Commentary
The Becoming: Students’ Reflections on the Process of Professional Identity Formation in Medical Education Joanna Sharpless, Nell Baldwin, Robert Cook, Aaron Kofman, Alessio Morley-Fletcher, MD, MMSc, Rebecca Slotkin, and Hedy S. Wald, PhD
Abstract Professional identity formation (PIF) within medical education is the multifaceted, individualized process through which students develop new ways of being in becoming physicians. Personal backgrounds, values, expectations, interests, goals, relationships, and role models can all influence PIF and may account for diversity of both experience and the active constructive process of professional formation. Guided reflection, including reflective writing, has been used to enhance awareness and meaning making within the PIF process for both students and medical educators
W
ithin medical education, professional identity formation (PIF) is the multifaceted process by which medical students transition from laypersons to physicians.1 To this process, students bring prior identities, ideas about physician role and image, and visions for their futures. They face the challenge of integrating identities and reconciling preconceived ideas about the physician role with the lived reality of medicine.2 Ultimately, the intention of both student and medical educator is to develop an identity consistent with the values and competencies of the medical profession.3 Although this may manifest as “professionalism,” or “ways of acting,”4,5 the more overarching PIF objective is developing new “ways of being.”6 The medical education literature reflects a growing number of inquiries Please see the end of this article for information about the authors. Correspondence should be addressed to Joanna Sharpless, Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI 02912; telephone: (301) 704-7498; e-mail: [email protected]. Acad Med. 2015;90:713–717. First published online April 15, 2015 doi: 10.1097/ACM.0000000000000729
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and to shed light on what aspects of medical education are most constructive for healthy PIF. Student voices about the PIF process now emerging in the literature are often considered and interpreted by medical educators within qualitative studies or in broad theoretical overviews of PIF. In this Commentary, the authors present a chorus of individual student voices from along the medical education trajectory. Medical students (years 1–4) and a first-year resident in pediatrics respond to a variety of questions based
into major influences on students’ constructive process of PIF and interest in implementing curricula to promote healthy PIF.1,7–11 Providing opportunities for students to engage in guided reflection on their critical formative experiences is one effective tool for helping learners use their experiences to construct meaning and clarify values within PIF,9,11–13 ultimately promoting a “self-sustaining pattern of a new way of being.”14 Rarely in the literature do we hear directly from learners at various stages of medical education, complementing more broad-based theoretical formulations or summaries of student perspectives. In this Commentary, we aimed to provide this type of first-person perspective about the PIF process. To achieve this, lead author J.S. (with author H.S.W. as faculty mentor) first conducted a literature review and used the results to develop questions based on key PIF themes. J.S. and H.S.W. then identified one student from each year at the Warren Alpert Medical School of Brown University and a resident from Massachusetts General Hospital–Harvard Medical School who had expressed interest in reflective learning and PIF. These learners were invited to join the author team and
on prevalent PIF themes extracted from the literature to reflect on their personal experiences of PIF. Topics queried included pretending in medical education, role of relationships, impact of formal and informal curricula on PIF (valuable aspects as well as suggestions for change), and navigating and developing interprofessional relationships and identities. This work aims to vividly illustrate the diverse and personal forces at play in individual students’ PIF processes and to encourage future pedagogic efforts supporting healthy, integrated PIF in medical education.
reflect on and respond via e-mail to PIF questions. Here, we present excerpts of these written reflections, edited and arranged for clarity and cohesion. This “chorus of voices” is not intended to be fully representative of all learners but is rather a snapshot of our lived experiences that may promote understanding PIF as both a personalized and socialized process. As a means of introduction, we provide background narrative about ourselves in Box 1. Selected responses from authors N.B., R.C., A.K., A.M.-F., and R.S. are provided for four questions (listed in detail in List 1), and each author’s level of study is indicated as follows: MS1 indicates first-year medical student; MS2, second-year medical student; MS3, third-year medical student; MS4, fourth-year medical student; and PGY1, postgraduate year 1. “Pretending” in Medical Education
Upon starting medical school, students are expected to immerse themselves in the values and behaviors consistent with physicianship.7 Often, this process requires that we “go through the motions” of being a physician before we
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Commentary
“imposter” illnesses, so any discomfort seems unwarranted.
Box 1 Background Information About the Authors Joanna Sharpless completed her undergraduate studies in English literature at Brown University, where she was a member of the Program in Liberal Medical Education, an eight-year combined BA/MD program. She recently completed a gap year doing medical research and writing for The Dr. Oz Show in New York City and plans to go into family medicine. She has particular interests in immigrant health and narrative medicine. Nell Baldwin was raised in Buffalo, New York, and Germany. She majored in environmental analysis at Pomona College in Claremont, California, then worked as a community organizer, farmer, and health educator doing addiction prevention work. Robert Cook completed English and philosophy majors at SUNY-Geneseo, then completed nursing school at the University of Massachusetts and worked as an emergency department nurse for several years. He plans to practice family medicine and is particularly interested in working to redesign primary care so that it can better serve the needs of the poor. Aaron Kofman studied international relations at Stanford University. He will be completing his residency in internal medicine at the University of California, San Diego, and is interested in HIV and infectious diseases. Alessio Morley-Fletcher was born and raised in Rome, Italy. He majored in history and philosophy and found his calling in medicine, specifically pediatrics. He earned his MD and MMSc at La Sapienza University of Rome before deciding to come to the United States to complete his clinical training at Massachusetts General Hospital–Harvard Medical School. He has strong interests in patient empowerment, team-building skills, and mind–body medicine. Rebecca Slotkin studied English literature and anthropology at Washington University in Saint Louis. She enjoys her work with the Physicians for Human Rights student group, the Quince literary review, and the medical education scholarly concentration. Hedy S. Wald is clinical associate professor of family medicine at the Warren Alpert Medical School of Brown University where she oversees the reflective writing curriculum in the family medicine clerkship. She obtained her PhD in clinical psychology from Yeshiva University and postdoctoral neuropsychology training from the Boston VA Hospital/Boston University School of Medicine. She provides interprofessional faculty development workshops internationally on using interactive reflective writing to foster reflective capacity (supporting professional identity formation) and resiliency in health care professions education and practice.
