The Problem and Power of Professionalism: A Critical Analysis of Medical Students' and Residents' Perspectives and Experiences of Professionalism

Navigating identity dissonance: subjectification to balance socialization

One of the main goals of medical education is to facilitate the development of a professional identity. As part of this effort, trainees are exposed to the values and cultures of the profession in a process known as socialization. Learners must then negotiate incongruent aspects between their preexisting identities and nascent professional identities. Individuals from historically underrepresented ethnic groups often undergo more significant changes due to their values and culture not being as prevalent within the dominant ideology of medicine. This transformative process can lead to identity dissonance and manifest as an internal discomfort resulting from perceived contradictions between one's existing identity and the required professional identity. Identity dissonance may be traumatic and pose a threat to the academic performance and professional integration of trainees. These detrimental effects harm the medical workforce by depriving it of a group crucial in addressing health inequities. Educators tasked with facilitating the professional development of learners must consider their implicit expectations about professionalism, explore the distinct challenges experienced by individuals from underrepresented backgrounds in their professional development, and work to develop strategies to help trainees navigate identity dissonance. Subjectification, an education philosophy that focuses on compelling individuals to explore the new possibilities and responsibilities imparted to them by their education, provides a theoretical framework to help educators guide learners through identity dissonance.

Professionalism lapses in health professions training: Navigating the 'Yellow Card' moments for transformative learning

INTRODUCTION

Health professions training programmes face increasing reports of professionalism lapses, which can delay, or end, trainee progression. How programmes respond to professionalism lapses to facilitate professional identity development has not been clarified. The objective of this study is to identify factors that facilitate and impair transformations around professionalism lapses in health professions training programmes.

METHODS

We conducted a qualitative study interviewing 5 faculty and 20 trainees with firsthand or secondhand experience with professionalism lapses from a range of health professions training programmes at McMaster University. Using reflexive thematic analysis, we coded verbatim transcripts informed by the lenses of social and transformative learning theories. We constructed themes through iterative and comparative analysis, seeking meaningful variation across professions and triangulating faculty and trainee perspectives.

RESULTS

Four themes were constructed. First, lapses are in the eye of the beholder with personal definitions intersecting with institutional and situation norms. Difficulties exist in recognising and convincing trainees to respond to lapses that are perceived to be minor or subject to interpretation. Second, responses to professionalism lapses occurred within power hierarchies, which impacted how trainees reacted to the remediation process, risked superficial trainee responses to concerns and led to concerns around inequitable treatment in how standards were applied. Third, fostering transformation involves building trainee confidence, agency, trust and engagement. Focused support and advocacy for trainees can empower and promote agency in tackling disorienting lapses. Fourth, perspective shifts involve deep engagement over time, including but not limited to self-reflection, structured discussion and seeking support.

DISCUSSION

Identifying and addressing professionalism lapses is complex and requires nuanced and contextual exploration of personal, institutional and situational dynamics at play. By fostering environments that promote genuine reflection and dialogue and focus on building trainee confidence, agency, trust and engagement, health professions training programmes can better support trainees in navigating these complex situations and contribute to the broader goal of socialising to a professional culture and practice.

How medical students learn about the social: Opportunities and limitations in service learning and volunteering

Medical education's integration of social determinants of health (SDOH) is essential for fostering equitable and comprehensive patient care. Despite this need, many medical schools struggle to effectively teach SDOH due in part to the hidden curriculum-subtle, institutional norms and values that implicitly shape student learning and, in this case, undermine an appreciation of SDOH. This article examines the potential and limitations of service learning (SL) as an experiential learning modality to address these challenges. Traditional didactic methods often fail to capture the complex, relational aspects of modern medical practice, necessitating a more interactive and community-engaged approach. When grounded in principles of justice and community partnership, SL can help transform medical students from passive recipients of knowledge into active, critical thinkers. We identify four key outcomes of SL in medical education: 1) development of empathic and reflective practices, 2) explicit engagement with social injustices, 3) promotion of diverse perspectives, and 4) cultivation of advocacy skills. To explore these possibilities, we present a case study of an urban medical school's SL program focused on prison health and mass incarceration, using it as a heuristic tool to illustrate both the strengths and challenges of SL in medical education. Through this analysis, we demonstrate how SL can disrupt the hidden curriculum, deepen students' understanding of SDOH, and enhance their ability to provide compassionate, equitable care while highlighting the need for future empirical research that systematically assess SL's long-term impact on medical education and health equity.

