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Transformative Learning and Professional Identity Formation During International Health Electives: A Qualitative Study Using Grounded Theory

Sawatsky, Adam P. MD, MS; Nordhues, Hannah C. MD; Merry, Stephen P. MD, MPH; Bashir, M. Usmaan MD; Hafferty, Frederic W. PhD

doi: 10.1097/ACM.0000000000002230
Research Reports
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Purpose International health electives (IHEs) are widely available during residency and provide unique experiences for trainees. Theoretical models of professional identity formation and transformative learning may provide insight into residents’ experiences during IHEs. The purpose of this study was to explore transformative learning and professional identity formation during resident IHEs and characterize the relationship between transformative learning and professional identity formation.

Method The authors used a constructivist grounded theory approach, with the sensitizing concepts of transformative learning and professional identity formation to analyze narrative reflective reports of residents’ IHEs. The Mayo International Health Program supports residents from all specialties across three Mayo Clinic sites. In 2015, the authors collected narrative reflective reports from 377 IHE participants dating from 2001 to 2014. Reflections were coded and themes were organized into a model for transformative learning during IHEs, focusing on professional identity.

Results Five components of transformative learning were identified during IHEs: a disorienting experience; an emotional response; critical reflection; perspective change; and a commitment to future action. Within the component of critical reflection, three domains relating to professional identity were identified: making a difference; the doctor–patient relationship; and medicine in its “purest form.” Transformation was demonstrated through perspective change and a commitment to future action, including continued service, education, and development.

Conclusions IHEs provide rich experiences for transformative learning and professional identity formation. Understanding the components of transformative learning may provide insight into the interaction between learner, experiences, and the influence of mentors in the process of professional identity formation.

A.P. Sawatsky is assistant professor of medicine, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: http://orcid.org/0000-0003-4050-7984.

H.C. Nordhues is chief resident, Internal Medicine Residency Program, Department of Medicine, Mayo Clinic, Rochester, Minnesota.

S.P. Merry is assistant professor of family medicine, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota.

M.U. Bashir is associate consultant, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota.

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

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: This study was deemed exempt by the Mayo Clinic Institutional Review Board (IRB ID 14-008381).

Previous presentations: This study was presented at the Society of General Internal Medicine 2016 Annual Meeting, Hollywood, Florida, May 11, 2016; and the 2017 International Conference on Residency Education in Quebec City, Quebec, Canada, October 21, 2017.

Correspondence should be addressed to Adam P. Sawatsky, Mayo Clinic, Division of General Internal Medicine, Gonda 17, Rochester, MN 55905; telephone: (507) 284-8913; e-mail: sawatsky.adam@mayo.edu.

International health electives (IHEs) in low- and middle-income countries are widely available1–4 to undergraduate and graduate medical trainees. These electives provide unique educational opportunities, including experiencing a wide variety of pathology, learning to work with limited resources, developing clinical and surgical skills, and teaching others.5–8 IHEs also affect learner attitudes, including increased awareness of the role of public health, the effects of cultural practices and socioeconomic factors on health, and the importance of health care in developing countries.7,8 Given the prevalence of IHEs, educators and accrediting bodies have evaluated how they fulfill core competencies and have proposed milestones to assess IHE experiences.6,9–11 IHEs provide other personal and professional benefits, including opportunity for “career planning and goals,” “changes in perspective,” and “learning about one’s self.”9 Studies have demonstrated that IHE participants are more likely than their peers to choose a career working in underserved communities in the United States or abroad, as well as to participate in global health advocacy.12,13

The effects of IHEs on the learner’s perspective, understanding of self, and future career decisions highlight the influential nature of IHEs on the personal and professional identity of trainees. Examining IHEs through the theoretical perspectives of professional identity formation and transformative learning may provide greater insight into the influential nature of IHEs.

