Authoring the identity of learner before doctor in the figured world of medical school

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.

What makes a 'good doctor'? A critical discourse analysis of perspectives from medical students with lived experience as patients

What constitutes a 'good doctor' varies widely across groups and contexts. While patients prioritise communication and empathy, physicians emphasise medical expertise, and medical students describe a combination of the two as professional ideals. We explored the conceptions of the 'good doctor' held by medical learners with chronic illnesses or disabilities who self-identify as patients to understand how their learning as both patients and future physicians aligns with existing medical school curricula. We conducted 10 semistructured interviews with medical students with self-reported chronic illness or disability and who self-identified as patients. We used critical discourse analysis to code for dimensions of the 'good doctor'. In turn, using concepts of Bakhtinian intersubjectivity and the hidden curriculum we explored how these discourses related to student experiences with formal and informal curricular content.According to participants, dimensions of the 'good doctor' included empathy, communication, attention to illness impact and boundary-setting to separate self from patients. Students reported that formal teaching on empathy and illness impact were present in the formal curriculum, however ultimately devalued through day-to-day interactions with faculty and peers. Importantly, teaching on boundary-setting was absent from the formal curriculum, however participants independently developed reflective practices to cultivate these skills. Moreover, we identified two operating discourses of the 'good doctor': an institutionalised discourse of the 'able doctor' and a counterdiscourse of the 'doctor with lived experience' which created a space for reframing experiences with illness and disability as a source of expertise rather than a source of stigma. Perspectives on the 'good doctor' carry important implications for how we define professional roles, and hold profound consequences for medical school admissions, curricular teaching and licensure. Medical students with lived experiences of illness and disability offer critical insights about curricular messages of the 'good doctor' based on their experiences as patients, providing important considerations for curriculum and faculty development.

Identity conflicts of student affairs officers in a medical university

INTRODUCTION

Collaboration between student affairs officers and the faculty is important in dealing with the recent rapid changes in medical education, and mutual understanding is essential to ensure that participants become a cohesive social group. This study explores the identity conflicts of student affairs officers in medical universities using the figured worlds theory.

METHODS

An exploratory qualitative case study was conducted with 24 student affairs officers at a private medical university in Japan. Data were collected through face-to-face, semi-structured interviews and analysed using thematic analysis from the perspective of a social constructivism paradigm.

RESULTS

Qualitative analysis revealed the following three themes regarding the identity conflicts of student affairs officers: differences in the perception of medical students, difficulties in building trusting relationships with the faculty, and resistance to the medical university's traditional atmosphere. Student affairs officers tended to provide support from a student-centred perspective when interacting with medical students, while the faculty employed a teacher-centred perspective.

DISCUSSION

To promote understanding between professions, it is necessary to set aside certain professional views and welcome dialogue with other professionals with different values, while also understanding the multi-layered context of medical education, so that conflicts can be handled optimally and relationships can be professionalised for social cohesion.

Identifying stressor criteria that hinder or challenge junior clinical medical student learning

INTRODUCTION

What makes something a stressor within clinical students' education is unclear. Medical students moving from a predominantly protected classroom environment to a situated-work environment provided an ideal transition point to explore the criteria that might make a learning experience a stressor and whether these stressors hinder or challenge learning.

METHOD

Data on the stressors associated with learning experiences in clinical education were collected from New Zealand undergraduate medical students. Free text comments, in a survey-based questionnaire were supplemented by focus group data. Using inductive thematic analysis with grounded theory, themes were generated about the characteristics of stressors; referred to here as stressor criteria. These stressor criteria were then classified according to their impact on perceived learning.

RESULTS

Under the broad headings of the nature of the learning task, external factors, internal factors, and social interaction; 12 stressor criteria groupings were defined. Some of these criteria were a positive challenge to learning (e.g. legitimacy of the task, novelty of the learning, social interactions) and others a hindrance.

DISCUSSION

Not all stressors hinder learning. Instead, and depending on their nature, many result in perceived assistance to learning. Stressors hindering learning need to be recognised by the teacher, especially those that can be converted from a hindrance to an assistance.

