SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References

Context  Medical education is as much about the development of a professional identity as it is about knowledge learning. Professional identities are contested and accepted through the synergistic internal–external process of identification that is constituted in and through language and artefacts within specific institutional sites. The ways in which medical students develop their professional identity and subsequently conceptualise their multiple identities has important implications for their own well-being, as well as for the relationships they form with fellow workers and patients.

Objectives  This paper aims to provide an overview of some current thinking about identity and identification with the aim of highlighting some of the core underlying processes that have relevance for medical educationists and researchers. These processes include aspects that occur within embodied individuals (e.g. the development of multiple identities and how these are conceptualised), processes specifically to do with interactional aspects of identity (e.g. how identities are constructed and co-constructed through talk) and institutional processes of identity (e.g. the influence of patterns of behaviour within specific hierarchical settings).

Implications  Developing a systematic understanding into the processes through which medical students develop their identities will facilitate the development of educational strategies, placing medical students’ identification at the core of medical education.

Conclusions  Understanding the process through which we develop our identities has profound implications for medical education and entails that we adopt and develop new methods of collecting and analysing data. Embracing this challenge will provide better insights into how we might develop students’ learning experiences, facilitating their development of a doctor identity that is more in line with desired policy requirements.

Medical Education 2010: 44: 40–49

‘...I’ve not really encountered death in such close proximity... I mean –a-as doctors we can define and limit... it’s like as if I want to be climbing this mountain that I’m not sure that I’ll ever be able to fully reach the top and, then again would I ever want to reach the top, would I ever want to accept death that much that I’d be so desensitised to it but, I just, wouldn’t be totally affected... seeing death in front of you and you have to go on and still be strong... you know and all these emotions that are being fired at you and your own emotions topping them all up, I mean where? I mean like I’m not a system and I like to believe I’m a fountain, I’ll probably overflow and in what direction? I mean you can’t keep bottling these things up...’

Kath, Year 1 medical student, aged 19 years; excerpt from her audio diary.1

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References

Identity matters. Who we are, and who we are seen to be, underlies much of what we do in medical education. Identity is rooted in language and interaction and, although we conceptualise identities, they are not fixed or static. Identities are realised through the ongoing dynamic process of identification: ‘it is not something that one can have or not; it is something that one does’.2 (p 5) As we go through life, our identities are constantly in the process of transformation.

Consider the excerpt above, taken from a longer story narrated by Kath as part of a longitudinal study investigating medical students’ professional identity formation.1 The event she narrates concerns something most doctors will encounter during their training: her first experience of witnessing death. What is important in her narrative is that although Kath has only been at medical school for 6 months, she has clearly begun to identify with her future role as a clinician: ‘a-as doctors we can’. As her narrative continues, it becomes obvious that the process of identification with the medical profession is not without problems as Kath struggles to come to terms with the issue of her own detachment from patients’ suffering and death, something she perceives as intrinsic to a doctor’s identity.3 Who Kath was, who she is, who she is seen to be and who she is becoming are all narrated in this small excerpt; yet nothing is determined.

It has been argued that it is necessary for professionals to successfully embrace a professional identity both ethically and practically. Internalising professional ethics through the process of identification facilitates the internal regulation of professionals.4 On a practical level, the development of a strong professional identity enables individuals to practise with confidence and with a ‘professional demeanour’, thereby giving others confidence in their abilities.5 So, even if medical students learn all the knowledge and skills required of them, they will find it hard to be successful as doctors until they have developed their professional identity.6

The issue of identity and identification has been a central concern within the social and human sciences for decades, yet it is rarely discussed openly within medical education and instead occupies a rather marginalised and frequently overlooked position within core medical education journals. This is not to say that aspects of medical students’ identification have been ignored, but that when the subject has been researched and openly theorised, the process has been mainly situated within a broader health and social sciences arena.7–10

Over the decades, identity theorists have taken their ideas from a broad range of paradigms. For some, identity has been conceived as representing a unified internal ‘agency’ whereby identity is seen as ‘a personal, internal project of the self ’ and treated as if it is ‘something to be worked on’.11 However, although it is still present in everyday thinking of the self, this ‘internal’ view has been supplanted by the notion that identities are a product of intersubjective and external social processes. Identities are constructed and co-constructed as we participate in day-to-day social activities and through the use of language and artefacts and within power relations. These ‘constructionist’ approaches highlight the importance of the social within identities and have led to a range of interconnected perspectives in psychology, sociology and sociolinguistics which highlight these aspects, including the psychosocial,12–14 sociocultural,15–17 performative18 and discursive19 perspectives.

