Perspective

A Schematic Representation of the

Professional Identity Formation and
Socialization of Medical Students and
Residents: A Guide for Medical Educators
Richard L. Cruess, MD, Sylvia R. Cruess, MD, J. Donald Boudreau, MD,
Linda Snell, MD, MHPE, and Yvonne Steinert, PhD

Abstract
Recent calls to focus on identity formation Identity formation is a dynamic process complexity and the large number of
in medicine propose that educators establish achieved through socialization; it factors involved.
Downloaded from http://journals.lww.com/academicmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 12/27/2020

as a goal of medical education the support results in individuals joining the medical
Drawing on the identity formation and
and guidance of students and residents community of practice. Multiple factors socialization literature, as well as experience
as they develop their professional identity. within and outside of the educational gained in teaching professionalism, the
Those entering medical school arrive with system affect the formation of an authors developed schematic representations
a personal identity formed since birth. As individual’s professional identity. Each of these processes. They adapted them
they proceed through the educational learner reacts to different factors in her to the medical context to guide educators
continuum, they successively develop the or his own fashion, with the anticipated as they initiate educational interventions,
identity of a medical student, a resident, and outcome being the emergence of a which aim to explicitly support professional
a physician. Each individual’s journey from professional identity. However, the identity formation and the ultimate goal of
layperson to skilled professional is unique inherent logic in the related processes medical education—to ensure that medical
and is affected by “who they are” at the of professional identity formation and students and residents come to “think, act,
beginning and “who they wish to become.” socialization may be obscured by their and feel like a physician.”

D uring the past two decades, attention A 2010 Carnegie Foundation Report continuously organizing their experiences
has been directed at the nature of medical proposed that professional identity into a meaningful whole that incorporates
professionalism and how best to teach formation should be a major focus for their personal, private, public, and
and assess it. The concept of professional medical education,1 an opinion echoed by professional “selves.”4–8,24,25 As they pass
identity has received some mention, albeit others in the field.2,3,9,10 For this to occur, through each stage, from infancy to
relatively little in medical education. medical educators must understand the childhood, adolescence, and beyond,
Recently, educators have suggested nature of professional identity, professional individuals gain experience and become
that the objective of teaching medical identity formation, and the process of capable of constructing an increasingly
professionalism is to support students socialization through which a professional complex persona. The theoretical
and residents as they develop their own identity is formed. The inherent logic of approaches to identity formation
professional identity.1–3 In this context, these issues, however, may be obscured suggest three domains through which
teaching professionalism becomes a by their complexity. We have therefore identity is influenced and developed, all
means to an end, with the end being the developed schematic representations of relevant to medical education: individual
development of a professional identity. identity formation, socialization, and identity, relational identity, and collective
An extensive literature in developmental learners’ roles and responses to this process identity.24 The identity of an individual
psychology illuminates how individuals to assist medical educators to better at any moment represents the sum of
develop a personal identity,4–8 and during understand these issues. We hope that the influences impacting these three
the past decade, this scholarship has such schemata prove useful in designing domains. The individual domain includes
served as the basis of original and creative educational interventions to more personal characteristics, self-chosen or
work examining the nature of physicians’ effectively guide identity formation in mandated commitments, beliefs about
professional identities and the factors that medicine as students and residents come to one’s self, and the impact of multiple
influence their emergence.9–22 “think, act, and feel like a physician.”23 life experiences. The relational domain
expresses the influence on identity
Please see the end of this article for information of significant individuals, such as
about the authors. Personal and Professional family members, friends, mentors, and
Correspondence should be addressed to Richard Identity Formation coworkers. The collective domain reflects
L. Cruess, Centre for Medical Education, Faculty of
Medicine, McGill University, 1110 Pine Ave. West,
Conceptually, professional identity the impact of the social groups to which
Montreal, Quebec, Canada H3A 1A3; telephone: formation must be congruent with an individual belongs or wishes to join.
(514) 398-7331; e-mail: [email protected]. the processes through which human An individual’s status within the group
beings develop a personal identity.24 and the group’s status within society are
Acad Med. 2015;90:718–725.
First published online March 17, 2015 Psychological theories propose that important contributors to this identity
doi: 10.1097/ACM.0000000000000700 individuals proceed through life component.24,25

