Does Pre-clerkship Medical Humanities Curriculum Support Professional Identity Formation? Early Insights from a Qualitative Study

Abstract

There is a lack of consensus about the outcomes of medical humanities training. In this qualitative study, the authors analyzed pre-clerkship small group discussions to assess the nature of learning in medical humanities. Twenty-two medical students (12 females and 10 males) in three humanities small groups consented to participate. The authors used inductive thematic analysis to qualitatively analyze the text from 13 weeks of curriculum. Findings indicate that students reflect about negotiating the clinician-patient relationship within the stressful environment characteristic of today’s healthcare systems, that they worry about sacrificing their personal values in pursuit of honoring professional expectations, and that they encounter and commonly confront ambiguity. These themes were used to develop a descriptive framework of humanities small groups as a structure and safe space for the early development of professional identity.

Introduction

Medical humanities education has broad and deep intuitive appeal, and medical educators widely accept that good doctors require more than technical skills and knowledge [1]. Yet there is little consensus about what medical humanities training as a whole should be aiming toward [2, 3]. Should humanities curriculum support the development of empathy? Ethics? Humanism? The fact of the matter is that there is little agreement in the field about appropriate outcomes for medical humanities training [2, 4]. Some medical educators have suggested that the goal of humanities is an instrumental goal—visual arts should be used to improve pattern recognition [5] and literature should be used to improve skills for handling medically ambiguous situations, such as diagnosis [6]. Still others advocate that humanities does (and should) affect personal development [7], development of empathy [8, 9], and the deepening of physicians’ capacity for reflection [8]. Kumagai and Wear argued that an important role for humanities (art, in particular) is to “make strange—that is, to trouble one’s assumptions, perspectives and ways of being in order to view anew the self, others, and the world.” [10] These varied definitions suggest that there is a lack of consensus in the field about the most basic question: what is the fundamental nature of medical humanities learning?

To begin to address this question, we conducted an exploratory study to analyze medical students’ humanities small group discussions during the pre-clerkship period of their training. Our study was inductive in that we had no pre-conceived ideas about what we would find. However, it quickly became apparent that our data set was steeped in the concept of professional identity formation.

Professional identity formation (PIF) is the process by which individuals integrate their personal identities with the appropriate roles and forms of their chosen communities of practice, [11–18] and has been identified by the Carnegie Foundation as the essential component of medical education [19]. Using the framework of PIF to contextualize our findings, we examined ways that students in humanities small groups react to challenging material, evaluate new ideas and experiences, and appraise contradictory and conflicting information as they begin to evolve their professional identities.

Method

The Medical Humanities Course

Medical students at Penn State College of Medicine have continuous required humanities coursework for the first 18 months of medical school. Students are assigned randomly into groups of 7–8 that stay together throughout the humanities curriculum, with a goal of equal numbers of men and women in each group. The class meets for 2 hours weekly; the first hour involves a large group session with a focused topic, followed by a second hour of faculty-facilitated small groups, where students can explore more fully the ideas that are introduced in the pre-class assignments and the large group session. To the extent possible, the small group discussion is student-led; the facilitators’ role is to help keep the students focused, illustrate points using their own clinical experiences, and ensure that single students do not dominate the groups’ discussion. Our analysis focused on the initial 13-week Medical Humanities course; data analysis included the sessions identified in Table 1. Sessions 5 and 11 deviate from the typical model for the course and so were excluded for the sake of consistency. Session 5 was devoted to an experiential component to the humanities curriculum, patients as teachers. Session 11 was a 2-hours small group session on the topic of aging.

Table 1.

Thirteen week humanities course

Session	Title	Data included
1	Cultures of Medicine and Medical Education	Group 3
2	Wellness-Illness Continuum	Group 3
3	Empathy	Group 2
4	Suffering	Group 1
5	Patients as Teachers	Not included
6	Virtues in Medicine (Addiction)	Groups 1, 2, and 3
7	Spirituality in Medicine	Group 1
9	Disability	Group 2
10	Family, Friends, Caregivers: The Other Patients	Group 2
11	Aging	Not included
12	Death and Dying	Group 3
13	Joy in Medicine	Group 1

Participants and Recruitment

Participants were first year medical students and humanities small group facilitators. Of the 20 humanities facilitators, we identified nine who facilitated a humanities group for the whole year and were willing to be involved in the study. We then approached their small groups during the first 2 weeks of medical school prior to the beginning of the Medical Humanities course. In order to participate in the study, all students in the group had to agree to participate; of the nine groups, six groups chose to participate and three were randomly chosen for this study. The first year class was comprised of 151 students, including 56% female students. Three groups enrolled in the study, resulting in 22 student participants, 54% of whom were female. Each student was assigned a unique identifier that included their gender, their number within the group, and their group number. For example, M-3-2 is a male assigned the number 3 in his group, which is group number 2. Of the three faculty facilitators, one was a male surgeon with a joint appointment in humanities, one was a female psychiatrist with a joint appointment in humanities, and one was a male family medicine physician. We did not collect data on age or minority status. The IRB at Penn State College of Medicine approved this study.

