Medical educators widely agree that they should foster students’ professional attitudes because individuals are more likely to act in accordance with the values of their profession if they have internalized the ideals and principles behind their responsibilities.1–3 Therefore, supporting a positive professional identity among physicians-in-training serves to complement knowledge- and skill-focused educational approaches and to more comprehensively address the developmental needs of these emerging professionals.4–6 In response, there has been an upsurge in educational innovations intended to foster professional identity formation (PIF), especially innovations that emphasize engaging students in reflection.7–11 However, there is still much to be learned about when and why students take up opportunities to examine and negotiate their emerging professional identities.
Historically, identity theories are based on developmental perspectives grounded in the notion that individuals progress through a series of stages marked by ego growth.12 While such theories foreground the role of each individual’s internal cognitive structures, more and more researchers are adopting social-cognitive theories that assert the interactional nature of identity development as a socially grounded process.13,14 In the context of medical education, PIF has been described as an “adaptive, developmental process that happens simultaneously at two levels: (1) at the level of the individual, which involves the psychological development of the person, and (2) at the collective level, which involves socialization of the person into appropriate roles and forms of participation in the community’s work.”4 Building from social-cognitive theories—that acknowledge both the individual and social dimensions of PIF—researchers have studied medical students’ narrative reflections because these reflections have the potential to illustrate the links students are making between clinical experiences and internal identity construction.8 Narrative reflections not only illuminate students’ experiences of PIF but also, according to some research, act as a learning mechanism that supports students as they develop their professionalism and identity.15,16 Narrative reflection literature particularly emphasizes how students relate their evolving selves to the impact of dramatic moments, such as their experiences of death and illness,17 anatomy lab exercises,10 and their first patient interactions.18 Less prevalent are reports of students reflecting on the more routine aspects of their day-to-day educational and clinical experiences, even though these may significantly affect their emerging professional identity.
In addition, few conceptual frameworks exist to facilitate interpretation of how reflective moments—either great or small—affect students’ evolving sense of professional identity in ways that can inform curricular efforts to link opportunities for reflection and PIF. In this study, we aimed to understand how students reflected on their emerging and changing professional identities throughout their third-year clinical clerkship, which is a critical transition period for medical students. We examined evolving medical student professional identity within the context of the pilot year of the Guided Reflection and Professionalization/Hidden Curriculum (GRAPHiC) course at the University of British Columbia (UBC).19,20
The initial purpose of this study was to examine third-year medical students’ experiences of PIF during their clinical clerkships to advance the medical education community’s understanding of how to support students’ professional growth during medical school. We relied on our interpretivist perspectives21 to engage in an analysis informed by a grounded theory approach. The study was conducted during the pilot year of the GRAPHiC course at UBC.19,20,22 As previously described, the GRAPHiC program was designed to support medical students as they worked to “unhide” the influences of the hidden curriculum in relation to their development as medical students and emerging professionals. GRAPHiC sessions (n = 10) were structured using a 4-step approach—priming, noticing, processing, and choosing—to guide the discussion and to engage all participants in active reflection (see Supplemental Digital Appendix 1, available at http://links.lww.com/ACADMED/A699).20 For example, facilitators first primed students to notice how the hidden curriculum was influencing them, then supported students as they processed what they were noticing, and, finally, helped them choose behaviors that might positively support their developing professional identity.
We invited all third-year students registered at UBC to participate in the study via email. To participate, students voluntarily enrolled in the GRAPHiC pilot course. Over the course of 1 academic year, volunteer third-year medical students engaged in 9 collaborative discussions with 3 faculty members (including C.L.H.), 1 emergency medicine resident, and 1 fourth-year medical student (G.R.L.C.). Students participated in group discussions, online journaling, and email correspondence with the lead facilitator (C.L.H.). The UBC Behavioural Research Ethics Board process provided ethical approval for this study.
