The Impact of Globalization on Medical Students' Identity Formation

Globalization on medical education and health care allows medical students, medical trainees and medical doctors to study and work in different countries with various cultural contexts. Despite understanding that this is inevitable nowadays, it introduces certain challenges in medical education especially in preparing medical students and medical trainees who are prepared to socialize and interact with different culture. The process will be facilitated by solid professional identity formation as part of professional development of medical students and trainees who are becoming future medical doctors. This literature review aims to explore personal and professional identity formation and how medical education may support medical students to be culturally aware and competent in facing changing and dynamic world. 


Introduction
Nowadays, medical students, medical trainees and medical doctors are increasingly moving from one cultural context to another as part of globalization. 1,2 In spite of that, this development is based on the assumptions that medical competence is universal. However, differences of medical competence, including professionalism, in different countries should be embraced. 3 Some studies have identified challenges and cultural transitions for international medical students, 4,5 nevertheless a very limited study has explored the impact of the transitions to their professional identity. 2 Professionalism has been emphasized strongly in medical education in the past several decades. According to systematic review completed by Wilkinson et al, 6 professionalism is defined into five key aspects which concern with adherence to ethical practice principles, effective interactions with patients and the significant people to patients, effective interactions within the health system, reliability, and commitment to improvement of competence in oneself, others, and systems.
The definition is considered complex, 7 hence it gives a challenge in the effort of developing professionalism among medical students. It is argued that medical education should move from discussing ethical and scientific aspects of professionalism to the complexity of professional identity formation. 8,9 It is also proposed that a fifth level should be added at the apex of the Miller pyramid. 10 The highest level should be 'is' which defines as capacity to consistently demonstrate the attitudes, values, and behaviours expected of one who has come to think, act and feel like a physician, rather than 'does' which reflects demonstration of behaviours expected of a physician. 11,12 This paper highlights current arguments on the impact of globalization on medical students' identity formation as part of an ongoing efforts in developing professionalism as future medical doctors.

Identity Formation
Identity and identity formation of medical students cannot be marginalized in recent era of medical education because they may affect medical students' relationships with patients, with doctors and with themselves. 13 An identity formation is an adaptive developmental process that happens simultaneously at two levels: (1) at the level of the individual, which involves the psychological development of the person and (2) at the collective level, which involves the socialization of the person into appropriate roles and forms of participation in the community's work. 14 According to Hafferty, 15 the fundamental uncertainties that underscore clinical decision making and the ambiguities that permeate medical practice, require a professional presence that is best grounded in what one is rather than what one does".
Identity is defined as a personal and internal project of the self and treated as if it is something to be worked on. 16 Individuals develop themselves in progressively more complex system for making sense of the world . 17 As a matter of fact, in addition to the internal construct, identities are a product of intersubjective and external social processes. 13 Identity is a dynamic construct which is constantly transformed. The construction and reconstruction of identity suggest the importance of daily social activities and the use of language and artefacts in one's life. The identity formation involves individual cognitive and social processes. The cognitive process will create a complex multidimensional classification of ones' places in the world as individuals and members of collectives. 18 The interaction and context in which people live, as what happens in academic and clinical settings for medical students; will affect the identification and identity formation. Monrouxe et al 13 suggests that the dynamic of identity formation will be influenced by the individual, the interactional and the institutional aspects.

