Professional identity formation is a developmental process whereby the characteristics, values, and norms of the profession are internalized as medical students and residents learn to think, act, and feel like physicians.1,2 Although the concept of professional identity formation in medicine is not new, it has become an important area of inquiry since the 2010 Carnegie Foundation report highlighted a lack of clarity in, and erosion of, professional values in medical education.3 The report recommended that medical education address this problem by placing an increased focus on supporting learners in forming a professional identity that is aligned with the accepted norms and values of the profession.3
Much of the literature that focuses on the professional identity formation of learners draws on developmental and social psychology theory.1,2,4,5 Empirical studies have explored the perceptions and experiences of medical students and, to a lesser degree, residents, seeking to understand influences on this developmental process.6–18 This literature shows that students enter medical school with various expectations of what it means to be a doctor and that their socialization process is influenced by prior experiences and preexisting identities.7–9 During medical school, factors internal to the curriculum (e.g., early patient exposure, formal teaching of professionalism, cadaveric dissection, experiences with death and dying)7,10–13 and external to medical school (e.g., societal expectations, life experiences)7 interact with preexisting identities to shape the development of a professional identity through a process of socialization.7–13 Medical students seem to begin to feel most like a physician during clinical clerkships,14–16 a time when they are more involved in the activities of the profession (e.g., patient contact) and become increasingly socially isolated from those outside of the profession.14 During clinical clerkship, medical students report that clinical teachers exert an important influence on their identity formation through role modeling, mentoring, formal and informal teaching, assessment, feedback, and interpersonal interactions.14–18 These same influences appear to continue to play a critical role in residency.6
Although several studies describe how medical students and residents perceive clinical teachers as essential to their identity development, to our knowledge, there are no studies exploring how clinical teachers perceive their role in that regard or if they are aware of their potential influence. Similar to how studies of clinical teachers’ perceptions of themselves as role models helped uncover strategies to improve their role modeling,19 we believe that understanding how clinical teachers perceive their role in supporting the professional identity formation of learners will help identify strategies to help them become more effective at doing so. This study aimed to answer the following research question: How do clinical teachers perceive their influence on the professional identity formation of their learners? A secondary research question, focusing on how clinical teachers conceptualize their own professional identity and its formation, was also posed to facilitate the answering of our primary question.
Method
Study design and theoretical framework
Our research design was qualitative description.20 We used the communities of practice21 theory as a sensitizing framework for designing the interview guide and conducting the analysis. Lave and Wenger describe a community of practice as being composed of individuals who engage in a process of collective learning in a shared domain of human endeavor.21 This shared domain is the basis of the identity of its members. Membership implies a commitment to the domain as well as a shared competence that distinguishes members from outsiders. Individuals move from peripheral participation toward central membership in the community via socialization. Through socialization, they acquire the identity of a community member.21 Role modeling, mentoring, feedback, and informal teaching are all thought to play a role in the socialization of medical students and residents,5 making communities of practice a useful lens with which to explore the potential influences of clinical teachers on identity formation.22
Population and sampling
We conducted the study between March and October 2017. The study population consisted of clinical teachers engaged in the clinical supervision and teaching of medical students and residents. Our sample included active clinical teachers (e.g., mentors, program directors) at McGill University (Montreal, Quebec, Canada). It is important to note that professional identity formation is explicitly stated as a core objective of medical training at McGill University, thereby potentially increasing the likelihood that clinical teachers would be able to speak to this complex phenomenon. Participants were purposively selected with the goal of generating heterogeneity with regard to years of experience and specialty of practice to ensure that a variety of perspectives, covering the diversity of clinical teachers at McGill University, would be captured. There were no additional criteria for inclusion or exclusion.
After obtaining approval from McGill University’s institutional review board, the lead researcher (R.S.) contacted a curriculum lead within the Faculty of Medicine to request the circulation of a recruitment email to clinical teachers with significant involvement in both undergraduate and postgraduate medical education. Interested participants then contacted the lead researcher who responded with an email outlining the details of the study, an offer of a $25 gift card as compensation for their time, a copy of the consent form, and the email address of the research assistant with whom to confirm their participation.