For the present study, we analyzed audio recordings and transcripts of the 9 group discussions (i.e., GRAPHiC or G sessions) that took place over the course of the students’ third year of medical school (June 2015–June 2016) and of 1 follow-up session in their fourth year (February 2017). One investigator (C.L.H.) who was present at each session listened to each audio recording and encoded the participants, deidentifying them in the transcripts. Each participant was encoded as either a male student (MS) or a female student (FS) and assigned a number. The sessions, encoded sequentially (G1–G10), were 2 hours in length. We designed these sessions, which consisted of strategic, planned prompts as well as unstructured discussions, to support students’ progress through the phases of priming, noticing, processing, and choosing.20
GRAPHiC curricular description
As previously described,19,20 the initial group meeting included a 1-hour didactic session (June 2015) introducing the concept of the hidden curriculum, as well as the constructs of compliance and conformity, to medical students. In addition, during this first session, the facilitators provided examples of the hidden curriculum from the personal realm and clinical workplace and invited discussion to sensitize students to their own experiences of acceding to peer pressure.19,20 The students were asked to take field notes between curricular sessions to record their daily activities. Through email reminders and verbal prompts, we coached the participating students to note and journal, specifically, their own process of enculturation. We asked them to notice and record moments when they experienced dissonance, that is, when they felt pressure to comply or conform to behaviors that moved them away from their best or ideal professional self.
We used a grounded theory approach to analyze the data resulting from the 10 GRAPHiC sessions because grounded theory suitably addresses inquiries related to process or change over time16,23 and facilitates developing a conceptually abstract explanation of “what is happening in a social setting.”24 Data analyses were supported by the use of Microsoft Excel (version 16.16.1, Redmond, Washington). Analyses involved 2 fourth-year medical students (G.R.L.C. and K.L.) reading transcripts, engaging in the act of analytic memoing,25,26 and generating emergent themes related to our research questions. Because a foundational issue for researchers employing a grounded theory methodology lies in the tension between the inductive creation of categories and codes and the potential for the researchers’ own theoretical sensitivities to influence data-driven analyses and conceptual thinking,21,27 a graduate student research assistant (K.A.M.) joined the team. K.A.M. engaged in data analysis as an outsider (from the Faculty of Education rather than the Faculty of Medicine), which gave her the perspective to check the degree to which the lead researchers’ theoretical sensitivities may have caused an imposition of conceptual categories. We parsed the initial comments into smaller units of meaning for the purposes of coding. Categories emerged as overarching findings (see below) and served as the model of action,28 which we used to discern patterns and relationships within and across each category. Throughout this process, 2 of us (K.A.M. and S.J.-S.) engaged individually in axial coding, using a constant comparative approach,28 and met biweekly to discuss, define, and interrogate not only the developing codes but also the categories’ properties and dimensions.26
Twelve students enrolled, and all 12 vocalized opinions across the 10 GRAPHiC sessions. The transcripts from all 10 sessions ranged from 1,137 to 1,976 lines of text, and we initially analyzed 114 individual comments. The analysis resulted in 2 substantive findings: (1) the development of a conceptual framework and (2) distinct PIF themes.
The emergence of a conceptual framework was an unintended but important finding. Through analyzing students’ experiences of PIF, we found 4 identifiable components that together constituted their professional stories (see Figure 1). Post hoc, we organized these into a framework that comprises (1) the contexts that student participants spoke about, (2) the focus of their stories, (3) the catalysts that seemed to spur students to introspect, and (4) how students process their identity beliefs.
We identified 2 overarching themes—being and becoming—in students’ descriptions of how they process and form a professional identity. We identified 2 dimensions of being through students’ (1) individual and (2) socially referenced reflections. As students described who they were becoming, they were thinking forward to their future identities in relation to the physicians they were observing and working with in clinical settings.
A conceptual framework for organizing students’ PIF stories
Students located the experiences that shaped their professional identity within a specific context, that is, the temporal, physical, and/or relational components of the clinical environment in which they were working. Students reflected on their experience, specifically, for example, in the emergency department, on a first clinical rotation, or upon getting feedback from a preceptor after a clinic shift.
