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What Does Context Have to Do With Anything? A Study of Professional Identity Formation in Physician-Trainees Considered Underrepresented in Medicine

Wyatt, Tasha R. PhD; Rockich-Winston, Nicole MS, PharmD, EdS; Taylor, Taryn R. MD, MEd; White, DeJuan MD

Author Information
doi: 10.1097/ACM.0000000000003192

Abstract

In medical education, research on professional identity formation has largely ignored how elements such as race, ethnicity, and the larger sociohistorical context work to shape medical students’ professional identity.1,2 This is particularly problematic for physicians considered underrepresented in medicine (URM), a designation made by the Association of American of Medical Colleges for individuals whose ethno-racial background is incommensurate relative to their numbers in the general population (e.g., African Americans, Latino/as, Native Americans, Native Alaskans, Native Hawaiians).3 Individuals from these communities have most likely experienced a lifetime of racism and discrimination as a result of ongoing political, social, historical, environmental, and cultural events that directly and indirectly influence these communities.4 Medical education research has yet to consider how these elements interface with and shape medical students’ professional identity, and as a result may be missing important opportunities to support URM medical students in their development as physicians.

We were interested in examining how African American/black medical students, one subset of those who are considered URM, engaged in identity negotiation5 as they constructed a professional identity. Drawing on research in social and organizational psychology that demonstrates how minoritized professionals construct their professional identities in ways that are different than other racial groups,6 we assert that all identity, including a professional identity, is a negotiated process between individuals and those in the community they aim to join.5 However, unlike other physicians, URM physicians—who are minoritized because their race, ethnicity, and culture are consistently compared to the relative prestige of white society7—must attend to larger sociohistorical contexts of racism and discrimination in the process of negotiating their professional identity. In doing so, they bear another form of “minority tax”—additional responsibilities, burdens, and inequities8 that, to our knowledge, have yet to be considered in the literature on professional identity formation. This study considered how URM students negotiated their professional identity given the unfavorable sociohistorical context surrounding minoritized individuals. (We use the term “minoritized” to mean “individuals who self-identified with ethnic/racial groups that have historically suffered systematic oppression.”9)

Background

Research on the formation of professional identity in medical education is concerned with the socialization process that teaches trainees how to think, act, and feel like a doctor.10 This process is concerned with individuals’ self-representations as they undergo the internalization of the profession’s characteristics, values, and norms.11 Early theoretical models guiding such research described physicians’ static traits and societal roles,12 but more recent models highlight the social construction of meaning13 as trainees acquire the skills, knowledge, and behaviors expected of those who practice medicine.14 Although this basic socialization process is widely accepted in medical education, Chow and colleagues15 argue that the theoretical models governing formation of professional identity assume physicians are white, non-Latino men16 and that physicians with minoritized identities have more to negotiate in the integration of their social and professional identities.15 Individuals from minoritized groups (i.e., URM physicians) are relatively fewer in number and are linked by historical systematic oppression.9

One potential reason race/ethnicity has not been well studied in professional identity formation research is because much of the work tends to occur in concrete contexts, including classrooms,17,18 workplaces,19 virtual spaces,20 and specific disciplines.21 These contexts are methodologically useful because researchers are afforded opportunities to draw manageable boundaries around a complex topic. At the same time, concrete contexts may not be broad enough to study how larger social, political, and historical issues may be influencing students’ professional identities. Largely overlooked in such research are sociohistorical contexts that exist within and beyond concrete contexts.22 Sociohistorical contexts influence social process and outcomes even though they are invisible.23 For example, when physicians noted a rise in obesity among African Americans, food deserts within low-income neighborhoods were implicated,24 which in themselves can be traced back to historical housing practices that discriminated against African Americans.25 Therefore, when obesity is examined in isolation, the larger sociohistorical context of racism in the United States remains invisible.

