{"id":72416,"date":"2024-03-25T11:12:30","date_gmt":"2024-03-25T03:12:30","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/taps\/?post_type=issues&#038;p=72416"},"modified":"2024-07-02T10:15:30","modified_gmt":"2024-07-02T02:15:30","slug":"defining-undergraduate-medical-students-physician-identity-learning-from-indonesian-experience","status":"publish","type":"issues","link":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/defining-undergraduate-medical-students-physician-identity-learning-from-indonesian-experience\/","title":{"rendered":"Defining undergraduate medical students&#8217; physician identity: Learning from Indonesian experience"},"content":{"rendered":"<p>Submitted: 16 July 2023<br \/>\r\nAccepted: 21 December 2023<br \/>\r\nPublished online: 2 April, TAPS 2024, 9(2), 18-27<br \/>\r\n<a href=\"https:\/\/doi.org\/10.29060\/TAPS.2024-9-2\/OA3098\">https:\/\/doi.org\/10.29060\/TAPS.2024-9-2\/OA3098<\/a><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">Natalia Puspadewi<sup><\/sup><\/span><\/p>\r\n<p style=\"text-align: justify;\"><i><span lang=\"EN-GB\">Medical Education Unit, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Indonesia<\/span><\/i><\/p>\r\n<p style=\"text-align: center;\"><b><span lang=\"EN-GB\">Abstract<\/span><\/b><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Introduction:<\/span><\/b><span lang=\"EN-GB\"> <\/span><span lang=\"EN-US\">Developing a professional identity involves understanding what it means to be a professional in a certain sociocultural context. Hence, defining the characteristics and\/or attributes of a professional (ideal) physician is an important step in developing educational strategies that support professional identity formation. To date, there are still limited studies that explore undergraduate medical students\u2019 professional identity. This study aimed to define the characteristics and\/or attributes of an ideal physician from five first-year and three fourth-year undergraduate medical students<\/span><span lang=\"EN-GB\">. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Methods<\/span><\/b><span lang=\"EN-GB\">: <\/span><span lang=\"EN-US\">Qualitative case studies were conducted with eight undergraduate medical students from a private Catholic medical school in Jakarta, Indonesia. The study findings were generated from participants\u2019 in-depth interviews using in vivo coding and thematic analysis. Findings were triangulated with supporting evidence obtained from classroom observations and faculty interviews. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Results:<\/span><\/b><span lang=\"EN-US\"> First-year participants modeled their professional identities based on their memorable prior interactions with one or more physicians. They mainly cited humanistic attributes as a part of their professional identity. Fourth-year participants <\/span><span lang=\"EN-GB\">emphasised<\/span><span lang=\"EN-US\"> clinical competence and excellence as a major part of their professional identities, while maintaining humanistic and social responsibilities as supporting attributes.<\/span><span lang=\"EN-US\"> <\/span><span lang=\"EN-US\">Several characteristics unique to Indonesian\u2019s physician identity were \u2018Pengayom\u2019 and \u2018Jiwa Sosial\u2019. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-US\">Conclusion:<\/span><\/b><span lang=\"EN-US\"> Study participants defined their professional identities based on Indonesian societal perceptions of physicians, prior interactions with healthcare, and interactions with medical educators during formal and informal learning activities.<\/span><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: justify;\"><b><span lang=\"EN-GB\">Keywords<\/span><\/b><b><span lang=\"EN-GB\">:<\/span><\/b><span lang=\"EN-US\">\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <i>Professional Identity Formation, Indonesia Undergraduate Medical Students, Physician Identity<\/i><\/span><b><span lang=\"EN-GB\"><\/span><\/b><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Practice Highlights<\/span><\/strong><\/p>\r\n<ul>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Defining the attributes of ideal physicians is important for developing strategies that support PI.<\/span><span lang=\"EN-GB\"><\/span><\/li>\r\n\t<li style=\"text-align: justify;\"><span lang=\"EN-GB\"> <\/span><span lang=\"EN-GB\">Prior interactions with healthcare and formal\/informal learning activities influence PI definition.<\/span><span lang=\"EN-GB\"><\/span><\/li>\r\n<\/ul>\r\n<div>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">I. <\/span><span lang=\"EN-GB\">INTRODUCTION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Supporting the (trans)formation of a medical student\u2019s identity, from a layperson to a professional, is an important process in preparing future physicians (Cruess et al., 2014; Goldie, 2012; Wald, 2015). This process includes professional identity formation (PIF) throughout their medical education continuum. Professional identity (PI) refers to how someone represents their profession\u2019s characteristics, values, and attributes through thoughts, actions, and behaviors (Cruess et al., 2014; Gee, 2003; Luehmann, 2011). It is highly related to professionalism, which influences and shapes one\u2019s identity in a professional context (Forouzadeh et al., 2018). The formation of PI involves developing one\u2019s understanding of their professional roles, responsibilities, and expectations that are socio-culturally dependent (Siebert &amp; Siebert, 2007). Therefore, the process of forming one\u2019s PI also involves developing one\u2019s cultural identity (Forouzadeh et al., 2018).