Medical student stories of participation in patient care-related activities: the construction of relational identity

Abstract

Professional identity formation is acknowledged as one of the fundamental tasks of contemporary medical education. Identity is a social phenomenon, constructed through participation in everyday activities and an integral part of every learning interaction. In this paper we report from an Australian ethnographic study into how medical students and patients use narrative to construct their identities. The dialogic narrative analysis employed focused on the production of meaning through the use of language devices in a given context, and the juxtaposition of multiple perspectives. Two stories told by students about their participation in patient care-related activities reveal how identities are constructed in this context through depictions of the relationships between medical students, patients and clinical teachers. These students use the rhetorical functions of stories to characterise doctors and patients in certain ways, and position themselves in relation to them. They defend common practices that circumvent valid consent processes, justified by the imperative to maximise students' participation in patient care-related activities. In doing so, they identify patients as their adversaries, and doctors as allies. Both students are influenced by others' expectations but one reveals the active nature of identity work, describing subtle acts of resistance. These stories illustrate how practices for securing students' access to patients can influence students' emerging identities, with implications for their future disclosure and consent practices. We argue that more collaborative ways of involving medical students in patient care-related activities will be facilitated if students and clinical teachers develop insight into the relational nature of identity work.

The Big D(eal): professional identity through discursive constructions of ‘patient’

“…These processes happen neither overnight nor in a vacuum. Rather, producing the foundations of a professional self is powerfully influenced in relation to others and through recurrent interactions with others . Professional identities are created in similarity; for example, the foundations of competence ‐ a key component of an appropriate professional medical identity ‐ are ‘shaped through interactions with attendings, residents, and interns throughout the course of clinical clerkships’ as students move into the professional sphere.…”

“…Yet, identities are also constructed in difference from others, including those outside the medical profession, for ‘only when there is an Other can you know who you are’ . It is in the early clinical years of training that ‘students enter the world of the hospital … [and] learn to construct sick persons as patients, perceived, analyzed, and presented as appropriate for medical treatment’ …”

Student and clinician identities: how are identities constructed in interprofessional narratives?

“…Therefore, it is important for students and practitioners to develop positive professional and interprofessional identities in order to maximise interprofessional learning and collaboration . Although the literature on identity formation in health professions education is now extensive, it is scant by comparison on student and clinician identities within interprofessional contexts . Although some identities research has recently adopted social constructionist approaches, previous research exploring interprofessional identities has typically chosen to use social cognition theories from an objectivist perspective, such as social identity theory, self‐categorisation theory and social identity complexity theory .…”

Where is student support most needed?

“…At another level, there is increasing research interest in the complex process through which medical students’ identities are being constructed as they participate in all their usual learning activities, including interacting with patients . The very ways they go about ensuring access to patients for learning, for example, has been found to influence their emerging medical identities . Once again, we see here, it is the interaction between the individual and the environment that requires attention as students strive to belong, to be a participant, to feel secure, to find their place and to optimise their learning on the way to being practitioners.…”