#KeyLIMEPodcast 261: Being while becoming

Reference

Jarvis-Selinger et. al., Understanding Professional Identity Formation in Early Clerkship: A Novel Framework Acad Med. 2019 Oct;94(10):1574-1580.

Reviewer

Linda Snell (@LindaSMedEd)

Background

When do you feel you ‘became’ a doctor? Much of the literature on identity formation suggests that this happens sometime during early residency, when trainees are immersed in the workplace with some autonomy. We know that clerkship is another important transition point. However PIF is not a sudden process, and these authors and others have written about learners being on the road to developing the identity of a physician or a specialist, while at the same time having or developing the identity of the stage they are at (student, resident…).

Concepts from psychology and sociology may help explain the adaptive developmental process of PIF: the psychological development of the person, and the socialization of the person into roles and participation in the community. Here reference socio-cognitive theories, communities of practice, kegan stages of identity development, Cruess et al PIF.

Reflection is an important process in PIF to make the implicit explicit, when thinking about clinical experiences or what a role model does. Recently many med schools have implemented programs to foster reflection so students have opportunities to examine their emerging identities.

Narrative reflections have a potential to show links students make between clinical experiences and PIF. They clarify students’ experiences of PIF and may also act to promote learning as students develop their professionalism and identity

The authors say that few conceptual frameworks exist to facilitate interpretation of how reflective moments—either great or small—affect students’ evolving sense of professional identity in ways that can inform curricular efforts to link opportunities for reflection and PIF

Purpose

To examine third-year medical students’ experiences of professional identity formation (PIF) during clinical clerkship, within the context of the pilot year of the Guided Reflection and Professionalization/Hidden Curriculum (GRAPHiC)

Key Points on the Methods

They looked at an existing (pilot) clerkship learning activity designed to ‘support medical students’ efforts to “unhide” the hidden curriculum in relation to their development as medical students and emerging professionals’.

They analyzed transcripts of recordings of 10 collaborative discussions with 12 students, 3 faculty members, a resident, and a fourth-year student. These discussions used a 4-step approach—priming, noticing, processing, and choosing—to guide the discussion and facilitate students’ active reflection on their professional journeys. Students took field notes on instances of the hidden curriculum and their process of enculturation.

Using a grounded theory approach informed by an interpretivist perspective, that facilitates developing a conceptually abstract explanation of “what is happening in a social setting.” 2 med students did primary coding, reflexivity addressed by having an ‘outsider’ PhD student in education, look at data. Developed categories, patterns and relationships.

Key Outcomes

(1) the development of a conceptual framework was unintended. It comprised 4 components useful for exploring and understanding students’ reflections on their PIF

• contexts that students spoke about (clinical experience, stage of engagement…)
• focus of their stories (what they concentrated on)
• catalysts to introspection, (e.g recent formal teaching applied to context and focus)
• process, defined as students’ awareness and navigation of their current or future professional selves’, or how they negotiate their identity beliefs.

(2) overarching PIF themes focused on either students’

• current identity (being)
• sense of future self (becoming).

Made distinctions between how they personally (me-to-me) positioned themselves in relation to their identity: past, present and future;

or socially (me-to-them) located their shifting, or new, identity in relation to others by distinguishing themselves from and their relationshipswith others before and after their stage.

Both these reflect identity dissonance.

Limitations: sample size, volunteer bias, social desirability, influence of facilitators,

Key Conclusions

The authors conclude that critical reflection is a powerful tool for understanding how roles within the social realm (e.g., medical student, physician) are internalized into an identity which shapes the conception of self.

The authors identified stimuli that generated participants’ introspection about or processing of PIF. Students engage regularly in the act of defining and negotiating their identities as a response to their day-to-day clinical experiences. However ‘the moments that generate profound feelings of awareness in students are often moments that would not be recognizable (even post hoc) as remarkable by others.’ So insight into the kinds of moments students focus on may guide efforts to actively support positive PIF. Examples are clinical autonomy, a sense of ownership over patients’ care, engaging in meaningful relationships and carrying real responsibilities (i.e., longitudinal integrated clerkships).

Authors suggest we apply the notion of ‘catalyst’ to examine aspects of the curriculum and learning environment to understand what is sparking students to reflect on who they are and who they are becoming.

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