718 Academic Medicine, Vol. 90, No. 6 / June 2015

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Perspective

Some aspects of an individual’s identity

are relatively stable throughout life, Table 1
whereas others are more dynamic Kegan’s Stages 2 to 4 of Identity Formation Adapted to Describe the Development
and change as the individual passes of a Professional Identity in Medicine
through each developmental stage and Manifestations in a
as his or her individual, relational, and Stage Personal characteristics professional context
collective relationships are altered. Some
2: Imperial An individual who takes into An individual who can assume
changes are brought about consciously, account the views of others but professional roles but is primarily
whereas others are more “automatic and whose own needs and interests motivated to follow rules and to
implicit.”24 Although identity stabilizes predominate be correct; self-reflection is low.
in early adulthood, transformation Emotions can overwhelm reason.
continues throughout life, with an 3: Interpersonal An individual who is able to view An individual who can assume
multiple perspectives simultaneously professional roles and is oriented
enduring core being ever-present.6,21,24 and subordinate self-interest; who towards sharing obligations; tends
is concerned about how she or he is to seek out those to emulate;
Building on the long-held belief that perceived by others is idealistic and self-reflective.
human beings develop their personal Emotions are generally under
identity in stages, our current knowledge control, and she or he generally
does the right thing.
of identity formation is based on
the theories of Piaget and Inhelder,4 4: Institutional An individual who can assume a role An individual who is able to
and enter into relationships while understand relationships in
Goffman,5 Erikson,6 Kohlberg,7 assessing them in terms of self- terms of different values and
and others. Continuing their work, authored principles and standards; expectations. The external values
Kegan8 proposed a framework for the the self is defined independently of of the professional become internal
longitudinal development of the self into others values. Reason is in full control over
needs, desires, and passion.
a moral and meaning-making entity,
which has helped us to understand Note: Adapted from Kegan R. The Evolving Self: Problem and Process in Human Development. Cambridge,
the development of a professional Mass: Harvard University Press; 1982.8
identity in dentistry,3 the military,3,26
and medicine.2,3,9 His classification,
which refers to identity formation in enduring identities defining the self. the authors’ experiences in teaching
general, consists of six stages, beginning Those who transition to Stage 5 do not professionalism. They have been modified
in childhood and extending into adult perceive themselves as having a single substantially following interactive
life. They include (0) incorporation, identity and are open to other influences. sessions with members of McGill
(1) impulsion, (2) imperial, (3) Information from the military indicates University’s Centre for Medical Education
interpersonal, (4) institutional, and (5) that few individuals are able to reach this and in response to feedback from
interindividual. The early and final stages stage in a lifetime.3,26 Bebeau3 described workshops at national and international
are not pertinent to the development of professional identity formation using meetings and at other medical schools.
a young adult, such as a medical student Kegan’s framework in this way: We hope that the diagrams will assist
or resident. Thus, a medical identity, medical educators in determining where
including one’s professional identity, Individuals move from self-centered
they can intervene in the process of
is thought to develop sequentially conceptions of identity through a
number of transitions, to a moral identity identity formation to cultivate a more
throughout Kegan’s Stages 2, 3, and 4. supportive, consistent, and effective
characterized by the expectations of a
profession—to put the interests of others process.
Table 1 adapts Kegan’s stages of personal before the self, or to subvert one’s own
identity formation to describe the ambitions to the service of society.
Identity formation and communities of
development of a professional identity.
Preparation and training for a career is an practice
In Kegan’s Stage 2, individuals take on
a professional role, but it is not fully important part of identity development. Figure 1 places identity formation
integrated into their identity. In Stage An individual’s vocation is a stabilizing within the context of medical education.
3, individuals begin to identify with the and integrative force in his or her personal Students enter medical school in late
profession, to the point that they become identity.25 The process is highly individual adolescence or early adulthood (Kegan’s
totally immersed in and integrated with with each person proceeding at a different Stage 2 or 3).8 Their identity is partially
it, as the concepts of altruism and service pace.8 However, as society and the formed, with the classic nature and
begin to take hold. Those who reach profession determine norms of behavior, nurture influences having been active
Stage 4 are characterized as the self- each individual wishing to join the for almost two decades. Their genetic
defining professional; they can negotiate profession must adhere to these norms.9 inheritance, including their sex, race,
conflicts between professional values and and personal characteristics, in part
their core belief system and criticize or determines “who they are.”6,24 Their life
challenge aspects of the profession. Their Identity Formation and Medical experiences, including culture, religion,
reason is in control of their emotions and Education and socioeconomic status, represent
desires. At this stage, a deep, authentic, The following schematic representations major influences, as do their education
and unshakable incorporation occurs were developed on the basis of the and sexual orientation.24 Finally, their
with professional identity and the other literature on identity formation and multiple personal relationships have

