Professional identity formation of family medicine residents in Singapore: a qualitative study to identify influencing factors

Abstract

Background

Physician burnout and retention are critical challenges in Family Medicine (FM). Professional Identity Formation (PIF) in family physicians (FP) fosters resilience and job satisfaction but is often overlooked in residency training, particularly in predominantly hospital-based programs where residents are disconnected from the primary care community.

Aim and methods

This qualitative study explored FP PIF in a predominantly hospital-based FM residency program in Singapore and identified factors influencing its development. Individual in-depth semi-structured interviews were conducted with FM residents and post-residency FPs selected through maximum variation purposive sampling. Data was collected and analysed iteratively using Braun and Clarke’s reflexive thematic analysis. Cruess et al.’s conceptual model for PIF was used as a sensitising framework, alongside Lankveld et al.’s framework describing psychological processes underlying identity formation.

Results

Thirteen participants were interviewed. Three themes were constructed. First, FP PIF wasunderpinned by four psychological ‘senses’ of competence, connectedness, appreciation, and career trajectory. Second, reflection and socialization drove development of these senses by enabling meaning-making, learning and belonging within the FM community of practice (CoP). Third, residency program features both enabled and/or constrained PIF; while some components scaffolded PIF, more intentional support was needed.

Discussion and conclusion

PIF is a dynamic, context-dependent psychological process shaped by reflective practice, social participation, and program structure. Intentional support through curriculum design and faculty practices may strengthen PIF. These findings extend existing PIF frameworks and have implications for curriculum design, faculty development, program evaluation, and future research on fostering PIF in hospital-based residency training.

KEY MESSAGES

1. This study provides new resident-centered insights on family physician professional identity formation (PIF) in a predominantly hospital-based Family Medicine (FM) residency context.

2. Family physician PIF is formed through developing senses of competence, connectedness, appreciation, and career trajectory, driven by reflection and socialization.

3. FM residency programs can enhance family physician PIF through supportive program features together with faculty development. Program features supportive of PIF include longitudinal clerkships, preceptor roles and structured reflections. Faculty development should be directed at equipping preceptors with the knowledge and skills to facilitate reflection and socialization around PIF.

Introduction

Professional identity is the set of unique values, beliefs, attitudes, and behaviors that define and distinguish a professional group [1]. What constitutes a family physician (FP)’s professional identity is well described – FPs value personal, primary, preventive, comprehensive, continuing, and coordinated healthcare of the individual in relation to his/her family, community, and environment [2–6]. FP professional identity formation (PIF) is the continuous and dynamic process of personal development and social construction in which these core values, beliefs, attitudes and behavioural norms are internalized, so that one thinks, acts and feels like a FP [7,8].

Professional identity increases one’s experience of meaning at work, through strengthening one’s perception of coherence, purpose, and significance [9]. Strong PIF is associated with increased well-being, resilience, adaptability, job satisfaction, and reduced burnout [9,10]. Therefore, nurturing PIF is not merely an educational ideal but a strategic imperative for healthcare systems aiming to retain a skilled and resilient FM workforce and mitigate the high costs of physician turnover. It is also postulated to enhance patient-centred care by enabling nuanced decision-making within complex social interactions and patient-family relationships [11]. Furthermore, FPs with a clear professional identity are able to better collaborate with other healthcare providers and advocate for the unique role and value of Family Medicine (FM) in the healthcare system [12].

However, the nature of FM practice and training may pose challenges to PIF that are unique to FM. FM’s value, skills and scope are harder to define compared to other specialties; personalized, comprehensive, continuing, and coordinated care is not easily measurable [13]. As such, FM is often undervalued compared to other specialties around the world - not only in terms of being perceived as less prestigious [14,15], but also in being underfunded by government healthcare spending [16,17] which can be damaging to PIF. A key mechanism through which PIF develops is socialization with the professional community of practice (CoP), where trainees internalize professional norms, values and ways of being through participation in a community of practice, interactions with role models, and engagement in shared professional discourse [7]. However, the breadth of FM practice necessitates exposing trainees to postings outside the FM CoP; such ‘learning away from home’ can impede socialization within the FM CoP, causing trainees to feel that they ‘lose the general practitioners’ perspective’ as described by Klitgaard et al. [18]. This is not helped by the fact that PIF remains a hidden curriculum [19], alluded to at best [20] in the curricula of FM residency programs worldwide [21–23] and in Singapore [24]. The lack of explicit articulation and intentional support for PIF contributes to slower consolidation of family physician identity [25,26].

PIF is therefore a process we should explicitly seek to understand and intentionally nurture within the FM context. While there is a large body of literature on PIF in health professions education, much of it is in the undergraduate context, in support of medical students in their professional identity formation as doctors [27–30]. Despite postgraduate residency training being a critical time for PIF [31], where work experiences are recognized to contribute to erosion of core values [11], there is comparatively less literature on and support for PIF after medical students transition to postgraduate residency training [32]. There are only three studies that have explored PIF in FM residency training [8,33,34]. Sawatsky et al. described how, amongst FM, internal medicine and emergency medicine residents, hidden ideological expectations such as perfectionism and self-sacrifice gave rise to tensions between personal and professional identities and struggles in PIF during residency [34]. Pratt et al. interviewed FM, surgical and radiology residents, and demonstrated that residents’ professional identities were constructed and evolved through work experiences that prompted identity renegotiation [33]. However in both studies, description of the residency training setting, and thus exploration of how aspects of work experiences specific to FM context influence PIF, was limited. Barnhoon et al. interviewed final-year FM residents on their PIF process, but this was in a predominantly outpatient-based residency program [8].

It is unclear how a predominantly hospital-based residency program structure affects PIF, or how FM residents experience PIF within such programs. Globally, there are settings [35] including the United States [36], South Africa [37], China [38], Taiwan [39] and Singapore [40] in which FM training programs are predominantly hospital-based [35], where residents spend the majority of their training time away from the FM CoP while posted to various hospital departments for breadth of clinical experience.

Therefore, this study aimed to explore the process of PIF among FM residents within a predominantly hospital-based residency program in Singapore. By identifying the key influencing factors, we sought to provide evidence-based guidance for fostering a stronger professional identity during residency training. The study was guided by the following research questions: (1) How do family medicine residents in a predominantly hospital-based residency program in Singapore experience professional identity formation? and (2) What factors influence this process?

Methodology

In this qualitative study, the study team adopted a constructionist epistemological stance which informed the overall research strategy and design. In-depth individual semi-structured interviews were conducted to explore the experiences of FM residents with regards to PIF and its influencing factors within a predominantly hospital-based FM residency program in Singapore.

Study setting and design

The study took place in a predominantly hospital-based FM residency program in Singapore; over a study period of January 2024 to August 2025. In this three-year-long FM residency [41–43] the first two years comprise of hospital-based rotations followed by one year of outpatient primary care. During hospital-based rotations, residents see patients at an outpatient primary care clinic one afternoon a week (Longitudinal Integrated Clerkships, locally known as Residents’ Continuity Clinic, ‘RCC’) under the supervision of a senior FP (‘Preceptor’). An overview of the program structure and features is also provided in Supplementary Appendix A.

Individual interviews were chosen over focus groups to allow in-depth sharing of details that participants may be uncomfortable to share with peers. Interviews were semi-structured, using a topic guide (Supplementary Appendix 2) developed based on a conceptual framework (see section on ‘Conceptual Framework’).

