Growing Professionals: Exploring the Impact of a Professional Identity Formation Curriculum in Medical School

Professional Identity Formation Curriculum

The longitudinal PIF curriculum, begun in 2007, has adapted over time as a more complex and multifaceted understanding of PIF became apparent. We sought to more broadly address the social context and the shifting societal, medical and educational landscapes, and consider how learners with different life experiences may choose to define their own PI as they integrate medicine's values into their own existing sense of self. The goals of the PIF Curriculum are to: (1) explicitly focus on the developmental nature of PIF, (2) explore challenges of integrating personal and professional identities and support students in assuming the responsibility to craft their own PI throughout their careers, and (3) provide a scaffolding and language, as well as the opportunity to discuss and understand professional values and behaviors.

The curriculum includes five workshops (90 min - 2 h) held over 4 years (Table 1), paired with writing Professional Identity Essays (PIEs) and reflecting on written developmental feedback about their writings (see Appendices A and B). Objectives include learning the language and framework of PIF, articulating the nature of medical professionalism, medicine's social contract, the values we hold as physicians, and describing the process of PIF and socialization. Students discuss barriers to professional behavior, including the “hidden curriculum,” ethical challenges they experience during their training, and reflect on their PI essay report with support from faculty. All workshops use active learning strategies paired with reflection and include facilitation by faculty and/or senior MSs. Recognizing that PIF is impacted by many other experiences beyond these formal sessions, most notably through clinical learning and role modeling that occur during clinical rotations, additional PIF support is thus integrated throughout the medical school curricula (Table 1). Students are encouraged to be active curators of their own PI, allowing for individualized pathways based on their own values and lived experiences, rather than a “one size fits all” prescriptive PIF.

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Table 1.

Professional Identity Formation Curricular Activities.

1. Medical Student (MS)1 Orientation workshop and PIE #1 assignment  a. Learning Objectives:  i. articulate the nature of medical professionalism and medicine's social contract​  ii. describe the process of professional identity formation and socialization ​  iii. recognize challenges of merging your personal identity with your emerging professional identity ​  iv. recognize bias in healthcare and its impact on identity formation  v. understand that professional values may at times conflict with each other in our complex health care system  vi. understand the value of completing the Professional Identity Essay (PIE)  b. Complete PIE #1 essay before next session 2. MS1 workshop and PIE #1 review  a. Learning Objectives:  i. review and discuss the nature of medical professionalism  ii. read and interpret your individualized feedback on your PIE ​from trained scorer  iii. reflect in writing on your own professional development as a physician (written reflection shared only at learners’ discretion) 3. MS2 clerkship orientation workshop and PIE #2 assignment  a. Learning Objectives:  i. recognize individual, community and systemic barriers to professional behavior​  ii. discuss scenarios posing ethical challenges experienced by clinical medical students on the wards and discuss options for facing these challenges  b. Complete PIE #2 essay before next session 4. MS 2/3 session #4 and PIE #2 review during core clerkship year  a. Learning Objectives:  i. Review the nature of medical professionalism​  ii. Review the process of professional identity formation and socialization ​  iii. Recognize opportunities and challenges to maintaining professional behavior and developing a professional identity during the core clerkship year  iv. read and reflect on your individualized feedback on your PIE ​from trained scorer  v. reflect on your own professional development as a physician (reflection shared only at learners’ discretion) 5. MS 3/4 Session # 5 Transition to residency  a. MS4 PIE #3 assignment - to be completed prior to session  b. Learning Objectives:  i. Anticipate challenges to your professional identity and to professional behavior in internship​  ii. Consider when there are conflicting professional values in the workplace and options and resources to responding when confronted with these 6. MS4 PIE #3 assignment 7. MS4 - Optional discussion session to review PIE #3 and feedback

Related curricular activities outside formal PIF curriculum that support PIF  a. MS1 diversity, equity, inclusion, identity workshop  b. MS2 ethics workshop  c. Mid clerkship year ethics workshop  d. Reflection/processing groups in psychiatry and internal medicine clerkships  e. Assessment of and feedback on professional behavior in each clerkship  f. Individual mentoring and academic coaching sessions with assigned faculty advisor throughout medical school (∼ 7 sessions) includes professional identity formation and professional behavior discussions  g. Small group sessions throughout medical school to promote students’ resilience and well-being

PIF, Professional Identity Formation; PIE, Professional Identity Essay.

