Traveling with a desirable destination: a dialogical analysis of professional identity formation among freshman medical students

Abstract

Background

We aimed to examine medical students’ perceptions regarding their professional identity and explore their creative narratives utilizing the Dialogical-Self Theory (DST).

Methods

This is a mixed-method study. First-year medical students at Tehran University of Medical Sciences (TUMS, Tehran, Iran wrote a creative narrative about their perspectives on their future profession. Based on DST, qualitative-directed content analysis and summative approach were used to identify and quantify different “I-positions” to assess professional identity formation.

Results

One hundred eighty-eight first-year medical students at TUMS participated in the study in 2021–2022. In the creative narratives, the reference to “I” was more than other pronouns (he/she/they). The use of “I” positively correlated with rank in the university entrance exam (P value = 0.03). The highest application of “I” per participant belonged to the “present I-position,” and the lowest to the “promoter,” which has the highest rank in the formation of professional identity. Women tended to use the “present I-position” more than men (P value = 0.03).

Conclusions

First-year medical students have accepted their self-role in forming professional identity; however, they have not found a vast perspective of it, as shown by their inability to use meta I-position and promoter I-position. Therefore, educators must provide plans within the curriculum to enhance competencies of professional identity formation. These plans can include incorporating narration writing to encourage medical students to reflect on their professional identity.

Background

The American Psychological Association (APA) defines identity as the individual’s sense of self, which can be shaped internally based on personal characteristics or externally through affiliations and social roles. By becoming a member of a new professional group, the individual gets to acquire a new identity. This dynamic process involves the simultaneous act of defining one’s self internally (who I am) and externally (who I think others think I am) [1]. Professional identity is an ongoing process that internalizes norms, values, and beliefs associated with becoming a professional [2, 3]. Integrating the professional identity with the personal identity may cause identity dissonance, which then leads to building a new worldview and new values [1, 4].

Professional identity formation from a socio-constructivist view, as an evolving, self-directed, and transformational journey [5–7], takes shape from the initial days of studying in the desired profession until the time of providing service. Throughout this process, individuals continuously explore what kind of professionals they aspire to be within their professional community [2]. Murray emphasizes the importance of understanding and acknowledging individuals’ perspectives on their professional identity, particularly during the early stages of their education [8]. Self-reflection is one of the ways to strengthen students’ understanding of their professional identity [9].

Self-reflection is an effective method for students to enhance their learning by critically examining their experiences and behaviors, fostering personal growth, and making progress throughout their education [10]. Self-reflection provides a unique opportunity for students to explore their attitudes and perspectives regarding their professional identity and outline their plans for professional development [11]. Professional narration is a technique that promotes self-reflection by encouraging students to articulate their viewpoints [12]. Students can cultivate their professional identity, embrace professional values, and better understand themselves through narrative identity. Moreover, it serves as an effective method for strengthening professional identity through expressing desired professional perspectives and values [13]. Among different types of narration, creative narrative in fictional writing or autobiography is a means of gaining insight into any profession [14]. Evidence has emphasized utilizing creative narratives to listen to students’ voices, comprehend their insights, and grasp their perspectives on their professional journey [15, 16]. Creative narratives, facilitated by self-dialogue, enhance self-awareness, and self-directed learning in medical education [17, 18].

Dialogical-Self Theory (DSM), based on the principle of self-dialogue, has been used in explaining the state of professional identity with the aim of explaining different selves or I-positions in the mind and the dialogue that takes place between them [19, 20]. The dialogical self can be interpreted as “a dynamic multiplicity of I-positions in the inner space of the self”, as first described by Hermans. By this definition, the self can work as a micro-society, as part of a bigger society. The “I” is incorporated in both time and space, and it has the possibility to move from one position to another when faced with changes in time and situation [21]. According to DST, the self can take both internal positions (e.g., I as a medical student, I as an ambitious worker), and external positions (my helpful classmate, my aspiring professor). By assuming that the external as well as internal positions can have the quality of I-positions, and by observing the other as part of the extended self, the definitions of “present” and “extended” I-positions were proposed [19]. A meta-position can be defined as a variety of specific positions, their respected narratives and the connections between them (e.g., ‘Upon reflection, I notice that there are things that I discover while talking about my experiences with my partner, that I am not able to see when I talk with my colleague’) [22, 23]. The promoter I-position can reflect the internal domain of the self as well as the external domain. This I-position can present variable possibilities in each person and in the life course of a single person (e.g., ‘I as a hardworking student’ to ‘I as a mentor to my children’). The meta-position functions as a “helicopter” which goes up and down and takes various distant views of the self, while the promoter position works on a horizontal axis, and pushes the “machinery” of the self in a desired direction [22].