In this paper I provide an overview of current thinking around identity and identification. Although there is not always agreement across scientific disciplines with respect to these core concepts of the self, I will offer a synergistic perspective on identity and identification, bringing together core psychological and sociological theories to enable understanding of the underlying psychological and social processes that have relevance for medical educationists and researchers. Indeed, as we see from the brief example provided by Kath’s narrative, identity and identification issues affect medical education in terms of students’ relationships with patients, with doctors and with themselves and thus are of central importance to the conception and development of medical curricula.

Identity: a brief overview

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References

Identification comprises basic cognitive and social processes through which we make sense of and organise our human world. It includes things that go on in our minds as we create a complex multi-dimensional classification of our places in the world as individuals and members of collectives.20 This self-categorisation process occurs within a social world through interactional relationships and in the context of social institutions with established ways of doing things.2 Thus this basic and essential process of identification is central to medical education: medical students are learning to become doctors in academic and clinical settings. Although these psychological and social processes are dynamically intertwined, we will now consider each aspect, the individual, the interactional and the institutional, and the implications they have for medical education in greater depth by focusing on one level at a time.

Embodied individuals

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References

The most important concept to hold is that identification is a two-way process which occurs during the simultaneous amalgamation of self-definition (who I think I am: internal) and the definitions of oneself as presented by others (who I think you think I am: external) through language and artefacts.2,15–17 Through this self-categorisation process, we not only identify who we are, but we also say something about who we are not: identities are constructed through attending to difference. In this section I will explain how the ways in which we form and conceive our multiple identities are important to medical education in terms of students’ (and doctors’) relationships with other professional groups and with patients.

Primary identifications

Identity formation begins in early childhood through the recognition of the separation of self and significant others and the development of language. Although identification is a two-way internal–external process, early on it is dominated by external factors.2 These early prescripted identities are therefore more authoritative and develop through weak internal responses, so rejection or modification is low: they become more accepted as how things are and more resistant to change.2 For example, gender identity begins early, through artefacts (clothes, toys) our caregivers create a gendered identity which is responded to by others and which we embody.

Along with gender, ethnicity and social class can be considered as primary, embodied identifications which, although not fixed, may be less malleable than identities developed later in life. One important implication here is that our unique mix of primary identities may facilitate or constrain the development of existing and newly developing identities.6 Additionally, our subjective representations of these multiple identities, how (or indeed, whether) we synergise these identities, can have important implications. These implications include the way we relate to other people (so-called ‘in-group’ or ‘out-group’ relations).

Identity dissonance

Costello found that women, members of lower socio-demographic classes and non-Whites underperform at professional schools and that one of the reasons for this is that they suffer from identity dissonance: ‘integrating new professional identities into personal identities is an easy process for people whose personal identities are consonant with their new professional role, but traumatic for those whose personal identities are dissonant with it’6 (my emphasis). So, for some, the development of a professional medical identity might entail the adoption of a different world-view, different values and emotional orientations.

Recall the excerpt presented earlier by Kath, who narrated her first encounter with death at 6 months into medical school. For reasons of expediency (the full narrative lasts 10 minutes, 48 seconds) and because of the constraints imposed by the medium of print (rather than audio, in which Kath’s emotions can be clearly heard in the paralinguistic aspects of her talk), the full extent of dissonance she expressed might not be readily apparent in the small excerpt presented. However, within her narrative Kath clearly struggles with the idea of emotional detachment, which she sees as an intrinsic aspect of becoming a doctor. Her perspective of how doctors should be is clearly dissonant with her perspective of her own emotional orientation as resembling a ‘fountain’ likely to ‘overflow’ and unable to ‘bottle things up’.1 Costello6 found that students with identity dissonance experienced powerful emotional disruptions that included uncertainty about their own ‘values, ambitions, abilities, affinities, and their very self-worth’ and developed haphazard coping mechanisms. These coping mechanisms included the outright rejection of the professional role (e.g. consciously dropping out of the programme), displaying aspects of identity that conflict with the professional role (e.g. inappropriate dress), and avoiding professional school-setting interactions whenever possible, and when not possible, ‘role playing’ in professional situations.