Sampling method and study participants

Current residents and FPs who were previous residents were eligible for participation. Maximum variation purposive sampling was done according to different stages of training: Current Year 1–3 residents (R1, R2, R3), and FPs who previously completed residency training. As PIF was conceptualized as a continuous process, this was chosen as the basis for maximal variation to capture the perspectives of individuals at different stages of developing their FP professional identity. We also chose to approach previous residents who are currently residency faculty because they might be able to reflect on the residency curriculum and program structure from both the resident and educator viewpoints. Eligible participants were invited to participate in the study via email. A member of the study team met with each interested individual to go through the study objectives and procedure in a private setting, before written informed consent was documented. Each participant also completed a self-administered questionnaire consisting of basic demographics and background data (Supplementary Appendix 3), and were reimbursed with $20 grocery vouchers.

The first three interviews were used to pilot the topic guide for each of the subgroups (current resident and post-residency FPs). The subsequent six interviews were to achieve maximal variation in sampling. Through the iterative process of data generation and initial analysis, it became clearer after the first nine interviews with a maximally-varied sample that R3 residents, having experienced the full arc of the residency program, provided the richest and most comprehensive reflections. R3 residents were able to recall and describe their R1-2 experiences in rich detail, draw comparisons to their R3 experience, and articulate their perceptions of how they have changed over time. In comparison, the R1-2 residents interviewed were limited to describing their current hospital rotation and RCC experiences while many of the post-residency FPs were unable to recall their early residency experiences in detail. Therefore, the sampling strategy was reflexively adapted to focus on the R3 resident group in the remaining four interviews, ensuring a depth of data that spanned the entire training experience. Additionally, it was serendipitous that the timing of the last three interviews occurred in the early part of the academic year – a few months after the transition from R2 to R3, while memories of hospital rotations were especially fresh. Final sample characteristics are summarized in the ‘Results’ section.

Conceptual framework

The conceptual framework for PIF by Cruess et al. [7] was used as a sensitizing framework for designing the interview topic guide (Supplementary Appendix 2). This model describes how individuals continuously negotiate and integrate new professional identities through reflection and socialization, as they move from peripheral to full participation within a community of practice (CoP). It also highlights factors that may influence this process such as clinical and non-clinical experiences, formal teaching curriculum, role models and mentors, the healthcare system and learning environment, as well as the attitudes of or treatment by patients, peers, healthcare professionals and the public. The questions in the topic guide aimed to explore how individuals experienced PIF through reflection and socialization, and through interactions with the various factors described in this framework. Different versions of the topic guide were prepared for different subgroups of participants (see ‘Sampling Method and Study Participants’ section). During pilot interviews, the study team found the topic guide questions to be adequately comprehensive, well-sequenced and understandable to participants. Thus, no further adjustments were made to the topic guide.

The study team also used Cruess’ conceptual framework as reference when generating initial codes during data analysis, while employing an inductive approach to identify the relationships within and between the themes. Later during data analysis, Lankveld et al.’s conceptual framework [44], although developed for educator PIF, was also applied. The study team found Lankveld’s description of professional identity as shaped through ongoing negotiation of one’s psychological senses of self (including competence, appreciation, connectedness, career trajectory and commitment) to be consistent with descriptions of PIF in the first few interviews.

The study team found these frameworks to be highly complementary. While both frameworks view identity as developmental and socially-situated, they differ in emphasis. Cruess et al.’s model provided a macro-level overview of external factors influencing reflection and socialization within a CoP, whereas Lankveld et al.’s offered micro-level vocabulary for the internal psychological processes that residents were describing, leading to a richer, multi-layered analysis. An adapted conceptual framework, based on Cruess’s and Lankveld’s models, is presented as Supplementary Figure 1 in Appendix 4.

Data generation and preparation

Participants were recruited between March and December 2024. Individual interviews, each approximately 60–90 min, were conducted either face-to-face or via online video conference.

As most participants were unfamiliar with the concept of professional identity, definitions of professional identity and PIF were included in the topic guide (Supplementary Appendix 2) provided to all participants at least one week in advance. This allowed participants to familiarize themselves with the concepts and to reflect on their training experiences with the interview questions in mind prior to the interview.

Interviews were conducted by MT and MST, with care taken to avoid residents being interviewed by their direct supervisors. Interviewers recorded notes during and after interviews to support ongoing reflexivity (example provided in Supplementary Appendix 5). All interviews were audio-recorded, transcribed by transcribers and de-identified for analysis. Data extracts were edited for readability by removing repeated and filler words, to facilitate presentation of analysis.

Recruitment ceased when the sample was judged to provide sufficient information power [45] in relation to the study aim, the specificity of the participant group, the use of established conceptual frameworks, the quality of dialogue, and the depth of analysis afforded by reflexive thematic analysis (see section ‘Data Analysis’ section below).

Data analysis

Data analysis was conducted following the reflexive thematic analysis method of Braune and Clarke [46]. Reflexive thematic analysis was selected for its suitability in examining professional identity formation as a socially constructed, context-dependent process, while enabling in-depth interpretation of residents’ narratives and acknowledging the researcher’s role in meaning-making.

First, MT and MST independently engaged in familiarisation through repeated reading of transcripts and reflexive note-taking. Second, MT and MST independently did initial inductive coding by tagging portions of data with labels detailing interpretations of meaning, before furthering analysis together through iterative inductive and deductive coding. Third, candidate themes and sub-themes were constructed by MT and MST together, through analytic interpretation of relationships between codes. Data extracts were collated to ensure that candidate themes were supported by participant responses. Fourth, themes and sub-themes were iteratively reviewed and refined by all study team members in relation to both the coded data and the dataset as a whole. Fifth, the study team defined and named the themes and sub-themes to capture their analytic essence. Finally, MT wrote a coherent analytic narrative that addressed study aims, which was reviewed and refined by MST, CSL and YYF.

Throughout the analytic process, MT engaged in regular reflexive discussions with MST and CSL to deepen interpretation, challenge assumptions and refine analytic insights, rather than to achieve coding consensus. NVivo software Version 10 was used to support data organization and management.

Trustworthiness

The team followed Bruan and Clarke’s reflexive thematic analysis reporting guidelines [47] when drafting this article, and created a checklist (Supplementary Appendix 6) to demonstrate adherence to its recommendations.

Iterative data collection (data analysis informed further data collection) and iterative data analysis (data was re-examined with new insights that emerged from data analysis) strengthened the dependability of study findings by being a consistent and traceable process that demonstrates how research findings are derived from the raw data.

Maximum variation purposive sampling, the intentional selection of a diverse sample of participants to capture the broadest possible range of perspectives or experiences, allowed identification of common themes that hold true regardless of the variation and improved the transferability of study findings to other settings.

Post-candidate theme construction, we also engaged participants to explore whether the analytic narrative resonated with their experiences. All participants were invited to provide feedback via email. All participants responded via email affirming that the analytic narrative presented in this manuscript is consistent with their experiences (example in Supplementary Appendix 7), strengthening credibility (the ‘truth value’ or believability) of study findings.