It has been suggested that medical students are investigating their professional identity continuously since the first year. They keep asking themselves about the qualifications they should have as a future doctor, and about how they should introduce themselves as doctors to others in the future [24]. Inattentiveness to such questions can lead to students’ inability to use their educational experiences to shape their professional identity [25]. It is believed as crucial to provide opportunities for medical students early in their educational curriculum to challenge themselves about their goals and values, norms, and beliefs regarding their future career, to manage their personal choices in a way that shapes their professional identity [2]. Requesting junior medical students to write creative narratives can be an efficient method to provide that opportunity [25].

Significant efforts have been devoted to the field of professional identity to explore its various aspects [26–30], development strategies [31, 32], and assessment methods [33–35]. However, medical students’ perceptions of their future profession during the early stages of their education demand further investigation. Considering that TUMS undergraduate medical curriculum has become competency-based education since 2011, and emphasizes making time for students to reflect on values and beliefs as early as possible during their years of studying. The current study stands out by incorporating creative narrative as the assessment method instead of relying solely on survey data. This study examines first-year medical students’ perceptions of their professional identity and explores their creative narratives utilizing the DST.

Methods

This is a mixed-method study. The study aimed to identify the types of I-positions related to a medical student’s future profession. Data was collected through writing students’ creative narratives in the first year of the undergraduate medical education curriculum. DST was used to explore first-year medical students’ professional identity and assess the I-positions within the self. A further aim was to assess the correlation between demographic data and stages of professional identity formation in which the students used the word “I” in their narratives. We used both qualitative and quantitative methods in our study: the qualitative method incorporated directed content analysis of narrations, and the quantitative method was a summative approach to quantify the number of extracted codes.

Setting

This study was conducted at Tehran University of Medical Sciences (TUMS), Iran, in 2021–2022. TUMS is the biggest medical university in Iran, and each year more than 200 students enter the medical program from all over the country. These students have attained the highest rank on the national admission exam. The undergraduate medical education at TUMS is a 7-year curriculum in two phases: pre-clinical (3 years) and clinical (4 years).

Participants

Our study enrolled the first-year students in the pre-clinical phase. A non-probability sampling technique was utilized to recruit participants. A total of 188 medical students participated; 59 (31.4%) were male and had 19.45 ± 0.45 high school Grade Point Average (GPA). The inclusion criteria of participants were as follows: (i) entering the undergraduate medical education curriculum at TUMS in 2021–2022, (ii) willingness to participate in the study. Exclusion criteria for participants were as follows: (i) failure to send written narration on time, (ii) being a guest medical student.

Process

First, the first-year medical students at TUMS were asked to write a creative narrative about their perspectives on their future profession. Afterwards, qualitative and quantitative analysis of the obtained data was performed. The participants were asked to fill in some background data, including gender, ranks in the national admission test, high school GPA, and first-semester university GPA. Open-ended questions and demographic information were designed in a Google form for electronic submission, and instructions were provided at the beginning. A two-week deadline was specified for writing the creative narrative. Follow-up reminders were sent two days before the deadline via email. Participants were asked to write a creative narrative between 500 and 700 words about how they would imagine their profession in the future. They needed to answer the open-ended question: “What kind of physician do you want to become?”. There was no specific structure for their narration writings, which was entirely upon their creativity. Written narrations were analyzed using the directed content analysis following Hsieh and Shannon’s (2005) approach [36]. Directed content analysis is a research methodology investigating a specific phenomenon using a theory as a framework [37]. Hence, DST was used to identify different “I-positions.” A DST-based approach was taken to demonstrate the stage of professional identity in which the students used the word “I” in their narratives.

