A Longitudinal Assessment of Professional Identity, Wellness, Imposter Phenomenon, and Calling to Medicine Among Medical Students

Abstract

Objective

This study assessed changes in professional identity, wellness, imposter phenomenon, and calling to medicine over time in medical school.

Methods

Medical students from the first through third years anonymously completed four validated measures: Perceived Wellness Survey (PWS), Brief Calling Scale (BCS), Physician In-group Identification Scale (PID), and Clance’s Imposter Phenomenon Scale (CIP). Survey completion implied informed consent. The study was exempted by the university IRB.

Results

All class of 2018 students (n = 110) returned surveys at the beginning of year 1; 58 completed surveys at the end of the preclinical years (post year 2, n = 44) and/or end of the third-year clerkship (post year 3, n = 35) and were analyzed. From pre to post preclinical years, there was a significant decrease in the PID. There were no statistically significant changes in the PWS, BCS, and CIP. From pre year 1 to post third-year clerkships, the PWS and PID decreased, the CIP increased, and the BCS did not change. Only 19% of students participated in all three survey administrations and this group was excluded from the analysis due to the low response rate.

Conclusion

Student wellness and sense of professional identity (in-group identity) dropped over 3 years of medical education, while imposter phenomenon increased. The BCS did not change over time. The decrease in identity as part of the physician community is concerning; future curriculum initiatives should focus on integration of professional identity into students’ individual identities and on initiatives to improve student well-being.

The growth of a medical student into a physician involves far more than acquiring knowledge of basic sciences, pathophysiology, and therapeutics. Students must learn to be humanistic as they also learn to be scientists. Skills such as interpersonal communication, self-care, and resilience are drawing more direct attention [1] as medical educators, physicians, and insurers gain appreciation for how the relationship of an individual to self, profession, and patients impacts not only the quality of patient care but also the health of the physician work force. Professional identity formation must cultivate the development of students’ emotional and spiritual dimensions in addition to their intellect by promoting self-reflection, emotional awareness, and by valuing resiliency and well-being [2]. This emotional and spiritual maturity is the difference between the doing of medical practice and the practice of being a physician.

One of the most important aspects of being a physician is professionalism, which is generally considered to be the set of behaviors expected of a professional, in essence, the doing of a physician [3]. Professional identity, however, is a complex concept, defined by Cruess et al. as “a representation of self, achieved in stages over time during which the characteristics, values and norms of the medical profession are internalized, resulting in an individual thinking, acting, and feeling like a physician” [4]. Both are important in medical student development. Likewise, medical student well-being is an important variable in personal growth and identity development. Well-being is generally conceptualized as inversely related to psychological distress and is also a critical factor in building and sustaining a resilient physician work force [2]. It is well established that high levels of psychological distress are more prevalent in medical students than in the general population [5] and have been found to correlate with increased burnout, decreased empathy, and increased lapses in professionalism [6]. Interestingly, a sense of in-group identity as a medical student or future physician has been positively associated with medical student well-being [7].

While the aspect of “calling” may be explored during medical school interviews, it is often forgotten once a student matriculates into medical school. Calling is broadly defined as a sense of purpose that motivates a person to engage in an activity, usually referring to a job, to serve others, or contribute to a greater good [8, 9]. The presence of calling to medicine has been associated with greater job satisfaction, lower rates of burnout, and an improvement physician wellness, indicating that calling may increase physician resilience and serve as a protective factor against burnout and workforce attrition [10, 11]. In medical students, the presence of calling to medicine has been shown to bolster students’ sense of self-efficacy [12] and has been identified as significant factor in specialty choice [13].

Another aspect that may be noted in medical students is imposter phenomenon, which refers to a pattern of beliefs held by high achieving individuals that they are less intelligent and less competent than others perceive them to be [14]. In medical students, imposter phenomenon increases the severity of psychological distress, has been positively correlated with burnout, cynicism, and depersonalization and shown to be greater in senior students [15, 16].

Although the existing literature has examined wellness and professional identity, calling to medicine, and imposter phenomenon independently or in concert, there is little available on how these individual factors vary throughout the medical school years. These four variables have also not been studied collectively. We sought to examine the developmental trajectory of these factors during the course of medical education. Specifically, we assessed professional identity, wellness, imposter phenomenon, and calling to medicine in a single cohort of medical students throughout their first 3 years of undergraduate medical education. To our knowledge, this is the first study to follow students longitudinally to examine the development of these internalized individual factors across preclinical and the first clinical year. We sought to better understand the trajectory of student wellness, professional identity, calling to medicine, and imposter phenomenon across their medical school experience. Based on the extant literature, we hypothesized that professional identity, perceived wellness, and presence of calling to medicine would increase over the preclinical and first clinical years, while search for calling and the imposter phenomenon would decrease.