Academic Medicine, Vol. 90, No. 6 / June 2015 719

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Perspective

an important formative impact.5,6,24 identity.14 Such negotiations can result in to the center occurs in stages, proceeding
Acceptance into medical school is the individual accepting all or part of the from observation to imitation, then
symbolically significant as it begins the new identity, arriving at a compromise to carrying out uncomplicated
long process of socialization through between the new and old identities, or tasks, culminating in more complex
which students transform from rejecting the new identity. For example, activities.32,33 This description applies to
members of the lay public to skilled recent generations have distanced the transformation of a medical student
professionals.27 This process has several themselves from the lifestyle of those from a member of the lay public to a
stages—the identity of a medical student whose professionalism has been described professional. The sense of belonging, an
is distinct from that of a resident, as “nostalgic”30 and have committed to important component of a community
which differs from that of a practicing configuring a different balance between of practice, translates into the collegiality
physician.9,19,23,28,29 It is difficult to “skip” lifestyle and work.31 of the profession.34 Finally, the profession
stages as, for example, issues facing a exerts a compelling social influence on its
resident may be incomprehensible to a The bottom of Figure 1 invokes social members as compliance with professional
first- or second-year medical student who learning theory to help understand the norms eventually emerges from within
is less developmentally advanced and has acquisition of a professional identity the individual.24,25,34
not yet participated in the full process of within medical education. The concepts
socialization.9 of communities of practice and situated The norms of medicine’s community
learning articulated by Lave and of practice change over time as the
Although the achievement of a Wenger32,33 are instructive.1,3,9 These social contract between medicine and
professional identity appropriate for authors propose that social interaction society evolves, altering the expectations
graduating medical students or emerging between individuals promotes learning of patients, society, and physicians.35
residents is a valid educational objective, and that a community of practice is Each individual wishing to join the
we emphasize that identity is not static created when those who wish to share community must adhere to these norms.
and that the identity of a practicing a common body of knowledge engage Failure to do so can inhibit progress to
physician will continue to evolve in activities whose aim is to become full membership or elicit sanctions or
throughout his or her practice.3,6,8,24 knowledgeable and skilled in a defined exclusion from the community.24
field. The learning takes place within the
The response of each individual to defined domain and thus is “situated.” In the past, the identity of physicians
socialization will vary, but all must enter As a consequence, the individual moves has been exclusionary as the profession
into a series of personal negotiations from “legitimate peripheral participation” was dominated by white males of
as they acquire their new identity. The to full participation in the community. the dominant religion.3,11,13,17 Even
“readiness” of individuals to alter their An important aspect of full participation, though progress has been made,
existing identity differs25; some navigate according to these authors, is the with the community becoming more
the process with little difficulty. Erikson6 acquisition of the identity associated representative of the society it serves,
believed that frequently some degree of with the community.32 This activity is minority and class distinctions still exist,
“repression” of one’s existing identity voluntary—the individual wishes to making entry challenging for many.3,10,11,17
is required. This repression can lead to join the community and, over time, In addition, tension may arise between
“identity dissonance” as aspects of one’s accepts the norms established by it.9 The the imperative to impose norms and
new identity conflict with one’s old movement from peripheral participation standards in an effort to homogenize

Existing personal
identities
“Who you are” Socialization Personal &
Genes Negotiation professional
Sex/Race
Personal characteristics identities
Experiences Acceptance “Who you become”
Religion/Culture Compromise
Class Rejection Student Resident Physician
Education
Sexual orientation
Other

Community of practice
Legitimate
Full
peripheral
participation
participation Social interaction

Figure 1 A schematic representation of professional identity formation, indicating that individuals enter the process of socialization with partially
developed identities and emerge with both personal and professional identities (upper portion). The process of socialization in medicine results in an
individual moving from legitimate peripheral participation in a community of practice to full participation, primarily through social interaction (lower
portion).

720 Academic Medicine, Vol. 90, No. 6 / June 2015

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Perspective

values and the desire of individuals to In addition, not all factors operate know but cannot tell.”43 The learner
maintain important aspects of their own simultaneously or at the same stage of is generally unaware that she or he
identity as they join the community of education. For example, the nature of is developing a professional identity
practice.10,11,13 the health care system may have little through this process.20,21 Although it is
effect during the early phases of medical clearly preferable for role models to be
Identity formation and socialization education, but its impact may grow as explicit about what they are modeling,
Figure 2 outlines the multiple factors that learners approach the end of their formal unconscious patterning will always be
influence the process of socialization in education. present and powerful.39
shaping a physician’s professional identity.
Not all of these factors exert equal Role models, mentors, experiences, and The literature on role modeling
influence. The most powerful are role reflection. Role models are “individuals highlights the potential negative impact
admired for their ways of being and of lapses in professional behavior
models, mentors, and the accumulation
acting as professionals.”36 Mentors, exhibited by role models, as students and
of individual experiences.9,12,16,18,20,22
characterized as being “experienced and residents may replicate these behaviors
In Figure 2, we have grouped these
trusted counselors,”37 have closer and in their own practice.39,44 However, every
influences together in the center box, both
more prolonged contact with learners practicing physician has both consciously
because of their importance and because
and can have a greater impact on their and unconsciously patterned his or her
they shape professional identity through professional identity.38 Role models and behavior on that of respected individuals,
complex conscious and unconscious mentors are members of the community and the overall impact of role models
processes that can lead to both explicit of practice that students and residents remains powerful and positive.42
and tacit knowledge.24,25 wish to join.9,25 Becoming like them in
action, appearance, and beliefs facilitates Both clinical and nonclinical experiences
Although role modeling and experiential the move from the periphery towards the also impact the development of a
learning are important, the impact of center of the community. learner’s medical professional identity
each factor on individual learners varies through conscious and unconscious
widely. For example, how an individual Role models and mentors generally exert pathways.40 Experience gained from
is treated by others may have a more their influence in two ways.39,40 First, direct encounters with patients and their
significant impact on those individuals learners consciously acquire knowledge families is foundational to the identity of
from visible minorities or those from through observation, imitation, and a physician.9,12,15,16
lower socioeconomic backgrounds.11,13,17 practice, a process made more effective
More mature medical students who have by guided reflection.39,41,42 Second, the Reflection on individual experiences
a more developed identity may respond unconscious patterning of behaviors to with role models and mentors as well as
differently compared with students which learners are exposed is equally on clinical and nonclinical experiences
proceeding directly from secondary powerful39 and results in the acquisition during medical education is fundamental
education to medical school. of tacit knowledge, “that which we to socialization.9,12,14,15 It leads to a

