What Does Context Have to Do With Anything? A Study of Professional Identity Formation in Physician-Trainees Considered Underrepresented in Medicine

Competence, mattering and belonging: An evidence-based and practical approach to understanding and fostering medical student professional identity formation

INTRODUCTION

Understanding professional identity formation (PIF) in medical education is essential for preparing future physicians to navigate their profession and integrate communities' of practice (CoP) values, norms, and expertise to meet patients' needs. Despite robust PIF literature, gaps persist due to greater focus on internal psychological processes than social-contextual influences. Empirically describing PIF within medical training's cultural context will enhance understanding and inform learning environment interventions.

METHODS

We employed a constructivist qualitative approach to examine social-contextual factors influencing students' PIF. In one-on-one interviews, 52 graduating students from 4 geographically diverse U.S. medical schools described their PIF from pre-medical school through graduation. We used an iterative, multi-stage, constant-comparison approach to data analysis, employing reflexive methods throughout.

RESULTS

Social-contextual cues defining PIF were identified in three domains: competence, mattering, belonging. As students received cues, their professional identity evolved. They described a gradual integration of personal and professional values, with growing confidence and a shifting position within the physician CoP.

CONCLUSIONS

This study provides a conceptual framework that describes how CoP members' interactions with medical students positively influence and at times undermine students' sense of competence, belonging, and mattering. Understanding these cues can help educators create a supportive environment that enhances students' PIF.

In Their Own Voices: A Critical Narrative Review of Black Women Faculty Members' First-Person Accounts of Racial Trauma Across Higher Education

Phenomenon: Black women often face more challenges in academic medicine than others and are leaving the profession due to unsupportive work environments, systematic neglect, and experiences of invisibility. Research offers insight into Black women faculty experiences, but studies have largely been conducted on their experiences rather than written by them. We analyzed first-person narratives exploring Black women faculty members' experiences with racial trauma across the academy considering the intersectionality of racism and sexism to lay the foundation for understanding Black women physicians' faculty experiences in similar spaces. Approach: We gathered first-person narratives of Black women faculty members in the U.S. from ERIC, Web of Science, and Ovid Medline. We used a variety of terms to draw out potential experiences with trauma (e.g., microaggressions, stigma, prejudice). Articles were screened by two researchers, with a third resolving conflicts. Drawing on constructs from Black feminist theory, two researchers extracted from each article authors' claims about: (a) their institutions, (b) their experiences in those spaces, and (c) suggestions for change. We then analyzed these data through the lens of racial trauma while also noting the effects of gendered racism. Findings: We identified four key themes from the 46 first-person accounts of racial trauma of Black faculty members in higher education: pressures arising from being "the only" or "one of few"; elimination of value through the "cloak of invisibility" and "unconscious assumptions"; the psychological burden of "walking a tightrope"; and communal responsibility, asking "if not us, then who?" Insights: Black women's narratives are necessary to unearth their specific truths as individuals who experience intersectional oppression because of their marginalized racial and gender identities. This may also assist with better understanding opportunities to dismantle the oppressive structures and practices hindering more diverse, equitable, and inclusive institutional environments where their representation, voice, and experience gives space for them to thrive and not simply survive within the academy, including and not limited to medicine.

Making the Invisible Visible: Asian American Speech-Language Pathologists' Experiences in Their Path to the Profession

PURPOSE

The purpose of the study was to explore the lived experiences of Asian American speech-language pathologists (SLPs) during their graduate training.

METHOD

This was a qualitative phenomenological study. Participants were 26 SLPs who self-identified as Asian American. All participants graduated from accredited master's programs in speech-language pathology in the United States and currently work clinically with adult populations. Participants attended one individual semistructured interview via videoconference to share their experiences being Asian in speech-language pathology. Thematic analysis was used to identify recurring patterns and themes from the interview data.

RESULTS

Three themes were derived from the participant interviews that reflect the Asian American SLPs' past experiences as graduate students and trainees. The first theme revealed the participants' motivations and affirmations for choosing the SLP career path. The second theme describes the expectations of mutual investment between the Asian American students' commitment to professional training and their training programs' support in their professional growth. The last theme talks about the social aspects of their trainee experiences that influenced their sense of belonging.

CONCLUSIONS

There were similarities between the Asian American SLP trainee experiences and experiences of underrepresented and minoritized students from speech-language pathology and other health professions reported in the literature. Two key aspects distinct to Asian Americans and speech-language pathology were the sense of belongingness created by the social environment and the perceived tie of speech and linguistic proficiency and clinical competence. Findings contribute to how educators, leaders, and researchers can support inclusion of Asian Americans pursing speech-language pathology.

An "integration" of professional identity formation among rural physicians experiencing an interplay between their professional and personal identities

The present understanding of professional identity formation is problematic since it underrepresents minority physicians and potentially excludes their professional identity formation experiences. Rural physicians are expected to have similar underrepresented aspects as minority physicians because of their specific sociocultural contexts and consequent private-professional intersection, which lead to ethical complexities. Therefore, to bridge this research gap, we interviewed 12 early- to mid-career Japanese physicians working in rural areas and explored their experiences. Through a narrative analysis guided by Figured Worlds theory, we analysed the data by focusing on the vocabulary, expressions, and metaphors participants used to describe their experiences. A central theme emerged concerning how the rural physicians configurated their personal versus professional participation in their local communities. Further, their identity narratives varied regarding how they constructed their identities, rural communities, and relationships as well as their identity formation ideals and strategies to achieve them. Informed by 'Big Questions' concerning worldview framework, we delineated four identity narratives as prototypes to describe how they participated in their communities. These identity narratives provide a preliminary understanding of how diverse identity formation is for rural physicians. In addition, our findings exposed the current professional identity formation framework as potentially biased towards single forms of participation in monolithic communities, overlooking complicated forms of participation in multiple communities. We argue that applying frameworks and concepts to capture these multiple forms of participation as well as revisiting the 'discourse of integration' are necessary steps to overcome the limitation of the current understanding of professional identity formation.

The assimilatory impact of professional Identity formation on racial and ethnic minority doctor of pharmacy students

The ideology of professional identity formation (PIF) is trending in pharmacy education. Therefore, we must initiate conversations about how the PIF framework impacts minoritized students. PIF is applied at default through the white racial frame, which is why making PIF inclusive is difficult. The concept of PIF itself is Eurocentric and relies on normative colonial systems, order, and viewpoints. Due to white centering, the PIF framework then becomes a tool of assimilation. This socially conditions marginalized and minoritized individuals to participate in the dominant culture's society according to those norms. Here we review the capitalistic angles of PIF, how PIF encourages assimilation, the interplay of role modeling on student development, and how to adjust the PIF framework to be more inclusive for minoritized learners.

Underrepresented in Medicine Trainees' Sense of Belonging and Professional Identity Formation after Participation in the Leadership Education in Advancing Diversity Program

BACKGROUND

There are persistent structural barriers that threaten inclusion and retention of underrepresented in medicine (UIM) residents and fellows (trainees) as future faculty in academic medicine. We developed the Leadership Education in Advancing Diversity (LEAD) Program at a single, academic institution, to address these barriers through a 10-month longitudinal curriculum across Graduate Medical Education for trainees to develop leadership and scholarship skills in diversity, equity, and inclusion (DEI).

OBJECTIVE

Explore how participation in LEAD impacted UIM trainees' sense of belonging and professional identity formation in academic medicine as well as perceptions about pursuing a career in academic medicine and future leadership roles.

METHODS

Institutional Review Board-approved qualitative study in August 2020-August 2021 with individual, semi-structured interviews of UIM LEAD graduates from the first four cohorts (2017-2021). Data were analyzed by two authors using modified grounded theory.

RESULTS

Fourteen UIM trainees were interviewed; seven themes emerged. Critical aspects of the program: 1) Creation of a community of shared DEI values, 2) Mentorship, 3) Role of allies. Results of the program: 4) Deepened appreciation of personal and professional identity as UIM, 5) Fostered belonging in academic medicine, 6) Appreciation of different careers in academic medicine and how to integrate DEI interests, and 7) Inspired trainees to pursue leadership roles.

CONCLUSIONS

LEAD can serve as a model for other institutions that seek to support UIM trainees' sense of belonging, professional identity formation, and perceptions about pursuing careers in academic medicine and future leadership roles.