Methods

Using a repeated measures design, students in the class of 2018 were surveyed at the beginning of their first year (pre year 1, academic year 2014–2015), at the end of their second year (post year 2), and the end (post year 3) of their third year (academic year 2016–2017). Post year 2 surveys represent the end of the preclinical years; post year 3 surveys were completed at the end of the required clerkship year. Students were invited to participate while in a large group setting, during a required educational activity at the beginning of their first year and end of second year, and by email at the end of third year. The voluntary nature of student participation and the consent form were included in a statement that completing the surveys implied consent to participate. The statement included a link to the survey, which was developed and distributed through Qualtrics software (Qualtrics, Provo, Utah). Responses were anonymous, but students were asked to create their own unique identifier in question 1 so that surveys could be matched over the three time periods. The study was determined to be exempt by the university Institutional Review Board.

Participating students completed the following four validated measures:

1) Perceived Wellness Survey (PWS): a 36-item survey that assessed students’ physical, emotional, spiritual, social, intellectual, and psychological wellness. Response options were from 1 = very strongly disagree to 6 = very strongly agree. Possible composite scores ranged from 4.8 to 28.8; higher scores indicated greater perceived wellness [17].

2) Brief Calling Scale (BCS): two 2-item scales that assessed students’ presence of calling (2 items) or search for calling (2 items). Response options were from 1 = not at all true of me to 5 = totally true of me [18]. Possible scores ranged from 1 to 5; higher scores indicated greater calling.

3) Physician In-group Identification Scale (PID): a 14-item scale that assessed students’ identity as a physician, adapted from a cultural in-group identification tool. Response options were from 1 = very strongly disagree to 5 = very strongly agree. Possible scores ranged from 14 to 84; higher scores indicated greater identification as a physician [19].

4) Clance’s Imposter Phenomenon Scale (CIP): assessed characteristics of the imposter phenomenon. A 20-item scale with response options of 1 = not at all true to 5 = very true. Possible scores ranged from 20 to 100; higher scores indicated higher degree of feeling like an imposter. [20].

The scores on the measures were tested for normality with Shapiro-Wilk tests. PWS, PID, and CIP scores were approximately normally distributed and were summarized with mean ± SD. BCS scores were left-skewed and were summarized with median (interquartile range). Pre year 1 vs. post year 2 and pre year 1 vs. post year 3 comparisons were made with paired t tests for the PWS, PID, and CWS, and Wilcoxon-signed ranks tests for the BCS. Students did not necessarily complete all four of the scales at the time periods in which they participated, so the sample size varied by scale. Analyses were performed with SPSS v24.0 (IBM Corporation). All analyses were two-tailed; p values less than 0.05 were considered statistically significant.

Results

All 110 students in the class of 2018 returned surveys pre year 1; of these, 58 (52.7%) completed surveys post year 2 and/or post year 3 and were included in the analyses. Forty-four students could be included in analyses of pre year 1 vs. post year 2; 35 students were included for pre year 1 vs. post year 3. A subset of the included students (n = 21) had surveys for all three time periods, but the response rate for all three time periods (19%) was considered too small to analyze. For the 110 students at the beginning of year 1, scores on the measures were PWS 15.7 ± 2.9, BCS presence 4.0 (1.5), BCS search 3.0 (2.0), PID 64.6 ± 7.3, and CIP 57.8 ± 11.2. There were no differences between included (n = 58) and excluded students (n = 52) on any of the measurements (two-sample t tests).

Table 1 shows the scores on the measurements at each time period and the changes between time periods. For the pre (pre year 1) to post (post year 2) preclinical years measures, there was a significant decrease in the PID. There were no changes in the CIP, PWS, or BCS measures. After the third-year clerkships (post year 3), both the PWS and PID decreased significantly from the pre year 1 values. The CIP score significantly increased, and the BCS measures did not change.

Table 1.