Following this initial recruitment (n = 8), we used snowball sampling to increase the size of our sample.23 To do so, each recruited participant was asked to provide the contact information of 1 or 2 colleagues whom they thought might be interested in participating in the study. Based on the demographics of those already recruited, we specifically sought individuals who would add to the heterogeneity of the sample along the 2 previously specified demographic variables. The lead researcher, using the same recruitment procedures described above, contacted the clinical teachers recommended by their colleagues.
Data generation
Interviews were semistructured, using an interview guide that was developed based on the literature on professional identity formation,1–5 as well as the theory of communities of practice.21 For the interview guide, see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A881. Two members of the research team piloted the interview guide with clinical teachers in the Department of Pediatrics at McGill University. The guide, which was adapted over the course of the study, includes questions regarding clinical specialty and years of experience.
After obtaining informed consent, a research assistant conducted face-to-face interviews. Interviews, approximately 45 minutes in duration, were audiorecorded and transcribed by the research assistant.
Data analysis
Data analysis was iterative starting after the first 3 interviews were transcribed. All members of the interdisciplinary research team, which included 2 active clinical teachers (R.S. and J.D.B.), a social scientist with expertise in qualitative research (M.E.M.), and 3 scholars in the fields of professionalism and professional identity formation (Y.S., R.L.C., S.R.C.), participated in the analysis.
The lead researcher (R.S.) led the analysis. All members of the research team began by reviewing the first 3 transcripts. As we realized the initial interviews only addressed the primary research question on a superficial level, we adapted the interview guide to help participants better focus on identity formation. We did so by asking them to reflect on when and how they began to feel like physicians (i.e., the secondary research question) before having them reflect on the role they play in the identity formation of learners. As interviews progressed, all researchers continued to participate in the analysis in an iterative fashion until the team developed, by consensus, a coding scheme using both inductive (from the words of the participants) and deductive (based on the literature and our theoretical framework) codes. We finalized the coding scheme after the analysis of 9 transcripts. Subsequently, R.S. continued the analysis independently. We held meetings at regular intervals during which all team members discussed individual transcripts and, through consensus, advanced the cross-case analysis of themes.
After the analysis of the first 11 interviews, significant similarities were evident across the data. We then conducted 3 additional interviews and, following analysis, did not find any significant new ideas or concepts. Two additional participants had already been scheduled for interviews and so these were conducted, after which recruitment was put on hold. Analysis of these final transcripts again did not produce new results. Preliminary analysis was then presented to members of the McGill Institute for Health Sciences Education, which included 5 clinical teachers, for their feedback and to verify the trustworthiness24 of our analysis. The results resonated with members, and as a result, we ceased recruitment and deemed our analysis complete.
Results
Our study included 16 clinical teachers representing 8 specialties, with 6 participants belonging to surgical specialties (general surgery, pediatric surgery, obstetrics and gynecology), and 10 participants belonging to family medicine and medical specialties (palliative care, pediatrics, public health, neurology, gastroenterology). Our participants’ mean experience as clinical teachers was 18 years, with a range of 3 to 30 years.
We identified 4 main findings related to our primary and secondary research questions:
- Clinical teachers need prompting to be able to describe professional identity formation.
- A physician’s professional identity is integrated with a personal identity.
- A physician’s professional identity is forged through caring for patients.
- Clinical teachers believe they influence learners’ professional identity formation, but they cannot discern the magnitude of their influence.
Clinical teachers need prompting to be able to describe professional identity formation
The potential influence that clinical teachers have on the professional identity development of learners was difficult for our participants to articulate as they did not seem to possess a language with which to describe who physicians are and how their identities form. Instead, they initially described professional identity in terms of various behaviors that make up the intrinsic CanMEDS roles25 (e.g., health advocate, communicator, collaborator) and tended to conflate professional identity with professionalism.
I think part of [professional identity] is how you interact with your colleagues … how you make sure that a patient’s care continues even if you’re not there … professionalism is quite broad. (P8, public health, 16–20 years’ experience)
To help participants move beyond CanMEDS roles, professionalism, and lists of behaviors, we began asking clinical teachers to reflect on when they began to feel like physicians and to describe experiences that resulted in this feeling. With this prompting, clinical teachers described personal and meaningful experiences (e.g., relationships with mentors, patient encounters) and told stories about interactions that played important roles in shaping their sense of professional self.