Learning
Role models &
Formal
environment mentors teaching &
assessment
Health care
Conscious Unconscious Self-
system reflection acquisition
assessment

Existing Personal &

personal Socialization professional
identities identities

Family & Symbols

Conscious Unconscious
friends reflection acquisition & rituals

Clinical/non- Attitude of/Treatment

Isolation clinical by patients, peers,
health care professionals,
from peers experiences public

Figure 2 A schematic representation of the multiple factors involved in the process of socialization in medicine. The large center box surrounded
by the dotted line, which includes role models and mentors and experiential learning, indicates their importance to this process. The direction of the
arrows from existing personal identities to personal and professional identities indicate the dynamic nature of this process.

Academic Medicine, Vol. 90, No. 6 / June 2015 721

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Perspective

repetitive pattern that begins with the they are influenced by the health Finally, the way in which students and
exploration of new knowledge and care system within which they must residents are treated by those with whom
experiences and results in the learner’s practice,49 resulting in several types they have relationships has a significant
assimilation into an existing identity.45 of “professionalism” and professional impact on their sense of self.14–16,18–20,24
When explicitly encouraged to reflect, identities.30 Market forces in health care Patients, peers, family, other health care
learners become active participants in systems may result in “entrepreneurial professionals, and the general public tend
the formation of their own identity.9,10,14 professionalism”30 that will impact to view medical students and residents as
According to Mann and colleagues,39 “as the emerging identity of the young members of the wider medical profession,
one’s professional identity is developed, physician.49 This effect can be direct, which can have a profound impact
there are aspects of learning that require as learners must function within the on how the proto-professionals view
understanding of one’s personal beliefs, health care system. However, the health themselves.9,21,24
attitudes, and values, in the context care system also can impact the learning
of those of the professional culture; environment, for example, by leaving Learners’ role and responses to
reflection offers an explicit approach to too little time for teaching or reflection. socialization
their integration.” The effectiveness of Providing an opportunity for learners Figure 3 depicts learners’ roles and
reflection is strengthened when facilitated to reflect on such issues during their their responses as their identity is being
by a role model or mentor or carried out formative years can foster their awareness formed.
as a group activity.9,12,39 of the potential impact of the health
care environment on their professional Becoming competent is a fundamental
Other factors. Although many factors identity formation and can encourage objective of medical education, and
that have an impact on professional them to cultivate a conscious framing of achieving competence is a necessary
identity formation contribute to the their own responses to it.39 component of professional identity
experiential learning of individuals, formation. With increasing competence,
those listed independently in Figure 2 Subsequently, a constant in medical learners both feel and are regarded by
exert a direct influence. We discuss them education through the ages has been their peers and instructors as being more
individually here because they can be the relative isolation of students secure in their role; thus, they move
affected by educational interventions. and residents and its role in identity away from peripheral participation in
formation.12,13,23,28,29 Family, friends, home medicine’s community of practice.32,33
First, formal teaching can impact environments, and other outside interests This perceived competence feeds back
professional identity formation; and influences provide a background for into the socialization process, reinforcing
educators can make identity formation acculturation and impact the identity an altered sense of self and helping
an educational goal and can explicitly formation process. They also can either learners to define and stabilize their
outline the nature of the socially support the commitment required to identity.25,50 Alternatively, if an individual
negotiated identity agreed on by the become a medical professional or inhibit does not feel comfortable in the required
profession and society.46 The aim is to it. These factors in the environment role or is perceived as lacking important
present the norms and standards of external to the culture of medicine have capabilities, professional identity
the profession and to foster a common become increasingly important as recent formation may be compromised.24
sense of the ideal.16,24,46 A guided self- generations of students, residents, and
assessment of an individual’s progress in medical practitioners attempt to readjust Individuals entering medical school,
the acquisition of a professional identity the balance between commitment to beginning clerkships or residency, and
encourages active participation in the medicine, personal health and well-being, entering practice must modify their
process, with individuals monitoring the and lifestyle, in part by reinterpreting existing identity.9,10,14,28 This process
course of their own journey.9,14,18,39 altruism.31 entails deconstructing elements of their
previous identities and filling a new role
Next, the impact of the learning Symbols and rituals also have a powerful for which their previous life experiences
environment on students’ attitudes and role to play in shaping identity.9,12,14,18,21 may not have fully prepared them.28,51
learning is well documented.47,48 Viewed By participating in these activities, Nevertheless, they are expected to fill
through the lens of communities of individuals publicly indicate that they the new role and demonstrate that
practice, a healthy and inclusionary are joining a community of practice, and they are acquiring the attitudes and
environment is welcoming and models the act of doing so helps to form their values of a physician. They therefore
appropriate behaviors.48 Conversely, identity.25 Thus, symbols and rituals, pretend that they understand and act
an exclusionary, hostile or negative such as the wearing of a stethoscope, accordingly.5,9,10,12,14,24 In addition to
environment, or one populated with participating in a white coat ceremony, becoming knowledgeable about disease
individuals who model unprofessional and reciting the Hippocratic Oath, and its management, students have many
behavior, can impact identity have special significance.12 Experiences, things to learn about the profession and
formation by failing to welcome such as a learner’s first contact with a how it functions. For example, medicine
learners into the community or by cadaver, the death of a patient, and the has its own language to be mastered9,10,28,29
communicating unacceptable norms of first viewing of an operation, take on and a hierarchy to be learned. Power
behavior.12,13,15,16,19,21,47 symbolic importance as transformative generally is distributed in line with that
events cannot and bring students closer hierarchy.9–13 Although most students
In addition, as individuals progress to full participation in the community of come to medicine believing that it is
through their educational experience, practice.12,15,50 characterized by certainty, they must