can fully embody this role. We considered Question 1 in the following responses. N.B. (MS1): Being a first-year medical student gives me latitude to admit ways in which I am an imposter. I am taught clinical skills, but have not yet learned
how the information I gather fits into diagnosis or treatment, or even what is relevant. When I prod standardized patients, I am often admonished to push harder, to “use a firmer touch.” To some degree, I fear hurting these patient actors—after all, I will not heal their
List 1 Questions Used to Prompt Written Reflections About Professional Identity Formation (PIF) From the Authors Question 1 Several authors have written about a stage of identity formation in which medical students feel like “imposters.”8,9 What role, if any, does “pretending” currently play in your professional life? If applicable, what have you done or what has allowed you to cross the line between “pretending” to be a medical professional and fully inhabiting your professional role? Question 2 What incidents or relationships during your medical education (whether in the context of your study/work or in your life outside of medical education) do you perceive as critical or meaning making for your PIF? Question 3 What formal or informal aspects, if any, of the curriculum provided at your medical school or in your residency program have you found to be particularly valuable in supporting your PIF and nurturing your personal growth? What, if anything, do you believe teachers or mentors could do differently in medical education to facilitate your process of PIF?
R.S. (MS2): First and second year of medical school, it seems our goal is pretense. We role-play with standardized patients, we dress up, and we fumble with our ophthalmoscopes. We wear our white coats, but we consciously do not yet inhabit the role they signify. As a second year, I feel more comfortable doing an interview and physical exam, but I am only just learning how to use this information to provide care. I am most aware of my pretenses when I inadvertently fool the hospital staff into thinking I have a role on the medical team that I do not yet know enough to inhabit—when I am asked to write orders or call consults. But, I admit I enjoy my imposter role: I am thrilled to look competent enough to be mistaken for part of the medical team and can enjoy my successful pretenses because the stakes and my responsibilities are still minimal. R.C. (MS3): We are apprentices, not yet masters. And like the sorcerer’s apprentice, it is expected that when we attempt to wear the “magic hat,” some havoc will ensue. The educational system acknowledges us as learners who need guidance if we are to fully develop our abilities, and in my experience, this offers some protection against self-doubt. Instead, a different kind of pretending plagues me: pretending that I am finished with the challenges of the apprenticeship process. I am tempted to escape the present moment (with its difficult lessons) and imagine that I have already passed through the fires of medical school and residency, and have emerged on the other side without needing to be burned and shaped by them. If I struggle with pretending, it is not so much with the notion of “fake it ‘til I make it,” for instructors reassure me that they do not expect perfection. Rather, I struggle with remaining present through this difficult process of PIF, so I can fully experience what it is like to be ignorant, even as I strive to gain knowledge.
Question 4 If relevant, how have your interactions with other health care professionals (nurses, therapists, nutritionists, pharmacists, etc.) during your training affected your understanding of your own professional identity? How, if at all, do you differentiate and/or reconcile your medical professional identity with an interprofessional identity?