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Studies on PI formation in medical education tend to focus on educational strategies that support PI formation during medical training (Adema et al., 2019; Ahmad et al., 2018; Cruess et al., 2015; Foster &amp; Roberts, 2016). These studies provide insights on how to support PI formation without really addressing what needs to be taught to support medical students\u2019 PI formation. Several theories on identity and PI formation suggest that one\u2019s identity is formed through dialectical conversations that facilitate the acceptance, rejection, or modification of the profession\u2019s characteristics and\/or attributes into one\u2019s core identity (Cruess et al., 2015; Gee, 2003; Siebert &amp; Siebert, 2007; Stets &amp; Burke, 2000). These characteristics and\/or attributes are usually context-dependent (Cruess et al., 2014). Thus, defining and understanding what it means to <\/span><span lang=\"EN-ID\">be a professional physician in a certain socio-cultural context is as important as finding out how best to facilitate its formation in an educational setting <\/span><span lang=\"EN-US\">(Wacquant, 2013)<\/span><span lang=\"EN-US\">.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Altruism and humanism are the two most cited values expected from a physician, along with integrity and accountability, honesty, and morality (<\/span><span lang=\"EN-US\">Cruess et al., 2014; Edgar et al., 2020; Hall, 2021)<\/span><span lang=\"EN-US\">. Additionally, care providers, researchers, and teachers are some professional roles of physicians often mentioned in the literature <\/span><span lang=\"EN-US\">(Ahmad et al., 2018; Branch &amp; Frankel, 2016; Carlberg-Racich et al., 2018; Hatem &amp; Halpin, 2019)<\/span><span lang=\"EN-US\">. Nevertheless, there might be other roles and characteristics that have yet to be fully elucidated, especially considering that the current literature on PI formation is mainly dominated by the Western representation of the medical profession.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">This study aimed to describe the characteristics and\/or attributes of ideal (professional) physicians in Indonesia as defined by undergraduate medical students. Undergraduate medical students are unique as they have limited opportunities to interact with real patients in a real workplace. Through this study, we hope to gain new insights from undergraduate medical students on what it means to be a professional physician.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">II. <\/span><span lang=\"EN-GB\">METHODS<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">This was a qualitative phenomenology research using case studies design at a private Catholic medical school in Jakarta, Indonesia. Participants were recruited using a purposive sampling method. Transitional phases in one\u2019s life are often associated with identity renegotiation as they are exposed to changes in their roles, responsibilities, and expectations <\/span><span lang=\"EN-US\">(Kay et al., 2019)<\/span><span lang=\"EN-US\">. Therefore, we sought to explore how Indonesian undergraduate medical students defined their professional identity at the beginning (first-year) and end (fourth-year) of their preclinical years. Ethical clearance was obtained from the school\u2019s Research Ethics Committee prior to the study.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">We set a quota of 5 participants for each study year (with a total of 10 study participants) to account for any possible socioeconomic status, ethnicity, religion, and gender variations. We recruited five first-year and five fourth-year preclinical students at the beginning of the study; however, two of the fourth-year participants dropped out during data collection; hence, only eight case studies constructed to depict the characteristics and\/or attributes of an ideal Indonesian physician.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Each case study participant was interviewed twice using semi-structured interviews. The first interview was conducted at the beginning of school semester (August 2021) and the follow up interview was conducted one month after. The purpose of the first interview was to determined participants\u2019 current understanding and views of what it meant to be a physician, while the second interview aimed to determine if there were any changes in their understanding or views and what precipitated the changes. Interview questions include: <i>What kind of physician do you aspire to be? Was there one or more specific moment that prompted you to become a physician (if so, please describe it)? What characteristics and\/or attributes should an ideal physician possess? Please explain.