Identity Work: A Qualitative Study of Residents' Experiences Navigating Identity Struggles

Introduction

Medical training traditionally holds a deterministic view of professional socialization wherein many medical learners struggle to construct a professional identity. Previous research has demonstrated the dysfunctional norms and conflicting ideologies that create identity struggle, disproportionally affecting women and individuals underrepresented in medicine. Symbolic interactionism can help explain identity struggles, emphasizing the influence of socio-contextual factors on identity construction. The purpose of this study was to explore how residents navigate identity struggles during residency training.

Method

We conducted a qualitative exploration of 12 residents in three specialties at three academic institutions in the United States. Participants engaged in rich picture drawings followed by one-on-one interviews. We coded transcript data and met regularly to identify themes related to residents' experiences with navigating professional identity struggles.

Results

We identified three main themes on navigating identity struggles: the weight of identity work, the isolating nature of identity work, and the navigation that occurs with and against socio-contextual currents. Residents described identity work as navigation like a boat at sea. This work felt weighty and at times overwhelming and residents often felt unable to discuss their identity struggles with others. Residents utilized what agency they had to either navigate with the current, navigating towards acceptable-albeit imperfect-paths forward, or attempting to go against the current to forge new paths through resistance.

Discussion

This study highlights how context enables and constrains identity construction, how contextual constraints can create dissonance between identities, and the considerable effort required to reconcile dissonance and construct professional identities. Training program adjustments, enhanced resident support, and cultural shifts are required to sustain residents' identity work. Medical professionals should engage in collective identity work to reimagine the profession's identity by addressing dysfunctional cultural norms.

Belonging in dual roles: exploring professional identity formation among disabled healthcare students and clinicians

The development of a robust professional identity is a pivotal aspect of every healthcare professional's educational journey. Critical social perspectives are increasingly influencing the examination of professional identity formation within healthcare professions. While understanding how disabled students and practitioners integrate a disability identity into their professional identity is crucial, we have limited knowledge about the actual formation of their professional identity. This study aims to investigate how disabled students and clinicians in healthcare professions actively shape their professional identity during their educational and professional journeys. We conducted in-depth semi-structured interviews with 27 students and 29 clinicians, conducting up to three interviews per participant over a year, resulting in 124 interviews. Participants represented five healthcare professions: medicine, nursing, occupational therapy, physical therapy, and social work. Employing a constructivist grounded theory approach, our data analysis revealed two prominent dimensions: (a) The contextualization of identity formation processes and (b) The identity navigation dimension in which the professional identity and disability identity are explored. This emerging model sheds light on the dynamic processes involved in identity formation, emphasizing the significance of a supportive environment for disabled students and practitioners. Such an environment fosters the negotiation of both professional and disability identities. Moreover, this study recognizes the importance of a re-examination of the concepts of professionalism and professional identity in healthcare professions. In conclusion, this research underscores the importance of understanding and supporting the multifaceted identity formation processes among disabled individuals within healthcare professions.

Traveling with a desirable destination: a dialogical analysis of professional identity formation among freshman medical students

BACKGROUND

We aimed to examine medical students' perceptions regarding their professional identity and explore their creative narratives utilizing the Dialogical-Self Theory (DST).

METHODS

This is a mixed-method study. First-year medical students at Tehran University of Medical Sciences (TUMS, Tehran, Iran wrote a creative narrative about their perspectives on their future profession. Based on DST, qualitative-directed content analysis and summative approach were used to identify and quantify different "I-positions" to assess professional identity formation.

RESULTS

One hundred eighty-eight first-year medical students at TUMS participated in the study in 2021-2022. In the creative narratives, the reference to "I" was more than other pronouns (he/she/they). The use of "I" positively correlated with rank in the university entrance exam (P value = 0.03). The highest application of "I" per participant belonged to the "present I-position," and the lowest to the "promoter," which has the highest rank in the formation of professional identity. Women tended to use the "present I-position" more than men (P value = 0.03).

CONCLUSIONS

First-year medical students have accepted their self-role in forming professional identity; however, they have not found a vast perspective of it, as shown by their inability to use meta I-position and promoter I-position. Therefore, educators must provide plans within the curriculum to enhance competencies of professional identity formation. These plans can include incorporating narration writing to encourage medical students to reflect on their professional identity.

Advancing Equity in Assessment in the Surgical Learning Environment

IMPORTANCE

Assessment is a fundamental part of teaching and learning that provides the basis for making inferences about the development of learners. Inequity in assessment disproportionately impacts underrepresented in medicine learners and can limit their opportunities for achievement.

OBSERVATIONS

Unfortunately, inequity in assessment is prevalent in the surgical learning environment due to systemic and individual factors. The Antideficit Achievement framework can be effectively applied to address sources of inequity.

CONCLUSIONS AND RELEVANCE

This paper explores sources of inequity in assessment in the surgical learning environment and illuminates them with a descriptive case study. Recommendations created using the Antideficit Achievement framework provide effective, practical ways to begin to advance equity in assessment in the surgical learning environment.

Pushing, standing and bringing to light: How medical trainees conceptualise professional resistance

BACKGROUND

Much of the literature on harm and injustice in medical education focuses on the impact of oppression rather than trainees' efforts to create change. To acknowledge and make visible these efforts, medical education professionals must grasp how trainees perceive resistance and their role in effecting change. Employing functional linguistic and 'everyday' resistance theories, this critical qualitative study aims to understand trainees' conceptions of resistance practices and their representational choices in moments when they talked about and conceptualised resistance.

METHODS

Gathering participants through professional networks and snowball sampling, this study employed in-depth interviews to explore the conceptualisations of resistance among North American medical trainees (9 medical students, 9 residents and fellows). With the use of an applied functional linguistic analysis framework, we analysed the representational metafunction in trainees' conceptualisation of their resistance efforts against social injustice. We began with open coding for 'everyday' acts of resistance and then shifted to focused coding on verbal process types in participants' language to characterise their conceptualisations of resistance.

FINDINGS

Participants conceptualised their resistance practices in three distinct ways: first, an almost physical pushing back, drawing largely on material process types (doing); second, an embodied standing up and being present, based predominantly on material and relational process types (being); and third, an epistemic bringing to light, grounded mostly in mental and verbal process types (thinking). These processes of resistance reflect participants' conceptualisations of their efforts to challenge the status quo around inequity, harm and injustice in medical education.

CONCLUSION

This study builds on resistance literature, offering a potential typology of resistance practices as pushing back, being and bringing to light. Because these are 'everyday' acts of resistance, these are tactics available to everyone, including faculty; we all have the power to resist, whether it is in teaching and learning or interacting with larger structures in medicine.

Exploration of Student Experiences and Perceptions of Self and Peer: Implications for Tailoring Supports

INTRODUCTION

Doctor of Physical Therapy (DPT) students have reported learning new behaviors, enhanced self-awareness, and personal and professional growth during their first year of DPT school. The purpose of this study was to explore in greater depth, through semistructured interviews, the student perceptions of self-identity and social identity.

SUBJECTS

Seventeen early second-year DPT students from 3 universities.

METHODS

This investigation is an extension of a larger multisite study. Qualitative interviews were employed to enable the use of a constructivist lens to explore the importance of personal context in participants' experiences during the first year of DPT school.

RESULTS

Students across programs shared similar characteristics and experiences. Three themes emerged: DPT students share common perceptions of themselves and classmates; sociocultural experiences shaped their actions and perceptions of self; and students recognized the need to change to be successful. The voices of the older second-career students and racially minoritized students were uniquely different from other participants.

DISCUSSION AND CONCLUSION

Doctor of Physical Therapy student experiences are similar across programs except for older students and racially minoritized students. Early professional identity formation was noted as well. A richer understanding of the personal characteristics, influential sociocultural factors, and student perceptions of self and classmates could enable educators to customize supports and educational strategies to help students understand the role their past and present experiences play in shaping their professional identities.

Racial and Ethnic Discrimination and Medical Students' Identity Formation

Importance

Investigating racial and ethnic discrimination in medical education is crucial for addressing disparities and fostering an inclusive environment.

Objective

To assess how racial and ethnic discrimination in medical school is associated with personal and professional identity formation (PPIF) by race and ethnicity.

