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Abstract
Objective Becoming a doctor involves transforming a lay person into a medical professional, which is known as professional socialisation. However, few studies have clarified differences in the professional socialisation process in detail. The aim of this study was to clarify the process of professional socialisation of medical students to residents to staff doctors.
Design We used narrative analysis in qualitative research as a theoretical framework.
Setting This study was conducted in Japan.
Participants Participants were collected using a purposive sample of doctors with over 7 years of medical experience. We conducted semistructured interviews from September 2015 to December 2016, then used a structured approach to integrate the sequence of events into coherent configurations.
Results Participants were 13 males and 8 females with medical careers ranging from 8 to 30 years. All participants began to seriously consider their own career and embodied their ideal image of a doctor through clinical practice. As residents, the participants adapted as a member of the organisation of doctors. Subsequently, doctors exhibited four patterns: first, they smoothly transitioned from ‘peripheral’ to ‘full’ participation in the organisation; second, they could no longer participate peripherally but developed a professional image from individual social interactions; third, they were affected by outsiders’ perspectives and gradually participated peripherally; fourth, they could not regard the hospital as a legitimate organisation and could not participate fully.
Conclusion The professional socialisation process comprises an institutional theory, professional persona, legitimate peripheral participation and threshold concepts. These findings may be useful in supporting professional development.
- medical education & training
- qualitative research
- social medicine
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Strengths and limitations of this study
This study used narrative analysis to illustrate the trajectory of medical professional identity formation.
Strengths include applying narrative analysis suitable for identifying the socialisation patterns of medical doctors in the continuity of their careers.
Limitations include a small sample size of 21 Japanese participants, of whom many were family physicians and only a small number were specialists.
Participants consisted of 13 males and 8 females with medical careers ranging from 8 to 30 years.
Introduction
The process by which a medical student matures into a healthcare professional is known as socialisation.1 Professional socialisation is defined as the process of transforming a beginner into a professional. This process integrates work-based norms, values, beliefs, knowledge, skills and expected roles, and adapts the beginner to the culture of the experts.2 A medical professional’s identity, constructed through medical professional socialisation, is defined as ‘a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalised, resulting in an individual thinking, acting and feeling like a physician’.3 That is, medical professional socialisation aims to develop a professional identity and adapt a person to the role of medical expert.4
In practice, the socialisation of doctors is affected by role models, clinical experience,5 the healthcare system and school or organisational environment, as well as by the attitudes of colleagues and supervisors towards patients.6 Additionally, most doctors adapt to the organisation by acquiring the necessary skills to carry out their duties.7 8 Doctors thereby become members of the organisation of a hospital, and are conscious of belonging to the community and of their responsibility as doctors.9 According to the concept of legitimate peripheral participation (LPP), medical students become incorporated into the community of doctors as members based on degree of participation and how participation and non‐participation change over time.9
A doctor’s professional socialisation and the development of their identity are some of the most important aspects of medical education.10–14 However, few studies have clarified the details of differences in the professional socialisation process, such as when and how doctors are influenced by organisations and the education system, and how their professional identity as a doctor is acquired. A formal outline of the process of socialisation might provide medical educators and programme directors with clues on how to prevent identity crises for doctors in training.
In particular, the specialty of family physician is more ambiguous than other specialties, and family physicians tend to struggle with their identity due to the overlap in the scope of their practice with that of general internal medicine, general paediatrics, psychiatry and obstetrics-gynaecology. Family physicians are more interested in their identity and how others perceive them15 because they have difficulties with professional identity formation within mainstream biomedicine and with the counterculture movement internationally.16 17 Thus, professional socialisation from a family physician perspective may better reveal details of how anguish and/or struggle with professional identity formation is manifested than the perspectives of other specialties.
Here, therefore, with a focus on evaluation from the perspective of family physicians, as distinct from the perspectives of other specialties, we aimed to clarify the process of professional socialisation of medical students to residents to staff doctors. In particular, the specific aim of this study was to examine how doctors perceive their acquired knowledge and values in the process of developing their professional identity as a doctor.
Methods
Theoretical framework
We used narrative analysis, which is characterised as a group of methods used to interpret commonality among stories.18 Our present aim is consistent with that of narrative analysis because we examined the subjects’ narrative as a whole rather than as decontextualised fragmented data. Narrative analysis inductively clarifies a typology of narratives, conceptually organises them into thematic categories, and then illustrates exemplar narratives or vignettes.18 19 Common thematic elements across a number of participants are used to develop a descriptive framework of professional socialisation.19 A number of other studies of the professional identity of medical professionals have also used narrative analysis.20 21 We, therefore, adapted narrative analysis as a theoretical framework for the present study.