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Introduction

Professional identity formation

The Carnegie Foundation report on reform in medical school and residency education was central to a call for a focus on professional identity formation, stating that “professional identity formation—the development of professional values, actions, and aspirations—should be a major focus of medical education.”14 Cruess and colleagues,15 citing earlier work by Merton,16 defined professional identity formation as “the function of medical education to ‘transmit the culture of medicine and … to shape the novice into an effective practitioner of medicine, to give him [or her] the best available knowledge and skills, and to provide him [or her] with a professional identity so that he [or she] comes to think, act and feel like a physician.’” Jarvis-Selinger et al17 identified professional identity formation as “an adaptive, developmental process that happens simultaneously at two levels: at the level of the individual, which involves the psychological development of the person, and at the collective level, which involves a socialization of the person into appropriate roles and forms of participation in the community’s work.” Theories of professional identity formation are adapted from diverse fields of study, including cognitive psychology (e.g., Kegan’s Stages of Identity Formation18) and sociology (e.g., Wenger’s Communities of Practice19,20).21 Within this theoretical overlay, the most powerful factors that shape a physician’s professional identity are “role models, mentors, and the accumulation of individual experiences.”21 It is within this framework of professional identity formation that we consider the impact of IHEs.

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Transformative learning

Mezirow22 defined transformative learning as “the process of effecting change in a frame of reference.” Frames of reference are shaped by “habits of mind,” or habitual ways of thinking, feeling, and acting as they are influenced by assumptions, and are expressed through “points of view”—the beliefs, value judgments, attitudes, and feelings that shape a particular interpretation.22 The process of transformation starts with a “disorienting dilemma” and proceeds through the core elements of individual experience, critical reflection, and dialogue, which leads to the adoption of a new perspective (List 1).23 Fostering transformative learning requires providing varied learning experiences that stimulate critical reflection and providing encouragement to sustain reflection.24 A review of the transformative learning literature highlighted the role of emotions in uncovering opportunities to engage in reflection, yet acknowledged that “despite all the research affirming the essentiality of affective ways of knowing, little is known about how to effectively engage emotions in practice.”25

List 1 Mezirow’s Phases of Transformative Learning, Used to Inform a Study of Residents’ Transformative Learning and Professional Identity Formation During International Health Electives, 2001–2014a

List 1 Mezirow’s Phases of Transformative Learning, Used to Inform a Study of Residents’ Transformative Learning and Professional Identity Formation During International Health Electives, 2001–2014a

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Profession identity (trans)formation during IHEs

Because IHE experiences have the potential to profoundly affect trainees’ perspectives on the practice of medicine, transformative learning theory provides a potential lens for viewing how trainees’ professional identities are challenged during IHEs. The process of identity formation involves the “deepening of one’s commitment to the values and dispositions of the profession into habits of the mind and heart.”26 The wording “habits of mind” links back to Mezirow’s22 discussion of transformative learning: “transformations in frames of reference take place through critical reflection and transformation of a habit of mind.” The Transformation in Medical Education task force identified professional identity formation as a “transformative journey.”27 Similarly, Cruess and colleagues21 emphasized that “identity is not static and that the identity of a practicing physician will continue to evolve throughout his or her practice.” Professional identity formation is a lifelong, transformative process that develops new identity frames as we challenge previous frames through the practice of medicine.

IHEs provide an opportunity to explore the convergence of transformative learning and professional identity formation as residents are exposed to new experiences that challenge their previous frames of reference of what it means to “think, act and feel like a physician.”15 The purpose of this study was to explore transformative learning and professional identity formation during resident participation in IHEs, and characterize the relationship between components of transformative learning and professional identity formation.

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Method

We used a modified constructivist grounded theory approach, with the sensitizing concepts of transformative learning theory and professional identity formation to guide analysis of narrative reflective reports of residents’ IHE experiences.28 We chose aspects of grounded theory methodology to build a theoretical understanding of transformative learning and professional identity formation within IHEs, and took a constructivist approach, recognizing the co-construction of theory through the researchers’ “involvements and interactions with people, perspectives, and research practices.”28

This study was deemed exempt by the Mayo Clinic Institutional Review Board.