722 Academic Medicine, Vol. 90, No. 6 / June 2015

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Perspective

come to recognize and account for the emotional engagement and detached the educational goal of supporting
ambiguity and uncertainty that are the concern is part of the emotional process professional identity formation.
norm.51 Finally, adopting the norms of of becoming a physician.50 Finally, some
dress, behavior, and relationships with learners have exhibited cynicism and loss Suggested actions
patients, peers, and other health care of innocence as they progress through the Establishing professional identity
professionals is fundamental.52 Although educational continuum.9,14,48 formation as an educational objective
each individual usually begins by with the full support of the educational
“pretending” to be a physician, with time establishment is a necessary first
From Theory to Practice
he or she ceases to act and “becomes” step.1–3 Educators should delineate,
one.5,9,10,18,24,25 The experience gained in teaching communicate, and model an identity
professionalism56 and the emerging appropriate for the current practice of
The rigor required by medicine and the literature on identity formation can medicine.1,10,13,21 Historically, the accepted
necessity of deconstructing a portion help educators to develop programs professional identity of a physician has
of a pre-existing identity is potentially specifically directed at promoting and stressed individual accomplishment,
stressful and can lead to “identity guiding identity formation during responsibility, and accountability, an
dissonance.”14 Some of this stress is medical education.2,3,10 The features approach that has been difficult to merge
unavoidable.12,20,21 However, becoming of successful programs devoted with the reality of modern practice,
a physician is a source of satisfaction to the teaching of professionalism which necessitates interprofessional
and often joy, a fact that is sometimes include longitudinal integration of collaboration.57 For example, a “merged
underemphasized.25,53 Both the stress material throughout the educational individual and organizational identity”
and the satisfaction that may be derived continuum, a cognitive base outlining is required58—one that encourages
from the socialization process can the nature of professionalism behaviors that do not revolve “around
impact a student’s emerging identity. and professional obligations, and individuals acting and thinking in
Resentment may result from overwork programmed opportunities for isolation, but as a group process in which
or humiliation-induced stress, inhibiting reflection on experiences relating to leaders and followers are joined together
identity formation.38,48 Alternatively, if professionalism.56 Most programs have and perceive themselves to be joined
stress results from constructive feedback, been implemented gradually around a together in a collaborative endeavor.”59
its impact may be positive.38 conceptual framework that serves as its
foundation. The concept of communities of practice
Medical students and residents respond offers a lens through which many aspects
to anxiety and stress by using the coping The schematics in this article (see of the educational environment can
mechanisms of all human beings. Figures 1–3) depict the processes of be examined and altered as needed.
Throughout the ages, medical students, identity formation, socialization, and Students and residents are the colleagues
residents, and practitioners have relied learners’ roles and responses. Ideally, these of the future; thus, conscious efforts to
on humor, appropriate or not, to deal diagrams will enable medical educators ensure that the community is welcoming
with stress.54 However, some also have to view these processes holistically and to all are prudent.1,3,9,25 Despite efforts
used silence as a means of disengagement to identify each factor, analyze its role in to make the profession more inclusive,
from difficult situations.55 The awareness their learning environment, and intervene differences in gender,60 class,11 and other
of, and continued effort to balance, appropriately to facilitate achieving factors17,18 still can create a learning

Learning the
language Learning to play Learning the
the role hierarchy &
“Pretend until you power
Learning to live become” relationships
with ambiguity

Existing Personal &

personal Socialization professional
identities identities

Detached concern Anxiety

Satisfaction
Increased
Loss of innocence Fear
Cynicism Joy competence
Stress
Humor or silence

Figure 3 A schematic representation of the roles that medical students and residents play during the process of socialization and their potential
responses to this process.

