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Chapter 13 Professional identity formation, the practicing physician, and continuing professional development
Mary is a fifty-year-old family physician who has worked for nearly two decades in a large suburban multidisciplinary family medicine clinic with eight other family physicians as well as nurses, pharmacists, and a dietician. Many of her patients and their families have been with her for several years. To better enjoy and support her children and aging parents, she has recently left the clinic to join a group of medical and radiation oncologists in a breast cancer clinic where she will be the only family physician providing primary care and counseling to their patients who don’t have a family physician. She wonders how she will adapt to this work environment in which other family physicians are not available on location to discuss cases with and calibrate her work. She is feeling anxious about working exclusively with cancer physicians, given how specialized their work is, and she does not know any other family physicians who have assumed this type of a role in a specialty clinic.
John is a forty-six-year-old MD-PhD working in a medical school. He has just been promoted to professor in his medical school based on the quality of his work as judged by peers within the medical school and internationally. However, he struggles to combine clinical work, teaching, research, and committee work. He frequently works twelve to fourteen-hour days to fulfill the responsibilities of his various roles and succeeds partly by compartmentalizing his work. When he is on clinical service, he tries to focus on being a physician and clinician educator to the medical students and residents on his service. When he is in the lab, he tries to focus on his research, getting grants, running the lab and ensuring graduate students are making progress. As a professor, he is now expected to bring in larger, more complex grants from international agencies and to support postdoctoral fellows as well as graduate students. Many days are difficult as he finds himself pulled with questions from his lab or from the clinic when he is not there. Hospital meetings occur regularly and he is expected to actively participate in quality assurance committee work. Dealing with the new expectations associated with the promotion has been difficult; he feels pulled in too many directions and is not staying on top of his work.
Introduction
A physician’s identity is 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.1
Physicians who have completed postgraduate medical education (residency) training and attained certification or independent practice continue to develop their professional identity throughout the rest of their careers and into retirement. While the formation of professional identity may be considered a phenomenon that occurs primarily during formal periods of learning, people do change over a career. It is critical to recognize the concept of professional identity as a process that continues throughout a physician’s life.
Professional identity is shaped by many forces. As Jarvis-Selinger et al.2 note, professional identity occurs at two levels: the individual level, which involves the psychological development of the person; and the collective level, which involves a socialization of the person into appropriate roles and forms of participation in the community’s work. Similarly, Sabel et al.3 note that it is helpful to think of identity within the context of social identity theory to bring together the self, internalized identity, and the identity that is co-constructed through social interactions. People work to integrate their roles (e.g., cardiologist, retired physician, “new” family physician) and status, along with their diverse experiences, into a coherent image of themselves, thus achieving their professional identity that continues to evolve.
Physician identity is achieved in stages and parallels adult psychological development. While the formative years for psychological development are during childhood, the potential for further development and change continues throughout adult life. In this regard, the formation of a physician’s identity begins in early adult life, within the context of prior psychosocial development, and is influenced by the individual’s specific generational and sociocultural environments.2,4 A consideration of theories of adult development that emphasize different aspects of psychological growth, and may influence how physicians engage with their role in society, helps to further understand facets of professional identity formation.
For example, Erikson’s5 widely known and influential theory of healthy adult male psychological development described step-wise resolution of task-related conflicts beginning in early childhood and extending throughout adult life. The stages relevant to professional identity begin in late adolescence with identity versus role confusion, followed by adult developmental stages of intimacy versus isolation (ages eighteen–forty), generativity versus stagnation (ages forty–sixty-five), and integrity versus despair (over sixty-five). Failure to successfully complete a stage can result in a reduced ability to complete further stages. Emphasizing the fluidity of identity formation, these stages, however, can be resolved successfully at a later time in the life cycle. Vaillant’s6 longitudinal study of healthy adult male development notes the importance of work and love over seven decades. Building on Erikson’s theoretical framework, Vaillant7 added two developmental tasks: career consolidation and keeper of meaning. Following mastery of intimacy, wherein the capacity for interdependence, reciprocity, and commitment in romantic relationships and friendship is matured, career consolidation is characterized by commitment, competence, contentment, and compensation, and the career contributes to the same enjoyment as did play in childhood.7 Subsequent to the stage of generativity, characterized by serving as a mentor or consultant, Vaillant’s7 description of the keeper of meaning task emphasizes the preservation of culture through tradition and history. This stage may be more evident in retirement.
