Supporting doctors' professional identity development through specialist training

Abstract

Anatomy‐centric specialties such as surgery, radiology, and anatomical pathology (AP) have workforce shortages, with attrition during the training phase proposed as a contributing factor. Current understanding of the reasons behind trainee attrition is limited, and there have been calls to increase the depth and richness of research in this area. Exploring trainees' professional identity (PI) development may deepen our understanding of why trainees resign and inform development of appropriate interventions. This study seeks to address this by exploring the field of AP as a model for specialist PI development and asks what factors affirm and/or challenge AP trainees' PI development? A qualitative research approach was undertaken using narrative inquiry. Interviews with AP trainees and consultants in Australia and New Zealand were interpreted as stories through a ‘re‐storying’ process. Story data of doctors' AP training experiences were thematically analyzed using framework analysis. Three themes were identified related to anatomy‐centric specialist training PI: What trainees do (‘learning opportunities’), where trainees learn (‘learning environment and context’), and who trainees learn from (‘people influencing learning’). ‘Learning opportunities’ appeared to be a dominant influence on trainees' PI development. Prominent PI challenges included perceptions of incompetence and dependence during the transition to specialist training and perceptions of disconnectedness throughout training. This study extends existing research to suggest ways educators could support trainees navigating perceptions of incompetence and dependence. Our study highlights how disconnectedness may be a factor in trainee attrition—suggesting that future research into this underexplored theme is warranted.

INTRODUCTION

Healthcare workforce shortages are a global dilemma ¹ , ² creating difficulties for many specialist areas of medicine, including the anatomy‐centric fields of surgery, ³ , ⁴ , ⁵ radiology, ⁶ , ⁷ , ⁸ and anatomical pathology (AP). ⁹ , ¹⁰ , ¹¹ , ¹² These specialist workforce shortages threaten patients' access to appropriate and timely medical care. ¹³ , ¹⁴ , ¹⁵ Contemporary research exploring these workforce deficits suggest challenges with specialty training recruitment ¹⁶ , ¹⁷ and retention ¹⁸ , ¹⁹ of doctors are contributing factors.

Literature exploring recruitment into specialist training has identified that a lack of exposure to specialist placements, ²⁰ , ²¹ , ²² prevailing misconceptions of the specialty, ²³ , ²⁴ , ²⁵ and a lack of specialty‐specific role models and mentors ²¹ , ²⁶ , ²⁷ , ²⁸ are some reasons why doctors do not consider pursuing certain specialties. In a qualitative study, Rozario et al. ²⁹ expanded on this by further characterizing why, when, and how doctors decide to pursue specialty training. The authors identified three portraits of doctors representing factors in choosing specialist training: 1) upon initial exposure prior to medical school, 2) after comparing specialties as a postgraduate doctor, and 3) solely to move away from another specialty during their postgraduate years. Supported by their study findings, the authors ²⁹ proposed a specialty‐specific framework outlining when and how best to target doctors into specialty training programs in an effort to support enhanced recruitment into fields with workforce shortages.

While studies into attrition have suggested factors such as race, gender identity, and dissatisfaction with work‐life balance increase the risk that doctors may leave certain specialty training programs, ³⁰ , ³¹ , ³² much of this literature is dominated by the analysis of survey data or retrospective reviews of trainee records. This limits deeper exploration regarding whether these attrition‐related risk factors are representative of underlying phenomena or if trainees are at increased risk of attrition during certain points in their training progression. Indeed, there have been calls to increase the depth and richness of research in this area ³² to help educators better understand why trainees exit and support the development of appropriate and timely interventions designed to address this trend.

Exploration of professional identity (PI) could be a valuable way to enhance our understanding of why doctors may choose to leave (or remain) in certain specialties. The definition of PI is variable ³³ ; however, core to most PI conceptualizations is a view that PI defines how individuals perceive themselves in the context of their work, ³⁴ in an effort to find meaning in their professional role. ³⁵ Similar to personal identity, one's PI is amenable to change over time as people make sense of interactions they have with others in their professional environment. ³⁶ , ³⁷ Studies have shown a strong sense of PI is linked to factors influencing retention, such as increased job satisfaction and well‐being, ³⁸ and a weak PI is linked to factors influencing attrition, such as burnout. ³⁹ , ⁴⁰ Thus, exploration of specialist‐specific PI development may be a valuable way to enhance our understanding of retention within specialist training.

Mylrea et al. ⁴¹ proposed PI development could be fostered through enhancing health professions students' perceptions of competence, autonomy, and relatedness in practice. This is supported by studies showing that autonomy and competence are linked to specialist‐specific PI development within medicine. ⁴² , ⁴³ In a qualitative study of 23 internal medicine trainees, Sawatsky et al. ⁴³ identified autonomy enhanced participants' PI development by making them feel more responsible for patient care and more engaged in clinical decision making. Through discussion of their personal experience with medical trainees, Sawatsky et al. ⁴² explored the complex interplay between perceptions of competence (in the context of competency‐based medical education) and trainees' PI development. While much of this research has been done outside of anatomy‐centric specialty training programs, the findings may inform the challenges facing these programs' attrition rates. The challenge remains that although perceptions of competence, autonomy, and relatedness may provide insights into influences affirming PI development, exploration of influences challenging PI development remains unclear. This is a notable gap in the literature considering suggestions that supporting trainees to navigate challenges could be profound in strengthening their PI development in the long‐term and influence retention. ⁴⁴ , ⁴⁵ , ⁴⁶

Medical educators—including those within the anatomical sciences—may be well‐placed to support specialist trainees to navigate PI challenges, particularly given the prominence and importance of anatomy within surgical, radiological, and AP training programs. ⁴⁷ , ⁴⁸ , ⁴⁹ However, a robust characterization of the influences to trainees' PI development is likely required before effective initiatives aimed at better supporting trainees' PI development can be developed, and as yet remains underexplored. Thus, this study attempts to address this gap, using the field of AP as a model, by asking the question what factors affirm and/or challenge AP trainees' PI development?