Reflexivity

MT (lead investigator) and MST are female FPs, residency faculty and previous residents. MT was trained in qualitative methodology through a workshop conducted by SingHealth Polyclinics research department. MST has prior experience conducting qualitative research. MT was mentored by CSL, a female FP with a Masters in Health Professions Education (MHPE) and experienced in qualitative and health professions education research. CSL also holds teaching roles in undergraduate and postgraduate education. YYF, who holds a PhD in Education and is an expert in qualitative and education research, provided invaluable guidance and advice.

Investigators practiced reflexivity to support confirmability of study findings. MT recognized that she endeavored to answer this research question because of her role as residency faculty and interactions with her residents – specifically, after noticing that residents’ responses to their training experiences differed depending on how well-formed their FP professional identities were. MT also held the belief that PIF is desirable and confers a positive impact on resident training experience and learning, especially after a review of literature as summarized in the ‘Introduction’ section. As a result, MT desired to support her residents’ PIF, and was aware she had a vested interest in finding actionable areas for improving support for PIF within the residency program. MT and MST possessed detailed understanding of the residency program curriculum and structure as former residents and current faculty members, which informed follow-up questions during interviews and allowed them to probe deeply and thoroughly around participants’ experiences. However, they were also predisposed to assumptions about certain structural program features as facilitators or barriers to PIF due to their own positive or negative experiences during their own past experiences as residents. These assumptions were examined through reflexive journaling, particularly when participants’ narratives diverged from expectations, allowing MT and MST to bracket prior beliefs and approach data analysis with greater analytic openness (examples from MT’s reflexivity journal in Supplementary Appendix 8).

Analysis

Thirteen people were approached; all agreed to participate. The participants included five males and eight females, aged 28–37 years (demographic characteristics in Table 1).

Table 1.

Participant characteristics.

Participant ID	Gender	Age	Position
P1	Female	28	R3
P2	Female	33	Post-residency FP with faculty appointment
P3	Male	32	Post-residency FP
P4	Male	32	R3
P5	Female	30	Post-residency FP
P6	Female	37	R2
P7	Female	29	R3
P8	Male	32	R1
P9	Female	36	Post-residency FP with faculty appointment
P10	Male	34	R3
P11	Female	32	R3
P12	Female	30	R3
P13	Male	29	R3

R: year of residency training; FP: family physician.

Three main themes with four, three and five sub-themes respectively, were constructed (see Table 2 for summary of key and supporting quotes for each theme). Firstly, FP PIF occurs through development of psychological ‘senses’ of competence, connectedness, appreciation and career trajectory. Secondly, reflection and socialization are driving mechanisms of FP PIF. Thirdly, the residency program is a major influencing factor with great potential to both help and hinder PIF.

Table 2.

Summary of themes, subthemes, representative quotes and conceptual linkages.