Levinson8 developed a highly influential, although controversial, theory of life structure, with sequential life stages for both men and women.8,9 Early, mid, and late adult life are three eras lasting about twenty-five years each, and requiring several years to complete the transition. Mid-life, which at the time of his research was not well understood, was of great interest to Levinson and his research team. The theme of tension between individuation and attachment is present in all eras, but particularly important in the middle period. Individuation refers to being separate from the world and its attachments, and to being self-generating. It also gives one the confidence and understanding to have more intense attachments in the world and to those one interacts with, to feel more fully a part of society, and, in turn, to help to further shape one’s identity. He also discussed vitalizing “dreams” that developed in the early to mid-twenties among men and developed creativity and life satisfaction. However, a careful review suggested that the “dream” among women was less vitalizing and thought to be subverted to an early sense of expectations of family responsibilities.10
Kohlberg’s11 theory of moral development is also useful to consider, given the importance of values and norms to physician identity. In Kohlberg’s model of justice-based morality, the highest level of moral development requires the use of principles to resolve ethical conflicts. Gilligan,12 who studied with both Kohlberg11 and Erikson,5 wrote the highly influential book In a Different Voice, which described a more relational approach to resolving moral dilemmas through an ethic of care. Her research and its interpretation have been soundly critiqued, and yet have stimulated further research that shows that women’s and men’s moral development is less polarized, and that ethical dilemmas may require evaluation of both care and justice. In this regard, Held12 beautifully articulates how moral reasoning best includes both care that considers the context of human dependence and value of emotions, and justice that upholds rational, abstract principles. To achieve a more nuanced physician identity, grappling with these considerations of morality is important.
As the preceding discussion indicates, adult psychological development influences personal identity. The potential gender differences described are more likely based on socialization interacting with biology.14 In this regard, socialization is also very important to professional identity, and how socialization interacts with the unique variation between individual physicians is important to consider. In fact, a gender-similarities hypothesis that finds that men and women are more similar than different has been upheld with recent meta-synthesis research15 on more than 100 meta-analyses. The remaining psychological differences included women’s greater interest in peer attachment and people than things, and among men, greater aggression and confidence in physical abilities.
With respect to socialization and female adult development, the typical role of women in relation to family has significant implications. That is, women’s roles in society and the role of female physicians have evolved greatly to accommodate white middle-class females16 as they have cracked the “glass ceiling” or navigated the labyrinth of leadership.18 This has required negotiating societal views about the role of professional women17 as well as a mothering ideology.19 Feminist research indicates that perspectives on “mothering” over the past seventy years have been strongly informed by the 1950s post-war stereotype of a white suburban family.19,20 From this perspective, mothering is viewed as highly child centered and best provided by a mother (Hays, 1996). Further, a mother’s identity is intertwined with balancing paid work and childcare.20
In this chapter, we begin by positioning professional identity within what is known about the topic, recognizing that it is situated within a broader context of adult development. We move next to considering the transitions within a physician’s career because they provide a useful way of thinking about professional identity. Transitions represent periods of change in which physicians must make sense of their new settings and experiences in order to re-form their identity. We will discuss some of the other phenomena that influence physicians’ identity, including personal, specialty, and work-setting characteristics that may influence professional identity given the interplay between the individual and the collective setting. We will then discuss the role that continuing professional development (CPD) appears to play in forming professional identity. We conclude with lessons learned and future directions.