These larger contexts are difficult to include in research; however, recent work demonstrates that they have significant influence on medical students’ professional identity formation26,27 as well as the identities of other professionals. Extant research shows minoritized professionals are often unable to enjoy the benefits of being a professional28 because unlike the prestige and privilege afforded to whites,29 society has difficulty viewing minorities as capable of simultaneously being both a minority and a professional. For many minorities, this experience results in “double consciousness,”30 a psychosocial experience described as having to see oneself and the world through the eyes of another (i.e., the dominant group). Double consciousness produces internal conflict and one’s identity feels divided without the possibility of unification. Feelings of dissidence arise because minoritized individuals’ professional identity is deeply embedded in their personal identity.31

Individuals who attempt to suppress their racial identity in favor of another identity are often left feeling further splintered.32 Rather, the task for minoritized professionals is to merge older selves (i.e., racial identity) with newer selves (i.e., professional identity) into an integrated whole,33 a process that relies somewhat on the professional community to recognize and support the students’ older and newer versions of themselves. Integration is conceptualized as a successful union of racial and professional identity and is considered an important characteristic of successful professionals.6

The purpose of this study was to examine how URM students took active steps to negotiate their professional identity, considering the larger sociohistorical context surrounding minoritized individuals. Understanding these nuances in URM students’ negotiation process of a professional identity will better inform medical schools interested in supporting the development of URM physicians.

Method

For this study, we employed a constructivist grounded theory34 approach to data collection, analysis, and interpretation. In this approach, the researcher rejects an objective or positivist stance in the research process in favor of a collaborative process with participants. Additionally, researchers rely on their collective personal and professional experience to interpret data.35 We collected and analyzed data iteratively to inform the research process, especially during the process of theoretical sampling and pursuit of additional lines of inquiry.

Participants were 14 black/African American students (2 male, 12 female) from 2 Southeastern medical schools, the Medical College of Georgia at Augusta University and Emory University College of Medicine. We used the terms “black” and “African American” interchangeably to reflect students’ self-referencing practice. Participants were recruited through a combination of researchers’ and students’ personal contacts including presentations made at local student organizations, personal email invitations to former students, and the snowball method in which participants recommend other potential participants in their personal/professional networks.36 Nine of the students were in their second year, 5 in their third year, and 4 in their fourth year. Two seasoned qualitative researchers (T.R.W. and N.R.-W.) who study the intersection of race/ethnicity/culture in health professions’ education37 conducted 45- to 60-minute semistructured interviews38 that explored students’ experiences as a URM medical student with particular attention on moments when they perceived their race/ethnicity was salient. Sample questions included “Describe a moment in your educational or clinical training when you perceived your race/ethnicity to be important” and “in what ways would you practice medicine differently if you weren’t a minority?” (The full set of interview questions is available in Supplemental Digital Appendix 1, at http://links.lww.com/ACADMED/A801.) Data from a pilot study exploring the personal and cultural assets of minoritized and rural students at the Medical College of Georgia39 had already established that URM students’ racial identity was tied to their professional identity. Therefore, we designed interview questions to help students identify where and how their race/ethnicity intersected with their experience in medicine. We collected and analyzed data from September 2018 to April 2019.

Each interview was transcribed and initially analyzed for causes, consequences, and conditions.38 We then discussed the interviews at length to understand when, why, and how students’ race/ethnicity was experienced as prominent. This first level of analysis alerted us to the larger sociohistorical context URM students were monitoring as they navigated medical school. An example of the level of analysis is a scenario such as this: a URM student forgot to wear his ID (condition influencing the phenomena), was questioned about his credentials (cause of the phenomena), and subsequently became hyperaware of his race/ethnicity (consequence of the phenomena).

Once we documented the sociohistorical context as relevant, our recruitment strategies continuously shifted to include URM students whose experiences differed from those represented in the data set. Given that this study of URM students sits within a larger study on the professional identity of URM physicians funded as a result of the pilot study data, by the 10th student interview, we had also heard similar stories from 28 other URM physicians, which supported the emergent findings in student interviews. To ensure saturation, in the 10th student interview, we began presenting students with a summary of the emerging findings from the larger study and invited them to comment on our evolving interpretation of the findings. Participant recruitment ceased when code saturation (“heard it all”) and meaning saturation (“understand it all”)40 were confirmed by our research team and participants, yielding a final count of 14 student participants.