There has been little research undertaken in medical education to directly investigate students’ emotional disruptions from the perspective of identity formation. However, role-playing in professional situations has been reported to represent a coping mechanism for students’‘shaky’ professional identities.21 Although numerous studies have demonstrated medical students’ negative coping strategies for stress, including excessive alcohol usage,22 research looking at potential causes of stress have concentrated on factors such as high workloads and have predominately used questionnaire methods of enquiry. Finally, some work has highlighted aspects such as female students reporting (and being independently scored for) higher anxiety and lower self-confidence than male counterparts during standardised patient interactions23 and students’ uncertainties about their own aptitude as medical students and future doctors,24 which reflect aspects of Costello’s identity dissonance. Given that we know some medical students struggle with their developing roles as doctors, research that considers medical students’ identification and how this relates to stress and underperformance is crucial for the development of our curricula and to facilitate students’ identity formation. Furthermore, research from this perspective will entail that we broaden our methods of data collection and analysis, utilising inductive methods25 and taking a deeper look at the processes involved before developing (or utilising existing) quantitative methods.

Relationships between multiple identities

It has been proposed that we structure our perception of our own multiple identities according to four different models: intersection, hierarchy, compartmentalisation, and merging. These models reflect different relationships between our multiple identities and have implications for interactions with in-group and out-group members.13

To understand these different models, I use a hypothetical example: Maria has developed multiple identities as Black, female and doctor. One way Maria can understand her identities is to focus on the intersection between them. In doing so, Maria will represent herself in the single unique identity of a ‘Black female doctor’. Those who do not share this identity (e.g. White male doctors, Black female nurses) will be considered to belong to out-groups. A second way in which Maria can consider her multiple identities is to construct a hierarchy of identities, in which one takes precedence over the others. So, Maria might place her identity as a doctor over that as a woman and over that of being Black. People who are also members of this dominant identity (i.e. other doctors) are considered in-groups. However, because the representation is hierarchical, Maria will feel closer to other doctors who are female or Black. People outside her dominant identity will be considered out-group members. A third way in which Maria might represent her multiple identities is through a process of differentiation and isolation, resulting in compartmentalisation. Identities are then activated within different contexts and situations. So, whilst at work Maria will identify with other doctors and will consider everyone else as out-group members. In other contexts her gender or her ethnicity might dictate who she identifies with. The ability to hold a complex representation of identities will lead Maria to develop a merged in-group identity that is highly inclusive and divergent. Here, Maria’s social identity ‘transcends single categorical divisions between people’.13 The more groups that Maria identifies with, the fewer people she will perceive as being part of an out-group.

The ways in which we conceptualise and manage our multiple identities have profound implications for the education of doctors. For example, identities are played out within interactional settings. Communication in intergroup contexts, such as multi-professional team-working, also involves intragroup communication (e.g. among nursing, medical and social workers). One important factor that might differentiate intergroup communication from intragroup communication is individuals’ awareness of their group memberships. Individuals who construct their identities as complex might demonstrate different communicative patterns within interprofessional team-working, such as communicating in a manner that manifests less social distance and demonstrates greater acceptance and trust.13

Furthermore, the ability to represent complexity within our multiple identities can have implications for patient care. It has been demonstrated that patients receive variable care according to factors such as race, ethnicity and socio-economic status26 and that this is associated strongly with doctors’ implicit perceptions of patients.27 In some medical settings, patients’ race is routinely included at the beginning of case presentations. Although at times this may be useful to the diagnostic process, reducing patients’ identities to racial or ethnic labels in this way might facilitate cultural or socio-economic stereotyping.28 Indeed, it has been demonstrated that doctors’ perceptions of the intelligence of a patient vary according to factors such as the patient’s race.29 This factor also affects doctors’ feelings of affiliation towards patients, along with doctors’ beliefs about patients’ likelihood of adherence with medical advice, physical activity preferences and risk-taking behaviour.29,30 It is therefore easy to see how the way we conceptualise our identities can unconsciously affect the way we relate to others.14

To date, there has been no research that has considered how medical students construct relationships between their different identities. However, we do know that a complex representation of identities provides a less precise representation of the social world than a simple representation. Furthermore, there are a number of inter-related constructs regarding individuals’ preferences when confronting complex ambiguous information and these are highly relevant within medical education: the need for closure, an orientation to uncertainty, the need for structure, and tolerance for ambiguity (TfA). Indeed, research has demonstrated that TfA, moderated by empathy, contributes to the prediction of medical students’ performance with standardised patients on history taking, doctor–patient interaction, and patient satisfaction over time: the higher the students’ TfA, the better they performed.31 So, within this framework of complexity and identity construction lies a fruitful area of research for the medical educationist: understanding the factors that facilitate or inhibit the development of complex and merged identities will have profound implications for both curriculum and faculty development.