Data analysis

Qualitative data analysis was conducted using MAXQDA software for identifying pronouns and types of I-positions in participants’ quotations. Before data analysis, the coding protocol for extracting “I-positions” was developed through a literature review. Two researchers independently coded 50 randomly chosen creative narratives, and inter-rater reliability was calculated (r = 0.87). The analysis process was then performed through an iterative process in which the rest of the narrations were coded by a researcher (MA). In the initial step of the coding process, a comprehensive examination of students’ narrations was conducted to identify the different I-positions based on coding protocol, for example, “I as a medical student at university” or “I as a physician in training.” The researcher read aloud the texts multiple times and extracted the codes. In the second step, the process involved coding the internal utterances of the student, explicitly targeting the voices of others echoed in the student’s head, such as their peers, role models, or parents. This coding process included identifying and categorizing third-person pronouns (He, She, They). Two researchers (MA and MKM) discussed all codes through three two-hour face-to-face sessions. Disagreements on emergent codes were resolved through collaborative discussion until a consensus was reached. In the third stage, a summative approach was used to count the I-positions according to DST [36]. Students’ narratives were analyzed to quantify the extracted codes’ frequency. The relationships between the background data and the frequency of the extracted codes were analyzed by SPSS. A P-value of less than 0.05 was considered a significant level. Two sessions were held to discuss the disagreements on the coding of the two raters, and they tried to reach a consensus over the disagreements.

To assess the rigor of our study, we used Guba and Lincoln’s criteria for establishing trustworthiness [38]. For credibility, we ensured persistent observation by the researchers in rechecking the codes and their prolonged engagement with the research. For confirmability, we used expert peer debriefing and we had two evaluators for coding. For dependability, we used an audit trail, by documenting the research process thoroughly, including data collection methods, analysis procedures, and decision-making, and inter-rater reliability, by having multiple researchers independently analyze data and compare results for consistency. For transferability, we asked for creative narratives of first-year students with different demographic characteristics.

Results

One hundred eighty-eight participants participated in the study, representing 68.8% of the first-year medical students at TUMS in 2021–2022. Demographic data for the participants is presented in Table 1.

Table 1.

Demographic characteristics of the participants

Variable	Scale	Number (percent%)	Min	Max	Mean	SD
First semester university GPA	Score out of 20	N/A	12.05	19.53	17.40	1.22
High school GPA	Score out of 20	N/A	17.25	20	19.45	0.43
Rank in national university admission test	Rank	N/A	1	338	55.53	-
City of residence	Native	21 (14.2%)	N/A	N/A	N/A	N/A
	Non-native	127 (85.8%)	N/A	N/A	N/A	N/A

GPA: Grade Point Average, Min: minimum; max: maximum; N/A: not applicable; SD: standard deviation

The analysis of creative narratives revealed that the participants had developed various I-positions related to their future professions. Examples of participants’ quotes related to each type of I-position are presented in Table 2.

Table 2.

Examples of participants’ quotes related to I-positions in the analysis of creative narratives based on DST

Type	Coding quotes
Present I-position	• I as a doctor… • I as a specialist… • I as a therapist… • I as a medical student… • I as a physician in training …
Extended I-position	• I want to work in a hospital as an internist because I want better patient communication. • I want to be a doctor whose practice is not determined by money, a higher position, etc., but by reaching values like love, sacrifice, service, and blessings. • I will not pay any attention to the wealth or social position of the patients in my practice. • I will be a doctor to whom the comfort and health of people are invaluable, who understands the patients and does not dissuade a patient from continuing the treatments due to his/her financial situation. • I want to feel that my patient, the woman who calls me “my girl,” is like my mother, for whom I can sacrifice my life. I do not want to see others moving about cash who are there to satisfy my financial needs. • I do not ever want to see the patient as a source of income; I want to prioritize the patient’s proper treatment so that I can treat the patient and make him/her satisfied.
Meta I-position	• I am a person who can work in a multi-specialty hospital, communicate with different specialists, and make progress because there are many people there from whom I can learn, and we can get promoted together. • I can work as an outstanding and hardworking doctor in society since I intend to present the services to my compatriots in emergencies and threatening situations. • I can help many people by studying medicine because I have great potential to change the environment and improve it for those around me. • I want to be a dedicated, capable, and expert specialist in my city because the city where I was born is deprived of many facilities. • I want to work as a doctor since I am very good at reasoning and analysis. • As a medical student, I can attend to my responsibilities very well.
Promoter I-position	• When I read the biographies of famous doctors such as Dr Gharib, I become confident that I want to specify my medical goals and try my best to reach them and gain professional competencies. • Nothing motivates me more than seeing my progression and success in medicine; my plan for the future is to be a successful physician. • After observing the pain and suffering of the patients in the hospitals, I decided to study medicine to get the best marks in medicine and finish it with the highest rank. • My next step for becoming a good doctor is to participate in national and international scientific congresses and have something to present. I want to be an expert professor loved by the students to facilitate their lives in the complicated maze of medicine. By becoming a faculty member at the Tehran University of Medical Sciences, I want to contribute to this university’s development as a community of practice member. • I should study very well, starting from now that I am in the first semester until I finish medicine. I should learn the key points very well because I might have wrong diagnoses and prescriptions that can lead to a catastrophe without knowing.