Design, Setting, and Participants

This retrospective cross-sectional study used deidentified data on 37 610 medical students who matriculated in 2014 or 2015 and took the Association of American Medical Colleges Graduation Questionnaire (GQ) between 2016 and 2020. Statistical analysis was performed from September 1 to November 20, 2023.

Exposures

Experiences of racial and ethnic discrimination were assessed through responses to 3 GQ questions about denial of opportunities, offensive remarks or names, and lower evaluations or grades due to race or ethnicity.

Main Outcomes and Measures

Personal and professional development were measured as 2 separate outcomes using 2 GQ statements rated on a 5-point Likert scale (where 1 indicated strongly disagree and 5 indicated strongly agree): "My medical school has done a good job fostering and nurturing my development as a person" and "My medical school has done a good job fostering and nurturing my development as a physician." Variables of personal and professional development were both dichotomized.

Results

Of 37 610 medical students, 18 200 (48.4%) were female, and 19 410 (51.6%) were male; 2458 (6.5%) were African American or Black, 7801 (20.7%) were Asian, 2430 (6.5%) were Hispanic, 21 380 (56.9%) were White, 2404 (6.4%) were multiracial, and 1137 (3%) were other race or ethnicity. Most respondents attested that their medical school fostered their personal (27 272 [72.5%]) and professional (34 560 [91.9%]) development. African American or Black students reported the lowest rates of personal (1603 of 2458 [65.2%]) and professional (2182 of 2458 [88.8%]) development, and experienced lower likelihoods of personal (adjusted risk ratio [ARR], 0.89 [95% CI, 0.86-0.93]) and professional (ARR, 0.95 [95% CI, 0.94-0.97]) development than White students. Racial discrimination was inversely associated with development, with the highest PPIF rates among those never experiencing discrimination (personal, 25 089 of 33 508 [74.9%]; and professional, 31 257 of 33 508 [93.3%]). Those experiencing isolated discrimination (personal: ARR, 0.83 [95% CI, 0.80-0.87]; professional: ARR, 0.92 [95% CI, 0.91-0.95]) and recurrent discrimination (personal: ARR, 0.63 [95% CI, 0.60-0.66]; professional: ARR, 0.82 [95% CI, 0.80-0.84]) had relatively lower likelihoods of PPIF. African American or Black students experienced the highest rate of recurrent discrimination (543 of 2458 [22.1%]). No significant PPIF risk differences were found for other racial and ethnic groups underrepresented in medicine without discrimination compared with White students without discrimination, but all groups with recurrent discrimination had relatively lower PPIF risk.

Conclusions and Relevance

In this cross-sectional study of US medical students, racial and ethnic discrimination was associated with lower PPIF across all racial and ethnic groups compared with White students without such experiences. African American or Black students disproportionately faced this discrimination. Systemic changes in medical education are needed to combat discrimination and ensure equity in holistic student development.

The Rubik's cube of doing and being: Factors influencing professional identity transition to the medical registrar

BACKGROUND

Professional identity transitions, such as the transition to medical registrar, are challenging. How minoritised identities influence transitions during medical training requires further study. This study aimed to explore the factors influencing the transition to the medical registrar in Scotland to guide support during training.

METHODS

Interviews exploring this transition with internal medicine trainees were audio recorded, transcribed verbatim and double-coded using template analysis. We applied an initial coding template informed by multiple and multidimensional transition theory of individual, interpersonal, systemic and macro-level factors. Using a critical theory lens, a further template analysis specifically sought to understand how trainees' social identities interacted with the various levels.

FINDINGS

Nineteen IM trainees were interviewed between January 2021 and February 2022. Influential factors reflected a parallel process of competence (doing) and identity (being) development. The interaction of social identities, such as gender (being a woman) and country of origin (being an international medical graduate), occurred across levels. This can be conceptualised as a Rubik's cube with the interplay between doing and being from an individual to a macro level with trainees' social identities interacting at all levels.

CONCLUSION

The transition to the medical registrar is multifaceted; with a challenging balance between support and independence in providing opportunities to perform (doing) whilst identity develops (being). Identity transitions involve multiple Rubik's-cube-like rotations between the facets of 'doing' and 'being,' until these align. Taking heed of influential factors and the interaction of minoritised social identities could guide a trainee-centred and smoother transition.

A scoping review and theory-informed conceptual model of professional identity formation in medical education

INTRODUCTION

Professional identity formation (PIF) is a central tenet of effective medical education. However, efforts to support, assess and study PIF are hindered by unclear definitions and conceptualisations of what it means to 'think, act, and feel like a physician'. Gaps in understanding PIF, and by extension, its support mechanisms, can predispose individuals towards disengaged or unprofessional conduct and institutions towards short-sighted or reactionary responses to systemic issues.

METHODS

A Systematic Evidence-Based Approach-guided systematic scoping review of PIF theories was conducted related to medical students, trainees and practising doctors, published between 1 January 2000 and 31 December 2021 in PubMed, Embase, ERIC and Scopus databases.

RESULTS

A total of 2441 abstracts were reviewed, 607 full-text articles evaluated and 204 articles included. The domains identified were understanding PIF through the lens of pivotal theories and characterising PIF by delineating the underlying factors that influence it and processes that define it.

CONCLUSIONS

Based on regnant theories and frameworks related to self-concepts of identity and personhood, the relationships between key PIF influences, processes and outcomes were examined. A theory-backed integrated conceptual model was proposed to delineate the interconnected relationships among these, aiming to untangle some of the complexities inherent to PIF, to shed light on existing practices and to identify shortcomings in our understanding so as to develop mechanisms in support of its multifaceted, interlinked components.

Changing the Approach in Supporting and Advancing Underrepresented in Medicine (UIM) Medical Students

Introduction

Research has shown the importance of diversity in improving patient care. Medical students from backgrounds underrepresented in medicine (UIM) face unique challenges, including minority tax, stereotype threat, and expectations to be the sole representative of their identity group. Mentors must be aware of these challenges and develop skills to address them.

Methods

We designed a 90-minute workshop about the challenges UIM students encounter in medical school and best practices in mentorship. Target audience and facilitators were undergraduate medical educators. Three videos and questions for case-based facilitated small-group discussion with medical school faculty and administrators were included. Using a retrospective pre-post design, we elicited participants' confidence level in recognizing and addressing issues UIM students may experience and plans to apply skills gained in the workshop.

Results

Workshop participants (N = 57) reported a mean increase in confidence rating of 20-26 points out of 100 for recognizing, identifying, and applying skills related to optimal UIM mentorship (mean confidence: 53-60 preworkshop, 79-81 postworkshop). Participants also reported a mean of 82 in readiness to apply skills learned. Participants rated the workshop a 4.6 in overall helpfulness on a 5-point Likert scale (1 = not helpful, 5 = extremely helpful).

Discussion

Health care professionals working with UIM medical students have an essential role in mentorship and support. This workshop provides a structured forum to discuss challenges and build awareness, comfort, and skills regarding engaging in meaningful discussions about race and the experiences of medical students, even when identities are incongruent.

"The faculty was really hearing what I had to say and really validating who I was": Learning from validation theory to support students of colour in undergraduate medical education

BACKGROUND

Medical students of colour face numerous challenges during their undergraduate training period, reflecting the harmful norms and cultures in the learning context of medical school. Despite negative experiences for students of colour in medicine, there are episodes of support and encouragement that come from faculty or staff. This asset-based qualitative study uses Rendón's Validation Theory to illuminate specific ways faculty at a community-based medical college support medical students of colour, thereby challenging structural injustices in medical school.

METHODS

This study is grounded in a humanising and asset-based perspective, where participants are viewed as legitimate knowers from whom researchers can learn. Twenty-four medical students of colour and 14 faculty identified by students as supportive participated in five focus groups where participants shared how they felt validated and supported during their undergraduate medical school experiences. Inductive open-coding followed by deductive thematic coding using Validation Theory-a theory that describes how external validation is a necessary component of fostering students' personal and academic drive-and literature about the context of medical school informed the three findings.

FINDINGS

Three major themes provide examples of ways faculty validated students. First, participants indicated the importance of acknowledging identities and experiences to understand the socio, historical and cultural context of learning. Second, participants implored the value of giving praise and offering encouragement to work against professional expectations. Finally, participants shared the intimacy of fostering personal relationships to reduce hierarchies.