<\/i> At the follow-up interviews, participants were asked to re-describe the characteristics and\/or attributes of physicians that they aspired to be and what prompted the changes. Furthermore, participants were also asked to describe any specific learning moments that might influence their understanding of what it means to be a professional physician. \u00a0Because of the COVID-19 physical distancing policy during the data collection phase, all data were obtained virtually or through electronic exchange via secured online platforms. All interviews were transcribed verbatim and analysed in vivo using abductive thematic analysis with Atlas.Ti 8<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">In addition to from the interviews, we also conducted several classroom observations. We observed the first- and fourth-year\u2019s large classroom lecture, problem-based learning, and skills laboratory session once, focusing on the teacher-student interactions and made note on how, if any, the faculty member facilitated students\u2019 PI formation in the classroom. We also interviewed several faculty members who interacted with the participants in teaching capacity during the data collection phase. Faculty members were asked to describe what kind of physicians they wanted their students to be based on institutional values and their own beliefs about what constitutes an ideal physician. They were also asked to elaborate on their efforts to facilitate those characteristics and\/or attributes in the formal and informal curriculum. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">\u00a0Data obtained from classroom observation and faculty interviews were used to triangulate the findings from the participants\u2019 interviews. Permission was obtained from all related parties to record and use the interviews and classroom interactions in the data analysis. Individual case study reports were generated by combining the data obtained from interviews and field notes. These case study reports were then cross-analysed to find commonalities across the case studies to define the characteristics and\/or attributes of an ideal physician that the participants aspired to be at their current stage of education.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">III. <\/span><span lang=\"EN-GB\">RESULTS<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The majority of participants were either Chinese or of Chinese descent. Five participants were Christian Protestants, one was a Buddhist, and two refused to disclose their ethnicity and religion. Note that the names used in these case studies are pseudonyms.<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p><i><span lang=\"EN-US\">A. <\/span><\/i><i><span lang=\"EN-US\">Case Study #1: Celine (First-year Student)<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Celine, a female of Chinese-Betawi descent from West Java, was raised in a devout Christian-Protestant family. Being a physician was not her childhood aspiration. Initially, she thought physicians tended to be \u201crude, bossy, had too much pride, unwilling to listen to suggestions\u201d (Celine, Interview 1, Line 42-43), which contradicted her personal values to being humble and helping others as a form of service and manifestation of her faith. Nevertheless, she developed a new appreciation toward physicians when she found out that there were physicians who gave back to the surrounding community by providing free healthcare (see Appendix No. 1).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Humility, and self-reflectiveness\u2014which Celine called \u201copenness to criticism\u201d (Celine, Interview 1, Line 39-44) were the characteristics she deemed important as a physician.\u00a0 She believed that a physician should engage in social actions and put the patient first. Furthermore, a physician should consider the patient\u2019s personal circumstances while providing individualised healthcare based on the patient\u2019s needs. A good physician should also believe that their most important role is to provide credible health information and educate the community to improve their health and well-being. Good communication skills, including active listening, empathy, building trust, and the ability to break bad news, were essential in supporting this role (see Appendix No. 2).<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p><i><span lang=\"EN-US\">B. <\/span><\/i><i><span lang=\"EN-US\">Case Study #2: Dimitri (First-year Student)<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Dimitri, a Christian-Protestant female of Chinese descent, was quite familiar with medicine and the medical profession as she was surrounded by people who either worked as or studied to become a physician. Additionally, she helped caring for her visually impaired sibling since she was young, which gave her opportunities to interact with various care providers as she accompanied her sibling for treatment. Being a physician naturally became her aspiration since childhood. Dimitri was appointed as a \u2018Dokter Kecil\u2019 (or, \u2018little doctor\u2019) in elementary school, assigned to provide first aid treatment to fellow students and promote health efforts conducted by the school. Before entering medical school, Dimitri\u2019s grandfather fell critically ill; therefore, she helped her family to care for him in the hospital. There, she met a cardiologist whom she respected. She recalled that she appreciated the way this cardiologist relayed which information could be shared with her grandfather to keep his spirit up and which information should be disclosed to her family to prepare for the worst possible outcome. She mentioned that her grandfather looked \u201ccalm and comfortable\u201d in his last days, which helped the family to accept his departure peacefully (Dimitri, Interview 1, Line 77-80).