Data Collection, Analysis, and Saturation

Each small group session was audio recorded in situ during academic years 2015–2016. Of 31 recordings across the three groups, a total of 12 were selected for transcription and analysis (see Table 1). One session was transcribed across all three groups to allow for triangulation of the coders. All audio-recordings were transcribed verbatim resulting in 470 pages of double-spaced text.

We used thematic analysis to analyze the transcripts [20]. The use of thematic analysis is appropriate in the early stages of a research inquiry [20] and involves searching across a data set to find repeated patterns of meaning [21]. Themes were identified inductively, in that data were coded without trying to fit it into a pre-existing frame, and using a realist method, which reports experiences, meanings, and reality of participants [21]. The identified themes were used to develop a descriptive framework of humanities small groups as a structure and safe space for the development of professional identity.

First, four members of the interdisciplinary research team with expertise in qualitative research, pedagogy, humanities, and medicine (RLV, MH, BMT, DW) reviewed and coded one session from each of the three groups to develop an initial codebook. Through an iterative process of four adjudication sessions, common or recurrent codes across groups were identified and a codebook was created and revised as appropriate. The final codebook included derivation of codes and exemplars illustrating each of the codes. We chose to code the students’ reactions and responses only (and excluded facilitators’ reactions and responses) during analysis, since the focus of our study was characterizing medical humanities learning from the student’s perspective.

After the coding scheme was developed, two coders (MH and RLV) used the final codebook to analyze the 12 transcripts using NVivo 11 qualitative software. We decided at the outset to code all transcripts regardless of when data saturation was reached because of the potential uniqueness of the different session topics and small group composition. Saturation was reached by the 9th transcript with no new themes emerging after that point. Throughout the coding process, the two coders met regularly to discuss findings and resolve differences.

Rigor was ensured by triangulation of the data that included multiple coders, regular checks for consistency and consensus in data analysis and interpretation with members of the interdisciplinary team, and adequate sampling for saturation. An end-of-study member check was conducted with two of the three small group facilitators and 5 students from across the three small groups.

Results

Three inter-related themes were identified: (1) students’ perception/understanding of medicine as a profession, (2) students struggling with and reflecting on alignment of personal values and priorities with those of the profession, and (3) students grappling with ambiguity. A descriptive summary of each is provided below.

Theme 1: Medicine as a Profession

This theme included students’ reflections about negotiating the clinician-patient relationship within the stressful environment characteristic of today’s healthcare systems. Two subthemes were identified: (A) students exploring clinician-patient relationships in challenging situations and (B) students expressing concern about what they perceive as the toxic medical environment.

In subtheme A, students often began by describing their hopes of developing patient-centered relationships: “I think for me it is recognizing the [patient’s] underlying emotions and trying to connect....” (F-3-2) However, students quickly went on to relay stories about how hard it sometimes was to maintain those positive connections:

....nobody at the office liked her. I remember, nobody was nice to her. One Monday we came in and she had died over the weekend from a drug overdose, and I remember the main [physician] who took care of her, there was a sigh of relief and he said, ‘thank God.’ And [in my mind] I pumped the brakes and was like, ‘ooh too far,’ and then I challenged myself, why am I putting this premium on empathy now that she’s dead versus when she came into the office. So I kind of had to challenge myself, why are you gonna act like she’s worthy of being cared about now that she’s not even alive versus when she was in the office. Yet going back, I’m still not sure that I could muster the appropriate response for her. (M-3-2)

Students acknowledged that some patients would challenge their ability to achieve their ideal physician-patient relationships: “…there’s always going to be some people or patients that you just can’t stand…I feel like one of the biggest challenges of being a doctor is being able to try and set aside your biases.” (M-1-2) Several students who had firsthand experience with challenging patients shared how they found it difficult to “curb judgmental thoughts.” Students also noted the consequences of losing patient trust, which was thought to be essential to maintaining the ideal physician-patient relationship: “…those [negative] interactions can influence every future interaction for that patient. If they have a terrible interaction with you, they may choose not to confide in their physician anymore.” (F-2-3) In sum, students struggled with identifying what a physician is and how a physician should behave, especially during challenging patient care situations.

In subtheme B, students reflected on the stressful medical environment, and the consequences of that environment on physicians. One student noted, “physicians are kind of required to go fast because they have so much that they need to do within a given amount of time” with the result that “the humanities aspects of things get overlooked and may be short-changed” (F-4-3). Another student reported that a primary care physician he knew felt “as if he was on an assembly line, being told by the hospital he worked for how many patients he had to see….” (M-1-2).

