PROFESSIONAL IDENTITY FORMATION AND COMMUNITIES OF PRACTICE Richard L. Cruess Sylvia R. Cruess & colleagues McGill University Faculty of Medicine

No Conflicts of Interest To Report

The central issue in learning is becoming a practitioner, not learning about practice. Brown and Duguid, 1991

OBJECTIVES OF THE SESSION By the end of this session, participants will be able to: Describe the relationship of professional identity formation to professionalism within a community of practice Identify factors that can positively or negatively affect identity formation Apply this knowledge to better understand their own identities and educational practices

THE DUAL GOALS OF MEDICAL EDUCATION NOT A NEW CONCEPT It is the function of undergraduate and postgraduate medical education to “transmit the culture of medicine and… to shape the novice into an effective practitioner of medicine, to give him the best available knowledge and skills, and to provide (him) with a professional identity so that he comes to think, act, and feel like a physician” Merton, 1957

“The greatest influence on professional identity formation takes place during residency” Ludmerer, 2015

HOW DID WE GET HERE? THE HISTORY OF THE “PROFESSIONALISM MOVEMENT” Arose in the 1980s and ‘90s because of perceived threats to medicine’s professionalism The ABIM “Project Professionalism” was seminal THE CHARTER Led to an examination of how medicine’s values were transmitted from one generation to another These values are embodied in the word “professionalism” Professionalism had not been taught explicitly, having been transmitted by respected role models It was agreed that depending upon role models alone was no longer effective

THE RESULT A consensus that professionalism should be taught explicitly The development of longitudinal curricula throughout the continuum of medical education that included methods of instruction and assessment This required a cognitive base Definitions of professionalism and its values and characteristics An understanding of medicine’s relation to society (the social contract) and of public expectations of medicine

Teaching Professionalism Year 1 Year 4 Level of Sophistication Add Social Contract Undergraduate Postgraduate Practice Imparting the Cognitive Base Capacity to Incorporate Values Promoting Self-Reflection

THE RESULT (CONT’D) An assumption that understanding professionalism would lead students to behave professionally An emphasis on promoting and assessing professional behaviors – on “doing” Of fundamental importance: teaching and assessing professionalism became a requirement for accreditation at the undergraduate and postgraduate levels-LCME, ACGME, ABMS, RCPSC(C), etc

BUT there was always the existential question: Does medical practice require “a professional presence that is best grounded in what one is rather than what one does?” Hafferty, 2009

RELEVANT BACKGROUND The Carnegie Foundation Report: professional identity formation should be a foundational element of medical education (Irby, Cooke & O’Brien, 2010) An extensive literature on professional identity formation in medicine emerged- mostly in UGME It was proposed that supporting professional identity formation in learners become the educational objective Conceptually supporting professional identity formation builds on what we have learned from teaching professionalism – “the norms”

THE NEW ASSUMPTION Professional identity formation throughout medical education and practice takes place through the process of socialization within a community of practice This process can be made more effective and reliable by: Being specific about the professional identity to be created Understanding the nature of identity formation Understanding socialization and communities of practice to create a curriculum and educational environment that facilitates the transition to the desired identity

PROFESSIONAL IDENTITY DIFFERENT FROM PROFESSIONALISM Professionalism: “a set of values, behaviors and relationships that underpins the trust the public has in doctors” (Royal College of Physicians of London, 2005) Professional identity: not just how others perceive you, but how you perceive yourself

MEDICAL PROFESSIONAL IDENTITY A representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting and feeling like a physician. Cruess, Cruess, Boudreau, Snell & Steinert, 2014

IDENTITIES Professional identity formation is superimposed on the normal process of identity formation The process starts at birth & continues throughout life, stabilizing in early adult life An individual can have several personal & professional identities Their expression is context dependent

DISCUSS WITH YOUR NEIGHBORS WHO ARE YOU? WHAT ARE YOUR PERSONAL IDENTITIES? WHAT ARE YOUR PROFESSIONAL IDENTITIES? DISCUSS WITH YOUR NEIGHBORS

HOW ARE IDENTITIES FORMED?