CONCLUSION

This study offers concrete guidance on teaching practices faculty can use to support students of colour. As medical schools may seek to move toward a more student-centred approach, promoting feelings of validation for students of colour can be a key practice in teaching and learning to ensure support for medical students throughout their medical school journey.

Being, becoming, and belonging: reconceptualizing professional identity formation in medicine

Over the last decade, there has been a drive to emphasize professional identity formation in medical education. This shift has had important and positive implications for the education of physicians. However, the increasing recognition of longstanding structural inequalities within society and the profession has highlighted how conceptualizations of professional identity formation have also had unintended harmful consequences. These include experiences of identity threat and exclusion, and the promotion of norms and values that over-emphasize the preferences of culturally dominant groups. In this paper, the authors put forth a reconceptualization of the process of professional identity formation in medicine through the elaboration of 3 schematic representations. Evolutions in the understandings of professional identity formation, as described in this paper, include re-defining socialization as an active process involving critical engagement with professional norms, emphasizing the role of agency, and recognizing the importance of belonging or exclusion on one's sense of professional self. The authors have framed their analysis as an evidence-informed educational guide with the aim of supporting the development of identities which embrace diverse ways of being, becoming, and belonging within the profession, while simultaneously upholding the standards required for the profession to meet its obligations to patients and society.

'I'm looking as white and as straight as possible at all times': a qualitative study exploring the intersectional experiences of BAME LGBTQ+ medical students in the UK

OBJECTIVES

The positive formation of professional identity is considered crucial in how medical students begin to feel and act as clinicians. Although, awareness of how Professional Identity Formation (PIF) may be affected among minoritised groups is increasing, understanding from an intersectional lens remains limited. The aim of this study was to explore the experiences of Black, Asian, Minoritised Ethnic (BAME) and Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) medical students in the undergraduate Bachelor of Medicine, Bachelor of Science programme.

DESIGN

Based on the methodology of phenomenography, all medical students identifying as BAME and LGBTQ+ were eligible for participation. Semistructured interviews were conducted with data collection continuing until theoretical saturation was reached. The coding framework was developed independently by the principal researcher and supervisor before being compared to create a shared analytical framework.

SETTING

University College London Medical School (UCLMS) between October 2022 and February 2023.

PARTICIPANTS

Six UCLMS students were recruited, one of whom was in the 'early' years (years 1-3) with the remainder in the 'later' years (years 4-6) RESULTS: Six main themes emerged from the data, which were categorised into three main areas: challenges to intersectionality, benefits to intersectionality and protective factors. Challenges to intersectionality included three themes, 'The BAME identity interacting with the LGBTQ+identity', 'BAME background influencing LGBTQ+identity exploration' and 'no true safe spaces for BAME and LGBTQ+ students to be themselves'. Benefits to intersectionality included 'greater insight into the self' and protective factors included two themes of 'peer support networks' and 'visibility within the university and clinical environments.'

CONCLUSION

By exploring PIF among medical students from an intersectional lens, this study highlights the increased emotional burden faced by those who identify as BAME and LGBTQ+, as they attempt to reconcile both these identities with becoming a future doctor, affecting their sense of belonging socially and within the profession. Despite being based at a single medical school, it highlights the importance of creating a truly inclusive environment through positive role modelling and increased visibility among the BAME, LGBTQ+ community in the undergraduate programme.

Who am I? Professional Identity Formation in Pharmacy Education Among Learners Underrepresented in Pharmacy

Professional identity formation (PIF) throughout the pharmacy curriculum is important for learners to transform from layperson to pharmacist. To be effective, PIF activities need intentional development and support. Professional identity is often seen as the core component of PIF; however, there must be an emphasis on integrating and aligning an individual's personal identity through this process. Moreover, there has been an emphasis on upholding diversity, equity, inclusion, and antiracism efforts in pharmacy practice and education. There is a need to explore experiences of PIF among diverse populations, including learners underrepresented in pharmacy. This commentary explores the differences in PIF among underrepresented learners in health care disciplines and is a call to action to explore evidence-based interventions that are inclusive and tailored to individual learners. This commentary sets a foundation for additional scholarly work and recommendations regarding PIF among underrepresented learners.

Moral injury and the hidden curriculum in medical school: comparing the experiences of students underrepresented in medicine (URMs) and non-URMs

Underrepresented students in medicine (URM) have more negative perceptions of the medical school learning environment (LE), a phenomenon that can contribute to higher rates of burnout and attrition in these populations. The hidden curriculum (HC)-defined as a set of values informally conveyed to learners through clinical role-modeling-is a LE socialization construct that has been critically examined for its role in shaping students' professional identities. Yet differences in how URMs and non-URMs experience the HC remain underexplored. The study used a pragmatic approach that drew on elements of grounded theory and employed both deductive and inductive reasoning. Investigators conducted qualitative, semi-structured interviews with a purposive sample of 13 URM and 21 non-URM participants at a Bronx, NY medical school. Interviews examined student experiences and reactions to the HC. Both cohorts witnessed patient disparagement and mistreatment. However, from these encounters, URM participants expressed more moral injury-the adverse emotional consequence of feeling pressured to accept ideologically incongruent values. URMs were also more likely to describe resisting the HC. Differences in group reactions appeared to arise from URMs' identity resonance with patients' lived experiences. Participants across cohorts emphasized increasing URM recruitment as one step toward mitigating these circumstances. URM participants experienced more distress and offered more resistance to the HC relative to non-URMs. The etiology of these differential reactions may stem from relative barriers in negotiating personal and professional identities. As such, URMs' perceptions of the LE may be adversely impacted given their more negative interactions with the HC.

Equity, diversity, and…exclusion? A national mixed methods study of "belonging" in Canadian undergraduate medical education

Equity, diversity, and inclusion remain a prominent focus in medical schools, yet the phenomenon of "belonging" has arguably been overlooked. Little is known regarding how belonging is experienced by medical students from groups that face systemic oppression and exclusion. We employed a sequential explanatory mixed methods design to explore how students from equity-deserving groups (EDGs) experience belonging during medical school, including those who are women, racialized, Indigenous, disabled, and 2SLGBTQIA+. First, we conducted a national cross-sectional survey of medical students (N = 480) measuring four constructs: belonging, imposter syndrome, burnout, and depression. Belonging scores were overall lower for students from EDGs and, more specifically, significantly lowest amongst racialized students. Structural equation models show that poor sense of belonging precedes imposter syndrome and further exacerbates burnout and depression. Next, we sampled and interviewed students (N = 16) from the EDG whose belonging scores were significantly lowest. Participants described the essence of belonging as being able to exist as one's "true self" while emphasizing feelings of acceptance, comfort, and safety as well as being valued and seen as an equal - yet described how routine experiences of "othering" inhibited a sense of belonging, often due to differences in social identity and structural privilege. Poor sense of belonging negatively affected learners' well-being and career trajectory. We illuminate the range of psychological and professional consequences associated with diminished sense of belonging and highlight the need to expand traditional notions of equity, diversity, and inclusion to consider structural barriers to belonging.

'When I stood up for something it's because I felt a… moral violation': Trainees' acts of resistance against social harm and injustice

INTRODUCTION

As medical students around the world enter their chosen profession, they inherit a system that they did not design nor create, yet are still responsible for it. This system is rooted in centuries of social harm and inequity. This study examines trainees' professional acts of resistance to understand what trainees hope to accomplish in their resistance efforts, why they are resisting, and the tactics they use.

METHODS

Drawing on counter-storytelling and critical theory, we collected in-depth qualitative interviews from nine medical students and nine residents/fellows across North America. Using theoretical guidance on how to study acts of resistance, data were analysed using a combination of coding techniques to understand resistors' intentions in resisting and the tactics they used to understand what, why, and how trainees were resisting. The analysis was returned to participants for member checking.

RESULTS

Trainees described resisting systems of harm and injustice bequeathed to them by an older generation whose values and practices were reflective of a different time. Their motivations stemmed from deep-seated moral distress from the mistreatment of patients and learners. They hoped to re-envision medical education to be patient- and learner-centred. The tactics they chose depended on the level of power they had in the system and the extent to which they wished to have their efforts known.

DISCUSSION

Trainees described intentional and deliberate acts of resistance to the social harm and injustice embedded in the broader profession to re-create the profession. Given that these acts spanned a large geographical area, this study suggests that trainees may be part of a larger social movement aimed at creating widespread change within the profession.