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Dimitri highlighted a physician\u2019s ability to handle the distribution of information as an important part of her ideal physician identity (See Appendix No. 3). She believed that it was acceptable for a physician to keep certain information from the patient if that information could add unnecessary stress or cause them to stop following the treatment (Dimitri, Interview 1, Line 90-98). Regardless, the physician should disclose all information to the patient\u2019s relatives as the patient\u2019s decision-maker. Dimitri aspired to be a caring and compassionate physician with good communication skills who can be held accountable for her actions. Aside from being a care provider, Dimitri believed that a physician should take on a role as \u2018Pengayom\u2019 (protector). She believed that patients were in vulnerable positions due to their health issues, and therefore the physician was responsible for protecting them like a parent would when their child was sick. Implied in the Pengayom role was the leader whose responsibility was to make the best decision for the patient\u2019s health and well-being (See Appendix No. 4).<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p><i><span lang=\"EN-US\">C. <\/span><\/i><i><span lang=\"EN-US\">Case Study #3: Faustine (First-year Student)<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Faustine, a Christian-Protestant female of Chinese descent, was born and raised in a remote area in Riau province, in the southern part of Sumatra Island. Her interest in biology and life sciences prompted her to browse online videos related to healthcare since she was young. She tended to feel sad if the people closest to her were suffering and she could not do anything to help. She made up her mind to study medicine when one of her high school friends was forced to seek treatment abroad because of limited healthcare access in her region. Prior to this, her father was misdiagnosed with a malignant tumor, which caused tremendous distress for her family. These incidents drove her to be a physician who could provide good quality care, especially to those closest to her (See Appendix No. 5).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Faustine aspired to be an empathetic physician, taking patients\u2019 mental or psychological state into consideration when planning for their treatment. She did not want to be a physician who focused on financial gain at the cost of the patient\u2019s wellbeing. Being aware of her limitations in providing care and continuously updating her knowledge and skills were characteristics she hoped to develop once she became a physician (Faustine, Interview 1, Line 103-115). Faustine also mentioned that a physician was responsible for being a reliable source of information and improving community wellbeing through education (See Appendix No. 6).<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p><i><span lang=\"EN-US\">D. <\/span><\/i><i><span lang=\"EN-US\">Case Study #4: Jasmine (First-year Student)<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Jasmine originated from Rembang, a small regency on the northeast coast of Central Java. Being a physician had always been her childhood aspiration because she loved helping people and interacting with others. Jasmine tended to her grandmother\u2019s health needs during middle school. This event confirmed her passion and desire to serve others. Putting others\u2019 needs above herself was a value instilled by her father since she was young. She wanted to be a physician who focused on social services, and was driven to help others sincerely without expecting anything in return.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">As Jasmine mentioned, an ideal physician should be honest, disciplined, possess high \u2018Jiwa Sosial\u2019 (an attitude that shows concern to perform actions that are beneficial for humanity and social community), and always put the patient\u2019s needs first (Jasmine, Interview 1, Line 50-53). Jasmine viewed her work as an extension of her faith, and she wanted to reflect Christian values, particularly the value of servitude, in her professional life (See Appendix No. 7-8).<\/span><\/p>\r\n<p><i><span lang=\"EN-US\">E. <\/span><\/i><i><span lang=\"EN-US\">Case Study #5: Rose (First-year Student)<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Rose, a Christian-Protestant female of Chinese descent, was born and raised in Ambon city, Maluku province, Eastern Indonesia. She was the oldest child in her family. Rose became interested in medicine when her mother was diagnosed with a serious illness and could not receive appropriate treatment. She disclosed that her mother ignored the early signs and symptoms of her illness until her condition became so severe that she could not be treated fully. From this experience, Rose was motivated to become a physician so that she could take better care of her family (See Appendix No. 9).