Reframing professional identity through navigating tensions during residency: A qualitative study

Professional identity is “a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting, and feeling like a physician [1].” Key features of an individual’s professional identity include what a professional believes, knows, and does [2]. Professional identity formation (PIF) is “an adaptive developmental process that happens simultaneously at two levels: (a) at the level of the individual, which involves the psychological development of the person and (b) at the collective level, which involves the socialization of the person into appropriate roles and forms of participation in the community’s work [1, 3].”

While PIF is defined as both an individual and a social process, most medical education literature has focused separately on either the psychological or sociological facets of identity formation. At the psychological level, PIF is an individual process of incorporating experiences into an evolving concept of self [4, 5]. Psychological studies of PIF use theories from developmental psychology (e.g. Kegan’s model of adult development) to describe stages across a professional’s career [5, 6]. However, internal processes alone cannot capture the complexity of PIF, as context and relationships are critical [5, 7, 8]. At the sociological level, PIF is a socialization process influenced by experiences, role models, and mentors, all within the larger context of learning environments and healthcare systems [5, 8]. Sociological models highlight the complexity of contributors to PIF in medical education. While these separate lines of examination are useful for characterizing aspects of PIF, examination of the dynamic interactions between the psychological and sociological influences may provide a deeper understanding of PIF.

Bridging sociology and psychology, social psychology seeks to explain how social influences affect an individual’s thoughts, feelings, and behaviors. A social psychological approach to studying identity examines the dynamic interaction between individual agency and the sociological influences on identity formation [9]. Lewin, a pioneer of social psychology, proposed that human behavior is shaped by the interaction between a person and their environment [10]. Expanding on Lewin’s work, Bandura introduced Social Cognitive Theory (SCT), proposing that personal factors, environmental factors, and behaviors exert bidirectional influence on each other, a process he named “reciprocal determinism [11]” (Fig. 1). While Bandura believed that a person’s thoughts and actions are shaped by environmental influences, an individual also has agency to shape their environment through thoughts and actions [11, 12]. Bandura acknowledged that many factors may lead to a given effect, that factors contribute unequally, and that factors’ influences vary over time [11]. Bandura further describes the personal factors that affect behavior as what people “think, believe, and feel [11].” Given this definition aligns closely with our definition of identity, we have adapted the model to place identity as the personal factor and used this model to guide our data analysis. While previous frameworks outline the internal (e.g. conscious reflection) and external (e.g. mentors, role models, and the learning environment) factors that shape PIF [5], examining the bidirectional influences of factors—namely identity, behavior, and context—may provide a lens for studying the dynamic nature of PIF and integrating psychological and sociological determinants of professional identity and behavior.

Understanding these bidirectional influences may clarify identity tensions faced by trainees. For physicians, residency is a critical time for navigating tensions as residents “reconcile dissonance between the stated values of the medical profession and the realities of medicine as practiced in the real world,” including tensions between values within medicine [7, 13, 14]. Residents balance the tensions inherent to the dual role of being a physician and a trainee [15]. Residents also balance the tension between standardization of medical training and a desire for diversity and individuality within the profession [16]. These tensions often result in residents staging a performance to meet assessment expectations, potentially hindering personal and professional growth [17‐19]. Expectations of residents can place undue strain (e.g. the demands of the role outstrip the resources to fulfill the role) and conflict (e.g. the role clashes with the demands of other roles), causing stress as residents navigate these tensions [20]. Exploring how residents navigate these tensions may provide insight into the processes of PIF during residency training [21].

The purpose of this study was to explore how residents navigate tensions during residency training and how that navigation affects resident PIF. Thus, we examined the experience of navigating tensions during residency through the lens of the bidirectional influences of person, behavior, and context, to further the conceptualization of PIF within medical education.

We used a constructivist grounded theory approach, using the experience of “navigating tensions” to explore the PIF process and the theoretical framework of “reciprocal determinism” from SCT to inform our data analysis [11, 12]. We chose grounded theory because we wanted to build upon the current theoretical understanding and develop a new model that provided a new perspective of PIF in medical education. We chose a constructivist approach because it acknowledges the researcher’s involvement in the construction and interpretation of data [22]. The research team was composed of faculty members that completed training in the studied residency program in the last 5 years (WLS, HCN, BEVS, JTR), reflecting on their roles as previous resident and current faculty member. One researcher (APS) has advanced training in medical education and qualitative research, helping guide the analysis process with opportunities to reflect on both the theory and practice of medical education. One researcher (FWH) is a sociologist who has written extensively on professionalism in medical education and brings a sociological perspective to PIF in medical education [23, 24]. Throughout data collection and analysis, the team met to discuss data analysis, challenge each other’s assumptions, provide unique ideas to frame data collection and analysis, and discuss theoretical framings that informed our research.

The Mayo Clinic Institutional Review Board approved this study (IRB ID 16-010131).