Setting
The setting was the Japanese medical education system (figure 1). Similarly to many other countries, eligibility to enter medical school in Japan is assessed in high school graduates. The standard undergraduate medical education programme is 6 years. The Japanese national exam comprises only a single examination, in sixth grade. In 2004, the Council for Matching, a non-government organisation, implemented and organised a system to match graduating medical students to 2-year residency programmes in Japan. A nationwide matching system had not been previously available, and residents had to randomly apply to individual training programmes in which they were interested. After the initial 2 years of required postgraduate training in Japan, each trainee advances into his or her own career path. Some doctors enter graduate school, while others proceed to advanced clinical training courses as fellows, or move on to become family physicians in the community.
Medical education system in Japan.
According to Organisation for Economic Co-operation and Development (OECD) data for 2017, the overall average number of doctors per 1000 people was 3.5, compared with 2.4 in Japan.22 In contrast, Japan has the greatest number of hospital beds among OECD countries and approximately 100 000 clinics, of which more than 90% are private and less than 10% are public.23 24 Additionally, many doctors traditionally open primary care clinics after several years of organ-specific training at medical school or a large hospital.25 For family medicine, however, the number of Japanese doctors who have officially completed training as family physicians as of April, 2020 is only 732.26 Due to this wide dispersion of relatively few doctors in hospitals and the paucity of family physicians, some organ-specific doctors encounter opportunities to work in primary care settings, where relatively small numbers of doctors often struggle to provide care to large numbers of patients.25 For this reason, many physicians in universities work in clinics and/or outpatient departments in community hospitals once or twice a week. In contrast, family physicians who belong to a clinic generally work only in that clinic.
Data collection: semistructured interview
We conducted semistructured interviews from September 2015 to December 2016. Semistructured interviews are the primary method used for data collection in socialisation studies.15 27 We interviewed each participant for 90–120 min in a private room or quiet cafe, after obtaining consent from the interviewee. We developed a series of questions that would allow us to compare the contents and diversity of expertise, and demonstrate the relationship between the socialisation of doctors and acquisition of knowledge and values. The questions were: ‘What kinds of things did you learn and how did you learn them when you were a medical student, junior resident, senior resident, and staff doctor?’; ‘Did you make changes between being a medical student and your training? If so, what did you change and how did you make these changes?’; ‘How did you feel about the image of the doctor you envisaged before entering the medical department, or becoming a medical student, junior resident, senior resident, and staff doctor? How did you select your professional career?’; and ‘Please describe the events that influenced your learning while developing as a doctor.’
JHar, SO and JHam conducted pilot interviews on each other to standardise the interviewing technique and interview questions. In addition, we chose the most appropriate interviewer for each participant such that the combination of interviewee and interviewer would allow the interviewee to feel at ease and provide frank answers to questions, such as those inquiring about relationships between residents and teaching doctors in previous workplaces. Moreover, if the interviewers could not conduct in-person interviews due to logistical issues such as residential distance, the interviews were conducted using the online communication tool Skype. Skype-conducted pilot interviews were conducted, in which the influence of the interviewer with respect to matters like sound quality were verified.
Patient and public involvement
Patients and the public were not involved in the design or conduct of the study.
Study participants
To clarify the professional socialisation process of family physicians, who typically have a more diverse career than other specialists, we selected study participants using purpose sampling, in which we discussed multifaceted aspects of the participants’ careers, such as facilities; location; career experience, including training organisation, university hospital, community hospital and clinic, and career changes; experience in academic research; and their cooperation with the interview. As much as possible, interviewers were paired with interviewees with whom they had not worked with for more than 1 year.
The inclusion criterion was a doctor with a medical career of 7 years or longer, on the basis that they would have sufficient experience to be able to look back and reflect on their training and career.
Data analysis
All interviews were recorded using a voice recorder and transcribed verbatim. The interview contents were analysed using the four steps of structural analysis proposed by Gregg28:
Step 1: Divide the text into episodes, which comprise the plot/sequence of the story.
Step 2: Eliminate material that is irrelevant to the plot (often facts).
Step 3: Identify the stanzas in each episode that contain an embedded story.
Step 4: Identify contrasts in binary oppositions and mediating terms (a blend of the shared features) within and across each episode.
