OʼBrien, Bridget C.

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.

Abstract In this article, we address the question, ‘What is the role of autonomy in physician development?’ Medical education is a developmental process, and autonomy plays a motivational role in physician development. Calls for increased supervision of residents have raised concerns that the resulting decreased autonomy might interfere with resident development, leading the authors to explore the relationship between supervision and autonomy. The medical education literature posits a simple inverse relationship between supervision and autonomy. Within competency frameworks, autonomy is operationalised as independence and viewed as the end goal of training. Alternatively, there is emerging empirical literature describing autonomy and supervision as dynamic and developmental constructs and point towards more complex relationship between supervision and autonomy. Self‐determination theory (SDT) presents a framework for understanding this dynamic relationship and the role of autonomy in physician development. Within SDT, autonomy is a fundamental psychological need, associated with motivation for learning, self‐regulation and an internal locus of control. Supporting learner autonomy can afford learners the opportunity to internalise the values and norms of the profession, leading to an integrated regulation of their behaviours and actions. Conceptualising autonomy through the lens of SDT provides an avenue for education interventions and future research on supervision and autonomy. Educators can integrate supervision and autonomy support in the clinical setting, seeking to motivate learner development by balancing optimal challenge and support and integrating autonomy support with ‘hands‐on’ approaches to supervision. SDT also provides a theoretical framework relevant to current discussions regarding feedback conversations and coaching in medical education. Lastly, conceptualising autonomy using SDT opens new avenues for investigation, exploring the complex relationship between supervision and autonomy and developing efforts to integrate autonomy support with clinical supervision.

With ever-growing emphasis on high-stakes testing in medical education, such as the Medical College Admission Test and the United States Medical Licensing Examination Step 1, there has been a recent surge of concerns on the rise of a “Step 1 climate” within U.S. medical schools. The authors propose an alternative source of the “climate problem” in current institutions of medical education. Drawing on the intertwined concepts of trust and professionalism as organizational constructs, the authors propose that the core problem is not hijacking-by-exam but rather a hijackable learning environment weakened by a pernicious and under-recognized tide of commodification within the U.S. medical education system. The authors discuss several factors contributing to this weakening of medicine’s control over its learning environments, including erosion of trust in medical school curricula as adequate preparation for entry into the profession, increasing reliance on external profit-driven sources of medical education, and the emergence of an internal medical education marketplace. They call attention to breaches in the core tenets of a profession—namely a logic that differentiates its work from market and managerial forces, along with related slippages in discretionary decision making. The authors suggest reducing reliance on external performance metrics (high-stakes exams and corporate rankings), identifying and investing in alternative metrics that matter, abandoning the marketization of medical education “products,” and attending to the language of educational praxis and its potential corruption by market and managerial lexicons. These steps might salvage some self-governing independence implied in the term “profession” and make possible (if not probable) a recovery of a public trust becoming of the term and its training institutions.