Students also centered their stories on a specific focus, which we defined as “what held their attention” in that particular context. For example, if the student described the context as a surgical rotation and his or her first time in the operating room (OR), the student’s focus might be on the team’s communication and interactions or on the tone and content of those interactions. Given that each context (e.g., the OR) could provide potentially hundreds, even thousands, of potential foci, we highlighted the specific pieces of information students noted: their focus.
Students often described how a specific catalyst stimulated them to reflect on and be introspective about their own identity within a particular context and focus. For example, a student could have just heard a lecture in class about professionalism, and that may have become the catalyst to view the OR team’s conversations not with a clinical learning lens but instead with a PIF lens; that is, the student considers not what relevant patient information is being presented but instead ponders, “Who am I in this situation?” or “What am I learning about how to be in the future?”
Finally, the last component, process—specifically building knowledge about how students process or negotiate their identity beliefs—was the initial aim of this study. Therefore, by elaborating more extensively on how students process their identity, we have also demonstrated the utility of our conceptual framework for patterning and understanding students’ experiences of PIF. We defined process as students’ awareness and navigation of their current or future professional selves. Students described having a sense of their current identity (i.e., who I am) in the present moment or a sense of who they might become in the future (i.e., who I will be). Within each superordinate theme of being and becoming, we identified patterns in the types of moments that, according to our student participants, served as catalysts for introspecting about or processing their identity. Below, we have paired illustrative quotations with the dominant themes identified through our analysis of how students processed their identities, and we have noted the G session, the transcript line numbers, and participant number of each quotation.
When students described their conceptions of who they were in the then-present moment, rather than who they might become in the future, they made distinctions between how they personally (me-to-me) or socially (me-to-them) positioned themselves in relation to their identity.
Me-to-me (personal) reflections.
Students described their evolving sense of identity in relation to who they had been in the past, who they expected to be at this point in their education/career, and how they were beginning to take on physician-specific ways of being.
In the first case, students observed how conceptualizations of themselves at present contrasted to notions about who they had been previously. Students identified a degree of transformation from their past to present selves. For example, FS6 described a new normal when recounting how she was “horrified” at her first cesarean section but is now shocked at how “things normalize so quickly . . . within a couple of days” (G5, 260–287).
Second, students described how their shifting sense of self evoked a tension between who they were and who they thought they would be by this point in their educational trajectory. In some cases, students felt the realities of the clinical context undermined the type of health care provider they intended to be. For example, FS4 experienced frustration with a patient and recognized how she “was not [her]self in that interview.” She described:
I was still polite, but just—I didn’t really have the same rapport that I have with other patients. And I walked out of that, like, you know, a little 5-minute interview . . . and I was really ashamed of that incident . . . that same day I had a really good interaction with someone. And I had heard them when I went away, say, “Oh, she’s going to be, like, an amazing doctor.” And I remember thinking, “Yeah, like, this is who I am now.” (G7, 675–700)
In this, and other instances, students contrasted a real-life example of who they were with aspirations of who they felt they should be.
Third, students described how they were adopting physician (i.e., not student) identities in their ways of working, thinking, and/or contributing. They reflected on experiences in which they were making decisions on equal footing with physicians. For example, MS5 stated that “it was kind of amazing that what I was saying actually translated to what happened with the patient’s care” (G7, 38–97). Some students linked instances of thinking like a physician or taking on more patient responsibility to feeling more like a physician. Others described a shift in their sense of ownership over patients or their learning. For example, 1 student emphasized the ways in which his psychiatry rotation allowed him to feel a sense of ownership, in part, because he saw
patients that I admitted and—so I felt like a huge sense of ownership and that they were my patients. I felt like I knew them better than [my preceptor] did . . . so I did feel like a doctor in psych. (G8, 430–489)
He went on to contrast that experience to his dermatology rotation, during which he did not feel like a physician because he was not seeing patients on his own. This and other examples illustrate how students navigated their own PIF as they began to see themselves as physicians.