The ways social networks shape reflection on early significant clinical experiences in medical school

BACKGROUND

Medical curricula are increasingly providing opportunities to guide reflection for medical students. However, educational approaches are often limited to formalized classroom initiatives where reflection is prescriptive and measurable. There is paucity of literature that explores the personal ways students may experience authentic reflection outside of curricular time. The purpose of this study was to understand how social networks might shape dimensions of reflection.

METHODS

This study employed a qualitative social network analysis approach with a core sample of seven first year undergraduate medical students who described their relationships with 61 individuals in their networks. Data consisted of participant generated sociograms and individual semi-structured interviews.

RESULTS

Many learners struggled to find significant ways to involve their social networks outside of medicine in their new educational experiences. It appeared that some medical students began in-grouping, becoming more socially exclusive. Interestingly, participants emphasized how curricular opportunities such as reflective portfolio sessions were useful for capturing a diversity of perspectives.

CONCLUSIONS

Our study is one of the first to characterize the social networks inside and outside of medical school that students utilize to discuss and reflect on early significant clinical experiences. Recent commentary in the literature has suggested reflection is diverse and personal in nature and our study offers empirical evidence to demonstrate this. Our insights emphasize the importance of moving from an instrumental approach to an authentic socially situated approach if we wish to cultivate reflective lifelong learning.

COVID as a catalyst: medical student perspectives on professional identity formation during the COVID-19 pandemic

BACKGROUND

As a result of the COVID-19 pandemic, a national decision was made to remove all medical students from clinical environments resulting in a major disruption to traditional medical education. Our study aimed to explore medical student perspectives of professional identity formation (PIF) during a nationally unique period in which there was no clinical training in medical undergraduate programs.

METHODS

We interviewed fifteen UBC medical students (years 1-4) regarding their perspectives on PIF and the student role in the setting of the COVID-19 pandemic. Data were analysed iteratively and continuously to create a codebook and identify themes of PIF based on interview transcripts.

RESULTS

We identified three key themes: (1) Medical students as learners vs contributing team members (2) Decreased competency as a threat to identity and (3) Doctors as heroes.

CONCLUSIONS

The impact of disruptions due to COVID-19 catalyzed student reflections on their role within the healthcare system, as well as the role of self-sacrifice in physician identity. Simultaneously, students worried that disruptions to clinical training would prevent them from actualizing the identities they envisioned for themselves in the future. Ultimately, our study provides insight into student perspectives during a novel period in medical training, and highlights the unique ways in which PIF can occur in the absence of clinical exposure.

Ambivalent professional identity of early remedial medical students from Generation Z: a qualitative study

BACKGROUND

Supporting professional identity development in medical students undergoing remediation in the first few years of their studies is an important topic. However, there is a lack of research on developing an effective and individualised process for successful remediation that targets learner identities. This study examined the identities of Generation Z remedial medical students through the lens of professional identity formation, focusing on the difficulties they faced and the support they sought.

METHODS

An exploratory qualitative case study was conducted within a constructivist paradigm. Twenty-two medical students (14 males and 8 females) who had experienced remediation in their first few years of medical university participated in this study. All participants were members of Generation Z. Qualitative data were collected through face-to-face, semi-structured interviews and analysed using thematic analysis.

RESULTS

Medical students undergoing remediation in the first few years experienced resistance to the medical profession and conflict due to the gap between the ideal and the reality they experienced after entering medical university. Students' professional identities were closely intertwined with their pre-university identities; this affected the process of professional identity formation after entering medical university. They preferred assurances of confidentiality as a prerequisite and immediately sought advice through social networks to support their professional identity development.

CONCLUSIONS

When planning professional identity development support for Generation Z medical students undergoing remediation in the first few years, it is necessary to carefully select integrative interaction methods, focus on the context of individual learners, and collaboratively discuss specific responses between students and faculty. The results of this study could be useful to faculty in developing support systems for future remedial medical students that focuses on professional identity development and mentoring of remedial medical students.