Transitions
Transitions are common in medicine. They are a dynamic process21 representing a period of change or movement between one state of work and another22 or one set of circumstances and another.21 Common transitions include changing one’s work or specialty or geographical location.22 Generally, transitions are “critically intense learning periods”22 associated with a limited time in which a major change occurs and that change results in a transformation. During transitions, people re-form their way-of-being and their identity in fundamental ways. Thus, transitions represent a process which involves a fundamental reexamination of one’s self, even if the processing occurs at a largely unconscious level.23 In transition periods, people enter into new groups or “communities of practice.”24 This involves adopting shared, tacit understandings; developing competence in the skilled pursuits of the practice; and assuming a common outlook on the nature of the work and its context.24 It is in this new site, or community of practice, that identities evolve.24
While transitions can be highly stressful and involve negative emotions, they also provide individuals with opportunities for rapid personal development and new behavioral responses to cope with the discontinuity in one’s life space.21 In a medical career, three critical transitions have been identified: the periods of “getting in,” “fitting in,” and “getting out.”25 However, while “getting in” and “getting out” may be more clearly marked periods, there are many transitions that physicians make during the course of practice that require attention and contribute to professional identity.
Entry to independent practice
Entry to independent practice is a particularly challenging phase. It is as difficult as the transitions that took physicians into and through medical school and residency.23,25–28 During this period, physicians must come to terms with their identity in a new role as an independent licensed physician with new expectations for patient care and workplace relationships.23,26,28 Many will feel confident about their clinical tasks.21,29 Others will struggle to feel as competent in the nonclinical tasks of their work that include teaching, management, and finance. These skills are often not taught or poorly taught in residency but are needed to assume new roles and expectations. Some physicians will enter into arrangements in which they need to hire or supervise staff. Others working with medical students and residents will assume responsibility as the senior physician for care in a teaching unit.21,29,30
Westerman’s26 description of the transition from resident to attending physician identifies three themes that interacted during the longitudinal process as the new identity was assumed. First, there were the disruptive elements of the new environment, which included both nonclinical tasks not previously learned as well as supervisory roles in which the physician carried the final medical responsibility for care. There was perception and coping, which included being medically well prepared but not well prepared for nonclinical tasks and having to reduce stress and feelings of incompetence. Last, there was personal development and outcome, in which the feelings of incompetence diminished and task mastery developed over time. As the physicians clarified their roles over time, they developed task mastery adjusted to the culture of the institution and its expectations. Nonetheless, more stress was experienced by those for whom the discrepancy between the tasks of residency and practice were the greatest.
Transitions in practice
The transitions that physicians experience during the course of a career occur in many ways. For example, they can occur in response to a community or personal need in which the physician narrows a clinical practice to a focused area (e.g., general obstetrics to infertility). Scientific advances may require additional training and supervision by those who need to maintain currency in the discipline. Physicians can assume new roles as researchers, administrators, or educators. Some physicians will move to a new community or country. Others will reenter practice following a leave or the identification of a need for remedial training.31 Further, as the healthcare system and expectations change, physicians must adapt to workplace changes, which are likely to include working more closely with other medical and health disciplines. While the transitions may be planned for some, for others they may be incremental, unplanned, and opportunistic.32
Several studies describe transitions into different “communities of practice” or work settings and how the physicians adapt and, in so doing, assume new identities. For example, Loh’s32 examination of transitions into management roles describes how physicians often take on these roles in incremental ways in order to have an impact on a larger population than would be possible if they continued as a clinician seeing individual patients. He noted that physicians can have an identity problem as their clinical colleagues do not see medical management as a real medical specialty, creating a dissonance for the transitioning physician who may have few role models and mentors. Research involving physicians who immigrate describes the hurdles the physicians must overcome to master the practice of medicine in a new country.33 This study showed that the immigrant