A.K. (MS4): The imposter role gets progressively more difficult as I advance in medical school. In the first year, it is easy to hide behind a cloak of ignorance. By my fourth year, many seem to consider me a de facto physician, and seek my advice accordingly, even if I have been out of the clinical setting for months
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Commentary
interviewing for residency. Some degree of the “imposter” feeling will always be impossible to shake; no matter how many my qualifications, there is always someone who may know better. The fact that medicine is a field where we learn every day also means it is one where we are humbled every day. The Role of Relationships
Personal and professional relationships have been shown to have a significant, early impact on professional identity development in medical education.8,15 In Question 2, we explored which relationships are most influential and what aspects of professional identity they nurture. N.B. (MS1): For me, an important patient interaction has been following a pregnant woman through the Medical Students Outreach to Mothers-to-Be preclinical elective: talking with her over the phone, attending her prenatal visits, and being present at her baby’s birth. I hope to attend her postpartum visits, and to continue to follow her as her son grows up. I think this longitudinal relationship helps me imagine what it will be like to have patients of my own. R.S. (MS2): I have found an incredible group of peers who are passionate about areas of medicine I have come to value, including work with the Physicians for Human Rights student group and with HIV/HCV community testing and outreach. Specific activities and people within medical school that remind me why I decided to go into medicine not only motivate me to study the long hours necessary, but are also important clues to figuring out how I will practice medicine. A.K. (MS4): The two extremes of a physician—those who do things so well that I am inspired to emulate them, and those who take shortcuts, grow jaded, and care little about communication or the nuances of individualized patient care—are the relationships that are key to my PIF. Though I enjoy my encounters with the former far more than the latter, my PIF is as equally tied to the doctor I want to be as the one I do not want to be. A.M.-F. (PGY1): My own health and my family’s health have significantly influenced my professional identity. When I was younger, I suffered from
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moderate-to-severe asthma. That experience not only got me interested in understanding how my body works, but also helped me relate to others with chronic conditions. In addition, making some clinical findings that led to a diagnosis of spinal muscular atrophy in my niece was a life-changing experience for me and for my family. That family experience reminded me that textbooks can teach me how to diagnose problems, not necessarily how to handle them. I have come to realize that we may underestimate our patients’ resilience. After all, not everything that counts can be counted, an adage attributed to Einstein that I have found to be particularly true in pediatrics. The Impact of Formal and Informal Curricula on PIF
In addition to teaching students the knowledge and technical skills for professional competency, medical schools are increasingly implementing formal and informal interventions to cultivate students’ personal and professional growth. In Question 3, we explored what our medical schools do to support PIF and what they could possibly improve. N.B. (MS1): In small groups, we are often given readings designed to stimulate reflection about difficult, controversial topics that physicians may face. Though some of the readings assigned have been inspiring, others have literally standardized empathy into a checklist format. I take the tasks of learning and personal growth seriously and sometimes I am disappointed by the feeling that PIF is one more thing to check off the list. R.S. (MS2): Although we are trained to master multiple-choice pathology, I do not think this approach to teaching medicine parallels the practice of medicine. The community mentor site and mentor relationship give us a glimpse of what it means to inhabit the physician’s role in the clinical setting. This often gives the seemingly esoteric facts we learn in the classroom more meaning by placing them in the correct context. Similarly, the personal exploration of medicine through preclinical electives, research, and community outreach events helps shape the direction our medical education will take and nurtures our professional growth.
R.C. (MS3): Many of my instructors have not taught me what they think they are teaching me. Each instructor seems to approach the material through his or her own lenses and biases without a sense of a “common text” to which every doctor has been exposed. I would learn more if instructors would explain, not simply perform, their thought process to me and encourage me to develop my own approach to problems. For example, when I get stuck on a clinical question, I wish more instructors would prompt me with, “How are you trying to approach the question?” rather than waiting in silence before offering the answer. A.M.-F. (PGY1): My residency program just started a pilot program called Personal and Professional Development (PPD), which is run by attending physicians who share an interest in helping the new generation of doctors create a sense of community. Many times, I left those sessions amazed and humbled by how much I learned from listening to my cointerns, attendings, or invited guests discuss topics ranging from work–life balance, to medical mistakes, to poetry and narrative writing. I would advocate that we need more initiatives like PPD. Navigating and Developing Interprofessional Relationships and Identities
Learning to build and negotiate interprofessional relationships and distinguishing between an emerging interprofessional identity and physician identity can be challenging, especially at initial stages of medical education.16 When compared and contrasted either with our own prior professional roles, or the roles of other medical professionals, interprofessional interactions have the potential to illuminate our understanding of the physician role. We considered Question 4. N.B. (MS1): Before medical school, I worked for a clinical trial as a health educator, counseling patients using motivational interviewing (MI). As a student doctor, I rarely use my MI training during my patient interactions. I wonder if after we are officially taught MI skills for smoking cessation, I will feel like I am “allowed” to counsel my patients. I think I feel the need to shed my past professional identity as research
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Commentary