Identity: The Cognitive Process (Who I Think I Am and Who I Think You Think I Am)
Identity formation begins since childhood through separation of significant others and self and development of language. At early stage, the external factors predominates the process. At this stage, external authoritative power exceeds internal responses (how things are). This process which takes place in gender identity, social class, and ethnicity identity is a primary identity formation. 13 Each individual has identity capitals which comprises tangible aspects (e.g student's social class, gender, prior degree(s), membership of clubs, etc) and intangible aspects (e.g ego strengths, self-esteem, a sense of purpose in life, the ability to self actualise and critical thinking abilities). 19 Given the dynamic nature of identity formation, ones from various backgrounds may be at risk for identity dissonance when the personal identities are dissonant with current or expected identity.
For example, medical students with disadvantage backgrounds may feel that they do not belong to the new medical education environment. One factor is the lack of tangible identity capital assets. Underperforming students often have difficulties in integrating their personal and professional identities. Such identity dissonance can lead to maladaptive coping mechanisms. On the other hand, those students with certain background and greater tangible and intangible assets can be more consonant with the environment and may find constructing new personal and professional identities easier. 20 An individual has its own multiple identities according to four different models: intersection, hierarchy, compartmentalisation and merging. 21 The use of the models will define how an individual see him/herself or others as in-group or out-group. For example, E, as a male, medical student and moslem. The implementation of the four models and their impacts will be as follows: 1. Intersection: E identifies himself as the three identities (male, moslem, medical student). Therefore, he feels that he is in-group when he is among a group of male, moslem, medical students and feels that he is out-group otherwise. 2. Hierarchy: despite recognizition of all of those identities, E places his identity as medical student as the most important. The out-group feeling when he is among medical student hence decreases even though he may feel closer to those who are male and moslems. 3. Compartmentalisation: E practices differentiation and isolation of multiple identities he has, depending on the context. When E is among medical student, his identity as a medical student is more dominant, whereas at some other occasions his actions will be defined by his other identities. 4. Merging: E is able to hold a complex representation of identities he has into a merged in-group identity that is highly inclusive and divergent.

Identity Formation: The Interactional Process
Identities are defined through continuous interactions as individuals would attempt to manage impressions of others of themselves and the identities they claim. 23 Individuals will use language or narratives to make sense of their experiences and to position themselves within cultural and social expectations. This interactional process of identity is argued to have a strong impact in medical education. 24 First, medical students are placed in certain situations, environments, activities related to relationships with medical doctors, medical teachers, residents, other health professionals, administrative staffs etc in their daily activities. Second, they are all people who have their own identification of themselves with own personal, emotional and cultural values i.e personal identities which influence their professional identities.
The rituals which show how medical doctors would think, speak and act therefore will be quite powerful for medical students' professional identity formation. 13 This process is also recognized as socialization which includes complex networks of social interaction, role models and mentors, experiential learning and knowledge acquisition which gradually determine how students can think, act and feel like a physician. 11,12 Identity Formation: Institutional Setting Institutions are where patterns of behaviour are embodied and established over time as 'the way things are done'. 24 The individual and interactional processes of identification should always be understood within specific institutional context in which it is constructed. This also includes any implicit rules and values which are reflected in practice. 12 Students who have internalized certain aspects (how things should be done) have the potential to challenge how things are done if those are conflicting. This is called as 'secondary adjustments' in which relatively powerless individual protect their interests and identities. 25 According to Goldie, 26 a medical student's identity can be classified at different levels: 1. Ego identity, is the fundamental subjective sense of continuity characteristic of the personality which is affected by intra-psychic and biological factors. The ego identity will be stronger when it is challenged to effectively manage information about itself and its environment. 27 2. Personal identity, is the interaction of individual uniqueness of their learning/life history and social identity of medical students. At this stage, the individual style can be constructed which however limited by institution's boundaries. 3. Social identity, the student creates identity as expected by cultural and role-related pressures.
The identity of the medical student is affirmed or denied in the interactions with others.