Current State of Diversity in Orthopaedic Surgery Residency and Future Direction: A Review

Orthopaedic surgery is one of the least diverse fields in medicine. Barriers to increasing the racial, gender, and sexual minority diversity of residents include pervasive negative impressions about the culture in orthopaedic surgery; lack of early exposure to and education about orthopaedics; new large-scale diversity, equity, and inclusion initiatives that have yet to become fully established; and lack of mentorship from those with shared backgrounds, gender, sexual orientation, or race. Recently, there have been several pipeline initiatives aimed at exposing women and underrepresented minority students to orthopaedics and medicine early in their careers, which have shown remarkable success. Toward this goal, recent recommendations from Nth Dimensions have provided a toolkit to help recruit and maintain diverse trainees. Furthermore, advocating for further funding and support of initiatives from national organizations that lead the field of orthopaedics will be paramount to institutionalizing efforts of diversity, equity, and inclusion within the orthopaedic community.

Is insufficient introspection a reason to terminate residency training? - Scrutinising introspection among residents who disputed dismissal

INTRODUCTION

Insufficient introspection as part of the 4I's model of medical professionalism (introspection, integrity, interaction, and involvement) is considered an important impediment in trainees. How insufficient introspection relates to decisions to terminate residency training remains unclear. Insights into this subject provide opportunities to improve the training of medical professionals.

METHODS

We analysed the Dutch Conciliation Board decisions regarding residents dismissed from training between 2011 and 2020. We selected the decisions on residents deemed 'insufficient' regarding introspection as part of the CanMEDS professional domain and compared their characteristics with the decisions about residents without reported insufficiencies on introspection.

RESULTS

Of the 120 decisions, 86 dismissed residents were unable to fulfil the requirements of the CanMEDS professional domain. Insufficient introspection was the most prominent insufficiency (73/86). These 73 decisions described more residents' insufficiencies in CanMEDS competency domains compared to the rest of the decisions (3.8 vs. 2.7 p < 0.001), without significant differences regarding gender or years of training.

CONCLUSIONS

Insufficient introspection in residents correlates with competency shortcomings programme directors reported in dismissal disputes. The 4I's model facilitates recognition and description of unprofessional behaviours, opening avenues for assessing and developing residents' introspection, but further research is needed for effective implementation in medical education.

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.

Allied health work readiness capabilities: a qualitative comparison of graduates, supervisors, and managers' perspectives

Researchers have highlighted gaps in the work readiness (WR) of allied health (AH) graduates and the capabilities required to successfully work in an interprofessional collaborative practice healthcare environment. In the studies conducted, the focus has generally been on one AH discipline or on one participant group across disciplines, such as new graduates. We explored WR capability of new AH graduates across three participant groups (managers, supervisors, and graduates) and across several AH disciplines in the health sector. Focus groups using Critical Incident Technique (CIT) were conducted with 47 participants (14 new graduates, 13 supervisors, and 20 managers) from four public health organisations across Eastern Australia. CIT identified examples where new AH graduates had/did not have necessary WR capabilities to manage situations in the collaborative practice environment. Using thematic analysis, we found four main themes related to WR expectations of AH graduates (work skills and knowledge, working with others, personal attributes, and organisational knowledge), with several sub-themes. Some aspects of identified themes/sub-themes were unique to the AH interprofessional work context. Understanding of AH graduates' WR from multiple perspectives could support development of programs to enable graduate success in interprofessional working environments.