"I might not fit that doctor image": Ideal worker norms and women medical students

Despite the increasing numbers of women students in medical schools, focused attention on their perceptions about medical school and the medical profession remain underexamined. These perceptions are important to understand, particularly since women students are likely burdened with a host of gender norms related to work, family, and their future roles as physicians. Early experiences in medical school offer important insights into the larger student experience and are tied to academic outcomes and feelings of belonging. To examine early experiences of women medical students, this qualitative study used sensemaking theory to describe the current context and "story" of ideal worker norms. Critical qualitative interviews of 38 women students were performed during their first 2 months of medical school and explored both how the students perceived and experienced ideal worker norms, and how they made sense of the "story" of ideal worker norms. The participants described ways they encountered gendering and ideal worker norms through displays of nurturing behaviour, expectations to balance a future family, and whether they looked or acted the part of a doctor. This article highlights the challenges women medical students are already aware they will face, the opportunities they look forward to, and the strengths they anticipate leaning on to navigate their profession. Results from this study have implications for women medical students' learning experiences and transitions into medical school and for faculty, staff, and scholars concerned with challenging gendering norms that shape medical education.

Exploring the preconception of the first year of medical students on medicine before entering medical school

PURPOSE

First-year students can form a preconception based on life experiences before entering college and identifying learners' existing characteristics can be useful foundation data for curriculum development. This study examines what preconceptions freshman students had about medicine before entering medical school.

METHODS

A total of 110 first-year students were asked about what preconceptions they had about "medicine". A total of 1,124 data were used in the content analysis method.

RESULTS

The results were extracted into 5, and 12 twelve categories. On the theme of "scientific discipline", the knowledge students had about general health was based on scant expertise and little evidence. Students perceived medicine as Western and scientific, considering Korean traditional medicine as unscientific. Students believed that "medical practice" should be a "disease treatment" and "patient-centered" approach rather than a "social responsibility". In "the role of the doctor", students were concerned about the doctor's being financially stable on the positive side, and about the high-intensity workload on the negative side. In "medical education", students believed that studying medicine would be "hard and difficult" because of the "importance of memorizing" and "extensive study load". In "specialty stereotype", students had biases that were mostly concentrated on "psychiatry" and "surgery".

CONCLUSION

Perception of "medicine" has been revealed to a varied range of themes, but some have been inaccurate or unrealistic. These prejudices and groundless beliefs have a gap with the learning outcomes that students should achieve in the curriculum, and these preconceptions seem to have been influenced by South Korea's unique cultural context.

Medical teachers' discursive positioning of doctors in relation to patients

CONTEXT

An important part of a doctor's identity is the social position he or she adopts relative to patients. Dialogic theory predicts that medical school discourses influence the positions students incorporate into their professional identities. As this may affect how students later exercise power in doctor-patient relationships, we set out to examine how medical teachers position doctors in relation to patients.

METHODS

Informed by Holland's Figured Worlds theory, which draws important assumptions from Bakhtin, we chose dialogic research methodology to examine how educators' language positions doctors and may influence students' identity formation. We recruited a maximum variation sample of 10 teaching staff and used open prompts in individual semi-structured interviews to elicit discourses of doctors' social position. We used Sullivan's dialogic methodology reflexively to identify informative speech acts (utterances) and to examine how the language used in these constructed doctors' positions.

RESULTS

Dominant discourses of Social Superiority, Technical Effectiveness, and Benevolence elevated doctors' positions based on their social status, applied knowledge and trustworthiness, respectively. These positions were defended by predicating medical care on doctors' mastery of treatments and their superior knowledge. A non-dominant discourse of Distributed Power and Responsibility narrowed the positional gap by constructing doctors as empowering patients.

CONCLUSIONS

Whereas three conservative discourses upheld doctors' elevated social position, a non-dominant, transformative discourse distributed power. We suggest that doctors will form the best relationships with patients when they are aware of these discourses and know how to navigate them. In pursuit of effective and compassionate patient care, we commend critical pedagogy as a means of articulating non-dominant discourses and increasing students', educators' and doctors' awareness of how they learn the positions of doctors.

Balint-style reflective practice groups in a year 4 undergraduate general practice attachment: experience of the first two years

BACKGROUND AND AIMS

Many undergraduate medical curricula include reflective practice sessions based on traditional Balint-groups. Those sessions can help students to acknowledge that experiencing 'negative' feelings in relation to patients is normal and may contain important information about the clinical encounter. They may also help to protect students from some of the emotional challenges of studying medicine. The Edinburgh University scheme provides all students in their first clinical year with two dedicated reflective practice sessions. Here we report on experience of the first two years.

