Cultivating Professional Identity in Medical Education

In this episode, CLIME Associate Director, Kate Mulligan talks with Dr. Audrea Burns about cultivating professional identity in medical education.Despite ongoing social and political disruptions, medical education has continued to refine how we can best cultivate the professional identities of our learners and faculty. Dr.Burns highlights current challenges in professionalism through discussion of emerging frameworks to support an antiracist and inclusive environment to allow for all members of the medical education community to flourish. 

Transcript

Cultivating Professional Identity in Medical Education 

Amanda Garza: Welcome to CLIMEcasts, I am Amanda Garza the CLIME program manager. In this episode, CLIME Associate Director, Kate Mulligan talks with Dr. Audrea Burns about cultivating professional identity in medical education. Dr. Burns completed her graduate studies and immunology in the department of biological sciences at the University of Chicago and her post-doctorate fellowship at Baylor College of Medicine in the science education pedagogy. She completed the master teachers fellows program for medical education at BCM. Dr. Burns co-developed a curriculum for physician scientist training. Framed and fostering dual professional identities and serves as the associate program director for the pediatrician scientist program, residency track, where she has been faculty since 2013.  Her research focuses on social justice and professionalism. With the focus and using social justice as a framework for fostering professional identity formation in health professions, education. Enjoy the episode! 

Kate Mulligan: Welcome to CLIMECasts, I'm Kate Mulligan and I'm delighted today to host, an episode with Dr. Audrea Burns. Dr. Burns gave a fabulous grand rounds here at the University of Washington School of Medicine and I thought it would be lovely to capture some of the main points from that and maybe riff on those a bit more with her for our CLIMECasts audience. 

So welcome Dr. Burns, thank you so much for joining us. So today we're going to be talking about professionalism and professional identity, especially in healthcare providers. And I was wondering if we could start perhaps with, some of your favorite definitions for professionalism and professional identity.  

Audrea Burns: Absolutely, I believe it's always useful to start with definitions and it, it helps us to create a, a shared mental model, especially in thinking about the formation of one's professional identity, which is a social construct that oftentimes we want to quantify with hard numbers especially for trainees as we want to ensure that we are developing, trainees to, espouse all of these values and, and traits and, and also to, to kind of check those accreditation boxes. 

So, happy to start off in thinking about, how I define these two terms. So, I really lean on a definition that's currently one of the most cited from longstanding work of Richard and Sylvia Cruz at McGill University. 

A definition that he provided from a combination of, of papers in academic medicine because, many of us, in health professions education utilize these definitions as a starting point so really builds upon and, Cruz state set professionalism is defined by essentially a set of, of values and virtues espoused by the profession such as honesty and integrity, professionalization, you know, this process of becoming a professional, humility and respect and that professionalism really serves as the basis of medicine's contract with society. 

And that's what led me here is I kept, you know, as a basic scientist, Kate, just kept trying to peel back the layers of correlate elements of how we engage with one another in our academic environments. What, you know, what are those common threads that allow for us to thrive? And whether we're in the graduate school or the school of nursing or dentistry or at the medical school. 

And it's, it's really, you know, it's professionalism. I'm, I'm always saying that all things stem back to professionalism because it's that contract that allows us to do what we do and it demands that we place the interests of patients above those of our own and particularly, he was referring, to the development of medical trainees and highlighted it's, it's placing those interests above those of the physician and that we have to set and maintain standards of competence and integrity, and we have to provide expert advice to society on matters of health. 

It's shared values that we all can agree upon. And, and those include virtues such as respect and humility. And that's from studies that have been done by, leading educators across the globe such as Muhammad Iraqi's work and, and others and those virtues differ and that they always have to align back to the culture, religion, and even the ethnicities represented in society. 

And so, you know, now professionalism has become a really hot topic, Kate, because oftentimes we find that those things that we do within our health system, and in our academic institutions have not always honored, the communities that we serve. And it doesn't represent the communities that we serve. 