THROUGH THE PROCESS OF SOCIALIZATION “The process by which a person learns to function within a particular society or group by internalizing its values and norms.” (OED) “Involves training for self-image and identity… melding knowledge and skills with an altered sense of self.” (Hafferty, 2009)

SOCIALIZATION EXISTING PERSONAL IDENTITIES “Who you are” GENES Sex / Race Personal Characteristics EXPERIENCE Religion / Culture Class Education Sexual Orientation Other PERSONAL & PROFESSIONAL IDENTITIES “Who you become” Practice Resident Student SOCIALIZATION NEGOTIATION of VALUES & NORMS Acceptance Compromise Rejection GENERATIONAL DIFFERENCES EXPRESSED Cruess et al., 2015

WHAT ARE THE NORMS? WHAT IT MEANS TO BE A PROFESSIONAL IS DETERMINED BY SOCIAL NEGOTIATIONS BETWEEN MEDICINE AND SOCIETY

DEFINITION: PROFESSION An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served, to their colleagues, and to society.” Derived from the Oxford English Dictionary and the literature on professionalism Cruess, Johnston, Cruess, 2004

ATTRIBUTES Professional Healer PHYSICIAN Competence Commitment Healer Professional ATTRIBUTES Competence Commitment Confidentiality Altruism Trustworthy Integrity / Honesty codes of ethics Morality / Ethical Behavior Responsibility to profession Caring/ compassion Empathy Insight Openness Respect for the healing function Respect patient dignity/autonomy Advocate for Patient Presence/Accompany Autonomy Self-regulation associations institutions Responsibility to society Team work Professional Healer Cruess & Cruess 2006 Based on the literature

WHERE DOES SOCIALIZATION TAKE PLACE WHERE DOES SOCIALIZATION TAKE PLACE? IN SOCIAL GROUPS CALLED COMMUNITIES OF PRACTICE

COMMUNITY OF PRACTICE SOCIALIZATION Social Interaction EXISTING PERSONAL IDENTITIES “Who you are” GENES Sex / Race Personal Characteristics EXPERIENCE Religion / Culture Class Education Sexual Orientation Other PERSONAL & PROFESSIONAL IDENTITIES “Who you become” Practice Resident Student SOCIALIZATION NEGOTIATION of VALUES & NORMS Acceptance Compromise Rejection GENERATIONAL DIFFERENCES EXPRESSED COMMUNITY OF PRACTICE Legitimate Peripheral Participation Full Participation Social Interaction Cruess et al., 2015

COMMUNITY OF PRACTICE A Social Learning Theory “A persistent sustaining social network of individuals who share and develop an overlapping knowledge base, set of beliefs, values, history and experiences focused on a common practice” Barab et al, 2002

MEDICINE AS A COMMUNITY OF PRACTICE Medicine: a macro-community of practice Medical specialties: meso-communities Departments etc: micro-communities “A Landscape of Practices” Physicians legitimately belong to multiple communities Students and residents voluntarily wish to join the community of practice In joining they acquire the identity of their chosen specialty, accepting and internalizing the values & norms established by the community

MEDICINE AS A COMMUNITY OF PRACTICE The values & norms of medicine’s community of practice are delineated by the meaning of the word “professionalism” The values and norms (professionalism) vary between cultures and between generations THE VALUES AND NORMS OF THE COMMUNITY MUST BE MADE EXLICIT definitions, desirable attributes, behaviors SOME ARE NON-NEGOCIABLE

DISCUSS WITH YOUR NEIGHBORS To which professional communities of practice do you belong? What factors influenced the development of your professional identities? DISCUSS WITH YOUR NEIGHBORS

SOCIALIZATION FOR PROFESSIONAL IDENTITY FORMATION

Existing personal identities New personal & professional identities Social Media Formal teaching & assessment Role models & mentors Learning environment Self-assessment Health care system Conscious reflection Unconscious acquisition Existing personal identities New personal & professional identities Socialization Conscious reflection Unconscious acquisition Symbols & rituals Family & friends Not all equal influence –influence varies over time and with individual and those in centre more influential. Role models may be + or – Most of these factors can be affected by education interventions Clinical/non- clinical experiences Attitude of / Treatment by patients, peers, health care professionals, public Isolation from peers . .. Cruess et al., 2015 31

HOW DO LEARNERS RESPOND?