Students expressed sadness and misgiving about the toxic environment they were entering:

It was also really sad the resident who spoke about the other resident who called the cerebral palsy patient like a retard and I feel like… I don’t know, I feel like that does happen a lot. (F-1-2)

…are they a jerk because that’s just who they have always been or are they a jerk because of something that has happened along this process that took them from being a kind, compassionate person to ‘I don’t really give a crap’ (M-3-2).

Theme 2: Exploring Conflicts Between Personal Values and Professional Expectations

Students often struggled with reconciling the disconnection between their personal values and professional expectations. This theme included two subthemes: (A) students worried about sacrificing their personal values in pursuit of honoring professional expectations and (B) students expressed concern about balancing their personal wellness with professional obligations.

In discussing conflicts between personal values and professional expectations, students discriminated between two broad contexts—situations that were urgent or life-threatening and those that were non-urgent. In emergency situations, students were quicker to prioritize professional obligations and set aside personal feelings and values—even as they noted the challenge of having to do so:

…so you have a team of doctors and nurses, all these people that are treating this person to, you know, help him stay alive, and you have to think, he was on a plane [and] tried to kill 250 people, and you have to, you know, set that aside and treat…thinking about myself in that position, how would you be able to let that go and give that person the right care and spend your time on him…. (F-4-2)

I think it comes back to the idea of being professional and just knowing that as a physician, our first and foremost priority is for the patient, like medically, like to treat them, if they’re dying is to save their life, and like even though they may be a criminal that did something we don’t agree with, but they’re still a human life and as a physician we are trained to save that even though after we save them they may still go out and do like things that we don’t agree with or things that are illegal but I don’t think as physicians, we’re the judge of that, and I think there are other people that have been given the role to do that, and as physicians, I don’t think that’s specifically one of our roles. (F-2-2)

One student said it would be “very, very tough for me to set aside my personal feelings” (M-1-2) and care for a known child molester needing immediate treatment. While this student understood that his professional role required him to treat that individual, he questioned whether he could do so without diminishing his ability to empathize and connect with the patient, both of which were personal values that were important to him.

Non-urgent situations involving conflicts between personal priorities and professional expectations seemed to be more challenging, and students struggled to find a suitable resolution that involved neither compromising their own values nor disregarding the professional ideal. For example, one group reflected on what they would do in response to a patient who requested that an African American physician be removed from the patient’s treatment team on the basis of the physician’s race:

… you just can’t go in on like in a shift or in a week completely change their ideas, and be like, you’re not gonna be racist any more cause it’s 2015, it just doesn’t work so…(M-1-1)

Like this is just socially not acceptable. Like if you want to go and ask someone to take the time out to do something for you, you have to appreciate that and that means you respect who they are as a human being….(F-2-1)

In subtheme B, students expressed concern about maintaining their own well-being. They worried that in the process of their professional socialization they might lose track of what is important to them, such as being close emotionally to their family, having an active social life, and pursuing personal hobbies.

It’s all kind of balancing those, kind of two main goals of how hard to we want to work to reach x,y,z goal and… I also want to have fun and have a social life. (M-1-2)

One thing that’s important to me is…balance in your life and then appreciating the people that are in it. (F-2-3)

Something that’s important to me is…making sure I’m still enjoying doing extra-curricular activities. Making sure I’m still making time to see my family… (F-1-3)

Theme 3: Confronting Ambiguity

Many of the sessions introduced topics characterized by uncertainty and ambiguity such as practicing physician addicts. This theme included two subthemes: (A) students questioning stereotypes and easy answers—engaging in deep questioning—and (B) students who were learning and thinking at more of a surface level.

While discussing ambiguous topics, students frequently questioned stereotypes and easy answers (subtheme A):

…you know, the prefix ‘dis’ means like not, so not able, not able to do what? …Disabled to me just sounds like you aren’t able to do anything which certainly isn’t the case, you know, you make accommodations and you adapt, you do things better, you know, than other people do, so you know, you figure out what you need to do. (F-3-2)

During small group discussions, students recognized the risk of making assumptions about others, and the need to avoid simplistic thinking. However, at times during the small group sessions, some students stayed more at the surface level, and were not able to recognize their own endorsement of stereotypes or oversimplifications (subtheme B), especially when it came to other physicians.

First of all, why are they still practicing and second of all, why, how come they didn’t have to go to jail for this? (F-2-2)

I thought what was really scary about it [physicians who described their past drug use while in training] is the fact that he kept mentioning, that there were no consequences at all. And that was completely shocking to me ‘cause he was doing all these things and all the doctors were doing all these things, but, normally, you have somebody who’s doing, you know, drugs and you can see it in their lives, they have problems at work, money problems but this, they were still so successful…. (M-3-3)

Interestingly, small group peers sometimes held their colleagues accountable (subtheme A) for their surface thinking (subtheme B). Students in one group challenged their peers’ assertion that physicians who are former addicts should not be permitted to practice, asking “Would you not let someone with cancer who’s under like chemotherapy operate?” (F-1-2) and “…people who’ve had brain cancer and it’s cured but then there’s the possibility of relapse and they might not notice their cognition declining, should they not be able to practice?” (F-3-2).