Professional Identity Essays

The PIE completed by our students, developed by Bebeau and Monson, is an adaptation of Kegan's Adult Developmental Model to focus on PI ⁷ and tailored to medical education. ⁸ This model describes development as a process of transforming to more complex ways of knowing and of making sense of the world. The essays, including nine prompts eliciting conceptions of the professional role (Appendix A), are evaluated by expert raters (who have no contact with students) who generate a stage score and an individualized report, highlighting the reasons for the assigned stage and ideas for reflection that are designed to broaden students’ reflections on ideas or situations. The stages, as set forth by Bebeau and Monson ⁷ based on Kegan's model, are described in Appendix B.

Explanations about the purpose of PIEs, and implementation processes (length and depth of responses expected, no “right answers”, what scoring means, feedback they will receive, privacy) are described at the first PIF workshop, and students are given 2-3 weeks to complete PIE assignments at a time convenient to them. They then receive written feedback including a description of their developmental stage, highlighting their strengths and including questions to consider that may prompt more complex consideration of PI issues. After a group debrief with trained faculty during a workshop, students write a confidential reflection on the report to cultivate insight on their PIF. In order to provide psychological safety in this reflection exercise, the essays, feedback, and their reflections are private, and only shared if, and when, the student chooses to do so. These essays are administered three times over the course of medical school: at the beginning, prior to beginning clinical rotations, and in the final year.

Statement of Purpose

We sought to evaluate the longitudinal PIF curriculum at our medical school. Using an inductive thematic qualitative method, we explored how MSs at an academic medical center experienced the PIF Curriculum.

Deciphering the Curriculum and Curricular Concepts

When asked to describe what participants understood as the PIF curriculum, most expressed some degree of uncertainty. While many noted specific PIF workshops and PIE essays respondents also described structured and unstructured discussions, reflective exercises and experiential learning that, while contributing to PI, were formally part of other curricula (eg, ethics lectures, doctoring courses). One interviewee said “I’m not really sure… I’m sometimes unaware [of] which curriculum I’m currently sitting in or doing” (Interview 12). While this may indicate a lack of clarity in messaging about the PIF curriculum, it also reflects the reality that PIF is a complex phenomenon and is (and should be) developed and reinforced across all aspects of the medical school curriculum.

Faculty teaching within the PIF curriculum attempted to clarify the distinction between PI and professionalism; however, this distinction was not clear to some students. During PIF workshops, PIF was presented as an individual, active growth process of crafting “what kind of doctor you choose to become” while professionalism involved standards for professional behavior. However, when asked about PI, some students referenced lectures by other faculty that focused on standards for behavior. Respondents’ uncertainty about the terms “professionalism” and “professional identity” was apparent in the student comment: “it's hard to separate out for me I think the idea of or at least the way that ‘professional behavior’ versus ‘professional identity’ is conveyed to us as medical students in that… oftentimes it feels as though ‘professionalism’ is being used as in a coercive way” (Interview 9). Nonetheless, unearthing this perplexity helped prepare students for learning about and developing their PI.

Grappling with the Concept of PIF

Upon entering medical school, students had a vague sense of PI and found the topic confusing to consider. One student noted, “The first time I filled it out [the PIE] …this feels extremely, extremely foreign … like even asking the question …‘how much do you feel like a doctor’ felt ridiculous.” (Interview 8). Discussions during early PIF sessions and writing about what being a physician meant to them seemed to be purely theoretical and not grounded in experience, yet served as seeds that grew over time.