The frequency of use of different pronouns (I vs. he/she/they) by medical students in their narrations is depicted in Table 3. This result elaborates that the “I” pronoun as a doctor in the creative narratives was more than a reference to the other pronouns (he/she/they) as a doctor.

Table 3.

Frequency of using pronouns by medical students in creative narratives

Pronouns	Median	Mean	SD	Min	Max	Confidence Interval (95%)
I (as a doctor)	8	8.22	4.72	0	22	7.54–8.90
He/ she and they (doctor/doctors)	2	3.20	3.81	0	21	2.65–3.75

Min: minimum; max: maximum; SD: standard deviation

We assessed the correlation between using different pronouns as a doctor/doctor with the demographic data consisting of university GPA, high school GPA, and rank in the national university admission test. As Table 4 depicts, no significant correlation exists between the number of times the “I” pronoun is used and the university or high school GPA. A weak positive correlation was found between the “I” pronoun and the rank in the national university admission test.

Table 4.

Correlation between the use of pronouns in creative narrative of professional identity and demographic characteristics of the participants

Pronouns	First semester university GPA		High school GPA		Rank in national admission test
	Spearman correlation coefficient	P-Value	Spearman correlation coefficient	P-Value	Spearman correlation coefficient	P-Value
I (as a doctor)	-0.02	0.70	-0.07	0.33	0.15	0.03*
He/ she and they (doctor/doctors)	0.12	0.08	0.09	0.21	-0.12	0.08

p-value ≤ 0.05

Using the Mann-Whitney test, we could not find a significant difference between females and males regarding “I” or other pronouns (P value = 0.08 and 0.86, respectively). A significant difference could be found regarding the use of the “I” pronoun between the native students (students from Tehran, the city where the university is located) and those coming from another city (P value = 0.04). The frequency of use of various I-positions is summarized in Table 5. It shows that the highest mean among the different positions of “I” per participant belonged to the “present I-position” and the lowest to the “promoter I-position.”.

Table 5.

Frequency of use of professional identity I-positions based on DST

I-positions	Mean	SD	Min	Max	Confidence Interval (95%)
Present I-position	4.21	2.89	0	15	3.82–4.64
Extended I-position	1.90	1.74	0	8	1.65–2.16
Meta I-position	1.92	1.77	0	9	1.69–2.18
Promoter I-position	0.73	1.14	0	6	0.54–0.89

Min: minimum; max: maximum; SD: standard deviation

Mann-Whitney test found a significant difference between female and male students using the present I-position (P value = 0.03). Females tended to use the present I-position more than males; however, such difference could not be found using other I-positions.

The correlation between using each I-position and high school or first-semester university GPA was insignificant. However, the present I-position and extended I-position showed a significant correlation with the rank in the national university admission test. As displayed in Table 6, the correlation coefficients for two of the I-positions were positive, which means that students with higher ranks in the entrance exam used more present and extended I-positions.

Table 6.

The correlation between rank in the national university admission test and professional identity I-positions

I-positions	Spearman correlation coefficient	P-Value
Present I-position	0.19	0.008*
Extended I-position	0.17	0.01*
Meta I-position	0.12	0.09
Promoter I-position	0.01	0.79

p-value ≤ 0.05

Discussion

This study was built on the dialogical inquiry to explore how medical students imagine their future professions in the first year of their education. Former studies have been published examining the professional identity development of teachers [39–41], and clinicians [42, 43]; however, this is the first study utilizing the conceptual framework of DST to explore the professional identity among medical students.

Our results presented that the lowest mean among the different positions of “I” per participant belonged to the “promoter I-position.” Moving to a higher level, considering the developmental aspects of the dialogical self, a new position emerges called promoter I-position. This position promotes the self in a particular direction [44]. Promoter I-position is considered the highest in dialogical self, regarding forming professional identity. Therefore, any footprints of this position in the narratives of our first-year medical students showed a great deal of professional identity formation and is essential.