Interactional relationships

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References

As highlighted above, identities are not fixed cognitive schemas; rather, identities are what we do. Identities are asserted and claimed through continual interactions; we seek to be and be seen to be as we attempt to manage others’ impressions of ourselves and the identities we claim.18 This performative and routine aspect of daily life is ever present and can be conscious or unconscious. Indeed, through continual role rehearsal, the presentation of the self is influenced by habitus (acquired patterns of thought and behaviour) and is unconscious.32 Therefore, this perspective places the focus on language as a performative aspect of the self, rather than on language as the externalisation of underlying mental processes or psychological states (e.g. motivations, traits, dispositions, attitudes etc.).

Performative aspects of identity are also present in the stories we tell to others (and ourselves): as we try to make sense of events our identities emerge as we story our individual experiences, positioning ourselves to cultural and social expectations.33 The concept of a narrative identity is not new, but it is a powerful way to understand how identities are shaped and re-shaped to make meaning, to provide a sense of coherence to our lives34 and to guide our actions.35 Moreover, narratives that instantiate identities are not just found in the ‘big stories’ we tell of our lives, but can be seen in fleeting moments of ordinary conversational contexts.9,10,19,36

Thus, identities are constructed and co-constructed within medical interactional settings as we go about our daily work,7,9,10,37,38 and as we recount events of our experiences to ourselves and others.1,3,39,40 That the process of identification is situated in and through talk has wide-ranging implications within medical education. The main messages I wish to convey here are that, firstly, identities are developed within relational settings through activities, and relationships are central components of identification. And, secondly, medical students (and doctors) are people, individuals with their own personal, emotional and cultural stories which influence their professional identities.

These two factors require much more attention that can be afforded here, but I will briefly mention implications for research and practice. Firstly, fostering appropriate relationship-centred educational practices is necessary, albeit a major challenge.41 Within interactional settings, linguistic rituals are learned. Linguistic rituals include particular language choices and the adopting of specific stances towards others. These rituals reflect a medical world-view that facilitates thinking, speaking and acting like a doctor. This process might inadvertently reinforce unwanted traditional cultural expectations of what it is to be a doctor (the so-called hidden curriculum) and run counter to developing new ways of doing things. For example, patient-centred care has been advocated to replace doctor-centred care as it facilitates more favourable outcomes. Despite successfully developing this stance in students during their pre-clinical years, Year 3 students have shown a progressive trend towards doctor-centred attitudes during their initial clinical year.42

If we want to know how our curricula impact on the development of tomorrow’s doctors we must develop a sensitivity to the ways in which identities are constructed, enacted, invoked or exploited in a variety of interactional settings.43 These settings include problem-based learning sessions, communication skills training, ward rounds, teaching seminars and student participation in surgical settings, and even interactional exchanges in informal settings. As researchers we must be aware of the minutiae within interaction and must attend to aspects of talk that are embedded in the routine and rituals of everyday professional interactions. Again, this requires that we embrace a wide range of research methodologies (e.g. ethnographic methods, video as data) and data analyses. Therefore, looking into more detail at the relational aspects of learning activities will provide a valuable insight into the process of students’ identification.

Secondly, we all have our story. Understanding and developing this story is essential to the successful development of our professional identity. Providing the ‘pedagogical space’37 to facilitate students’ sense-making processes through their narrative telling and re-telling of clinical experiences, thereby enabling them to understand their own developing identities as doctors, is essential in medical education. Indeed, this goes beyond the individual reflective practice that many students routinely undertake as part of their training. A more interactional context is required, within which multiple meanings are explored, facilitating students’ own understandings of who they are and who they might be. Further, as researchers, thoughtful analyses of the ways in which students narrate their experiences at medical school will also shed light on the processes involved (potential difficulties and successes) as students develop their professional selves and synergise their multiple identities.1,3,40

Institutional settings

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References

‘Whatever else organisations do, they do identification:’2 institutions are the most important places within which identification becomes consequential. Accordingly, institutions can be conceived as representing patterns of behaviour within specific hierarchical settings, signifying the way things are done: ‘Precisely because identities are constructed within, not outside, discourse, we need to understand them as produced in specific historical and institutional sites within specific discursive formations and practices, by specific enunciative strategies.’44 Therefore, an important aspect of understanding the process of medical students’ identification is to pay particular attention to how things are accomplished within the specific institutional sites that they encounter. This includes paying attention to the unofficial rules and implicit values, beliefs and attitudes that may also be inadvertently conveyed.