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Setting and participants

The Mayo International Health Program (MIHP) provides funding and support for residents and fellows to participate in an IHE in low- and lower-middle-income countries in resource-limited settings. Residents and fellows from all training programs across all Mayo Clinic sites (Rochester, Arizona, and Florida) were eligible to participate and rotated through 1 of 14 designated partnership sites, or established an independent rotation that met the requirements of the program.5,6 These electives ranged from one week to one month in duration, surgical subspecialties often being shorter and medical residencies and fellowships IHEs usually lasting one month. We included all narrative reflective reports from MIHP participants from the inception of the program in 2001 through the end of 2014, excluding two reports containing incomplete data (n = 377). The data were collected in 2015 for analysis.

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Data collection

Each MIHP participant was required to complete a postrotation report. This report included demographic information, a case log, and “a minimum one page personal reflection of your experience, including … a statement indicating how this experience impacted you either personally and/or professionally,” as stated in the elective requirements. The narrative reflection was the source of data for this study.

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Data processing

The narrative reflections were uploaded to NVivo 10 (QSR International, Australia), a computer software program to support the analysis of qualitative data. Three members of the research team (A.P.S., H.C.N., M.U.B.) read through all 377 narrative reflections and identified reflections that specifically used the wording “why I went into medicine” or “what it means to be a doctor.” As a team, we identified these reports as explicitly reflecting on personal and professional identity and used these 24 reports as our theoretical sample and developed a codebook through open coding, analytic memos, and group discussion. This codebook was then applied to all 377 reflective reports; three team members (A.P.S., H.C.N., M.U.B.) coded the first three years of narratives in duplicate until appropriate agreement was reached, and the remaining narratives were coded individually. Codes were then organized by one team member (A.P.S.) into axial codes representing components of the transformative learning process within these reflections on professional identity, including “disorienting experience,” “emotional response,” “critical reflection,” “perspective change,” and “commitment.” These codes and the represented narrative passages served as the basis for analysis of the process of transformative learning and professional identity during IHEs.

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Data analysis

Using the identified codes and resulting quotations, we started by identifying themes explaining areas of professional identity that were challenged and developed during IHEs. Around these professional identity themes, we identified components of transformative learning. Using a constructivist grounded theory approach guided by a focus on process, the use of comparative methods, and the development of inductive analytic categories through systematic data analysis,28 we developed a model of transformative learning during IHEs to understand the impact of IHE experiences on resident professional identity. This theory was refined through constant comparison against new data as we expanded coding and data analysis from our theoretical sample to the complete set of reflective reports. Through group discussion, we agreed that we had achieved theoretical saturation, with no new theoretical concepts identified in the data set, and a complete understanding of the identified concepts was achieved.

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Results

From 2001 to 2014, there were 377 residents and fellows who completed an IHE through the MIHP (Table 1). The residents came from 23 different specialties from the three Mayo Clinic training sites and participated in IHEs in 56 different countries.

Table 1

Table 1

Through analysis of postrotation reflective reports, we identified five components of transformative learning: a disorienting experience, an emotional response, critical reflection, perspective change, and a commitment to future action (Figure 1). Below, we outline each step in the process of transformative learning during IHEs, and highlight the relationship with professional identity formation. Quotations are referenced by the year, country, and specialty.

Figure 1

Figure 1

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Disorienting experience

IHEs provided a wide variety of opportunities for residents to learn about and provide medical care in underserved regions of the world. IHE experiences provided a stark contrast between the practice of medicine at residents’ home versus host institutions. These experiences were difficult and overwhelming, as well as positive and inspiring.

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Stark contrast.