The value of planting seeds about PIF early on in medical school became apparent to students over time, and in fact, gave them a language to identify the process of PI development and empowered them to act. They recognized that the questions posed during the early sessions and in the PIE allowed them to deepen their understanding of what it means to be a part of the profession. “I think in retrospect, it probably is helpful to plant the seeds of those [PIE] questions . . . I think the first one at some point during pre-clinical was really helpful as a baseline, you know, before really embarking on any parts of the journey (Interview 15). And, “I don’t think I would have had the …conscious level… that I was like ‘oh I’m starting to think of myself more as a physician’ if I hadn’t been primed with the question. It was helpful to think about [professional identity] early on and helped me to adjust to considering myself in the role of physician” (Interview 8).

As they progressed through their training, the curriculum, and writing PIE essays, students came to more clearly appreciate their growth. Many respondents noted changes in their perspectives in their responses to the essays over time. “When I would write the next one, I would look back at what I’d said before, and I was surprised that things changed” (Interview 5).

Opportunities for reflection individually, with peers, and with faculty fertilized the seeds of PIF planted during early sessions, allowing them to flourish. “Having space for a discussion about professional identity has been really important … it's not something that I have necessarily actively thinking about on my own” (Interview 6). Sharing information and skills during workshops were also highlighted. For example, role-playing responses to unprofessional behaviors, ¹¹ were noted to be “pretty realistic” and “helpful to see how my peers handled them, what faculty, people with more power, thought about those situations and how to handle them” (Interview 5). And, “[the school] doesn’t want this to happen yet it also recognizes that sometimes it does happen and that students need to recognize when it's happening and be able to discuss with someone that it's happening or their own reactions to it” (Interview 15).

Actively Crafting an Identity

As students progressed into their clinical years and took on the professional role, they experienced exceptional growth in their PI using earlier discussions and reflections about PIF to actively craft their PI in the clinical realm. Students observed a wide range of physician behaviors and skills and formed relationships with near-peers and attendings. Exposure to physicians in practice allowed them to reflect on values they would like to assume, and behaviors they would choose to emulate. Active discussion of values and expectations within the PIF curriculum before entering the clinical environment allowed learners to consider how professional and personal values and expectations fit (or not) together and to actively choose their values. This theme was highlighted in all of our interviews. Students actively craft their identities by observing others, practicing being in the role with all its attendant pressures and making choices about how to adopt, adapt or reject the behaviors they see in role models.

As one student noted, “where I really benefited was in clinics where … I now have …an idea of my own conception of what it means …to be a doctor. And then [reflecting on] ‘ based on what I’ve seen, how has my own self-conception changed? How do I want that self-conception to change going forward?’” (Interview 2).

The framing of PIF through the curriculum also provided a lens to negotiate responding to other professionals’ behaviors: “this gave me the tools … to reflect on …something I’m observing. What do I think about it? Is it something I want to hold onto? Is it something I need to escalate? Those questions about experiences in professional spaces, it definitely spurs that kind of thinking” (Interview 5).

Challenges to Engaging with PIF Curriculum

Students identified challenges as they tried to make sense of both the PIF curriculum and their own developmental journey and to integrate that development into the broader medical school experience. They noted time pressures that made attending to and completing the PIE reflective writing tasks difficult given the competing demands of higher stakes assignments. “It's not just professional identity, but anything … gets pushed to the wayside a bit, because I’m much more focused on performance and them [faculty] analyzing my performance” (Interview 14).

Students noted the tension inherent in needing to “perform” in different clinical settings and adopt behaviors that may conflict with their aspirations. “I think it's much easier to adopt the practices of the people around you particularly as a medical student when you are constantly trying to fill the shoes of what you think the team wants you to do as a clerkship student where you’re worried about grades … that can be a pitfall for students to adopt behaviors that are maybe maladaptive if they think it's going to impress or make them fit in better on that particular service” (Interview 9).

