Not “How Should I Learn?” or “How Should I Act?” but, “Who Shall I Become?”: A Précis on the Roots of Early Professional Identity Formation in the Anatomy Course

Abstract

Recently, I attended an informative Education Grand Rounds at my institution on professional identity formation (PIF). It was delivered by a clinician and sociologist with most of the presentation focusing on the transition of medical students into residency and on how the residency curriculum might provide support for the development of professional identity. The presenters summarized the complexity of the history of professionalism in medical education (Coulehan, 2005; Hafferty and Castellani, 2010) and suggested that the utility of such a construct should not be limited to the assessment of student behavior, but should contribute to a student’s formulation of their professional identity. Beyond merely “how to act,” professionalism should speak to “who to become.” Recent literature seats the professional identity at the core of medical education (Cooke et al., 2010; Cruess et al., 2016) with the emphasis on reshaping and modifying the academic discourse on professionalism to include the professional identity formation (PIF) (Cruess et al., 2014). For example, the Miller’s traditional four-layered pyramid (Miller, 1990) which scaffolds knowledge (“Knows”—level), competence (“Knows how”—level), performance (“Show how”—level), and action (“Does”—level) into a four-tiered pedagogic hierarchy has been augmented (Al-Eraky and Marei, 2016; Cruess et al., 2016) to include a fifth “Is” layer (a new tip of pyramid) emphasizing identity. Educators now believe that health care professionals in training should “consistently demonstrate the attitudes, values, and behaviors expected of the one who has come to ‘think, act, and feel like a physician’” (Hafferty, 2009; Cruess et al., 2016). Cruess et al. (2016) espouse the development of professional identity as a new principal goal for medical education. Now several reflective tools designed to measure the PIF have been developed (Bebeau and Monson, 2012; Kalet et al., 2017, 2018). Nonetheless, much work apparently needs to be done. One highly cited study examined the PIF in medical students through reflective essays. During orientation incoming, first-year medical students were introduced to the concept of PIF and assessed for the baseline PIF during orientation and then again, 15 months later, prior to clinical clerkships (Kalet et al., 2018). De-identified essays were scored by an adult developmental educational psychologist based on the Kegan’s Subject-Object Interview platform for assessing the adults’ identity development (Kegan, 1995). This study found that 46% of students in this medical class remained at the same stage in their professional development and 15% of students scored lower than at the time of matriculation to medical school (Kalet et al., 2018). While we can all hope that these results are not the norm, the prospect that half of our trainees might remain stagnant in their PIF through their first two years of training poses a distinct challenge to medical educators. I believe that the basic sciences should play a bigger role in teaching professionalism and in developing the PIF and that this process should commence as early as possible (Bryan et al., 2005; Pawlina, 2006). All our optics should be on the transition from undergraduate education to the medical school environment. Over a decade ago, I organized a plenary session and symposium at the 2007 Association for Medical Education in Europe meeting on the role of the basic sciences in medical education. One of the invited presenters, Dr. Ingeborg Netterstrøm from the University of Copenhagen, spoke on the role of basic sciences in the professional development as a physician (Netterstrøm, 2007). She cited a longitudinal study that followed a cohort of Danish medical students throughout the medical school. From this study, Dr. Netterstrøm learned that medical students have high expectations of themselves in their future role as a doctor. The scope of what they can accomplish in this role is expansive and hopeful. Dr. Netterstrøm was one of the first researchers who brought to the surface the notion that anatomy has a bigger role to play in the PIF than we knew before. Her work was published in one of the first issues of ASE (Netterstrøm and Kayser, 2008) and we are proud indeed to have an early outlet for this important message. In the preclinical phase (especially in anatomy courses), students are exposed to the medical school environment and to the intense study required to fulfill their own high expectations of the ideal doctors they hope to become. Helping students to remain emotionally attuned to this adjustment/adaptation period is necessary to ensure that students successfully navigate the first phase of their continued identity formation as professionals. And this is the work in store for the psychologically-minded anatomy professor. Here, the anatomy teacher is more than a dispensary of knowledge, more than a guide or coach for those with diverse educational backgrounds, cultures, and experiences. Here the anatomy professor has an opportunity to be a counselor and mentor to young doctors who are hungry to learn not just what they need to know, or how they need to act but who they are and who they might become. In the 2006 special issue of Clinical Anatomy on “Professionalism and Anatomy” (Pawlina, 2006), anatomists were in the vanguard of incorporating professionalism in basic EDITORIAL