Our ongoing discussions were an important aspect of the initial analytical process in which we used our collective background knowledge and experiences to make important theoretical and conceptual connections within the data. The lead researcher (T.R.W.) grew up in Hawai‘i, a postcolonial context that is keenly aware of hegemonic practices that continue to shape the local culture.41–43 Her experience has afforded her the opportunity to develop expertise in supporting indigenous communities searching for educational self-determination,44 and identification of the unarticulated ways power and privilege work to maintain the status quo.45 The other researchers are URM physicians (T.R.T., D.W.) and health science professionals (N.R.-W.) who help students navigate medicine as minoritized individuals. As a collective, we attempted to divulge and track our assumptions, yet we acknowledge that these ways of seeing and thinking may have influenced the study in ways that we could not possibly know.

To elevate the analysis, we applied Swann’s concept of identity negotiation5 as an analytical lens, which allows for the inclusion of individual and context-level data. Identity negotiation describes how individuals negotiate their identity using self-conceptions and the reaction of others in the construction of a new identity. Through this lens, individuals are seen as displaying identity cues and interaction strategies5 that attempt to bring the community’s perception in alignment with how individuals see themselves.

Identity cues are indirect forms of negotiation, such as physical appearance, body posture, titles, occupational labels, and so forth. Interaction strategies are direct actions individuals take to elicit favorable or desired responses. Identity cues and strategies are positioned as the tools URM students use to signal their professional and racial identity within the negative sociohistorical context surrounding URM physicians.

We analyzed all data using Dedoose, version 8.0.35, a web application for managing, analyzing, and presenting qualitative and mixed methods research data (SocioCultural Research Consultants, LLC, Los Angeles, California). This multi-institutional study was approved by the Medical College of Georgia at Augusta University’s institutional review board.

Results

Our analysis of participant interviews indicates that URM students were aware of the negative stereotypes ascribed to black individuals and the potential for the community to view them in this damaging and prejudicial way. In their desire to be perceived as both black and a physician, students went to great lengths to communicate and negotiate their identity as racialized professionals. The most significant opportunity for merging identities was when students mentored other African Americans interested in practicing medicine. These opportunities afforded them with moments to experience being black and representative of the profession. Additional opportunities for identity merging included being mentored by non-URM physicians. These relationships represented acknowledgment that students could be both black and accepted in the medical community and that their identity cues and strategies were successful in communicating their racial and professional identities.

Dispelling stereotypes

All 14 medical students identified their race/ethnicity as “the most important thing” about them, underscoring the extent to which URM students identified with their racial identity even while pursuing professional training as a physician. However, students expressed that their desire to be viewed as both black and as a physician was wrought with challenges and required negotiation of their race/ethnicity within the medical community. In some cases, students felt they were only viewed as being black and in other cases, students’ ethnicity was overlooked in favor of their role as a student. One student expressed the challenge this way:

You don’t want your race and ethnicity to be the most salient thing that [others] interact with. You want [others] to be interacting with you also as somebody who wants to join the profession. (Student 8)

They indicated the recognition of both their identities was important because, as one student explained:

[Our race] kind of makes us who we are, and I never want to feel like those parts of me are being like shoved under the rug. (Student 5)

However, in the process of creating a professional identity and integrating it with their racial identity, students felt the larger sociohistorical context often cast them in negative light. Specifically, URM students perceived that the community held negative views of them, which forced them to consider how they were being perceived. One student observed:

As a black person, there’s so many things that are being said about us on the news that is being portrayed in a negative way. You sit in the same seat as somebody else, and you have to work twice as hard to take those stereotypes away…. Whatever stereotype they have about that skin color is already portrayed on me before I say anything. (Student 1)

Students often made personal references to this larger sociohistorical context of discrimination, while many others referenced the Tuskegee experiments46 and the use of Henrietta Lack’s cancer cells47 in research. These comments indicate students’ awareness of the sociohistorical context surrounding African Americans and the need to consider themselves from an outsiders’ perspective.