Impact of Mentoring for Underrepresented Groups in Undergraduate Medical Education: A Systematic Review

OBJECTIVES

Despite efforts to mitigate challenges to advance underrepresented groups (URG) groups' representation in medical education, diversity remains underwhelming. In response to this several mentoring programs to increase diversification within medical education have been implemented. However, the impact of these programs on URG representation across disciplines is unknown. The aim of this review is to evaluate the impact of structured mentoring programs on URGs in undergraduate medical education.

DESIGN

Systematic review.

METHODS

A comprehensive search strategy was performed of electronic databases including PubMed, Ovid Medline, and EMBASE between January and September 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Both qualitative and quantitative outcomes including characteristics of the mentoring structure explored within each study were collected, and differences in study outcomes analyzed.

RESULTS

In total 17 studies were included for analysis. Mentoring within URGs resulted in an increase in research opportunities, exam performance, medical specialty applications, and residency matching. Structured feedback yielded positive experiences by both mentors and mentees participating in programs, with both emotional and cultural competence issues explored across studies included for analysis.

CONCLUSIONS

Mentoring for medical students underrepresented in medicine across mentoring relationships including peer, senior, formal, and informal structures yield positive outcomes within research, academic modules, and career pathways. Future applications of mentoring programs should consider the use of tandem mentoring from both senior and peer mentors to optimize benefits URG students derive from each mentoring relationship.

Methodological Challenges in Studies of Personal and Professional Identity Formation

Demographic information about the identities of faculty, staff, students, and trainees is frequently collected in pharmacy education. A wide range of identities and characteristics can influence the choices and experiences of students as they progress through curricula and develop their professional goals. Understanding personal and professional identity formation within dynamic and complex environments is critical to promoting the success of pharmacy education and practice. Emerging research efforts highlight the importance of considering identity development from varying perspectives, and offer new methods for collecting and analyzing data. The objective of this commentary is to reflect on the methodological challenges of identity formation research in pharmacy education and offer recommendations for those interested in this work.

Contradictions and Opportunities: Reconciling Professional Identity Formation and Competency-Based Medical Education

The widespread adoption of Competency-Based Medical Education (CBME) has resulted in a more explicit focus on learners' abilities to effectively demonstrate achievement of the competencies required for safe and unsupervised practice. While CBME implementation has yielded many benefits, by focusing explicitly on what learners are doing, curricula may be unintentionally overlooking who learners are becoming (i.e., the formation of their professional identities). Integrating professional identity formation (PIF) into curricula has the potential to positively influence professionalism, well-being, and inclusivity; however, issues related to the definition, assessment, and operationalization of PIF have made it difficult to embed this curricular imperative into CBME. This paper aims to outline a path towards the reconciliation of PIF and CBME to better support the development of physicians that are best suited to meet the needs of society. To begin to reconcile CBME and PIF, this paper defines three contradictions that must and can be resolved, namely: (1) CBME attends to behavioral outcomes whereas PIF attends to developmental processes; (2) CBME emphasizes standardization whereas PIF emphasizes individualization; (3) CBME organizes assessment around observed competence whereas the assessment of PIF is inherently more holistic. Subsequently, the authors identify curricular opportunities to address these contradictions, such as incorporating process-based outcomes into curricula, recognizing the individualized and contextualized nature of competence, and incorporating guided self-assessment into coaching and mentorship programs. In addition, the authors highlight future research directions related to each contradiction with the goal of reconciling 'doing' and 'being' in medical education.

The Intersection of Professional Identity Formation, Bias, and Marginalized Identities

OBJECTIVES

The objective of this integrative review is to call attention to the limited published literature on professional identity formation (PIF) in students who hold marginalized identities and to promote more inclusive PIF models.

FINDINGS

A person's identity is complicated and PIF is a dynamic and continuous lifelong process. A foundational component to PIF is for students to integrate their developing professional identity with their existing selves. Most PIF theoretical frameworks used in health education were created with a dominant culture lens and during a time when most professionals in practice were cisgendered, White, and/or male. These frameworks do not consider ways in which PIF may differ in learners who hold marginalized identities nor the influence that their marginalized identities may have on facilitators and barriers to their PIF journeys.

SUMMARY

PIF is a growing area of focus in pharmacy education and scholarship. To effectively support PIF for each member of a diverse student body, pharmacy educators must recognize the limitations of existing PIF theoretical frameworks owing to the historical exclusion of considerations of students' and practitioners' marginalized identities as a layer of professional identity, especially in the context of historical injustices. As members of the pharmacy Academy begin or continue to explore PIF in pharmacy education, they must be mindful and intentional about how they account for the impact that students' marginalized identities may have on their PIF.

A Qualitative Study of Underrepresented Minority (URM) Student Pharmacists' Intersectionality and Professional Identity Formation

OBJECTIVE

To determine how underrepresented minority (URM) student pharmacists' intersectionality affects professional identity formation early in their academic career.

METHODS

A qualitative study was undertaken. All students from Classes 2022 through 2025 at Texas A&M University School of Pharmacy were required to engage in reflection on a personal statement of philosophy of practice early in their first year of pharmacy as part of the structured longitudinal co-curricular course requirement. Statements of the URM students who referenced their intersecting identities were selected for deductive analysis per Bingham and Witkowsky and inductive analysis using Lincoln and Guba's approach to content analysis.

RESULTS

Of the 221 URM student pharmacists within the 4 cohorts who submitted a statement, 38 statements (92% Hispanic students) met the inclusion criteria. Student hometowns and the identity domains of the individual, relational, and collective were selected a priori for the deductive analysis. Students most often referenced individual identity characteristics that fit under the Principles I, IV, V, and VII of the Code of Ethics for Pharmacists. Three themes emerged from the inductive analysis: (1) defining experiences and resulting realizations, (2) motivating forces, and (3) aspirations as a pharmacist. A working hypothesis was developed.

CONCLUSION

The URM students' intersecting identities (race, ethnicity, socioeconomic class, and belonging to an underserved community) influenced their early professional identity formation. The desire to bring about racial uplift was observed among the Hispanic students as early in their P1 year through the School's required co-curricular reflection. Such reflective practice serves as an effective vehicle for the students to recognize their intersecting identities that impact their professional identity.

Professional identity struggle and ideology: A qualitative study of residents' experiences

INTRODUCTION

To enter a profession is to take on a new identity. Professional identity formation can be difficult, with medical learners struggling to adopt professional norms. The role of ideology in medical socialisation may offer insight into these tensions experienced by medical learners. Ideology is the system of ideas and representations that dominates the minds of individuals or social groups and calls individuals into certain ways of being and acting in the world. In this study, we use the concept of ideology to explore residents' experiences with identity struggle during residency.

METHODS

We conducted a qualitative exploration of residents in three specialties at three academic institutions in the United States. Participants engaged in a 1.5-hour session involving a rich picture drawing and one-on-one interview. Interview transcripts were coded and analysed iteratively, with developing themes compared concurrently to newly collected data. We met regularly to develop a theoretical framework to explain findings.

RESULTS

We identified three ways that ideology contributed to residents' identity struggle. First was the intensity of work and perceived expectations of perfectionism. Second were tensions between the developing professional identity and pre-existing personal identities. Many residents perceived messages regarding the subjugation of personal identities, including the feeling that being more than physicians was impossible. Third were instances where the imagined professional identity clashed with the reality of medical practice. Many residents described how their ideals misaligned with normative professional ideals, constraining their ability to align their practice and ideals.

CONCLUSION

This study uncovers an ideology that shapes residents' developing professional identity-an ideology that creates struggle as it calls them in impossible, competing or even contradictory ways. As we uncover the hidden ideology of medicine, learners, educators and institutions can play a meaningful role in supporting identity development in medical learners through dismantling and rebuilding its damaging elements.

Developing Evidence for Equitable Assessment Characteristics Based on Clinical Learner Preferences Using Discrete Choice Experiments

PURPOSE

Medical education is only beginning to explore the factors that contribute to equitable assessment in clinical settings. Increasing knowledge about equitable assessment ensures a quality medical education experience that produces an excellent, diverse physician workforce equipped to address the health care disparities facing patients and communities. Through the lens of the Anti-Deficit Achievement framework, the authors aimed to obtain evidence for a model for equitable assessment in clinical training.