Additionally, awareness of being continually evaluated by others influenced students’ reactions to developmental feedback on PIE essays. Although students were regularly reassured that they were early in their lifelong PI journey, students experienced discomfort at not being at the top developmental level. Interestingly, few students described this as their own experience, but many presented this as the experience of their peers. For example, one student states that “it's challenging for people to be in that position where they feel like ‘oh no I’m at the bottom, I have to get to the top of that scale.’ … but really emphasizing to people this is about growth, you’re at the bottom and that is appropriate and–at medical school you’re not going to be at the top necessarily and that's appropriate as well” (Interview 9).

There was tension over how often to have structured reflection on PIF and who should lead these discussions, with psychological safety concerns. A few respondents felt that discussions about PIF were most relevant once they were in clinical settings, although most acknowledged that early discussions helped them consider their experiences in light of those earlier discussions. Regarding frequency, one student commented, “The first two times I actually really answered the questions and then this most recent time, I was like, these questions aren’t even relevant to how I want to live my life in the future, I just am going to write something down to fulfill the requirements” (Interview 11).

Finally, for a few learners, written reflections about PIF were not seen as helpful. One student commented, “the essays themselves are always really hard for me to produce because I feel like I can never really say what I’m thinking on paper” (Interview 6).

Strengthening the Curriculum

Students expressed the desire for more opportunities for reflection and more integration of such reflections into their ongoing learning and experiences.

There was a desire for a clearer understanding of PI as distinct from professionalism and a clarification of how both of those concepts are assessed. “Before we can come up with the curriculum, we need to address the people who are evaluating the programs that we’re using to assess our students and then the assessment themselves, so that we have a shared set of language and definitions”(Interview 11). Some students noted that at times there was a discrepancy between the values espoused in the curriculum and what they observed in practice. “There are plenty of behaviors that… don’t square particularly well with the professional identity curriculum… that we’re being given” (Interview 9). Finally, the uncertainty that students experienced as they tried to make sense of the complexity of PIF was reflected in their desire for clear “right answers” as they moved through their development. “Students are very used to… you answer a question then there is … if not a right answer, there's at least a way you should be thinking” (Interview 4).

Students’ views differed on the appropriate discussion guides based on their own sense of psychological safety. Some students were hesitant about engaging in open and honest discussions with faculty who were in positions to evaluate them. “It’d be nice if … we could talk … about our experiences with someone who's not in a hierarchy of grading us. Because it's really difficult to talk about professionalism when you’re being graded by an advisor, and the dean and all of your attendings” (Interview 10). Others felt that having PIF discussions integrated into their clinical rotations would allow them to process their thoughts and feelings about experiences in real time, and with faculty who were familiar with specific situations and with the learners’ strengths and challenges. “There's a connection missing when you’re trying to reiterate an instance to somebody a week or two later. You forget those visceral feelings. … And I think if that was established on a routine basis throughout all clerkships, that would really help with growth of professional identity.”

Finally, in spite of the challenges of making sense of this complex issue, students appreciated that the school highlighted the importance of PIF. As one student noted, “I think it's a good thing that [the school] cares that we develop a professional identity” (Interview 12). And they recognized that the uncertainty experienced during their journey may be part of the process. “I was kind of surprised in the whole process at how it naturally comes about, and I was very skeptical just getting the tools and skills pre-clinical. But it is helpful to be introduced to these things, forget about it, and then once you’re in a situation … it's helpful to have a toolkit so you can pull things out when you need and when you think it's appropriate. That was the major surprise to me in how successful that actually was, because I was very skeptical at first” (Interview 3).