The three authors analysed the entire narratives provided by the 21 participants and divided them into five sections: before medical school, medical student, junior resident, senior resident and staff doctor. JHar extracted relevant material from the interviews of eight participants, as did SO for six participants and JHam for seven participants. Subsequently, the three authors together checked whether the plots matched the contents that each author individually had divided into stages using the original data. In step 3, we identified the stanzas in which the participant’s narrative was associated with professional socialisation. JHam, SO and JHar compared the series of stories on professional identity formation and clarified the themes based on the concept of professional socialisation. We ensured that the themes appeared as a consistent narrative pattern across each interview. We conducted periodic data analysis, and checked the steps performed by each author to ensure consistency in interpretation and appropriate sampling to improve the robustness of the analysis.19
All participants provided informed consent prior to participation. To protect privacy, interviewee quotes in this paper are identified by randomly assigned number codes rather than the participants’ names.
Results
Demographic data of the participants
The 21 participants included 16 Japan Primary Care Association-certified Family Physicians, of whom one had a subspecialty of cardiology; two had a subspecialty of palliative medicine and one was a PhD student in the UK. The remaining five consisted of two gastroenterologists, one brain surgeon, one obstetrician and gynaecologist, and one emergency and orthopaedic surgeon. Eight of the 21 participants were female, and all had clinical experience ranging from 8 to 30 years. The participants belonged to eight city hospitals, five clinics and seven universities, while one was a graduate student in the UK (table 1). By location, the participants worked in Ibaraki Prefecture, Tokyo, Hokkaido, Kanagawa, Kyoto, Okinawa and the UK.
Demographic data of study participants
Overview of professional socialisation as a doctor
We conducted in-person interviews with all participants except two, who were interviewed using Skype. We found that all doctors related to the common themes of ‘Realisation as a Doctor’ as medical students in clinical practice and ‘Organisational Socialisation’ as residents through the process of becoming a member of their attending hospital. Subsequently, we identified four distinct patterns of professional socialisation among the participants. These four patterns may represent the different ways individuals balance organisational socialisation according to their particular specialty area and self-learning style (table 2, figure 2).
Four patterns of self-learning style and specialty area
Professional socialisation as a doctor. LPP, legitimate peripheral participation.
Realisation as a doctor
Medical students began to compare their observations of doctors, healthcare professionals, the community and hospitals with their imagined concepts, and started to seriously consider doctors’ tasks, attitudes and way of thinking during clinical practice. They contemplated their own career and whether they themselves aligned with their image of a doctor. When the two did not match, they explored and embodied their ideal image through the clinical experience of other doctors and patients (table 3).
Emergent themes and professional identity formation based on interviews about realisation as a doctor and organisational socialisation
Organisational socialisation
During their junior residency, which refers to a 2-year period of work experience following graduation as a doctor, all participants experienced organisational socialisation in hospitals as they conducted rotations across the medical departments. They had to carry out tasks as instructed by their supervisors and in this way learnt their role as doctors in the hospital.
In addition, doctors valued their colleagues as an inner group, as doctors with whom they felt a kinship and friendship because of what they had been through together as residents. Some compared their own ability, motivation, and enjoyment of work with that of their colleagues. In contrast, some felt emotional undulations such as depressive moods because they regarded colleagues as rivals, with envy, as markers of their own success or failure and as competitors.
They strengthened their mutual connections with colleagues in their inner group in order to reflect on their experience. Some experienced effects of catharsis when they shared such feelings, and the resulting reflection brought about a shared emphasis on their mutual emotions. Participants who could not develop relationships with their colleagues or who did not have colleagues relied on senior and teaching doctors of similar ages. These participants developed similar relationships to those that others developed with their inner group.
During this organisational socialisation as a doctor, relationships with this inner group of colleagues or close supervising doctors brought out a range of responses which had both positive and negative effects on their adaptation in the hospital (table 3).
Professional socialisation
The four patterns of professional socialisation that we identified differed with respect to three themes: specialty area, self-learning style and organisational socialisation (table 4).
Emergent themes and professional identity formation based on interviews about 4 patterns of professional socialisation
Pattern 1: sophisticated balance between LPP and individual learning style
Participants exhibiting this pattern established their professional image in the early stages and seriously considered themselves doctors and handled tasks smoothly by working in an organisation that matched their professional image.
Those who struggled to be a doctor that matched the image required by their hospital sometimes created new ways to solve this problem by involving other staff. The participants, who had no obligation to help, supported their hospital and staff because they felt a belonging to and professional identity with the hospital. These behaviours of the participants are concordant with the model of a reflective practitioner in an organisation. Through the reflection, participants were able to voluntarily commit to education, partnership, leadership and administration work as a doctor, which gave them increasing opportunities to train residents and to work with various healthcare professionals.