Now that we have a more diverse training body, we have to reflect and ask if these definitions still represent these values and virtues still honor all of our, our trainees and our communities. And that's where we are as a, a profession. 

Kate Mulligan: And what about professional identity formation then? 

Audrea Burns: And so, in switching to then thinking about professional identity formation, Cruz defines this as a representation of self it's achieved in stages over time, during which these characteristics, these values, these virtues and, and norms of the medical profession become internalized. 

And this internalization process is really a journey and oftentimes we have blended the definition of identity formation with work from sociologist Robert Martin. And, and he notes that this journey of forming professional identity, particularly in reflecting on work with medical school students, that it shapes the novice into an effective practitioner of medicine. 

And so professional identity formation is really a transformative process, and it's that continual integration of the knowledge, skills, and values into one identity, and we're on that journey. I think that's why Kate, even as basic scientists, we have met in this space, in this journey of, of what it means to be a health professions educator. 

Kate Mulligan: Thanks Audrea, could we nail down a little bit the relationship between professionalism and professional identity? I, I'm struggling a little bit with. 

Audrea Burns: Absolutely, that's a great question because they are distinct professionalism is not professional identity formation but professional identity formation or, PIF as we like to abbreviate, it really represents this journey of integrating the values of professionalism into one's identity. And hence, as you know, we talked a little bit about in the previous question, that's why it's, it's the lifetime journey. 

Interestingly and recent qualitative studies within health professions education, really is starting to unpack how professionalism is learned amongst trainees and acknowledges the longitudinal nature that this experience occurs amongst our trainees. And so it's the myriad of experiences, both not only in the classroom through kind of didactic PowerPoints of what to do on what not to do,what's considered misconduct, what's considered appropriate. 

But it's through dialogical interactions and engagement between us as facilitators, faculty, facilitators, and, and trainees that allows for us unpack these experiences while we're practicing, while we're becoming, and it's through, having that psychologically safe environment and those discussions in which students are able to really have those epiphanies, those aha moments of how they can incorporate those virtues into their professional identity. 

Kate Mulligan: In your recent grand rounds talk at UW there were themes of connection and wellness that came through strongly to me as factors that are helpful in, striving to encourage professionalism in our learners, and helping them develop, an appropriate professional identity. 

Would you like to comment on these and other factors that you think help us, help our students to become the professionals that we want them to be?  

Audrea Burns: Great question. You know, Kate, I, I really want to just honor very strong work from a number of educators in spaces such as, understanding burnout and wellbeing and, mental health and connections such as Shane, uh, tan Felt, and others that have really shed light on our, our current crisis in health professions education. And that's around, this term of, of disconnection and you and I have talked about in other spaces, you know, the pandemic has really turned everything that we do upside down. But it's also shed light on some preexisting challenges around supporting the wellbeing and mental health of our, our trainees. 

And so, these elements of mental health and wellbeing directly relate to professionalism because studies have shown that both undergraduate and graduate medical trainees have increased lapses in professionalism, which we know put patient safety at risk, that's documented when they feel burnout and when their mental health is not supported. 

And now there are, validated instruments and data showing our resident trainees are feeling burnout, that they're feeling disconnected, that there are increased challenges with suicidality and depression and a lack of professional fulfillment. And so by fostering a culture, a positive culture and a sense of belonging in our learning environments and by fostering connection even through intentional and evidence informed initiatives, we're able to start to positively foster the formation of professional identity and professionalism that's rooted back in values that align with our health system, our academic institutions and society. 

It just becomes a, a win-win for everyone. And so developing one's professional identity, again and I'll say over and over again, it's really lifelong. And, and the reason why I keep bringing that up, Kate, because oftentimes once we start to get down into how this maps back to our curriculum, we think in a very reductionist approach. 

And I'm very guilty of that. You know, uh, can we fit this into a one hour session, or one elective, or one outpatient rotation. But it's that, it's the journey and ultimately our initiatives around fostering the wellbeing of our trainees have to continue beyond just the trainees, but also for the faculty as well. 