METHOD

A discrete choice experiment approach was used which included an instrument with 6 attributes each at 2 levels to reveal learner preferences for the inclusion of each attribute in equitable assessment. Self-identified underrepresented in medicine (UIM) and not underrepresented in medicine (non-UIM) (N = 306) fourth-year medical students and senior residents in medicine, pediatrics, and surgery at 9 institutions across the United States completed the instrument. A mixed-effects logit model was used to determine attributes learners valued most.

RESULTS

Participants valued the inclusion of all assessment attributes provided except for peer comparison. The most valued attribute of an equitable assessment was how learner identity, background, and trajectory were appreciated by clinical supervisors. The next most valued attributes were assessment of growth, supervisor bias training, narrative assessments, and assessment of learner's patient care, with participants willing to trade off any of the attributes to get several others. There were no significant differences in value placed on assessment attributes between UIM and non-UIM learners. Residents valued clinical supervisors valuing learner identity, background, and trajectory and clinical supervisor bias training more so than medical students.

CONCLUSIONS

This study offers support for the components of an antideficit-focused model for equity in assessment and informs efforts to promote UIM learner success and guide equity, diversity, and inclusion initiatives in medical education.

The Influence of Intersectionality on Professional Identity Formation among Underrepresented Pharmacy Students

OBJECTIVE

The objective of this study is to explore professional identity formation (PIF) among student pharmacists from underrepresented groups (URGs).

METHODS

In this qualitative study, 15 student pharmacists from the University of Georgia and Midwestern University Colleges of Pharmacy were recruited for interviews to explore the influence of intersectionality of race, ethnicity, and gender on PIF. Interview data were analyzed using constructivist grounded theory to identify themes and then further analyzed using Crenshaw's theory of intersectionality, namely structural, political, and representational intersectionality.

RESULTS

Intersectionality of identities created situations where participants expressed advantages belonging to certain social categories, while simultaneously being disadvantaged belonging to other social categories. This awareness led to strategies to overcome these collective obstacles for themselves and their communities. Participants then described ways to shift perceptions of how society depicts pharmacists and the pharmacy profession. The results depict these processes and how intersectionality influences PIF for URG student pharmacists.

CONCLUSION

The sociocultural aspects of race, ethnicity, and gender influence the PIF of student pharmacists who belong to URGs. Intersectionality helps us better understand the ways in which inequality compounds itself, and this results in URG student pharmacists creating opportunities for belongingness and representation. Resultantly, URGs create opportunities for inclusivity and representation. To continue to facilitate this it is essential for educators and university systems to promote ways to foster and incorporate PIF in student pharmacists.

The intersectionality of professional and personal identity formation in a virtual pre-health pathway program

BACKGROUND AND PURPOSE

To describe the development and implementation of professional and personal identity formation content in a virtual pre-health pathway program.

EDUCATIONAL ACTIVITY AND SETTING

Content within a six-week pre-health program for underrepresented and/or disadvantaged college students was redesigned to a virtual format with enhanced focus on professional and personal identity formation. Sessions on personal identity formation were also enhanced through a partnership with local mental health clinicians specializing in trauma-informed care and culturally relevant practices and strategies.

FINDINGS

The 2020 and 2021 programs were restructured to include pharmacy professional identity formation content around the following weekly themes: Roadmap to Pharmacy, What Does it Mean to be a Pharmacist?, Expanding Knowledge of Pharmacy, Gaining Insight and Dispelling Myths, Practicing Knowledge and Exploration, and Moving Forward. These pre-pharmacy components emphasized diversity of career paths, pharmacy-based clinical services, and the pharmacist's role in promoting health equity. Overarching components of interprofessional collaboration coupled with health policy applications further emphasized the professional identity of a pharmacist in the collaborative design and delivery of health care. New personal identity formation sessions were implemented in tandem with this content and centering around the following themes: Supporting Scholars in Self-Authorship, Building a Community among Peers, and Strategies for Coping in Times of Challenge.

SUMMARY

This project has the potential to serve as a model for the implementation of both personal and professional identity formation initiatives at other programs to promote pharmacy as a desirable and attainable career to pre-health students.

The impact of underrepresented minority or marginalized identity status on training outcomes of MD-PhD students

Dual-degree MD-PhD programs have historically lacked diversity of race, ethnicity, gender, sexual orientation, and other facets of identity. Like MD- and PhD-granting programs, MD-PhD program training environments are also marked by structural barriers that negatively impact measurable academic outcomes of underrepresented and/or marginalized students in academic medicine (racial and ethnic minority groups considered underrepresented by the National Institute of Health, sexual and gender minorities, individuals with disabilities, and individuals of low socioeconomic status). In this article, we review the existing literature on MD-PhD program disparities affecting students from these groups and provide recommendations grounded on the reviewed evidence. Our literature review identified four generalizable barriers that can impact the training outcomes of students from these marginalized and/or underrepresented groups: 1) discrimination and bias, 2) impostor syndrome and stereotype threat, 3) lack of identity-similar mentors, and 4) suboptimal institutional policies and procedures. We propose goal-oriented interventions that may begin to ameliorate the disparities present in MD-PhD program training environments that affect students from marginalized and/or underrepresented groups in academic medicine.

Exploring the Professional Identity Formation of Racial/Ethnic Minoritized Physician Assistants

INTRODUCTION

The purpose of this article is to (1) describe how professional identity intersects with physician assistants' (PAs') and PA students' racial and ethnic identities and cultural backgrounds; (2) examine how sociohistorical contexts shape professional identity in racial/ethnic minoritized PAs and PA students; and (3) identify the role of PA program administrators and faculty to address the needs of racial/ethnic minoritized PAs and PA students.

METHODS

This study draws on elements of constructivist grounded theory to investigate the professional identity formation (PIF) experiences of 45 PA students and alumni from 3 institutions. Participants were recruited using a snowball method and identified as 23 Black/African American, 12 Hispanic/Latino, 6 mixed race, and 4 Native American/Indigenous. Interview data were analyzed using sociocultural theory as an analytic framework.

RESULTS

The results suggest that participants felt that their racial/ethnic identity was an important part of their identity, yet many indicated they experienced frequent micro- and macroaggressions from fellow students, faculty, lecturers, administrators, preceptors, patients, and supervisors. Additionally, they indicated that they need more support from their programs than what is currently provided.

DISCUSSION

The results of this study suggest that social experiences before, during, and after PA training strongly influence PIF development in racial/ethnic minoritized PAs. Administrators and professional PA organizations should evaluate methods to support those individuals who identify as a racial/ethnic minority throughout their careers.

Professional identity research in the health professions-a scoping review

Professional identity impacts the workforce at personal, interpersonal and profession levels however there is a lack of reviews of professional identity research across practising health professionals. To summarise professional identity research in the health professions literature and explore how professional identity is described a scoping review was conducted by searching Medline, Psycinfo, Embase, Scopus, CINAHL, and Business Source Complete using "professional identity" and related terms for 32 health professions. Empirical studies of professional identity in post-registration health professionals were examined with health profession, career stage, background to research, theoretical underpinnings and constructs of professional identity being extracted, charted and analysed using content analysis where relevant. From 9941 studies, 160 studies across 17 health professions were identified, with nursing and medicine most common. Twenty studies focussed on professional identity in the five years post-entry to the workforce and 56 studies did not state career stage. The most common background for the research was the impact of political, social and healthcare reforms and advances. Thirty five percent of studies (n = 57) stated the use of a theory or framework of identity, the most common being classified as social theories. Individual constructs of professional identity across the research were categorised into five themes-The Lived Experience of Professional Identity; The World Around Me; Belonging; Me; and Learning and Qualifications. Descriptions of professional identity are broad, varied, rich and multi-layered however the literature is under theorised with current theories potentially inadequate to capture its complexity and make meaningful contributions to the allied health professions.

