Three perspectives on relational professional identity formation

Abstract

Professional identity formation is an important topic in the higher education and pharmacy literature and a key outcome of the PharmD program. Recently, Neubert et al. explored the impact of the pharmacy curriculum on professional identity formation in a cohort of students by evaluating their responses to a survey administered at 3 time points over a 2-year period (beginning of first, second and third years). Students were asked to describe what they would say to the physician when intervening on behalf of the patient to change a medication because of an allergy. Responses were analysed for the presence of indicators of patient centredness (e.g., demonstrating concern for impact on the patient) and physician collaboration (e.g., having a sense of shared care for a patient) and absence of indicators of physician deference (e.g., demonstrated by the ability to make a clear recommendation)—key aspects of relational professional identity for the pharmacist. Overall, students’ responses failed to meet expectations, often lacking a strong recommendation to the physician to prescribe an alternate drug. Study results suggest that the relational professional identity of students at 3 time points in the PharmD program was poorly developed regarding both patients and physicians. The reasons why students failed to demonstrate a skill they have been taught is open to speculation. I offer 3 perspectives that may inform curriculum delivery and hopefully enhance professional identity formation—issues related to mental models, collaboration and influencing others, and critical thinking and communication skills. The first perspective derives from the field of implementation science, which is concerned with the implementation of evidence-based interventions. The concept of mental models has been proposed as one way to view implementation challenges and guide the selection of strategies to deliver evidencebased interventions. The failure of students to deliver the anticipated intervention in such a real-world challenge could be considered a failure of implementation, possibly due to an existing mental model that fosters a perception of lower status relative to physicians. Such a perception could sabotage the training received related to patient advocacy and in interprofessional collaboration. The second perspective pertains to the concepts of collaboration and influencing others. Status, certainty, autonomy, relatedness and fairness (SCARF) have been described as 5 key areas that influence human behaviour. The SCARF model is based on the premise that the brain seeks to minimize threats and maximize rewards. Accordingly, maximizing rewards should help a person perform better, whereas being in the state of minimizing danger could lead to disengagement. The perception of threats in any of the 5 domains could sabotage the curriculum, while the perception of rewards could strengthen curricular messages and increase students’ confidence. The third perspective pertains to critical thinking and communication skills. Questions are central to both critical thinking and communication. Questioning another person may come naturally to some individuals, but others may be inhibited due to factors such as conditioning or aspects of culture. Hence, question interactions may be viewed as inherently conflicted, rather than collaborative. In the Neubert et al. study, questioning the physician’s choice of therapy may be unsettling for some students. Questioning also occurs internally, in preparation for a pending communication. Adam’s “Question Thinking” theory asserts that the brain works by asking and answering one’s own questions. The actions/behaviours we observe are likely preceded by a (conscious or unconscious) question(s). The (internal) responses to these questions constitute one’s plan for how the interaction will play out. For instance, the student will need to consider the tone, language and complexity to use in delivering the proposed change in therapy. Applying critical thinking skills to the realm of communication, especially questioning skills, is a potential area for exploration. Strengthening the curriculum’s ability to impart PharmD students with a strong professional identity will require some reimagining of the approaches used to achieve this goal. The 3 perspectives I have proposed here may help in this effort.