Performing identity within Longitudinal Integrated Clerkships: a multi-site, international exploration

Introduction: Continuity facilitates high quality medical care, yet, most clinical education is fragmented,
devoid of opportunities for students to develop meaningful relationships. Longitudinal Integrated
Clerkships (LICs) have been implemented worldwide to address this fragmentation, promoting ‘student
participation in the comprehensive and multidisciplinary care of patients over time’ (1). Studies have found
LICs attract practitioners to underserved areas and specialities and can mitigate the hidden curriculum.
Less is known about how LICs impart their benefits. One explanation is that LICs strengthen identity
development, which is important for career choice (2). Despite the explanatory potential of this
hypothesis, the impact of the model on identity remains unclear. Therefore, this thesis asks: “How do
medical students construct and perform medical professional identities within longitudinal clinical
placements?”.

Methods: The programme of study included a systematically conducted scoping review and in-depth
longitudinal qualitative study. The scoping review, following Arksey and O’Malley’s framework, mapped
research in regard to identity development within LICs to date to identify gaps in the literature. Operating
from a social constructionist paradigm, a longitudinal qualitative study was conducted, recruiting 33 LIC
students across four institutions within the UK, Ireland and USA, to explore students’ identity development
during their longitudinal placements. In-depth, semi-structured interviews were conducted with
participants at the entrance (n=33) and exit (n=29) of their programme. They also completed audio diaries
throughout their placement. Data were analysed inductively using a reflexive thematic approach and
Goffman’s dramaturgical model (3) was applied as a sensitising theoretical lens.

Results: The scoping review highlighted research that participation in LICs facilitates identity development.
Through contextual continuities and increasing responsibility, students are co-providers of patient care.
Most research conceptualised identity from sociocultural theoretical perspectives. There are studies of
how LICs relate to identity and morals, but these are underdeveloped. In this presentation I will discuss
how the review's findings informed the subsequent longitudinal qualitative study, which identifies four
themes which speak to the ways in which students construct and perform their identities within LICs: 1.
Students’ domains of role within longitudinal placements adhere to more ‘doctor-like’ social norms; 2.
Longitudinal relationships play central roles in role recognition and identity performance; 3. Longitudinal
placement experiences shape performance of moral identity; and 4. Longitudinal placements, voluntary or
mandatory, influence career aspirations.

Discussion and Conclusions: This thesis explores how LICs, through educational continuity, encourage
relationship-building and the realisation of students medical identities. Students roles within LICs (which
are facilitated by the contextual continuities of time and space and the relationships students develop)
permit them to perform identities which adhere more closely to their perceptions of what a doctor is and
should be like, and allow them to receive recognition of their status from others- be that through
becoming a patient advocate, adhering to the status quo of professionalism, becoming increasingly
competent, or assuming an increased level of responsibility. Continuity manifested differently between
sites and systems, though there was evidence of enhanced benefit when students move between settings.

Longitudinal relationships with patients were a site of moral identity development, as continuity of care
challenged the ways in which students thought about patients, promoting person-centred practice.
Placements influenced career aspirations through challenging negative speciality or demographic
stereotypes, highlighting the importance of continuity of care, and facilitating a sense of belonging. By
highlighting the ways in which longitudinal placements influence professional identity development, these
findings offer important insight for health professions education in regard to the future development,
delivery and promotion of LICs. Further, for non-LIC programmes, this thesis offers transferrable findings
regarding ways to centre and encourage relationships which foster identity development within medical
education.

References:
1. Adams J et al. Reflective Writing as a Window on Medical Students’ Professional Identity
Development in a Longitudinal Integrated Clerkship. Teach Learn Med. 2020;32(2):117-25.
2. Richardson PW et al. Teacher professional identity and career motivation: A lifespan perspective. 2018:
Springer. p37-48.
3. Goffman E. The presentation of self in everyday life. Harmondsworth; 1978.