Rethinking professional identity formation amidst protests and social upheaval: a journey in Africa

The under-representation of minoritized or previously oppressed groups in research challenges the current universal understanding of professional identity formation (PIF). To date, there has been no recognition of an African influence on PIF, which is crucial for understanding this phenomenon in places like South Africa, a society in which the inequity of the apartheid era still prevails. In addition, there is little data examining how social upheaval could impact PIF. This study uses interviews with medical students to explore PIF within the context of social upheaval during the 2015-2016 protests that rocked South Africa when students challenged asymmetries of power and privilege that persisted long after the country's democratic transition. The combination of the primary author's autoethnographic story, weaved into the South African sociohistorical context and ubuntu philosophy, contributes to this study of PIF in the South African context. The use of an African metaphor allowed the reorientation of PIF to reflect the influence of an ubuntu-based value system. Using the calabash as a metaphor, participants' experiences were framed and organized in two ways: a calabash worldview and the campus calabash. The calabash worldview is a multidimensional mixture of values that include ubuntu, reflections of traditional childhoods, and the image of women as igneous rocks, which recognizes the power and influence on PIF of the women who raised the participants. Introducing an African ubuntu-based perspective into the PIF discourse may redirect the acknowledgement of context and local reality in developing professional identity.

Intersectional Identities: Making Sense of Skill Development on Clinical Placements

OBJECTIVE

Little is known about the influence of personal experiences on learners' trajectories toward mastery. Newell's theory of constraints articulates the relationship between environmental, individual, and task-related factors for skill development. This study explores how undergraduate pharmacy students experience skill development on placements and what the barriers and facilitators are within Newell's framework.

METHODS

Year 3 undergraduate pharmacy students were invited to take part in focus groups exploring Newell's theory relative to skill development. Verbatim transcripts were analyzed using an interpretive phenomenological approach.

RESULTS

Five focus groups were conducted with 16 students. The placement task provided structure through entrustable professional activities (EPAs). The resulting skill development varied but included EPA expected behaviors and also skills for mastery, eg, self-reflection. Students' personal identities acted as both barriers and facilitators. For example, expecting or experiencing racial microaggressions limited participation; having a local accent facilitated rapport with patients. Students worked toward integration into the community of practice (the ward), where the staff was critical to inclusion. Where students had barriers related to their identities, they found it more difficult to access the community of practice.

CONCLUSION

Factors related to the community of practice (environment), students' identities (individual), and the EPA behaviors (task) can influence skill development during placement. For some students, these factors will be more prevalent, and elements of their identities may intersect and conflict, acting as both barriers and facilitators to skill development. Educators can consider the influence of intersectionality on student identity when designing and preparing new placements and assessing students.

Breaking boundaries through Doctors Reaching Minority Men Exploring Neuroscience: a mentorship model to foster a pipeline for underrepresented minorities

OBJECTIVE

In 2015, the Association of American Medical Colleges report titled "Altering the Course: Black Males in Medicine" showed a decline in the number of Black men matriculating into medical school. To alter this trend, the authors' hypothesis was that formally exposing Black men to the clinical neurosciences during high school would enhance their chances of entering the physician workforce. For this reason, in 2007, the Doctors Reaching Minority Men Exploring Neuroscience (DR. MMEN) program was established at the Icahn School of Medicine at Mount Sinai. The program aimed to provide early exposure, mentorship, and inspiration to high school-age Black and Latinx men. The aim of this study was to evaluate the impact of the DR. MMEN program in the context of the recent race and ethnicity trends among medical school matriculants (MSMs).

METHODS

Association of American Medical Colleges data on MSMs stratified by race and ethnicity were reviewed for the period between 2015 and 2020. Data pertinent to the academic achievements of DR. MMEN participants, such as matriculation to college and/or medical school, were prospectively tracked and incorporated with mixed-methods exit assessment data. Qualitative responses were coded and analyzed using a thematic concept analysis method.

RESULTS

Over the study period, the increase of MSMs in the US was 1.0% and 1.7% for Black and Latinx individuals, respectively. Changes for the male MSM cohort were negligible: 0.3% for Black and 0.7% for Latinx. With respect to DR. MMEN, 42% of participants from 2017 to 2019 earned college scholarships, and 25% of students from the 2017-2018 cohort matriculated to a combined college-medical program. Survey data showed that 100% of DR. MMEN participants found the program useful. Analysis of qualitative data revealed that participants considered pursuing a career in neurosurgery or in another medical field. Diligence and a passion for medicine were identified as the top two most important lessons in the program, and witnessing patient satisfaction and observing a neurosurgery operation were described as the most important experiences. Participants considered availability to give advice and feedback and a passion for teaching as the principal attributes of their mentors.

CONCLUSIONS

Over the past 6 years, the slight increase in Black and Latinx MSMs has not been significant enough to remedy ethnoracial disparities among MSMs. In particular, Black male matriculation to medical school has remained stagnant. The DR. MMEN program is a promising model to inspire young scholars and improve diversity within neuroscience and medicine at large.

Black Physicians' Experiences with Anti-Black Racism in Healthcare Systems Explored Through An Attraction-Selection-Attrition Lens

Anti-Black racism is a specific form of racism directed at Black people. In healthcare, there are poignant examples of anti-Black racism in the recruitment, selection, and retention stages of the job cycle. Research shows that anti-Black racism is associated with inequitable work outcomes and the under-representation of Black physicians. However, empirical findings are scattered with no organizing framework to consolidate these findings. To add to the literature, in this paper we present the attraction-selection-attrition (ASA) model (Schneider, 1987) as an organizing framework to discuss Black physicians' experiences with anti-Black racism and discrimination throughout their careers. We draw from previous literature to highlight specific experiences of Black physicians at each stage of the job cycle (i.e., attraction, selection, retention), and we offer considerations on how practitioners can mitigate anti-Black racism throughout the job cycle. In the wake of COVID-19 and highly publicized social justice movements, healthcare systems are seeking ways to increase the recruitment, selection, and retention of Black physicians to ensure health equity. We believe this guide will be valuable to practitioners, leaders, researchers, and program directions seeking to advance diversity, equity, and inclusion of Black physicians in their healthcare systems. We conclude by providing practical implications and directions for future research.

Becoming by doing: How women in academic health sciences build a leadership identity through project experiences

PURPOSE

Leadership development programs often use institutional projects to activate learning. We explored how project work shaped leadership identity formation in senior women leaders from one academic health science center who enrolled in The Hedwig von Ameringen Executive Leadership in Academic Medicine (ELAM^®) program.

MATERIALS AND METHODS

We interviewed ELAM Fellows and conducted a qualitative analysis of transcripts. Our primary analysis focused on the influences of projects on Fellows and institutions. Leadership identity formation emerged as a distinct pattern, so this narrative content was separated for secondary analysis. All authors approved the final assignment of themes and codes.

RESULTS

Participants described a multi-dimensional process for developing a leadership identity. Themes encompassed participants' View of Self and One's Image as a Leader, Interpersonal Relationships, and Commitment to a Value-based Goal. These internal factors grounded external influences, such as interactions with colleagues and institutional leaders, and the world beyond the institution.

CONCLUSIONS

We examined the process of leadership identity formation from the perspective of women leaders in academic health sciences who completed an institutional project during a leadership development program. Findings illustrate how internal and external forces, experienced in the context of project work, combine to influence leadership identity formation in women.

Professionalism and professional identity formation in dental students: Revisiting the professional role orientation inventory (PROI)

OBJECTIVE

Professionalism is a hallmark of health professions education. Professional identity formation is a growing field of exploration in medical education, and the dental literature is sparse on just how professional identity formation is developed and assessed within dental education.

METHODS

The validated professional role orientation inventory (PROI) was administered to 2nd year dental students during a spring semester ethics course. The PROI includes four 10-item scales representing four attitudinal factors: Authority, Responsibility, Agency, and Autonomy.

RESULTS

When compared to a historical sample of dental students in the early 1990s, dental students today scored significantly higher on Responsibility (p = 0.0309) and lower on the Agency factor (p = 0.0001). Authority scores in the current sample of dental students were significantly associated with age and race, with an increase in age associated with a decrease in Authority (p = 0.0504) and Caucasian respondents demonstrating significantly higher scores than Asian or Other races. Debt was associated with differences in Autonomy (p = 0.0683) and Agency (p = 0.0106), with those in the 100k-300k anticipated debt range demonstrating lower levels of both Autonomy and Agency. Race was marginally associated with Responsibility with those in the Other race category (Hispanic, Black/African American, Other/Multiracial) demonstrating higher levels than Caucasian (p = 0.0513).

CONCLUSION

Dental students' scores denote a continued commitment to others yet a feeling of less sense of control as a practicing professional. A redefining of professionalism to include social activism and advancing health equity is required given their altruism and commitment to others, which remains high.