Using anatomical pathology as a specialist model of professional identity

Anatomical pathology is a medical specialty grounded in anatomical sciences and devoted to the tissue diagnosis of disease. ⁵⁰ , ⁵¹ The field faces global workforce shortages ⁹ , ¹⁰ , ¹¹ , ¹² placing at risk patient access to timely diagnosis and treatment, particularly related to cancer care. The literature suggests AP shares similar attrition‐related features with a wide variety of healthcare specialties, including burnout, ⁵² occupational stress, ⁵³ , ⁵⁴ and low satisfaction concerning specialty choice. ⁵⁵ In Australia and New Zealand, the AP career journey also shares a similar trajectory to a wide variety of specialties—including the anatomy‐centric specialties of surgery and radiology—where medical graduates usually enter specialist training following at least two years working as a postgraduate doctor ⁵⁶ with training undertaken via specialist colleges. ⁵⁷ , ⁵⁸

Anatomical pathology also shares similarities with surgical and radiological specialties concerning the prominence of anatomy knowledge required during training. ⁵⁹ , ⁶⁰ , ⁶¹ Like surgeons and radiologists, anatomical pathologists need a solid foundation in the anatomical sciences, and anatomy educators can play a key role in influencing the career choices of the anatomical pathologists of tomorrow. ⁴⁸ Indeed, Rozario et al. ⁴⁸ illustrated how valuable anatomy education can be in influencing students career choice to pursue AP and navigate AP work during periods of technological change.

In addition to the anatomy‐centric nature of AP, other similarities shared between AP, radiology, and surgery also include the importance of the diagnostic role they play in patient care ⁶² and similarities with work undertaken in these roles regarding the evaluation and dissection of human tissues. ⁶³ These similarities between AP and other anatomy‐centric specialties, as well as specialist training in general, form the justification for using AP as a model to further our understanding of specialist‐specific PI development generally, and those with an anatomy focus more specifically.

MATERIALS AND METHODS

Theoretical framework underpinning the study

A social constructionist paradigm ⁶⁴ informed the study design. This paradigm aligns with the view that identities, including professional ones, are strongly influenced by the people, environment, and contexts one interacts with ⁶⁵ and are likely to change over time. ⁶⁶ This aligns with the authors' conceptualization of PI, where PI development occurs from individuals' subjective interpretations of the relationships, institutional structures, and culture they are socialized into at work. ³⁴

Study design

This study used a narrative inquiry approach ⁶⁷ to collect and analyze people's stories of AP training to understand what and how training experiences shape PI within AP. Ethical approval was sought and granted by the institutional human research ethics committee (number 29467). All participants provided written informed consent prior to participation.

Sampling and recruitment

Anatomical pathology registrars/trainees and AP consultants from Australia and New Zealand were purposively recruited to the study using a criteria and theory‐based recruitment strategy. ⁶⁸ Participants were eligible for the study if they were a member of the Royal College of Pathologists of Australasia (RCPA), working as a doctor in AP, and were currently practicing in Australia or New Zealand. Anatomical pathology registrars and consultants were recruited to the study as they could facilitate narration of their experiences during AP registrar training (by providing current and/or retrospective accounts of their experience). Recruitment occurred over one year. Recruitment methods included distribution of promotional material via social media, emails to AP heads of department, word‐of‐mouth, through the RCPA media channels (e.g., college magazine, social media), and snowballing. Eleven participants were recruited.

Data collection

Data collection occurred from February 2022 to January 2023 and involved two elements: a demographic survey and narrative inquiry interviews. Participants' demographic information (e.g., age, gender identity, employment nature and status) was collected through an online survey using Qualtrics (Qualtrics, Provo, UT).

This study included seven AP registrars and four AP consultants (n = 11). A registrar is defined as a doctor undergoing training as a specialist. In North America, the term “resident” is used to denote a doctor of similar status. A consultant is defined as a doctor of senior rank within a specialized field, and who has attained fellowship of the relevant medical college (alternatively known as a “specialist”). Participant reported ages ranged from 27 to 57 years old (mean: 39), and years worked as a medical practitioner ranged from 3 to 32 years (mean: 15). Most participants were employed full‐time at the time of interview (n = 10), but the sector they worked in varied (public sector: n = 8; private sector: n = 3).

Interviews were structured in a narrative style to privilege the participants' perspective and allow them to control the direction and content of the interview. ⁶⁹ To begin, participants were asked to recall and describe memorable stories from their time as AP trainees. Participants had autonomy to choose what stories to tell and how to tell them. Once the interview commenced, participants determined the interview content and direction and were only prompted to elaborate on aspects of their stories or to recall other memorable experiences. Interviews were conducted via Zoom conferencing (San Jose, CA) or face‐to‐face according to participants' choice. Interview duration ranged from 1.0 to 1.7 hours (average 1.4 hours, total interview time 15.7 hours), and were audio recorded. All participants were invited to a follow‐up interview to provide feedback on (and if they deemed necessary, refine) their re‐story, which represented a reconstruction of the participant data into a chronological, synthesized, first‐person account of their experiences. Eight participants completed the follow‐up interview.

We engaged information power—informed by the work of Malterud et al. ⁷⁰ —as the basis for identifying qualitative rigor because of its congruence with our worldview of interpretivism and social constructionism. We applied the principles of information power prior to and during the study. Prior to the study commencing, information power was engaged to anticipate the number of interviews predicted to achieve data sufficiency. During the study, we used information power to assess the point in data collection where we had collected adequate data to answer our research question. Information power for this study was deemed as high and was influenced by the relatively narrow scope of the research question, purposive sampling of study participants, the richness of interview dialogue, and the theory‐informed data analysis strategy used. ⁷⁰

Data analysis

Participants' demographic information, collected via surveys, was analyzed using descriptive statistics. Interview data were initially auto‐transcribed using Otter.ai software (Otter.ai, Mountain View, CA) and edited by the lead author to ensure transcription accuracy and include speech mannerisms (and verbal emotional responses) not initially captured. Data analysis included multiple stages: 1) re‐storying, 2) participant consultation, and 3) thematic analysis of re‐storied narratives.

Re‐storying interviews

Interview transcripts were transformed into a story via a re‐storying process adapted from Ollerenshaw and Creswell. ⁷¹ The re‐storying method aids in sensemaking where the process of deconstructing the interviews and reconstructing them into re‐stories was a necessary part of identifying the key elements of PI development for each participant. Re‐storying can be done through different lenses, defined by Konopasky et al. ⁷² which are applied in the data analysis stage, and include the:

1. Holistic lens, used to synthesize data into an overall interpretation or theme

2. Situated lens, used to foreground the cultural context(s) of narratives

3. Linguistic lens, used to explore the form and structure of narratives

4. Agentive lens, used to understand the purpose of stories

5. Sequential lens, used to order events in narratives, and in doing so, impute causality

As the goal of this work was to explore the longitudinal experience of trainees, the sequential lens was used for data analysis to facilitate organizing the data in a temporal sequence.