assistant/counselor/health educator in order to take on a new one. This is a strange realization because many of my professional role models are doctors who interpret their professional identity broadly—who are advocates, researchers, policy advisors, and clinicians. R.S. (MS2): This fall, we had an interprofessional workshop with students from a variety of health care professions including nursing, social work, physical therapy, and pharmacy. When we approached a complex patient case together, the other students clearly identified their roles—the pharmacist handled the medications, the social worker the living conditions, the nurse the glucometer, etc.—except for me. Maybe it was due to the specific case, but the role of the doctor ended up being everything and nothing. It was pulling all of the pieces and people together, but not necessarily performing any specific task or procedure. The workshop was a humbling and eye-opening experience. I had never considered how my medical degree might be understood on an interprofessional level and the leadership role I might be invited to play automatically. Right now, my interprofessional identity is something for my professional identity to aspire to and grow into. R.C. (MS3): As a former emergency department (ED) nurse, I know that the system we work in is stressful, filled with long hours of routine punctuated by periods of overwhelming chaos. Each profession—physicians, nurses, respiratory therapists, phlebotomists, certified nursing assistants, etc.—works with the others to try to manage those routines and to survive the chaos together. Add to this the goals of the patients we care for (which are not always directly aligned with those of our professional routines), and the system becomes incredibly complex. I want to continue to draw on my past experiences in the ED to help me navigate and negotiate multifaceted interprofessional relationships in the service of providing more integrated, optimal care for my patients. Discussion and Conclusions
The voices of this Commentary illustrate variations on the theme of an active, constructive process of PIF. These “snapshots” highlight various mentor,
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peer, interprofessional, family, and patient relationships as instrumental for our PIF process. Meaningful relationships with patients and mentors help us envision our future clinician roles, while peer relationships can help us strengthen shared interests and values that preceded medical school. We also appreciate the powerful impact of our own personal experiences within the health care system, which help us remain humble as we assume the provider role. Consequently, we encourage medical education models to provide guided opportunities to process and contextualize our experiences of patient care and self-care, both inside and outside the classroom. We also support efforts to design curricular innovations stimulating reflection-on-action17 and reflection-on-being11 alongside role models who appreciate the role of relationships in PIF and who are trained in effective small-group facilitation skills. The heterogeneity in our comments as linked to level of training underlines potential utility of developmental curricula within created “developmental space”18 tailored to the educational stage of the learner. Within such curricular efforts, guided reflection can be a mirror, revealing our professional transformation through the medical education process.19 Developing self-awareness of this evolving process may serve to crystallize elements of our professional identities and promote the evolution of others. We realize that even aspects of PIF perceived as difficult or challenging may become rewarding within the context of critical reflection. Grappling with the “imposter” experience, for example, can cultivate a sense of humility15 and promote self-awareness and reflective openness to others, potentially contributing to emotional resilience and well-being.11 Similarly, identity conflicts can be a source of “creative tension”2 as personal meets professional and/or one strives for an idealized professional self. As evolving professionals, we often confront new realities of medical practice that depart from our initial expectations, and must adapt and reconcile the imagined and lived versions of professional identity. For example, we note that confronting the limits of a physician’s knowledge and influence, although daunting, may motivate us to shift our focus away from knowing all the answers towards acquiring “cognitive tools” that allow us to search for answers (and recognize when answers
may be elusive) as well as “emotional tools” to help with tolerating ambiguity. In general, the process of negotiating such conflicts potentially spurs further identity development by encouraging us to question and at times reinforce core values and critical behaviors. In general, we gain insight into and assume more ownership over our professional lives within a developmental, integrative PIF process that includes recognizing our personal beliefs and values and committing to professional values and goals. All of this can support our career design and even specialty choice20 as we become more aware of authoring the story of our emerging professional selves. Hence, our presented Commentary may be regarded as a “microcosm” of the “macrocosm” of curricula-supported engaged reflection for the conscious development of professional identity.21 It is our hope that the presented “chorus” of student voices and similar future dialogue can help inform medical educators’ efforts to support students’ active PIF processes. Given that our identities prior to medical education significantly impact our PIF, further study of the PIF process and development of supportive curricula within premedical education may be useful. We also hope that students will become increasingly invested alongside medical educators in devising and implementing best practices to cultivate and assess progress toward healthy PIF. Inviting students to contribute ideas within medical education curriculum development and to participate directly in research into the PIF process may result in surprising and successful changes to how the PIF process is understood and promoted. Funding/Support: H.S. Wald is grateful for support from Brown University predoctoral training grant #D56HP2068. Other disclosures: None reported. Ethical approval: Reported as not applicable. J. Sharpless is a fourth-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island. N. Baldwin is a first-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island. R. Cook is a third-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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Commentary A. Kofman is a fourth-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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A. Morley-Fletcher is a first-year resident, Department of Pediatrics, Massachusetts General Hospital–Harvard Medical School, Boston, Massachusetts.
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R. Slotkin is a second-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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H.S. Wald is clinical associate professor of family medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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References 1 Holden M, Buck E, Clark M, Szauter K, Trumble J. Professional identity formation in medical education: The convergence of multiple domains. HEC Forum. 2012;24:245–255. 2 Monrouxe L. Negotiating professional identities: Dominant and contesting narratives in medical students’ longitudinal audio diaries. Curr Narrat. 2009;1:41–59. 3 Wald HS, Reis SP, Monroe AD, Borkan JM. “The loss of my elderly patient:” Interactive reflective writing to support medical students’ rites of passage. Med Teach. 2010;32:e178–e184. 4 Cohen J. Linking professionalism to humanism: What it means, why it matters. Acad Med. 2007;82:1029–1032. 5 Wilson I, Cowin LS, Johnson M, Young H. Professional identity in medical students:
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Pedagogical challenges to medical education. Teach Learn Med. 2013;25:369–373. Goldie J. The formation of professional identity in medical students: Considerations for educators. Med Teach. 2012;34:e641–e648. Boudreau JD, Cruess SR, Cruess RL. Physicianship: Educating for professionalism in the post-Flexnarian era. Perspect Biol Med. 2011;54:89–105. Cohen MJ, Kay A, Youakim JM, Balaicuis JM, Balacius JM. Identity transformation in medical students. Am J Psychoanal. 2009;69:43–52. Miller E, Balmer D, Hermann N, Graham G, Charon R. Sounding narrative medicine: Studying students’ professional identity development at Columbia University College of Physicians and Surgeons. Acad Med. 2014;89:335–342. Wong A, Trollope-Kumar K. Reflections: An inquiry into medical students’ professional identity formation. Med Educ. 2014;48:489–501. Wald HS, Anthony D, Hutchinson TA, Liben S, Smilovitch M, Donato AA. Professional identity formation in medical education for humanistic, resilient physicians: Pedagogic strategies for bridging theory to practice. Acad Med. 2015;90:753–760. Wald HS, Davis SW, Reis SP, Monroe AD, Borkan JM. Reflecting on reflections: Enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med. 2009;84:830–837. Reis SP, Wald HS, Monroe AD, Borkan JM. Begin the BEGAN (The Brown Educational Guide to the Analysis of Narrative)—a
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framework for enhancing educational impact of faculty feedback to students’ reflective writing. Patient Educ Couns. 2010;80:253–259. Haidet P. The profession of medicine and professionalism. Presented at: Kienle Symposium on Medical Humanities; May 25, 2014; Hershey, Penn. Coulehan J. On humility. Ann Intern Med. 2010;153:200–201. Khalili H, Orchard C, Laschinger HK, Farah R. An interprofessional socialization framework for developing an interprofessional identity among health professions students. J Interprof Care. 2013;27:448–453. Schon DA. Educating the Reflective Practitioner. San Francisco, Calif: JosseyBass; 1987. van der Zwet J, Zwietering PJ, Teunissen PW, van der Vleuten CP, Scherpbier AJ. Workplace learning from a socio-cultural perspective: Creating developmental space during the general practice clerkship. Adv Health Sci Educ Theory Pract. 2011;16:359–373. Wald HS. I’ve got mail. Fam Med. 2008;40:393–394. White M, Borges N, Geiger S. Perceptions of factors contributing to professional identity development and specialty choice: A survey of third- and fourth-year medical students. Behav Sci Med Educ. 2011;17:18–23. Ryynanen K. Constructing Physician’s Professional Identity—Explorations of Students’ Critical Experiences in Medical Education [doctoral dissertation]. 2001. http://herkules.oulu.fi/isbn9514265211/ isbn9514265211.pdf. Accessed February 17, 2015.
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The Becoming: Students’ Reflections on the Process of Professional Identity Formation in Medical Education Joanna Sharpless, Nell Baldwin, Robert Cook, Aaron Kofman, Alessio Morley-Fletcher, MD, MMSc, Rebecca Slotkin, and Hedy S. Wald, PhD
Abstract Professional identity formation (PIF) within medical education is the multifaceted, individualized process through which students develop new ways of being in becoming physicians. Personal backgrounds, values, expectations, interests, goals, relationships, and role models can all influence PIF and may account for diversity of both experience and the active constructive process of professional formation. Guided reflection, including reflective writing, has been used to enhance awareness and meaning making within the PIF process for both students and medical educators
W
ithin medical education, professional identity formation (PIF) is the multifaceted process by which medical students transition from laypersons to physicians.1 To this process, students bring prior identities, ideas about physician role and image, and visions for their futures. They face the challenge of integrating identities and reconciling preconceived ideas about the physician role with the lived reality of medicine.2 Ultimately, the intention of both student and medical educator is to develop an identity consistent with the values and competencies of the medical profession.3 Although this may manifest as “professionalism,” or “ways of acting,”4,5 the more overarching PIF objective is developing new “ways of being.”6 The medical education literature reflects a growing number of inquiries Please see the end of this article for information about the authors. Correspondence should be addressed to Joanna Sharpless, Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI 02912; telephone: (301) 704-7498; e-mail: [email protected]. Acad Med. 2015;90:713–717. First published online April 15, 2015 doi: 10.1097/ACM.0000000000000729
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and to shed light on what aspects of medical education are most constructive for healthy PIF. Student voices about the PIF process now emerging in the literature are often considered and interpreted by medical educators within qualitative studies or in broad theoretical overviews of PIF. In this Commentary, the authors present a chorus of individual student voices from along the medical education trajectory. Medical students (years 1–4) and a first-year resident in pediatrics respond to a variety of questions based
into major influences on students’ constructive process of PIF and interest in implementing curricula to promote healthy PIF.1,7–11 Providing opportunities for students to engage in guided reflection on their critical formative experiences is one effective tool for helping learners use their experiences to construct meaning and clarify values within PIF,9,11–13 ultimately promoting a “self-sustaining pattern of a new way of being.”14 Rarely in the literature do we hear directly from learners at various stages of medical education, complementing more broad-based theoretical formulations or summaries of student perspectives. In this Commentary, we aimed to provide this type of first-person perspective about the PIF process. To achieve this, lead author J.S. (with author H.S.W. as faculty mentor) first conducted a literature review and used the results to develop questions based on key PIF themes. J.S. and H.S.W. then identified one student from each year at the Warren Alpert Medical School of Brown University and a resident from Massachusetts General Hospital–Harvard Medical School who had expressed interest in reflective learning and PIF. These learners were invited to join the author team and
on prevalent PIF themes extracted from the literature to reflect on their personal experiences of PIF. Topics queried included pretending in medical education, role of relationships, impact of formal and informal curricula on PIF (valuable aspects as well as suggestions for change), and navigating and developing interprofessional relationships and identities. This work aims to vividly illustrate the diverse and personal forces at play in individual students’ PIF processes and to encourage future pedagogic efforts supporting healthy, integrated PIF in medical education.
reflect on and respond via e-mail to PIF questions. Here, we present excerpts of these written reflections, edited and arranged for clarity and cohesion. This “chorus of voices” is not intended to be fully representative of all learners but is rather a snapshot of our lived experiences that may promote understanding PIF as both a personalized and socialized process. As a means of introduction, we provide background narrative about ourselves in Box 1. Selected responses from authors N.B., R.C., A.K., A.M.-F., and R.S. are provided for four questions (listed in detail in List 1), and each author’s level of study is indicated as follows: MS1 indicates first-year medical student; MS2, second-year medical student; MS3, third-year medical student; MS4, fourth-year medical student; and PGY1, postgraduate year 1. “Pretending” in Medical Education
Upon starting medical school, students are expected to immerse themselves in the values and behaviors consistent with physicianship.7 Often, this process requires that we “go through the motions” of being a physician before we
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Commentary
“imposter” illnesses, so any discomfort seems unwarranted.