Me-to-them (social) reflections.
Students located their shifting, or new, identity in relation to others by distinguishing themselves from laypeople, from health professionals for whom a given context/occurrence is normal, and from practicing physicians.
Students articulated how their new identities differed from those of laypeople either in the clinical context or in their personal lives. They outlined how new ways of thinking about themselves could be attributed to interactions with others, and they described how these new experiences and perspectives helped them appreciate or perceive themselves as different. For example, FS6 described how she is no longer “amazed by some of the things we do.” She elaborates, “Like, I was sewing a guy’s nose back together the other day . . . it’s just kind of wild what becomes the norm . . . I’m like, if my family could see me right now, this would be crazy” (G7, 195–245). In another instance, MS7 recognized how a conversation with a nervous second-year medical student spurred him to think about where he was in relation to someone more junior:
I’d been 2 weeks into obstetrics and just finished the surgery portion of obstetrics. And we were in labor delivery and a second year was in as well because they were shadowing a family doctor. The second year came to me and said, like, “I’m going to be shadowing Dr. X in OR, super nervous about it. Have you been in OR? Can you tell me a bit about it?” And so then I actually just took her to, like the OR that’s in the back of the obstetrics ward and showed her, like, how to scrub and everything and, like, stick to rules and sterile fields and everything. And, like, maybe 10, 15 minutes in she was like, “Whoa, whoa, whoa, this is way too much. How did you learn this stuff?” And I didn’t realize, like, wow, I actually have learned this stuff . . . like now it’s just like second nature. (G7, 346–371)
These students demonstrated a sense that they had moved on from the layperson positions and/or junior learner roles they formally occupied.
A second way in which students distinguished themselves from others was in their sense that remarkable occurrences were not as normal to them as they were to others. For example, FS8 described the first time she was in the OR witnessing a cesarean section—“At one point, the obstetrician . . . pulls [the uterus?] out of the abdomen and starts kind of massaging it. And helping it contract . . . fallopian tubes and all”—an occurrence, which she framed as “normal for everybody else in the OR but” extraordinary “when you’re in the OR for the first time.” She recalls thinking, “How is this normal?” (G5, 202–228). This reflection illustrates the ways in which students themselves felt othered in the clinical context because of their identity as novices.
A third way in which students described their evolving sense of identity was in how they related to physicians. While in some cases students described feeling like a physician, in others, they described themselves as distinct from practicing physicians. In one example, FS6 described how trying to understand patients’ stories is “easier as a medical student than a doctor.” She notes: “If I take 20 minutes for an emergency consult or whatever, no one’s going to be mad at me. But when you’re an actual doctor, I think you don’t have quite as much time to do that” (G7, 1103–1155). During a GRAPHiC session, after hearing from a peer about how a physician communicated a diagnosis of terminal cancer to a patient, multiple students described themselves as straddling the doctor and student roles. One student (MS2) commented:
In being a student . . . we get to stand back and just watch . . . and we see it so clearly. And I’m sure that there are situations—if we, despite how jaded we become, I think there’s something so unique about having that—sort of step back to just observe.
FS8 responded by noting: “Well, I kind of feel like we’re almost the bridge. Like, we kind of have one foot in, one foot out.” MS2 agreed: “You’re right. Both worlds basically” (G5, 655–682).