I really enjoyed the general surgeons there. They were sort of the old crusty guys, but if you knew how to play the game, you could kind of crusty back at them a little bit, and they would tell stories [about] how things were great in the days of old. (P9, pediatric surgery, 21–25 years’ experience)
Now what was important was also what I felt was in line with my own values and the way that I wanted to be as a physician. “Ahhh, those are people who speak the same language!” (P6, palliative care, 21–25 years’ experience)
After reflecting on their own defining experiences, participants were able to speak more clearly and precisely about professional identity formation and perceptions of their influence on this process in their learners. They also commented on the value of the interview in getting them to think about themselves and ways in which they can better support learners in the future.
I’ve never thought of this before. Of course, interviews like this help with this. You helped the way I perceive … all these parts that come together because you are looking specifically, I think, … [at] this process of professionalization and enculturation. (P15, general surgery, 26–30 years’ experience)
A physician’s professional identity is integrated with a personal identity
The clinical teachers in this study described the formation of their own professional identity as consisting of learning knowledge, skills, attitudes, behaviors, and values deemed essential to being a physician. Many participants described this process as somewhat overwhelming and at times uncomfortable and at odds with how they viewed themselves as people.
So I think at the beginning … there was this overwhelming feeling that I need to acquire all of this knowledge and try not to lose myself in it. (P6, palliative care, 21–25 years’ experience)
Participants described feeling more secure in their professional selves as their careers progressed; this security allowed them to bring more of a personal identity to their work as physicians and more of a professional identity to their personal lives. Ultimately, the participants described a merging of their personal and professional selves into an integrated whole.
I don’t feel that I’m a different person with you and with my patients. The way I’m talking to you now is pretty much how I talk to my patients. I don’t have a different voice. (P1, pediatrics, 21–25 years’ experience)
The development of an integrated whole was not described as linear or discrete. Participants described it as tense and iterative, acknowledging that it would likely never be complete.
Why am I suddenly a doctor, all compassionate over here by the stretcher, [be]cause the patient [has] got a band around their wrist, but if they’re the same exact person around in the Metro [subway], I’m not walking past them like, “Ahh, what am I gonna do?” (P1, pediatrics, 21–25 years’ experience)
I think it’s still changing. To consider it as static, [or] reach[ing] a plateau, I don’t think that is the case. (P9, pediatric surgery, 21–25 years’ experience)
A physician’s professional identity is forged through caring for patients
Participants reported several important ingredients that enabled their professional identities to develop. They universally reported that the process began to solidify in the clinical years of medical school (i.e., clerkship). For many, this represented a first opportunity to be exposed to hospital culture and to apply the knowledge acquired in their preclinical years by actively participating in the care of patients.
[I began to feel like a physician] when I started to be exposed to the hospital culture, to patients, and had some knowledge that I could actually apply. (P7, public health, 1–5 years’ experience)
While participation in the clinical settings was felt to play a big role in identity formation during medical school, as participants gained more experience in the clinical environment and in caring for patients during their residencies, they were provided with increasing responsibility and autonomy. Participants reported that opportunities to be responsible for patient care were essential to their professional identity formation.
[Residency] was when it dawned on me that I had a real autonomy and responsibility towards my patients…. I think this responsibility changed my identity as a doctor as well. (P7, public health, 1–5 years’ experience)
Clinical teachers believe they influence professional identity formation, but they cannot discern the magnitude of their influence
After having reflected on their own professional identity and its development, participants identified several ways in which they thought they influenced the professional identity of their learners. Role modeling was described as one of the most important ways in which they believed they could exert an influence.
Even though they’re not saying anything, they’re still watching, so you have to think about that too I think, in terms of how you model your behavior. (P4, neurology, 11–15 years’ experience)
In addition, participants described engaging learners in conversations about challenging aspects of the profession as a way in which they could support professional identity development. These suggestions included debriefing, providing feedback, and reflecting with learners on their own challenges.
I like to talk to them about uncomfortable situations and see how they respond. And I think the more you talk about uncomfortable situations, the more they evolve into being more secure doctors. (P16, obstetrics and gynecology, 31–35 years’ experience)
For 7 participants, these challenging conversations included explicitly addressing the tensions and challenges involved in integrating personal and professional identities.