Theme and subthemes	Analytic summary	Representative quote	Additional supporting quotes
Theme 1. Development of Psychological “Senses” that Anchor FP Identity FM residents’ professional identity forms through four evolving psychological “senses”: competence, connectedness, appreciation, and career trajectory. These “senses” underpin how residents begin to “see themselves” as FPs.
Sense of Competence	Attainment of FP skills and competencies is crucial to be able to identify as one	“I think that professional identity grows as what I do aligns with how I should practice (as a FP). I feel proud of myself when I see my growth in competencies that make me a good FP, like being able to manage a wide range of conditions and addressing concerns in a comprehensive manner (…) and proud of the work we (FPs) do as a community.” (P12, Y3)	“Sometimes, I feel guilty and helpless (…) because I’m not competent in this area yet (…) my patients may not have optimal management because of my lack of knowledge.” (P12,Y3) “During hospital postings (…) people ask, “You’re from FM (…) what would you do for (chronic condition like diabetes)?”. My knowledge still has gaps (…) no confidence to answer their questions now (…) only when I can, then I can call myself a FP.” (P6, Y2) “I think I would be uncomfortable saying that I belong (to the FP professional group) (…) until I can see my patients as well as if they had seen a FP.” (P11, Y3)
Sense of Connectedness	Belonging within the FM community fosters motivation and resilience.	“Feeling that I’m part of this clinic (…) that I belong to this place (…) I take ownership and feel invested in what the team is doing. And because I feel connected, all the more I want to contribute to this place to so that other people also feel as supported as I have been.” (P12, Y3)	“The friends I made (…) all said my personality and strengths really suit the values of FM (…) that’s when I first felt that I belonged in FM.” (P8, Y1) “Having fellow FM friends around helps with emotional support in difficult moments (…) useful to learn together (…) consolidate what we’ve seen or want to see together (…) and talked about how we’d deal with certain cases.” (P6, Y2)
Sense of Appreciation	External validation from patients and colleagues reinforces pride and purpose.	“Seeing a growing appreciation and recognition for FPs (…) within the medical fraternity and society as a whole (…) makes me feel happy, that I made the right choice (to join FM).” (P4, Y3)	“What I enjoy the most and what keeps me going is when the patient shows appreciation. When they say “Oh you know, no other doctor has explained to me about this before, the way you explain it is so clear” or “Thank you for spending time to listen to me, nobody else gave me the time to share this.” (P1, Y3) “I value that they (hospital specialists) see value in our presence, that they are able to tap on our skills and knowledge, rather than us just being an extra person to type notes or run clinics..” (P5, Post-residency FP)
Sense of Career Trajectory	Envisioning future FP roles gives direction and meaning to training.	“If we really know what the life of an FP looks like… we can build on what we lack… and learn better because we have a goal to work towards.” (P6, Y2)	“Having a clear idea of what a career as an FP looks like (…) Through seeing FPs engaged in those roles and having opportunities to interact with them (…) I can say, “Oh, this is who I can potentially be down the road.” (P12, Y3) “In (name removed) clinic, we have a lot of senior FPs who have been through many years of family medicine practice (…) that really helps because we can see the timeline, what their career trajectory was like.” (P7, Y3) “We hear bits and pieces about career options, nothing structured or in-depth (…). It would be better if (…) at the start (…) somebody actually told us about what are the career options, what is the trajectory, what can we expect.” (P6, Y2) “Sometimes I’m still confused what I am doing MMed (Masters of Medicine, Family Medicine) for. (laughs) Everyone, even my own family, keeps asking me (…) what’s this qualification for? It doesn’t seem like it will make a difference to your life after you get it, you can just leave now already and start your own practice. Further FM training qualifications don’t seem to be formally recognised… It’s not very clear what the future implications or purpose of having the MMed qualification are.” (P7, Y3)
Theme 2. Reflection and Socialization as Mechanisms of PIF Identity formation is driven by the dynamic twin processes of reflection and socialization, through supporting the development of psychological “senses” described in Theme 1.
Reflection: Turning Experience into Growth	Enables learning through meaning-making, emotional regulation, and adaptive learning within system constraints.	“If I see a patient with a complaint that I haven’t seen before (…) I write it down and find out more later (…) Like when should I review again? What are the indications to refer? What medicines are available in our formulary for this? (…) The next time I see the same condition, I am faster, more familiar.”(P12, Y3) “Sometimes I leave clinic frustrated by time constraints (…) because I didn’t manage to finish exploring all the issues with my patients. But as I reflect, I’m learning to prioritise. Some issues can wait till the next visit.” (P12, Y3)	“Cases that I feel uncertain about, I will save on a list (…) and see later whether they re-attend clinics or go to the Accident and Emergency (…) so if I did miss anything, that would be when I reflect about what I could have done differently.” (P11, Y3) “I felt disheartened when I tried to propose collaborations to bring something useful (from specialist posting) home (polyclinic), but repeatedly the doors are closed. I realised it’s about having the right people and the right time (…) So that disappointment has now morphed into acceptance, that as a single individual in the grand scheme of things, change is hard (…) make small steps instead.” (P4, Y3)
Socialization: Learning and Persevering through Role Models and Community	Observation of role models and engaging in peer discussions transmits values and practical wisdom.	“We learn through role models… when I see an FP putting it into practice, I feel inspired to do the same.” (P4, Y3) “When we get together and talk about cases, it’s helpful just knowing you are not the only person struggling with the high clinical load.” (P12, Y3)	“Conversations with like-minded people in my clinic helps with frustrations (about the system) (…) speaking with people who want to see change and have tried things (…) getting a deeper understanding of what failed and why it failed (…) it’s heartening because I know I’m not alone.” (P4, Y3)
Socialization: Supporting Career and Purpose	Interactions with FM community of practice supports understanding of career trajectory and sense of meaning and purpose.	“Attending FM seminars and conferences… helps us see what other FPs are doing and how we fit into the community – it gives our training more meaning and purpose.” (P6, Y2)	“Having a clear idea of what a career as an FP looks like (…) Through seeing FPs engaged in various roles and having opportunities to interact with them (…) I can say, "Oh, this is who I can potentially be down the road."” (P12, Y3)
Theme 3. The Residency Program as Enabler and Barrier of PIF Structural elements of training—rotations, continuity clinics, preceptorship, and assessments—shape opportunities for reflection and socialization, either supporting or impeding identity formation.
Hospital Rotations: Building Breadth but Disrupting Belonging	Hospital rotations strengthen clinical competence but limit connection to FM CoP and reflection on FM-relevant aspects	“I can bank on my experiences from those rigorous postings (…) to have confidence, speed and flexibility in switching between different knowledge fields – a hallmark of an FP.” (P3, Post-residency FP) “Most of the week is spent in the hospital, surrounded by non-FM colleagues (…) I wouldn’t remember that I was FM resident – I was a chameleon, trying to be like everyone else. I got lost in the rapid rotations(…) when I start getting a hang of things, it’s time to move on (…) no time for debrief or feedback, not much learning or sense of fulfilment. I didn’t make conscious links back to FM (…) I should have thought about how I would manage these patients in primary care (…) but I didn’t do any of that reflection.” -P7, Year 3 Resident	“I don’t think FM residents are very bonded (…) You don’t cross paths with everyone in the cohort enough to make deeper connections. You only make friends with the residents you do some postings with or those you’re in RCC with. I feel like in other disciplines may be closer because they work together in the hospital all the time, together.” (P5, Post-residency FP)
Primary Care Year: Solidifying Identity through Competency and Connection	Extended immersion greatly facilitates increases in competency and connection, although high workload can impede fidelity to FM values and erode professional identity.	“My professional identity as a FP started getting stronger in R3 (…) being embedded in polyclinic, seeing more patients, interacting with other FPs.” (P9, Post-residency FP with faculty appointment) “Keeping up with 6–7 patients per hour (…) goes against what FPs are trained to do (…) I was unable to use my FP skills (…) and started not to enjoy doctoring because it was dehumanising (…) I felt like an efficient machine rather than a doctor.” (P10, Y3)	“In R3, I could see more of what being an FP was like (…) and find role models. In R1-2, being in the clinic once a week, it’s difficult to see what FPs do.” (P5, Post-residency FP) “In R3, it felt like I have a home.” (P12, Y3) “I feel that my last few patients are shortchanged (…) when I am drained of mental energy and emotional reserve towards the end of clinic (…). I know the care I give is suboptimal (…) so I feel apologetic towards them (…) a sense of moral distress, because I’m not doing the best that I can do for them.” (P11, Y3)
Longitudinal Clerkships (RCCs) – Safe Spaces for Reflection and Belonging	Provided “home base” for reflection and connection with FM community, as well as graduated autonomy and contextualization of learning to FM.	“RCC felt like home (…) a place where I don’t feel like I’m just a manpower headcount (…) a respite from feeling like a foreigner in hospital postings (…) and a constant during the first two years of constant posting changes. When I go back each week it’s like, “(Ah)! This is where I can see myself.” Everything that I’m doing here is directly relevant to my training. My preceptors here are invested in my learning.” (P12, Y3)	“RCCs provide graduated supervision levels (…) so R3s, with more knowledge, skills and confidence (…) are given space to be more independent (…) with the preceptor still around to discuss more complex cases. It is important for residents to have the opportunity to feel they have led patients’ care.” (P9, Post-residency FP with faculty appointment “In R1-2, RCC helped us get more understanding of the primary care setting (…) What am I able to do in clinic? What do I need to do for the patient in this setting? When do I refer on to hospital? Knowing the ‘What can I do (in primary care)?’ was very helpful because (…) I could prioritise what is directly relevant to my work.” (P12, Y3)
Preceptors: Role model, Reflective Partners, and Gatekeepers of Psychological Safety	Preceptors are central to role modelling identity but seldom make PIF explicit.	“She doesn’t just teach us – she walks the talk (…) I learned from the little nuances in how she interacts with patients.” (P1, Y3) “Professional identity is not really something we talk to junior doctors about, (…) it’s the top of the Miller’s pyramid, it should develop when you have the clinical foundation.” (P2, Post-residency FP with faculty appointment)	“When we first transitioned to R3, our preceptor instructed us to save the patients we were uncertain about (…) she would give us her input about what she could have done differently and what we did well.” (P11, Y3) “Preceptors mainly sit-in and observe us (…) there’s not much role-modelling, we don’t see FP skills in action.” (P3, Post-residency FP) “There’s no formal conversation around identity or career (…) Not unless you look for it yourself, or it happens to come opportunistically. This interview with you right now (…) on PIF forced me to reflect (…) would be great to discuss these questions with our preceptors.” (P4, Y3) “In R1, my preceptor was strict (…) I would get scolded, “how come you don’t know”(…). So instead of a refuge… RCC became another source of stress. In R2, under a different preceptor who was more approachable (…) it was more comfortable to raise questions without being judged (…) so I can always go to her, (…) I could learn better.” (P6, Y2) “My R1 preceptor was my one connection to the community (…) we are not around often enough to meet the rest of the clinic doctors. I felt comfortable sharing with her about my work and personal struggles.” (P12, Y3)
Assignments and Assessments: Balancing Structured Reflection and Administrative Burden	Structured assignments and assessments can prompt or stifle reflection depending on approach.	“Usefulness of the Individualized Learning Plan (ILP) depends on the resident. Honestly, I did find it an administrative burden. But as I wrote more ILPs then, I started to appreciate actually why this is important. It helps us to draw boundaries for ourselves (…) Like what are the things that we absolutely need to focus on learning (that are important for FM practice) regardless of service requirements, versus what are things that we have to learn (even if not so relevant to FM) in order to be a helpful member in the department. But many who still see it just as an administrative task will just go to the provided list of posting learning objectives and copy and paste them into their ILP (…) instead of intentionally and mindfully looking at the learning objectives and thinking how to best make use of the rotation to meet these learning objectives.” (P12, Y3)	“The reflection questions are optional, so some residents ignore them. It depends on the preceptors too (…) some provide written comments and further reflective questions (…) others only focus on the medical aspects. (…) reflections and linking back to primary care is not very emphasised by every preceptor.” (P1, Y3) “During (formative) assessments, my preceptor talks about what I need to work on (…) so there was more reflection and knowing what I need to improve.” (P6, Y2) “When I pass Masters of Medicine in FM exam (…) it will be more official (…) like, “Yes, you are safe and able to practise at this level,” (P11, Y3) “Once we turn R3, the message is, "Ok, let’s get you prepared for exams." (…) there’s a lack of opportunity to think about (PIF).” (P1, Y3)

Theme 1: Development of psychological ‘senses’ that anchor FP identity

Participants described their professional identity formation as the progressive development of psychological ‘senses’ – of competence, connectedness, appreciation and career trajectory. These dimensions parallel the psychological processes of identity formation outlined by Lankveld et al. and illustrate the movement from peripheral to full participation on community of practice described by Cruess et al. The stronger and more integrated these senses became, the more confidently residents saw themselves as FPs.