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Growing up, Rose heard several stories in which a patient did not receive appropriate healthcare due to their socioeconomic status. She aspired to be a competent and non-discriminative physician. Putting the patient\u2019s needs first, being responsible, helpful, patient, disciplined, and continuously improving her knowledge and skills were the characteristics that she hoped to develop by the time she became a physician. Aside from being a care provider, Rose believed that a physician was responsible for improving the wellbeing of the community through education (See Appendix No. 10).<\/span><\/p>\r\n<p><i><span lang=\"EN-US\">F. <\/span><\/i><i><span lang=\"EN-US\">Case Study #6: *Anton (Fourth-year Student)<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">*Anton, a Christian-Protestant male of Chinese-descent, had an interest in biology since childhood. He was dissatisfied with Indonesian healthcare services, particularly with the healthcare workers\u2019 communication skills when treating his father. This incident occurred when he was in middle school. *Anton observed a power imbalance between the patients and physicians, where the healthcare providers held more power over their patients. As a patient, he felt disadvantaged because he could not demand a better quality of care nor asked for a lower cost of the care he received (See Appendix No. 11). He described the two roles of physicians: as a healthcare provider and educator. As a healthcare provider, one should be able to help patients understand what is best for them while still respecting their autonomy. As educators, physicians have the responsibility to provide valid evidence-based information for patients. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">For *Anton, an ideal physician\u2019s fundamental values and skills included providing good quality care that kept the patients\u2019 best interest, respecting patients\u2019 autonomy, doing no harm, having all necessary medical competencies as listed in the Competence Standards of Indonesian Physician, the drive to learn for a lifetime, patience, humility, competence, and the ability to engage in interprofessional collaboration (See Appendix No. 12).<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p><i><span lang=\"EN-US\">G. <\/span><\/i><i><span lang=\"EN-US\">Case Study #7: *R (Fourth-year Student)<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">*R is a Chinese Buddhist female from Sintang, central Indonesia. *R wanted to pursue medicine because physician was portrayed as a noble profession in Indonesia and as a \u2018role model\u2019 in her family. She wanted to serve marginalised areas in East Indonesia after hearing about the poor health situation in those areas from several alumni and fellow students who served there in various capacities. This experience, along with her formal learning experiences, shaped her ideal physician image, which included being detail-oriented, confident, honest, thorough, and caring. She believed that physicians should be able to fulfill the roles and responsibilities of a healthcare provider, which required good proficiency in medical competencies, based on several fundamental values such as honesty, willingness to serve marginalised and under-served communities, and being sensitive to patients\u2019 needs (See Appendix No. 13).<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p><i><span lang=\"EN-US\">H. <\/span><\/i><i><span lang=\"EN-US\">Case Study #8: *Anastasia (Fourth-year Student)<\/span><\/i><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">*Anastasia, who identified as a female, wanted to be a physician since elementary school. She did not have a specific motivation to enter a medical school when she first started. Nevertheless, there were several past experiences that she claimed to have influenced her image of ideal physicians. She mentioned feeling comfortable being examined by her pediatrician during her childhood. This made her consider the pediatrician as her role model. She also followed several healthcare professionals\u2019 whom she admired on their social media accounts. She claimed that these figures influenced her to be selfless and put the patients\u2019 needs above her own. She acknowledged the importance of entrepreneurial skills in aiding her goal of being selfless yet still able to make a living for herself. Her ideal physician image is someone who has good communication skills, clinical competence, and willingness to learn continuously. She identified healthcare provider as the essential role of a physician, who was responsible for providing physical and mental healthcare, as well as participating in preventive and promotive healthcare. She particularly considered female medical teachers at her school as her role models because she admired the way these figures divide their time and energy to work professionally\u2013both as healthcare practitioners and teachers\u2013and keeping up with their personal and family time. She aspired to be someone who could divide her focus like these figures once she graduated (See Appendix No. 14).<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">IV. <\/span><span lang=\"EN-GB\">CROSS-CASE ANALYSIS AND DISCUSSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Cross-case analysis revealed four major attributes of physician identity as defined by the first- and fourth-year participants (indicated by * behind their pseudonyms), including characteristics, values, roles and responsibilities, and skills. First-year participants drew their ideal image of a physician based on their interactions with one or more healthcare provider whom they met in their earlier lives. These interactions left a significant impression that further strengthened their motivation to study medicine and influenced the kind of values or other things that they held important and were willing to stand for as future physicians.