A major finding was that the overwhelming majority of students’ conceptualizations about their future identities were responses to observations about physicians in clinical contexts. One student (MS7) spoke of an “incredible” internist who was an exemplar of professionalism for students, helping them to have high standards for themselves. The student described setting his own standards based on the internist’s model:
Is this something Dr. X would—is this the way she would do it? Or, how would she do this? And I know she would just spend more time and she’d ask more questions, and she’d listen a lot longer. Dr. X would—is this [what] the formula would be, and I just remind myself. No, that’s the formula. You just spend more time. You listen a bit more. You ask more questions. You think about it a bit longer. (G2, 936–998)
Students expressed dismay when they perceived physicians to be insensitive toward patients. To illustrate, MS1 described the tension he felt when he mimicked an insensitive preceptor’s approach—even though he felt empathy toward the patient:
And I felt bad about it. Like, I felt—’cause I actually kind of really did feel for the patient. But at the same time, I was, like, what do I know? This person’s [preceptor] been dealing with this patient for a long time and tells me a few stories about them so I guess they know what they’re talking about and I don’t. . . . But he didn’t seem to have a lot of empathy for the patients. . . . It was for chronic pain so it’s one of those places where you’d think empathy would be a big part of what’s going on there. But yeah, it was just an interesting experience for me. I know it’s going to happen again and I always tell myself I don’t want to be that person. (G1, 466–516)
When the facilitator prompted the student participants to consider how they might avoid becoming the physicians they did not want to become, the students rarely shared potential solutions. Instead, they mostly alluded to the inevitability of becoming insensitive over time, as exemplified by [MS1]’s comment:
I don’t want to get to the point where I’m, like, well, I see this all the time. People have cancer 50 times a day for me. It’s ‘you have cancer 1 time a day’ for you, like, today. . . . We’ll all just get there and maybe we all will. But I don’t want to. (G5, 632–654)
In sum, students reflected on the person they might become in the future in response to what they saw from more experienced physicians.
Critical reflection is a powerful tool for understanding how role designations within the social realm (e.g., medical student, resident, physician) are internalized into a professional identity and shape the conception of self.11 In this study, we sought to uncover not only how medical students begin to consciously reflect on their changing identities but also what kinds of experiences they drew on to do so.
The moments that seem to generate profound feelings of awareness in students are often moments that others would not recognize (even post hoc) as remarkable. While PIF research often focuses on the big events that are easily recognizable as powerful afterward (e.g., the first time students work with a cadaver or experience the death of a patient), in our research, we observed that significant moments for students were often mundane for others (e.g., talking to lay friends and family members, a routine operative task). Because students are engaged in the near-constant act of (re)defining and (re)negotiating their identities as a response to their day-to-day experiences in early clerkship, knowing when these moments will occur is difficult. However, if medical educators assume that some experiences are more fruitful than others for students to reflect on as they negotiate their professional identity,29 then studies like ours—that provide insight into the kinds of moments students focus on—will guide efforts to actively support positive PIF.
While the reflections we have recorded here were prompted, reflection on identity is often (if not always) a relational process of participating/othering. Individuals felt a stronger sense of being a physician when they had appropriate clinical autonomy and a sense of ownership over patients’ care. This observation aligns with the findings of others who observed that contexts in which students are allowed to engage in meaningful relationships and to carry real responsibilities (i.e., longitudinal integrated clerkships) influence the formation of professional identity.30,31 Students’ conceptualizations of identity were adaptive; they based their notions of identity on how they were relating to laypeople (e.g., patients, family members), other students, and health care professionals. They drew on experiences from clinical contexts and interpersonal interactions to describe how they were included/excluded. This finding—that students used their experiences to form a normalized health professional perspective—underscores the influence of the sociocultural context on PIF.32–34
