The view from within: Professional identity formation when safety events involve trainees

Short abstract

Given the dangers, complexity and nuance required when dealing with safety events, McDougall outlines how education systems can enable growth rather than worsening wounds.

Every serious safety event involving a medical trainee triggers an organisational scramble. Who takes the lead on involving trainees in a QI review, the hospital or the university? Which policies guide the response? Who decides if the learner should be included in reviews? Rowland et al.'s analysis maps these institutional tensions. ¹ While their organisational lens highlights important systemic dynamics, there is a parallel medical education story that deserves attention. Safety events do not just expose system uncertainties. They can disrupt a developing physician's sense of professional self and career trajectory. We suggest that alongside and inside these organisational dynamics, safety events trigger individual and relational processes that fundamentally alter what clinical learning environments actually teach.

Safety events do not just expose system uncertainties. They can disrupt a developing physician's sense of professional self and career trajectory.

Consider the spectrum of serious safety events that residents navigate, as captured by medico‐legal data coding frameworks. As McCleery et al. demonstrate, patient safety incidents encompass events which could have resulted, or did result, in unnecessary harm to the patient. ² A near miss where no harm occurred might trigger internal self‐doubt without external scrutiny. An adverse outcome with actual harm may activate institutional review processes, team debriefs for systems learning or even involvement by the medical regulatory authority. A complaint without harm might seem disproportionate to clinical reality. A complaint with harm can launch residents into months or years of hospital, regulatory or civil legal matters while they are still trying to learn medicine. ³ , ⁴ When these events involve trainees, the contributing factors extend beyond individual provider actions to encompass team dynamics, system resources and organisational culture. ¹ Each configuration creates distinct learning conditions, yet neither residents nor preceptors can predict which type of event they are experiencing until well into the process. What begins as a clinical moment becomes refracted through multiple lenses of analysis, each with its own language, timeline and consequences for professional development.

Our research examining physicians who experienced patient complaints during residency reveals a consistent pattern. ⁵ Routine clinical care can evolve into medico‐legal complexity that challenges professional identity. Physicians who received complaints during residency told us they felt ‘blindsided’, questioned whether they ‘deserve to be a resident’ and wondered whether they had ‘conned everyone into believing [they're] capable’. ⁵ These experiences create what we termed ‘professional identity disruption’. Rowland et al.'s findings help explain the organisational context: They describe how learners are shielded from ‘red tape bureaucracy’, excluded from QCIPA‐protected discussions and caught in debates about whether safety learning means developing clinical expertise or participating in quality improvement. ¹ Their organisational ambiguities—uncertainty about which protocols apply, who should be involved, which accountability structures take precedence—create the conditions for the identity disruption we observed.

Physicians who received complaints during residency told us they felt ‘blindsided’, questioned whether they ‘deserve to be a resident’ and wondered whether they had ‘conned everyone into believing [they're] capable’.

This positioning problem intensifies during safety events. Residents describe situations where they believe both speaking up and staying silent present risks to their professional standing.

Residents describe situations where they believe both speaking up and staying silent present risks to their professional standing.

The temporal dimension shapes outcomes. Initially, residents experiencing complaints report stigma, isolation and shame, often self‐imposed through silence. Over time, many reframe these experiences as catalysts for growth in communication and collegial support. This transformation requires structured support, transparent communication and mentorship that helps residents integrate these experiences into their professional narratives. ⁵

The misalignment between resident intentions and patient perceptions reveals a structural tension. Residents operate in supervised environments where responsibility remains ambiguous. One physician in Rowland et al.'s study claimed that ‘from a medicolegal environment, students and residents don't exist. They are a pair of hands that are actually mine on delegated authority’. ¹ This statement, while reflecting a common perception, is incorrect in Canada. Resident physicians are independent practitioners with the same legal, regulatory and professional obligations as any physician. This contradiction between perceived and actual legal status intensifies identity challenges when safety events occur. The resident is simultaneously a supervised learner in the educational hierarchy and a legally responsible practitioner. Patients, meanwhile, experience care as delivered by individuals, not systems.

The resident is simultaneously a supervised learner in the educational hierarchy and a legally responsible practitioner. Patients, meanwhile, experience care as delivered by individuals, not systems.

The tension between resident education and patient privacy shapes how safety learning occurs. While residents involved in safety events may participate in hospital reviews as agents providing care, Rowland et al. demonstrate how interpretations of privacy legislation create barriers to comprehensive learning. Universities may be excluded from reviews because they are not health care providers under certain privacy frameworks. Residents receive filtered information with educational context removed. Safety recommendations may not reach trainees who lack hospital email accounts. These administrative interpretations of privacy requirements, whether legally necessary or institutionally cautious, truncate learning opportunities.

Medical education programmes need frameworks that address both the organisational complexities Rowland et al. identify and the professional identity challenges these events create for trainees. Whether as direct participants in an incident or observers of the review process, residents must navigate competing demands: learning from safety events while managing threats to their emerging professional identity.

The implications extend beyond individual residents. Support during safety events shapes future approaches to patient care, willingness to engage with quality improvement and capacity to support colleagues. One physician in our research stated: ‘By sharing my own experiences, I aim to equip my residents with the knowledge to better handle similar situations’. ⁵

Understanding clinical learning environments as negotiated orders, as Rowland et al. demonstrate, remains essential. These spaces also forge professional identities through challenging experiences. The organisational dynamics the authors map create conditions for formative moments. How education systems respond determines whether these moments become opportunities for growth or sources of lasting wounds. Both patients and the profession require evidence‐based approaches to navigate these complexities.

How education systems respond determines whether these moments become opportunities for growth or sources of lasting wounds.

McDougall A. The view from within: Professional identity formation when safety events involve trainees. Med Educ. 2026;60(2):98‐100. doi: 10.1111/medu.70127