As teachers, we train learners to be knowledgeable and competent in the practice of medicine. No less important is the way teachers impact the development of learners’ professional identity. Social scientists in the 1950s noted medical education’s charge “to shape the novice into the effective practitioner of medicine, to give [them] the best available knowledge and skills, and to provide [the novice] with a professional identity so that [they] come to think, act, and feel like a physician.”1 Many have stressed the importance of curricula focused on learners’ personal and professional development.2 An awareness of professional identity development helps teachers understand some of the workplace differences noted between generations, particularly with millennial learners. Continuing the Council on Medical Student Education in Pediatrics series on great clinical teachers, our article focuses on supporting professional identity formation (PIF) in millennial learners.

Professional identity formation (ie, the socialization and professionalization of a physician) develops in stages over time.3 PIF consists of ordering and reordering personal and professional priorities as one progresses from student to effective practitioner.3,5 This process has been linked to one’s personal identity development.6 Characteristics of 3 important stages of physician PIF include the following5:

  • Early: foundational education (premedical students and early medical students)

    • follow social roles and rules

    • appreciate others’ viewpoints, yet self-views predominate;

  • Middle: training and/or supervised practice (later medical students and residents)

    • view medical practice through multiple perspectives

    • subordinate self-interests more effectively

    • feel a sense of belonging but not yet “professional”

    • may still have trouble reconciling competing expectations;

  • Later: practicing professional (practicing physicians)

    • understand differing values and perspectives

    • own and embody expectations of the profession

    • begin to internalize the external values of the profession

    • reconcile challenges between personal and professional expectations more effectively.

An identity as a physician is the foundation for professional behaviors. For example, a major pillar of professionalism is a commitment to maintaining trust by subordinating self-interest and managing professional responsibilities.5,7 Through acknowledgment, questioning, and role modeling, clinical teachers can support a learner’s professional identity development, ensuring smooth transitions. Understanding personal identity formation and PIF is central to teaching, mentoring, and remediating learners.

Concern exists about the millennial generation’s preparedness to meet the expectations of the profession. Millennials (born 1981–2000) are said to have been reared in a “child-focused” world with high parental involvement and relationships shaped by media.8 In medicine, millennials have been characterized as having less commitment to and ownership of patients, a work life shaped more by personal demands, and a sense of greater importance to an organization despite a relative lack of experience. These factors could lead to conflicts with teachers about expectations and commitment.9,10 Nonetheless, millennials bring many strengths to medicine, such as collaborative learning, acceptance of diversity, and a strong sense of social consciousness.11 In Table 1, we summarize millennials’ characteristics that potentially impact PIF in positive and negative ways.

TABLE 1

Millennial Attributes That May Positively and Negatively Interact With PIF and the I-CA2R2E Framework

Millennial Attributes Potentially Impacting Physician Identity DevelopmentMethods to Address I-CA2R2EComments
Positive interaction Individual connection Connect with learners through a variety of methods and determine a preferred method; pay attention to the learner’s journey to medicine and outside interests. 
 Relationship centered  
 Expect personal connection with supervisors  
Negative interaction  
 Conflict with hierarchy  
 Occasional distrust of authority   
Positive interaction Create Create a safe space for honest dialogue; provide opportunities for learners to share the important experiences and pivotal moments in their identity development as a physician (ie, the process of becoming medical professional). 
 Equality and diversity  
 Team centered and collaborative learning  
Negative interaction  
 Personal learning needs are valued more than group learning and/or team training  
Positive interaction Acknowledge and adjust Acknowledge learner perspectives; validate story and concerns; adjust approaches on the basis of learner values, reactions, stage of life, and training; adjust teaching methods on the basis of learner preferences; and adjust and challenge your own expectations of “what is right.” 
 Desires routine feedback  
 Social consciousness  
Negative interaction  
 Easily bored with traditional education (didactics)   
 May have trouble with independent decision-making   
 Frustrated with “menial” tasks   
Positive interaction Reflect and role model Encourage reflection on personal experiences; provide nonjudgmental feedback when values and ideals conflict; role model expected behavior; and coach as learners order and reorder priorities. 
 Desire for meaning in work  
Negative interaction  
 May view feedback as judgment and not an opportunity for growth  
 Need for explicit instructions   
 Exchange Arrange for ongoing dialogue, connection, and follow-up; if learners acknowledge ongoing problems, ask if they would like to hear potential solutions. 
Millennial Attributes Potentially Impacting Physician Identity DevelopmentMethods to Address I-CA2R2EComments
Positive interaction Individual connection Connect with learners through a variety of methods and determine a preferred method; pay attention to the learner’s journey to medicine and outside interests. 
 Relationship centered  
 Expect personal connection with supervisors  
Negative interaction  
 Conflict with hierarchy  
 Occasional distrust of authority   
Positive interaction Create Create a safe space for honest dialogue; provide opportunities for learners to share the important experiences and pivotal moments in their identity development as a physician (ie, the process of becoming medical professional). 
 Equality and diversity  
 Team centered and collaborative learning  
Negative interaction  
 Personal learning needs are valued more than group learning and/or team training  
Positive interaction Acknowledge and adjust Acknowledge learner perspectives; validate story and concerns; adjust approaches on the basis of learner values, reactions, stage of life, and training; adjust teaching methods on the basis of learner preferences; and adjust and challenge your own expectations of “what is right.” 
 Desires routine feedback  
 Social consciousness  
Negative interaction  
 Easily bored with traditional education (didactics)   
 May have trouble with independent decision-making   
 Frustrated with “menial” tasks   
Positive interaction Reflect and role model Encourage reflection on personal experiences; provide nonjudgmental feedback when values and ideals conflict; role model expected behavior; and coach as learners order and reorder priorities. 
 Desire for meaning in work  
Negative interaction  
 May view feedback as judgment and not an opportunity for growth  
 Need for explicit instructions   
 Exchange Arrange for ongoing dialogue, connection, and follow-up; if learners acknowledge ongoing problems, ask if they would like to hear potential solutions. 