METHODS

Students' attitudes to the sessions were ascertained using a questionnaire, and views of the group leaders were assessed using a questionnaire and through informal verbal and email discussions. Practical difficulties were recorded as they arose.

RESULTS

Students generally rated the sessions positively with regard to exploring relationships and self-reflection, and they found the sessions interesting and helpful. The sessions did not seem to affect career choice. The free-text comments suggested four positive themes and four areas for future modification.

CONCLUSION

We have succeeded in providing all undergraduate students with an opportunity to take part in a reflective practice. We have highlighted aspects which have been successful and suggested future improvements.

A Review of Strategies for Enhancing Clarity and Reader Accessibility of Qualitative Research Results

Objective. To characterize elements of the results section of qualitative research reports that make findings more accessible to readers. Methods. Two analytical methods were used for this review. First, published reviews and textbooks written by experts outlining how to evaluate qualitative research were retrieved and reviewed to identify common elements that enhance clarity of the results section. In the second analysis, the authors analyzed the results sections of a subset of qualitative studies to identify, from a reader's point of view, aspects that enhanced and detracted from communication of the results. Findings. Four elements improve accessibility of the results section for readers of qualitative research reports. Content, the first element, describes what information the reader should look for in the results section. Style of results, the second element, identifies wording choices that improve reader accessibility and understanding. Narrative flow, the third element, describes a results section that flows smoothly and logically. Structural cohesiveness, the final element, outlines effective organization of the results section. Results. While authors take several approaches to the presentation of results in qualitative research reports, some strategies appear to be more common and effective than others. The efficient presentation of results can impact a reader's assessment of the quality and credibility of a study. Identified content and stylistic elements should be considered by authors hoping to make the results of their qualitative research more accessible and comprehensible to readers.

Understanding Professional Identity Formation in Early Clerkship: A Novel Framework

PURPOSE

Medical educators should foster students' professional attitudes because individuals are more likely to act in accordance with medicine's professional values if these values have been internalized. Still, there is much to be learned about how students examine and negotiate their emerging identities. This study examined third-year medical students' experiences of professional identity formation (PIF) during clinical clerkship.

METHOD

The authors relied on an interpretivist perspective, informed by a grounded theory approach, to analyze data, which were collected from a pilot course designed to support medical students' efforts to "unhide" the hidden curriculum in relation to their development as medical students and emerging professionals.

RESULTS

Twelve third-year medical students engaged in 10 collaborative discussions with 3 faculty members, a resident, and a fourth-year student (2015-2016). Discussions facilitated students' reflection on their professional journeys. Analysis of transcribed discussions resulted in a conceptual framework useful for exploring and understanding students' reflections on their PIF. Through analyzing students' experiences, the authors identified 4 components that constituted PIF stories: context, focus, catalyst, process.

CONCLUSIONS

The analysis resulted in the development of a conceptual framework and distinct identity formation themes. Discrete reflections focused on either students' current identity (being) or their sense of future self (becoming). The study identified catalysts that sparked participants' introspection about, or their processing of, identity. The moments that generate profound feelings of awareness in students are often moments that would not be recognizable (even post hoc) as remarkable by others.

Minding the Form That Transforms: Using Kegan's Model of Adult Development to Understand Personal and Professional Identity Formation in Medicine

The formation of a physician's professional identity is a dynamic process shaped by and intertwined with the development of that person's larger adult identity. Constructive-developmentalist Robert Kegan's model of adult development describes four mental lenses used for meaning-making and the trajectory through which they transform over time. These lenses determine the way people take in and integrate complex influences into forming their adult identities.When people use a particular lens to construct meaning, Kegan describes them as being "subject" to that lens: The lens "has them," and they are unaware of the ways it shapes their world. Transformations occur when individuals are able to take a lens to which they were subject and regard it objectively. Kegan's lenses that are relevant to medical educators are called instrumental-focused on rules and rewards; socialized-attending to social norms and expectations; self-authoring-seeking to build internal values; and self-transforming-seeing gaps in one's closely held value systems and being open to those of others.When individuals have difficulty facing current challenges, they begin to grow a more complex lens. Subsequent lenses bring the ability to deal with more complexity but also bring their own challenges. Familiarity with Kegan's model can help educators provide more effective support to groups of learners as well as individuals, support learners' transformational growth through the challenging situations inherent in medical education, and supply a common language for many important areas of medical education, including competencies and entrustable professional activities, remediation, leadership development, and curriculum planning.