I think you try to teach them how complicated it is to be a good human being and a doctor at the same time. Not easy sometimes. Now if I can teach that, then I’m happy. (P16, obstetrics and gynecology, 31–35 years’ experience)
Finally, participants felt that they supported professional identity formation by providing learners with an appropriate balance of supervision and autonomy based on an assessment of the abilities and needs of the individual learner.
There [are] a small number of people who ride a bicycle very easily the first time they get pushed. There’s a lot of people who fall. And I think the idea for me is, give them a push. Some you’ll hang on to the seat a little bit; others you kind of let them roll out, but you know everybody could crash…. But I think [it’s about] figuring out where my person across the table is. (P9, pediatric surgery, 21–25 years’ experience)
Despite describing various ways in which they thought they were helping learners develop professional physician identities, the participants reported being uncertain of the magnitude of their impact. Many described hoping they were having an impact and expressed being unsure if they were any good at role modeling or supporting identity formation in other ways. As previously stated, several reflected they had not been aware of how they were influencing professional identity formation before participating in this study and reflected on how they might do it more explicitly moving forward.
But I think it’s a way of being clear about what’s important and more valued. How that affects their identity, I don’t know, like, you know, I can only guess. (P6, palliative care, 21–25 years’ experience)
Discussion
Our results illustrate several important aspects of how clinical teachers perceive professional identity formation. It is noteworthy that clinical teachers with active teaching roles in a faculty of medicine that explicitly lists supporting professional identity formation as a core objective required prompting to be able to discuss this phenomenon. Further, they needed to be encouraged to reflect on their own identity and its formation before they could describe how they support identity development in their learners. That said, once participants were focused on identity formation, they were able to provide valuable insights into this process. Clinical teachers in this study viewed their professional identities as integrated with their personal identities and saw caring for patients and participation in the clinical culture and environment as the elements most central to the formation of their professional identities. Participants described this integration occurring after a period of discomfort and as the result of a continually evolving process. Finally, clinical teachers were able to identify role modeling, engaging in difficult conversations, and providing graded autonomy as ways in which they could potentially influence the identity development of their learners.
The difficulty this experienced group of clinical teachers had in discussing their influence on professional identity formation was, at first glance, unexpected given the importance attributed to this topic by the Faculty of Medicine at McGill University. However, there are several possible explanations as to why their theoretical understanding of professional identity formation may have been difficult to translate into practice. For example, participants in this study expressed not being confident in the degree to which they influence identity formation. It is well described in the knowledge translation literature that self-efficacy, defined as people’s judgment of their own capabilities to attain the desired performance with the skills they possess,26 is an important factor in the degree to which knowledge is translated by clinicians.27 It may be that despite knowing the “cognitive base” of professional identity formation, our participants never formally translated this knowledge into their teaching practice due to a perceived lack of self-efficacy. It is also possible that professional identity formation, like many other aspects of teaching practice, is composed of tacit knowledge that is not readily accessed by the conscious mind.28 Similar to studies showing that clinical teachers tend to role model implicitly,29 clinical teachers may tend to be implicit rather than explicit when dealing with issues of professional identity as well. As such, their contribution to the identity formation of learners would be more unconscious and therefore difficult for them to describe in the context of a semistructured interview. In addition to the examples above, there are likely several other structural and cultural issues that influence the ability of physicians to translate their knowledge about professional identity formation into conscious and explicit practice. Gaining a better understanding of these influences remains an important area for future research.
Our participants expressed not having spent much time thinking about identity formation before participating in this study. However, reflection is known to play a critical role in the process of professional identity formation.30 In particular, reflection offers an explicit approach to the integration of personal beliefs, attitudes, and values with those of the profession.30,31 Engaging in a very brief period of reflection about their professional identity during our semistructured interview seemed to help our participants begin to articulate the ways in which they may be supporting the identity formation of learners as well as how they could do so more explicitly and effectively in the future. Therefore, we may first need to enable clinical teachers to engage in a personal reflection on identity formation for them to be able to successfully facilitate this reflective process in their learners.