Common phenomena within any institution are the ‘rites of passage’ which comprise part of the transition from one identity (imminent membership, legitimate peripheral participation) to another (authentic membership, full participation). For example, the White Coat ceremony, when performed for incoming medical students, explicitly signifies a transition into the medical profession through the conferring of this symbol of professional membership, albeit as a student member. This can be conceived as formal ascription to the medical profession. However, there are other, more implicit rites of passage that medical students undergo (e.g. dissecting cadavers, working long hours) that are informal ascriptions to the profession. Indeed, the lack of informal ascriptions can indicate a rejection of professional identity for the medical student by legitimate members of the profession (a kind of ascriptive rejection: ‘You’re not a real doctor until you have...’) that can have serious consequences.

Accordingly, the development of professional identities within institutional settings can impact on aspects such as cultural change. Indeed, we have seen how experiences within the clinical setting can have detrimental effects on students’ learning in the early years.42 However, the reverse may also be the case. Students who have successfully internalised aspects of the way things should be done within their medical school setting have the potential to later challenge the way things are done if those ways conflict. For example, small acts of resistance to the existing culture – so-called secondary adjustments – represent ways in which relatively powerless individuals protect their interests and identities.45 The following example comes from an ongoing study investigating medical students’ experiences of dilemmas relating to professionalism. When discussing these dilemmas, students frequently narrated situations in which their superiors represented their identities as doctors (rather than students) to patients when gaining consent for student involvement. One commonly narrated act of resistance to this concerned students openly correcting their superiors: ‘A doctor called me a doctor-in-training and asked me to examine a patient, and before I examined the patient, I told them that I was a medical student…I’d prefer just to, let the patient know exactly where I’m at, and we’re very specific in this programme, we say exactly what stage we’re at, we say what year we’re in… so, we’re very precise... it’s just ingrained in us’ (Year 4 student, male, in Australia; data taken from an international research study examining medical students’ explanations of behaviour in dilemmas relating to professionalism).46 We can see how this student narrates his small (yet important) act of defiance through a strong identification to his medical school; beginning by owning his actions –‘I’d prefer’– then explaining why he prefers to act this way by drawing on his identification: ‘we’re very specific in this programme…’. Within medical settings, as actors, students have the potential to act as role models for clinicians (e.g. students purposively washing their hands in front of clinicians who lack this rigor encourages clinicians to follow suit). Further, narrating these acts to others (stories of resistance) comprises a performative aspect of identity for the student with implicit embedded values and moral principles, describing both what enables and what constrains action. As narratives, through the telling and re-telling, they have the potential to empower others to act.

Identities are constructed through language in institutional sites which have historical practices –the way things are. Medical educationists who wish to develop cultural change need to understand the intricate and nuanced ways in which historical practices are replicated, subtly changed and even challenged and the impact this might have for development. As highlighted above, small acts of defiance have the potential to act as catalysts for cultural change. But do they? Can they change medical culture? We need to understand the ways in which new policies, as delivered through the medical curricula, are adopted and challenged. This will necessitate that medical education researchers consider issues such as how power relations are negotiated within identity performances and identification processes, across and within academic and clinical institutional sites.

Conceptualising and researching identity in medical education

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References

In presenting current perspectives on identity and identification, and through my focusing on the different processes within embodied individuals, interactional relationships and institutional settings, I have outlined a loose ‘theoretical landscape’ for researchers. I have also made tentative suggestions for some ‘sites of research’ that medical education researchers might address. I will now focus on the more practical aspects of research: the methods of data collection and analysis that researchers might employ when investigating identity. However, I take this step cautiously. No single method of data collection or of analysis is ‘right’. As with any research, the most appropriate method of data collection and the best analytical tools can only be discerned from the specific research question itself. Furthermore, not all research questions are a priori; within qualitative research, sometimes new research questions emerge as we interrogate our data. These can then be legitimately analysed a posteriori through the careful selection of the most appropriate analysis for the specific question in hand (which is also dependent upon the skills and theoretical ideologies of the research team). Finally, purely for reasons of expediency, there are omissions in this section. I will concentrate on researching identity through the analysis of talk. Researching and analysing other aspects mentioned earlier (e.g. cognitive processes involved in the synergising of multiple identities and the use of artefacts) will not be considered.