The initial stage of re‐storying participants' AP training experiences was data familiarization, which began during the interview transcription stage by the lead author. Familiarization continued as each transcript was re‐read at least two times, and story elements of plot structure (characters, settings, actions) were identified (Table 1).

TABLE 1.

Definition of story elements identified in participant transcripts.

Plot element	Definition a
Characters	Aspects of characters' personality and behavior
Settings	The context, environment, conditions, place, time, and year
Actions	Thoughts, feelings, intentions, steps taken, or reactions

^a Definitions based on Ollerenshaw and Creswell. ⁷¹

Plot structure elements were sequenced chronologically by the lead author, using Microsoft Word (Microsoft, Redmond WA). The table of sequenced elements was used to synthesize participants' transcripts into a concise first‐person narrative of participants' AP training experiences. Participants' linguistic patterns and mannerisms were retained, where possible, to maintain the authenticity of the participant's voice. Verbal mannerisms were maintained in participant transcripts by including communication patterns (e.g., ‘um’, ‘uh’), pauses, notes on tone of voice, and non‐verbal observations (e.g., large sighs) in the transcript text. Early on, re‐stories were cross‐checked by co‐authors (MDL and MKF) for authenticity and reproducibility of the re‐storying process. An example of the re‐storying process used in this study can be found in Appendix S1.

Participant consultation

Of the 11 invited participants, eight completed a follow‐up interview (led by the lead author). A crucial step was to verify that re‐stories resonated with participants before proceeding to data analysis. During participant consultation, participants were presented with their re‐story and were invited to explore their perceptions of the narrative's authenticity to their experiences, the extent to which the re‐story captured all important elements of their AP training experience, or any amendments to the story they would like to make (e.g. alterations, additions, or removal of events).

Four participants altered terminology and added story details during the follow‐up interview, with edits incorporated by the lead author in real time. Edits spanned from grammatical changes to the expansion of stories to include AP training experiences not previously discussed. Participants were sent a final copy of their re‐story post‐edits for their records.

Thematic analysis of re‐stories

Team‐based framework analysis ⁷³ was used to identify themes in all re‐stories as they related to participants' PI development within AP training. This was conducted in five stages: 1) familiarization, 2) identification of a thematic framework, 3) indexing, 4) charting, and 5) mapping and interpretation.

Data familiarization occurred during the re‐storying process. Re‐stories were re‐read at least twice to appreciate the range and diversity of experiences represented. This process continued iteratively while identifying a thematic framework, indexing, and data charting. Re‐stories were coded abductively ⁷⁴ , ⁷⁵ by the lead author, where themes identified related to existing PI development thematic frameworks were applied deductively, and inductive codes were applied that extended beyond this framework. As coding breadth and complexity increased, codes were organized into broad themes and sub‐themes and hierarchically distributed. MDL and MKF reviewed preliminary codes, and as the coding progressed, also reviewed the coding structure and code definitions, iteratively discussing these to finalize the thematic framework.

Following thematic framework finalization, the lead author indexed all re‐stories using NVivo version 12 (QSR International, Melbourne, Australia). The indexing of extracted data was reviewed and discussed by all authors, representing a shared interpretation. Predominant themes/sub‐themes were identified if a theme/sub‐theme featured importantly and/or consistently within a participants' re‐story or across participant re‐stories.

To identify themes/sub‐themes influencing PI development, the lead author performed a second round of coding through the lens of self‐determination theory against the themes of affirming and challenging PI development influences. Affirming influences were deductively identified if trainees reported a sense of competence, autonomy, and relatedness according to Mylrea et al. ⁴¹ Challenging influences were inductively identified beyond the Mylrea et al. ⁴¹ framework when trainees reported the opposite counterpart, defined as a sense of incompetence, dependence, and disconnectedness (Table 2).

TABLE 2.

Definitions used to identify themes/subthemes affirming (A) and challenging (C) PI development.

PI development influence	Definition
Competence (A)	Reporting feeling effective in whatever actions (cognitive and practical) one pursues and performs
Autonomy (A)	Being one's own origin or source of thoughts, feelings, and actions/behavior
Relatedness (A)	Reporting of connection with others, caring and being cared for, and/or having a sense of belonging (to others or to the AP community)
Incompetence (C)	Trainees reporting they lack the qualities, skills, and/or capability expected within AP
Dependence (C)	Reporting that one does not have the right, power, or capability for self‐governance at work, without input from senior colleagues
Disconnectedness (C)	Reporting detachment from others, not being cared for or valued, and/or lacking a sense of belonging (with others or to the AP community)

Abbreviation: PI, professional identity.

To complete mapping and charting of the data, the function of matrix analysis in NVivo was used ⁷⁶ , ⁷⁷ to examine where the initial coding of the dataset (i.e., ‘learning opportunities’, ‘learning environment and context’, and ‘people influencing learning’ themes) intersected with the second coding of the dataset to self‐determination theory.

Reflexivity

A team‐based reflexivity activity was undertaken before study commencement ⁷⁸ to explore how research team experiences and perspectives may impact the interpretation of the data, and routinely explored as the research progressed. Research team members identified as female (three members) and male (one member) aged 30 to 48 years. Research team members had prior experience working in clinical (physiotherapy, medicine) and academic (anatomy and health education research) environments. Although one research team member was familiar with the nature and structure of specialist training in AP, no research team member had been involved in AP specialist training in any professional capacity.

A range of qualitative research experiences were represented by the team, but most research team members had limited prior experience with narrative inquiry methods, which increased as the research process continued and through discussions at team meetings. All members shared an interpretivist and social constructionist worldview and were aligned with the methodological approach used in this study. All members were unified in their goal to explore how we may better support doctors through AP training to increase retention of registrars within the field.

RESULTS

Description of themes

Thematic analysis of re‐stories identified three broad themes, defined below:

• ‘Learning opportunities’: Formal and informal educational activities, roles, and responsibilities undertaken during AP training.