Participants with this pattern initiated LPP smoothly in the organisation and identified their own professional image within 2 years after graduation because they had a role model in the training hospitals. They subsequently proceeded to professional socialisation as a part of continuous organisational socialisation.
Pattern 2: focused more on their own professional image than LPP in the hospital
Participants with this pattern generated their professional image or learning style in their own way. Based on this, they clarified their own values and roles in practice. When they were junior residents, for example, when the participants’ professional image was clearer, they could actively participate in the training hospital and develop their own goals. They had opportunities to transform their learning style by following their role models’ advice.
In addition, they experienced transformative learning when they struggled to adapt to their changing life cycle and new environment, which they had never experienced previously. Through their experience, they developed the ability to reflect on their learning style and role as a doctor and look back on themselves from a broad perspective.
Even those who were able to create a professional image in the early stages of their training could transform their values if they came into contact with others with better values. In this way, they confirmed their own role by creating relationships with others and exploring meaningful perspectives for their own growth.
Pattern 3: clarified their own vague professional image by referring to role models or the organisations to which they belonged (specific persons or organisations)
Participants with this pattern had not established their own professional image as a doctor when they were medical students and trainees. Therefore, they adapted their learning styles to those accepted by the organisation concerned. Through these adapted styles, they were able to become like their superior role models or establish a professional image that was as close as possible to the externally recognised professional image accepted within the organisation.
Several characteristics of this pattern differed between specialists and generalists. Even when specialists such as neurosurgeons or obstetrician-gynaecologists had not adequately established their own professional image while they were trainees, they stayed in these specialty departments and were eventually able to successfully establish their own individual learning styles and stably place themselves in strategic positions within the organisation. They could be distinguished from other specialists and were externally recognisable professionals. That is, they established their own professional image under the apprenticeship system embedded in the organisation and through experiential learning, which helped them build their own specialty. Their professional socialisation, therefore, occurred through their organisational socialisation.
In contrast, family physicians and emergency doctors are less defined by a particular procedural skill or role. They, therefore, struggled to adapt to organisational socialisation because their externally recognised professional belonging remained vague. In addition, the learning styles of family physicians and emergency doctors varied depending on the organisation, and it therefore took them longer to establish their own learning styles.
In this way, they experienced LPP in any organisation to which they were assigned. They experienced organisational socialisation at each of their training hospitals while they participated in clinical rotations, and made comparisons with their own professional image.
Pattern 4: professional image was unclear
To identify their ideal image of a doctor, participants with this pattern adapted to the ways accepted by their organisation for the fulfilment of duties, relied on recognition from others, and limited their activities to those required by the organisation. As a result, they failed to establish their own learning style at the beginning, and wanted teaching doctors to lead them, or to accumulate experience in areas in which they had not yet acquired experience. They were not confident as doctors and tended to confirm the validity of their decisions with staff who were widely trusted in the organisation. This demonstrates that doctors continue to explore their own professional image even after they become established doctors. As a result, they wanted a place of training where they could fill holes in their knowledge. Some doctors established their image as a doctor under the conditions provided to them, while others tried to find their personal identity through relationships with other doctors.
Discussion
This study showed that, in the early stages of their socialisation process, doctors experienced not only realisation as doctors, but also organisational socialisation, in which they adapted to the hospital in which they underwent residency training. Subsequently, the doctors exhibited four patterns of professional socialisation that differed according to three themes: specialty area, self-learning style and organisational socialisation. Some doctors—even those who developed into established doctors—became lost in the professional socialisation process. Our study uniquely demonstrates the chronological patterns of the professional socialisation of Japanese doctors including their hospital training, using educational theories.
Our finding that there are common factors between the realisation and organisational socialisation of doctors is in agreement with the institutional theory.29 Medical universities are predetermined to train doctors using both intended and hidden curriculum. Several studies have indicated that medical students in a university’s medical school are ideologically socialised as clinicians with respect to their vision and experience.30 In clinical training for medical students, realisation as a doctor is interpreted as anticipatory socialisation.31 This realisation has been suggested to begin when a person starts to realistically review his/her career, while focusing on their profession, before he/she participates in a specific organisation. In contrast, when students become junior residents, they fulfil roles required by the organisation, such as a hospital, to secure progress in their organisational socialisation.32 33 During this period, however, the students’ skills have not reached a high level and they therefore contribute to their organisations by fulfilling the various roles required by the organisation. Through these processes, they become adapted to the hospital as established doctors and achieve socialisation.