Conceptualising identity and identification as a relational process which emphasises the emergence of identities in discourse through meaningful activities synergises a number of diverse approaches to language and interaction. These approaches include social constructionism, narrative enquiry, sociolinguistics, conversation analysis and social practice theory. Different approaches will necessarily have different implications on methods of data collection. However, although each of these approaches might differ in terms of its underlying ideologies (e.g. identity as an accomplishment of interaction, as (co)constructed in interaction, as shaped by societies’ dominant discourses, as historical processes, etc.), they converge insofar as they focus on language and social action. Furthermore, each perspective provides insights into either macro or micro levels of interaction and thus they are not mutually exclusive.

A number of qualitative methods for data collection and analysis are appropriate when adopting the ‘theoretical landscape’ I have outlined above. These include ‘traditional’ methods such as interviews and focus groups, which are commonplace in medical education research. Appropriate methods also include more ‘novel’ approaches such as the use of audio or video diaries, online discussion forums and blogs. When considering how identities are constructed during workplace activities (such as bedside teaching encounters) ethnographic approaches to data collection would be more appropriate. Indeed, the exact method selected for the collection of data needs to be sensitive to the research question that is posed and researchers need to think creatively about the methods they use. For example, in my longitudinal research project designed to investigate medical students’ developing professional identities, I have employed the little-used solicited audio diary as a method of data collection.1,3,40 This method reveals important personal reflective moments of students’ identity formation, aspects of their in-the-moment sense making, that could not be captured using interviews or focus group methods. Furthermore, the appropriate method of analysis for these data took me beyond the thematic content analyses commonly used in medical education research.

Utilising analyses that provide insights into aspects of identity and identification necessarily entails that different forms of knowledge are explicated from the data collected. Thus, it entails moving away from the analysis of content themes within our data (i.e. what people say), towards the analysis of identity performances and identity claims (i.e. how people talk). For example, membership categorisation analysis pays attention to the situated and reflexive use of membership categories (e.g. doctor, student, patient) by people in everyday interactions and considers the micro-processes within language use: ‘Membership of a category is ascribed (and rejected), avowed (and disavowed), displayed (and ignored) in local places and at certain times, and it does these things as part of the interactional work that constitutes people’s lives.’47 As categorisation confers rich inferential resources regarding what members of that category can (or must) do (so-called ‘category-bound activities’), an understanding of how these identifications are used and the features they infer is an important aspect of medical education practice. Membership categorisation analysis can be employed across a range of data (including interview and focus group data as well as the more traditional ethnographic data within which it has been used).

Other methods of data analysis consider the discourses and ideologies echoed in the data, enabling analysts to also draw on cultural knowledge as interpretive resources (e.g. critical discourse analysis, positioning theory and narrative analysis). Furthermore, different approaches to analysis can be combined with one another in order to develop ‘layers’ of understanding by looking at both macro- and micro-processes of language. For example, narrative analysis has been combined with positioning theory to consider how identities are constructed between speaker and audience. This combination considers the positions speakers adopt (e.g. active or passive, powerful or powerless, etc.) within their narratives. Moreover, the narratives they tell, be they autobiographical ‘big’ stories of their lives or ‘small’ stories of everyday events, contain plotlines that are frequently drawn from society’s dominant discourses or master narratives. Within medical education, students draw on a number of master narratives when recounting everyday events. These include ‘the privilege narrative’ (the privileged position of being a doctor or doctor-to-be), ‘the healing doctor narrative’ (where the role of the doctor is to cure the sick) and, as we saw in the earlier excerpt from Kath’s narrative, ‘the detached doctor narrative’.1,3 Analysts working within positioning theory consider micro-linguistic aspects of the narrators’ talk, such as indexicals (e.g. nouns, pronouns, verbs), direct reported talk of self and others (actual utterances quoted) and formulaic expressions (e.g. ‘all of a sudden’), and how these are used within the wider construction of the story itself as expressions of identity.48

One final point I wish to make in this section links with my assertion that we need to think more creatively about methods of data collection and interpretation. In order to do this successfully, we need to bring together researchers with different skills, knowledge and experiences. This will entail the formation of truly interdisciplinary research teams which might include a mix of not only social science researchers and clinicians, but also service users and medical students themselves. Through such diversity, we might achieve new understandings of how identities are produced (and received) in addition to increased awareness of how we might translate our research into practice.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References