Resident reports often began by reflecting on the stark contrast between their home and host institutions. One contrast was exposure to poverty, as one resident remarked: “This was an unforgettable experience. We rode through some of the poorest villages I have ever seen. The contrast with the affluence seen here in America was stark. I was beginning to feel the true setting of the developing world” (2002/Mexico/ear, nose, and throat [ENT]). Another resident reflected, “The extent of poverty seen was staggering” (2007/India/internal medicine). Poverty was linked to a lack of health care resources: “I was extremely saddened to find that the reality for these folks was a pervasive lack [of care]—pregnant women without prenatal care, infants and children without vaccinations, lack of birthing facilities” (2012/Philippines/internal medicine). The lack of resources contrasted with residents’ home institutions, as one resident reflected: “The substantial lack of access to medical resources amongst the patients we encountered strikingly contrasts with the situation in the United States. I find it surreal to conceptualize that by mere virtue of being born a few miles on one side or the other of a man-made imaginary line, an individual’s socioeconomic fate can be so radically affected” (2002/Mexico/internal medicine).

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Difficult experiences.

In addition to poverty and limited resources, residents also reflected on the difficulty of the situations that they encountered on their IHEs, including ethical dilemmas, advanced illness, and death. Residents were forced into ethical dilemmas surrounding the use of limited resources, as one resident commented: “This often posed an ethical dilemma, as limited resources meant denial of proper care to some patients in order to treat others” (2004/India/internal medicine). Residents also dealt with advanced illness: “The head and neck clinic was a sad sight. All the cases that presented were advanced cases with no chance for cure” (2014/Ghana/ENT). Dealing with death, particularly “unnecessary death,” was difficult for residents: “There were instances that were truly heartbreaking, particularly with the death of young patients secondary to the lack of emergent service, who would have likely otherwise survived in a developed country” (2014/Cambodia/neurology).

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Positive experiences.

There were numerous positive experiences that generated reflection, including exposure to new people, cultures, and role models: “Had the images of disease and death been the only images I retained from this trip, I would have been enriched with clinical experience but would have been left emotionally distraught. However, experiencing the richness of the Haitian culture and the beauty, gratitude and resilience of its people became the most enriching aspect of this experience” (2002/Haiti/internal medicine). Interacting with new people and cultures were positive experiences that helped facilitate transformation.

Residents also reflected on the influence of local physicians, care providers, trainees, and expatriate workers, admiring their dedication to patient care, breadth of experience, and sacrifice. One resident commented: “I was impressed by the dedication of the children’s hospital staff to their patients, despite the fact they could earn three times more at a private hospital” (2005/Vietnam/urology). Residents commented on the breadth of experience and ability of local staff: “These physicians can only be admired. Each of them really is ‘the’ doctor. Anything from colicky babies to cesarean sections to exploratory laparotomy, ‘the’ doctor on call handles it” (2005/Kenya/internal medicine). Working alongside committed physicians was clearly transformative: “Working with him gave me the opportunity to witness the fulfillment of a lifelong commitment to excellent patient care for underserved populations. I was moved by his emotional connection with the patients and his sympathy for their circumstances, and I hope to always keep his example in mind and seek out opportunities to provide similar care” (2009/Dominican Republic/anesthesiology).

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Emotional response

Expressions of emotion were central to residents’ reflections on disorienting experiences. As with their variety of experiences, there was a range of emotional responses, from heartbreak, frustration, and guilt to inspiration and gratification.

Difficult experiences often elicited difficult emotions. One resident reflected: “Having seen all of these things, I finally broke down and cried at a prayer meeting. The poverty, suffering, and death were breaking my heart” (2004/Kenya/neurology). Because of limited resources, one resident commented, “I experienced frustration in facing the limitations of medical practice in the third world” (2001/Mexico/internal medicine). Frustration also elicited hopelessness: “A sense of hopelessness was experienced multiple times when the patient required more than we were capable of providing with the available resources” (2005/Honduras/internal medicine). Difficult feelings even elicited guilt: “The horror of realizing that people really live like this and the utter shame and embarrassment that I felt realizing how blessed I truly am while others go cold, dirty and hungry. There is no way to express the shame one feels” (2006/Cameroon/physical medicine and rehabilitation).

