Hafferty, Frederic W.

Abstract Context Professional identity formation (PIF) involves the development of professional values, actions and aspirations and is central to medical education. Current understanding of PIF is informed by psychological and sociological theories. One ideal of medicine is responsibility to the patient; the development of this ideal is related to learner autonomy. The purpose of this study was to further theorise the relationships between the individual and contextual aspects of PIF through exploring the associations amongst autonomy, making decisions and responsibility for patients during residency training. Methods Using constructivist grounded theory, we conducted 23 semi‐structured interviews with internal medicine residents at an academic medical centre. Interview transcripts were de‐identified and processed through open coding and analytic memo writing. During data collection and analysis, we identified social cognitive theory (SCT), specifically reciprocal determinism, or the triadic and reciprocal relationship between context, person and behaviour, as a useful theoretical lens through which to illuminate the relationship between autonomy and PIF. Using SCT to guide analysis, we organised themes, identified relationships amongst themes, and refined them through group discussion and constant comparison with new data. Results Residents discussed three main themes: autonomy; making decisions, and responsibility for patient care. Autonomy allowed residents to feel personally responsible for patient care, and build confidence and trust. Autonomy allowed residents to feel engaged in making ‘real decisions’ for patient care. By displaying confidence in their decision making, residents were granted more autonomy. Lack of autonomy led to disengagement and lack of ownership over patient care. Conclusions This study highlighted the role of autonomy in the PIF of learners. Exploring the tension between autonomy and supervision through the lens of SCT highlighted the interconnectedness of context, behaviour and identity in PIF. To ensure optimal learning environments for PIF, educators should weigh the need for autonomy against the demands for supervision and patient safety.

Professional identity formation, with its focus on the development of professional values, actions, and aspirations, is the ideal goal of medical education. Medicine is a community of practice, and medical education is a socialization process by which novice trainees become full community members. The authors believe coaching provides an ideal means for promoting this socialization process to develop a learner’s identity as they engage in the community. Coaching involves an orientation toward growth and development, valuing reflection and nurturing continuous reflection, and embracing failure as an opportunity for learning. However, there are challenges to implementing coaching in medical education. Competency-based medical education has provided clear outcomes (competencies) for medical education and programs of assessment around these competencies. Yet, there is a tension in medical training between professional identity formation (the process of socialization into the profession) and the formal assessment process. The ideal of multiple low-stakes assessments and written evaluations, intended as formative assessments, are perceived by residents as high-stakes evaluations with significant consequences for their future. The authors present a resident story that highlights this tension. They outline Goffman’s theory of impression management, postulating that medicine’s assessment system encourages residents to stage a performance for evaluators that displays their competence and conceals their perceived weaknesses. This performance hinders coaching and the formation of an appropriate professional identity. Coaching, the authors believe, provides a model that aligns assessment and professional identity formation. Given the challenges to implementing coaching in medical education, the authors propose several questions to contemplate when integrating coaching into medical education to facilitate the goal of professional identity formation.

Abstract Context Myth busting engages scholars in the critical examination of commonly accepted but poorly evidenced claims with the goal of instilling quality and trust in knowledge making. The debunking of such knowledge “myths” and associated misguided practices purportedly serves to avert resources and attention from wasteful and dangerous scholarship. We address the myth that “all myths in medical education deserve to be busted”. Methods Using a critical narrative approach, we searched the medical education literature for orientations to myths and myth busting, and reviewed this literature analytically drawing from the sociology of science and Merton's concepts of manifest and latent functions. The results of this analysis are presented in the form of a narrative that deploys the articles reviewed to explore the utility of myth busting for medical education reform and begins with a brief exploration of the etymology of “myth” and how meaning making is related to symbols, practices and storytelling. Results Our analysis revealed the important function of myths in the social practice of medical education and practice. A deconstruction of five salient examples of the contemporary myth in medical education (the myth of the “ideal candidate”, the myth of “cut‐throats”, the myth of “cadaver stories”, the myth of “learning styles”, and the myth of “patient information leaflets”) demonstrates that myths continue to have material effects even after they have been busted. Conclusions Our analysis makes evident that myth busting disrupts, renegotiates and reconstitutes socio‐epistemic relationships rather than simply correcting falsehoods. We also argue that myths play important and inescapable roles in the social practice of medical education and the negotiation of values, and in constructing the conditions for group change and transformation. Imperatives related to humanism , compassion and patient engagement offer a healthy humanising counter‐mythologising that we suggest must survive any contemporary myth‐busting endeavour aimed at improving medical education practice.

Purpose Mission statements (MSs) express an organization’s purpose and reflect the broader social environment in which they function. The authors analyze MS text to explore how medical schools can be relationally viewed and how particular thematic narratives within MSs can be deployed to associate schools in hithertofore unexplored ways. Method The authors analyzed the MSs (as of 1/1/2017) of 144 U.S. Liaison Committee on Medical Education–accredited schools. Using schools as their unit of analysis, they coded MSs using 44 themes. They employed content analysis to identify themes within MSs, factor analysis to identify core thematic dimensions embedded in MSs, and network analysis to examine relationships among schools based on these thematic dimensions. The authors used four standard school characteristics to examine the validity of their results. Results Content analysis revealed 20 core themes. Factor analysis identified four thematic dimensions: Primary Care/Diversity; Future Learning–External; Traditional; and Learning Environment–Internal. Based on the 20 core themes and using the MSs of 125 schools with nonextreme MS code counts, the authors found that schools form a complete network, and that schools form distinctive network-based clusters based on the identified factors. The four thematic dimensions were significantly differentiated across the four standard school characteristics. Conclusions The authors found distinctive patterns of MS linkages among schools along with thematic linkages within MS themes, supporting the contentions that medical schools can be both differentiated and connected based on their MSs and that understanding MS content must move beyond simple frequency counts of MS attributes.