Kate Mulligan: Thanks for that Audrea. I really feel like this is an opportunity to reclaim humanity in our learning environments and in our patient care environments. And I'm, that's one, maybe one positive thing that comes out of the pandemic if we pay attention enough. I'm guessing that you have some other tips for us on best practices for helping develop professionalism in our students beyond, increasing wellness and connection among us all. 

Audrea Burns: Excellent question, I think I should just provide a disclaimer that I, I feel as though I won't do this service because we could really stay in this space for a really long time. 

But just very briefly, we know that from fred Ty's longstanding work to highlight that the predominant standards for professionalism does not come from our didactic teaching. It, it doesn't come from what we tell our trainees what they should and shouldn't do, but it, it comes from the culture that the trainees experience. 

In concert with those teachings. And so, it's very important for us to acknowledge the hidden curriculum that exists at our individual institutions. And we know from studies that we're doing at our institution and those published since the hidden curriculum was defined back in, the seventies, I believe that the hidden curriculum consists of entrenched norms of hierarchy, of, of power, privileged structures, of discrimination, of all sorts and unhealthy, norms of communication. 

And so it's critical that we center teaching and professionalism to be focused in all of the best practices around medical humanities. That it's longitudinal, that it's, uh, that it's narrative oriented. That it's, that it involves storytelling, that it's case based. It, it centers these discussions as I I previously mentioned in domains that tackle. 

These entrenched norms in our hidden curriculum, and that it's most importantly relevant to one's learning milu. And so those social norms are different. They're geographically di different, we have pervasive issues at our institution that may not be as relevant at yours. And so we have to really create content that's very specific and that's what our, our trainees tell us. 

And that it's also important for faculty to role model that behavior. But that being said, it's hard for faculty to be well, if we don't also, Nurture faculty development initiatives that allow for supporting and fostering a positive culture for our faculty. And so when our faculty are well, and they role model, then, then they can help to be the mentors and the educators that foster and promote these values that are needed to develop, a positive professional identity. 

Kate Mulligan: I'm so glad you brought that up. I mean, I think faculty need as much nurturing as we can possibly give them so that they can go out and be the best teachers that they can be. In the same way that you need doctors to take care of themselves and to be taken care of so that they can give their best to their patients too. So thank you for reminding us about that. 

On another note, maybe you could, help us recognize what the most serious threats or challenges to cultivating professionalism might be. I think we've, we could extract it from what you said, but it's nice to hear you just state, state them out loud for us. 

Audrea Burns: Thanks, Kate. That's a, that's a wonderful question. One of the biggest threats that we have is a lack of intentionality in developing our curriculum. We have historical pieces that have of our curriculum and, and professionalism has been one that, the definitions and our standards have not allowed for frameworks of inclusivity that does not incorporate, the perspectives and the challenges faced by, our current student body, which includes women, which includes those of diverse backgrounds. That includes perspectives from underrepresented and medicine, trainees of diverse, intersectional identities, religion of gender, and, even diverse thought. And so as we are thinking about how to promote spaces that fosters the development and support of all of our trainees, those of differing abilities, we have to ensure that our professionalism curriculum fosters, the work that has been honored in the literature of hearing those voices and allowing the community's voices to be heard from and that really speaks to work in medical humanities. And so as we have intentionality of integrating the medical humanities, we could start and be open to lifelong learning in the development of our curriculum. Then we will, allow for the fostering of positive mental health and belonging for everyone. 

Kate Mulligan: I'm glad that you brought that up too because it feels like it's hard to be intentional if we don't recognize the importance of something. And that's part of the reason for wanting to have you come talk to us on CLIMEcasts, is to bring the issue of professionalism up to a, a broader audience than maybe just a clinicians, at the other end of the building, so thank you for that. 

Audrea Burns: It's such a pleasure. And, and thank you.  