Residents also described emotions elicited by positive experiences. The example of staff was inspirational: “The people I met [staff] taught me many things about the proverbial art of medicine and what it means to be a ‘good physician’” (2009/Tanzania/family medicine). The experience with patients was gratifying: “I have never met patients so gracious, so in need, as these. It was extremely gratifying to administer health care to this community” (2001/Mexico/internal medicine). Being involved in patient care and education was rewarding: “What was most rewarding were the interactions with the interns and residents in training. They were a remarkable group of young men and women who treated their patients with compassion and had a hunger to learn” (2012/Kenya/pulmonary and critical care).

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Critical reflection

We identified three categories of themes within residents’ critical reflections that represent facets of their professional identity that were challenged by participation in IHEs: making a difference, the doctor–patient relationship, and medicine in its “purest form” (Table 2).

Table 2

Table 2

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Making a difference.

Many residents felt that participating in an IHE was satisfying because of feeling that they were making a difference: “the feeling you are doing something that counts” (2001/Haiti/internal medicine). They recognized the need of their patients, as one resident described: “Taking care of the patients there really put things into perspective for me and got me back into the mind-set of why I wanted to be a physician. It was very rewarding to help those patients who were truly in need at a devastating time in their lives” (2013/Kenya/orthopedic surgery). Additionally, residents described the feeling of being the patients’ only option for health care: “The experience was professionally satisfying, as it allowed me to provide surgical care in my area of training that those patients would not have otherwise been afforded … helping the people in need was life changing” (2009/Peru/ENT). Some residents described the evident need as the “true needs” of the patient, in contrast to patients they have cared for in the United States. Lastly, making a difference stimulated thoughts on selflessness: “I learnt the value of selfless service there—service with no compensation or reward, just the gratitude seen in the patient’s eyes” (2009/India/internal medicine).

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Doctor–patient relationship.

Several aspects of the doctor–patient relationship influenced residents’ thoughts on their professional identity. The most widespread was their reflection on the gratitude of their patients: “The patients were so grateful, even for simple things! I found myself remembering why I really wanted to be a doctor again!” (2005/Mexico/internal medicine). Their patients’ gratitude was often contrasted with patients at home: “One overarching sentiment that I took away from the experience was a feeling of gratitude on the part of those patients and families that we served … this aspect of a wholesome doctor–patient relationship is often lost in our health care system” (2014/Ecuador/anesthesiology). Along with patient gratitude, residents also reflected on the trust that patients placed in them as physicians: “I was amazed to see the level of respect for physicians.… A doctor’s advice and recommendation is considered a doctrine and no patient questions or challenges a physician’s authority. In the U.S., I have had patients curse at me because of the bad hospital food!” (2008/India/internal medicine). Lastly, residents remarked about the resilience of the patients for which they cared: “I was encouraged by their mental and spiritual fortitude in the face of adversity. My patients displayed courage, bravery, and stoicism in the face of suffering that I haven’t witnessed very often in the U.S. The most rewarding aspect was their gratitude for what little relief we could provide. I found this to be invigorating in my desire to practice surgery” (2005/Kenya/general surgery).

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Medicine in its “purest form.”

Residents reflected on their reliance on clinical skills, avoidance of “distractions” from patient care, and understanding of the limitations of medicine during their IHEs. One resident commented: “Reliance on laboratory and imaging is nonexistent and the physician must use his or her clinical judgment. It is medicine in its purest form” (2007/Dominican Republic/internal medicine). Residents discussed freedom from pagers, documentation, electronic medical records, and other “distractions” present in their home medical system, and felt freedom to provide health care for free, apart from the “business of medicine.” Resident participation in IHEs stimulated “an understanding of the limitations of us as doctors and of the hospital as an institution” (2004/Cambodia/internal medicine), allowing the resident to focus on “providing the best possible medical care with limited resources, teaching me the need for simplicity, flexibility and gratitude.… It reminded me of why I chose medicine as a profession” (2007/Honduras/general surgery).