Medical education is as much about learning to talk and act like a doctor as it is about learning the content of the medical curriculum. Identification synergises the cognitive and interactional processes within institutional settings as we develop our identities and has profound implications for medical education. Developing a systematic understanding into the processes through which medical students develop their identities will facilitate the development of educational strategies, placing medical students’ identification at the core of medical education. Undoubtedly, focusing on these relational processes will entail that we adopt (and even develop) new methods of collecting and analysing data, which, in turn, will present us, as researchers, with new challenges. Nevertheless, we should embrace such challenges: the deeper understanding that this work will bring will provide better insight into how we might develop aspects of our students’ learning experiences and better facilitate their development of doctor identities that are more in line with policy requirements, thus developing our doctors of tomorrow.

Acknowledgements:  none.

Funding:  none.

Conflicts of interest:  none.

Ethical approval:  ethical approval is not required for review papers.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Identity: a brief overview
  5. Embodied individuals
  6. Interactional relationships
  7. Institutional settings
  8. Conceptualising and researching identity in medical education
  9. Conclusions
  10. References
  • 1
    Monrouxe LV. Solicited audio diaries in longitudinal narrative research: a view from inside. Qual Res 2009;9:81103.
  • 2
    Jenkins R. Social Identity, 3rd edn. London, New York, NY: Routledge 2008;1–246.
  • 3
    Monrouxe LV. Negotiating professional identities: dominant and contesting narratives in medical students’ longitudinal audio diaries. Current Narratives 2009;1:4159, Available online: http://currentnarratives.com/issues/issue1.htm.
  • 4
    Friedson E. Professionalism Reborn: Theory, Prophecy and Policy. Chicago, IL: Chicago University Press 1994;1–238.
  • 5
    FreedmanDP, HolmesMS, eds. The Teacher’s Body: Embodiment, Authority and Identity in the Academy. Albany, NY: State University of New York Press 2003;1–274.
  • 6
    Costello CY. Professional Identity Crisis: Race, Class, Gender and Success at Professional Schools. Nashville, TN: Vanderbilt University Press 2005;1–264.
  • 7
    Lingard L, Garwood K, Schryer CE, Spafford M. A certain art of uncertainty: case presentations and the development of professional identity. Soc Sci Med 2003;56:60316.
  • 8
    Madill A, Latchford G. Identity change and the human dissection experience over the first year of medical training. Soc Sci Med 2005;60:163747.
  • 9
    Monrouxe LV, Rees CE, Bradley P. The construction of patients’ involvement in hospital bedside teaching encounters. Qual Health Res 2009;19:918–30.
  • 10
    Rees CE, Monrouxe LV. Is it alright if I-um-we unbutton your pyjama top now?’ Pronominal use in bedside teaching encounters. Commun Med 2009;5:171–82.
  • 11
    Taylor C. Sources of the Self: the Making of the Modern Identity. Cambridge, MA: Harvard University Press 1989;1–628.
  • 12
    Tajfel H. Social Identity and Intergroup Relations. Cambridge: Cambridge University Press 1982;1–544.
  • 13
    Roccas S, Brewer MB. Social identity complexity. Pers Soc Psychol Rev 2002;6:88106.
  • 14
    Hewstone M, Rubin M, Willis H. Intergroup bias. Annu Rev Psychol 2002;53:575604.
  • 15
    Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press 1991;1–138.
  • 16
    Wenger E. Communities of Practice: Learning, Meaning and Identity. Cambridge: Cambridge University Press 1998;1–318.
  • 17
    Holland D, Lave J. History in Person: Enduring Struggles, Contentious Practice, Intimate Identities. Santa Fe, NM: School of American Research Press 2001;1–389.
  • 18
    Goffman E. The Presentation of Self in Everyday Life. London: Allen Lane 1969;1–147.
  • 19
    De Fina A, Schiffrin D, Bamberg M, eds. Discourse and Identity. Cambridge: Cambridge University Press 2006;1–462.
  • 20
    Ashmore RD, Deaux K, McLaughlin-Volpe T. An organising framework for collective identity: articulation and significance of multidimensionality. Psychol Bull 2004;130:80114.