Professional Identity Formation
Professional identity formation is a series of integrated developmental process which incorporates core values, moral principles and self awareness. 28 According to Cruess et al, "A eJKI Vol. 6, No. 3, Desember 2018 physician's identity is a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting, and feeling like a physician". 11,13 There are three principles to be noted in discussing professional identity formation: 11,12 1. The personal identity of individuals, including of medical students or residents, is the foundation for further professional identity formation as they will undergo a lot of transitions in their training. The significant aspects of the personal identity will still be present in the future. 13, 29 2. Individual's internal and external factors such as gender, culture, family and friends will always be influential despite subsequent physical and cultural isolation and future career selection. 13 3. According to developmental theory, 17 identities of incoming medical students and residents are still in formative state. It is maybe more susceptible to the influence of culture and learning environment. One would not expect a fully developed professional identity whose personal and professional values are fully integrated and consistently applied, early to mid 30s, according to Kegan's last stage. 14 Holden et al 28 suggests that professional identity formation is an integration of three domains which are professionalism, identity development and formation. The professional identity formation requires a significant process called socialization in which personal experiences, reflection of the experiences and social interaction take place in a learning environment. 30,31 The experiences are filtered through individual reflection and the unique filter of each individual leading to exploration and commitment to certain professional identities. 28 All learning environments where medical students and residents have the training hence are very influential for their professional identity formation. 15 These also include the health system in which the medical training takes place. In medical training, students will increasingly connect their identity with their roles as medical student, resident or house officer, consultant or clinical supervisor. 11 An individual becomes an accepted member of a certain professional culture once he/she can display the relevant norms, values and behaviours according to the required role. 2 A definition of good physician is suggested to be a socially negotiated ideal. 32,33 Certain core values and expectations such as the desire for a caring and compassionate physician who will listen are universally accepted yet some individual, national and cultural differences are to be considered in defining the good physician. As identity is constantly transformed, this ideal is also consistently negotiated according to changes in inside and outside of medicine. 32

Figure 1. Domains of Professional Identity Formation 28
Based on Erikson's development theory, Marcia 34 provided descriptions of various states of identity formation. According to Marcia,34 there are four statuses of identity development: diffusion, moratorium, foreclosure, and achievement. The status describes the balance between exploration of developmental alternatives and commitment to the adopted options. They are not sequential and each individual may move and revisit among the statuses as needed. 34 Identity diffusion reflects little exploration of identity options and little commitment to any identity, whereas the identity achievement signifies commitment of individuals to certain identities after appropriate exploration. Those in foreclosure demonstrate strong commitment without preceding exploration and those in moratorium show significant exploration without commitment.