Sense of competence

Residents equated competence with being able to practice according to the standards of the FM community. Perception of growth in FP clinical competencies brought satisfaction and increased identification as a member of the FP community.

I think that professional identity grows as what I do aligns with how I should practice (as a FP). I feel proud of myself when I see my growth in competencies that make me a good FP, like being able to manage a wide range of conditions and addressing concerns in a comprehensive manner (…) and proud of the work we (FPs) do as a community. – P12, Year 3 Resident

Conversely, self-perception of insufficient knowledge or competence evoked guilt and self-doubt, hindering identification as an FP as they felt they had not yet ‘earned’ the title of FP. This aligns with Lankveld’s ‘sense of competence’ as a foundational element of professional identity.

Sometimes, I feel guilty and helpless (…) because I’m not competent in this area yet (…) my patients may not have optimal management because of my lack of knowledge. – P12, Year 3 Resident

During hospital postings (…) people ask, ‘You’re from FM (…) what would you do for (chronic condition like diabetes)?’. My knowledge still has gaps (…) no confidence to answer their questions now (…) only when I can, then I can call myself a FP. – P6, Year 2 Resident

I think I would be uncomfortable saying that I belong (to the FP professional group) (…) until I can see my patients as well as if they had seen a FP. – P11, Year 3 Resident

Sense of connectedness

A feeling of belonging within the FM fraternity emerged when residents’ personal values and strengths aligned with the FM discipline’s ethos and when this was validated by members of the FM community. This sense of connectedness or belonging fostered motivation to contribute to the FM community.

The friends I made (…) all said my personality and strengths really suit the values of FM (…) that’s when I first felt that I belonged in FM. – P8, Year 1 Resident

Feeling that I’m part of this clinic (…) that I belong to this place (…) I take ownership and feel invested in what the team is doing. And because I feel connected, all the more I want to contribute to this place to so that other people also feel as supported as I have been. – P12, Year 3 Resident

Feeling connected to peers also enhanced emotional resilience and collaborative learning. Residents describe mutual encouragement and shared problem-solving as sustaining them through demanding clinical postings.

Having fellow FM friends around helps with emotional support in difficult moments (…) useful to learn together (…) consolidate what we’ve seen or want to see together (…) and talked about how we’d deal with certain cases. – P6, Year 2 Resident

Sense of appreciation

Residents’ perception that their work in FM was valued by patients and the larger medical community reinforced professional pride and renewed commitment to the specialty.

What I enjoy the most is when the patient shows appreciation (…) When they say ‘No other doctor has explained to me about this before, the way you explain it is so clear.’ or ‘Thank you for spending time to listen to me, nobody else gave me the time to share this. – P1, Year 3 Resident

I value that they (hospital specialists) see value in our presence (during hospital rotations), that they are able to tap on our FM skills and knowledge, rather than us just being an extra person to type notes or run clinics. – P5, Post-residency FP

Seeing a growing appreciation and recognition for FPs (…) within the medical fraternity and within Singapore as a whole (…) makes me feel happy, that I made the right choice (to join FM). – P4, Year 3 Resident

These moments of external validation supported residents’ internalization of FM’s values, reinforcing professional identity.

Sense of career trajectory

Understanding of the FP career trajectory supported residents’ ability to envision their future as a FP, provided residents with insights on what they needed to learn to become an FP as well as orientation and motivation towards that career goal.

In (name removed) clinic, we have a lot of senior FPs who have been through many years of family medicine practice (…) that really helps because we can see the timeline, what their career trajectory was like. – P7, Year 3 Resident

Having an idea of what a career as an FP looks like (…) through seeing FPs engaged in various roles and having opportunities to interact with them (…) I can say, ‘Oh, this is who I can potentially be down the road. – P12, Year 3 Resident

If we really know what the life of an FP looks like (…) we can build on what we lack (…) and learn better because we have a goal to work towards. – P6, Year 2 Resident

However, opportunities to learn more about career trajectory were described as variable, with residents desiring earlier and more structured conversations around potential career pathways. When residents lacked clarity about the FP career trajectory, they described having difficulty seeing meaning or purpose in attaining further FM qualifications.

We hear bits and pieces about career options, nothing structured or in-depth (…). It would be better if (…) at the start (…) somebody actually told us about what are the career options, what is the trajectory, what can we expect. (P6, Y2)

Sometimes I’m still confused what I am doing MMed (Masters of Medicine, Family Medicine) for (laughs). Everyone, even my own family, keeps asking me ‘What’s this qualification for? It doesn’t seem like it will make a difference to your life after you get it, you can just leave now already and start your own practice.’ Further FM training qualifications don’t seem to be formally recognised… It’s not very clear what the future implications or purpose of having the MMed qualification are. – P7, Year 3 Resident

Theme 2: Reflection and socialization as driving mechanisms of PIF

Residents described reflection and socialization as the twin engines driving their PIF. Reflection allowed them to make meaning of experiences and integrate learning. Through socialization, they absorbed norms, values and ways of thinking characteristic of FPs. Together, they animated the psychological ‘senses’ described in Theme 1, illustrating how identity formation is shaped and supported by this dynamic interplay between internal meaning-making and external participation.

Reflection: turning experience into growth

Residents consistently linked growth in clinical competence to deliberate reflection on patient encounters. Reviewing challenging cases, tracing outcomes and identifying gaps strengthened their confidence and competence.

If I see a patient with a complaint that I haven’t seen before (…) I write it down and find out more later (…) What are the indications to refer a patient on? How soon I should bring a patient back for review if the patient should be brought back? Even logistical things like what medicines is available in our formulary to give to the patient? (…) The next time I see the same condition, I am faster, more comfortable (managing it). – P12, Year 3 Resident

For the cases that I feel very uncertain, I will save on a list (…) and I will go back and stalk to see whether they re-attend clinics or go to the A&E [Accident and Emergency] (…) so that if in the event that I did miss anything, at least I will learn from that experience. (…) and that would be the time when I reflect about what I could have done differently. – P11, Year 3 Resident

Reflection also helped residents reframe frustration arising from time or system-based constraints. By stepping back to consider broader patient journeys and the challenges of change management, they cultivated adaptive acceptance over helpless disempowerment.