Box 1 Background Information About the Authors Joanna Sharpless completed her undergraduate studies in English literature at Brown University, where she was a member of the Program in Liberal Medical Education, an eight-year combined BA/MD program. She recently completed a gap year doing medical research and writing for The Dr. Oz Show in New York City and plans to go into family medicine. She has particular interests in immigrant health and narrative medicine. Nell Baldwin was raised in Buffalo, New York, and Germany. She majored in environmental analysis at Pomona College in Claremont, California, then worked as a community organizer, farmer, and health educator doing addiction prevention work. Robert Cook completed English and philosophy majors at SUNY-Geneseo, then completed nursing school at the University of Massachusetts and worked as an emergency department nurse for several years. He plans to practice family medicine and is particularly interested in working to redesign primary care so that it can better serve the needs of the poor. Aaron Kofman studied international relations at Stanford University. He will be completing his residency in internal medicine at the University of California, San Diego, and is interested in HIV and infectious diseases. Alessio Morley-Fletcher was born and raised in Rome, Italy. He majored in history and philosophy and found his calling in medicine, specifically pediatrics. He earned his MD and MMSc at La Sapienza University of Rome before deciding to come to the United States to complete his clinical training at Massachusetts General Hospital–Harvard Medical School. He has strong interests in patient empowerment, team-building skills, and mind–body medicine. Rebecca Slotkin studied English literature and anthropology at Washington University in Saint Louis. She enjoys her work with the Physicians for Human Rights student group, the Quince literary review, and the medical education scholarly concentration. Hedy S. Wald is clinical associate professor of family medicine at the Warren Alpert Medical School of Brown University where she oversees the reflective writing curriculum in the family medicine clerkship. She obtained her PhD in clinical psychology from Yeshiva University and postdoctoral neuropsychology training from the Boston VA Hospital/Boston University School of Medicine. She provides interprofessional faculty development workshops internationally on using interactive reflective writing to foster reflective capacity (supporting professional identity formation) and resiliency in health care professions education and practice.
can fully embody this role. We considered Question 1 in the following responses. N.B. (MS1): Being a first-year medical student gives me latitude to admit ways in which I am an imposter. I am taught clinical skills, but have not yet learned
how the information I gather fits into diagnosis or treatment, or even what is relevant. When I prod standardized patients, I am often admonished to push harder, to “use a firmer touch.” To some degree, I fear hurting these patient actors—after all, I will not heal their
List 1 Questions Used to Prompt Written Reflections About Professional Identity Formation (PIF) From the Authors Question 1 Several authors have written about a stage of identity formation in which medical students feel like “imposters.”8,9 What role, if any, does “pretending” currently play in your professional life? If applicable, what have you done or what has allowed you to cross the line between “pretending” to be a medical professional and fully inhabiting your professional role? Question 2 What incidents or relationships during your medical education (whether in the context of your study/work or in your life outside of medical education) do you perceive as critical or meaning making for your PIF? Question 3 What formal or informal aspects, if any, of the curriculum provided at your medical school or in your residency program have you found to be particularly valuable in supporting your PIF and nurturing your personal growth? What, if anything, do you believe teachers or mentors could do differently in medical education to facilitate your process of PIF?
R.S. (MS2): First and second year of medical school, it seems our goal is pretense. We role-play with standardized patients, we dress up, and we fumble with our ophthalmoscopes. We wear our white coats, but we consciously do not yet inhabit the role they signify. As a second year, I feel more comfortable doing an interview and physical exam, but I am only just learning how to use this information to provide care. I am most aware of my pretenses when I inadvertently fool the hospital staff into thinking I have a role on the medical team that I do not yet know enough to inhabit—when I am asked to write orders or call consults. But, I admit I enjoy my imposter role: I am thrilled to look competent enough to be mistaken for part of the medical team and can enjoy my successful pretenses because the stakes and my responsibilities are still minimal. R.C. (MS3): We are apprentices, not yet masters. And like the sorcerer’s apprentice, it is expected that when we attempt to wear the “magic hat,” some havoc will ensue. The educational system acknowledges us as learners who need guidance if we are to fully develop our abilities, and in my experience, this offers some protection against self-doubt. Instead, a different kind of pretending plagues me: pretending that I am finished with the challenges of the apprenticeship process. I am tempted to escape the present moment (with its difficult lessons) and imagine that I have already passed through the fires of medical school and residency, and have emerged on the other side without needing to be burned and shaped by them. If I struggle with pretending, it is not so much with the notion of “fake it ‘til I make it,” for instructors reassure me that they do not expect perfection. Rather, I struggle with remaining present through this difficult process of PIF, so I can fully experience what it is like to be ignorant, even as I strive to gain knowledge.
