From Trickle Up Professionalism Education to Professional Identity Formation
4-5 Minute Read
Author: Judy Bolstad-Hanrahan, JD, MA
Purpose
Over the course of the next three editions of Preceptor, we will be discussing issues of teaching, assessing, and role-modeling professionalism. We hope this series will inspire you to deliberately and formally include professionalism and professional identity formation in your clinical teaching and will increase your familiarity with tools and concepts to aid you in this endeavor. Today we start with a very short history of professionalism in the medical school curriculum and an introduction to the concept of professional identity formation.
Learning Objectives
1. Define professional identity formation; and
2. Describe the history of professionalism in the medical school curriculum.
Professionalism has not always been a part of the formal medical school curriculum.(1) Prompted largely by the work of Sylvia and Richard Creuss, the inclusion of professionalism in the formal curriculum occurred in the United States and Canada around the late 1990s and early 2000s. In 1997 the Creusses noted that,
“Most doctors do not fully understand the obligations they must fulfill to satisfy public expectations and maintain professional status.”(1 p1674)
Medical schools began formally teaching the “origins and nature”(1) of a physician’s professional obligations including the social-contract relationship between a profession and society, the underlying values and goals of practice, and the virtues associated with professional medical practice.(2) Because this material was taught in the first two years of medical school, students entered clinical rotations with attendings who had not been formally taught this material. This is not to say that the clinical educators were unprofessional, rather it is to acknowledge that there was likely a lack of shared vocabulary around what it means to be a professional. A bit of back of the envelope math suggests that more than 50% of physicians practicing in 2020 would have graduated medical school before professionalism and ethics were included in the formal curriculum.(3)
This same phenomenon is primed to happen again as AI is formally introduced into the medical school curriculum. Without a deliberate effort by clinical educators to engage in continuing professional development on the topic and/or by faculty developers to prepare clinical educators in this area, students will soon be starting clerkships conversant in and prepared to use AI as a clinical tool while many clinical educators will be unprepared to reinforce and supervise the use of AI in the clinic.
In the early 2000s I encountered this illustrative case:
A third-year medical student was uncomfortable when their clinical preceptor initiated a detailed discussion of a patient, using the patient’s name and intimate details about the patient’s medical condition, in a full public elevator. This student told the dean of medical education about the disconnect between what was taught about professional obligations (and HIPAA rules) and how doctors “actually” practice medicine. The medical education dean responded to the student something along the lines of, “did you tell your preceptor that they shouldn’t be talking about patients in such detail in public?”
This example is illustrative for several reasons, 1) implicit in this example is the expectation that the professionalism curriculum will trickle up from medical students to attendings, 2) the dean’s response fails to recognize the power imbalance between a third-year medical student and an attending, and 3) the example illustrates the power of the “hidden curriculum” in how medical students learn to become physicians.
1) Implicit in this example is the expectation that the professionalism curriculum will trickle up from medical students to attendings
While there are clearly important aspects of medical practice where attendings and students learn from each other, it is certainly not the student’s job to guide and develop the attending’s professional identity. Moreover, professionalism like any other subject taught in medical school, “requires an understanding of concepts, practice applying the concepts, and ultimately opportunities for the trainee to operationalize them in various aspects of medical practice.”(2)
2) The response fails to recognize the power imbalance between a third-year medical student and an attending
Current practice in professionalism education aims to support and nurture students’ professional identity formation rather than merely “teaching professionalism.”(4) Under this model, the role of the attending is both to model professional medical practice and to actively engage students in reflection on the development of their own identity as a medical professional. Professional identity formation is described as
“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.”(5 p1447)
Creuss et al. acknowledge, “The acquisition of a professional identity by physicians is not a new phenomenon. Although the term was not used until recently, it has represented a foundational element of medical education for centuries, having been characterized in the past by words such as ‘character’ or possessing the right ‘characteristics.’” (6 p647)
Finally, 3) the example illustrates the power of the “hidden curriculum” in how medical students learn to become physicians.
Much ink has been spilled over medical education’s “hidden curriculum,” and next week we will spill more as we discuss the importance of role-modeling for teaching professionalism and nurturing professional identity formation.■
References
(1) Cruess SR, Cruess RL. Professionalism must be taught. BMJ. 1997;315(7123):1674–1677.
(2) Gillis M, Bolstad-Hanrahan J. Faculty Development for Professionalism. In: Merlo G, Harter T, eds. Medical Professionalism: Theory, Education, and Practice. Oxford University Press; 2024 (Forthcoming).
(3) Young A, Chaudhry HJ, Pei X, Arnhart K, Dugan M, Simons KB. FSMB census of licensed physicians in the United States, 2020. J Med Regul. 2021;107(2):57–64.
(4) Cruess SR, Cruess RL, Steinert Y. Supporting the development of a professional identity: general principles. Med Teach. 2019;41(6):641–649. doi:10.1080/0142159X.2018.1536260
(5) Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. Acad Med. 2014;89(11):1446–1451. doi:10.1097/ACM.0000000000000427