• ‘Learning environment and context’: Perceived working conditions, social factors, and/or expectations influencing AP training.

• ‘People influencing learning’: Perceived attributes of AP consultants and senior AP registrars.

‘Learning opportunities’ was the dominant theme identified, followed by ‘learning environment and context’. All three themes are described in more detail in the following sections.

Learning opportunities

The ‘learning opportunities’ theme describes the formal and informal educational activities, roles, and responsibilities of AP trainees as described by participants. Of the seven learning opportunities identified, trainee participation in cut‐up (where tissue is dissected and sampled in preparation for microscopic examination) and reporting (the process of writing a detailed report describing the characteristics of a tissue sample examined under a microscope) were the dominant subthemes (Table 3).

TABLE 3.

Summary of sub‐themes within the ‘learning opportunities’ theme (dominant sub‐themes denoted with *) with illustrative quotations.

‘Learning opportunities’ theme
Sub‐theme	Definition	Exemplar quote
Cut‐up*	Dissecting and sampling tissue in preparation for microscopic examination	‘I had to dissect this germ cell tumor from this teenage girl which weighed like five and a half kilos… It's challenging trying to figure out how to sample all the different bits of tumor to get all the different looking tumor types.’—Participant 1 re‐story
Reporting*	Providing a diagnosis (verbal or written) on a case based on one's observations, interpretations, or investigations	‘From day one, they expected you to start reporting stuff, which makes you feel as if you have ownership over what you report… When I was training, they had this set‐up where you report in the morning and then double‐head a with the boss in the afternoon. It was really good as a training site. The bulk of my interpretive skill set came from the way I was taught there, which I put mostly down to having to report.’—Participant 6 re‐story
Autopsies b	Cause of death determination through postmortem body examination	‘When I started as a path reg at the hospital I worked, we got 300–360 autopsies a year. So, it wasn't uncommon on Monday for there to be six autopsies. For us, it was easy to do autopsies. I also did two rotations in obstetric hospitals, so I did a lot of perinatal autopsies as well and I was able to use my technical expertise with that too.’—Participant 5 re‐story
Multidisciplinary meetings (MDMs) c	Consultation with non‐AP specialists to discuss patient diagnosis, prognosis, and treatment options	‘Another thing that surprised me when I started was the amount of MDMs pathologists do, and how keen the surgeons are to know the pathology, and how it can influence treatment for the oncologist. I've sat in a good few MDMs but have not presented at them: I've just, sort of, listened to the consultants present.’—Participant 7 re‐story
Structured classes	Trainee participation in tutorials, lectures, and conferences	‘I remember being in a tutorial a couple of months in, where I was asked to diagnose a slide labeled “skin rash”. And it wasn't human tissue, I think it was from a cat. So, it was just me, my consultant, and three other registrars in the room. And I remember trying to describe it like, “Neurocutaneous granulomatous inflammation with hypertrophic nerves” and then I asked, “Is this leprosy?” and they said, “Yes!” I just thought, “Yes! I got it right! I'm learning!”—Participant 1 re‐story
Exams	Participation in formal assessments during AP training	‘I did my part one exam in my fourth year, and I passed! That was a real turning point because that year, the pass rate was only 40% and a lot of people failed that year. It was a really difficult exam. And I passed it! I know I was in my fourth year not my third year, so I'd had that advantage, but it was still a really important moment… It really gave me the confidence to think, “Well, maybe I could be a good pathologist.”—Participant 11 re‐story
Role as a teacher	Involvement in educating or mentoring junior colleagues during AP training	‘I'd say teaching has been a big part of my career, right from when I was a registrar teaching medical students. I do lots of registrar level teaching now, and I just love it. I've always loved teaching.’—Participant 9 re‐story

^a To “double‐head” refers to viewing a histological slide with a double‐headed microscope, such that two people (e.g., a consultant and a registrar) can microscopically examine the same slide together in real time.

^b “Autopsies” are post‐mortem examinations intended to determine the cause of death or extent of disease.

^c Multidisciplinary meetings (MDMs) occur when health professionals from different specialties (e.g., AP, radiology, surgery, oncology) gather together to discuss a patient's care and treatment options.

Trainees discussed the importance of learning how to efficiently cut‐up tissue, but a subset of participants identified struggling with this activity when transitioning to AP training. Others recounted experiences in cut‐up when they dissected interesting tissue (e.g., germ cell tumors), performed cut‐up efficiently (e.g., on busy days), or cut‐up tissue in novel ways (which was well‐received by their consultants). Other trainees, however, discussed being treated like a “cut‐up monkey” where they disclosed that performing too much cut‐up negatively impacted their ability to learn and engage in reporting.

Discussion of reporting opportunities featured prominently within the data, including narrations that exposure to reporting opportunities was beneficial to trainees' learning (e.g., by increasing their interpretative abilities and fostering confidence) and suitably prepared trainees for consultant practice. However, a subset of trainees identified challenges with finding adequate time and identifying people to facilitate reporting opportunities—indicating this was a prominent issue within AP training.

A subset of trainees also described other learning opportunities including participation in memorable autopsies (e.g., interesting diagnoses, the first time they correctly ascertained cause‐of‐death), attendance at structured classes (e.g., during tutorials where they performed well), passing or failing exams, perceived positive and negative interactions experienced during multidisciplinary meetings (MDMs), and their enjoyment of adopting a role as a teacher.

Learning environment and context

Working conditions and social factors influencing perceptions of AP training were identified within the ‘learning environment and context’ theme (Table 4).

TABLE 4.

Summary of sub‐themes within the ‘learning environment and context’ theme (dominant sub‐themes denoted with *) with illustrative quotations.