Question 4 If relevant, how have your interactions with other health care professionals (nurses, therapists, nutritionists, pharmacists, etc.) during your training affected your understanding of your own professional identity? How, if at all, do you differentiate and/or reconcile your medical professional identity with an interprofessional identity?
A.K. (MS4): The imposter role gets progressively more difficult as I advance in medical school. In the first year, it is easy to hide behind a cloak of ignorance. By my fourth year, many seem to consider me a de facto physician, and seek my advice accordingly, even if I have been out of the clinical setting for months
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Commentary
interviewing for residency. Some degree of the “imposter” feeling will always be impossible to shake; no matter how many my qualifications, there is always someone who may know better. The fact that medicine is a field where we learn every day also means it is one where we are humbled every day. The Role of Relationships
Personal and professional relationships have been shown to have a significant, early impact on professional identity development in medical education.8,15 In Question 2, we explored which relationships are most influential and what aspects of professional identity they nurture. N.B. (MS1): For me, an important patient interaction has been following a pregnant woman through the Medical Students Outreach to Mothers-to-Be preclinical elective: talking with her over the phone, attending her prenatal visits, and being present at her baby’s birth. I hope to attend her postpartum visits, and to continue to follow her as her son grows up. I think this longitudinal relationship helps me imagine what it will be like to have patients of my own. R.S. (MS2): I have found an incredible group of peers who are passionate about areas of medicine I have come to value, including work with the Physicians for Human Rights student group and with HIV/HCV community testing and outreach. Specific activities and people within medical school that remind me why I decided to go into medicine not only motivate me to study the long hours necessary, but are also important clues to figuring out how I will practice medicine. A.K. (MS4): The two extremes of a physician—those who do things so well that I am inspired to emulate them, and those who take shortcuts, grow jaded, and care little about communication or the nuances of individualized patient care—are the relationships that are key to my PIF. Though I enjoy my encounters with the former far more than the latter, my PIF is as equally tied to the doctor I want to be as the one I do not want to be. A.M.-F. (PGY1): My own health and my family’s health have significantly influenced my professional identity. When I was younger, I suffered from
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moderate-to-severe asthma. That experience not only got me interested in understanding how my body works, but also helped me relate to others with chronic conditions. In addition, making some clinical findings that led to a diagnosis of spinal muscular atrophy in my niece was a life-changing experience for me and for my family. That family experience reminded me that textbooks can teach me how to diagnose problems, not necessarily how to handle them. I have come to realize that we may underestimate our patients’ resilience. After all, not everything that counts can be counted, an adage attributed to Einstein that I have found to be particularly true in pediatrics. The Impact of Formal and Informal Curricula on PIF
In addition to teaching students the knowledge and technical skills for professional competency, medical schools are increasingly implementing formal and informal interventions to cultivate students’ personal and professional growth. In Question 3, we explored what our medical schools do to support PIF and what they could possibly improve. N.B. (MS1): In small groups, we are often given readings designed to stimulate reflection about difficult, controversial topics that physicians may face. Though some of the readings assigned have been inspiring, others have literally standardized empathy into a checklist format. I take the tasks of learning and personal growth seriously and sometimes I am disappointed by the feeling that PIF is one more thing to check off the list. R.S. (MS2): Although we are trained to master multiple-choice pathology, I do not think this approach to teaching medicine parallels the practice of medicine. The community mentor site and mentor relationship give us a glimpse of what it means to inhabit the physician’s role in the clinical setting. This often gives the seemingly esoteric facts we learn in the classroom more meaning by placing them in the correct context. Similarly, the personal exploration of medicine through preclinical electives, research, and community outreach events helps shape the direction our medical education will take and nurtures our professional growth.