Sometimes I leave clinic frustrated by time constraints (…) because I didn’t manage to finish exploring all the issues with my patients. But as I reflect, I’m learning to prioritise. Some issues can wait till the next visit. – P12, Year 3 Resident

I felt disheartened when I tried to propose collaborations to bring something useful (from specialist posting) home (polyclinic), but repeatedly the doors are closed. I realised it’s about having the right people and the right time (…) So that disappointment has now morphed into acceptance, that as a single individual in the grand scheme of things, change is hard (…) make small steps instead. – P4, Year 3 Resident

Through such meaning-making, reflection became not only a learning strategy but a means for emotional regulation, sustaining motivation and aligning daily work with FM’s values of continuing, patient-centred care.

Socialization: learning and persevering via role models and community

Social interactions were described as important for PIF. Witnessing experienced FPs enact holistic, patient-centred care helped residents to translate ideals into tangible practice.

We learn through role models. When I see an FP putting FM values into practice, it’s different (from reading about it on paper) – I see that it is doable and feel inspired to do the same. – P4, Year 3 Resident

Aside from transfer of knowledge through mutual discussion and sharing of advice, conversations with peers and mentors provided emotional safety and solidarity in the face of workload-related frustrations. Knowing that others shared similar struggles reduced isolation and enabled perseverance.

When we get together and talk about cases, it’s helpful just knowing you are not the only person struggling with the high clinical load. – P12, Year 3 Resident

Conversations with like-minded people in my clinic helps with frustrations (about the system) (…) speaking with people who want to see change and have tried things (…) getting a deeper understanding of what failed and why it failed (…) it’s heartening because I know I’m not alone. – P4, Year 3 Resident

Socialization: strengthening career understanding and sense of purpose

Exposure to and interacting with FPs in diverse roles better enabled them to envision their place within the larger professional landscape and future career trajectories, increasing their experience of meaning and purpose during the course of training.

Attending FM seminars and conferences (…) helps us see what other FPs are doing and how we fit into the community – it gives our training more meaning and purpose. – P6, Year 2 Resident

Having an idea of what a career as an FP looks like (…) through seeing FPs engaged in various roles and having opportunities to interact with them (…) I can say, "Oh, this is who I can potentially be down the road." – P12, Year 3 Resident

Theme 3: Residency program as major influencing factor for FP PIF

Residents described the FM residency program structure as an influential factor that could both facilitate and impede PIF as FPs. Program features such as rotation design, longitudinal clerkships (RCCs), assignments and assessments, and preceptor interactions shape opportunities for reflection and socialization. When well aligned, these experiences nurtured residents’ evolving ‘senses’ of competence, connectedness, and career trajectory; when fragmented, they disrupted the identity-forming process.

Hospital rotations: building breadth but disrupting belonging

Residents appreciated the structured exposure to the breadth and rigor of hospital rotations, which strengthened clinical knowledge and confidence. It allows residents to build a bank of illness scripts, and reinforced the sense of competence essential for FP identity.

I can bank on my experiences from those rigorous postings (…) to have confidence, speed and flexibility in switching between different knowledge fields – a hallmark of an FP. – P3, One-year post-residency FP

However, short and rapidly changing rotations also limited opportunities for reflection and connection with the FM community. Residents described ‘losing sight’ of their FM role while immersed in other specialties’ CoPs, and failing to contextualize their hospital rotation experiences back to the FM context.

Most of the week is spent in the hospital, surrounded by non-FM colleagues (…) I wouldn’t remember that I was FM resident – I was a chameleon, trying to be like everyone else. I got lost in the rapid rotations (…) when I start getting a hang of things, it’s time to move on (…) no time for debrief or feedback, not much learning or sense of fulfilment. I didn’t make conscious links back to FM (…) I should have thought about how I would manage these patients in primary care (…) but I didn’t do any of that reflection. – P7, Year 3 Resident

I don’t think FM residents are very bonded (…) You don’t cross paths with everyone in the cohort enough to make deeper connections. You only make friends with the residents you do some postings with or those you’re in RCC with. I feel like in other disciplines may be closer because they work together in the hospital all the time, together. – P5, Post-residency FP

The 1-year primary care posting: solidifying identity through competency and connection

During the final year, extended time in primary care allowed residents to develop competence and confidence through seeing primary care patients and discussions with other FPs. Increased exposure to FP role models in the clinic community gave them a better grasp of the FP role and career trajectory as compared to during R1-2. They also developed a sense of belonging, as being posted for a longer duration allowed them to form bonds with the community. Unsurprisingly, many residents indicate this period as when their FP identity ‘solidified.’

My professional identity as a FP started getting stronger in R3 (…) from being embedded in polyclinic, seeing more patients, interacting with other FPs. – P9, Post-residency FP with faculty appointment

In R3, I could see more of what being an FP was like (…) and find role models. In R1-2, being in the clinic once a week, it’s difficult to see what FPs do. – P5, Post-residency FP

In R3, it felt like I have a home. – P12, Year 3 Resident

However, when unable to practice FM competencies or values due to high patient load, residents experienced erosion of meaning and even moral distress, which impeded PIF.

Keeping up with 6-7 patients per hour (…) goes against what FPs are trained to do (…) I was unable to use my FP skills (…) and started not to enjoy doctoring because it was dehumanising (…) I felt like an efficient machine rather than a doctor. – P10, Year 3 Resident

I feel that my last few patients are shortchanged (…) when I am drained of mental energy and emotional reserve towards the end of clinic (…). I know the care I give is suboptimal (compared to FP standards) (…) so I feel apologetic towards them (…) a sense of moral distress, because I’m not doing the best that I can do for them. – P11, Year 3 Resident

Thus, this year-long posting in primary care was both the crucible and potential crucifier of professional identity, depending on the balance between learning support and service demands.

Longitudinal clerkship (RCCs): safe spaces for reflection and belonging

RCCs were psychological and educational ‘anchors’ amidst constant flux from hospital rotations. Residents valued RCCs for contextualizing hospital experiences to FM practice, and for offering a stable ‘home base’ and mini-CoP. Graduated supervision in RCCs also helped residents build confidence and capacity for independent practice in a safe and progressive manner.

RCC felt like home (…) a respite from feeling like a foreigner in hospital postings (…) Everything I do here is directly relevant to my FM training. – P12, Year 3 Resident

In R1-2, RCC helped us get more understanding of the primary care setting (…) What am I able to do in clinic? What do I need to do for the patient in this setting? When do I refer on to hospital? Knowing the ‘What can I do (in primary care)?’ was very helpful because (…) I could prioritise what is directly relevant to my work. – P12, Year 3

RCCs provide graduated supervision levels (…) so R3s, with more knowledge, skills and confidence (…) are given space to be more independent (…) with the preceptor still around to discuss more complex cases. It is important for residents to have the opportunity to feel they have led patients’ care. – P9, Post-residency FP with faculty appointment

Preceptors: role model, reflective partners, and gatekeepers of psychological safety

Preceptors emerged as pivotal figures in residents’ identity journeys. They were well-placed to role model how FPs think and communicate, guide reflection, and provide emotional support and career advice.

She doesn’t just teach us – she walks the talk (…) I learned from the little nuances in how she interacts with patients. – P1, Year 3 Resident

When we first transitioned to R3, our preceptor instructed us to save the patients we were uncertain about (…) she would give us her input about what she could have done differently and what we did well. – P11, Year 3 Resident

My R1 preceptor was my one connection to the community (…) we are not around often enough to meet the rest of the clinic doctors. I felt comfortable sharing with her about my work and personal struggles. – P12, Year 3 Resident

Residents also emphasized that psychological safety determined how much they could learn from mistakes. Supportive preceptors encouraged curiosity and reflection; critical or intimidating preceptors hindered both.