Professional organisations are affected bya professional image34,which is composed of the perspectives of outsiders and self-recognition of one’sown competency.34 Doctors struggle to develop an external person a consistent with the expectations of their surroundings. In patterns 3 and 4, in which the professional image is vague or unclear and is not recognised by the organisation, the participants temporarily experienced a ‘pretend’ socialisationin terms of the culture of their training hospital and their role in it. However,their experience differed from that of the ideal identity in their specialty area, and they, therefore, required role models as external examples. Accordingly, they had to accumulate experience in areas in which they were not competent to establish an image as a doctor that matched the professional image (eg, family physician or emergency physician). In contrast,specialists, for whom the professional image is externally established (eg, gastroenterologists, obstetrician-gynecologists and neurosurgeons) began practising LPP in the organisation once they had chosen their specialisation. They were subsequently integrated as members of the organisation while developing their professional identity as specialisation once they had chosen their specialisation.They were subsequently integrated as members of the organisation while developing their professional identity as specialists.
In pattern 1, medical doctors who wanted to become family physicians continued to engage in LPP in the organisation after they had established a professional identity and externally recognised persona as a family physician within the hospital. These experiences can promote determination as a doctor through threshold concepts (TCs).35 TCs, which are usually transformative, integrative, irreversible, bounded and often troublesome, are key to formalising a professional identity in a vague professional image. In particular, TCs often arise when doctors engage in the reflective practice of playing the multiple ambiguous roles expected of them within their organisation, based on the sense of noblesse oblige—the notion that doctors should use their social position to help others.36
In this way, training at an organisation which provides a professional image that is consistent with that of the trainee enables LPP and helps the trainee to develop their professional identity. We found, however, that when professional images differed, some trainees distanced themselves or struggled to become a member of the organisation. These series of processes for building the professional identity and socialisation of doctors may enable medical teachers or residency programme directors to provide career support to medical students or junior residents.
This study had the following limitations: we only interviewed 21 participants in Japan, of whom many were family physicians and only a small number were specialists; many of the participants had advanced their careers as doctors relatively satisfactorily; only two doctors had experienced pregnancy and childbirth; and none became doctors after 2010, when the Japanese government revised the rules for clinical training for doctors. The findings may be subject to a degree of sample selection and response bias in that some participants were known to the interviewers and volunteered to participate. The study results should be interpreted with these limitations in mind, along with the fact that the findings reflect the perspectives of family physicians and Japanese culture in the above-mentioned context.
Allowing for these limitations, this study clarified the process of socialisation of medical doctors. This clarification was based on detailed interviews which focused on the continuity of the participants’ careers as doctors from a family physician perspective, as compared with the perspectives of other specialties. Nevertheless, doctors in other specialties may also find our results useful given that very few studies of this type have been conducted. Our findings have the potential to substantially impact the development of future medical school curricula. For example, in career education, the patterns of socialisation of medical doctors may provide trainee doctors with an idea of career milestones and ways to choose a career. In addition, these findings will act as a guide for individual doctors considering their career plans, and may help organisations which consider doctors’ career plans by showing the potential need to reflect on the four patterns of self-learning style and specialty areas at milestones. Our future plans to evaluate medical professional identity formation include cross-sectional studies or cohort studies to check the robustness of our present results at larger scale.37
Conclusion
This study suggests that anticipatory socialisation and organisational socialisation of medical doctors may be similarly achieved, and that professional socialisation may be affected by the extent to which medical doctors establish their professional identity; the extent to which their professional image matches that of the organisation; and the extent to which the professional image is externally recognised. Our study uncovers the process by which doctors are socialised, and is expected to offer insight to various stakeholders engaged in medical education.
References
Footnotes
Contributors JHar, SO and JHam were involved in the conception and design of this study, carried out all qualitative enquiries, analysed the data and wrote the paper.
Funding This study received education/research funds from the Department of Primary Care and Medical Education, University of Tsukuba, and was supported by Ministry of Education, Culture, Sports, Science and Technology, New Paradigms - Establishing Centers for Fostering Medical Researchers of the Future; and Doctors for Communities (DOCS) - Fostering Research-Minded General Physicians.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Ethics approval This study was conducted with prior approval from the Ethics Committee of the Faculty of Medicine, University of Tsukuba (No.1001).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.