Incorporating equity, diversity and inclusion (EDI) into the education and assessment of professionalism for healthcare professionals and trainees: a scoping review

BACKGROUND

Current definitions of professionalism for healthcare trainees often lack equity, diversity and inclusion (EDI) in the expectations and assessment of professionalism. While professionalism teaching is incorporated in healthcare training, equity-deserving groups still experience discrimination. This scoping review investigates the literature to understand how EDI and associated domains of cultural humility, and advocacy can be incorporated in healthcare trainees' education and assessment of professionalism.

METHODS

The Arksey and O'Malley framework was applied to this scoping review. MEDLINE, Embase & PsychINFO were searched up to March 2023, with terms surrounding health professionals, professionalism, EDI, cultural humility, and advocacy. Titles and abstracts (n = 3870) and full-texts (n = 140) were independently screened by two reviewers. Articles were included if they focused on EDI, cultural humility, or advocacy among healthcare students/trainees, and had outcomes related to professionalism. Articles lacking discussion of professionalism as an outcome were excluded. Themes were generated by mutual discussion. Risk of bias was assessed using the Cote et al. and Medical Education Research Study Quality Instrument (MERSQI) tools.

RESULTS

48 articles underwent thematic analysis. Studies investigated the disciplines of medicine, nursing, social work, physiotherapy, and dentistry. Most studies were qualitative in methodology (n = 23). Three themes emerged: (1) EDI-related interventions are associated with improved professionalism of healthcare trainees/workers (n = 21). Interventions employed were either an EDI-associated educational course (n = 8) or an exchange program to promote EDI competencies among trainees (n = 13). (2) Trainee definitions and perceptions of professionalism include themes related to EDI and cultural humility (n = 12). (3) Current standards of professionalism are perceived as non-inclusive towards historically-marginalized populations (n = 15). Literature investigating advocacy as it relates to professionalism is limited.

CONCLUSION

This review identified that core EDI principles and its associated domains of cultural humility and advocacy are often viewed as integral to professionalism. These findings create a strong impetus to incorporate EDI principles within professionalism frameworks in healthcare education. Future research should employ standardized tools for professionalism assessment to provide more conclusive evidence. Incorporating patient perspectives of professionalism can inform actionable recommendations for fostering inclusive healthcare environments.

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.

Incorporating Anti-racist Principles Throughout the Research Lifecycle: A Position Statement from the Society of General Internal Medicine (SGIM)

Biomedical research has advanced medicine but also contributed to widening racial and ethnic health inequities. Despite a growing acknowledgment of the need to incorporate anti-racist objectives into research, there remains a need for practical guidance for recognizing and addressing the influence of ingrained practices perpetuating racial harms, particularly for general internists. Through a review of the literature, and informed by the Research Lifecycle Framework, this position statement from the Society of General Internal Medicine presents a conceptual framework suggesting multi-level systemic changes and strategies for researchers to incorporate an anti-racist perspective throughout the research lifecycle. It begins with a clear assertion that race and ethnicity are socio-political constructs that have important consequences on health and health disparities through various forms of racism. Recommendations include leveraging a comprehensive approach to integrate anti-racist principles and acknowledging that racism, not race, drives health inequities. Individual researchers must acknowledge systemic racism's impact on health, engage in self-education to mitigate biases, hire diverse teams, and include historically excluded communities in research. Institutions must provide clear guidelines on the use of race and ethnicity in research, reject stigmatizing language, and invest in systemic commitments to diversity, equity, and anti-racism. National organizations must call for race-conscious research standards and training, and create measures to ensure accountability, establishing standards for race-conscious research for research funding. This position statement emphasizes our collective responsibility to combat systemic racism in research, and urges a transformative shift toward anti-racist practices throughout the research cycle.