Once prompted to reflect on and describe their own professional identities, our participants reported an initial period of discomfort. This was followed by an emergent understanding of the gradual and ongoing integration of their personal and professional identities into a unified sense of self. Experiences that participants felt to be important to this integration included exposure to hospital culture, the development of relationships with more senior clinicians, and the gradual entrustment given to them by their supervisors as they assumed increasing responsibility for patient care. While the process of professional identity formation has been studied from the perspective of learners, to our knowledge, this is the first study to provide empirical data on the perspectives of experienced clinicians. Nonetheless, our results are consistent with studies of medical students that suggest that they begin to feel most like physicians during clinical clerkships when they are most involved in caring for patients14–16 and that relationships with role models and mentors have an important influence on their identity formation.14–18 Our results also provide additional empirical support for the conceptual framework put forth by Cruess et al5 that describes how a medical student’s existing identities develop into personal and professional identities through socialization into a community of practice as a result of multiple factors including role models, clinical experiences, and learning environments. Therefore, our data support the use of communities of practice21 as a valuable lens with which to understand and study professional identity formation.
Clinical teachers in this study viewed role modeling, engaging learners in difficult conversations, and providing learners with graded autonomy as ways in which they could support identity formation. However, they were not confident in the magnitude of their influence. Literature on faculty development and professional identity formation has tended to focus on developing one’s identity as a teacher and helping teachers understand the importance of identity formation as an educational objective.32,33 However, faculty development programs that are aimed specifically at helping faculty support learners in their formation of a professional identity have not been well described.34 Based on experiences with faculty development in the area of professionalism, it has been proposed that faculty development programs in support of professional identity formation should focus on teaching professionalism, enhancing role modeling, promoting reflection, capitalizing on work-based learning, supporting communities of practice, and addressing organizational culture.34 Our results suggest that such programs would be of value. They also provide guidance on how faculty development programs could address reflection, role modeling, and work-based learning and help clinical teachers make the implicit explicit. We suggest the incorporation of experiences designed to engage faculty in reflections on their own identities and identity formation, to help faculty make their role modeling more explicit, to guide faculty on how to engage learners in challenging conversations about who they are and who they hope to become, and to support faculty in assessing learners so they will be able to provide their learners with appropriately graded supervision. The development and evaluation of such faculty development programs might represent an important contribution to the literature on professional identity formation.
Our results highlight several strategies that individual clinical teachers can use to help support learners in their formation of a professional identity. These include (1) reflecting on influences important to their own professional identity development in order to be able to incorporate those influences into their interactions with learners, (2) being aware that they are always role modeling for learners, (3) being explicit in their role modeling by deliberately focusing learners on the characteristics and/or values being modeled, (4) building relationships with learners and engaging them in meaningful conversations about challenging aspects of the profession and of their professional life, and (5) checking in with learners to ensure that the supervision provided is appropriate for their level of training and objectives.
Study limitations
Because this was a single-center study, the transferability of results may be limited. Second, we were limited to self-reported data, thereby restricting how richly we could theorize the phenomenon of interest (i.e., we lacked other methods, such as participant observation). Despite these limitations, our findings provide insights into future research directions that may help clinical teachers in supporting identity development in learners.
Conclusions
This study is the first to explore professional identity formation from the perspective of practicing clinicians. Our results suggest that helping clinical teachers reflect on their own identities and how they were formed is essential if they are going to be able to meaningfully support learners in their formation of a professional identity. Our results are also consistent with published studies of medical students and residents and demonstrate that clinical teachers can have an important influence on the professional identity formation of learners through role modeling in an explicit fashion, providing graded autonomy and responsibility and engaging learners in challenging conversations about what it is to be a physician. The 2010 Carnegie Foundation report called for an increased focus on professional identity formation. Giving clinical teachers the space and guidance to reflect, helping them make the implicit explicit, and supporting them in using their own experiences as learners to inform their teaching appear to be critical to achieving this goal.
Acknowledgments:
The authors wish to thank Ms. Anastasiya Voloshyn for her contribution as a research assistant on this study, the membership of the McGill University Institute of Health Sciences Education for their guidance in study design, and the McGill Osler Fellowship Planning Committee for helping to support this study.
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