Purpose International health electives (IHEs) are widely available during residency and provide unique experiences for trainees. Theoretical models of professional identity formation and transformative learning may provide insight into residents’ experiences during IHEs. The purpose of this study was to explore transformative learning and professional identity formation during resident IHEs and characterize the relationship between transformative learning and professional identity formation. Method The authors used a constructivist grounded theory approach, with the sensitizing concepts of transformative learning and professional identity formation to analyze narrative reflective reports of residents’ IHEs. The Mayo International Health Program supports residents from all specialties across three Mayo Clinic sites. In 2015, the authors collected narrative reflective reports from 377 IHE participants dating from 2001 to 2014. Reflections were coded and themes were organized into a model for transformative learning during IHEs, focusing on professional identity. Results Five components of transformative learning were identified during IHEs: a disorienting experience; an emotional response; critical reflection; perspective change; and a commitment to future action. Within the component of critical reflection, three domains relating to professional identity were identified: making a difference; the doctor–patient relationship; and medicine in its “purest form.” Transformation was demonstrated through perspective change and a commitment to future action, including continued service, education, and development. Conclusions IHEs provide rich experiences for transformative learning and professional identity formation. Understanding the components of transformative learning may provide insight into the interaction between learner, experiences, and the influence of mentors in the process of professional identity formation.

This article explores the assessment of professionalism within a cohort of medical students during a sequential 13‐week medical school histology and anatomy course. Across seven data points, students were asked to identify a professionalism role model from amongst their peers and to score Likert‐structured rationales for their decision. Based on density scores, an initial social network analysis identified six peer‐nomination “stars.” However, analysis of these stars revealed considerable variability and random‐like “noise” in both the nomination and explanation data sets. Subsequent analyses of both data sets explored the possibility of underlying patterns in this noise using tests of reliability, principal components factor analysis, and fixed‐effects regression analysis. These explorations revealed the presence of two dimensions (professional vs. supportive) in how students sought to explain their nomination decisions. Although data variability remained quite high, significantly less variability was present in the professional than in the supportive dimension, suggesting that academic helpfulness rationales are both empirically distinct and more mutable than rationales grounded in professionalism‐related factors. In addition, data showed that the greater the stability in one's choice of a professionalism role model nomination over the T1–T7 data periods, the more stable one's reasons for that nomination—both for professionalism and supportive dimensions. Results indicate that while peer assessment of professionalism by first‐year medical students may not be very reliable, students can differentiate between more personal and professional factors, even at this early stage in their professional development. Formal instruction within the pre‐clinical curriculum should recognize and address this distinction. Anat Sci Educ. © 2018 American Association of Anatomists.

In this Commentary, the authors explore the scoping review by Lawrence and colleagues by challenging their conclusion that with over 25 years’ worth of “ambiguous and seemingly ubiquitous use” of the hidden curriculum construct in health professions education scholarship, it is time to either move to a more uniform definitional foundation or abandon the term altogether. The Commentary authors counter these remedial propositions by foregrounding the importance of theoretical diversity and the conceptual richness afforded when the hidden curriculum construct is used as an entry point for studying the interstitial space between the formal and a range of other-than-formal domains of learning. They document how tightly delimited scoping strategies fail to capture the wealth of educational scholarship that operates within a hidden curriculum framework, including “hidden” hidden curriculum articles, studies that employ alternative constructs, and investigations that target important tacit sociocultural influences on learners and faculty without formally deploying the term. They offer examples of how the hidden curriculum construct, while undergoing significant transformation in its application within the field of health professions education, has created the conceptual foundation for the application of a number of critical perspectives that make visible the field’s political investments in particular forms of knowing and associated practices. Finally, the Commentary authors invite readers to consider the methodological promise afforded by conceptual heterogeneity, particularly strands of scholarship that resituate the hidden curriculum concept within the magically expansive dance of social relationships, social learning, and social life that form the learning environments of health professions education.

In this Invited Commentary, the author examines two curated Academic Medicine volumes showcasing foundational research and key writings on professionalism in medicine and medical education, collectively spanning from 1994 to 2016. The author reviews the beginnings of the medical professionalism movement and examines how the trends and themes reflected in the first volume—specifically the work to define, assess, and institutionalize professionalism—capture key elements in this movement. He then examines how the trends and themes in the second volume align with and build on those from the first, noting two themes that extend across a number of second volume articles: a unit-of-analysis issue and the challenge of context. The author identifies several topics that have yet to be adequately mined and calls attention to two bridge-spanning articles in the second volume that, respectively, take us into the future (around the topic of identify formation) and back to the past (on the hidden curriculum). Finally, the author reflects on “directions home” in medicine’s noble search for its moral core and collective identity.