Students experienced identity development temporally as evidenced in the ways they described their current or future identities, sometimes in relation to beliefs about who they thought they would/should be by this point. Group discussions and critical, narrative reflection have the potential to support students as they consider the interplay among (1) their sense of being (e.g., I am a student); (2) becoming, which is “an iterative concept that eschews notions of arrival and end-point achievement of expertise”35; and (3) experiences of identity dissonance.5,6,36,37 Such discussions and reflection also have the potential to help students not only redefine and strengthen professional commitments and values38 but also build a sense of professional agency,39 which can, in turn, support their capacity to reshape and negotiate professional identity.4,40 Notably, students readily affirmed their current sense of being a student and expressed more ambiguity when forecasting aspects of becoming a physician. They did, however, express an awareness of being a physician when, for example, they related their experiences to laypersons. Similarly, becoming also included becoming a fourth-year student or a first-year resident and did not include just the end goal of becoming a physician. Fostering students’ intentional awareness of the legitimacy of their “learner” identity as they engage in the process of PIF might help mitigate tensions between students’ current and future identities.41
Contexts such as GRAPHiC provide students with the opportunity to draw on their own and others’ unique perspectives while negotiating “who I am.”42,43 Additionally, such contexts not only allow students to actively construct their unique identities (rather than becoming part of a collective “us”) but also help them negotiate the interplay of being while they are becoming.44 Indeed, future research focused on the process of developing a professional identity will help combat the notion that there is a discernible and desirable end point to PIF. Such research should chart and examine how students’ diverse perspectives and positionalities influence their individual trajectories as they engage in moments of being and in moments of becoming.42
Our data are based on the discussions of a small number of volunteer medical students who, as volunteers, might be assumed to possess an eagerness to engage collaboratively in self-reflection. The small number of participants also potentially means that the conceptual framework is based on a unique student experience and may not be generalizable. While the number of individuals who participated may be small, having 10 focus group encounters yielded a comprehensive, longitudinal set of data over a critical transition time, allowing an in-depth analysis of students navigating their journeys. Future research might address these issues of sample size and participant openness either by comparing findings across multiple cohorts of students engaging in group reflection or by increasing participant numbers. Since our conceptual framework is based on just 12 participants, future research might focus on examining whether the conceptual framework is a robust, applicable, and generalizable approach to understanding the process of PIF.
Another potential limitation of this study is the influence the group facilitators may have had on student narratives and reflections. The GRAPHiC course was designed to empower students to engage in the hidden curriculum through a 4-step approach (described above) with little interference from facilitators—except to support students as they considered their medical school experiences. In the present study, we conducted a post hoc analysis of students’ PIF; therefore, we assumed that facilitators’ responses did not influence the GRAPHiC discussions of identity formation. However, instructor presence undoubtedly shaped the groups’ discussions, and future research might examine how peer-led groups engage in reflection differently from educator-led groups.
Our research approach supported our understanding of when, how, and why students took up opportunities to reflect on, and negotiate, their emerging professional identities. Our analysis produced a conceptual framework that could be used in several ways. As shown here, the conceptual framework is helpful for understanding the complex concept of PIF by allowing researchers to explore different aspects of students’ reflections about their journeys. Specifically, the concept of catalyst is a novel way of looking at how students use experiences, conversations, reflections, etc., to spark their own process of, and reflection on, identity transformation. Medical educators could also apply the notion of catalyst to proactively examine aspects of the curriculum and/or learning environment to understand what is sparking students to reflect on who they are and who they are becoming. More broadly, the conceptual framework allows medical educators to look critically at how students are taking the overwhelming amount of information being presented to them across learning environments (i.e., contexts) and keying in on certain aspects (i.e., focus) that help them navigate their journey into and through a community of practice.
We plan to use a grounded theory approach and our novel conceptual framework in future studies to examine how students relate context, focus, and catalyst to processing identity. Further, our novel conceptual framework might serve as a resource for other researchers who wish to interrogate the ways in which context, focus, catalyst, and process manifest in learners’ and others’ developing identities within medical education and other health disciplines. Understanding the potential influence of seemingly small moments across the medical education continuum and the reflective interplay between the individual and social aspects of PIF will help medical educators support students learning to become physicians.
The authors would like to acknowledge the medical student volunteers who participated in this study for their time, engagement in the process, and valuable reflections on their journeys. They would also like to thank Alyssa Rempel, Kelowna, British Columbia, Canada, for designing the graphic used in Figure 1.
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