Supporting the Development of Professional Identity in the Millennial Learner

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Supporting the Development of

Professional Identity in the

Millennial Learner

Michael A. Barone, MD, MPH,a,b_{Chad Vercio, MD,}c,d_{Thanakorn Jirasevijinda, MD}e

As teachers, we train learners to be knowledgeable and competent in the practice of medicine. No less important is the way teachers impact the development of learners’professional identity. Social scientists in the 1950s noted medical education’s charge“to shape the novice into the effective practitioner of medicine, to give [them] the best available knowledge and skills, and to provide [the novice] with a professional identity so that [they] come to think, act, and feel like a physician.”1Many have stressed the importance of curricula focused on learners’ personal and professional development.2An awareness of professional identity development helps teachers understand some of the workplace differences noted between generations, particularly with millennial learners.

Continuing the Council on Medical Student Education in Pediatrics series on great clinical teachers, our article focuses on supporting professional identity formation (PIF) in millennial learners.

Professional identity formation (ie, the socialization and

professionalization of a physician) develops in stages over time.3PIF consists of ordering and reordering personal and professional

priorities as one progresses from student to effective practitioner.3–5 This process has been linked to one’s personal identity

development.6Characteristics of 3 important stages of physician PIF include the following5:

Early: foundational education (premedical students and early medical students)

•follow social roles and rules

•appreciate others’viewpoints, yet self-views predominate;

Middle: training and/or supervised practice (later medical students and residents)

•view medical practice through multiple perspectives

•subordinate self-interests more effectively

•feel a sense of belonging but not yet“professional”

•may still have trouble reconciling competing expectations;

Later: practicing professional (practicing physicians)

•understand differing values and perspectives

•own and embody expectations of the profession

•begin to internalize the external values of the profession

•reconcile challenges between personal and professional expectations more effectively.

An identity as a physician is the foundation for professional behaviors. For example, a major pillar of professionalism is

a commitment to maintaining trust by subordinating self-interest and

a_{National Board of Medical Examiners, Philadelphia, Pennsylvania;} b_{School of Medicine, Johns Hopkins University, Baltimore, Maryland;} c_{School of Medicine, Loma Linda University, Loma Linda, California;} d_{Riverside University Health System, Moreno Valley, California; and} e_{Weill Cornell Medical College, Cornell University, New York, New York}

Drs Barone, Vercio, and Jirasevijinda conceptualized and drafted the initial manuscript and reviewed and revised the manuscript; and all authors approved theﬁnal manuscript as submitted and agree to be accountable for all aspects of the work.

DOI:https://doi.org/10.1542/peds.2018-3988 Accepted for publication Dec 17, 2018

Address correspondence to Michael A. Barone, MD, MPH, National Board of Medical Examiners, 3750 Market St, Philadelphia, PA 19104. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FINANCIAL DISCLOSURE:The authors have indicated they have noﬁnancial relationships relevant to this article to disclose.

FUNDING:No external funding.

POTENTIAL CONFLICT OF INTEREST:The authors have indicated they have no potential conﬂicts of interest to disclose.

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managing professional responsibilities.5,7Through acknowledgment, questioning, and role modeling, clinical teachers can support a learner’s professional identity development, ensuring smooth transitions. Understanding personal identity formation and PIF is central to teaching, mentoring, and remediating learners.

Concern exists about the millennial generation’s preparedness to meet the expectations of the profession. Millennials (born 1981–2000) are said to have been reared in a“ child-focused”world with high parental involvement and relationships shaped by media.8In medicine, millennials have been characterized as having less commitment to and ownership of patients, a work life shaped more by personal demands, and a sense of greater importance to an organization despite a relative lack of experience. These factors could lead to conﬂicts with teachers about expectations and commitment.9,10Nonetheless, millennials bring many strengths to medicine, such as collaborative learning, acceptance of diversity, and a strong sense of social

consciousness.11In Table 1, we summarize millennials’

characteristics that potentially impact PIF in positive and negative ways.

Generational differences between teachers and learners may create conﬂicts. We propose the I-CA2R2E (individual connection, create, acknowledge and adjust, reﬂect and role model, and exchange) framework (Table 1) to provide strategies to maximize learners’PIF. The

framework addresses the 3 pillars of Self-Determination Theory, which are autonomy, competence, and

relatedness.12The 3 brief cases that follow illustrate how I-CA2R2E can help guide clinical teachers.