Another finding of our study was that the first-year medical students described their roles in professional identity formation early in their education, i.e., they used the “I” pronoun more than other pronouns. According to Ibarra, professional identity is more adaptable and changeable early in a person’s career [45]. She argues that individuals tend to adapt to new professional roles by imagining future professional situations. We discovered that the “I” pronoun was not associated with first-semester university or high school GPA; however, it positively correlated with rank in the national university admission test. Among the different I-positions, the admission test ranking had a weak positive correlation with present and extended I-positions.

Iran’s national university admission test is a national exam all students must take to enter universities. The achievers of the top marks have the chance to enter medical school at TUMS. Getting these higher ranks mandates studying hard for at least a few years. The higher-ranking students have had a deeper perception of their goals, what they want to accomplish, and the professional identity they want to obtain. As Monrouxe argues, identities are constructed repeatedly as we participate in daily activities [1]. Based on the study’s findings, students seem to imagine multiple identities in the first months of entering university, such as “I as a doctor” and “my responsibility towards my patients.”

Regarding the university GPA, it should be noted that the students who took part in this study were first-year students. Medical school imposes considerable stress and changes in lifestyle and studying patterns on the students. Many students might need help showing their capacities in the first semester’s exams. That is why we can suggest that the first-year grade average is not an efficient marker of the student’s professional development. Considering that the students who enter the medical school at TUMS have the highest academic potential, the mean of their high school GPA is high and within a limited range. If this study were performed in lower-rank universities or majors other than medicine, the distribution of the high school GPA would probably be wider. We can suggest that the reason for us being unable to find an association between the use of the “I” pronoun and the diploma grade average is this concentrated distribution.

No gender difference was found among our students based on using different pronouns (I vs. he/she/they). However, female students used present I-positions more than male students. The latter finding is more compatible with the previous studies. For example, in one study among university students, girls tended to have a better-formed professional identity, which could be related to better social adaptation and higher self-confidence [46]. Although this new generation of medical students enters medical school with the lowest background of gender differences, it must be kept in mind that gender disparities in the medical professional environment still exist. Many of the roles and expectations are male-normative; patients and colleagues question the decisions of the female practitioners, and females have to put more effort to prove their competencies [47, 48]. There would be some issues in professional identity formation, especially for girls, and this area needs a thorough and watchful eye.

We found a significant difference regarding using the “I” pronoun between the students from Tehran (the city where the university is located) and those from another city. Although this is an early observation and further investigation is required to address the situation fully, attention must be paid to the slightest sense of disparity or being a foreigner among the students, which can influence the students’ professional identity formation [49–51].

Our study has some limitations. First, it was performed among medical students from one center, which could limit the generalizability of the findings to other settings. Second, some first-year medical students did not submit their narratives, and the reason for non-participation should be investigated. Third, we used a written creative narrative to explain students’ perceptions of the professional identity they imagined for themselves. Using multiple narratives over time will reveal more information about students’ professional identities. Finally, our study aimed to find and emphasize the impact of identity and basic characteristics of students on professional identity formation; however, we suggest further studies to be performed for medical students of different years in order to follow the trend in the professional identity development process.

Conclusions

First-year medical students have accepted their self-role in forming professional identity; however, they have not found a vast perspective of it, as shown by their inability to use meta I-position and promoter I-position. Therefore, educators must provide plans within the curriculum to enhance competencies of professional identity formation. These plans can include incorporating narration writing to encourage medical students to reflect on their professional identity.

Abbreviations

APA

American Psychological Association

DST

Dialogical-Self Theory

GPA

Grade Point Average

TUMS

Tehran University of Medical Sciences

Author contributions

MA, MK, and AS have made substantial contributions to the work design and data acquisition, analysis, and interpretation. MK, KA, and EB have drafted the work. All authors read and approved the final manuscript.

Funding

This study was carried out with the financial support of the Health Professions Education Research Center of Tehran University of Medical Sciences with project number 1400-1-410-52409.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical considerations were considered following principles outlined in the Declaration of Helsinki. The research protocol was reviewed and approved by the Ethics Committee of the Medical School at TUMS (IR.TUMS.MEDICINE.REC.1400.298). Informed consent was obtained from all participants. Participants were guaranteed that their information would be handled confidentially and anonymously and would only be used for the study. Participants were free to withdraw from the study at any time without consequences.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.