Professional Identity Formation and Changing Roles

Role Changes and Professional Identity Formation

Professional identity formation is the process of developing an understanding of oneself as someone who thinks, acts, and feels like a physician while learning the characteristics, values, and norms of medicine. Moving from student to resident, and from resident to an independently practicing attending, changes both the tasks undertaken and the judgment and responsibility expected by others. When values related to patient care, personal life, and organizational practices clash, individuals reconsider the kind of physician they will become. Professional identity formation encompasses the experience of taking on new roles and aligning those roles with personal values while gaining recognition from others.

Current Status and Educational Methods of Professional Identity Formation Research

This literature review synthesized empirical and case studies on learners’ PIF to categorize educational activities, learning environments, and assessment approaches (Han & Suh, 2021). The research team searched Web of Science as of January 27, 2021, combining ‘professional identity formation’ and ‘medical education’ without time restrictions. Of the 282 documents retrieved, 124 remained after title review and 85 after abstract review. Full-text review excluded literature reviews, conceptual papers, and studies of faculty identity, leaving 37 articles on learners. The two researchers independently reviewed the literature, collaboratively coded educational methods, subjects, regions, and assessments, agreed on categories through 6 discussions, and synthesized recurring content and relationships through a further review of the literature. With some studies covering multiple regions, over 70% of the research concerned North America, 22% Western Europe, and 16% other regions. Apart from a study comparing the Netherlands and Taiwan, none of the empirical studies concerned East Asia. Qualitative studies, including mixed methods research, accounted for over 99%.

Studies that did not apply specific educational strategies accounted for 30%; among studies reporting educational activities, self-reflection accounted for 46%, arts subjects for 11%, and other activities for 22%, with some overlap. Self-reflection included recording experiences and emotions in writing or audio, as well as creating a portfolio before and after a clerkship and revisiting it at the end of the semester. In Guided reflection, learners were asked about their expectations of being a physician and experiences that changed their thinking, and they received descriptive feedback. In small-group co-reflection, they explored with peers and faculty the values and emotions underlying difficulties in patient care. Elective courses included reflection on the moral failures of medical professionals through ‘the Holocaust and medicine’, medical comics and the healer’s art elective, and activities depicting the current self and the ideal physician on the inside and outside of a mask. Experiences with patients included home visits by first-year students coached by senior students and long-term mentoring of patients with chronic diseases and their families. They also included participation in care while building ongoing relationships with community patients in longitudinal integrated clerkships. Cases involving residents centered on changes in decision-making authority, responsibility, and autonomy. Seminars, group coaching, and mentoring provided time to review personal values and professional expectations.

These experiences were interpreted through the perspectives of informal learning and the hidden curriculum. The account of the learning environment included identity changes arising incidentally through community service and patient care, as well as everyday conversations and feedback between educators and learners. Studies of reflective activities relied mainly on self-assessments and opinions. Changes expressed in writing, interviews, and discussions require consideration of how learners interpret their experiences alongside internal changes already underway. Socioeconomic background, race, and personal experiences also shape the process of becoming a physician. A socially and psychologically safe environment was proposed in which learners could share their backgrounds and emotional responses without fear of stigma. The review examined the challenges of applying behavior-centered competency assessments to long-term, nonlinear PIF. It also proposed observing and supporting the process of ‘becoming’ in light of individual backgrounds and professional interests.

Curricula and Faculty Roles Supporting Professionalism Education

The paper on the experience of Yonsei University College of Medicine examined the implementation of medical professionalism in the curriculum (An & Bu, 2012). Against the backdrop of the separation of drug prescribing and dispensing and medical strikes in 2000, followed by conflicts over the Diagnosis-Related Group system in 2012, the paper described the need for education that responds to societal demands and understands patients as individuals. The research team reviewed the development and operation of the Curriculum Development Project 2004 (CDP2004). It analyzed graduation surveys from the 2009–2012 academic years, surveys of first- and second-year medical students from 2009–2011, and open-ended responses about medicine and society from 252 enrolled students. Data from 2008–2012 also addressed graduates’ understanding of themselves as members of the medical profession. The curriculum introduced in 2004 centered on integrated education, self-directed learning, and medical humanities. It reduced large-group lectures from 2,531 hours to 1,440 hours and provided early clinical exposure and time for self-study through an Introduction to Clinical Medicine course. PBL was allocated 4 hours per week, totaling 80 hours. Electives in clinical and basic medicine began with 28 courses in 2004, with a median annual offering of 50 courses until 2011.