Academic Medicine, Vol. 90, No. 6 / June 2015 723

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Perspective

environment that is antithetical to professionalism57,62,63 may be considered past, the versions included here have not been
acquiring a professional identity. within a context of identity formation previously presented.
Finally, the norms established by the with appropriate adjustments,
R.L. Cruess is professor of surgery and core faculty
community must be flexible enough adaptations, and/or redevelopment for member, Centre for Medical Education, McGill
to ensure professional behavior while relevancy. University Faculty of Medicine, Montreal, Quebec,
allowing individuals to remain true to Canada.
themselves.10 Finally, admissions criteria can be S.R. Cruess is professor of medicine and core
examined from the perspective of identity faculty member, Centre for Medical Education,
A lesson we learned from developing formation. A significant disconnect McGill University Faculty of Medicine, Montreal,
programs to teach professionalism is Quebec, Canada.
between the identity of an incoming
that faculty development is an essential student and the desired professional J.D. Boudreau is associate professor of medicine
early step in altering the curriculum.61 identity of the institution can lead to and core faculty member, Centre for Medical
Education, McGill University Faculty of Medicine,
These activities allow faculty members increased dissonance and stress. Therefore, Montreal, Quebec, Canada.
to become a part of the professional institutions should attempt to select
formation process of students, L. Snell is professor of medicine and core faculty
students who already possess many of the member, Centre for Medical Education, McGill
understand educational goals and dispositions of a professional. Multiple University Faculty of Medicine, Montreal, Quebec,
methods, and become knowledgeable and mini-interviews, for example, offer an Canada.
skilled in communicating and modeling a opportunity to accomplish this goal by Y. Steinert is professor of family medicine and
professional identity. selecting applicants who demonstrate the director, Centre for Medical Education, McGill
qualities of the “good physician.”64 University Faculty of Medicine, Montreal, Quebec,
Many of the influences depicted in the Canada.
presented schematics are directly affected Final thoughts
by the curriculum. Formal teaching and In a classic 1957 study of undergraduate References
assessment, role models and mentors, medical education, sociologist Robert
and the learning environment can be 1 Cooke M, Irby DM, O’Brien BC. Educating
Merton23 stated that the task of a medical Physicians: A Call for Reform of Medical
examined individually in the context of school is to “shape the novice into the School and Residency. San Francisco, Calif:
identity formation, and actions can be effective practitioner of medicine, to Jossey-Bass; 2010.
taken to align them with educational give him the best available knowledge 2 Cruess RL, Cruess SR, Boudreau JD, Snell
objectives. Scheduled time for guided L, Steinert Y. Reframing medical education
and skills, and to provide him with a to support professional identity formation.
reflection on clinical and nonclinical professional identity so that he comes to Acad Med. 2014;89:1446–1451.
experiences and their impact on think, act, and feel like a physician.” He 3 Bebeau MJ. Evidence based character
identity formation is fundamental.39 articulated what unquestionably has been development. In: Kenny NP, Shelton WN,
Understanding that students acquire understood as the dual roles of medical eds. Lost Virtue: Professional Character
their identity by playing a role over Development in Medical Education. Oxford,
education through the ages—to ensure England: Elsevier; 2006.
time until the details of that role that all individuals entering the practice 4 Piaget J, Inhelder B. The Psychology of the
become internalized can guide the of medicine are clinically competent Child. New York, NY: Basic Books; 1969.
nature of educational interventions.3,24 and adhere to the standards of conduct 5 Goffman E. The Presentation of Self in
Expectations should be established expected of a professional. The inclusion Everyday Life. New York, NY: Doubleday; 1959.
based on recognizing the developmental 6 Erikson EH. The Life Cycle Completed. New
of identity formation as an educational York, NY: Norton; 1982.
stage of each student.1,3,9,25 Personalized objective throughout the continuum of 7 Kohlberg L. The Psychology of Moral
curricular approaches contextualizing medical education promotes the explicit Development: The Nature and Validity of
students’ clinical and other experiences pursuit of these goals. The presented Moral Stages. San Francisco, Calif: Harper &
through guided, individualized feedback schematic representations can assist Row; 1984.
on their reflections can facilitate the 8 Kegan R. The Evolving Self: Problem and
educators and learners in this valuable Process in Human Development. Cambridge,
professional identity formation process.39 enterprise. Mass: Harvard University Press; 1982.
Identifying and encouraging reflection 9 Jarvis-Selinger S, Pratt DD, Regehr G.
on the impact of the factors beyond the Acknowledgments: The authors express their Competency is not enough: Integrating
formal curriculum that can influence sincere gratitude to their colleagues at the identity formation into the medical
students and residents, such as the nature Centre for Medical Education of McGill education discourse. Acad Med.
University and those who attended interactive 2012;87:1185–1190.
of the health care system48 or the attitudes 10 Frost HD, Regehr G. “I am a doctor”:
workshops in North America and abroad
of family and friends,12,24 may contribute during which these ideas and diagrams were Negotiating the discourses of standardization
to professional identity formation by developed. Their contributions to the schematic and diversity in professional identity
deepening students’ understanding of representations included in this article were construction. Acad Med. 2013;88:1570–1577.
who they are and who they wish to be.38 many and significant. 11 Beagan BL. Everyday classism in medical
school: Experiencing marginality and
Funding/Support: None reported. resistance. Med Educ. 2005;39:777–784.
No tools are currently available 12 Hafferty FW. Professionalism and the
in medical education to follow an Other disclosures: None reported. socialization of medical students. In: Cruess
individual’s progress towards the RL, Cruess SR, Steinert Y, eds. Teaching
acquisition of a professional identity, Ethical approval: Reported as not applicable. Medical Professionalism. Cambridge,
England: Cambridge University Press; 2009.
although such frameworks do exist Previous presentations: While earlier versions of 13 Lempp H. Medical-school culture. Pierre
for dentistry and the military.3,25 The the schematic representations have been used as Bourdieu and the theory of medical
utility of current methods to evaluate the basis for workshops and presentations in the education: Thinking “rationally” about