Globalisation and Professional Identity Formation
As mentioned above, the ideal professional attributes is complex and in accordance with the dynamics in and out of medicine including the health system and socio-cultural contexts. Expectations of people in certain sociocultural contex to medical professions can be different. [35][36][37] For example, Al-Eraky et al 35 study in Arabian countries identified the 'Four-Gates' of medical professionalism: Dealing with Self, Dealing with Tasks, Dealing with Others, Dealing with God. In addition, in the eastern context, physicians have more authority in decision-making processes than patients whereas the balance is more directed toward patient autonomy in western context. 36,38 Another example would be in regards to being accessible to patients which is more essential among Asian and North American doctors than it is among UK doctors. 39 Patient's privilege and confidentiality vary considerably in different contexts. For example, physicians in Saudi Arabia have to obtain consent to interact with female patients from their male guardian (a husband, father, brother or son). On the contrary, in countries such as Netherlands, children younger than 18 years old are allowed to request physician-assisted suicide. 37 Based on the analysis of Bushido which appreciates rectitude, courage, benevolence, politeness, honesty, honor and loyalty, Nishigori and colleagues 36 also argued a concept underlying certain values such as altruism and social justice as rooted in western culture, was multifaceted when considered by other cultural values. For example, in Bushido, the concept of altruism is a blend of rectitude, benevolence and loyalty whereas the concept of social justice (as implemented in a universal health care) is reflected from rectitude, honor and loyalty together. 36 The differences highlight the context of specificity in medical professionalism.
Personal identity formation involves both individual and social interactions which depicts emotional and moral reasoning as inseparable aspects. It is hypothesized that western identity is mainly absolute with stronger focus on the personal values of individuals, whereas in the Eastern culture, it is mainly relative and social as it considers relations with others. 31 In addition, in culture such as Confucian, the importance of relation to others is also reflected from showing respect to seniors or elderly people. 36 In addition to rich concepts of professionalism which are increasingly important to understand, globalization in medical education is inevitable. 1 The globalization results from the movement of medical students, residents and medical doctors around the world as well as expansion or movement of medical schools to certain countries. 1 The idea has been strengthened by realization that modern medicine is global; the skills of doctors from around the world contribute to the quality of global health and other nations benefit from doctors trained elsewhere (General Medical Council 2014). 40 McKimm and Wilkinson 2 argued that regardless of the national culture, international medical graduates had to make two major shifts: professional socialization and acculturation, whenever they commit to work in different health systems in other countries. Professional identity formation indeed is a very dynamic process given the changes of professional expectation and norms overtime and transformative process within each individual. 11,13,26,28 Recalibration is required in such a transition because a medical student or a graduate who are primarily consonant to certain values, culture and system (or their home culture) need to adjust to the society with different values, culture and system into which they are moving. 2 In other words, while a medical student or graduate is in the process of having professional socialization and identity formation when entering the profession itself, they have to learn how the professionalism is expected differently in different contexts when they decide to move to other institutions and/or countries. The component of cultural competence is highly required in this process. The double shift of acculturating to a new society and a new professional culture means that both an individual's social and professional identity becomes redefined. 2 Failure to adjust in cultural transitions may lead to problems of acculturation and unprofessional behaviours. The failure may take place in certain points as follows: 2 1. The transition to professional socialization or identity formation. For example, a student who does not pay attention to the importance of punctuality during clinical clerkship (failure to act as future doctors), or on the other hand, a student who is over-confident in performing a procedure which is beyond his/ her competence and authority (failure to act as student). 2. The acculturation. For example, a student who is doing study abroad may fail to act appropriately when communicating with supervisors or when suggesting expensive medications or investigations. 3. Imposing own cultural values and beliefs on a patient/service user from a different culture. For example an international medical graduates from South East Asia who works in a hospital in USA is reluctant to give information on a malignancy diagnosis to a female patient and chose to impart the information to the patient's family.
eJKI Vol. 6, No. 3, Desember 2018 Some strategies to facilitate professional socialization and acculturations of international medical students or graduates are suggested, as follows: 2 1. Define which part of the socialization is arrested; is it professional socialization, acculturation or both. 2. Provide expectations and ground rules so that people would understand the differences of certain cultures compared to theirs more explicitly. 3. Provide a mentor who has encountered similar cultural transitions or who can help interpret the new culture from the perspectives of students coming from different culture. 4. Include students/graduates from other institutions/country in the 'in group' or team without alienating others. 5. Make opportunities for informal conversations between international students/graduates and supervisors. 6. Avoid judgmental approach and stereotyping of the international students/graduates and seek to understand why they behave the way they are. 7. Be open to their perspectives being as, or more, valid than the host country's norms.
Cultural awareness is the key in defining and redefining professional identity as well as in practicing medicine even within one's own institution or home country. 2 The awareness may be started from what is seen aspects e.g clothing and other aspects of appearances, ways of eating, greetings etc to some 'unseen' or deeper values which influence how people perceive things.
Medical students or medical doctors will be working in different settings and cultures, will be seeing patients and their family with different backgrounds and will be collaborating with colleagues and other health professionals with specific values and norms. Therefore, the abilities of medical students and medical doctors to actively reflect on personal and professional identity, to be aware of the cultural differences and how they will impact interactions and expectations to medical profession and to adjust appropriately are very critical in this globalization era. This review concludes that medical education needs to be responsive to the globalization issues and the complexity of medical students' professional identity by paying attention to relevant individual and social interaction factors. 41

Conclusion
Personal and professional identity formation is a critical aspect in professional development of future medical doctors. The development process within self, supported by social interactions encompasses construction of being a medical student or medical doctor' rather than only on acting as medical student or medical doctor. The importance of social interaction including the values, norms, and culture embedded within the setting is argued to influence professional identity formation in several ways. First, the sociocultural context within, in which a medical student grows, will contribute to the individual characters and potentials. Second, the socio-cultural factors also define the expectations of medical professionals from the patient, family and society.
The medical migration, multi-cultural societies and the increase ofglobal practitioner lead to lots of required cultural transitions which made us to ensure that our students, graduates and practicing doctors will be competent to adjust themselves in such situations. Making cultural transitions is a complex process which involves the professional socialization transition, the acculturation transition, cultural sensitivity and a double shift in social and professional identity formation.