Number of Citations: 1

Submitted: 4 May 2021
Accepted: 22 July 2021
Published online: 4 January, TAPS 2022, 7(1), 106-108
https://doi.org/10.29060/TAPS.2022-7-1/PV2532

Shamalee Wasana Jayarathne¹ & Lambert Schuwirth²

¹Medical Education Unit, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Sri Lanka; ²Prideaux Centre for Research in Health Professions Education, Flinders University, Australia

Medical Professional Identity Formation (PIF) has been suggested as a fundamental outcome in medical education (Cruess et al., 2014). Medical professional identity is development of both personal and professional identity as a physician. PIF achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalised, resulting in individual thinking, acting, and feeling like a physician (Cruess et al., 2014).  It is basically not a process of learning to demonstrate professional behaviour but of change into a “professional being” or professional physician. Throughout the journey of PIF, moments of dissonance between personal values and professional values are likely to occur. So logically, there will be phases of learning and unlearning. Learning is generally well-defined, but unlearning has been conceptualised through different lenses both on the process of unlearning and the unlearnt content, leading to conflicting views.

Unlearning has been conceptualised through different lenses. Hislop et al. (2014) have described unlearning as “abandoning or giving up knowledge or behaviours without making any judgement on the status of the knowledge or behaviours being unlearned”. In addition, Macdonald (2002) has explained unlearning in terms of transformative unlearning, which is as a process of questioning, reflecting and giving up some core values, assumptions, knowledge and practices. On the other hand, some authors have given subjective value to unlearnt knowledge and practices. Srithika and Bhattacharyya (2009) have defined unlearning as a process that includes judging the knowledge, values or practices with current knowledge. If current knowledge is superior to previous knowledge, individuals do unlearn previous knowledge. In this background, we hypothesise unlearning to be a meta-cognitive process and not as a permanent loss of something. Instead, we recognise it as a person consciously discarding, abandoning, or giving up particular values, knowledge, or behaviour and consciously choosing not to continue using them; a meta-cognitive process.

Several authors have categorised unlearning in various ways, which leads to sometimes conflicting views on the characteristics of the process of unlearning. Rushmer and Davies (2004) have categorised unlearning into three categories namely, ‘fading’, ‘wiping’ and ‘deep unlearning’. Fading occurs due to lack of use and it occurs over time. Wiping is deliberate process, occurs due to external change or due to an experience. Wiping is a process in which unlearning of behaviours and complex social learning (beliefs, values, attitudes, assumptions, and interpersonal skills) happens. Deep unlearning was defined as a “sudden, unexpected, and potentially painful event that ruptures part of our way of being or deeply held understanding of the world” (Rushmer & Davies, 2004). They further explained that deep unlearning occurs in an unpredictable, disruptive way and it is less planned and less deliberate. It trigged by a sudden action or an event (Rushmer & Davies, 2004). Although, transformative unlearning is defined similar to the concept of deep unlearning, the characteristics of the process of unlearning are rather conflicting in deep unlearning and transformative unlearning. Transformative unlearning is conceptualised as a process of reflecting upon, questioning and giving up some values, assumptions and practices (Macdonald, 2002). This transformative unlearning process has three phases which are “receptiveness, recognition and grieving”. Hence, during this process a “person loses prior ways of seeing [which] until now had brought certainty and security”.  However, this is a slow process.

There is a scarcity of empirical studies found in relation to individual unlearning process. One study in the UK explored health care managers’ engagement in unlearning and the impact of unlearning in decision making (Coombs et al., 2013). Authors distinguished two types of unlearning based on these health care managers’ experiences: “behavioural unlearning” and “cognitive unlearning”.  Behavioural unlearning has similarities with wiping, whereas cognitive unlearning has similarities with deep unlearning. Behavioural unlearning is triggered by a deliberate process of change that had been externally imposed, while deep unlearning is triggered by questioning individuals’ basic assumptions due to an external event. Hence, the descriptions on characteristics of process of unlearning is conflicting in deep unlearning, transformative unlearning and cognitive unlearning and it is worth further exploration.