physician may lack the tacit knowledge that their Canadian trained colleagues had learned through common experiences in medical school, residency, and professional networking. As the immigrant physician enters the new culture and setting, tacit knowledge has to be gained by trial and error based on feedback from colleagues, other healthcare professionals, and patients. Initially, this leaves the physician frustrated because it is difficult to calibrate his or her work to meet expectations. Things become easier over time as the physicians assume the work expected and gain confidence, seeing themselves in new ways. McLean’s34 study of physicians from other nations who became medical educators in the Middle East describes the development of identity as a cyclical process in which, through experiences and reflection, individual world views and perspectives are continually modified and developed. Transitioning geographically within a country can also be challenging. One study of physicians moving within Canada suggested that some physicians, particularly those who were pragmatic about the move, had moved previously, had supportive spouses, or had previously lived in the city appeared to be less challenged personally by the move and more able to integrate and assume new working roles quickly. Conversely, those physicians who did not come to a job, did not have a previously established network, or moved due to a spousal move took longer to establish themselves because they had to manage both personal and professional integration.35
It is common in medicine to assume more than one role; physicians often perform work as clinicians while maintaining roles as researchers, educators, and administrators. A recent study examined the experiences of physician and basic science educators who conducted faculty development workshops. They found that these individuals had faculty educator identities as well as their (clinician) professional identity. Their faculty educator identity evolved over time and tended to merge with their professional identity.36 However, there were variations. Some physicians had a compartmentalized identity: at times one was a physician and at other times an educator. Some adopted a hierarchical identity, which placed being a physician–scientist above being a physician–educator or vice-versa. For others, there were parallel identities that existed simultaneously but without conscious overlap, and merged identities in which both roles were integrated and coexisted simultaneously.36 In another study of early career medical educators, the authors observed that this group understood their medical-educator role to be secondary to their roles as a scientist or clinician and had not developed an emotional attachment to the field, maintaining their relationship at an operational one revolving around roles and responsibilities.3
Transitions out of practice
Leaving practice or retiring from practice is another period of transition in which professional identity is also challenged. Many fear the potential loss of the identity they have assumed over many years. Some find it difficult to change roles, give up roles, bring others along, or negotiate new roles.37 Further, the decision to retire or reduce work leading to retirement is likely to be accompanied by significant decision-making that can be accompanied by recognized declines in cognitive function,38,39 financial concerns,40 succession planning,37 and continuing to work as workload expectations change.40 For example, there may be changes in cognitive function as cognitive performance may decline with age.38,39 Older age can be accompanied by a loss of skill and confidence. A large ten-year UK study of cardiac surgery identified an increased risk of mortality in patients operated on by longer serving surgeons.41 Similarly, a study of anesthesiologists found a higher frequency of litigation and a greater severity of injury in patients treated by anesthesiologists in the age sixty-five or older group.42 It can be stressful to remain in positions as the organization’s needs change or to redirect one’s work given previous decisions the physician may have made to reduce or focus the scope of work.43 Physicians may also find it difficult to manage heavy patient loads and night work.40 For physicians who are employed or dependent on group earnings, there may be pressure to leave, particularly if the physician is not able to meet workload expectations or obtain research grants.43 Physicians whose professional identity is tightly linked to their professional roles often find it difficult to “let go.”37 Retirement is not always accompanied by a sense of loss or fear. For some, retirement offers an opportunity to grow in different ways using medical expertise to volunteer or do part-time teaching. For many, it is a time of reinvention, choice, and opportunity to explore new, otherwise dormant, or previously restricted activities.44
Transitions are periods when physicians have a chance to reflect and determine how they will move ahead and into new roles and responsibilities. Along the way, physicians will work toward a new sense of who they are.
Personal identity and life stages
As discussed in relation to adult development, personal identity (e.g., gender, ethnic background, religious orientation, sexual preference) and life stages intersect and interact with and influence ongoing socialization in relation to physician identity.