Are Pre-clerkship Remediation, Grading, and Reporting Practices Equitable in the U.S.? A National Survey

Phenomenon: With the proliferation of pass/fail grading practices in the pre-clerkship phase of undergraduate medical education, questions arise about the transparency and variability of grading and grade reporting practices, raising issues of equity in assessment, particularly regarding residency matching. The purpose of this survey was to determine the remediation and academic performance reporting practices of United States (U.S.) allopathic medical schools in the pre-clerkship phase of their curricula. Approach: After an extensive literature search and feedback from curriculum deans and learning experts, we developed a survey that we sent in the Spring of 2022 to pre-clerkship curriculum officials at all 154 accredited U.S. allopathic medical schools. It addressed curriculum content and structure; pre-clerkship remediation (e.g., course retakes) and reporting (e.g., permanency of transcript notation) practices; documentation and reporting of nonacademic competencies; and participant opinions and recommendations regarding reporting, transparency, and equity. We generated descriptive statistics and did manifest coding of open-ended responses. Findings: We had a response rate of 40% (62/155), with over 71% indicating mainly organ systems-based curricula. Depending on the situation, there were a wide range of remediation approaches for single- and multiple-course failures, including tutoring or learning support, re-exams, and referrals to a promotion board. Professionalism concerns were a top priority to report to residency directors, with significant variability in respondent opinions and practices in reporting remedial activities. Respondents were concerned about equity, both in terms of flexible grading practices and transparency of reporting practices. Insights: The variability in reporting practices across schools, while allowing holistic and individualized approaches to academic support, also creates potential inequities. More work is needed to understand how different reporting practices across institutions may disadvantage marginalized and minoritized student groups at different points in their preparation.

Professionalism Policies and Practices as Experienced by First-Generation Medical Students, Residents, and Physicians

Phenomenon: While professionalism is largely understood to be complex and dynamic, it is oftentimes implemented as if it were static and concrete. As a result, policies and practices reflect dominant historical norms of the medical profession, which can cause tension for trainees from marginalized groups. One such group comprises those who identify as first-generation physicians - those whose parents have not earned an associate's degree or higher. This group is highly diverse in terms of gender, race, ethnicity, and socioeconomic status; however, their experiences with institutional professionalism policies and practices has not yet been fully explored. In this study, our aims were to understand the ways in which these participants experience professionalism, and to inform how professionalism can be more inclusively conceptualized. Approach: In November 2022-March 2023, we conducted semi-structured interviews with 11 first-generation medical students, residents, and physicians and analyzed select national and institutional professionalism policies in relation to key themes identified in the interviews. The interviews were designed to elicit participants' experiences with professionalism and where they experienced tension and challenges because of their first-gen identity. Data were analyzed using thematic analysis through a critical perspective, focused on identifying tensions because of systemic and historical factors. Findings: Participants described the ways in which they experienced tension between what was written, enacted, desirable, and possible around the following elements of professionalism: physical appearance; attendance and leaves of absence; and patient care. They described a deep connection to patient care but that this joy is often overshadowed by other elements of professionalism as well as healthcare system barriers. They also shared the ways in which they wish to contribute to changing how their institutions conceptualize professionalism. Insights: Given their unique paths to and through medicine and their marginalized status in medicine, first-generation interviewees provided a necessary lens for viewing the concept of professionalism that has been largely absent in medicine. These findings contribute to our understanding of professionalism conceptually, but also practically. As professionalism evolves, it is important for institutions to translate professionalism's complexity into educational practice as well as to involve diverse voices in refining professionalism definitions and policies.

Digging Deeper, Zooming Out: Reimagining Legacies in Medical Education

Although the wide-scale disruption precipitated by the COVID-19 pandemic has somewhat subsided, there are many questions about the implications of such disruptions for the road ahead. This year's Research in Medical Education (RIME) supplement may provide a window of insight. Now, more than ever, researchers are poised to question long-held assumptions while reimagining long-established legacies. Themes regarding the boundaries of professional identity, approaches to difficult conversations, challenges of power and hierarchy, intricacies of selection processes, and complexities of learning climates appear to be the most salient and critical to understand. In this commentary, the authors use the relationship between legacies and assumptions as a framework to gain a deeper understanding about the past, present, and future of RIME.