The educational objectives of medical humanities included a biopsychosocial understanding of patients, the ability to live with others, and the ability to recognize and solve problems. The pre-medical program used discussions of readings, reflective writing, and portfolios. From 2010, creative assignments and discussions were structured around birth, aging, illness, and death. In the medical program, a spiral curriculum was introduced in 2009, linking leadership, career selection, and an understanding of professionalism across academic years. Students positively evaluated opportunities to develop perspectives and understand medicine (48.1%), understand and reflect on themselves and others (39.3%), share experts’ visions and experiences (28.6%), and become aware of physicians’ roles and responsibilities (21.4%). Responses concerning the abstract nature of the content (42.1%), the appropriateness of assessment (32.9%), and overlapping topics or disconnected content (28.6%) informed coordination among instructors and improvements in assessment. Among 456 respondents to questions about WHO physician roles, 316 (69.3%) indicated that university education helped them acquire competencies as a care provider, 317 (69.5%) as a decision maker, and 227 (49.8%) as a community leader. Among the 2012 graduates, 84 (78.5%) agreed that economic compensation had declined and 74 (69.2%) that social respect had declined. Greater influence for medical professionals in health promotion and disease prevention was considered possible by 82 (76.6%).

These responses were interpreted as affirming responsibility toward patients and society while acknowledging a difficult medical environment. The repeated surveys and self-assessments provide data on students’ educational experiences and perceived competencies. Changes from admission to after graduation were identified as a focus for prospective observation. As the curriculum was implemented, the teaching load per faculty member for second-year medical students increased from 3.63 hours to 10.03 hours. Clinical and research workloads and unfamiliarity with the facilitator role made it difficult to recruit tutors even for PBL, which runs continuously for at least 4 weeks. These challenges were followed by the introduction of education-focused faculty and separate performance evaluation criteria in 2010 and the Medical Education Scholar Association program in 2011. Faculty development education credits were included in promotion and salary advancement requirements for the 2012 academic year. Role models, formative assessment, and ongoing faculty-student relationships were also discussed in examining the relationship between the formal and hidden curriculum.

Autonomy and Responsibility Experienced in Electives

AMEE Guide No. 88 synthesized prior literature and examples of elective provision to describe the educational possibilities of electives and principles for their implementation (Lumb & Murdoch-Eaton, 2014). The elective was described as a period in which students select and organize experiences according to their needs and interests. Five types were distinguished: global health, project activity, career choice, specified elective, and wellness elective. Learning encompassed clinical skills and task performance, as well as communicative learning aimed at understanding others’ emotions and needs. From the perspective of transformative learning, encounters with unfamiliar healthcare systems, cultures, and resource conditions offer opportunities to reflect on existing judgments. Common principles included clear educational objectives, pre-departure preparation, supervision by local and home institutions, projects useful to the host institution, and reflection before, during, and after the elective.

In the studies cited in the guide, approximately half of the students experienced illness during their electives. In one study, 77% of the illnesses reported involved self-limiting gastrointestinal symptoms. At the authors’ university, 1–2% returned early each year because of anxiety, stress, illness, or personal problems. The average elective cost in a 2009/10 British Medical Association survey was £2268. In Hong Kong, 2 students returned after 2 weeks citing gastrointestinal illness, without having reported rent increases and threats of violence. Interpreting the risks and benefits of remote electives requires consideration of local supervision, communication systems, and the conditions under which students can report difficulties, alongside the reported figures. The guide proposed arrangements linking pre-departure health and safety training and written risk assessments with confirmation of local support contacts, communication systems during the elective, and post-return counseling, medical care, and debriefing.

Judgments about roles became difficult when students were expected to perform procedures beyond their competence in under-resourced settings. A desire to help patients, the burden of requesting supervision, and local staff expectations could all contribute to these situations. The guide proposed assessing competence and available supervision and negotiating roles. Cooperation between institutions also took account of the host institution’s supervisory burden and the benefit to the community. For post-return debriefing, students were encouraged to revisit their thoughts, actions, emotions, and unintended consequences with peers and faculty. Time to share recollections immediately after return was distinguished from time to interpret experiences weeks later.

How Residents Handle Identity Conflicts

A study of residents’ identity work examined the conflicts individuals experience and how they respond while internalizing the norms of medicine (Sawatsky et al., 2024). The research team used maximum variation sampling and reflexive thematic analysis informed by constructivism and symbolic interactionism. Participants included 7 residents in internal medicine, 3 in emergency medicine, and 2 in family medicine. Of these, 7 were from Mayo Clinic, 3 from the University of Washington, and 2 from Duke University. There were 10 women and 2 men. From July 2021 to June 2022, 12 participants took part in rich picture activities lasting up to 30 minutes and individual interviews lasting up to 60 minutes. The drawings prompted descriptions of experiences, while the analysis focused on interview transcripts. The research team collected and analyzed data concurrently, directly inviting 2 residents who showed no outward signs of identity conflict to explore experiences that differed from the emerging interpretations.

The analysis identified three themes: the weight of identity work, its isolating nature, and the process of navigating by conforming to or resisting socio-contextual currents. Residents experienced identity work as an additional burden alongside clinical care and learning. One account described questioning whether treatment had helped a patient even after successfully inserting a central venous catheter. Participants felt pressure to appear competent while still learning. They explained that although they could discuss clinical difficulties, they found it difficult to discuss feeling emotionally overwhelmed by patients. Supporters outside the workplace also struggled to understand professional identity conflicts, and residents sometimes felt alone in managing them. Feelings of isolation eased when female physicians recognized their care for patients or when a senior resident privately supported a junior resident struggling with an attending physician’s inappropriate behavior.