Kate Mulligan: So you've done some interesting research in identity-based discrimination and how that affects professional identity formation, especially in trainees from marginalized groups. Could you give us a little synopsis of those research findings and address how we can use the research findings to inform our approaches to our trainees? 

And just for our audience, we do have the grand rounds, recording on the website and we'll put a link to that in the show notes. But maybe just a brief synopsis here would be helpful. 

Audrea Burns: Thanks Kate. Absolutely. Yeah, we're looking forward to publishing these results soon, but happy to, to share early findings. We really wanted to think more deeply about how professionalism is learned and why lapses in professional behavior occur and, and really start to unpack that with hearing the perspectives through a qualitative research study. 

So we performed a focus group with resident trainees, but then also with fellows and senior clinical educators, from almost every region of the country, so that we could start to, to also hear from those who had already went through this professionalization process and could look back and reflect on their own aha moments. 

And so, we conducted, these focus groups over the period of one summer and, um, identified very similar to published literature that our students had very highly nuanced definitions of what it meant to be a professional. I would argue sometimes more than the, the faculty members. And they had understood it in, in very thoughtful ways, even, you know, really thinking about the metacognitive processes that are involved and ones evolving professional identity, but, you know, they, they really highlighted our hidden curriculum is serving as a strong barrier to the continual integration and development of their professional identity and specifically, highlighting and unpacking some very painful, examples of experiencing microaggressions and racism and sexism and classism, not only amongst themselves, with members of the interprofessional healthcare team, but also, their feeling of powerlessness and the mental stress when they saw this being enacted towards patients. 

And so, you know, we realized that our data started to point to some really strong themes about this discrepancy between professional behaviors that are expected and then what's commonly witnessed and even tolerated. They point it to what happens when the doors are closed. 

And we're not there sometimes as faculty educators to witness these behaviors. But then also they highlighted some of these complex challenges in professionalism. Both at an individual, but also as a systems level and these stressors are, are highly contextual to different types of clinical learning environments, and so that even though they found this to be a very significant challenge during their training, they highlighted that even having the opportunity in the focus group to continually reflect on both exemplar and lapses in professional behavior allow for their refinement of forming their identity and that they wanted additional opportunities for having discussions, that included all members of the clinical learning environment, all members of the interprofessional teams to come together and talk about those in a safe space so that they could see what are some of those miscommunications and disagreements and allow for fostering a healthier culture. 

Kate Mulligan: In fact, your point about connection, right? If we, if we had strong connections between all the members of the teams, maybe we wouldn't have to formally organize focus groups, et cetera. But thank you for that, it sounds like very complicated and heavy work to do. I'm really grateful that you're wading in there and doing that, cause that that's a lot of emotional depth to deal with and, I'm glad that the student focus group attendees and your research subjects find value in being in the research too, which is that that must have a good feeling for you must present a good feeling for you.  

Absolutely. So going back, you mentioned a little bit about microaggressions that some of your trainees had talked about. 

 Should we just back up a little bit and have you give us a definition of microaggressions from your perspective and how they play into professionalism or trying to develop a professional identity? 

Audrea Burns: Thanks, yes, Kate. You know, it's, it's interesting because microaggressions is a worth that we're hearing a lot about, but oftentimes is not formally defined. 

So happy to provide a, definition. So the literature defines microaggressions as these brief and commonplace daily verbal behavioral or environmental indignities, whether intentional or unintentional that communicate hostile, derogatory, or negative slights and insults towards marginalized groups. 

And one beautifully kind of noted quote is that it's, it's almost like death by 1000 paper cuts. Mm-hmm. , and I know in speaking to women in leadership mentorship groups, you know, lots of women talk about historically through their careers, of experiencing these, these paper cuts that really start to take their, their pull on, on one professionally and even personally. 

And so microaggressions are subtle. Oftentimes they're unreported or, and or underreported by trainees, but they start to inhibit and really attack one's personal and, and professional morale and starts to develop a negative identity. And there's quite a bit of work that talks about how it can reinforce stigmatized identities as well. 