<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">First-year participants mainly mentioned humanistic and altruistic values as the characteristics and\/or attributes that define their professional identity. Honesty, humbleness\/humility, accountability, patience, <i>jiwa social<\/i>, prioritising patients\u2019 needs, empathy, care, and compassion are some of the characteristics mentioned by the first-year participants as characteristics of an ideal physician. These characteristics correspond to society\u2019s expectations of professional physicians to put patient\u2019s interest above all else, which is then further translated into medical professionalism and professional responsibilities <\/span><span lang=\"EN-US\">(Alrumayyan et al., 2017; Elaine Saraiva Feitosa et al., 2019)<\/span><span lang=\"EN-US\">. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Different from their counterparts, fourth-year participants focused on clinical excellence and competence when citing the ideal characteristics and\/or attributes of an ideal physician based on the national Competence Standards for Indonesian Physician. This indicates that fourth-year participants were aware of the standards as well as the ethical principles and physician\u2019s code of conduct that were being enforced in Indonesia (See Appendix 15-16).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The way fourth-year participants described their physician identity aligned with the image of a professional physician painted by the school\u2019s teaching faculty. According to interviews with several key faculty members, meeting the minimal standard of competence, being aware of one\u2019s limitations, practicing evidence-based medicine, honesty, and discipline were some of the fundamental physician attributes\/values\/characteristics that they tried to instill in their students during education. These institutional values were most notably found in the way first-year participants described their physician identity during their second interview (See Appendix No. 17-18).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The attributes of Indonesian physicians mentioned by all case studies participants closely resemble China\u2019s framework of professionalism, where they emphasise altruism, integrity and accountability, excellence, and religion\/moral values <\/span><span lang=\"EN-US\">(Al-Rumayyan et al., 2017)<\/span><span lang=\"EN-US\">. Possessing <i>jiwa sosial <\/i>(inherent sense of social responsibility, empathy, and engagement) and being a <i>pengayom <\/i>(mentor\/guardian\/protector) are two unique attributes that represent the Indonesian ideal physician. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">There were minimal overlaps between the first- and fourth-year participants\u2019 ideal physician images. First-year participants placed humanism\/altruism and social responsibility as the focal points of their physician identity, whereas fourth-year participants chose clinical excellence and competence to represent their physician identities. Social interactions play a major role in identity formation <\/span><span lang=\"EN-US\">(Thomas et al., 2016)<\/span><span lang=\"EN-US\">. This may explain the shift in the first- and fourth-year participants\u2019 definition of an ideal physician. First-year participants modeled their ideal physician identity after their memorable interactions with physicians who provided care for them or their family members. Positive past interactions with healthcare providers shaped the characteristics and\/or attributes that participants aspired to be, whereas negative past interactions motivated them to develop the opposite of observed characteristics and\/or attributes. Fourth-year participants also integrated the characteristics and\/or attributes they identified from the formal and informal learning experiences with their evolving understanding of an ideal physician. In these case studies, fourth-year participants cited clinical competencies and excellence, as well as discipline and honesty\u2014which were emphasised by the teachers during their undergraduate medical training\u2014as the major characteristics and\/or attributes that defined their physician identity.<\/span><\/p>\r\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2024\/03\/OA3098-Figure-1-300x117.png\" alt=\"\" class=\"wp-image-72417 aligncenter\" width=\"959\" height=\"374\" srcset=\"https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2024\/03\/OA3098-Figure-1-300x117.png 300w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2024\/03\/OA3098-Figure-1-1024x399.png 1024w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2024\/03\/OA3098-Figure-1-768x300.png 768w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2024\/03\/OA3098-Figure-1-1536x599.png 1536w, https:\/\/medicine.nus.edu.sg\/taps\/wp-content\/uploads\/sites\/10\/2024\/03\/OA3098-Figure-1.png 1956w\" sizes=\"auto, (max-width: 959px) 100vw, 959px\" \/><\/p>\r\n<p align=\"center\"><span lang=\"EN-US\">Figure 1. Shift in First-Year and Fourth-Year Participants\u2019 Definition