724 Academic Medicine, Vol. 90, No. 6 / June 2015

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
 Perspective

medical students and medical curricula. In: 30 Hafferty FW, Castellani B. A sociological 49 Lesser CS, Lucey CR, Egener B, Braddock
Brosnan C, Turner BS, eds. Handbook of the framing of medicine’s modern-day CH 3rd, Linas SL, Levinson W. A behavioral
Sociology of Medical Education. London, professionalism movement. Med Educ. and systems view of professionalism. JAMA.
England: Routledge; 2009. 2009;43:826–828. 2010;304:2732–2737.
14 Monrouxe LV. Identity, identification and 31 Ross S, Lai K, Walton JM, Kirwan P, White 50 Wald HS, Reis SP, Monroe AD, Borkan JM.
medical education: Why should we care? Med JS. “I have the right to a private life”: Medical “The loss of my elderly patient:” Interactive
Educ. 2010;44:40–49. students’ views about professionalism in a reflective writing to support medical
15 MacLeod A. Caring, competence and digital world. Med Teach. 2013;35:826–831. students’ rites of passage. Med Teach.
professional identities in medical education. 32 Lave J, Wenger E. Situated Learning: Legitimate 2010;32:e178–e184.
Adv Health Sci Educ Theory Pract. Peripheral Participation. Cambridge, England: 51 Pitkala KH, Mantyranta T. Professional
2011;16:375–394. Cambridge University Press; 1991. socialization revised: Medical students’ own
16 Monrouxe LV, Rees CE, Hu W. Differences 33 Wenger E. Communities of Practice: conceptions related to adoption of the future
in medical students’ explicit discourses Learning, Meaning, and Identity. physician’s role—a qualitative study. Med
of professionalism: Acting, representing, Cambridge, England: Cambridge University Teach. 2003;25:155–160.
becoming. Med Educ. 2011;45:585–602. Press; 1998. 52 Fox RC. Medical uncertainty revisited. In:
17 Weaver R, Peters K, Koch J, Wilson I. “Part 34 Ihara CK. Collegiality as a professional Albrecht GL, Fitzpatrick R, Scrimshaw SC,
of the team”: Professional identity and social virtue. In: Flores A, ed. Professional Ideals. eds. Handbook of Social Studies in Health
exclusivity in medical students. Med Educ. Belmont, Calif: Wadsworth; 1988. and Medicine. Thousand Oaks, Calif: Sage;
2011;45:1220–1229. 35 Cruess RL, Cruess SR. Expectations and 2002.
18 Burford B. Group processes in medical obligations: Professionalism and medicine’s 53 Kalet AL, Sanger J, Chase J, et al. Promoting
education: Learning from social identity social contract with society. Perspect Biol professionalism through an online
theory. Med Educ. 2012;46:143–152. Med. 2008;51:579–598. professional development portfolio:
19 Goldie J. The formation of professional 36 Côté L, Leclère H. How clinical teachers Successes, joys, and frustrations. Acad Med.
identity in medical students: Considerations perceive the doctor–patient relationship 2007;82:1065–1072.
for educators. Med Teach. 2012;34:e641–e648. and themselves as role models. Acad Med. 54 Wear D, Aultman JM, Varley JD, Zarconi J.
20 Helmich E, Bolhuis S, Dornan T, Laan R, 2000;75:1117–1124. Making fun of patients: Medical students’
Koopmans R. Entering medical practice for 37 “Mentor.” Oxford English Dictionary. 2nd ed. perceptions and use of derogatory and
the very first time: Emotional talk, meaning Oxford, England: Clarendon Press; 1989. cynical humor in clinical settings. Acad Med.
and identity development. Med Educ. 38 Sambunjak D, Straus SE, Marusić A. 2006;81:454–462.
2012;46:1074–1086. Mentoring in academic medicine: A systematic 55 Cruess RL, Cruess SR, Steinert Y, eds.
21 Monrouxe LV. Identities, self and medical review. JAMA. 2006;296:1103–1115. Teaching Medical Professionalism.
education. In: Walsh K, ed. Oxford Textbook 39 Mann K, Gordon J, MacLeod A. Reflection Cambridge, England: Cambridge University
of Medical Education. Oxford, England: and reflective practice in health professions Press; 2009.
Oxford University Press; 2013. education: A systematic review. Adv Health 56 Lingard L. Language matters: Towards an