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Perspective change

Residents acknowledged changes in perspective regarding their clinical practice: “This trip … helped me to see things from a different perspective” (2014/Vietnam/plastic surgery). One resident defined this change as “a paradigm shift of thought in respect to the way that we are able to practice medicine” (2003/Mexico/ENT). Perspective change was driven by exposure to “what poverty and lack of health care is really like” (2009/Thailand/cardiology), and residents felt “enriched by the eye-opening experience to cultural differences and similarities” (2001/Mexico/internal medicine). IHEs also left residents with a sense of humility: “This was a lesson in humility and showed me how limited we are by the disease and by the equipment we have around us” (2003/Guatemala/ENT). They were also humbled by their privilege, the struggle of their patients, and the opportunity to serve others.

Ultimately, residents identified a change in their personal and professional identity, described as a discovery, or rediscovery, of the purpose of medicine and the identity of a physician: “Such an experience inherently redefines for an individual why they entered the medical profession in the first place … to remind myself that the most important job as a physician is to care for patients” (2002/Haiti/internal medicine). Many residents were reminded of values of which they had lost sight: “The most important aspect of the experience is that it reminded me why I went into medicine—treatment of the underserved. It is so easy to get overcome by the ‘daily grind’ of residency and lose sight of the goals I set for myself when I started” (2007/Dominican Republic/internal medicine). Through a shift in perspective, residents reignited a purpose and passion for being agents of change for their patients: “I rediscovered that the greatest reason to spend myself helping those patients was the passion for their dignity and the awareness that the big change happens always as result of microscopic contributions, of infinitesimal acts of sharing and caring. And I realized that this is true in any part of the world” (2003/South Africa/internal medicine).

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Commitment to future action

Residents expressed a commitment to change the way they approach their life, their work, and their future. They committed to personal and professional self-improvement, cultural awareness, continued service of the medically underserved, and education and development.

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Personal and professional self-improvement.

Residents discussed how a shift in perspective challenged them and instilled “a renewed desire to be a better person and to appreciate how fortunate we are” (2004/Mexico/ENT). Residents were reminded of their core values: “The most important thing I have learned, or rather confirmed, from my experience is that no matter where in the world one is seeing patients and practicing medicine, ensuring that patients leave feeling better about their condition and themselves is what matters most” (2012/Tanzania/geriatrics). They committed to live and work with a sense of gratitude: “These experiences made me thankful for the many seemingly inane conveniences we take for granted in our medical practice” (2004/Cuba/internal medicine).

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Cultural awareness.

Residents committed to an awareness of the cultural perspectives of their patients. One resident reflected: “On a personal level, this experience helped me become more flexible and opened my eyes to the great differences in cultures and how that difference shapes the manner in which people view their health” (2007/Dominican Republic/internal medicine). While IHE participation made cultural awareness more explicit, residents identified “the need to understand the culture/worldview of the patient in order to provide what they would consider a satisfying clinical encounter.… These lessons apply just as much to my practice [at home]: each patient is unique and listening closely to understand their expectations and viewpoint proves to be fruitful” (2007/Dominican Republic/physical medicine and rehabilitation).

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Career choice.

Residents committed to providing care to the medically underserved, either locally or globally: “We hope to continue to use our training and skills to provide medical care and education to underserved areas. Our trip confirmed that though such work is often strenuous, it is clearly worth it” (2004/Kenya/neurology). Residents expressed a range of commitments, from a hope to continue similar work to a deep sense of responsibility: “Being exposed to the needs for quality health care for children in the developing world created in me a sense of responsibility, that I personally have an obligation to help meet these needs throughout my professional career. We are truly blessed with incredible training and resources here in America, and if we choose to share this with others, including our lives, we will find what our souls are searching for: a sense of purpose and meaning” (2006/Kenya/orthopedic surgery).

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Education and development.