To manage the community’s perceptions, students employed several identity cues to help them look and act the part of a physician. These physical cues were intentionally used to defuse negative attributes created by the larger sociohistorical context. For example, students discussed changing their clothes, hair, makeup, and other aspects of their physical presentation to not invoke what one student described as the community’s “automatic assumptions.” Many wore their medical student ID in an easily accessible place or went to great lengths to manage others’ perceptions of their belongingness in the profession. One student described this effort:

Everybody deals with the same thing…. Let me control my tone. Let me make sure I don’t have too many inflections…. I may not move my head too much as I talk. I don’t want people to assume that I’m this type of person when I’m not. (Student 5)

Employment of identity cues afforded students opportunities to influence others’ perceptions and shift the community’s vision to how students wanted to be perceived—as both black and a professional. Monitoring others’ perception was critical, and students were aware their peers may not have the same burden, as one student stated:

I realized that human perception is everything…. How they see you matters. I think if I was amongst the majority, I may not care as much. Hopefully, that shapes their opinion of me. (Student 4)

Although students believed their employment of these cues were successful, they came at a mental and emotional cost. One student described it as a “gigantic mental burden … that can feel both isolating and exhausting” (Student 10). Yet, without their employment, students felt they would be viewed negatively by the medical community.

Engendering positive perceptions

While identity cues were primarily used to dispel negative stereotypes, using interaction strategies with the African American community was considered a safe place to begin integrating their identities. Specifically, students described “giving back to their community” as an important expression of their integrated racial and professional identity. For example, many students held leadership positions in medical student organizations, provided medical school admission preparation sessions for undergraduates, and tutored students in high school math. Although these extracurricular activities benefitted their ethno-racial community, students thought of them as an expression of their professional identity, as this student explained:

Being a leader [in the black community] is part of my professional identity, which has been developed through medical school. (Student 5)

Assisting the next generation of black physicians provided an avenue for students to be both black and a physician in a way that did not rely on the community’s recognition of this integrated identity. In other words, “giving back” as a future black physician momentarily circumvented the need for students to consider the medical community’s perceptions of them.

While students pursued these opportunities to mentor other future black physicians, being a recipient of mentorship was also significant. Being mentored translated into acceptance in the community and symbolized that students’ use of identity cues and negotiation strategies were successful in shaping the community’s perceptions. Many described initially reaching out only to other black physicians because of the physicians’ previous success in navigating the sociohistorical culture of medicine. These relationships were often the first ones they pursued because black physicians were socially and culturally familiar. As one student noted, “They look like me, and that’s what I was used to. That’s what made me feel comfortable” (Student 4). However, mentors did not have to be black, and in many cases non-URM physicians could have greater professional influence. One student explained, “They can be African American or not, but having an ally or a mentor who has gone through what you’ve gone through [is helpful]” (Student 7). In fact, students described being mentored by white men and women as being particularly helpful because they represented the ethno-racial majority in medicine and thus provided an avenue into a community that had previously excluded them.

However, these 2 opportunities were not enough for students to overlook their feelings of futility when the medical community did not recognize major events in the black community. In these moments, such as when their schools were silent on topics related to police shootings of unarmed black men, their racial identity felt invisible. Their lack of acknowledgment created feelings of separation between students’ racial and professional identity, and students expressed that the medical community needs to understand how these events shape them as physicians. These events represent the larger sociohistorical context that African Americans navigate on a day-to-day basis. As one student explained:

[We need] the space to talk about current events that are happening in the black community. When your [medical] school recognizes it, you just feel like they’re a part of you and you’re a part of them. (Student 5)

Feelings of belongingness and recognition were seen as vital to students’ ability to embrace both black and physician professional identities. When students were unable to elicit a desired response from a community, they were left feeling splintered and without the ability to communicate the importance of their racial identity to their professional community.

Discussion

This study demonstrates that those URM students whom we interviewed negotiated invisible forces that shaped and influenced their professional identity in ways that have not been accounted for previously in professional identity formation research. Earlier studies have demonstrated that URM physicians feel invisible and isolated48,49 and experience a general lack of immediate belongingness to the medical profession. Previous work has also demonstrated that URM physicians experience the effect of racism, discrimination, and inequity.48,50 However, to our knowledge, the effect of these forces has not been included in research on professional identity formation, even though a modicum of studies have raised these issues.1,2,15,51

In this study, students actively negotiated a professional identity by employing identity cues and interaction strategies to bring the medical community’s perceptions into alignment with how they viewed themselves, even as their identities were in flux. They intentionally presented themselves in ways that would garner acceptance from the medical community and engaged in activities that afforded them opportunities to integrate their racial and professional identities. Clearly, the creation of a professional identity requires all students to negotiate an earlier identity16; however, professional identity formation research may have disregarded the significance of the sociohistorical context because early writings on the socialization of medical students were written at a time when the medical profession was primarily white and male.52,53 The timing of these writings may have limited researchers’ ability to consider larger, invisible influences on students’ professional development, such as race/ethnicity and the larger sociohistorical context.54 Regardless, this study demonstrates that the larger sociohistorical context must be taken into consideration in the study of professional identity formation, especially with regard to URM physicians.