Generational differences between teachers and learners may create conflicts. We propose the I-CA2R2E (individual connection, create, acknowledge and adjust, reflect and role model, and exchange) framework (Table 1) to provide strategies to maximize learners’ PIF. The framework addresses the 3 pillars of Self-Determination Theory, which are autonomy, competence, and relatedness.12 The 3 brief cases that follow illustrate how I-CA2R2E can help guide clinical teachers.

A clerkship student meets with her preceptor to discuss dissatisfaction with feedback she received, concerned that the preceptor pointed out areas for improvement.

The learner, in her early stage of PIF, may view clinical work in a self-focused manner and perceive feedback as judgment and not an opportunity for growth.11 

  • I - Make individual connection and explore the learner’s experience with previous feedback.

  • C - Create a safe space to discuss how the feedback impacts the learner’s view of herself and her role (ie, as test taker versus lifelong learner).

  • A - Acknowledge grading pressures in medical school and the learner’s concerns that grades are “all that matters” for residency selection.

  • A - Adjust your own views on feedback and recognize how generational differences play a role in how feedback is received.

  • R - Reflect: encourage reflection on key influences in the learner’s identity development (mentors, patients, other experiences).

  • R - Role model by sharing how feedback has benefitted you (for example, how listening to the observations and perspectives of others provided opportunities for personal and professional growth).

  • E - Exchange: arrange for follow-up with the learner to check in on challenges and successes.

A subintern visiting from another institution is upset because of his attending’s raising concerns about his level of commitment. The subintern’s assignment on his patient’s adjustment to a serious diagnosis was submitted late. When asked, the subintern explains he “prefers taking care of his patients” and that written assignments “matter less” than clinical care.

The learner may not fully be able to subordinate self-interests and have trouble reconciling competing priorities.

  • I - Make a connection by exploring personal background and career goals.

  • C - Create a safe space to explore how this learner prioritizes competing commitments.

  • A - Acknowledge that competing demands can be difficult to manage.

  • A - Adjust your own potential biases about this learner being “disengaged” or “uninterested.”

  • R - Reflect: encourage the learner’s reflection on his ordering of priorities.

  • R - Role model by sharing how you have grappled with managing competing priorities.

  • E - Exchange: provide rationale for assignments and offer to assist and exchange ideas about the how this subintern can order future priorities.

A senior resident objects to the residency program’s decision to limit intern shifts to 16 hours. He complains program leadership is “getting soft” and publicly challenges other residents for having supported the program’s decision.

The learner may have a limited ability to consider multiple perspectives. The senior resident’s emotional approach to sharing his perspective is not productive.

  • I - Recognize this resident’s individual perspective as he approaches unsupervised practice.

  • C - Create an opportunity for the resident to articulate rationale, not simply emotional reactions.

  • A - Acknowledge that the resident is entitled to his point of view, yet the decision-making process (program leadership and other resident input) should be respected. Encourage the resident to focus on outcomes and not only resident work hours.

  • A - Adjust your personal biases and understand that generational differences impact expectations of learners.

  • R - Reflect and role model: probe the resident’s view on how his action manifested as role modeling for others (ie, hours in the hospital versus a focus on quality, safety, and relationships with patients). Reflect on a time when your own first impressions were modified over time.

  • E - Exchange: set a time for follow-up and ask for ideas about how future group decisions can be collaborative.

Although it may seem a distant memory to great clinical teachers, the early stages of a medical learner’s PIF can be disconcerting and filled with conflict, self-doubt, and an inadequate sense of belonging to the profession. Millennial learners may particularly need guidance through challenges to make critical decisions (ordering and reordering priorities) that ultimately lead to the embodiment of professional behaviors (ie, thinking, acting, and feeling like a physician). Supervisors who approach teachable moments with open-mindedness, a willingness to challenge expectations, and tools to stimulate exploration and self-reflection (I-CA2R2E) will be able to promote learners’ development of a strong foundational identity in medicine. When learners experience the investment of a clinical teacher in their professional journey, everyone benefits, including patients, who ultimately receive care from physicians who truly embody the expectations of the medical profession above their own needs.

Drs Barone, Vercio, and Jirasevijinda conceptualized and drafted the initial manuscript and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

We thank Dr Nicholas Potisek for his thoughtful contributions in conceptualizing this article.

I-CA2R2E

individual connection, create, acknowledge and adjust, reflect and role model, and exchange

PIF

professional identity formation

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.