Being a woman and a physician can influence career consolidation and professional identity as a physician. For example, while the last fifty years have witnessed a tremendous increase in the proportion of women in full-time work, and men are more involved in raising children, including as single parents,45 female physicians with children are less likely to work full time than their male counterparts with children.46 Similarly, with respect to adult female development, another significant mid- to late-life role common to women is that of providing or managing care for elderly parents or disabled spouses.47
There is some adverse socialization through discrimination that women may experience from patients and healthcare workers. For example, among Canadian general internists, women physicians are more likely than men physicians to report gender discrimination that is not influenced by the woman’s age, community size, or academic affiliation.48 Fortunately, there may be a generational shift in the healthcare context16 in that physician daughters of mothers who are physicians report lower rates of gender, racial, and ethnic discrimination than did their mothers. Despite this improvement, they reported similar rates of sexual harassment and overall, gender discrimination rates remained high. These adverse experiences within the healthcare system associated with lower career satisfaction may interfere with consolidation of physician identity. Female physicians find opportunities to reflect on the intersection of their personal and professional identities through online discussion boards (e.g., American College of Surgeons – Women Surgeons), blogs, and professional development programming developed specifically for women physicians.52
There are other examples of how personal identity intersects with physician identity. A moving and reflective account by a transcultural psychiatrist49 conveys how her ethnicity and early experiences with bullying and an outsider identity led to working in her chosen field. In this account, Madelyn Hicks, a part-Chinese, part-Caucasian American academic psychiatrist and mother working in London, chooses to call her field cross-cultural to convey what she describes as intentional interaction with difference, including within personal and professional identities. Her experience as an outsider and with racism promoted her capacity to care for the vulnerable and to uphold ethics. Hicks’ experience evokes Symonds’50 description of a “divided or uncertain sense of identity” as she maintains her academic career through part-time work, job-sharing, and taking a break from clinical work to maintain her research and writing. Her narrative role models the value of reflecting, connecting with mentors and peers, and engaging with relevant literature to process challenging and complex experiences.
The intersection of the healthcare environment with personal identity may interfere with physician identity. Medical students and residents who are lesbian, gay, bisexual, transgender, or queer (LGBTQ) describe the healthcare environment as frequently homophobic. They face rarely discussed challenges throughout their career, including remaining closeted to avoid expulsion, being denied supportive recommendations from advisors, and being exposed to blatant prejudices from colleagues that affect patient care.51 Identity concealment is particularly problematic as it has been shown to have significant negative effects on physical and mental well-being.51 Homophobic remarks by patients or other members of the healthcare team were reported by forty percent of internists.48 For some gay medical students and residents, their experiences as “outsiders” in a conservative environment had the potential to enhance their capacity for identifying patients’ inner conflicts, recognizing bias against minorities, and making a choice to use inclusive language as part of their professional identity.52 Established practitioners who are open about their LGBTQ identity may find greater integration between the elements of their personal and physician identities.
Other phenomena that influence identity
Physicians are also shaped by the teams within which they work, the context of their work, and their specialization.
Teams
As healthcare evolves, there is a great emphasis on working in interdisciplinary teams. Work in multispecialty clinics has been shown to affect specialists’ perceptions of identity with some specialties affected more than others.53
As Molleman et al.53,54 note, specialists with a strong professional identity derive part of their self-view from belonging to their specialty as they see their specialty in a positive light. This can affect their team functioning and identity differentially. Some will adopt common expertise norms and behaviors within the team more easily. Others will want to demonstrate the importance of their work for patient care, and this can be challenged by other members of the team. Molleman et al. note that identity threat is more likely to occur when different specialties have competing opinions about treatment in complex healthcare situations, when new specialties enter the domain of existing specialties, and when technological developments shift the boundaries between specialties.3
Working in and collaborating in interdisciplinary teams requires team skills (e.g., attitudes and behaviors focused on collaboration and communication for effective team care). These latter attitudes and behaviors may be different than those expected in other settings, where the physician may be more autonomous. This may require a shift in how physicians see themselves. For example, Wright et al.55 found that family physicians working on geriatric teams struggled with but held a continuum of beliefs about the role they should play on teams, including whether the family physician should be autonomous or a collaborative decision-maker, work inside or outside the team, and be leaders or members of the team. In another setting where physicians were given explicit training to enhance team skills, it was clear that physicians changed their perceptions of themselves and of the team over the training period. They identified personal and professional growth as outcomes of the program. Some assumed new roles as developers of team skills within the medical school curriculum and members of group research grant teams.56
Certainly contemporary management of chronic diseases is challenging traditional perceptions of identity, as physicians recognize that identity centered on autonomy, authority, and the ability to “heal” may be counterproductive in chronic disease care, which demands interdependency between physicians, their patients, and teams of multidisciplinary healthcare providers.57
Context
The context of physician practice has been shown to affect identity in a number of settings. For example, in settings in which physicians provide care to indigenous populations, physician effectiveness appears to depend on developing a more “fluid” identity so that the physician’s cultural and professional beliefs and practices can intersect with the expectations of culturally safe practice shaped by the indigenous context. In these settings, identity is negotiated through differences in language, role expectation, practice, status, and identification. In another example, physicians trained in a modality of complementary and alternative medicine integrate complementary and alternative medicine and biomedical medicine to develop a hybrid professional identity that comprises two sets of healthcare values.58 An exploration of how physicians experience and cope with vulnerability facing the life and death aspects of their clinical work, and how such experiences affect their professional identities, showed that they could deal with death and mostly keep it at a distance. In these settings, vulnerability was closely linked to professional responsibility and identity, perceived as a burden to be handled.59 However, physicians who direct their focus to the humanistic aspects of care in the physician-patient relationship, and physicians who administer needed interventions to reduce pain and suffering at the end of life, have the privilege of experiencing particularly poignant moments with patients nearing death.60 In this regard, competence in psychosocial aspects of care and acceptance that dying is a part of life may enhance the humanistic aspect of physician identity.