Education and service: how theories can help in understanding tensions

OBJECTIVES

This paper reviews why tensions between service and education persist and highlights that this is an area of medical education research (MER) that, to date, lacks a robust body of theory-driven research. After carrying out a review of the literature on service-education tensions in medical education and training, we turn to consider how theory can help provide new insights into service-education tensions.

METHODS

We conducted a search of the literature on service-education tensions since 1998 to examine the use of theory in studies on this topic.

RESULTS

We identified 44 out of 603 relevant papers. Their focus fell into four broad categories: time residents spent on 'service' and 'education'; perceptions of the balance between service and education; considerations of how best to define service and education, and the impact of structural and systems changes on education/training. Of the papers reporting primary research, the dominant methodology was the bespoke survey. Rarely were the precise natures of tensions or how different factors interact to cause tensions examined in detail.

DISCUSSION

Through discussion and reflection, we then agreed on the applicability of four sociocultural theories for illuminating some examples of service-education tensions. We present four sociocultural theories: Holland's figured worlds, Kemmis et al.'s practice architectures, Lave and Wenger's situated learning and Engeström's cultural-historical activity theory (CHAT or AT). We describe each and then briefly illustrate how each theory can support new ways of thinking and potential directions for research focusing on education-service tensions.

CONCLUSIONS

The use of theory in research studies will not resolve service-education tensions. However, what theory can do is illuminate and magnify different aspects of service-education tensions, to generate new insight and knowledge that can then be used to inform future research and changes in practice.

The Resources We Bring: The Cultural Assets of Diverse Medical Students

In response to the need for a more diverse workforce, our medical school developed new policies and procedures that focus on the recruitment and selection of diverse students with a specific focus on those considered underrepresented in medicine. To understand what these students bring to the practice of medicine, researchers investigated their perception of their cultural assets and how they plan to use these assets as physicians. A cross-section of 23 ethnically, culturally, and geographically diverse medical students were interviewed and data were analyzed through phenomenographical methods. The results indicate that students view themselves as having multiple assets that could be of significant value in their future practice of medicine, including: a) an interest in science and access to family members in medicine, b) personal and familial struggles with health, c) self and family as immigrants, and d) strong family and community orientations. Students perceived these as cultural assets because they could directly identify where these assets could be valuable in medicine but questioned how to maintain them throughout medical school. Now that our institution has identified these assets, next steps include administrators' investigation of ways to leverage them through curricular and educational programs.

'I feel like I sleep here': how space and place influence medical student experiences

CONTEXT

Buildings and learning spaces contribute in crucial ways to people's experiences of these spaces. However, this aspect of context has been under-researched in medical education. We addressed this gap in knowledge by using the conceptual notions of space and place as heuristic lenses through which to explore the impact of a new medical school building on student experiences.

METHODS

We carried out an exploratory case study to explore the impact of a new medical school building on student experiences. Data were collected from archived documents (n = 50), interviews with key stakeholders (n = 17) and focus group discussions with students (n = 17 participants) to provide context and aid triangulation. Data coding and analysis were initially inductive and conducted using thematic analysis. After themes had emerged, we applied the concepts of boundary objects, liminal space and Foucault's panopticon to provide a framework for the data.

RESULTS

There were specific visions and intentions for the place (the location) and space (the facilities) of the new medical school building (e.g. it was positioned to facilitate flow between educational and clinical settings). However, the unintentional consequences of the planning were that students felt disconnected from the wider university, trapped on the health care campus, and under pressure to behave not like students but in a manner they believed to be expected by clinical staff and patients.

CONCLUSIONS

Despite much effort and a focus on creating an idyllic space and place, the new medical school had both positive and (unintentionally) negative impacts on student experiences. These findings highlight the importance of reflecting on, and exploring, how space and place may influence and shape students' learning experiences during the formative years of their development of a professional identity, a necessary consideration when planning new medical school learning spaces or changing these spaces.

Medical students are not blank slates: Positionality and curriculum interact to develop professional identity

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