Residents displayed a clear commitment to provide sustainable benefit to underserved populations through education and development in global health. One resident reflected on education: “I would like to be involved in the development of postgraduate medical education in the developing world. This trip helped to refine that vision, and provided contacts” (2010/Kenya/internal medicine). Another committed to obtaining further training in policy and development to benefit underserved populations: “As a direct result of my time here, I have been charged to research master’s programs in health care policy with the idea that in my lifetime I may make a difference in the administration of health care for all” (2006/India/internal medicine).

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Professional identity transformation

In summary, one resident encapsulated the transformational nature of IHEs: “This four-week international, cross-cultural experience was transformative for my life. I would challenge anyone to see this poverty and these extremes of life and not be changed by it. After such an experience one may be tempted to allow one’s self to be overwhelmed by the enormity of the problems and throw up one’s hands and say, ‘There’s nothing I can do.’ It may be possible to return to one’s prior way of life, happy to be enriched by such an experience, have stories to tell, and move on. But I did not have that kind of experience. I will not be able to forget the desperate need of these multitudes that I have briefly served and go back to serving the medically saturated” (2011/Ethiopia/family medicine). Resident experiences during IHEs link to components of transformative learning theory, leading to critical reflection on topics central to professional identity formation (Figure 1).

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Discussion

Previous research points to the transformative nature of participation in IHEs.9,12,13 In this study, we identified five components of transformative learning—a disorienting experience, the emotional response, critical reflection, perspective change, and commitment to future action—and their relationship to reflections on professional identity transformation in residents participating in IHEs. Resident reflections were closely linked with professional identity, describing a discovery—or rediscovery—of the meaning of being a physician. Residents’ meaning centered on three categories of themes: to make a difference, to experience a fulfilling doctor–patient relationship, and to practice the “purest” form of medicine. Using the lenses of transformative learning and professional identity formation to view residents’ experiences during IHEs, this study suggests three propositions: residents undergo professional identity formation during IHEs; transformative learning theory can help explain the process of learning during IHEs; and transformative learning theory may be useful in explaining the process of professional identity transformation, within and outside of IHEs.

First, the formation of professional identity is an important educational outcome of resident participation in IHEs. IHEs present several challenging experiences that can shape a participant’s identity, including ethical concerns, role uncertainty, cultural differences, medical tourism, and reciprocity in capacity building.29–31 In one study of core competencies in IHEs, pediatric residents identified a separate category of learning entitled “professional and personal development,” which included themes of “perspective change” and “career planning and goals”—themes linked to professional identity formation.9 Nursing students who participated in IHEs identified similar themes, leading researchers to suggest that the “primary effects of international placements were identified as personal development and transcultural adaptation.”32 Residents in our study reflected on their experiences and directly linked them to the ongoing transformation of their professional identities, as they wrestled with issues of distribution of limited resources and the stark contrast in the practice of medicine between host and home institution.

Second, transformative learning theory can help explain how residents learn during IHEs. In this study, we demonstrated components of transformation, including disorienting experience, emotional response, critical reflection, perspective change, and commitment to future roles. Although transformative learning has not been previously applied to IHEs, a study of experiential learning in underserved settings established that students demonstrate transformative learning, starting with a disorienting experience, and engaging in reflection to identify new roles and relationships, new knowledge and understanding of the situation, and a commitment to action.33 The emotional response to disorienting experiences while on IHEs challenges residents’ underlying attitudes to foster perspective change through critical reflection and dialogue about important issues of professional norms, standards of practice, cultural competence, and management of differential access to resources.34 Using the lens of transformative learning can foster critical reflection and dialogue on the professional values that should be addressed in preparing for, engaging in, and reflecting on IHEs.35

Newer proponents of transformative learning theory have highlighted that attention to emotional responses is a necessary component of critical reflection on experiences to enable true transformative learning.36 Taylor36 suggests that “in large measure, it is emotions that limit what the brain will take into account…. Emotions establish the agenda for desires and beliefs.” During IHEs, challenges within residents’ experiences trigger deep emotional responses that provide the impetus for reflection and a focus on underlying issues of personal and professional values. Apart from guiding reflections, emotion can also indicate unconscious issues evoked by the learning environment, and the expression of emotions is tied to “individuation, the process by which we come to recognize and develop an awareness of who we are and relate to others.”37 The roles of experience and emotion are therefore tied to critical reflection and transformative learning during IHEs.

