Background
Professional identity formation (PIF) as a general practitioner (GP) enhances the experience of meaning at work, reduces burnout, promotes patient-centred decision making and strengthens advocacy for the unique role of family medicine within the healthcare system. Unfortunately, there is insufficient emphasis on PIF in GP residency programs; it often remains a hidden curriculum. External factors limiting GP trainees’ exposure to their own general practice community of practice further impede PIF. Thus, fostering general practice PIF requires deliberate, focused efforts; however, there is little empiric evidence on the GP professional identity or how to foster it.
For the purposes of this article, we will be using the term ‘general practitioner’ (GP) to refer to providers of primary care in the community setting. In other countries, the terms ‘family physician’ or ‘primary care practitioners’ are also used. Similarly, the terms ‘trainee’ and ‘training program’ used in this article are synonymous with the terms ‘resident’ or ‘registrar’ and ‘residency program’, respectively.
Professional identity is the unique set of values, beliefs, attitudes and behaviours that define and distinguish a professional group.1 What constitutes the general practitioner (GP) professional identity is well described – GPs value and pursue the provision of personal, primary, preventive, comprehensive, continuing and coordinated healthcare of the individual in relation to their family, community and environment.2,3 Howefver, there is a lack of focus on GP professional identity formation (PIF),4,5 described as the dynamic process of personal development and social construction in which these core values, beliefs, attitudes and behavioural norms of general practice are internalised, such that one thinks, acts and feels like a GP.6,7
PIF increases one’s experience of meaning at work, through strengthening one’s sense of coherence, purpose and significance.8 It is through this that strong PIF is associated with positive outcomes, such as an improved sense of wellbeing,8 increased job satisfaction and reduced burnout.9 Strong PIF is also linked to lower turnover intention (the intention to quit one’s profession).10–12 PIF could be an important ingredient for communities struggling with retention of talent, such as the rural generalist community.13,14 PIF is also postulated to enhance patient-centred care by enabling nuance in decision making within the complexities of social interactions and patients’ relationships with their families.15,16 Finally, GPs with a well-developed professional identity can also better collaborate with other healthcare providers and advocate for the unique role and value of primary care within the healthcare system, thereby promoting the advance of the entire speciality.17
PIF and its significance is not new to the GP community, with calls to strengthen PIF as early as 2014.18 But why has there been so little change almost 10 years on?4 One reason is that PIF often remains a hidden curriculum.19 Although many GP training programs worldwide emphasise professionalism and ethical behaviour in their curricula,20–23 GP PIF is alluded to at best.4 The extent to which GP trainees experience PIF can vary depending on the favourability of existing program structures, the degree of opportunistic role modelling by clinical supervisors, and personal reflection on their professional practice.
Additionally, several external factors act as barriers to a GP trainee’s PIF. Time constraints arising from high workload and long hours4 can limit opportunities for reflective practice and self-reflection. Limited exposure to the GP community of practice, especially in the early or pre-vocational years of training, might impede the socialisation process that is the key driver of PIF.6 Fragmented patient encounters that result from frequent rotations might also limit trainees’ experience of long-term patient relationships and continuity of care, which is one of the cornerstones of general practice. During required hospital-based rotations, GP trainees can also experience cognitive dissonance between the working priorities of the hosting hospital department and what is relevant to learn for general practice. The culture within many healthcare institutions that prioritises the depth of specialist knowledge and skills training and research, over the personal, primary, preventive, comprehensive, continuing and coordinated healthcare values of general practice24 further impedes GP PIF.
Thus, GP PIF is challenging and unlikely to develop without deliberate efforts to foster it. Curricular enhancements aimed at fostering PIF have been informed by social learning theories.6 Such enhancements include reflective practice,25,26 narrative medicine,27,28 peer-assisted learning,29,30 simulation,31,32 role modelling,33–35 involvement in professional communities of practice,36–38 longitudinal integrated clerkships39 and professional development programs.40–42
Much of the literature on PIF has been focused on medical students and young doctors forming the professional identity of being a compassionate and competent physician.43–47 Little has been published on GP professional identity5,48 and how to foster its formation.18,34 Role modelling has traditionally been used to imbue GP trainees with beliefs, values and principles, through mentoring, supervision, coaching, tutoring and advising.34 Innovative efforts include Nothnagle’s ‘Forum’ intervention,18 in the form of scheduled individual and group discussions, as opportunities for guided reflection on PIF.
Recognising that developing the professional identity of a GP is a process of socialisation, we use the framework described by Creuss et al6 and propose being explicit about PIF in three key areas.