Specialization
The type of physician one is and becomes is also linked to professional identity. In moving from medical school through residency, physicians begin to adopt the identity of their teachers along with the appropriate knowledge and behaviors. In doing so, they differentiate themselves from other disciplines in this community of practice.61 It is not always an easy transition. For example, neonatal residents described the conflicts experienced in becoming neonatologists as they learned to care for very sick and dying babies. In this study, they identified multiple conflicts of identity as members of the neonatology team, as members of the medical profession, as members of their own families, and as members of society. These conflicts often led them to question their own morals and their role in the medical profession.62 The transformation into a specialty can also be detrimental, as Jin et al.63 point out in their examination of surgeons’ professional identity, which they note is constructed and negotiated within a surgical culture. The hidden curriculum, which calls for displaying confidence and certainty, gives rise to “appropriate” surgical behavior, which can impact surgical judgment and decision-making. Identity formation takes time, often extending beyond residency. Gendron et al.64 found that professional identity as a gerontologist took time, and that success could be predicted by length of time in the field, age, satisfaction with coworkers, and satisfaction with opportunities for advancement.
Physicians will also construct their identity within their specialty in response to changes made by the speciality. Specialties change boundaries. As noted in a retrospective analysis of the disciplines of medical oncology and hematology, the work and the professional identities of physicians in both disciplines changed when medical oncologists, in pursuit of specialty status, claimed wide-ranging expertise over the treatment of all patients suffering from malignant disease.65 Currently family medicine is struggling for a clear identity between generalist and specialist roles. On the one hand are physicians who would preserve all the professions’ traditional functions while adapting to changing contexts. Other physicians would like to concentrate on areas of expertise and moving toward creating “specialist” general practitioners, in response to a rapidly expanding scope of practice and to the high value attributed to specialization by society and the professional system.66
Summary
Many factors affect how physicians see and identify themselves within the profession of medicine. Identity formation is influenced by the transitions that occur through work and a physician’s personal life. It is affected by gender, age, and family. The type and setting of practice as well as specialty also have an influence. In the next section, we will explore how the requirement that physicians keep up their learning through continuing professional development activities can and should enhance identity.
Continuing professional development and professional identity
Physicians have a responsibility to develop their competence through focused learning activities throughout their careers. As noted in Chapter 14, this obligation is mandated through maintenance of competence, certification, and relicensure programs established by professional organizations and by regulatory bodies who require varying forms of evidence. Two cases were described at the beginning of the chapter – Mary and John. Both are within transition periods. Both need to reflect on the changes in their lives and focus their learning activities to meet the new demands. Mary is trying to enhance how she integrates her home and professional life through changing her clinical work context. While each person in transition needs to find the best approach to ease the transition, Mary might find it helpful to shadow surgeons, medical and radiation oncologists, and other members of the healthcare team with whom she is now working, to learn about their work in order to fit into the team more comfortably. National or regional oncology meetings may be useful in identifying family physicians in comparable positions as potential mentors, as well as in helping her gain knowledge of breast cancer and oncology. Given that she is providing primary care services within the clinic, she will need to maintain her own competence as a family physician, albeit while working in a nontraditional context. She may enjoy meeting with peers in a study group, to help her manage the emotions evoked in her new work context. John’s situation is different as he struggles to achieve a better balance among his commitments and to feel comfortable in the role of “Professor” with its emerging demands. Mentorship from other faculty members who have successfully made the transition and appear to be able to juggle various commitments may be helpful. They may also help him understand the complexity and feasibility of writing grant applications for international funding. Discussions with his department head may be necessary to determine workload, gain a commitment for protected time, and establish realistic expectations. Education related to time and personnel management may prove helpful. In both cases, the physician’s identity – as a family physician with expertise in breast cancer and as an MD-PhD academic – is evolving to meet the new work challenges.