Third, transformative learning theory may be a useful framework for understanding the relationship between the individual, their experiences, and role modeling/mentoring within the context of professional identity formation. Cruess and colleagues21 present several schematic representations of the socialization process that surrounds the professional identity formation of becoming a physician and have highlighted the powerful roles of individual experiences and mentors. They further state that the objective of mentoring is to encourage reflection and “[shift] the learning to the conscious pathway, making it explicit.”38 Having identified in this study a link between transformative learning and professional identity formation, transformative learning may represent one process through which learners make sense of their professional experiences. The ability to reflect on experience and drive perspective change requires awareness that reflection is required and the skills needed to reflect, pointing to the need for a facilitator to guide learner reflection.39 Mentors, by recognizing challenging situations and trainees’ emotional responses, can use both as triggers for guided reflection, or “pedagogical entry points,” to initiate reflection and dialogue on issues of professional identity.40 By focusing reflection on the identified domains of identity—making a difference, the doctor–patient relationship, and medicine in its “purest” form—mentors can help facilitate professional identity formation through challenging underlying assumptions that triggered the emotional response and facilitating perspective change and a deeper commitment to the values of the profession.41 This can be applied to medical education outside of IHEs as well, as medical trainees regularly face challenging situations in the practice of medicine, including ethical dilemmas,42 patient death,43 clinical uncertainty,44 and medical errors.45 Transformative learning may also be applied to teaching within the core competencies of systems-based practice and practice-based learning and improvement, to provide a framework for learners to reflect on systems or practice issues, challenge underlying assumptions, and develop new perspectives to create transformation in systems and personal practice and integrate these competencies into the learner’s identity as a physician.46

There are limitations of this study. First, the data were originally collected for rotation evaluation, which is not typical of grounded theory research. Because of the inability to theoretically sample residents, this may limit the generation of substantive theory. Given the large amount of collected reflections, we felt that as a research team we were still able to use a modified grounded theory approach, developing the theory from an initial theoretical sample, and then employing constant comparison and iterative theory development to the rest of the data set to challenge our theoretical understanding and to ensure theoretical saturation. Second, adequate discussion of ethical challenges and negative experiences may be underrepresented in our sample. For example, we did not identify the emotions of “anger” or “outrage” at health inequities experienced in host countries. This may be due to the collection of data after the experience, when emotions have faded, and therefore strong emotions were not expressed in these reflections. Nonetheless, participants still described difficult experiences, emotions, and ethical challenges. Third, we chose two specific theoretical lenses through which to analyze the data, which give us a certain view of these narrative reflections. Because we chose to look at professional identity formation, our themes are very centered on the individual, and we did not examine transformation in other aspects of the affective domain—for example, attitudes toward culture, social determinants of health, health activism, or other topics addressed in the reflections. We used transformative learning theory, which takes a more individual approach to learning, and therefore did not examine aspects of social learning theory or other more sociological lenses for examining these reflections.

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Conclusions

IHEs provide rich experiences for residents to reflect on their personal and professional identities. We have identified transformative learning as a possible mechanism that links the individual to the process of professional identity formation through the elements of a disorienting experience, the emotional response, critical reflection, perspective change, and commitment to future action. Attention to these components of transformative learning, both within IHEs and within the normal training environment, can provide educators the opportunity to help understand and foster professional identity transformation.

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Acknowledgments:

The authors would like to thank Michelle L. Pederson, Mayo International Health Program Coordinator, for her assistance with data gathering. The authors would also like to thank John Ratelle, MD, and Tina Martimianakis, PhD, for their critical review of the manuscript.

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