Discussion

Our evaluation of a longitudinal PIF curriculum revealed that students experienced identity formation as gradual, multifaceted, and shaped by structured opportunities for reflection. Participants described initial uncertainty about PI, followed by growing clarity as they engaged with workshops, PIEs, and dialogue. These activities “planted seeds” early in training that later grew into deliberate efforts to craft identity during clinical rotations. Students valued the curriculum for directly discussing these issues and for providing language and tools to interpret their experiences, though they also noted challenges such as competing demands, lack of clarity between professionalism and PI, and discomfort with reflective writing. Learners emphasized the need for more frequent, integrated reflection and the importance of psychological safety and non-evaluative faculty support.

By purposely seeking out students with strong reactions to our PIF curriculum, both positive and negative, we obtained a wide range of viewpoints. These findings highlight PIF as a dynamic developmental process in which learners integrate medicine's values into an authentic sense of self. Identity is not passively acquired but actively curated through reflection, critical evaluation, and selective integration of observed behaviors. By positioning students as agents in their own identity development, educators can foster deeper engagement and more adaptive trajectories.^4,11

The curriculum's structured activities supported this process by scaffolding reflection across training. Developmental and transformative learning theories suggest that repeated cycles of reflection and application, supported by open discussion and guided questioning, promote more complex and integrated ways of making sense of the professional role.^12,13 Participants particularly valued direct, honest conversations that helped them reconcile personal values with professional expectations and identify strategies to enact their role with integrity. Faculty-led dialogue and modeled reflective practice signaled that identity work is legitimate, further normalizing this as a central aspect of medical education. Further work is necessary to expand the capacity of more clinical faculty to directly support and model such practice during clinical rotations. One challenge to this is the dual role of clinical faculty in both evaluating students and supporting them by creating the psychological safety necessary for self-disclosure and reflection.

Unsurprisingly, the students’ PIF accelerated during their clinical rotations where patient care experiences and the opportunity to observe those further along in their medical training provided students the opportunity to visualize their future professional role. This is consistent with the literature ¹⁴ and points to the importance of embedding reflection within clinical contexts. Real-time reflection with trusted faculty makes identity work more relevant, bridging abstract discussion with patient care experiences and reinforcing the notion that PI is both contextually grounded and personally owned. Such integration may also reduce the sense that reflection is an added task competing with high-stakes evaluations.

While students learn the language and framework of PIF, clinical supervisors are not necessarily reinforcing the PIF curriculum. Faculty and housestaff development in this domain would likely enhance the clinical learning environment. ¹⁵ Although learners noted tensions such as the hidden curriculum, they described how the curriculum gave them tools to address these challenges constructively. They valued learning strategies to address professional challenges (eg, how to respond to unprofessional behavior of others, where/ how to seek support, how to report such behaviors). Brown et al note ¹⁶ the negative impact role modeling, stereotyping and organizational culture (ie, the “hidden curriculum”) can have on students’ PI and giving students tools to mitigate those impacts is essential to PIF. Explicit permission and support to question observed norms fostered professional agency and reframed PIF as not merely adapting to culture but shaping a better future for the profession. This shift from defensive resistance to generative contribution underscores the growth potential of well-designed PIF curricula.

Limitations

Despite a purposeful sampling strategy, input from students with minoritized identities was relatively limited. This includes individuals with prior personal and professional experiences that may challenge professional norms in unique ways. Faculty could also be viewed as gatekeepers of participants as they were asked to identify initial students for this study. Finally, our purposive sampling strategy, designed to obtain the full range of perceptions about the curriculum, may have excluded quieter students with other views. Future research is needed to further expand our understanding of the PIF process to support inclusion of the widest range of experience possible. Of course, the generalizability of our findings is limited because this study reflects the experience of students at one medical school with a curriculum that developed locally over a 16-year period.

Conclusions and Practice Implications

In sum, our results support moving beyond professionalism as a prescriptive list of behaviors to actively engage learners in the challenges of creating their own unique PI that can align with the aspirational goals of the profession. A formal PIF curriculum that creates intentional, psychologically safe spaces where learners can reflect, question, and integrate their personal values with those of the profession, provides the necessary scaffolding to develop a mature PI that we hope can serve them as they move through their career.