"Finding My Piece in That Puzzle": A Qualitative Study Exploring How Medical Students at Four U.S. Schools Envision Their Future Professional Identity in Relation to Health Systems

PURPOSE

Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation.

METHOD

Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives.

RESULTS

Most students anticipated enacting one or more systems-related roles as a future physician, categorized as "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at a system or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to systems challenges affecting patients; supportive classmates, faculty, and institutional culture). Students also described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences).

CONCLUSIONS

This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings inform practical strategies to support professional identity formation inclusive of systems engagement.

"Walking on eggshells": experiences of underrepresented women in medical training

INTRODUCTION

Medicine remains an inequitable profession for women. Challenges are compounded for underrepresented women in medicine (UWiM), yet the complex features of underrepresentation and how they influence women's career paths remain underexplored. This qualitative study examined the experiences of trainees self-identifying as UWiM, including how navigating underrepresentation influenced their envisioned career paths.

METHODS

Ten UWiM family medicine trainees from one Canadian institution participated in semi-structured group interviews. Thematic analysis of the data was informed by feminist epistemology and unfolded during an iterative process of data familiarization, coding, and theme generation.

RESULTS

Participants identified as UWiM based on visible and invisible identity markers. All participants experienced discrimination and "otherness", but experiences differed based on how identities intersected. Participants spent considerable energy anticipating discrimination, navigating otherness, and assuming protective behaviours against real and perceived threats. Both altruism and a desire for personal safety and inclusion influenced their envisioned careers serving marginalized populations and mentoring underrepresented trainees.

DISCUSSION

Equity, diversity, and inclusion initiatives in medical education risk being of little value without a comprehensive and intersectional understanding of the visible and invisible identities of underrepresented trainees. UWiM trainees' accounts suggest that they experience significant identity dissonance that may result in unintended consequences if left unaddressed. Our study generated the critical awareness required for medical educators and institutions to examine their biases and meet their obligation of creating a safer and more equitable environment for UWiM trainees.

Wearing hats and blending boundaries: harmonising professional identities for clinician simulation educators

Many clinicians working in healthcare simulation struggle with competing dual identities of clinician and educator, whilst those who harmonise these identities are observed to be highly effective teachers and clinicians. Professional identity formation (PIF) theories offer a conceptual framework for considering this dilemma. However, many clinician simulation educators lack practical guidance for translating these theories and are unable to develop or align their dual identities.

An unusual experience involving the first author’s suspension of disbelief as a simulation facilitator sparked a novel reflection on his dual identity as a clinician and as a simulation educator. He re-framed his clinician and simulation ‘hats’ as cooperative and fluid rather than competing and compartmentalised. He recognised that these dual identities could flow between clinical and simulation environments through leaky ‘blended boundaries’ rather than being restricted by environmental demarcations.

This personal story is shared and reflected upon to offer a practical ‘hats and boundaries’ model. Experimenting with the model in both clinical and simulation workplaces presents opportunities for PIF and alignment of dual identities. The model may help other clinician simulation educators navigate the complexities of merging their dual identities.

Into the Unknown: Experiences of Social Newcomers Entering Medical Education

PURPOSE

Amid efforts to diversify the medical profession, research has yet to fully explore the role of early social ties to the field. This study examined diversity through the experiences of students without early ties to medicine through family members working in health care (i.e., "newcomers") in comparison with more-connected peers (i.e., "insiders"), examining how social newcomers to medicine negotiate challenges stemming from their outsider status.

METHOD

The author conducted an exploratory qualitative study from 2018 to 2021 using a constructivist grounded theory approach. Following a voluntary preliminary survey of 2 cohorts of first-year medical students about their social connections in health care, the author conducted interviews over the next 2 years with students who had indicated their willingness to participate. Interviews addressed how social context shaped-and continued to influence-their journeys into medicine. Eighty second- and third-year students participated in 94 interviews, including some follow-up interviews for longitudinal insight into outsider status. Interviews from the second year (58 new, 14 follow-up) provided the foundation of the qualitative results.

RESULTS

Students experienced outsider status primarily on the basis of being newcomers to medicine, often compounded by intersectional characteristics, including first-generation college status, rural or low-income background, race or ethnicity, and nontraditional status. For some, an early shortage of social capital became internalized, continuing to influence confidence and belonging well into training, in line with social reproduction theory. However, newcomers also experienced benefits associated with diverse backgrounds which helped them find a sense of belonging in medicine, as suggested by community cultural wealth and antideficit perspectives.

CONCLUSIONS

Newcomer status proved to be a central cause of outsiderness for students from all backgrounds and warrants greater attention from stakeholders, perhaps mirroring the undergraduate focus on first-generation college-goers. Findings suggest institutions that provide robust networking and community-building opportunities are best positioned to support newcomers.

Beyond Humility: Empowering Minoritized Learners Through Culturally Reflective Medicine

In the wake of the Black Lives Matter and other antiracism justice movements, medical education is evolving to incorporate health equity principles for all medical students and residents, while also increasing institutional diversity recruitment of minoritized physicians. As the demographics of U.S. medical trainees shift to reflect a rapidly evolving patient population, the prevalence of culturally concordant patient-physician visits, where patients share elements of language, religion, customs, and identities with their physician, is also expected to increase. However, existing antiracist curricula are standardized to all learners and there is a dearth of cultural sensitivity training designed specifically for minoritized learners to interrogate the culturally concordant space they share with patients and mentors. In this article, the authors propose a new model for minoritized learners' cultural training, culturally reflective medicine (CRM) that identifies unanticipated tensions that may arise as minoritized learners bridge both White and Eurocentric professional and personal identities, examines how intersectionality can both strengthen encounters and lead to shared blind spots, and empowers minoritized physicians with tools for self- and group reflection to advocate for their communities. CRM is contextualized within the current landscape of cultural sensitivity training in medical education. The authors provide 2 clinical vignettes to demonstrate how CRM can unveil more nuanced understandings of health disparities than existing cultural training. As institutions work toward diversity, equity, justice, and antioppression, CRM provides a novel framework for redesigning medical education that better acknowledges and incorporates the unique knowledge of minoritized learners.

Ova-looking feminist theory: a call for consideration within health professions education and research

The role of feminist theory in health professions education is often 'ova-looked'. Gender is one cause of healthcare inequalities within contemporary medicine. Shockingly, according to the World Health Organisation, no European member state has achieved full gender equity in regard to health outcomes. Further, contemporary curricula have not evolved to reflect the realities of a diverse society that remains riddled with inequity. This paper outlines the history of feminist theory, and applies it to health professions education research and teaching, in order to advocate for its continued relevance within contemporary healthcare.

A comparison of professional identity experiences among minoritized medical professionals

OBJECTIVE

Professional identity formation (PIF) is considered a fundamental process in the development of healthcare providers. In medical education, the PIF literature has historically centered on medicine's socialization practices involving white male physicians. However, recently researchers have begun to reveal how larger socio-historical contexts influence PIF in minoritized physicians. To better understand what influences Black/African American physicians' PIF, this study compares their PIF experiences to a group of minoritized physician assistants (PAs). In comparing Black physicians' experiences to another provider, this study explored what PIF experiences may be attributed to participants' minoritized status and what might be attributed to the culture of medicine.

METHODS

In this cross-case analysis, 45 minoritized PA students and practicing PAs were recruited from several Southeastern universities. The PA participants included 23 Black/African Americans, 12 Latinx, 4 Indigenous/Native, and 6 of mixed races/ethnicities. Interview data were then compared to previously collected data from 41 Black/African American medical trainees and physicians. Using constant comparative method, similarities and differences in PIF were explored.

RESULTS

Similarities between the two groups included the importance of participants' racial/ethnic identity to patient care, experiences on-going microaggressions from patients and peers, and a desire to engage in racial uplift. However, one marked difference was found, namely that PAs felt they could bring their entire selves to the profession, whereas physicians described feeling splintered early in their training.

CONCLUSIONS

Several possibilities that might explain why Black physicians and minoritized PAs have this one marked difference in their PIF experience, including identity threat, internalization of different discourses, and length of training for physicians. While this study was not designed to answer this question, it is clear that there is something in the culture of medicine and the training of physicians that signals to Black physicians that they cannot bring their whole selves to the profession.