And so it's important as a community that we highlight and address, microaggressions that are commonplace in clinical learning environments and also provide students safe ways to report that behavior so that they can continue to thrive and that we don't foster a negative identity. 

And, and interesting. I'm actually conducting another, national study with another group that's looking at the relationship between microaggressions and other forms of discrimination to the development of professional identity and underrepresented in medicine trainees. And we have data and, um, surveying hundreds of trainees nationally that increased experiences of discrimination with microaggressions being one of that leads to a feeling of less fulfillment and an even a desire to want to stay in academia. And so it's so important to address these types of behaviors.  

Kate Mulligan: Wow. We'll have to have you back for another grand round soon, I guess, I think you have some tips for us on how to maybe incorporate allyship with our learners, especially those from marginalized populations to help counter the effect of microaggressions. 

Audrea Burns: Sure, thank you allyship has been a tool that many of us can use and especially those that have spaces and, and places of power and privilege to support, trainees and even faculty of marginalized identities and backgrounds. And I love, thinking about little mnemonics to help me and, and others to remember how one can serve as an ally. 

And so one that has been reported in the literature, uses ally itself. So the A stands for Always center. The impacted L is listen and learn from those who live in oppression. The other L is for leverage, your privilege and Y is yields the floor. And then there's another, it's not a mnemonic, but it's kind of a six step, quick tip guide that was published by, uh, a dear colleague and mentor, Dr. Jamie Buari, who is a visiting professor at Marick University and, and practices as a health professions education leader and clinician in Aruba. And he highlighted in a recent manuscript these kind of six steps to serve as an ally. And one is being so creating safe spaces for those that are less privileged. 

And two is knowing. So that it's important for us to continue that lifelong journey of understanding microaggressions and other forms of identity-based discrimination. Three is feeling to just acknowledge your feelings towards experiences in which one witnesses microaggressions or have experienced that. Four is doing. So it's extending those feelings to action of not only recognizing, but also addressing the microaggression. Then five is promoting. So how can we continue to promote diversity in our spheres of influence? And six is acting. So how can we continue to dismantle racist structures in medicine?  

Kate Mulligan: Great. Thank you. So being, knowing, feeling. Doing, promoting and acting. That's great. I, I, I think I'll probably be able to remember the four things for the Ally, Mnemonic, more easily than six, but I'm sure there are some younger listeners out there who will cope with everything. 

Thanks, Andrea, this is something that didn't come up in your grand rounds topic, but I know a lot of faculty especially are really feeling at sea with the idea of professionalism as it applies to social media and the use of social media in learning and patient care. 

I'm wondering if you have any tips for us on that. It really feels like an un uncharted sort of territory. 

Audrea Burns: Absolutely and thank you, Kate, because I think this is such a relevant topic as it's one that we see in the news almost on a weekly basis with political leaders and other leaders in our society. 

And we have institutional policies that are continuously evolving around social media, but you know, in the context of professionalism, I was listening to a recent grand rounds at our institution from our director of our Center for Professionalism Dr. Ellen Friedman, and, she spent quite a bit of time talking about social media and I wanted to share some tips from her as I thought that they were so relevant. 

And it was briefly summarized in remembering that you should only share what you would like people to have access to for an entire lifetime. I think oftentimes because so many apps feels very transient and quick to use and easy to use that it feels temporary in what we could see. But that that content has a lifetime that can be potentially infinite and so in thinking about our role both with our dual dually integrated personal and professional identity within our academic institution and our health system, what information do we want to share that will be accessible for a lifetime? And does that represent the values that we hold true and that our institution holds true as we have a, a professional role within that institution. And I think that that's a really good guidepost, uh, for me. And I, and I like to share with our trainees here. 

Kate Mulligan: Yes. It seems like I'm just thinking about this now, it seems like slowing down your responses in the social media sphere might be a good idea too. I, I mean, email is almost a thing of the past, but the idea that if you write a reactive email, you let it sit before you send the or before you consider looking at it again and sending it for exactly what the reasons that you've been saying that, do you want this to be around forever? 

