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      Medical students are not blank slates: Positionality and curriculum interact to develop professional identity

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          Abstract

          As Stubbing et al. [1] have rightly pointed out, medical students do not enter their training as ‘blank slates’. We carry with us diverse life experiences, which influence early notions of what it means to be a doctor. As co-authors of this accompanying commentary, and as medical students from universities in the US, Canada, and Australia, we entered medical school with a range of preconceptions of what makes a doctor. In writing this commentary, we have drawn from our varied and unique perspectives, including our respective experiences as members of communities often underrepresented in medicine, including LGBT (lesbian, gay, bisexual and transgender), racialized, disabled, refugee, undocumented, and low socioeconomic status communities. Of course, we do not represent the communities to which we belong, and our composite identities include communities well-represented in medicine. Further, our lived experiences cannot possibly capture the multifarious backgrounds of physicians in training. However, these experiences have been influential in our trajectory—they guided our aspirations to pursue medicine as a career, and at times hindered our pathway to medicine, and continually shape our notion of what it means to be a physician. As a result, this commentary aims to reflect on how diverse medical student positionalities influence professional identity formation. Moreover, we aim to highlight the role of medical education institutions’ formal and hidden curricula in empowering students to develop a professional identity that embraces their positionality. Diversity matters Medical schools internationally have embraced a mandate of social accountability, so that medical students may reflect the diverse populations they will serve [2, 3]. However, when these increasingly diverse medical students enter training, they are confronted with pressures to conform to a preset professional identity [4]. These pressures occur both at the level of formal curricular teaching, and through the hidden curriculum—that is, the institutional practices, policies, and language that shape learners’ perceptions of their student role [5]. Stubbing et al. rightly describe the learner identity as one important element of early professional identity formation [1]. As medical students, our pre-conceived ‘figured world’ is indeed at odds with the reality of medical training for a number of reasons, and supporting medical students through this tension is vital. However, we contend that learners’ lived experiences—in particular, the diverse identities we held before medical school—are essential to acknowledge as we develop our professional roles (Fig. 1). To illustrate this, we provide three thematic examples: privilege, stigma, and micro-aggressions. Fig. 1 Integrating past and future: Supporting student backgrounds in professional identity formation How we self-identify in relation to privilege impacts our figured preconceptions of medical school. For example, while some students have physician parents or significant exposure to medicine, others enter medical school with limited knowledge about the profession. The social capital disparity is manifest in many communities, such as those of low socioeconomic status, racial and ethnic minorities, and rural upbringings. This disparity lingers throughout medical school, challenging these students’ preparedness for academic and clinical endeavours [6, 7]. At the same time, we find compelling what one medical student from an ‘underprivileged’ background wrote that her unique identity enhanced her ability to practice empathic care and understand the social determinants of health [8]. Learners with marginalized identities may also face significant stigma. For example, medical culture often frames illness as a weakness or failure to cope [9, 10]. As a result, medical students with disabilities often hesitate to disclose a disability out of fear of being scrutinized by classmates or teachers, or being judged as less competent [11]. Similarly, sexual and gender minorities face stigma, with one study finding that 29.5% concealed their identity for fear of discrimination [12]. Yet these learners hold valuable perspectives—for example, as recipients of healthcare and as self-advocates—which we translate into our own development as healthcare providers. Beyond the effects of overt stigma, discrimination and harassment, learners commonly experience everyday slights and micro-aggressions in their educational and clinical placements [7, 13, 14]. In particular, we who identify as racial minorities must navigate this climate daily, which can adversely impact our wellbeing [15]. Our professional identity is fashioned by our sociocultural upbringing in parallel with our medical training, and many of us face the particulars of this ‘emotional tension’ without adequate support. Implications for curriculum development How then can medical institutions support students to become physicians who honour their lived experiences? While the medical education community is making great efforts to address this issue, we draw on our experiences as students to suggest three key approaches institutions can adopt to better facilitate professional identity formation by meaningfully embracing diversity [16]. Access to student services Issues surrounding wellbeing (including discrimination, harassment and mental health) can disproportionately affect students from marginalized backgrounds [14, 17]. We urge medical institutions to provide appropriate accommodations (e. g. flexibility in scheduling), disability services [18], mental health and counselling services, well-being workshops, and adequate financial support. Making these services available is one component of a greater cultural and structural change aimed at restructuring the hidden curriculum [5]. Near-peer and faculty mentorship As the significance of role models in professional identity formation is well established [19], we suggest tailored mentorship programs that increase exposure to role models with similar lived experiences to empower trainees to embrace their unique experiences. This approach is supported by emerging evidence regarding gender disparity in surgery, which suggests that a paucity of same-gender role models prevents women from conceiving of a career in surgery [20, 21]. Mentorship programs for staff have also been identified as an effective way to increase recruitment and retention of underrepresented minorities in medical school faculties [22, 23], which could in turn increase the availability of diverse role models. Formal curricula Formal teaching that acknowledges students’ diverse experiences and draws on those experiences as forms of expertise will better prepare all students to treat the diverse populations they serve [24, 25]. In their work on underrepresented minority medical students, Rumala and Cason [26] illustrate the value of formally collaborating with student minority organizations in improving peer support and recruitment programs. The curriculum, with support from senior leadership in the medical institution, can therefore empower students to value and learn from their diverse positionalities as assets to their professional identity formation [27]. In closing, we are grateful to medical institutions for their efforts to increase diversity in medical school classes. However, the next important step is to support the more personal influences on our ‘figured worlds’ that bear real-world significance. Empowering students to integrate their pre-medical backgrounds into their developing identity is crucial not only to improving the process of professional identity formation for diverse students, but also to nurturing empathic and insightful physicians uniquely suited to respond to the plights of their patients.

