Number of Citations: 0

Submitted: 31 January 2024
Accepted: 22 July 2024
Published online: 1 October, TAPS 2024, 9(4), 68-70
https://doi.org/10.29060/TAPS.2024-9-4/PV3238

Ardi Findyartini^1,2 & Azis Muhammad Putera²

¹Department of Medical Education, Faculty of Medicine, Universitas Indonesia, Indonesia; ²Medical Education Center, Indonesian Medical Education and Research Institute, Faculty of Medicine, Universitas Indonesia, Indonesia

I. ON PROFESSIONAL IDENTITY FORMATION

Professionalism in medicine can be considered as attributes, behaviours, and identity of the professionals who put the needs of their patients and the community they serve above their individual needs. The concept of professionalism is dynamic and might be perceived differently over time, in different contexts, and by different fields, although some ground values like excellence, competence, and altruism might persist. 

Identity formation is an inseparable part of professionalism as it underlines the importance of “being” in addition to the essence of “behaving”. Professional identity formation (PIF) in medical education is both an active psychological process conducted by individuals in internalising their values and others’ expectations. It is also a dynamic socialisation process allowing an individual to be part of the professional community with increasing roles and recognitions. This applies for both medical students who grow to become medical professionals and for medical teachers who probably juggle their different identities as clinicians/researchers to be able to enact their roles as teachers (Cruess et al., 2014).

There is no “one-size-fits-all” rule as to how their PIF should be navigated, as PIF is a journey unique to each individual. The students need to be supported to form their identity from the stage where they just follow the rules to become individuals who can internalise values and expectations from their professional community as an integral part of themselves. The medical teachers, on the other hand, still have to develop their professional identities as teachers and educators in addition to their other identities.

II. CULTURE: WHY DOES IT MATTER?

Given the importance of individual and socialisation processes in PIF, we suggest that it is time for us to consider the influence of cultural factors in students’ and teachers’ PIF. It has been well-established that culture plays a pivotal role in how education is designed, developed, and delivered systematically. However, the frameworks by which medical curricula and faculty development programs are developed, as well as literature informing the commonly understood concepts of PIF, often stem from Western countries. Recent understanding of culture, professionalism, and PIF acknowledges that professionalism is context-specific, with notable differences between norms adopted by the contemporary Western world and in non-Western settings (Al-Rumayyan et al., 2017). Herewith, we use Hofstede’s cultural framework to discuss this matter, where countries are characterised by spectrums of hierarchy, collectivism, uncertainty avoidance, long vs short term orientation, femininity vs masculinity, and self-indulgence and restraint (Hofstede, 2001).

For instance, our research highlights the importance of culture in the PIF of medical teachers. Four main factors seemed to influence the PIF of medical teachers in our settings: an interplay between internal values and external influences, empowerment of teachers’ roles by early socialisation, experiential workplace learning, and future prospects of their careers as teachers. Looking deeper, we identified several relatively unexplored factors influencing the PIF of our teachers: the importance of divine values and religious beliefs, influence of family, and how their roles are recognised by the society (Wahid et al, 2021).

The influence of religious beliefs and societal recognition on PIF seems to be predominant in Arabic and Islamic countries, something that may not be predominant in Western countries. The strong religious influence built a perception of teaching as an act of good deed and opportunity to enact one’s faith in God, cultivating the motivation to pursue a teaching career. From Hofstede’s framework viewpoint, familial influence plays a critical role in a collectivist society like ours, as proven in our study where the participants’ decision to be medical teachers was strongly influenced by also considering coexisting personal roles in the family (especially evident in female teachers). The existence of a family member acting as a role model and internal decision making in the family also supported the decision to pursue a teaching career (Wahid et al., 2021).

The communality in collectivistic society was also notable, since societal recognition was deemed as a reward to develop oneself professionally, showing a stronger emphasis on social relationship as opposed to the Western counterpart which might put more emphasis on individual values and self-fulfilment. The importance of socialisation was evident as many admitted that early in their teaching careers, they would often shadow their seniors, engage in faculty development programs, and nurture their identity by engaging with students and patients. Interacting with fellow teachers helped them to grow professionally and remind them of their roots, creating a valuable interplay between their internal motivation and external influences. This shows an important implication for faculty development (FD) programs: since FD plays an important societal role in supporting the teachers’ PIF, FD programs should be developed with an emphasis on workplace and social learning (Wahid et al., 2021).

Our study among medical students also emphasises the need to address cultural factors such as high power distance, uncertainty avoidance, and collectivism. Our findings suggest that the role of the learning environment is pertinent. In a hierarchical setting with large power distance like ours, we found that socialisation through the hidden curriculum might result in negative role-modelling, which might hinder students’ professional development. The hierarchical and collectivistic settings also influenced students’ responses to professional dilemmas, causing internal conflicts and confusion as to how they should act later on when misconducts are normalised by their hierarchical environment. Considering the study context, teachers have a great role on students’ PIF through good role modelling and facilitation for students in dealing with ethical and professional dilemmas during their learning process, especially in clinical practice. A practical implication is how our students preferred a more structured approach and clear guidance to develop reflective skills and feedback-seeking behaviour in this setting with high uncertainty avoidance compared with other settings (Findyartini et al., 2022).

