#KeyLIMEPodcast 254: The Making of a Young Physician: Supervision, Autonomy, and Identity Formation

The authors in Jason’s selected article looked at professional identity formation, examing both individual and social aspects of behaviour. Using constructivist grounded theory, the authors sought to characterize the relationship between individual aspects and the context in which residents work, with a special focus on autonomy, making decisions, and responsibility for patients. Jason calls the methods in this one ‘exemplary’ – don’t miss out and check it out here!


KeyLIME Session 254

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Sawatsky et.al., Autonomy and Professional Identity Formation in Residency Training: A Qualitative Study. Med Educ. 2020 Jan 28.


Jason R. Frank (@drjfrank)


There is something very special about residency education, that time period between basic medical/health training and practice. When done right, it is magical. We are transformed from scared learners to confident and compassionate and competent clinicians. What is in the secret sauce? There is something about being immersed in health care practice, taking responsibility for aspects of care of patients, enjoying the camaraderie from a shared challenge, having the courage that comes from supervision and previous successes, and the coaching that shapes future performance.

Much has been written about these mystical experiences, but only recently have scholars applied social and cognitive theories to try to explain them. Professional identity formation (PIF) is a current hot topic in #meded, and there are 2 families of relevant theories—those that deal with individual aspects, and those that deal with social / contextual aspects. None have yet been show to adequately explain PIF in residency education.


Enter Adam P. Sawatsky, Fred Hafferty, & co from Mayo…Thinking about professional identity formation, they sought to characterize the relationship between individual aspects and the context in which residents work, with a special focus on autonomy, making decisions, and responsibility for patients.

Key Points on the Methods

The authors used constructivist grounded theory, recruiting 23 Mayo Internal Medicine residents for 1:1 interviews using purposeful sampling. The methods are exemplary for this approach, detailing how they developed and modified an interview guide, recorded interviews, transcribed, deidentified, and coded. The author group walked through their coding process in detail, iteratively using “open” then “axial” coding, then “theoretical” coding.

The authors made an effort to touch on reflexivity, albeit very superficially.

They sought theories that address both individual and social aspects of behaviour to assist with understanding their codes, and chose Bandura’s Social Cognitive Theory and its key element of reciprocal determinism. The latter being the concept that an individual’s behaviour, thoughts, and feelings and their social context interact and influence each other.

Key Outcomes

Setting is Mayo in US. 144 IM residents were invited, 23 were sampled to achieve sufficiency.

Three main themes emerged, as residents talking about developing an identity as a doctor:

  1. Autonomy (context) – the social space to make decisions, even mistakes, feel motivated by responsibility, mediated by supervisor trust, and motivated by high expectations.
  2. Making decisions in patient care (behaviour) – the opportunities to apply what they have learned,
  3. Taking responsibility for patients (person) – being invested, having accountability for patient care.

The authors used a constructivist grounded theory to characterize how Autonomy – Decision making – Responsibility interact in positive and negative ways for PIF. Appropriate measures of each reinforce performance and confidence. Inappropriate levels trigger a retreat and stunted growth.

Their model reflects previous writings by ten Cate on entrustment.

Key Conclusions

The authors conclude that they have characterized the interaction of Autonomy—Decision-making—Taking Responsibility in the PIF that occurs in residency education. They point out the implications for right-sizing supervision: keeping patients safe, but providing the room for residents to grow.

The authors also conclude that therefore CBME can be harmful, which seems like a massive misunderstanding of CBME.

Spare Keys – other take home points for clinician educators

  1. This is a model constructivist grounded theory paper. The writing is elegant for the space provided. A useful template for those exploring this method.
  2. PIF is a hot topic in #meded. It seems important but no one has yet satisfactorily articulated all the implications for #meded.
  3. The paper is also an example of a program of research and dividing distinct findings into a series of papers.

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