A scoping review and theory-informed conceptual model of professional identity formation in medical education: Commentary from a clinical psychology perspective

Abstract

As Sarraf-Yazdi et al. discuss, professional identity is critical to the education of medical trainees and—eventually—the clinical practice of medical practitioners.¹ The same applies to clinical psychologists. Like medical trainees, clinical psychology trainees are socialised into their chosen healthcare profession. Through that process, they continuously construct and reconstruct their professional identities over time. In this commentary, we propose that although professional identity research is less developed within clinical psychology than in medicine,² the two professions have faced and continue to face a similar challenge: to adopt a sophisticated theoretical perspective that enhances research processes, findings and recommendations when exploring professional identities. This might be due to the breadth and complexity of identity theorising across social science disciplines that often differ from the disciplines in which healthcare professions education researchers have been trained.³ We suggest, however, that we all stand to gain from ensuring our research efforts engage with, and build upon, these sophisticated theoretical approaches as we develop our own understanding of professional identities for specific healthcare professions.

We start by acknowledging the perspective from which this commentary is written. Who we are inevitably influences what comes next. We identify as white and female and work clinically and academically across the areas of clinical psychology and professional identity. Collectively, we have an interest in the education and training of clinical psychologists, clinical practice and professional identities. Our research is primarily informed by a social constructionist perspective.⁴ Together, we collaborated on a recent review of professional identity literature in clinical psychology.²

Drawing upon those perspectives, we consider Sarraf-Yazdi et al. to have undertaken an ambitious academic pursuit. Reviewing, synthesising and constructing a theory-informed conceptual model of professional identity formation in medical education from their findings of a sizable literature base ‘to inform future action and exploration’ (p. 6, our emphasis) is undeniably a large undertaking. Furthermore, we acknowledge that research in the field of healthcare professional education serves both service (e.g., education) and science (e.g., rigorous pursuit of knowledge) interests.⁵ As such, this work is important as it will be welcomed by educators interested in the host of factors that might influence professional identities, enabling them to be accounted for in education and training programs (i.e., by those amongst us who will be taking future action). The difficulty, we suggest, is the issue of exploration (i.e., those who wish to investigate professional identity formation and its related constructs). This is not new or unsurprising. Difficulties arising from theoretical and linguistic/construction variation on this concept abound, not only across both medicine and clinical psychology but also across the various fields of psychology, sociology and anthropology: the very academic basis on which the majority of current thinking in this area originates.³

We initially set out to examine this model theoretically, examining how professional identity is understood in medicine in comparison with clinical psychology. We quickly realised, however, that both professions would benefit from revisiting how theorising on identity construction can enhance research and education efforts. After all, the process of becoming a health professional involves acquiring ways of knowing and doing that stand true irrespective of the specific healthcare profession. So, what is to be gained by returning to theory for both medicine and clinical psychology? We agree with Sarraf-Yazdi et al. that a social constructionist lens has much to offer. Professional identities, when viewed from a social constructionist perspective, are understood as both a product of—and as produced in—interaction with others in the social world.^{4, 6} Our identities are shaped and constrained by the wider social discourses around us, as well as being actively and agentively constructed as we navigate our social world. There is a mutually constructive relationship between the individual and the social. Moreover, this process never ends: our identities are continuously being renegotiated in and through interactions with others. This can appear abstract and academic, and devoid of practical application. Yet, this perspective invites an appreciation of the individual, interpersonal, interactional, organisational and national levels within which our identities operate alongside the complex processes at play at each of these levels. Essentially, we are alluding to how doctors and clinical psychologists come to understand themselves as clinicians (which then informs clinical practice) through their interactions (for instance, with educators, learning spaces, organisations and so on). This insight allows educators to guide the process of identity construction in optimal ways that support the provision of quality clinical care.

The desire for a model with practical recommendations for educators and clinicians (those taking future action) is understandable. Models that generate solutions that can be easily applied have appeal in time and resource-constrained environments. Nevertheless, this desire for models that promise to make something as complex as our identities more digestible should not supersede the value-add of holding true to the rich (albeit complex) nature of what is known about identities and how they are constructed (see Ajjawi & Eva⁷ for discussion of risks of ‘solutionism’ in medical education). This is true across both medicine and clinical psychology. The model proposed by Sarraf-Yazdi et al., while developed following a comprehensive review of the existing literature and a broad array of empirical data with strong face validity, is empirically driven and therefore lacks a unified theoretical foundation. The model has yet to undergo the necessary stages of theorisation, operationalisation, testing and refinement and so is at a very early stage of inception. Moreover, while the model identifies many factors influencing identity development, it does not detail the underlying processes involved (i.e., how this takes place) nor the content of identities, leaving much speculation for those interested in both future action and the exploration of professional identities. For example, how do societal factors such as leadership or the hidden and formal curricula influence professional identity development? Without this knowledge, how are educators to know how to, for instance, address hidden and formal curricula or adjust leadership in training programs?

Despite our reservations, we acknowledge the authors' valuable effort in synthesising a vast body of literature and agree on the benefits of such an approach. So how do we take this forward? We offer suggestions for advancing this work. Schwartz et al.³ provide us with a comprehensive review and integration of identity theorising alongside practical suggestions for researchers (too detailed for us to recount in this commentary). Although we recognise the risk of diluting the strengths of individual theories, we see value in their recommendations. In line with this work, we reiterate that researchers across healthcare professions education consider multiple levels of identity construction, the interaction between short-term and long-term processes and the balance between agentive and socially determined identity construction. Further, as we develop our testable models, in turn, these will be crucial for further future action, better enabling educators to identify, address or modify factors within training programs by providing actionable insights and clear direction for educational practices. Ultimately, the complexity involved in developing testable models is challenging but also has applied benefit: as Kurt Lewin's Maxim asserts, ‘there is nothing so practical as a good theory’.

Nil.