Because it's an indelible sort of artifact. So I think that's probably a good thing too. Yeah. Thank you.  

Audrea Burns: Oh, that's really beautiful. Yeah. And no, that's, that's so beautiful, Kate, because you know, we now know that there are social media platforms that. Can promote academic scholarships such as mm-hmm. uh, Twitter, for example. Mm-hmm. . And in thinking about what we want to post and if we want to use it to support our professional work, how can we just double check with a, a mentor or a colleague to ensure that it represents and upholds the values and, you know, how can we do the least harm, right? 

Kate Mulligan: This, this might not be the question that we wanna talk about in a limited time. I think we could probably do a whole other podcast on it, but I feel like I've seen professionalism almost weaponized on occasion when faculty don't agree with student ways of addressing issues or policies that they don't like, would you like to share your ideas on how we can make sure that we don't unintentionally or unintentionally weaponize professionalism in the learning environment? 

Audrea Burns: That's a, it's a really important and relevant question as especially since the death of Mr. George Floyd, in which, his death really allowed for a global outcry against injustice and oppression and oppressive practices. And so we have been, as a health profession's education community, really critically thinking about the practices that we have in place to ensure that we are, um, adhering and upholding the values of our institution. 

And, and also meeting accreditation standards to foster the development of professional trainees that are able to enact and uphold that, that professional contract with society. You know, but one thing that we're starting to really take a look at very closely within the professionalism community is what are these historical structures that have been used to really underpin our definitions and our understanding of what it means to be a professional, a medical professional. And those definitions were based in historically exclusionary and racist practices that excluded women and underrepresented in medicine groups. And so that has led to the continual exclusion and oppression and really harmful, effects of developing kind of stigmatized identities for large groups of our trainees for women, for, for those that have all sorts of marginalized intersectional identities, whether that is gender minorities or those of racialized minorities of religious minorities. 

And so now it's so important for us to first as faculty to commit to continuing our professional development in the spaces of understanding our own biases, both implicit and conscious, to recognize those biases, to check those biases and to work with others to commit to looking at our curriculum within professionalism and ensure that we are not, Creating and development curriculum and assessments that allow for the continual discrimination and exclusion of many of our trainees and students. 

And so historically, professionalism has been used as a very vicious weapon within the health profession's education continuum. But now many leaders, both nationally and internationally, are rapidly conducting studies and making rapid cycle improvements to their curriculum to, eliminate and ameliorate these negative impacts. One case study is Steven Rosensweig at Dr. Drexel University, who has a beautiful curriculum and, and, uh, professionalism along with many others, and so very excited to be in this space of rethinking and going back to the drawing board to improve what we've been been teaching and how we've been supporting our learners. 

Kate Mulligan: Thanks, Audrea. Thank you for being brave enough to address some of those points with me. I really appreciate you doing that.  

Audrea Burns: I'm just honored to have the opportunity to talk about a few of my spaces of passion and, hope to continue to dialogue with, with many of you in the Climecast community around, issues and topics in medical education and particularly those in professionalism. 

Kate Mulligan: thank you so much Dr. Burns for joining us today for spending time discussing this really important topic of professionalism and professional identity development. 

I'm so glad that we had a chance to surface and center this topic because it's just so important and it feels like it links to so many of the initiatives that we're undertaking here at UW and I'm sure broadly, more broadly throughout the medical education environment. I did wanna remind our listeners that we've got show notes and a link to your wonderful recording of the Grand Rounds presentation, and we'll have some extra resources for people who'd like to take a deeper dive. 

Audrea Burns: It has been a pleasure. Thank you so much and looking forward to continuing to engage with the UW. 

Amanda Garza: Thank you to Dr. Burns for taking the time to talk to us about cultivating professional identity and medical education.  Don't forget to subscribe the CLIMEcasts on the streaming app of your choice to get updated when new episodes are released. Thanks!