‘Learning environment and context’ theme
Sub‐theme	Definition	Exemplar quote
Culture*	Perceptions of prevailing attitudes in the AP workplace	‘You interact with lots of people and you're never really alone. It's not as isolating as people make it out to be, you always have someone to back you up. Pathologists are very open and constantly have their doors open to each other. They constantly show their work to each other and ask for advice or second opinions.’—Participant 3 re‐story
Daily organization	Aspects of trainee's daily work (e.g., workload, working hours) which is perceived to be predetermined or arranged in advance	‘I don't like the idea of working myself into the ground and I like the 9–5 work‐life balance, so I think pathology suits me well. In pathology, you've also got your set workloads and once you get that done, you're done for the day, which I like.’—Participant 7 re‐story
Removal from patient contact	Perceptions of not working directly (i.e., face‐to‐face) with patients in AP practice	‘I do miss the patient contact because it was great to get to know the people I was speaking to. It added a bit of variety and there was a lot of intellectual scope. It's funny though, most of the people that I've spoken to in pathology kind of like the fact that they're not having to deal with patients anymore.’—Participant 6 re‐story
Workplace variability	Perceptions of, or discrepancies noted between, AP training environments (e.g., public and private laboratories)	‘I do think that training is probably not as good as it should be. It's very lab dependent. If you end up in a good lab with supportive consultants that put the effort into teach you then, you know, you'll generally do fairly well and be well prepared for your exams. But there are plenty of people who end up in places where they're not as lucky and they don't have consultants that are as involved. And that means that they have to put in a lot of time themselves to get to the same sort of level, which I think isn't ideal.’—Participant 2 re‐story
Nature of knowledge	Perceived expectations of the type and breadth of knowledge required in AP practice	‘I loved that learning element and how broad anatomical pathology was. That it wasn't just this one thing, you know, you had this expectation to learn across the whole body.’—Participant 10 re‐story

This theme was dominated by descriptions of the perceived culture (or prevailing attitudes) within the AP trainees' workplaces. A subset of trainees identified collaboration (where two or more parties work together to share opinions, ideas, and/or knowledge) as a prominent feature, with this collaboration supporting them to make diagnoses, enhance their learning, and foster enjoyment during training. Other trainees also identified a relaxed environment of AP workplaces (free from stress, tension, or anxiety) which fostered the space required to contemplate diagnoses—and this was recognized as beneficial to their learning. A respectful and supportive environment was also discussed to allow a subset of trainees to “thrive” within AP practice.

The subthemes within the ‘learning environment and context’ theme also represents trainee narrations regarding: appreciation of the daily organization of AP work (e.g., having regular working hours and achievable set workloads), perception of being removed from patient contact (which a subset of participants missed, but others appreciated), workplace quality variability in terms of training value between laboratories (e.g., how the range and nature of work differ between public and private laboratories), and the perceived nature of knowledge (e.g., extensive, multisystem) required in AP practice.

People influencing learning

The perceived attributes of AP consultants and senior AP registrars were identified in the ‘people influencing learning’ theme (Table 5). Dominant attributes discussed included the regarded positive and negative aspects of AP consultants' and senior AP registrars' personality and devotion to the profession.

TABLE 5.

Summary of sub‐themes within the ‘people influencing learning’ theme (dominant sub‐themes denoted with *) with illustrative quotations.

‘People influencing learning’ theme
Sub‐theme	Definition	Exemplar quote
Personality*	Aspects of nature, disposition, and temperament	‘There are other consultants who are just very kind and lovely people, who work hard, and try to provide advice to us along the way, so I've learnt a lot from them.’—Participant 6 re‐story
Devotion to the profession*	Perceived enthusiasm, passion, and dedication to teaching	‘I remember one of the guys who I worked with was a few years ahead of me and he was very keen to teach. We'd always go and do multi‐header sessions a together, and he taught me some basics… Those sorts of people shape your experience.’—Participant 5 re‐story
Performance	Related to perceived success and efficiency in role	‘There are pathologists I particularly admire who have a good balance between being thorough but also practical. To me, ‘thorough but practical’ refers to thinking about all the different considerations and picking up everything you need to, but also being efficient in terms of the work.’—Participant 8 re‐story
Aptitude	Related to intelligence or knowledge base	‘There was a pathologist I connected with really well. I saw him as a mentor during my training. I saw him as a mentor even as a consultant, until he retired. He was just clever. He was really clever.’—Participant 10 re‐story

^a “Multi‐header sessions” refer to viewing a histological slide with a multi‐headed microscope, such that a group of people can microscopically examine the same slide together in real time (commonly used for teaching purposes in AP training).

A subset of personality traits (e.g., being caring, social, approachable, and understanding) was identified to support and enhance trainee learning. Other personality traits (e.g., being confrontational) were reported to cause anxiety and inhibit trainee learning. A subset of trainees strongly emphasized the importance of those willing to teach them (senior AP registrars, AP consultants) in the devoted to the profession subtheme. Other trainees recounted stories of memorable colleagues from whom they learned because they were particularly enthusiastic, passionate, and proactive about teaching. Other trainees recounted working in laboratories where they distinguished consultants as not being as devoted to the profession because they were unwilling to teach or provided inadequate supervision by the trainees' standards (e.g., authorizing a trainee‐initiated diagnosis without checking the slides and report).

Impact of anatomical pathology training to registrars' professional identity development

Matrix analysis helped identify coding patterns related to influences on trainees' PI development. This process supported the researchers in identifying that the ‘learning opportunities’ theme had dominant influence in both affirming and challenging trainees' PI development.

Influence of learning opportunities on professional identity development

All ‘learning opportunities’ subthemes were identified to interact with the themes of competence and autonomy in practice (Figure 1).

FIGURE 1.

Results of matrix analysis showing areas of interaction between sub‐themes of ‘learning opportunities’ with PI development influences (De: Dependence; I: Incompetence; Di: Disconnectedness; C: Competence; A: Autonomy; R: Relatedness).

Receiving feedback was identified as an important way a subset of trainees achieved a sense of competence in practice and featured prominently in particular trainee re‐stories, especially when trainees performed cut‐up and reporting work. Other trainees reported receiving positive feedback from senior colleagues (i.e., AP consultants, senior laboratory technicians) on their diagnostic accuracy (e.g., getting diagnoses correct while reporting, performing autopsies, participating in structured classes) as well as other aspects of their work (e.g., being a good teacher, performing well in MDMs, performing cut‐up quickly) made them feel more competent in their role. Other trainees regarded passing exams were an external indication of their competency in practice, letting them know whether they were “on the right track”.

‘Learning opportunities’ appeared to support trainees' sense of practice autonomy when they were supported to work independently (e.g., performing cut‐up by themselves, practice reporting on their own prior to receiving consultant advice, leading MDMs), found enjoyment in their work (e.g., through a love of teaching, being intellectually stimulated during autopsy participation) or decided to actively engage in (and direct the course of) their own learning (e.g., prompted when they passed exams and got diagnoses correct during structured classes). The autonomy subtheme was identified to prominently overlap with both cut‐up and reporting subthemes when trainees reported their consultants encouraged them to work independently and trainees found enjoyment in their work.