LEARNER ROLES AND POTENTIAL RESPONSES Learning the language Learning to play the role “Pretend until you become” Learning the hierarchy & power relationships Learning to live with ambiguity Existing personal identities New personal & professional identities Socialization Top of slide – Roles learned and parts needed Bottom of slide – reactions, in part from identity dissonance from de- and re-constructing identity Increased competence is a goal of med ed, affects how peers interact and view learner and how learner feels (move from periphery to centre) Detached concern Loss of innocence Cynicism Humor or silence Anxiety Fear Frustration Stress Satisfaction Joy Increased competence Cruess et al., 2015

CRITICISM OF A COMMUNITES OF PRACTICE AS A THEORY Bourdieu: Social structures tend to reproduce themselves, perpetuating existing hierarchies, power structures, and inequities- “self-deluding and self-reinforcing social behavior can take place within communities of practice” Solution: identify and address the issues socioeconomic, gender, race, hierarchy & power, etc.

A POTENTIAL NEGATIVE ASPECT OF THE PROCESS The process of socialization can inappropriately suppresses important aspects of one’s personal identity. Solution: The faculty must be aware of the issue & ensure that this does not occur

How can you alter your program to specifically support professional identity formation in your residents? DISCUSS WITH YOUR NEIGHBORS

General Principles for Supporting Professional Identity Formation Establish professional identity formation as an educational objective and aspirational goal Explicitly embrace communities of practice as the educational theory underpinning medical education Provide institutional support Allocate responsibility Establish and explicitly teach the cognitive base The norms (professionalism) The nature of identity formation (PIF) and socialization Communities of practice (COP)

Supporting Professional Identity Formation Year 1 Year 4 Level of Sophistication Add Social Contract Undergraduate Postgraduate Practice Imparting the Cognitive Base Healer & Professional Socialization PIF & COP Capacity to Develop Professional Identity Experiences Reflection

General Principles for Supporting Professional Identity Formation Provide faculty development to ensure that faculty understand the concept and impact of PIF, socialization, & COP Engage students in their own identity formation, establishing membership in the community as an explicit aspirational goal Stress that students MUST retain their own personal identities in spite of possible “identity dissonance” Be intentional: provide regular time and opportunities for guided reflection on professionalism, PIF, & COP

General Principles for Supporting Professional Identity Formation Ensure that the community of practice is welcoming and supportive of its future members role models/mentors institutional factors emphasis on continuity, social events, rituals Establish programs to assess progress towards the acquisition of a professional identity Assess professional behaviors- how others see you Stress guided self-assessment- how you see yourself

10 9 8 7 6 5 4 3 2 1 ENGAGE STUDENTS IN GUIDED REFLECTION & SELF-ASSESSMENT Lay-person Physician Where are you on your journey?

THE ASPRATIONAL GOAL: A shift in emphasis from faculty teaching professionalism to one in which learners are actively engaged in developing their own professional identity with support from peers and faculty

“Expertise is not simply a property that passes from teacher to learner, but a dynamic commodity that resides within communities of practice; learning, according to the theory, is a process of absorbing and being absorbed into the culture of such a community“ Dornan et al., 2002

CENTRE FOR MEDICAL EDUCATION THANK YOU! CENTRE FOR MEDICAL EDUCATION richard.cruess@mcgill.ca sylvia.cruess@mcgill.ca

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