CASE 1: THE PERFORMANCE-FOCUSED LEARNER

A clerkship student meets with her preceptor to discuss dissatisfaction with feedback she received,

concerned that the preceptor pointed out areas for improvement.

Potential Issues

The learner, in her early stage of PIF, may view clinical work in a self-focused manner and perceive feedback as judgment and not an opportunity for growth.11

Proposed Solutions Using the I-CA2R2E Framework

I - Make individual connection and explore the learner’s experience with previous feedback.

C - Create a safe space to discuss how the feedback impacts the learner’s view of herself and her role (ie, as test taker versus lifelong learner).

A - Acknowledge grading pressures in medical school and the learner’s concerns that grades are“all that matters”for residency selection.

A - Adjust your own views on feed-back and recognize how genera-tional differences play a role in how feedback is received.

R - Reflect: encourage reflection on key influences in the learner’s identity development (mentors, patients, other experiences).

R - Role model by sharing how feed-back has beneﬁtted you (for ex-ample, how listening to the observations and perspectives of others provided opportunities for personal and professional growth).

E - Exchange: arrange for follow-up with the learner to check in on challenges and successes.

CASE 2: THE SELF-INTERESTED LEARNER WITH MISPLACED PRIORITIES

A subintern visiting from another institution is upset because of his attending’s raising concerns about his level of commitment. The subintern’s

assignment on his patient’s

adjustment to a serious diagnosis was submitted late. When asked, the subintern explains he“prefers taking care of his patients” and that written assignments“matter less”than clinical care.

Potential Issues

The learner may not fully be able to subordinate self-interests and have trouble reconciling competing priorities.

I - Make a connection by exploring personal background and career goals.

C - Create a safe space to explore how this learner prioritizes competing commitments.

A - Acknowledge that competing demands can be difﬁcult to manage.

A - Adjust your own potential biases about this learner being“ dis-engaged”or“uninterested.”

R - Reﬂect: encourage the learner’s reﬂection on his ordering of priorities.

R - Role model by sharing how you have grappled with managing competing priorities.

E - Exchange: provide rationale for assignments and offer to assist and exchange ideas about the how this subintern can order future priorities.

CASE 3: THE LEARNER WITH A LIMITED VIEWPOINT

A senior resident objects to the residency program’s decision to limit intern shifts to 16 hours. He

complains program leadership is “getting soft”and publicly challenges other residents for having supported the program’s decision.

Potential Issues

The learner may have a limited ability to consider multiple perspectives.

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The senior resident’s emotional approach to sharing his perspective is not productive.

I - Recognize this resident’s individual perspective as he approaches un-supervised practice.

C - Create an opportunity for the resident to articulate rationale, not simply emotional reactions.

A - Acknowledge that the resident is entitled to his point of view, yet the decision-making process (program leadership and other resident input) should be respected. Encourage the resident to focus on outcomes and not only resident work hours.

A - Adjust your personal biases and understand that generational

differences impact expectations of learners.

R - Reflect and role model: probe the resident’s view on how his action manifested as role modeling for others (ie, hours in the hospital versus a focus on quality, safety, and relationships with patients). Reflect on a time when your own first impressions were modified over time.

E - Exchange: set a time for follow-up and ask for ideas about how future group decisions can be

collaborative.

CONCLUSIONS

Although it may seem a distant memory to great clinical teachers, the early stages of a medical learner’s PIF

can be disconcerting andﬁlled with conﬂict, self-doubt, and an inadequate sense of belonging to the profession. Millennial learners may particularly need guidance through challenges to make critical decisions (ordering and reordering priorities) that ultimately lead to the embodiment of

professional behaviors (ie, thinking, acting, and feeling like a physician). Supervisors who approach teachable moments with open-mindedness, a willingness to challenge

expectations, and tools to stimulate exploration and self-reﬂection (I-CA2R2E) will be able to promote learners’development of a strong foundational identity in medicine. When learners experience the investment of a clinical teacher in their professional journey, everyone beneﬁts, including patients, who TABLE 1Millennial Attributes That May Positively and Negatively Interact With PIF and the I-CA2R2E Framework

Millennial Attributes Potentially Impacting Physician Identity Development

Methods to Address I-CA2R2E Comments

Positive interaction Individual connection Connect with learners through a variety of methods and determine a preferred method; pay attention to the learner’s journey to medicine and outside interests.

