#11 Break on through to the other side of PIF

May 8, 2023

Host: Lara Varpio

Enjoy listening to us at your preferred podcast player.

Episode article

Verwer, S., & van Braak, M. (2022). Subjectification in Health Professions Education: Why We Should Look Beyond the Idea of Professional Identity Formation. In M. E. L. Brown, M. Veen, & G. M. Finn (Eds.), Applied Philosophy for Health Professions Education: A Journey Towards Mutual Understanding (pp. 23–37). Springer Nature. https://doi.org/10.1007/978-981-19-1512-3_3

In this episode, Lara brings a book chapter to the discussion which asks if we need to think differently about professional identity formation (PIF). The hosts discuss the strengths and weaknesses of current ways of thinking about PIF and they review the concept of subjectification and how this concept might help the field move to new, and exciting new ways of thinking about being a clinician.

Background

For quite some time, the way professional identity formation (PIF) has been discussed in health professions education has been bugging me. It hasn’t been sitting quite right with me. So I searched for a manuscript that might help us think differently about PIF, or at least offer insights into why PIF has been bothering me.

Results/Findings

The Last Word –

Comments from the author, Robert Sternszus MDCM,MA (Ed), FRCPC

Hi Linda. Thanks for the heads up on the podcast. I’m truly thrilled that it is being discussed and that really was the whole point (the stated intention of the paper was ‘to start a conversation.’) In case anyone was concerned, I was in no way offended by the critique although I disagreed with much of it.

In particular, the premise of the entire critique implies that the paper was interpreted in a completely opposite way to which I felt it was written. And that, in and of itself , is interesting and important in terms of how we talk about these concepts moving forward.

The ‘blurb for the podcast’ sets it up with: ‘Is a competency-based approach to health professions education compatible with professional identity formation? These authors say no and offer some remedies.’

And yet, the closing sentence of the introduction/purpose statement of the paper explicitly states the opposite:

‘In this paper, we argue that CBME and PIF are not only compatible, they can also both be enhanced by reconciling one with the other.’

The argument line was intended to reflect that the ways in which PIF and CBME have both been described and operationalized, which are sometimes actually at odds with their theoretical underpinnings (as the group highlighted), have made them seem incompatible to many when they in fact are not. The importance of identifying and naming the perceived contradictions lies in being able to debunk them and point to opportunities and solutions Which, I agree with Jason and Linda, is the value of the paper. Ultimately, initiatives explicitly intended to help support reflection and engagement with PIF have not been meaningfully incorporated into many curricula in part because curriculum designers struggle to see how to do that in a curriculum that is entirely centered on EPAs and competencies.

Lastly, I think the discussion around assessment is an important one. Professional identity and professional identity formation are NOT competencies (agree fully!) And, also agree fully that one’s professional identity should not be assessed. However, I think formative guided self-assessment of the process of forming a professional identity can be a powerful trigger for reflection. And, given that CBME implementation has often meant exclusion/minimization of things that cannot be ‘assessed’ (again, not what CBME theory says but what plays out in practice) conceptualizing assessment around the process of PIF is a launch point to help curriculum designers include it meaningfully.

All of that said, it’s been really fun to see the chatter the paper has generated (it was selected as a MedEd must read for February in addition to being in the podcast). And I am grateful for the time and thought that was put in by the Papers Podcast team in reviewing it.

A demain

Robert

To date, PIF research has had 2 orientations. The first looks at the unique individuality of each person who is becoming part of the profession. The second looks at the social aspects of PIF, highlighting how identities are co-constructed through interactions in social settings, created through language, and not limited to just the individual’s cognition.

But here’s the problem: Both of these ways of thinking about PIF focus on the individual fitting into the molds that are prescribed and pre-defined by the profession. In both these ways that our field has been thinking about PIF, the autonomous, individual learner is expected to take on the language, the demeanor, the traditions of the profession. They fit our mold.

Subjectification

The radical revision that these authors propose is to refocus our attention to look at subjectification. Subjectification is about the possibilities that are available to the individual who is becoming a doctor. It is what you are free to do. It is about what is not possible for that person. It is what you can’t do as a doctor. If identity is about who am I as a doctor. Then subjectification is about what can I do as a doctor. If identity asks you to take on the role of a doctor and figure out what that means for you, then subjectification asks what is it like to exist as a doctor in the world? What is easy to do? What resistance do you face? If a focus on identity has the learners asking who am I, then subjectification asks how am I, how do I exist as a doctor, what can I do with my identity as a doctor.

This could really change the way we think about becoming a doctor. It asks us to worry less about how our learners fit the mold for a good doctor, worry less about socializing learners to be like one of us. Instead, our role as educators is about teaching students how to act in the world as a doctor. What are you free to do? What responsibilities do you have? What limitations do you need to contend with? What choices will you make?

References and resources

Editors: Brown, M. E. L., Veen, M., & Finn, G. M. (Eds.). (2022). Applied Philosophy for Health Professions Education: A Journey Towards Mutual Understanding. Springer Nature. https://doi.org/10.1007/978-981-19-1512-3

Megan EL Brown, Teaching fellow at Imperial College London. On Twitter @Megan_EL_Brown
Mario Veen, Assistant Professor, Erasmus MC. On Twitter @MarioVeen
Gabrielle Finn, Professor at the University of Manchester. On Twitter @gabs_finn

Other resourses on PIF

Cruess, R. L., Cruess, S. R., & Steinert, Y. (2016). Amending Miller’s Pyramid to Include Professional Identity Formation. Academic Medicine: Journal of the Association of American Medical Colleges, 91(2), 180–185. https://doi.org/10.1097/ACM.0000000000000913

Cruess, S. R., Cruess, R. L., & Steinert, Y. (2019). Supporting the development of a professional identity: General principles. Medical Teacher, 41(6), 641–649. https://doi.org/10.1080/0142159X.2018.1536260

Mount, G. R., Kahlke, R., Melton, J., & Varpio, L. (2022). A Critical Review of Professional Identity Formation Interventions in Medical Education. Academic Medicine: Journal of the Association of American Medical Colleges, 97(11S), S96–S106. https://doi.org/10.1097/ACM.0000000000004904

Yiu, S., Yeung, M., Cheung, W. J., & Frank, J. R. (2022). Stress and conflict from tacit culture forges professional identity in newly graduated independent physicians. Advances in Health Sciences Education. https://doi.org/10.1007/s10459-022-10173-z