of Physician Identity<\/span><\/p>\r\n<\/div>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The first year of the medical curriculum was indicated to be an important transition point that shaped all participants\u2019 PI. In particular, all participants mentioned the school orientation as one of the learning moments that triggered their identity negotiation. Participants were introduced to the school\u2019s expectations of them as medical students and future physicians. These expectations include the characteristics of self-regulated and life-long learners and those of professional physicians (See Appendix No. 19-20). For example, Jasmine \u201c<\/span><span lang=\"EN-ID\">learned to be disciplined and responsible and she believed that the school orientation <i>\u201c<\/i>helped shape [her]<i> <\/i>basic personality as a physician [who needs] to be disciplined and responsible [as well as] trustworthy.\u201d (Jasmine, Interview 1, Line 115-118). <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The shifts in participants\u2019 physician identity definition indicated that participants engaged in a dialectical conversation that stimulated them to merge their core or personal identity with the institution\u2019s perception of ideal physicians (\u201cvirtual\/ideal identity) as interpreted in their curriculum, which was a part of one\u2019s identity negotiation process <\/span><span lang=\"EN-US\">(Gee, 2003)<\/span><span lang=\"EN-US\">. In the cross-case analysis, we found that participants\u2019 reactions toward the values, characteristics, and attributes instilled by the faculty varied. For example, some participants saw the importance of being on time (\u2018discipline\u2019) as well as being academically honest by avoiding plagiarism and cheating during exams (\u2018honesty\u2019), which they accepted as a part of their physician identity. On the other hand, other participants struggled to understand the relevance of being on time and academically honest with their future physician roles or aspirations. This became a major challenge for these participants in incorporating those values into their physician identity. Nevertheless, no participants rejected any characteristics\/attributes instilled by the institution even if those characteristics\/attributes were distinctly different from their personal beliefs system (See Appendix No. 21-23).<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Any new or contradictory characteristics or attributes to one\u2019s core identity pose a professional dilemma that triggers an identity negotiation <\/span><span lang=\"EN-US\">(Spencer et al., 1997)<\/span><span lang=\"EN-US\">. During this identity negotiation process, the study participants tried to merge their core identity, which was represented by their definition of the ideal physician that they aspired to be, either by accepting, rejecting, or integrating the new characteristics\/attributes into their core identity <\/span><span lang=\"EN-US\">(Cruess et al., 2015)<\/span><span lang=\"EN-US\">. <\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The acceptance of new characteristics\/attributes into one\u2019s physician identity will be easier if it is consistent with one\u2019s core identity; however, it is still possible to instill characteristics\/attributes that contradict one\u2019s core identity if they are provided with the long-term benefit of accepting those characteristics\/attributes <\/span><span lang=\"EN-US\">(Guillemot et al., 2022)<\/span><span lang=\"EN-US\">. This underlined the importance of providing students with the relevancy of developing certain characteristics\/attributes desired from a professional physician during their educational phase to support their PIF.<\/span><span lang=\"EN-GB\"><\/span><\/p>\r\n<p style=\"text-align: center;\"><span lang=\"EN-GB\"><\/span><strong><span lang=\"EN-GB\">V. CONCLUSION<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">This case study found that first-year participants prioritised humanistic characteristics as the foreground of their professional identity, and medical professionalism as their background. Meanwhile, fourth-year participants developed a projected identity that embodied the general values of the medical profession and those promoted by their institution. The perceived image of ideal physicians as constructed by the Indonesian society\u2019s ideal image of a physician, prior interactions with Indonesian physicians that influenced their decisions to study medicine, and interactions with the medical teachers during formal and informal learning activities influenced the way participants defined their professional identity. <\/span><span lang=\"EN-GB\"><\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Notes on Contributors<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">Natalia Puspadewi contributed to the work\u2019s conception and design by developing the study proposal, protocols and instruments, data collection, analysis, and interpretation. Further, Natalia also drafted and revised the manuscript and ensured that all aspects of the work were accountable, and followed all procedures to ensure data security and anonymity.