Discussion

Medical school is broadly characterized by concrete facts, right or wrong answers, and multiple-choice exams, an orientation that does not often allow for robust consideration of the gray. Medical humanities, on the other hand, is characterized by variable and sometimes conflicting interpretations, dilemmas with no clear right or wrong answer, and problems requiring tradeoffs rather than simple answers. The dissonance that is provoked by this uncertainty provides a liminal space for change—for seeing connections, integrating new ways of thinking, and exploring emergent understandings [22, 23].

Our study of medical students’ humanities small groups sought to explore the fundamental nature of humanities learning, in the hopes of advancing the discussion about educational outcomes of medical humanities curriculum. Our study was inductive in that we had no pre-conceived ideas about what we would discover. We found that the discussions in preclinical medical humanities small groups circled around three broad themes: reflections on medicine as a profession, struggles with aligning personal values and priorities with those of the profession, and exploration of ambiguity and uncertainty. These three themes can be understood, collectively, as the students struggling to create their own conception of what a physician ought to be. Before trainees can assimilate into the profession—engage in the process of becoming the professional—they must have a sense of what it is that they are aiming at becoming. We think our results provide insight into the very early stages of professional identity formation (PIF): learners are discovering and articulating what they want (and do not want) to become—a necessary pre-requisite for the future work of actually becoming the professional.

Related to but distinct from professionalism, PIF occurs through an ongoing process of integrating self-conceptions—attributes, values, and principles by which people define their unique selves—with the appropriate roles and forms of the chosen communities of practice [11–13, 16–18, 24]. While successful formation of a professional identity has been linked to career success, a mismatch or conflict between a person’s internal bearings and the roles and expectations of the profession can create anxiety, frustration, and feelings of inadequacy, sometimes leading the individual to leave the profession [25, 26]. Interest in how medical students construct professional identities has grown substantially in the last decade [27–32].

PIF is affected by a host of variables such as relationships with mentors, role models, and other students [23, 33]; the hidden curriculum and to a lesser extent the overt curriculum [13, 34]; clinical and non-clinical experiences [35, 36]; and personal identity [12, 25]. We recognize that PIF is a complex and ongoing process in which preclinical humanities small groups play only a small role. Nevertheless, they provide a rare opportunity for students to don the mental mantle of a clinician and reflect in a safe space about what type of physician they want to become. Recent research suggests that small group learning impacts students’ professionalism development [22]; the findings from this exploratory study suggest that early-stage PIF may be one way to characterize the potential purpose of preclinical medical humanities training. Future research should examine this possibility, that medical humanities curriculum—and the dissonant, sticky issues that tend to arise therein—may help support the early development of PIF in preclinical trainees.

Our study has several limitations. First, there is the possibility of selection bias, since we studied only those groups whose facilitators and student members agreed to participate in the research. Additionally, since only 3 out of 20 groups (14%) participated in the study, it is possible that themes were missed. This raises questions about whether what we observed in the selected groups was also occurring in the groups we did not select. Relatedly, since this was a single-site study, our findings may not be generalizable to other medical humanities courses at other schools. However, as a qualitative study, the goal was transferability (not generalizability), building understanding for educational practice with a similar cohort in a similar context. Finally, as in other studies of small group settings [37], we noticed that many of the most thoughtful comments came from one of the groups. The group with more thoughtful comments tended to have more on-task time and less passive behavior from group members. This difference could be attributed to facilitator skill or the makeup of the groups—an important area for future study. Future research should seek to conduct multi-site research exploring the nature and purpose of humanities small group teaching and learning.

Conclusion

Kumagi recently argued that one key role of the medical humanities was to disrupt, to complicate: humanities teaches us “to question taken-for-granted assumptions, biases, and ideas; to think of how to look at people and situations with fresh eyes and open minds” [38]. The questioning, exploring, and searching that students do in medical humanities coursework help them explore what kind of physician they aspire to become. This exploration and subsequent articulation of values, preferences, and goals for the future sets the stage for integration of personal and professional identities—for professional identity formation. Our study suggests that medical humanities small groups may support our student colleagues in their difficult task of becoming.

Funding

Characterizing learning and communication in humanities small groups. Woodward Endowment for Medical Sciences Education, 2016–2017.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

The IRB at Penn State College of Medicine approved this study.

Informed Consent

Written informed consent was obtained by every study participant.