A sense of relatedness in practice was achieved when a subset of trainees reflected on the importance (and necessity) of their role in consulting pathologists' ability to undertake diagnoses and patient care, particularly when participating in cut‐up and MDMs and when trainees felt they were looking out for others (e.g., by easing pathologists' workloads when reporting, mentoring junior colleagues, or helping registrar colleagues to study and pass exams).

Cut‐up, MDMs, reporting, and exams were four ‘learning opportunities’ subthemes identified to challenge PI development, and all interacted with a sense of disconnectedness (Figure 1). A sense of disconnectedness in AP training practice was identified from trainee discourse that their work did not align with AP consultant responsibilities (e.g., performing too much cut‐up and/or not getting enough opportunities to report), their role was not valued or understood by colleagues (during MDMs), or they were unsure whether they will ever belong to the AP community (particularly when they failed exams). Importantly, a sense of disconnectedness was identified throughout various stages of AP training in a subset of trainees' re‐stories whereas incompetence and dependence were PI development challenges identified to influence other doctors early in training (particularly during the first six months). Early in training, a subset of trainees perceived a sense of incompetence when they struggled performing cut‐up, explained diagnoses incorrectly during MDMs, or received negative feedback on their lack of diagnostic accuracy during tutorials. A sense of dependence was identified when new trainees were learning to cut‐up tissue and they deemed they had to frequently rely on others' assistance.

Other influences on professional identity development

The influence of the ‘learning environment and context’ and ‘people influencing learning’ themes on AP trainees PI development is shown in Figure 2.

FIGURE 2.

Results of matrix analysis showing areas of interaction between sub‐themes of ‘learning environment and context’ and ‘people influencing learning’ with PI development influences (De: Dependence; I: Incompetence; Di: Disconnectedness; C: Competence; A: Autonomy; R: Relatedness).

‘Learning environment and context’ interacted with a sense of relatedness when trainees considered a collaborative, supportive, and respectful work culture made them feel cared for and valued in their role. Other trainees expressed a sense of autonomy when they deliberately moved through many training sites to gain a variety of experience and enhance their learning. However, the nature of knowledge subtheme overlapped with the incompetence theme where trainees reported struggling to learn the large amount of information required in AP.

‘People influencing learning’ interacted with a sense of relatedness when a subset of trainees reflected that role models who were caring, intellectually honest, and had good social skills (i.e., their personality traits) helped them feel a sense of belonging to the AP community particularly when they were struggling to recognize diagnoses or had failed exams. Role models keen to teach (i.e., devoted to the profession) were identified to help other registrars get through their training, especially when their perceived training conditions were not ideal. Role model aptitude interacted with a sense of relatedness when a trainee reported feeling connected to a “clever” consultant who acted as a prominent mentor for him throughout his training.

DISCUSSION

This study robustly explored affirming and challenging influences on doctors' PI development during specialist training, using re‐storying and thematic framework analysis, to help begin to address the gap in understanding—and attempt to prompt further research—related to specialist attrition. Key themes identified included what trainees do in practice (i.e., ‘learning opportunities’), where trainees learn (i.e., ‘learning environment and context’), and who trainees learn from (i.e., ‘people influencing learning’). ‘Learning opportunities’ was the dominant theme identified and appeared to have the greatest influence on PI development across all affirming (i.e., competence, autonomy, and relatedness) and challenging (i.e., incompetence, dependence, and disconnectedness) influences.

While this study had a unique focus on AP training, the wider literature on specialist PI development supports our study findings that trainees' work fosters competence when doctors receive positive feedback ⁷⁹ , ⁸⁰ , ⁸¹ , ⁸² and cultivates perceptions of autonomy when trainees are supported to work independently. ⁴³ , ⁸³ , ⁸⁴ This wider specialist‐specific literature also supports our study findings that trainees' work fosters relatedness when trainees engage in self‐reflection, ⁴⁴ , ⁸⁵ work within a supportive culture ⁸⁶ , ⁸⁷ and are exposed to specialist role models. ⁸⁶ Despite this broader evidence coming largely from exploring non‐AP training programs—such as general practice/family medicine, ⁴⁴ , ⁸¹ , ⁸² , ⁸⁶ obstetrics and gynecology, ⁸⁵ emergency medicine, ⁸³ internal medicine, ⁴³ and pediatrics ⁷⁹ , ⁸⁰ , ⁸⁴ —this alignment suggests the affirming PI development influences identified in this study could be useful across specialist training. The current study also further extends the field by characterizing challenges of specialist‐specific PI development, an underexplored area of PI formation. Given the paucity of wider literature exploring specialist‐specific PI‐development challenges, the goals of the remainder of this discussion are to: 1) explore how and to what extent PI‐development challenges identified in the current study may be present within the wider literature, 2) discuss the similarities and differences between PI challenges identified in the current study and the wider literature, and 3) propose how this could be useful to support further research exploring ways to address the PI challenges identified in the current study.

Characterization of professional identity challenges during specialist training

This study identified that perceptions of incompetence, dependence, and disconnectedness were prominent challenges to PI development during specialist training. A time‐dependent nature to these challenges was also identified, with incompetence and dependence featuring early in the narrative of participants' training journey and disconnectedness remaining throughout. We were interested in exploring these challenges further both in their definition and how to address them by exploring similarities into the themes identified in this study with those described in the literature. On examination of the broader literature of specialist‐specific PI development, we found that participants' narrations of 1) incompetence appear to align with elements of imposter syndrome, 2) dependence appears embedded within the graded responsibility discourse, and 3) disconnectedness has been linked to attrition from specialist medical programs.

Perceptions of incompetence and imposter syndrome

Participant narrations of incompetence characterized in the current study share some features with imposter syndrome described in the broader literature. Researchers have defined imposter syndrome as a phenomenon where high‐achieving individuals doubt their own intellect, skills, and/or achievements ⁸⁸ and where self‐perceptions of incompetence feature prominently. ⁸⁹ , ⁹⁰ , ⁹¹ This definition overlaps with participant narrations of incompetence identified in the current study wherein some trainees expressed that they lacked the qualities, skills, and/or capability expected within their specialist training programs. However, it is important to note that imposter syndrome is also typically characterized by a self‐perception of incompetence that is out of proportion to a persons' actual competency in practice and is commonly associated with anxiety and depression ⁸⁸ , ⁹² —features not explored in the current study.