<\/span><span lang=\"EN-ID\"><\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Ethical Approval<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">This study was a part of a doctoral dissertation. The University of Rochester acted as the author\u2019s host institution, and Atma Jaya Catholic University of Indonesia, School of Medicine and Health Sciences, was the research site. Ethical approval was provided by the University of Rochester RSRB (a letter of exempt determination was obtained on July 8<sup>th<\/sup>, 2021 for Study ID 00006273) and the Atma Jaya Catholic University of Indonesia, School of Medicine and Health Sciences Ethics Committee (ethical clearance certificate\u00a0 No. 08\/07\/KEP-FKUAJ\/2021).<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Data Availability<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">The data supporting the findings of this study are openly available in the Figshare repository<\/span><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.6084\/m9.figshare.23684235\"><span lang=\"EN-GB\">https:\/\/doi.org\/10.6084\/m9.figshare.23684235<\/span><\/a><\/span><span lang=\"EN-GB\">. The data were not translated into English to preserve the Indonesian sociocultural nuances captured in the interviews. All data were coded and analysed in vivo in Bahasa Indonesia before being translated into English for presentation in this manuscript.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Acknowledgement<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">We would like to express our gratitude to those who have contributed to this study and article development: Dr. Rafaella Borasi as the head of the dissertation committee and advisor, Dr. Sarah Peyre as dissertation committee member, and Gracia Amanta, MD and Cristopher David, MD who helped with manuscript organisation and layouts.<\/span><span lang=\"EN-GB\"><\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Funding<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-GB\">This study was funded by the Atma Jaya Catholic University of Indonesia and American Indonesian Cultural and Education Foundation.<\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">Declaration of Interest<\/span><\/strong><\/p>\r\n<p style=\"text-align: justify;\"><span lang=\"EN-US\">The author has no conflicts of interest to disclose.<\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p align=\"center\"><strong><span lang=\"EN-GB\">References<\/span><\/strong><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Adema, M., Dolmans, D., Raat, J. a. 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Group interaction as the crucible of social identity formation: A glimpse at the foundations of social identities for collective action. <i>Group Processes &amp; Intergroup Relations<\/i>, <i>19<\/i>(2), 137\u2013151. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1177\/1368430215612217\">https:\/\/doi.org\/10.1177\/1368430215612217<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Wacquant, L. (2013). Homines in extremis: What fighting scholars teach us about habitus. <i>Body &amp; Society<\/i>, <i>20<\/i>(2), 3-17. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1177\/1357034X13501348\">https:\/\/doi.org\/10.1177\/1357034X13501348<\/a><\/span><span lang=\"EN-US\"><\/span><\/p>\r\n<p style=\"text-align: left;\"><span lang=\"EN-US\">Wald, H. S. (2015). Professional identity (trans)formation in medical education: Reflection, relationship, resilience. <i>Academic Medicine<\/i>, <i>90<\/i>(6), 701. <\/span><span lang=\"EN-US\"><a href=\"https:\/\/doi.org\/10.1097\/ACM.00000000000%2000731\">https:\/\/doi.org\/10.1097\/ACM.00000000000 00731<\/a><\/span><span lang=\"EN-US\"> <\/span><\/p>\r\n<p style=\"text-align: left;\">*<span lang=\"EN-GB\">Natalia Puspadewi<\/span><br \/>\r\n<span lang=\"EN-GB\">School of Medicine and Health Sciences<\/span>, <br \/>\r\n<span lang=\"EN-GB\">Atma Jaya Catholic University of Indonesia,<\/span><br \/>\r\n<span lang=\"EN-GB\"><span lang=\"SV\">Jl. Pluit Selatan Raya No. 19, Penjaringan,<\/span><\/span><br \/>\r\n<span lang=\"EN-GB\"><span lang=\"SV\">Jakarta Utara, 14440<\/span><br \/>\r\nEmail: natalia.puspadewi@atmajaya.ac.id<br \/>\r\n<\/span><\/p>","protected":false},"featured_media":0,"parent":0,"menu_order":3,"template":"","issues_category":[12],"archive_category":[],"issue_type":[25],"volume_category":[61882],"class_list":["post-72416","issues","type-issues","status-publish","hentry","issues_category-original-articles","issue_type-past-issue","volume_category-volume-9-number-2-april-2024"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Defining undergraduate medical students&#039; physician identity: Learning from Indonesian experience - The Asia Pacific Scholar<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/defining-undergraduate-medical-students-physician-identity-learning-from-indonesian-experience\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Defining undergraduate medical students&#039; physician identity: Learning from Indonesian experience - The Asia Pacific Scholar\" \/>\n<meta property=\"og:description\" content=\"Submitted: 16 July 2023 Accepted: 21 December 2023 Published online: 2 April, TAPS 2024, 9(2), 18-27 https:\/\/doi.org\/10.29060\/TAPS.2024-9-2\/OA3098 Natalia Puspadewi Medical Education Unit, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Indonesia Abstract Introduction: Developing a professional identity involves understanding what it means to be a professional in a certain sociocultural context. 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