Participants adjusted their career paths or engaged in small acts of resistance as they negotiated differences between the physicians they aspired to be and the expectations of the training environment. Holding a pager for a colleague who had been unable to eat was one way of sustaining the forms of care and relationships they valued. Decisions to resist depended on the emotional energy and authority available that day. Accounts of specific conflicts were collected during the COVID-19 pandemic in the US training environment. The results show the meanings participants assigned to situations and responses, with limited insight into the frequency of conflicts or long-term changes. Reliance on individual reflection could place the burden of resolving conflicts on learners. Shared spaces for reflection within the curriculum and support from coaches and mentors were proposed.

Balancing Responsibility and Supervision Learned as a Junior Attending

A study of the Junior Attending (JA) role explored how residents in their fourth year of training or higher experienced working as an attending under supervision, in relation to the Transition to Practice (TTP) stage of Canada’s Competence by Design (Dunbar-Yaffe et al., 2022). The research team conducted a qualitative collective case study across 6 teaching hospitals affiliated with the University of Toronto, using a constructivist grounded theory approach to analysis. The two cases compared were the Most Responsible Physician (MRP) JA, who led a general internal medicine inpatient care team, and the Consultant JA, who supervised consultations and follow-up care in infectious diseases and rheumatology. From September 2017 to May 2020, 20 individuals were interviewed, including 9 supervising faculty, 8 individuals with JA experience, and 3 participants without experience in the JA role. Data collection and analysis proceeded concurrently, with line-by-line coding performed in NVivo 12.6.0. The research team reported reaching meaning saturation at the 18th interview.

The analysis identified three themes: balancing independence and supervisory feedback, the relationship between supervising faculty and JAs, and the legitimacy of the JA’s role within the medical team. Participants described the JA role as an opportunity to work almost autonomously while remaining able to seek a supervisor’s help. A supervising faculty member’s presence during rounds could reduce the team’s acceptance of the JA as the person responsible. Reviewing patients without other team members present allowed autonomy and feedback to coexist. Opportunities to make judgments, review them with a supervisor, and gain recognition as a leader from the team were central to the JA’s learning to assume responsibility in the role. Negotiating goals in advance, defining roles, understanding each other’s competencies, and establishing trust supported this relationship. Rapid access to the supervisor was necessary when patients deteriorated or communication became difficult. Participants explained that providing appropriate supervision and education required at least as much time and effort as working without a JA.

General internal medicine participants placed greater emphasis on non-medical competencies such as team management and learner supervision, while infectious diseases and rheumatology participants emphasized the development of medical expertise. The interpretation also considered how long participants had worked with complex cases in each specialty. Leadership roles could overlap with those of second- and third-year residents. Junior learners sometimes felt disadvantaged in obtaining evaluations, mentoring, and reference letters because they had less contact with faculty. Some participants described a hybrid arrangement in which faculty remained involved in education and independently assessed learners. The interviews involved medical specialties within a single university. The findings on confidence and managing uncertainty reflect participants’ perceptions of their experiences.

Reading notes

From an HRD perspective on workplace learning, assigned tasks and decision-making authority, relationships through which help is sought, time to review experiences, and organizational recognition of educational roles can be examined together. How the team received the JA’s judgments needs to be interpreted in light of the supervising faculty member’s presence or absence during rounds. Examining records of CDP2004 curriculum delivery alongside learners’ accounts can reveal how participation in faculty development and approaches to recognizing educational duties support learners’ role changes and assessment experiences.

References

• An, S., Bu, S. (2012). Reflection on the experience of medical professionalism education at Yonsei University College of Medicine. Korean Medical Education Review, 14(1), 25–36. https://doi.org/10.17496/kmer.2012.14.1.025
• Dunbar-Yaffe, R., Wu, P. E., Kay, T., Mylopoulos, M., McDonald-Blumer, H., Gold, W. L., & Stroud, L. (2022). Understanding the influence of the junior attending role on transition to practice: A qualitative study. Journal of Graduate Medical Education, 14(1), 89–98. https://doi.org/10.4300/JGME-D-21-00728.1
• Han, H., & Suh, B. (2021). Current status and directions of professional identity formation in medical education. Korean Medical Education Review, 23(2), 80–89. https://doi.org/10.17496/kmer.2021.23.2.80
• Lumb, A., & Murdoch-Eaton, D. (2014). Electives in undergraduate medical education: AMEE Guide No. 88. Medical Teacher, 36(7), 557–572. https://doi.org/10.3109/0142159X.2014.907887
• Sawatsky, A. P., Matchett, C. L., Hafferty, F. W., Cristancho, S., Bynum, W. E., IV, Ilgen, J. S., & Varpio, L. (2024). Identity work: A qualitative study of residents’ experiences navigating identity struggles. Perspectives on Medical Education, 13(1), 540–552. https://doi.org/10.5334/pme.1549