Our findings suggest that PIF is indeed a fluid process and socialisation is essential. Many students admitted as they got involved further in their medical education journey and continuously reflected on their experience, they were able to understand the complexity of their PIF more. Many were aware about their psychological journey into becoming a professional and how they continuously internalise the traits expected of a professional. External influences like the hidden curriculum, the learning environment, and the behaviours of their peers seemed to intercalate with their initial motivations through continuous socialisation forms, showing a dynamic psychosocial transition (Findyartini et al., 2022).

III. RETHINKING CULTURE AND PIF: THE IMPLICATIONS

We propose two major ways by which culture influences PIF. First, it dynamically influences the societal expectation of professional traits. This should pose some questions, like what kind of professionals does the community need? How does the community currently, and probably in the near future, perceive what a professional is? By this first understanding of ours, it is then pertinent to continuously reflect and identify the needs of the community in defining the traits of a professional. Thus, simply adopting findings from Western literature might not be beneficial and results must be interpreted contextually, and this should call for further studies on professional identity formation in diverse socio-cultural contexts. We would also like to reiterate that professionalism is a temporal and contextual concept, and this will be continuously reinterpreted and redefined with influence from scientific breakthroughs, industrialisation, and globalisation. 

Second, we think of culture as a subtle yet powerful force saliently affecting the process to reach the intended outcome i.e professional identity, as elaborated before. Culture exerts substantial influence on the development process itself, and this is where culture operating on individual and institutional levels, we argue, plays a critical role. Take, for example, our findings on how our students preferred a more direct, structure-driven, and clear guidance in navigating their professional development, or how our teachers were greatly driven by religious beliefs and familial motivation. The communality informs how curriculum for students and FD programs for teachers could be developed. The concepts of intertwining roles of each unique individual student/teacher and the socialisation process involving the learning environment, role models and relevant experiences play a pivotal role in this matter. Curricula and FD program should be developed around the concept of the target as subjects with their own internal values and preferred ways of thinking and doing influenced by the communities of practice around them. We would like to also underscore that the PIF of students and teachers are very much interrelated and we expect that students’ PIF will be highly facilitated by the teachers whose PIF as educator is well internalised.

To summarise, we would like to reemphasise the role of culture and understanding of cultural diversity in the context of PIF. We urge students, teachers, and educators to look at and understand culture as a subtle force driving the aim and process to be professionals. Since socialisation is central in the identity development of both teachers and students, special attention should be given to first reflect and identify cultural values in different levels, most importantly the institution, to develop culturally-sensitive curriculum and faculty development programs.

Notes on Contributors

Ardi Findyartini (AF) currently serves as a Professor of Medical Education and the Head of Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia. AF led the study, developed the ideas, wrote, and critically revised the manuscript.

Azis Muhammad Putera (AMP) is a researcher at the Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia. AMP developed the ideas, wrote, and critically revised the manuscript.

Acknowledgement

The authors would like to thank all teaching and academic staffs of the Department of Medical Education, Faculty of Medicine, Universitas Indonesia, as well as the researchers, research assistants, research interns, and administrative staffs at the Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia for the great collaboration by which this paper can be produced.

Funding

The authors received no funding for this work.

Declaration of Interest

The authors declare no competing nor conflict of interests.

References

Al-Rumayyan, A., Van Mook, W. N. K. A., Magzoub, M. E., Al-Eraky, M. M., Ferwana, M., Khan, M. A., & Dolmans, D. (2017). Medical professionalism frameworks across non-Western cultures: A narrative overview. Medical Teacher, 39(sup1), S8–S14. https://doi.org/10.1080/0142159X.2016.1254740

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

Findyartini, A., Greviana, N., Felaza, E., Faruqi, M., Zahratul, T. A., & Firdausy, M. A. (2022). Professional identity formation of medical students: A mixed-methods study in a hierarchical and collectivist culture. BMC Medical Education, 22(1), 443. https://doi.org/10.1186/s12909-022-03393-9

Hofstede, G. (2001). Culture’s consequence: Comparing values, behaviors, institutions, and organisations across nations. Sage Publications. https://doi.org/10.1016/S0005-7967(02)00184-5

Wahid, M. H., Findyartini, A., Soemantri, D., Mustika, R., Felaza, E., Steinert, Y., Samarasekera, D. D., Greviana, N., Hidayah, R. N., Khoiriyah, U., & Soeselo, D. A. (2021). Professional identity formation of medical teachers in a non-Western setting. Medical Teacher, 43(8), 868–873. https://doi.org/10.1080/0142159X.2021.1922657

*Ardi Findyartini
Faculty of Medicine,
University of Indonesia
Salemba 6 Central Jakarta 10430
+62 21 3901814
Email: ardi.findyartini@ui.ac.id