In R1, my preceptor was strict (…) I would get scolded, ‘how come you don’t know’ (…). So instead of a refuge… RCC became another source of stress. In R2, under a different preceptor who was more approachable (…) it was more comfortable to raise questions without being judged (…) so I can always go to her, (…) I could learn better. – P6, Year 2

However, opportunities to watch preceptors role-model or for reflective conversations with preceptors were variable and dependant on preceptor or resident initiative.

Preceptors mainly sit-in and observe us (…) there’s not much role-modelling, we don’t see FP skills in action. – P3, Post-residency FP

There’s no formal conversation around identity or career (…) Not unless you look for it yourself, or it happens to come opportunistically. This interview with you right now (…) on PIF forced me to reflect (…) would be great to discuss these questions with our preceptors. – P4, Year 3 Resident

Despite their influence, few preceptors spoke explicitly about professional identity, focusing mainly on clinical competence and exam preparation. As one faculty noted,

Professional identity is not really something we talk to junior doctors about, (…) it’s the top of the Miller’s pyramid, it should develop when you have the clinical foundation. – P2, Post-residency FP with faculty appointment

Assignments and assessments: balancing structured reflection and administrative burden

Reflective assignments (e.g. Individualized Learning Plans and case log writing) were viewed as potentially useful scaffolding for reflection by some, but were not always utilised as intended by others who viewed them as administrative tasks. When guided by engaged preceptors, assignments and formative assessments prompted useful self-assessment and linkage between hospital experience and primary care practice.

Usefulness of the Individualized Learning Plan (ILP) depends on the resident. Honestly, I did find it an administrative burden. But as I wrote more ILPs then, I started to appreciate actually why this is important. It helps us to draw boundaries for ourselves (…) Like what are the things that we absolutely need to focus on learning (that are important for FM practice) regardless of service requirements, versus what are things that we have to learn (even if not so relevant to FM) in order to be a helpful member in the department. But many who still see it just as an administrative task will just go to the provided list of posting learning objectives and copy and paste them into their ILP (…) instead of intentionally and mindfully looking at the learning objectives and thinking how to best make use of the rotation to meet these learning objectives. – P12, Year 3 Resident

The reflection questions (for case log writing) are optional, so some residents ignore them. It depends on the preceptors too (…) some provide written comments and further reflective questions (…) others only focus on the medical aspects. (…) reflections and linking back to primary care are not emphasised by every preceptor. – P1, Year 3 Resident

During (formative) assessments, my preceptor talks about what I need to work on (…) so there was more reflection and knowing what I need to improve. – P6, Year 2 Resident

Summative assessments provided validation of competence, boosting confidence. However, they may impose a pressure to focus to exam performance, potentially at the expense of reflection on their professional identity.

When I pass Masters of Medicine in FM exam (…) it will be more official (…) like, ‘Yes, you are safe and able to practise at this level’, – P11, Year 3 Resident

Once we turn R3, the message is, ‘Ok, let’s get you prepared for exams.’ (…) there’s a lack of opportunity to think about it (PIF). – P1, Year 3 Resident

Discussion

Summary of key findings

FP PIF occurs as the psychological senses of competence, connectedness, appreciation, and career trajectory develop, with competence linked to confidence in independent practice, connectedness linked to belonging and support, appreciation increasing enjoyment and recognition, and career trajectory providing focus and clarity on professional goals. Reflection and socialization are key drivers for FP PIF; while reflection helps residents identify knowledge gaps and manage challenges, socialization fosters a supportive community for learning and insights into career trajectories. The FM residency program in Singapore provides a supporting scaffold for facilitation of PIF while also introducing potential barriers. Hospital rotations support competence-building but can disrupt connectedness; longitudinal attachments and supportive preceptors re-embed residents in the FM community but remain variably enacted; assignments and assessments pose both reflection opportunities and administrative burden or performance pressures respectively.

Comparison with existing literature

A scoping review found that seeing oneself as becoming and belonging to a discipline are important aspects of PIF [48]. This is consistent with Theme 1’s findings, where learners desired not only to feel competent, but also appreciated, connected to the CoP, and able to see who they are becoming.

The psychological ‘senses’ of competence, connectedness, appreciation and career trajectory described in Theme 1 are also similar to those described in Lankveld et al.’s conceptual framework for educator PIF [44]. Theme 1’s resonance with Lankveld et al.’s focus on the ‘internal’ psychological processes of PIF strengthens the credibility of our results, and complements Cruess et al.’s more ‘external’ factor focused framework by adding a new layer of understanding to the clinician PIF process. This aligns with a recent scoping review of PIF in medical education, which discussed the importance of the ‘internal’ PIF process and the need for both the ‘internal’ (psychological) and ‘external’ (socialization) lenses [49]. Notably, however, our data did not reflect a distinct ‘sense of commitment,’ the fifth psychological ‘sense’ described in Lankveld et al.’s framework. Instead, commitment appeared to be implicit and emergent, arising organically when residents experienced alignment across other psychological senses of competence, connectedness, appreciation, and a clear career trajectory. This suggests that, in the context of residency training, commitment may be an outcome of identity consolidation rather than a separate psychological driver, highlighting a potential contextual difference between educator and clinician PIF.

Alternatively, Self-Determination Theory (SDT) can be used as a lens for the ‘internal’ PIF process. SDT posits that individuals experience increased motivation and well-being when their psychological needs for competence, relatedness and autonomy are supported. While there is no direct mention of PIF in SDT, there is some literature describing SDT as a useful model for PIF in teacher professional identity [50] and undergraduate pharmacy students [51]. The psychological ‘senses’ described in our findings have some conceptual similarities with the psychological needs that SDT describes; Residents did describe how developing a sense of competence and connectedness (or relatedness), together with sense of appreciation and career trajectory, enhanced the meaning and motivation they derived from training. Viewed through this lens, supporting PIF may not only be about supporting socialization and reflection, but also about supporting residents’ motivational needs.

Our findings are also consistent with existing literature regarding the central role of socialization in PIF [52]. Applying Vygotsky’s social learning theory [53,54], socialization through interactions with teachers and peers facilitates learning within the learner’s zone of proximal development, with knowledge and skill acquisition supporting identity formation. An earlier study has also emphasized the importance of teachers in transmitting professional values and fostering bonds during the socialization process of PIF [55]. Additionally, our findings align with literature demonstrating a positive relationship between reflective ability and PIF [56]. Rath has suggested that learners can foster PIF through reflection, by critically examining the alignment of their beliefs with professional expectations [57].