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          Most cited references 27

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          Beyond curriculum reform: confronting medicine's hidden curriculum.

           F Hafferty (1998)
          Throughout this century there have been many efforts to reform the medical curriculum. These efforts have largely been unsuccessful in producing fundamental changes in the training of medical students. The author challenges the traditional notion that changes to medical education are most appropriately made at the level of the curriculum, or the formal educational programs and instruction provided to students. Instead, he proposes that the medical school is best thought of as a "learning environment" and that reform initiatives must be undertaken with an eye to what students learn instead of what they are taught. This alternative framework distinguishes among three interrelated components of medical training: the formal curriculum, the informal curriculum, and the hidden curriculum. The author gives basic definitions of these concepts, and proposes that the hidden curriculum needs particular exploration. To uncover their institution's hidden curricula, he suggests that educators and administrators examine four areas: institutional policies, evaluation activities, resource-allocation decisions, and institutional "slang." He also describes how accreditation standards and processes might be reformed. He concludes with three recommendations for moving beyond curriculum reform to reconstruct the overall learning environment of medical education, including how best to move forward with the Medical School Objectives Project sponsored by the AAMC.
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            'I wouldn't want it on my CV or their records': medical students' experiences of help-seeking for mental health problems.

            Medical education is reported to be demanding and stressful and previous work with doctors suggests that there is a resistance within the profession to help-seeking and an ad hoc approach to dealing with stress and distress. To explore the attitudes of medical students at the University of Manchester, UK to the causes of stress and to examine their views on help-seeking. A qualitative study using semistructured interviews, with analysis of the data using the technique of constant comparison. Medical students at the University of Manchester were invited to participate in the study. Sampling made the research representative of medical students in terms of gender, ethnicity and UK/overseas students. Semistructured interviews, with open questions, were conducted and audio-taped with consent. The tapes were transcribed verbatim. The schedule was revised in the light of the emerging themes. Medical students recognised that studying medicine contributes to stress, as experienced in their undergraduate careers. Students reported that perceptions of stigma associated with mental illness, including stress, were prevalent in the student body and were perceived to continue throughout the medical profession. Avoidance of appropriate help-seeking behaviour starts early and is linked to perceived norms which dictate that experiencing a mental health problem may be viewed as a form of weakness and has implications for subsequent successful career progression. The preparation of medical students for life as doctors involves more than facilitation of the acquisition of knowledge and skills, so that new doctors can conform to the principals of professional conduct. Support and mentoring are required so that stress can be identified early and dealt with appropriately.
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              A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators.

              Recent calls to focus on identity formation in medicine propose that educators establish as a goal of medical education the support and guidance of students and residents as they develop their professional identity. Those entering medical school arrive with a personal identity formed since birth. As they proceed through the educational continuum, they successively develop the identity of a medical student, a resident, and a physician. Each individual's journey from layperson to skilled professional is unique and is affected by "who they are" at the beginning and "who they wish to become."Identity formation is a dynamic process achieved through socialization; it results in individuals joining the medical community of practice. Multiple factors within and outside of the educational system affect the formation of an individual's professional identity. Each learner reacts to different factors in her or his own fashion, with the anticipated outcome being the emergence of a professional identity. However, the inherent logic in the related processes of professional identity formation and socialization may be obscured by their complexity and the large number of factors involved.Drawing on the identity formation and socialization literature, as well as experience gained in teaching professionalism, the authors developed schematic representations of these processes. They adapted them to the medical context to guide educators as they initiate educational interventions, which aim to explicitly support professional identity formation and the ultimate goal of medical education-to ensure that medical students and residents come to "think, act, and feel like a physician."
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                Author and article information

                Contributors
                kirk.fergus@ucsf.edu
                Journal
                Perspect Med Educ
                Perspect Med Educ
                Perspectives on Medical Education
                Bohn Stafleu van Loghum (Houten )
                2212-2761
                2212-277X
                5 January 2018
                5 January 2018
                February 2018
                : 7
                : 1
                : 5-7
                Affiliations
                [1 ]ISNI 0000 0001 2297 6811, GRID grid.266102.1, School of Medicine, , University of California—San Francisco, ; San Francisco, CA USA
                [2 ]School of Medicine, Western Sydney University—Campbelltown, Sydney, Australia
                [3 ]ISNI 0000 0004 1936 8649, GRID grid.14709.3b, Faculty of Medicine, , McGill University, ; Montreal, Quebec Canada
                [4 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, Faculty of Medicine, , University of Toronto, ; Toronto, Ontario Canada
                Article
                402
                10.1007/s40037-017-0402-9
                5807268
                29305819
                © The Author(s) 2018

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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                Education

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