Curriculum: Creating space and time for PIF in curriculum
Prevocational training
To fully reflect the health needs of a population, prevocational training should occur in a range of settings, including hospitals in metropolitan, regional and rural communities, general practices and other community-based health services.
For example, in Australia and New Zealand’s prevocational training program,49 postgraduate year 2 doctors complete a longer 24-week ‘blended’ term in a rural setting that combines general practice, ward-based and emergency department experience. Different days of the week are spent in different settings with different supervisors, or some weeks are spent in one setting before switching to another. Incorporating opportunities for exposure to general practices and the GP community of practice allows potential GP trainees to begin developing GP PIF even before they enter GP training.
GP training
GP training programs should be structured to allow GP trainees to remain connected to the GP community of practice and the work of general practice, as well as adequate opportunity to reflect on and discuss GP PIF.
For example:
- Weekly general practice clinics in a ‘home’ clinic throughout the entire GP training period, where trainees see patients under the tutelage of dedicated GP supervisors; akin to a longitudinal integrated clerkship. Doing the work of a GP socialises the GP trainee into the GP community, and helps trainees shift from doing as a GP to thinking, acting and feeling like a GP (ie becoming a GP).5 Starting this process early is especially helpful for residents in GP training programs that front-load hospital-based postings in the first one to two years of GP training, such as in Singapore and the United States.20,23 Having a ‘home’ clinic throughout the entire GP training period allows GP trainees to build relationships with patients and provide continuing care. Having a dedicated GP supervisor creates room for mentorship and role modelling to take place.
- Designated learning activities focused on PIF; this can take the form of guided reflection opportunities by GP supervisors for their GP trainees to make meaning of challenging or conflicting experiences during training.43
Teaching and learning: Developing a language for professional identity
Much like naming and acknowledging emotions in difficult conversations, there is power in inviting the GP trainee to mentally place themselves in the role of a GP and explicitly commit to what they would do for their patients. There is also power in verbal affirmation50 when GP trainees have demonstrated the values, beliefs, attitudes or behaviours of a GP. For example:
- When GP supervisors discuss patients that GP trainees encountered in the hospital, we might ask ‘If this patient were to have presented to you in primary care, how would you have managed him/her?’
- When discussing patients that GP trainees see in primary care, we might ask ‘What do you think your role as a GP is in this consultation, at this point in the patient’s care?’
- When a GP trainee has compassionately and effectively addressed a patient’s specific concerns, we might say ‘That was a therapeutic encounter for the patient, and you have done well to provide personalised care and advice.’
Faculty development: Emphasis on intentionality
Although programs or interventions are helpful for facilitating the development of GP PIF, they will lack effectiveness if GP supervisors are not intentional about or not equipped with the knowledge and skills to guide conversations around GP PIF. Rather than hyper-focus or over-rely on programmatic interventions, GP training programs should consider prioritising faculty development for PIF.7,37 Using the cognitive apprenticeship model, faculty members should intentionally seize learning moments to role model, coach and explicitly articulate GP professional identity values, beliefs, attitudes and behaviours during structured teaching and observed clinical encounters.51 GP supervisors should also be adept in facilitating GP trainees’ reflections and explorations of their GP professional identities.
Amidst rising concerns of physician burnout and waning job satisfaction, GP PIF is an important factor in sustaining physician wellbeing, upholding patient-centred care and in the growth of the GP community of practice – all of which are in line with the focus areas of the Australia and New Zealand Medical Deans Strategic Plan.52 More can to be done to intentionally and explicitly develop GP values, beliefs, attitudes and behaviours through programmatic interventions, reducing barriers, as well as faculty development. Tools for measuring GP PIF need to be developed,53,54 in order to evaluate outcomes of interventions and direct future efforts. The transformative journey of PIF does not end with medical schools, but should continue into GP training programs and beyond. Let GPs unite as a community to provide continuing and coordinated support for GP trainees on their GP PIF journey.
Key points
- GP professional identity formation (PIF) is important for the GP community of practice to grow. It protects against burnout, enhances patient-centred care and enables better advocacy for the value of general practice within the healthcare system.
- GP PIF is challenging in GP training and is less likely to develop without deliberate efforts to foster it.
- Strategies for overcoming the barriers to GP PIF include:
- creating space and time for GP PIF within the training curriculum
- developing a language for professional identity
- developing faculty to be intentional and equipped to facilitate reflective conversations around GP PIF.
- Tools for measuring GP PIF need to be developed in order to evaluate outcomes of interventions and direct future efforts.
- Let GPs unite as a community to provide continuing and coordinated support for GP trainees on their GP PIF journey.