Student’s survey scores and comparisons between pre year 1, pre year 3, and post year 3 time periods

Measures and time periods compared	n	Pre time period	Post time period	Post-pre	Test statistic	p value
PWS
Pre yr1 vs. post yr2	44	15.3 ± 3.2	14.8 ± 3.1	− 0.4 ± 2.9	1.004 t	0.321
Pre yr1 vs. post yr3	34	15.4 ± 3.2	14.6 ± 2.4	− 0.9 ± 2.4	2.125 t	0.041
BCS: presence of calling
Pre yr1 vs. post yr2	34	4.0 (1.5)	4.0 (1.0)	− 0.5 (1.5)	1.286 z	0.198
Pre yr1 vs. post yr3	24	4.0 (1.5)	4.0 (1.0)	0.0 (1.5)	0.265 z	0.791
BCS: search for calling
Pre yr1 vs. post yr2	34	3.0 (2.0)	3.0 (2.5)	0.0 (1.8)	0.877 z	0.380
Pre yr1 vs. post yr3	24	2.8 (2.4)	2.5 (1.0)	0.0 (1.5)	0.592 z	0.554
PID
Pre yr1 vs. post yr2	4435	65.2 ± 7.7	60.8 ± 8.8	− 4.4 ± 8.6	3.394 t	0.001
Pre yr1 vs. post yr3		66.6 ± 7.0	59.2 ± 8.3	−  7.4 ± 7.2	6.105 t	<0.001
CIP
Pre yr1 vs. post yr2	41	57.3 ± 11.1	61.2 ± 14.9	3.9 ± 12.9	− 1.925 t	0.061
Pre yr1 vs. post yr3	34	58.5 ± 12.3	63.3 ± 11.8	4.8 ± 10.3	− 2.712 t	0.011

Values are mean ± SD for the PWS, PID, and CIP, and median (interquartile range) for the BCS. PWS, Perceived Wellness Survey; BCS, Brief Calling Scale; PID, Physician In-group Identification Scale; CIP, Clance’s Imposter Phenomenon Scale; yr1, year 1; yr2, year 2; yr3, year 3

Discussion

This study sought to examine the developmental trajectory of several key variables in professional identity formation during the course of medical education. Specifically, we assessed the changes in professional identity, perceived wellness, imposter phenomenon, and calling to medicine in a single cohort of medical students through 3 years of undergraduate medical education.

Our data revealed a significant decrease in sense of professional identity in medical students from matriculation to the end of the third year. The decline in professional identity was significant during the preclinical years (pre year 1 to post year 2), and remained significant over the clinical years (pre year 1 to post year 3). Pratt et al. assert that professional identity is built when medical trainees experience the tension between what a physician does and who they are [21]. Medical educators would be wise to cultivate this fertile ground of students’ lived experience by providing space to process their struggle with this tension.

The significant decline in students’ perceived wellness (pre year 1 to post year 3) is quite concerning. Studies indicate that medical students experience greater levels of distress than their non-medical student peers [5] and the impact of medical school on individual student wellness should be more closely examined in future studies.

We also observed a statistically significant increase in imposter phenomenon over the medical school years. Our data reflected generally high scores on Clance’s Imposter Phenomenon Scale [14], which is consistent with the literature that has found high levels of Imposter Phenomenon in graduate and professional students [15]. Education focused on increasing awareness of imposter phenomenon, clearly stated expectations and definition of success and peer and mentor support programming are all potential considerations for educators to consider to address imposter phenomenon [22].

The absence of change in the BCS search for calling and presence of calling is interesting in the context of a decline in student wellness. Other studies have associated the presence of calling to medicine with increased resiliency and decreased burnout (increased wellness) in medical students and physicians [10, 18, 23]. Perhaps the presence of calling in our students played a protective role, buffering against a decline in wellness but not preventing the decline entirely.

Interpretations of our findings are limited by multiple factors. These data represent a single class of medical students at one midwestern medical school and so should not be considered generalizable to a national sample. Also, the authors chose to use an in-group identity measure adapted for identity as a physician from the social identity literature, which is not a fully standardized instrument and it is not known how well this would translate to assessment professional group identity. Although all 110 students in the class were invited to participate in each data collection period, participation declined with time. Data were not collected after year 4 due to the challenges of locating senior medical students and anticipation of an even lower response rate. Data collected from graduating senior medical students would have provided an interesting conclusion to our longitudinal data set.

To our knowledge, this is the first data set to examine the change of these internalized factors across preclinical and clinical years of medical education. Given that a greater sense of in-group identity has been associated with greater wellness, future curriculum initiatives should begin to integrate professional identity into students’ individual sense of self at matriculation. Medical educators should continue to efforts to integrate wellness initiatives early and not neglect to continue wellness programming during the clinical years. These wellness initiatives should address imposter phenomenon early and aim to decrease it. Future research should further examine how wellness, professional identity, calling to medicine, and imposter phenomenon change as medical students mature. As medical educators seek to understand the transition of undergraduate student to medical school graduate, curriculum should include a focus on the development of physician identity across medical education and an emphasis on individual wellness and self-care in the clinical years, in order to bolster the health and resilience of a future physician workforce.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.