Implications

Three important implications result from our findings. First, researchers interested in supporting URM students must draw from work in other fields to inform their work, particularly work that examines the experiences of minoritized individuals within larger sociohistorical contexts. We suggest medical education researchers incorporate tenets of postcolonial theory,45,55,56 which has potential in framing ways to interrogate power structures and systems of oppression within our medical education system. By failing to consider URM physicians in a sociohistorical context, researchers lose the ability to appreciate the tension these physicians experience in creating their professional identity and the work they do to integrate themselves.15 By continuing to study medical students as a singular group, researchers erase the tensions students experience as a result of their social, cultural, historical, political, and racial differences. The potential consequence of such omissions is the reproduction of racial inequalities in medical education.54

Second, those URM students we interviewed integrated their racial and professional identities through participating in what is known as “racial uplift,”57,58 a term describing how African Americans repay their community for the support they received in pursuing their educational and professional goals. Many minoritized professionals have discussed this as an obligation once they have achieved a modicum of success,50 but this phenomenon has yet to be explored in the context of a developing professional identity for URM physicians. Our data demonstrate that racial uplift allowed participating URM physicians to begin integrating their racial and professional identities while they continued to negotiate the medical community’s negative perception of African Americans. We recommend exploring the concept of racial uplift, which provides a conceptually rich opportunity for further research.

Third, our findings show that students’ struggle to integrate their racial and professional selves was greatly facilitated when they received mentorship. Previous work has shown that URM physicians view mentorship and role models as crucial for their success,59,60 in part because mentors help them feel that they belong.50 However, at present, there are not enough URM physicians available to mentor URM students, which is the typical recommendation arising out of research on issues of diversity.61 Further, the responsibility to mentor URM students should not be instituted as another form of a minority tax on URM physicians who likely already have more burden than necessary.8 We suggest developing robust training programs for non-URM physicians to learn how to mentor URM students, a practical suggestion also made by others.62 Previous work demonstrates that even though cross-cultural differences can be problematic in mentoring relationships, what is most important is that students are engaged in a supportive relationship.63 These programs should help non-URM physicians understand the larger sociohistorical context surrounding URM students, how students actively negotiate their professional identities as minoritized individuals, and specifically target ways in which mentors can support students in the integration of their racial and professional identities.

Limitations

There are several limitations to our study. First, although we intentionally pursued URM students with different experiences, ultimately, we used our personal and professional networks for recruitment, and this may have influenced the data set. Additionally, those of us conducting the interviews were white nonphysicians, which may have influenced students’ willingness to share details of their experiences. We tried to mitigate this limitation by affirming our interest in supporting URM physicians and relying on the URM physicians’ experiences to guide the analysis; however, some participants may have perceived our affiliation to be primarily with the dominant ethno-racial group and protected themselves from revealing other identity negotiation cues and strategies not reported in our findings.

Finally, this study was conducted in the American South, which is a well-defined geographic area with a sociohistorical context that is well known for its racial tension, strife, and embattlement.30 Historical research indicates that many of these issues can be traced back to colonial English settlers who brought structures of inequity with them,64 which begs the question of how sociohistorical context should be defined within research. How far back does a medical education researcher go in their definition of context?65 The question of boundaries is messy, and many disciplines will assert their expert opinion. We suggest this point be given further consideration and that future research incorporate this methodological consideration in the continued exploration of professional identity formation in URM physicians.

Conclusions

The concept of professional identity formation has begun to transform the way medical educators approach both undergraduate and graduate medical education. As research continues, the voices and experiences of URM physicians and physicians-in-training deserve greater attention and recognition. Considering the larger sociohistorical contexts is crucial to fully elucidating the complex process of formation of professional identity across the careers of physicians. Faculty development and targeted mentoring may provide the fundamental support needed.

Acknowledgments:

The authors would like to thank participating students for their candid discussions on race/ethnicity and its intersection with medical education.

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