  • 21
    Mantyranta T, Pitkala KH. Professional socialisation revised: medical students’ own conceptions related to adoption of the future physician’s role – a qualitative study. Med Teach 2003;25:15560.
  • 22
    Pritchard ME, Wilson GS, Yamnitz B. What predicts adjustment among college students? A longitudinal panel study J Am Coll Health 2007;56:1521.
  • 23
    Blanch DC, Hall JA, Roter DL, Frankel RM. Medical student gender and issues of confidence. Patient Educ Couns 2008;72:37481.
  • 24
    Moffatt KJ, McConnachie A, Ross S, Morrison JM. First year medical student stress and coping in a problem-based learning medical curriculum. Med Educ 2004;38:48291.
  • 25
    Cassell C, Symon G. Essential Guide to Qualitative Methods in Organizational Research. London: Sage Publications 2004;1–408.
  • 26
    Moy E, Dayton E, Clancy CM. Compiling the evidence: the national healthcare disparities report. Health Aff 2005;24:37687.
  • 27
    Burgess D, Van Ryn M, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med 2007;22:8827.
  • 28
    Nawaz S, Brett AH. Mentioning race at the beginning of clinical case presentations: a survey of US medical schools. Med Educ 2009;43:14654.
  • 29
    Van Ryn M, Burke J. The effect of patient race and socioeconomic status on physicians’ perceptions of patients. Soc Sci Med 2000;50:81328.
  • 30
    Van Ryn M, Burgess D, Malat J, Griffin J. Physicians’ perceptions of patients’ social and behavioural characteristics and race disparities in treatment recommendations for men with coronary artery disease. Am J Public Health 2006;96:3517.
  • 31
    Morton KR, Worthley JS, Nitch SR, Lamberton HH, Loo LK, Testerman JK. Integration of cognition and emotion: a postformal operations model of physician–patient interaction. J Adult Dev 2000;7:315.
  • 32
    Bourdieu P. The Logic of Practice. Cambridge: Polity 1990;1–340.
  • 33
    Schiffrin D. Narrative as self-portrait: sociolinguistic constructions of identity. Lang Soc 1996;25:167203.
  • 34
    McAdams D. The Stories We Live By. Guildford Press: New York, NY 1993;1–336.
  • 35
    Ricoeur P. Oneself as Another. Chicago, IL: University of Chicago Press 1992;1–363.
  • 36
    Georgakopoulou A. Small Stories, Interaction and Identities. Amsterdam: John Benjamins Publishing 2007;1–185.
  • 37
    Atkinson P. Medical Talk and Medical Work. London: Sage Publications 1995;1–164.
  • 38
    Holland D, Lachicotte W Jr, Skinner D, Cain C. Identity and Agency in Cultural Worlds. Cambridge, MA: Harvard University Press 1998;1–368.
  • 39
    Clandinin DJ, Cave MT. Creating pedagogical spaces for developing doctor professional identity. Med Educ 2008;42:76570.
  • 40
    Monrouxe LV, Sweeney K. Contesting narratives: medical professional identity formation amidst changing values. In: PattisonS, HanniganB, ThomasH, PillR, eds. Emerging Professional Values in Health Care: How Professions and Professionals are Changing. London: Jessica Kingsley (in press).
  • 41
    Haidet P, Stein HF. The role of the student–teacher relationship in the formation of physicians: the hidden curriculum as process. J Gen Intern Med 2006;21 (Suppl):1620.
  • 42
    Haidet P, Dains JE, Paterniti DA, Hechtel L, Chang T, Tseng E, Rogers JC. Medical student attitudes toward the doctor–patient relationship. Med Educ 2002;36:56874.
  • 43
    Richards K. Language and Professional Identity. New York, NY: Palgrave Macmillan 2006;1–245.
  • 44
    Du GayP, EvansJ, RedmanP, eds. Identity: a Reader. London: Sage Publications 2000;1–400.
  • 45
    Ewick P, Sibley S. Narrating social structure: stories of resistance to legal authority. Am J Sociol 2003;108:132872.
  • 46
    Monrouxe LV, Rees CE, Rees-Davies L, Sweeney K. ‘Oh I’d better wash my hands because you’re there’: effects of medical students’ acts of resistance during medical workplace learning encounters. Association for the Study of Medical Education Annual Scientific Meeting, 15–17 July 2009, Edinburgh.
  • 47
    Antaki C, Widdicombe S, eds. Identities in Talk. London: Sage Publications 1998;1–224.
  • 48
    Moita-Lopes LP. On being white, heterosexual and male in a Brazilian school: multiple positioning in oral narratives. In: De FinaA, SchiffrinD, BambergM, eds. Discourse and Identity. Cambridge: Cambridge University Press 2006;228–313.