Outside of the FM setting, there are several studies on PIF in residents of other disciplines. Chang et al. demonstrated a positive correlation between professional identity descriptors and clinical competency milestones attained in emergency medicine residents [58]. Also in emergency medicine, Yamamoto et al. described how authentic clinical participation, teamwork, role models, and peer interactions during mandatory rotations facilitated residents’ sense of belonging and professional identity development through increasing autonomy and participation in the emergency medicine CoP [59]. Similarly, in internal medicine residents, Sawatsky et al. described that competence autonomously exercised during opportunities for ‘real’ clinical decision-making and responsibility for patient care were closely tied to identity development [60]. Santivasi et al. further described how internal medicine residents continuously reframed their professional identities while navigating tensions between personal ideals, workplace realities, and contextual pressures within residency training [61]. In surgical residency, Bransen et al. showed that both positive and negative ‘role model moments’ shaped residents’ values, behaviors, and career trajectories through observation and reflection [62]. Likewise, Hoang et al. demonstrated in pediatric residency that longitudinal coaching relationships fostered trust, belonging, reflection, and integration of personal and professional identities [63]. Collectively, these studies align with our findings – that supporting the development of competence and connectedness using reflection and socialization within the context of workplace experiences (through opportunities for role modelling, longitudinal coaching and graduated legitimate participation within professional CoPs), are important for PIF during residency training.

Beyond agreement with existing literature that reflection and socialization are important for PIF, this study extends current understanding of reflection and socialization – that they should be directed towards developing the aforementioned psychological ‘senses’ and supported by faculty practices and program structures.

Implications for FM training

Our findings suggest that efforts to support FP PIF should attend to residents’ developing senses of competence, connectedness, appreciation and career trajectory. As reflection and socialization emerged as key drivers of these psychological senses, residency programs may benefit from considering how training environments create opportunities for these processes to occur intentionally rather than leaving them as hidden curriculum.

In particular, the findings suggest value in three areas:

• First, to strengthen residents’ connection to the FM community of practice. Increasing early and sustained exposure to primary care and the FM CoP may help mitigate challenges to identity formation during rapid hospital rotations. As shown in this study, longitudinal integrated clerkships in primary care (RCCs) from the start of training and throughout hospital postings provided opportunities for reflection on FM-relevant aspects and connection to the FM CoP. This aligns with Hansen et al.’s study, where programmatic curricular changes, such as increased contact time with FM mentors and reordering of postings to allow earlier exposure to primary care, positively influenced PIF among first-year FM residents [64].

• Second, to invest in faculty development [26] and support longitudinal relationships with preceptors, especially given the crucial role of preceptors in shaping residents’ professional identities [7,65,66]. Preceptors require support in fostering psychological safety, facilitating reflection, providing effective mentorship and engaging in explicit conversations about professional identity and career trajectories. Providing residents with opportunities to observe preceptors in authentic FP roles, such as during patient consultations, multidisciplinary meetings, or career talks, further leverages on socialization for PIF.

• Third, to create protected opportunities for reflection and dialogue about professional identity. Structured opportunities for reflection should be intentionally designed and supported [67,68]. Assignments such as case logs and Individualized Learning Plans can facilitate reflective learning when their purpose is clearly communicated and when they are meaningfully discussed with preceptors [68,69]. They also provide opportunities for learners to ask questions and allows timely identification of struggling residents for early support. Beyond written reflection, scheduled small-group discussions focused explicitly on PIF may further enhance learning, as demonstrated by Nothnagle’s evaluation of structured group discussions as reflective spaces for final-year GP residents [32].

While these implications arise from the Singaporean FM residency context, they may have relevance for other broad-based, predominantly hospital-based training programs where sustained socialization within a specialty community of practice may be similarly challenged.

Implications for future research

The programmatic recommendations arising from this study may serve as a framework for evaluating residency programs with regards to their support for PIF. Program evaluation studies could examine for the presence and implementation of specific program features such as longitudinal continuity, reflective structures, and preceptor practices. Using these findings as an evaluative lens may allow educators and researchers to more systematically examine the alignment between program design, learning experiences, and professional identity outcomes.

Future research directions

Future studies should explore preceptors’ perspectives on PIF, as preceptors play a central yet underexamined role in shaping residents’ PIF. This would inform targeted faculty development and help bridge the gap between implicit modelling and intentional educator practices.

In addition, several participants described being influenced by how FM is spoken about by patients, the wider medical community, and colleagues within FM itself. Language not only reflects but also constructs professional values and hierarchies. Future research could employ discourse analysis to examine how this language affirms or undermines the value and identity of FM, offering important insights into subtle mechanisms shaping FP PIF. Such work would require discourse-analytic approaches beyond the scope of the present study but could meaningfully complement experiential accounts of PIF.

Assessment design and execution warrant further study, as assessments can shape learners’ orientations toward practice and learning. When aligned with growth and feedback, assessments may support PIF by encouraging reflection and mastery (‘striving to thrive’); conversely, when perceived as high-stakes or misaligned with values, they may prompt surface compliance and erode meaning (‘striving to survive’) [70]. Exploring this relationship would deepen understanding of how assessment practices influence not only development of competency but also PIF.

Finally, a comparative qualitative study between predominantly hospital-based and outpatient-based FM residency programs could help isolate the specific impact of the training environment on PIF, providing even clearer guidance for program design across different contexts.

Strengths of this study

Our study uses maximum variation purposive sampling of current residents from all years of training, and post-residency FPs, to ensure a comprehensive representation of perspectives across different stages of professional development. Additionally, we made efforts to minimize power imbalances between interviewers and participants, and fostered an environment conducive to open and honest dialogue. Furthermore, we practiced reflexivity throughout all interviews, allowing us to critically examine our own assumptions, thereby enhancing the credibility and depth of the findings.

Limitations of this study

There are several limitations of our study. First, transferability may be limited as we did not interview individuals from other training programs in Singapore, where program structure and support differ (More details Supplementary Appendix 1). Secondly, most participants were unfamiliar with PIF prior to the interview, which may have limited the depth of reflections. Third, the majority of participants interviewed were R3s. While this was intentional, as they could reflect on challenges across all three years of training, and recount experiences in detail as memories were fresh, there may still be recall bias and skewing of the data towards perspectives more relevant to later stages of residency. Future studies to include multiple institutions and to interview residents longitudinally through their residency training would be helpful in addressing these limitations.

Conclusion

In summary, PIF among FM residents is a psychological process shaped by the interaction between reflective practice, social participation and program design. This process should not be left as hidden curriculum but prioritized and supported as an important educational responsibility essential to developing resilient and purpose-driven practitioners. In training contexts where residents are frequently separated from their discipline’s community of practice, program structure and faculty practices are particularly critical for supporting PIF. This study expands on existing frameworks and offers practical strategies for how residency programs may intentionally nurture professional identity alongside competence. These findings also have implications for educational design, faculty development, and program evaluation, and provide a foundation for future research on measuring PIF and assessing the impact of PIF-supporting interventions.

Funding Statement

This study was funded by the Family Medicine Academic Clinic Program Philanthropic Fund [14/FY2023/EX/191-A246(a), 14/FY2023/EX(SL)/191-A246(b), 14/FY2023/EX(SLP)/191-A246(c)].

Ethical approval

Ethical approval was received from SingHealth Centralised Institutional Review Board (CIRB Reference Number: 2023/2633). All study procedures were conducted in accordance with relevant ethical guidelines and regulations, which includes the Declaration of Helsinki.

Study team members’ roles

MT and MST conducted the interviews, with CSL supervising the initial interviews. Transcribers transcribed audio recordings of interviews. MT audited all transcriptions for accuracy. MT and MST independently coded and analyzed the data. MT wrote the manuscript. CSL provided supervision throughout the study design, data generation, data analysis and writing process. YY supported conceptualization of study design and the data analysis process.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.