Along with literature concerning the identification of transitions and the difficulties that physicians face as they work through transitions, there is a literature about the types of things that help physicians at both the individual and the group level. Regardless of the type of transition, several themes recur. Ensuring clinical competence is important. This may require additional intensive formal training, which improves confidence,67 or training that might occur longitudinally through workshops, discussions, and reading. For physicians who are moving into a very different clinical system or setting (e.g., country to country, small to large clinic), formal orientation and mentorship programs are warranted.33,68 Most physicians benefit from the support of friends and colleagues.28,67 While physicians who join functioning units appear to have fewer problems, it appears that physicians who appear to have more difficulty with transitional periods often are those who join dysfunctional groups, those without clearly defined roles, those without professional networks in the city, and those entering community rather than an institutional practice.35 Collegial, continuing professional development, and institutional and systems support can clearly benefit physicians as they make sense of their emerging professional identity.
Continuing professional development (CPD) or continuing medical education consists of educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession.69 As examples, CPD activities include conferences, courses, rounds, traineeships, mentoring relationships, online learning, self-assessment programs, reading, and discussions with colleagues. In the same way that physicians are shaped by periods of transition, the natural progressions of adulthood, and other phenomena that define their lives and work, the CPD the physician undertakes can also shape professional identity. CPD can influence professional identity at the individual level by maintaining the physician’s competence through activities they determine will enhance the quality of their work as well as through activities in which the physician is a member of a group and is learning from others within that group. Skilled CPD designers need to recognize that both individual and group learning activities are critically important facets of development and need to be built into educational programming. Similarly, physicians need help learning how they will benefit from both individual and group activities in which they strive to develop the skills they need for competent practice as individuals as well as from being part of a learning community of physicians and other healthcare team members.
Individual CPD
Research on self-assessment reveals that adults have difficulty accurately self-assessing in domains of knowledge and skills in which they are less competent.70,71 Physicians with competency gaps are those most in need of CPD but are less likely to seek it out because they do not or cannot acknowledge gaps in their knowledge and skills. To address this, physicians require benchmarks of competent practice, including feedback about their knowledge, skills, performance, and behaviors. Self-assessment quizzes and certifying-body testing can help physicians identify and address knowledge gaps. Simulation labs with task trainers and high-performance simulators can provide feedback on skills. Physicians’ own practice performance data allows physicians to more clearly see how their practice outcomes compare to others.72 Clinical audit data helps physicians enhance clinical expertise. Multisource feedback data provides information about professionalism, communication skills, collaboration, and team effectiveness. Data from these and other sources can be a powerful motivator for physicians to address gaps in their practices and therefore fulfill their professional responsibilities to remain competent. Increasingly, assessment data is being adopted as a requirement in relicensure and maintenance of competence.73,74
As physicians grow in awareness of their learning needs, educational programs may be helpful to maintain and improve their clinical competence. In addition, some will benefit from formalized mentorship programs, particularly as they enter independent practice, are gaining new skills, or are remediating.75–78 As Harrison et al.76 note, mentorship may prevent or reduce active failures, be used to identify patient safety threats in the local working environment, and encourage a healthier safety culture. Similarly, coaching has been advocated as another way physicians can improve their work and identity as physicians.79–81 Helping physicians to identify and seek out role models is also important. By seeking out role models and observing them, the cognitive and behavioral processes associated with successfully internalizing roles (e.g., the good doctor–medical educator) begin to be embodied82 and become part of professional identity.
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