Another similarity between perceptions of incompetence identified in participant narrations and imposter syndrome appears to concern the timing of each phenomenon. The current study identified some trainees who narrated perceptions of incompetence on transitioning to AP training, which appeared to resolve over time. This is consistent with propositions that imposter syndrome is more likely to impact doctors during times of career transitions, such as on the commencement of specialist training. ⁹³ , ⁹⁴ , ⁹⁵ Although we do not claim that trainee narrations of incompetence identified in the current study are fully representative of imposter syndrome, the shared features between the two phenomena could support further research exploring whether some activities designed to support those experiencing imposter syndrome could also be used to help address perceptions of incompetence narrated by participants in the current study.

What is currently known is that the provision of immediate, constructive, and thoughtful feedback is valuable to help trainees combat imposter syndrome. ⁹³ , ⁹⁶ Research also suggests that imposter syndrome can be addressed by engaging mentors who openly disclose and normalize shared experiences ⁹⁰ , ⁹³ , ⁹⁶ and by providing trainees with reassurance that their performance will improve over time. ⁹⁴ , ⁹⁷ , ⁹⁸ This begs the question as to whether there is a role for this feedback‐centric approach and mentor engagement (and if so, to what extent) in addressing the perceptions of incompetence narrated by participants in the current study. Indeed, further research would be well placed to explore the potential value of feedback and mentorship in addressing perceptions of incompetence given the findings of this study within the context of the broader literature.

Perceptions of dependence, supervision, and graded responsibility

Perceptions of dependence appear to be embedded within the broader discourse as they relate to supervision during specialist training. The current study defined dependence as trainee perceptions about their reliance on others' assistance to perform their role. In our study, dependence was most prominent when participants were recalling their commencement of specialist training. This aligns with the assertion that new trainees exhibit more dependent decision‐making behaviors, such as heavily relying on senior team members for directing their practice. ⁹⁹ This dependence, however, appears to lessen as trainees learn to adapt to the work of their new role. ¹⁰⁰ The implication of this is that perceptions of dependence are likely a normal and expected part of the early learning process, and that supporting trainees to understand and navigate this challenge may be an important aspect of their PI development journey.

Our study suggests an approach to supporting trainees navigate dependence is by enhancing their autonomy in practice by facilitating independent work. In considering this, there may be a tension that arises between the identified dependence that challenges PI development and that of autonomy that supports PI development. This tension is illustrated by trainee perspectives that close supervision of their practice contradicts their desire for autonomy and leads to feelings of insecurity and demotivation ¹⁰¹ , ¹⁰² but is also a desired aspect of training. ¹⁰¹ , ¹⁰³ , ¹⁰⁴ , ¹⁰⁵ Indeed, it has been suggested that trainees value close supervision to help manage their anxiety and experiences of uncertainty when starting a new role, ⁹⁴ and to provide them with reassurance that they are practicing safely. ¹⁰⁶ , ¹⁰⁷ This tension—between too much or too little supervision—suggests that approaches to support trainees navigating dependence in practice could be most effective through implementation of graded responsibility.

Graded responsibility is a teaching approach where trainees are supported to progressively assume increasing responsibility with decreasing supervision over time. ¹⁰⁸ , ¹⁰⁹ , ¹¹⁰ , ¹¹¹ Proponents of the approach have advocated for more robust implementation of graded responsibility in healthcare training but acknowledge that training programs lack clear guidance on how to achieve this. ¹¹² One way to enhance implementation of graded responsibility in specialist training programs could be through ensuring trainees have realistic expectations of the degree of autonomy appropriate at each level of training. This is supported by evidence that trainees are often unsure of what is expected of them regarding their appropriate skill level and the degree of independent practice they should achieve at each stage of training. ¹¹³ This may lead to a failure in appreciating that perceptions of dependence are likely to lessen over time as they have increasing responsibilities and opportunities to practice. Thus, we propose an effective way to support trainees to navigate a sense of dependence could be through 1) discussing expectations with trainees regarding the level of skill and degree of independence appropriate for their stage of training to help them recognize realistic goals, 2) implementing graded responsibility in practice (i.e., supporting independent work), and 3) reassuring trainees that perceptions of dependence (if experienced) will likely improve over time.

Perceptions of disconnectedness and attrition

Our study identified disconnectedness as a prominent PI challenge affecting participants throughout their training journey, and the wider literature points to disconnectedness as a contributing factor to trainee attrition from specialist training programs. Two key features of disconnectedness characterized in the current study included doctors' perceptions they were not valued or did not belong to their specialist community. Trainee perceptions that they are devalued in their role has also been reported in qualitative studies exploring the experiences of junior doctors ¹¹⁴ , ¹¹⁵ , ¹¹⁶ and has been found to be a prominent reason why doctors decide to quit surgical training. ¹¹⁷ A survey‐based study exploring perceptions of social belonging and well‐being ¹¹⁸ found that surgical trainees who perceived a lack of social belonging to the surgical community were at increased risk of attrition. These studies suggest that trainees' perceptions of disconnectedness could prominently influence doctors' behavior in leaving specialist training programs. Combined with our findings that disconnectedness is related to PI development, this could mean that helping trainees to navigate a sense of disconnectedness in practice may be crucial to supporting their specialist‐specific PI and reducing the attrition risk.

Despite the wider literature providing some insights about how perceptions of incompetence and dependence may be addressed during specialist training, approaches to addressing disconnectedness remain less clear—as our study is one of the first to identify this theme as challenging trainees' specialist‐specific PI development. This area is, therefore, ripe for further research. Our study does suggest, however, a potential way to address disconnectedness through enhancing perceptions of relatedness in practice by: 1) promoting a supportive culture, 2) facilitating role modeling, and 3) encouraging self‐reflection. Further research could look at whether these findings hold up in practice.