R.C. (MS3): Many of my instructors have not taught me what they think they are teaching me. Each instructor seems to approach the material through his or her own lenses and biases without a sense of a “common text” to which every doctor has been exposed. I would learn more if instructors would explain, not simply perform, their thought process to me and encourage me to develop my own approach to problems. For example, when I get stuck on a clinical question, I wish more instructors would prompt me with, “How are you trying to approach the question?” rather than waiting in silence before offering the answer. A.M.-F. (PGY1): My residency program just started a pilot program called Personal and Professional Development (PPD), which is run by attending physicians who share an interest in helping the new generation of doctors create a sense of community. Many times, I left those sessions amazed and humbled by how much I learned from listening to my cointerns, attendings, or invited guests discuss topics ranging from work–life balance, to medical mistakes, to poetry and narrative writing. I would advocate that we need more initiatives like PPD. Navigating and Developing Interprofessional Relationships and Identities
Learning to build and negotiate interprofessional relationships and distinguishing between an emerging interprofessional identity and physician identity can be challenging, especially at initial stages of medical education.16 When compared and contrasted either with our own prior professional roles, or the roles of other medical professionals, interprofessional interactions have the potential to illuminate our understanding of the physician role. We considered Question 4. N.B. (MS1): Before medical school, I worked for a clinical trial as a health educator, counseling patients using motivational interviewing (MI). As a student doctor, I rarely use my MI training during my patient interactions. I wonder if after we are officially taught MI skills for smoking cessation, I will feel like I am “allowed” to counsel my patients. I think I feel the need to shed my past professional identity as research
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Commentary
assistant/counselor/health educator in order to take on a new one. This is a strange realization because many of my professional role models are doctors who interpret their professional identity broadly—who are advocates, researchers, policy advisors, and clinicians. R.S. (MS2): This fall, we had an interprofessional workshop with students from a variety of health care professions including nursing, social work, physical therapy, and pharmacy. When we approached a complex patient case together, the other students clearly identified their roles—the pharmacist handled the medications, the social worker the living conditions, the nurse the glucometer, etc.—except for me. Maybe it was due to the specific case, but the role of the doctor ended up being everything and nothing. It was pulling all of the pieces and people together, but not necessarily performing any specific task or procedure. The workshop was a humbling and eye-opening experience. I had never considered how my medical degree might be understood on an interprofessional level and the leadership role I might be invited to play automatically. Right now, my interprofessional identity is something for my professional identity to aspire to and grow into. R.C. (MS3): As a former emergency department (ED) nurse, I know that the system we work in is stressful, filled with long hours of routine punctuated by periods of overwhelming chaos. Each profession—physicians, nurses, respiratory therapists, phlebotomists, certified nursing assistants, etc.—works with the others to try to manage those routines and to survive the chaos together. Add to this the goals of the patients we care for (which are not always directly aligned with those of our professional routines), and the system becomes incredibly complex. I want to continue to draw on my past experiences in the ED to help me navigate and negotiate multifaceted interprofessional relationships in the service of providing more integrated, optimal care for my patients. Discussion and Conclusions
The voices of this Commentary illustrate variations on the theme of an active, constructive process of PIF. These “snapshots” highlight various mentor,
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peer, interprofessional, family, and patient relationships as instrumental for our PIF process. Meaningful relationships with patients and mentors help us envision our future clinician roles, while peer relationships can help us strengthen shared interests and values that preceded medical school. We also appreciate the powerful impact of our own personal experiences within the health care system, which help us remain humble as we assume the provider role. Consequently, we encourage medical education models to provide guided opportunities to process and contextualize our experiences of patient care and self-care, both inside and outside the classroom. We also support efforts to design curricular innovations stimulating reflection-on-action17 and reflection-on-being11 alongside role models who appreciate the role of relationships in PIF and who are trained in effective small-group facilitation skills. The heterogeneity in our comments as linked to level of training underlines potential utility of developmental curricula within created “developmental space”18 tailored to the educational stage of the learner. Within such curricular efforts, guided reflection can be a mirror, revealing our professional transformation through the medical education process.19 Developing self-awareness of this evolving process may serve to crystallize elements of our professional identities and promote the evolution of others. We realize that even aspects of PIF perceived as difficult or challenging may become rewarding within the context of critical reflection. Grappling with the “imposter” experience, for example, can cultivate a sense of humility15 and promote self-awareness and reflective openness to others, potentially contributing to emotional resilience and well-being.11 Similarly, identity conflicts can be a source of “creative tension”2 as personal meets professional and/or one strives for an idealized professional self. As evolving professionals, we often confront new realities of medical practice that depart from our initial expectations, and must adapt and reconcile the imagined and lived versions of professional identity. For example, we note that confronting the limits of a physician’s knowledge and influence, although daunting, may motivate us to shift our focus away from knowing all the answers towards acquiring “cognitive tools” that allow us to search for answers (and recognize when answers
may be elusive) as well as “emotional tools” to help with tolerating ambiguity. In general, the process of negotiating such conflicts potentially spurs further identity development by encouraging us to question and at times reinforce core values and critical behaviors. In general, we gain insight into and assume more ownership over our professional lives within a developmental, integrative PIF process that includes recognizing our personal beliefs and values and committing to professional values and goals. All of this can support our career design and even specialty choice20 as we become more aware of authoring the story of our emerging professional selves. Hence, our presented Commentary may be regarded as a “microcosm” of the “macrocosm” of curricula-supported engaged reflection for the conscious development of professional identity.21 It is our hope that the presented “chorus” of student voices and similar future dialogue can help inform medical educators’ efforts to support students’ active PIF processes. Given that our identities prior to medical education significantly impact our PIF, further study of the PIF process and development of supportive curricula within premedical education may be useful. We also hope that students will become increasingly invested alongside medical educators in devising and implementing best practices to cultivate and assess progress toward healthy PIF. Inviting students to contribute ideas within medical education curriculum development and to participate directly in research into the PIF process may result in surprising and successful changes to how the PIF process is understood and promoted. Funding/Support: H.S. Wald is grateful for support from Brown University predoctoral training grant #D56HP2068. Other disclosures: None reported. Ethical approval: Reported as not applicable. J. Sharpless is a fourth-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island. N. Baldwin is a first-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island. R. Cook is a third-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Academic Medicine, Vol. 90, No. 6 / June 2015
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Commentary A. Kofman is a fourth-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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A. Morley-Fletcher is a first-year resident, Department of Pediatrics, Massachusetts General Hospital–Harvard Medical School, Boston, Massachusetts.
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R. Slotkin is a second-year student, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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H.S. Wald is clinical associate professor of family medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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