It is important to recognise the similarities and differences between to forgetting and unlearning. Some researchers tend to use unlearning and forgetting interchangeably (Rushmer & Davies, 2004). According to Rushmer and Davies (2004) fading occurs due to lack of use and it occurs over time. This is not an intentional action and it equals to forgetting. However, they have conceptualised fading under the concept of unlearning, which is questionable.  Equally, several authors observed the contrasting nature of unlearning and forgetting. They distinguish the deliberate, conscious nature of unlearning (Coombs et al., 2013) from unintentional nature of forgetting. Our stance is that forgetting as loss of knowledge not necessarily planned or intended, which is distinct from unlearning.

Although there is conflicting conceptual literature, the concept of unlearning is worthwhile to explore; especially the different conceptual models of ‘transformative unlearning’ (Macdonald, 2002) ‘deep unlearning’ (Rushmer & Davies, 2004) and cognitive unlearning (Coombs et al., 2013) in relation to PIF in physicians. Unlearning is important in PIF process, because an inability to give up values, norms, practices when they no longer match the demand of one’s current perspectives inevitably leads to rigidity in thinking and lack of flexibility. It is plausible that individuals who enter into the career of medicine have their own personal values and assumptions or specific world views. But professional values of medicine are often a set of values defined by society and public. It is proven that, professional attributes are contextually depended. Physicians need to keep to these professional values based on the context in which they work. During the journey of PIF moments of dissonance between personal values and professional values are likely to occur. These can be struggling points for both medical students and physicians while they unlearn their worldviews and replace them by new or adapted ones. Also, there are still many unclear areas concerning PIF and unlearning. For instance, can individuals unlearn deep values and assumptions? would that process really entail deep unlearning or merely wiping? Why is this unlearning cognitively and emotionally challenging for some individuals?  Exactly how does unlearning of deep values and assumptions of individuals occur during PIF of physicians is currently under-researched. Thus, understanding the process of professional identity formation in the light of unlearning of deep values and assumptions of individuals is important in medical education to support journey of PIF of physicians and medical students.

Notes on Contributors

YGSW Jayarathne, MBBS, PG Dip in MEd, MD in MEd is a Senior Lecturer in Medical Education and was involved the conceptual development, argument building, ethics application and the development of the manuscript.  

Lambert Schuwirth, MBBS, MD, PhD, FANZHPE is a Professor of Medical Education and Director Prideaux Centre for Research in Health Professions Education, College of Medicine and Public Health, Flinders University and was involved the conceptual development, argument building and the development of the manuscript.

Acknowledgement

No acknowledgement is associated with this paper.

Funding

No funding sources are associated with this paper.

Declaration of Interest

There are no conflicts of interests related to the content presented in the paper.

References

Coombs, C. R., Hislop, D., Holland, J., Bosley, S. L. C., & Manful, E. (2013). Exploring types of individual unlearning by local health-care managers: An original empirical approach. Health Services and Delivery Research, 1(2), 1–146.

Cruess, R. L., Cruess, S. R., Boudreau, J. D., Snell, L., & Steinert, Y. (2014). Reframing medical education to support professional identity formation. Academic Medicine, 89(11), 1446-1451. https://doi.org/10.1097/ACM.0000000000000427

Hislop, D., Bosley, S., Coombs, C. R., & Holland, J. (2014). The process of individual unlearning: A neglected topic in an under-researched field. Management Learning, 45(5), 540-560. https://doi.org/10.1177/1350507613486423

Macdonald, G. (2002). Transformative unlearning: Safety, discernment and communities of learning. Nursing Inquiry, 9(3), 170-178. https://doi.org/10.1046/j.1440-1800.2002.00150.x

Rushmer, R., & Davies, H. T. (2004). Unlearning in health care. BMJ Quality and Safety, 13(Suppl 2), 10-15. https://doi.org/10.1136/qshc.2003.009506

Srithika, T. M., & Bhattacharyya, S. (2009). Facilitating organizational unlearning using appreciative inquiry as an intervention. Vikalpa, 34(4), 67-78. https://doi.org/10.1177/0256090920090406

*YG Shamalee Wasana Jayarathne
Medical Education Unit,
Faculty of Medicine and Allied Sciences,
Rajarata University of Sri Lanka
Email: wasana@med.rjt.ac.lk, wjayaratna@yahoo.com