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

2. No Conflicts of Interest To Report

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

4. 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

5. 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

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

7. 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

8. 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

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

10. 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

11. 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

12. 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”

13. 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

14. 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

15. 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

16. 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

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

18. HOW ARE IDENTITIES FORMED?

19. 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)

20. 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

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

22. 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

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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

30. SOCIALIZATION FOR PROFESSIONAL IDENTITY FORMATION

31. 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

32. HOW DO LEARNERS RESPOND?

33. 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

34. 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.

35. 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

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

37. 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)

38. Supporting Professional Identity Formation
Year 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

39. 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

40. 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

41. 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?

42. 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

43. “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

44. CENTRE FOR MEDICAL EDUCATION
THANK YOU!
CENTRE FOR MEDICAL EDUCATION

45. Academic Medicine
November, 2014
Academic Medicine
June, 2015

46. Academic Medicine
February, 2018
Academic Medicine
February, 2016