her feel uncomfortable in the current situation. To address this tension, she decides to go back to the nurses, seeking to better understand their attitudes toward end-of-life care and interprofessional collaboration. In conversations with the nurses, she learns that they know quite a bit about the social context of the patient, explaining why this patient decided to withdraw further treatment and why she wanted to make this decision alone. When talking about the different roles in the team or the community of practice on this specific ward, Amany learns that the nurses value and expect shared decision making and did not intend to overrule her decisions as a doctor. They accept that Amany is a newcomer in Dutch society and that she is still in the position of a medical trainee. They understand and respect some of her perspectives but disagree with others. By discussing these differences and working together, they gradually find a way to provide meaningful care for patients within their shared social practice, in which Amany is sometimes a leader, sometimes a learner, and sometimes both.
Professional identity formation is not only about learning to display appropriate professional behavior but is fundamentally about developing a new, professional identity as a physician. This implies that medical educators should familiarize themselves with theories about identity development and understand the emotional nature of professional identity formation.
In this Article, we have shown that medical professional identity formation depends on context and that different values and norms in different countries or cultures differently impact how medical trainees develop a new, professional identity. Becoming a doctor in and of itself may evoke many emotions. These emotions will be stronger when personal values conflict with expectations that come with the desired new identity—for example, when doctors need to take care of patients with different expectations (whether or not the different expectations arise from different cultural backgrounds), or when a medical trainee or practitioner needs to change or adapt a previously developed professional identity after moving to a country with a different culture.
Medical educators need to learn to interpret behaviors in view of contextual factors and to use a range of strategies (see below) to foster professional identity formation in their students at various levels, such as self, role, and group. They also need to acknowledge emotions, because strong emotions may arise when personal values are at stake. In the case of professionalism or professional lapses, or when professional identities are found to be challenged, we recommend that medical educators not only look at behaviors but also take into account the developing identities of their learners, inviting them to actively articulate who they are and who they would like to become. To raise awareness of underlying values and expectations, educators may want to ask their students to explicate their core values and reflect on how these may influence their process of becoming a doctor. New approaches to foster a context-specific approach to professional identity formation could include discussing values and practices with “buddy” students from different cultures, which could be facilitated by the use of new media (such as social media).
In sum, in the context of the globalization and migration of both patients and medical professionals, the context-specificity of professional identities becomes extremely salient. Effectively adjusting to a new cultural context can be facilitated by a nuanced understanding that identities are constantly being constructed and reconstructed in relation to personal and cultural values as well as different role or group expectations. As medical educators, we need to find new ways to make future physicians aware of how values and expectations can be culturally bounded and to prepare them for a lifelong process of negotiating and renegotiating their professional identities.
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