Synthesizing approaches to address professional identity development challenges

The PI challenges identified in this study have been linked to attrition either directly, in the case of disconnectedness, or indirectly, in the case of incompetence and dependence. Indeed, it has been suggested that burnout—a prominent attrition‐related factor ¹¹⁹ , ¹²⁰ —is influenced by perceptions of incompetence ¹²¹ , ¹²² , ¹²³ and dependence. ¹²⁴ , ¹²⁵ Thus, a robust approach that addresses and targets each PI challenge identified in this study may be a valuable way to increase retention within specialist training programs.

Figure 3 synthesizes the findings of the current study with the broader literature about specialist PI development challenges to illustrate what is known about current approaches to address trainees' perceptions of incompetence, dependence, and disconnectedness.

FIGURE 3.

Illustration of how educators may support doctors to navigate PI development challenges during specialist training. Perceptions of incompetence and dependence were PI development challenges identified to be prominent during the transition to specialist training in the current study, and approaches to address these challenges appear to be supported by the wider literature. Perceptions of disconnectedness were identified to affect trainees throughout training but remain underexplored in existing literature. The current study suggests educators could address disconnectedness by enhancing experiences fostering relatedness in practice, but further research is likely required.

Strengths and limitations of the study

The narrative interview methods used in this study, purposive sampling of participants, and theory‐informed data analysis facilitated a richness and depth of data with information power. The re‐stories captured key features of participants narratives, with participant consultation confirming only minor refinements to re‐stories were needed, increasing confidence that the re‐storying process authentically captured participants' experiences. Given that PI has elements that are unique to each individual, ¹²⁶ the authors acknowledge this study was unlikely to capture all PI development influences during specialist training, and that there may be other influences not represented by the current dataset.

This study robustly characterized the affirming and challenging influences experienced by trainees within the field of AP. While some parallels can be drawn between the findings of this study and other specialties discussed within the wider literature, it is difficult to confirm to what extent these findings relate to other specialties due to the paucity of literature robustly exploring PI development within non‐AP training programs and the focus of this study on AP trainees. Indeed, further exploration of PI influences in non‐AP fields will be valuable to confirm to what extent these study findings are transferable to non‐AP contexts—particularly those that are patient facing. As such, this study sets a strong methodological foundation to support further PI exploration in both AP and non‐AP specialties.

CONCLUSIONS

This study uses AP as a model to identify experiences influential to doctors' PI development during specialist training. Using narrative inquiry, re‐storying, and thematic framework analysis, this study characterizes three specialist‐specific PI development challenges—perceptions of incompetence, dependence, and disconnectedness. Participants described that their self‐perceptions as incompetent and dependent created challenges for them as they commenced their training journey. Perceptions of disconnectedness, however, seemed to affect participants throughout their training journey. These themes and their timings have similarities with constructs discussed in the broader discourse such as imposter syndrome and graded responsibility. Despite this, the identified theme of disconnectedness remains underexplored notwithstanding its potentially important link to specialist training attrition, particularly in surgical fields.

This study adds to the existing literature by characterizing opportunities to affirm PI development. These affirming opportunities include addressing perceptions of disconnectedness by promoting a supportive training workplace culture, facilitating role modeling, and encouraging self‐reflection. Thus, this work builds foundational knowledge of affirming opportunities and provides a framework for further, intentional investigation of doctors' PI development through all stages of specialist training.

AUTHOR CONTRIBUTIONS

Shemona Y. Rozario: Conceptualization; methodology; writing – review and editing; writing – original draft; visualization; formal analysis; project administration; data curation. Melanie K. Farlie: Methodology; writing – review and editing; supervision; data curation. Mahbub Sarkar: Writing – review and editing; methodology; supervision; data curation. Michelle D. Lazarus: Conceptualization; methodology; formal analysis; writing – review and editing; supervision; data curation; visualization.

ETHICAL APPROVAL

Ethical approval for this study was granted by the Monash University Human Research Ethics Committee (number 29467). Permission to conduct the interviews for the purposes of this research was obtained from all respondents, who were fully informed about the purposes of this research and how their responses would be used and stored.

Supporting information

Appendix S1. Supporting Information.

Biographies

Shemona Y. Rozario, B.Bio.Med.Sci., M.D., Ph.D., A.F.A.N.Z.A.H.P.E., is a medical practitioner who recently completed her doctoral studies in the Department of Anatomy and Developmental Biology, Biomedical Discovery Institute, Faculty of Medicine, Nursing and Health Sciences at Monash University, Clayton, VIC, Australia. Her research interests lie in the professional identity development of doctors after graduation from medical school. She now works as a lecturer in the Department of Medical Education, Melbourne Medical School, at The University of Melbourne, Melbourne, VIC, Australia. She also works as a Learning and Development Specialist at the Postgraduate Medical Council of Victoria (PMCV) where she develops, implements, and evaluates educational training programs for junior doctors and their supervisors in health services across the state of Victoria, Australia.

Melanie K. Farlie, F.H.E.A., B.Physio ., Ph.D ., is a senior lecturer and physiotherapist in the Department of Physiotherapy, Faculty of Medicine, Nursing and Health Sciences at Monash University, Frankston, VIC, Australia. She is also a senior lecturer and research fellow in the Monash Centre for Scholarship in Health Professions Education, education lead for the Monash Musculoskeletal Research Unit in the School of Primary and Allied Health Care, and faculty in the School of Clinical Sciences. She teaches research methods to physiotherapy students, and her research focuses on improving clinical decision‐making in exercise prescription, optimization of training for the health workforce, and service delivery models.

Mahbub Sarkar, S.F.H.E.A., Ph.D ., is a senior lecturer at the Faculty of Medicine, Nursing and Health Sciences at Monash University, Clayton, VIC, Australia. He is also an academic development specialist at the Monash Education Academy and a research coordinator of the Monash Centre for Scholarship in Health Education. He has extensive experience in researching a range of STEMM education issues. His current research interests include developing employability capitals for healthcare students and improving professional learning for tertiary educators.

Michelle D. Lazarus, S.F.H.E.A., Ph.D . , is a professor and Director of the Centre for Human Anatomy Education in the Department of Anatomy and Developmental Biology, Biomedical Discovery Institute, Faculty of Medicine, Nursing and Health Sciences at Monash University, Clayton, VIC, Australia. She is also the Deputy Director for the Monash Centre for Scholarship in Health Education, and her research focuses on understanding how anatomy education can foster healthcare workforce professional identity. She leads the clinical anatomy portion of the undergraduate entry medical degree at Monash University.