In this study, residents reframed their definition of a “good doctor” during residency because of navigating tensions between their preconceived ideals of medicine and the realities of medical practice. Bidirectional influences between residents’ evolving identities, the behaviors they engaged in during residency, and the context of residency education affected the reframing of residents’ identities as “good doctors” when faced with these tensions. A resident’s developing identity guided their behavior and shaped their social context, and it evolved through their interactions within the residency training environment. SCT describes how the complex interaction of previously identified factors important to PIF, namely experiences, reflection, role models, mentors, and the learning environment, affects the development of residents’ professional identities. Growing evidence demonstrates that PIF is an individualized, non-linear process influenced by the formal, informal, and hidden curricula [27]. Exploring the bidirectional influences between identity, behavior and context can illuminate both the socialization process shaping an individual’s professional identity and an individual’s agency to shape context and relationships to align with their developing professional identity. Thus, SCT may provide a useful framework to further investigate the interaction between influences of PIF.

While residency training aims to help residents attain the knowledge, skills, and attitudes to be excellent physicians, the residency environment also presents challenges to their developing identity. Self-doubt and imposter syndrome are prevalent among resident trainees and are associated with increased anxiety, depression and burnout [28]. The culture of residency training, including constant critique and messaging that help-seeking and uncertainty are weaknesses, can perpetuate self-doubt and imposterism [28, 29]. Specific events can even lead to shame, particularly in training where residents compare themselves to others and are performance-focused, resulting in isolation, disengagement and impaired wellness [30]. In our study, we demonstrate that initial ideals may be unrealistic (e.g. “A good doctor knows everything”) and need to be reframed during training. While we focused on reframing ideals in a positive way, we can imagine how either failure to reframe these unrealistic ideals or framing them in less productive ways may lead to self-doubt, shame, imposterism, and their untoward effects.

In this study, role models and mentors had a significant effect on reshaping ideals. Role models are an important part of clinical training, especially as they perpetuate healthy behaviors and learners are encouraged to reflect on behaviors before adopting them [31]. To encourage modeling of healthy behaviors, there are calls to make PIF more explicit in residency training [32‐34]. Structured opportunities for reflection and peer engagement may provide an opportunity for educators and peers to openly discuss important aspects of physician identity and intentionally affect PIF [35, 36]. While these initiatives have many potential benefits, including enhanced social support, stress reduction, and improved coping [35], they often occur outside of work. While this space can encourage reflection, it may lead residents to view these efforts as less valuable than the structured curriculum. Studies demonstrate that supervisor support, conversations with others, and changing the culture of assessment in medicine may help mitigate shame and self-doubt and support growth and identity development [18, 19, 30, 37]. Our study supports calls for supervising physicians to demonstrate intellectual and emotional candor to promote learning and combat the unrealistic expectations in medical training and practice [38, 39]. Understanding the challenges residents face and how they navigate those tensions can provide opportunities to discuss and reflect on those tensions within the workplace.

Attempts to measure PIF within medical education are influenced by calls to add identity (“is”) above behavior (“does”) to Miller’s Pyramid, a model for educational assessment [40‐43]. Bidirectional influences between identity and behavior suggest that they are not discrete entities to be assessed separately. In addition, aspects of identity, especially attitudes and values, are private experiences, limiting reliable assessment [44]. There is likely value in multiple, varied assessments of resident behaviors and the values, attitudes, and beliefs that drive those behaviors; however, the assessment of observable behaviors and values may not fully capture professional identity [44, 45]. Given the significant contribution of context to PIF, it is also critical to assess the contextual factors within residency training that affect PIF. Programs like the ACGME’s Clinical Learning Environment Review [46] are important to examine the ways the structure of residency training shapes residents’ identities.

Our study has several limitations. First, we did not explore the origins of pre-existing ideals, only how residents’ ideals were shaped during residency training. There are widely accepted premises within medicine, similar to our study, that are inherent to the culture and implicitly transmitted through social interaction [23, 47]. Future research could utilize SCT to further examine how these premises integrate into the developing professional identities of medical trainees. Second, we did not assign direction to the developing identities, either positive or negative, but remained neutral in examining the process of navigating tensions. Additional research should continue to examine how the sociocultural context of medicine shapes professional identities, including the navigation of identity conflicts of trainees. Research examining sociocultural influences on PIF is limited; SCT can help examine ways that “learners from traditionally under-represented cultures do not fit in with the identity of the dominant health professions culture” and explore the agency of learners to reshape their environment [48]. Lastly, the specific examples presented in our results may not be transferrable to residents in other specialties with different training structures and durations, clinical experiences, and patient populations. The theoretical underpinning of bidirectional influences between context, identity, and behavior is transferrable and provides opportunities to explore examples in other contexts.

Residency is a critical time for the developing physician, exposing learners to multiple tensions that exist between the ideals and the realities of medical practice. SCT provides a framework to explore PIF in residency, highlighting the bidirectional influences between identity, behavior, and context. As residents engage in clinical experiences, receive feedback, and follow role models, they reframe their ideals while navigating tensions faced during residency. Sensitivity to these processes and assessment of the context of medical education can provide educators with opportunities to facilitate residents’ intentional reflection on professional identity and recognize and mitigate negative influences on PIF.