22 Wilson I, Cowin LS, Johnson M, Young H. Sci Educ Theory Pract. 2009;14:595–621. understanding of silence and humour in
Professional identity in medical students: 40 Epstein RM, Cole DR, Gawinski BA, medical education. Med Educ. 2013;47:
Pedagogical challenges to medical education. Piotrowski-Lee S, Ruddy NB. How students 40–48.
Teach Learn Med. 2013;25:369–373. learn from community-based preceptors. 57 Lingard L. What we see and don’t see when
23 Merton RK. Some preliminaries to a Arch Fam Med. 1998;7:149–154. we look at “competence”: Notes on a god
sociology of medical education. In: Merton 41 Kolb DA. Experiential Learning: term. Adv Health Sci Educ Theory Pract.
RK, Reader LG, Kendall PL, eds. The Student Experience as the Source of Learning 2009;14:625–628.
Physician: Introductory Studies in the and Development. Englewood Cliffs, NJ: 58 Spears R. Group identities: The social
Sociology of Medical Education. Cambridge, Prentice-Hall; 1984. identity perspective. In: Schwartz SJ, Luyckx
Mass: Harvard University Press; 1957. 42 Kenny NP, Mann KV, MacLeod H. Role K, Vignoles VL, eds. Handbook of Identity
24 Vignoles VL, Schwartz SJ, Luyckx K. Toward modeling in physicians’ professional Theory and Research. New York, NY:
an integrative view of identity. In: Schwartz formation: Reconsidering an essential but Springer; 2011.
SJ, Luyckx K, Vignoles VL, eds. Handbook of untapped educational strategy. Acad Med. 59 Haslam SA, Ellemers N. Identity processes
Identity Theory and Research. New York, NY: 2003;78:1203–1210. in organizations. In: Schwartz SJ, Luyckx
Springer; 2011. 43 Polanyi M. Personal Knowledge: Towards K, Vignoles VL, eds. Handbook of Identity
25 Skorikov VB, Vondracek FW. Occupational a Post-Critical Philosophy. Chicago, Ill: Theory and Research. New York, NY:
identity. In: Schwartz SJ, Luyckx K, Vignoles University of Chicago Press; 1958. Springer; 2011.
VL, eds. Handbook of Identity Theory and 44 Leo T, Eagen K. Professionalism education: 60 Bleakley A. Gender matters in medical
Research. New York, NY: Springer; 2011. The medical student response. Perspect Biol education. Med Educ. 2013;47:59–70.
26 Forsythe GB, Snook S, Lewis P, Bartone Med. 2008;51:508–516. 61 Steinert Y, Cruess RL, Cruess SR, Boudreau
PT. Professional identity development for 45 Luyckx K, Schwartz SJ, Goosens L, Beyers W, JD, Fuks A. Faculty development as an
21st century army officers. In: Snider DM, Missotten L. Processes of personal identity instrument of change: A case study on
Matthews LJ, Marshall J, eds. The Future of formation and evaluation. In: Schwartz SJ, teaching professionalism. Acad Med.
the Army Profession. New York, NY: McGraw Luyckx K, Vignoles VL, eds. Handbook of 2007;82:1057–1064.
Hill; 2005. Identity Theory and Research. New York, NY: 62 Wilkinson TJ, Wade WB, Knock LD.
27 Hilton SR, Slotnick HB. Proto- Springer; 2011. A blueprint to assess professionalism:
professionalism: How professionalisation 46 Daniels N. Just Health Care. Cambridge, Results of a systematic review. Acad Med.
occurs across the continuum of medical England: Cambridge University Press; 2008. 2009;84:551–558.
education. Med Educ. 2005;39:58–65. 47 Brainard AH, Brislen HC. Viewpoint: 63 Hodges BD, Ginsburg S, Cruess R,
28 Becker HS, Geer B, Hughes EC, Strauss AL. Boys Learning professionalism: A view from the et al. Assessment of professionalism:
in White: Student Culture in Medical School. trenches. Acad Med. 2007;82:1010–1014. Recommendations from the Ottawa 2010
Chicago, Ill: University of Chicago Press; 1961. 48 Benbassat J. Undesirable features of the Conference. Med Teach. 2011;33:354–363.
29 Bosk CL. Forgive and Remember: Managing medical learning environment: A narrative 64 Eva KW, Rosenfeld J, Reiter HI, Norman GR.
Medical Failure. Chicago, Ill: University of review of the literature. Adv Health Sci Educ An admissions OSCE: The multiple mini-
Chicago Press; 1979. Theory Pract. 2013;18:527–536. interview. Med Educ. 2004;38:314–326.

Academic Medicine, Vol. 90, No. 6 / June 2015 725

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.