Hierarchies and tribes: is it time to reconsider professional identity formation in health professional education?
Background
Professional identity formation is a relatively new concept within medical education. The majority of literature has appeared since the Carnegie Foundation called for its inclusion into curricula on the 100th anniversary of the Flexner Report of 1910 [1]. This report called for faculty to hold students to high professional standards through role modelling and relationship building and suggested that curricula include symbolic rites of passage such as honour codes, pledges, and white coat ceremonies. Since then almost 200 articles have appeared in the medical education literature with a variety of stances and evolving interpretations which have yet to be interpreted through a critical lens.
Methods
We conducted a scoping review of the literature on professional identity formation, and meta-thematic synthesis of the most recent papers by the eight most cited authors. We discuss these in relation to key concepts and theories from the fields of critical theory, sociology, psychology and organisational scholarship.
Results
We present themes and examples from the literature relating to diverse schools of thought on the purpose and process of professional identity formation, alongside a critical analysis of some of the current academic discourses and recommendations for educators. Deductive arguments are presented inline with our results.
We question the educational benefits of espousing idealised professional identities, when the lived experience of learners includes needing to actively mitigate against professional tribes and witnessing the adverse effects of siloed working. We suggest that professional identity is an expression of hierarchy and power, particularly between professions and between those identifying as primary, secondary and community care professionals. Non-traditional students with different tangible social capital related to race, class or gender may find themselves deliberately or unconsciously included or excluded from the professional guidance and mentorship espoused by the Carnegie Foundation. We raise the question of whether professional identity genuinely transcends personal identity and why there are continued gender, race and class disparities between healthcare professions. In an era of identity politics we argue that those with multiple non-traditional characteristics may increasingly face intersecting and compounding disadvantages, exacerbated by cultures of inclusivity and exclusivity according to whether you are perceived to fit within historical professional norms. The cloak of professional identity may also be used to excuse collective behaviours that an individual would not be able to justify, leading to moral distress or injury. Fear of exclusion from a hierarchical closed community may prevent bottom up reform or even criticism of socially accepted but injurious practices. We also argue that the static nature of professional identities is related to an inertia in medical education and training and an inability to adapt to the role fluidity and technological advancements that are increasingly shaping clinical practice.
Discussion/ Conclusions
Our recommendations for educators include transforming education for professional identity formation from a backward looking practice that re-enforces the status quo and potentially exclusionary social norms, to a more forward looking one: fostering a culture of criticality, social action and role fluidity to support much needed reform and a more sustainable future for healthcare.

1. Irby DM, Cooke M, O'Brien BC. Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine. 2010;85(2):220-7