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Developing “A Way of Being”: Deliberate Approaches to Professional Identity Formation in Medical Education

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Developing “A Way of Being”: Deliberate Approaches to Professional Identity Formation in Medical Education Academic Psychiatry https://doi.org/10.1007/s40596-019-01048-4 IN DEPTH ARTICLE: COMMENTARY Developing “a Way of Being”: Deliberate Approaches to Professional Identity Formation in Medical Education Latha Chandran1 & Richard J. Iuli1 & Lisa Strano-Paul1 & Stephen G. Post 1 Received: 19 December 2018 /Accepted: 24 February 2019 # Academic Psychiatry 2019 Professional socialization and the development of reflec- Definitions of Professional Identity Formation tive capacity are critical elements that shape a medical trainee’s professional identity. A 2010 Carnegie In 1957, Merton stated that medical education should “shape Foundation Report argues that professional identity for- the novice into the effective practitioner of medicine, to give mation should be an important focus of medical educators him the best available knowledge and skills and to provide him and that identity transformation remains the highest with a professional identity so that he comes to think, act and purpose of medical education [1]. Education achieves this feel like a physician” [8]. Rabow focused on the moral conflicts highest purpose when a person develops new ways of that students will face in medical practice, suggesting that the thinkingandrelatingwithpeers[2]. Ultimately, the pro- goal of professional identity formation is to anchor foundational fessional ideal is to develop physicians who can bring principles in the trainee and prepare them to navigate such their “whole person to provide whole person care” [3]. inevitable conflicts in the future [9]. Jarvis-Selinger discusses An ideal professional identity embraces empathy, mindful professional identity formation as developmental and adaptive attention to patient care, integrity, self-awareness, team- processes at the individual and collective levels [10]. At the work, beneficence, respect, and equal regard for all, as individual level, professional identity formation involves well as an eagerness to learn, resilience, and attention to trainees’ psychological development. At the collective level, self-care. Professional identity formation has antecedents professional identity formation involves appropriate socializa- in the student’s life prior to matriculation into medical tion into the professional roles that allow for community par- school, but it is a lifelong endeavor, achieved through ticipation. Cruess, Cruess, Boudreau, Snell, and Steinert critical reflection and exposures to role models who “pass redefined professional identity formation as “a representation the torch” from generation to generation. Professional of self, achieved in stages over time during which the charac- identity formation is measured externally by reputation teristics, values, and norms of the medical profession are inter- for excellence among peers and patients. nalized, resulting in an individual thinking, acting, and feeling In this paper, we discuss how at Renaissance School like a physician” [11]. Holden views professional identity for- of Medicine at Stony Brook University we have inte- mation as a transformative journey that involves ongoing inte- grated evidence-based approaches to enhance profession- gration of the profession’s knowledge, skills, values, and be- al identity formation among our trainees and faculty. In haviors into one’s own individual identity [12]. a time of increasing burnout among physicians and trainees, we believe purposeful integration of such ap- proaches into an institution’s learning processes may enhance resilience and a sense of belonging and well- Identity Formation, Evolution, being within a community of practice [4–7]. and Integration As shown in Fig. 1, three types of identities—individual, re- lational, and collective—dynamically interact within a com- munity of practice to form a trainee’s professional identity * Richard J. Iuli [13]. Based on social development theory and situated learn- [email protected] ing theory, trainees enter medical school with an individual identity shaped by their genetic predisposition and past per- 1 Stony Brook University, Stony Brook, New York, NY, USA sonal experiences [14, 15]. Relational identity influences their Acad Psychiatry Fig. 1 The development of professional identity occurs through the dynamic interaction of individual, relational, and collective identities within a community of practice individual identity as they navigate relationships in social en- displayed by patients, peers, and superiors; complexities vironments. The medical profession’s collective identity, with of the healthcare system; curricular elements that focus on its explicit and implicit norms, hierarchies, values, and behav- professional ethics and enhance reflective capacity; pro- iors, heavily influences the dynamic evolution and molding of fessional symbols and rituals; and personal well-being, trainees’ professional identity. connectedness, and support of family and friends [19]. Professional socialization plays a key role in the During professional training, students learn how to deal transformation to a more mature personal and profes- with clinical uncertainty and moral ambiguity and how to sional identity. Participation in a community of practice, play their part in the community of practice. Emotional initially peripheral and tentative, progresses to full par- responses to personal experiences during professional so- ticipation through extensive social interactions, during cialization can range from detachment, cynicism, anxiety, which the individual’s identity aligns with the and stress on the one hand, to joy, meaning, and gratifi- community’s values and beliefs. Continuous professional cation on the other. Matured socialization is typically ac- identity formation is sustained not only by mentorship companied by an increasing sense of self-confidence and and self-reflection, but also by experiences that uphold competence. the best practices of the profession through negotiation, Role models and mentors are members of a community of rejection, acceptance, emulation, and compromise [9]. practice whom the student seeks to emulate in actions and These experiences may lead to “repression” of elements beliefs [10]. Through conscious observation and imitation of one’s individual identity, but throughout the develop- and powerful subconscious patterning of behavior, the learner mental process, an enduring core of personal values internalizes a model of professional identity. Although much remains [16]. has been written about the significant negative impact of a toxic work environment and negative role modeling on pro- fessional identity formation, a recent systematic review found The Significance of Professional Socialization that the overall impact of role models in professional identity formation is mostly powerful and positive [20]. Socialization has been defined as “the process by which a Clinical experiences with patients and families are funda- person learns to function within a particular society or mentally important in professional identity formation. Positive group by internalizing its values and norms” [17]. experiences build the trainee’s nascent sense of competence Whereas training results in new knowledge and skills, and self-confidence and can reinforce the values and behav- socialization develops identity: an “altered sense of self” iors expected in their professional role. Providing pedagogic [18]. Multiple factors influence professional socialization space for conscious reflection, writing, and discussion of clin- in medicine. The shaping influence of role models and ical experiences within mentor-guided circles of trust is fun- mentors occurs explicitly by observation of and reflection damental to socialization and professional identity formation. on a variety of clinical encounters and tacitly by way of Curricular opportunities for reflection, such as mentor- experiences that affect the learner more subtly (e.g., via facilitated discussion groups or narrative writing, enable the hidden curriculum). Influential factors include a sense learners to participate actively in the construction of their of security and trust in the learning environment; attitudes own professional identities [10, 21]. Acad Psychiatry Professionalism and Professional Identity space to enhance the professional identity formation of their Formation trainees. Wald describes three vital elements in profes- sional identity formation: reflection, relationships, and Professionalism and professional identity formation are not resilience [25]. the same thing, but they are bidirectional and considerably influence each other [22]. Professionalism is defined by the Reflection Sharing personal narratives in trusted mentor- set of values and virtues espoused by the profession including facilitated peer groups supports the social construction of pro- universally accepted core values such as competence, com- fessional identity. In such groups, trainees can compare their passion, and integrity. Professional identity formation is the own perspectives with those of their peers, reflect upon, and journey of assimilating individual identity into the profession- either accept or reject others’ ideas as they dynamically con- al ethos of the community of practice, thereby constructing a struct their professional identity. Wald depicts reflective ca- “fully integrated moral self” [23]. Professional identity does pacity as the roots of a tree that are fertilized by mentor feed- not develop in a linear fashion, nor is it monolithic. Sentinel back and exposure to the humanities.
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