Relationship centered Expect personal connection with

supervisors Negative interaction

Conﬂict with hierarchy Occasional distrust of authority

Positive interaction Create Create a safe space for honest dialogue; provide opportunities for learners to share the important experiences and pivotal moments in their identity development as a physician (ie, the process of becoming medical professional).

Equality and diversity

Team centered and collaborative learning

Negative interaction

Personal learning needs are valued more than group learning and/or team training

Positive interaction Acknowledge and adjust Acknowledge learner perspectives; validate story and concerns; adjust approaches on the basis of learner values, reactions, stage of life, and training; adjust teaching methods on the basis of learner preferences; and adjust and challenge your own expectations of“what is right.” Desires routine feedback

Social consciousness Negative interaction

Easily bored with traditional education (didactics)

May have trouble with independent decision-making

Frustrated with“menial”tasks

Positive interaction Reflect and role model Encourage reflection on personal experiences; provide nonjudgmental feedback when values and ideals conflict; role model expected behavior; and coach as learners order and reorder priorities.

Desire for meaning in work Negative interaction

May view feedback as judgment and not an opportunity for growth

Need for explicit instructions

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ultimately receive care from physicians who truly embody the expectations of the medical profession above their own needs.

ACKNOWLEDGMENT

We thank Dr Nicholas Potisek for his thoughtful contributions in

conceptualizing this article.

ABBREVIATIONS

I-CA2R2E: individual connection, create, acknowledge and adjust, reﬂect and role model, and exchange PIF: professional identity

formation

REFERENCES

1. Merton RK, Reader GG, Kendall PL, eds.

The Student-Physician: Introductory Studies in the Sociology of Medical

Education. Cambridge, MA: Published

for the Commonwealth Fund by Harvard University Press; 1957

2. Inui TS.A Flag in the Wind: Educating

for Professionalism in Medicine.

Washington, DC: Association of American Medical Colleges; 2003

3. Johnston S. See one, do one, teach one: developing professionalism across the generations.Clin Orthop Relat Res. 2006;449(449):186–192

4. Cruess SR, Cruess RL. Teaching professionalism - why, what and how.

Facts Views Vis ObGyn. 2012;4(4):

259–265

5. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators.Acad Med. 2015; 90(6):718–725

6. Kegan R.The Evolving Self: Problem and

Process in Human Development.

Cambridge, MA: Harvard University Press; 1982

7. American Board of Internal Medicine Foundation. The physician charter.

Available at: http://abimfoundation.org/ what-we-do/physician-charter. Accessed November 1, 2018

8. Clark University. About the Clark University poll. Clark University poll. Available at: http://www2.clarku.edu/ clark-poll-emerging-adults/. Accessed November 1, 2018

9. Eckleberry-Hunt J, Tucciarone J. The challenges and opportunities of teaching“generation y”.J Grad Med Educ. 2011;3(4):458–461

10. Shaw H.Sticking Points: How to Get 4 Generations Working Together in the 12

Places They Come Apart. Carol Stream,

IL: Tyndale House Publishers; 2013

11. Lancaster LC, Stillman D, Mackay H.

When Generations Collide: Who They Are, Why They Clash, How to Solve the

Generational Puzzle at Work. New York,

NY: Collins Business; 2005

12. Kusurkar R, ten Cate O. AM last page: education is notﬁlling a bucket, but lighting aﬁre: self-determination theory and motivation in medical students.

Acad Med. 2013;88(6):904

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DOI: 10.1542/peds.2018-3988 originally published online February 5, 2019;

2019;143;

Pediatrics

Michael A. Barone, Chad Vercio and Thanakorn Jirasevijinda

Supporting the Development of Professional Identity in the Millennial Learner

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DOI: 10.1542/peds.2018-3988 originally published online February 5, 2019;

2019;143;

Pediatrics

Michael A. Barone, Chad Vercio and Thanakorn Jirasevijinda

Supporting the Development of Professional Identity in the Millennial Learner

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