정체성, 정체성 확립, 그리고 의학교육(1)

(출처 : http://izquotes.com/quote/277180)

"정체성이란 그것을 가지고 있느냐 그렇지 않느냐의 문제가 아니라, 어떠한 행동을 하느냐의 문제이다" 

정체성확립은 스스로의 세계관을 형성해나가는 인지적, 사회적 과정이다. 또한 이것은 양방향 과정이다.

즉, 스스로 생각하는 자신의 모습과 다른 사람에 의해서 정의되는 자신의 모습을 합병해나가는 과정이다.

어릴 적에 외부에 의해 결정된 정체성은 더 영향력이 강하고 내적인 저항이 적기 때문에, 

후에 그것이 없어지거나 변화되는 경우가 적다. 

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INTRODUCTION

정체성은 정체성확립이라는 역동적 과정을 꾸준히 밟아갈 때 생긴다. "정체성이란 그것을 가지고 있느냐 그렇지 않느냐의 문제가 아니라, 어떠한 행동을 하느냐의 문제이다" 살아가면서 우리의 정체성은 모습은 끊임없이 바뀐다.

Identities are realised through the ongoing dynamic process of identification: ‘it is not something that one can have or not; it is something that one does’.2 (p 5) As we go through life, our identities are constantly in the process of transformation.

윤리적인 측면과 현실적인(practical) 측면 모두에서 전문직으로서의 정체성을 갖는 것은 반드시 필요하다. 다른사람에게 신뢰를 주기 위해서는 전문직의 윤리를 내면화해야 하며, 자신감과 전문직으로서의 태도를 가지고 진료를 할 수 있어야 한다. 따라서 의과대학 학생들이 지식과 술기를 모두 터득했다고 하더라도 전문직업적 정체성(professional identity)를 가지기 전에는 성공적으로 의사가 되었다고 할 수 없다.

It has been argued that it is necessary for professionals to successfully embrace a professional identity both ethically and practically. Internalising professional ethics through the process of identification facilitates the internal regulation of professionals.4 On a practical level, the development of a strong professional identity enables individuals to practise with confidence and with a ‘professional demeanour’, thereby giving others confidence in their abilities.5 So, even if medical students learn all the knowledge and skills required of them, they will find it hard to be successful as doctors until they have developed their professional identity.6

일상적인 사회 활동에 참여하고, 권력관계속에서 말고 행동을 해나가는 과정에서 정체성이 확립된다. '구성주의적' 접근에서는 정체성에서 '사회적 측면'이 가지는 중요성을 강조하는데, 이는 심리학, 사회학, 사회언어학, 심리사회적, 사회문화적 행동적,담화적 관점을 모두 포괄한다. 

Identities are constructed and co-constructed as we participate in day-to-day social activities and through the use of language and artefacts and within power relations. These ‘constructionist’ approaches highlight the importance of the social within identities and have led to a range of interconnected perspectives in psychology, sociology and sociolinguistics which highlight these aspects, including the psychosocial,12–14 sociocultural,15–17 performative18 and discursive19 perspectives.

Identity matters. Who we are, and who we are seen to be, underlies much of what we do in medical education. Identity is rooted in language and inter- action and, although we conceptualise identities, they are not fixed or static. Identities are realised through the ongoing dynamic process of identification: ‘it is not something that one can have or not; it is something that one does’.2 (p 5) As we go through life, our identities are constantly in the process of transformation.

 

It has been argued that it is necessary for profes- sionals to successfully embrace a professional identity both ethically and practically. Internalising profes- sional ethics through the process of identification facilitates the internal regulation of professionals.4 On a practical level, the development of a strong professional identity enables individuals to practise with confidence and with a ‘professional demeanour’, thereby giving others confidence in their abilities.5 So, even if medical students learn all the knowledge and skills required of them, they will find it hard to be successful as doctors until they have developed their professional identity.6

 

The issue of identity and identification has been a central concern within the social and human sciences for decades, yet it is rarely discussed openly within medical education

 

This is not to say that aspects of medical students’ identification have been ignored, but that when the subject has been researched and openly theorised, the process has been mainly situated within a broader health and social sciences arena.7–10

 

Over the decades, identity theorists have taken their ideas from a broad range of paradigms. For some, identity has been conceived as representing a unified internal ‘agency’ whereby identity is seen as ‘a personal, internal project of the self ’ and treated as if it is ‘something to be worked on’.11 However, although it is still present in everyday thinking of the self, this ‘internal’ view has been supplanted by the notion that identities are a product of intersubjective and external social processes. Identities are constructed and co-constructed as we participate in day-to-day social activities and through the use of language and artefacts and within power relations. These ‘con- structionist’ approaches highlight the importance of the social within identities and have led to a range of interconnected perspectives in psychology, sociol- ogy and sociolinguistics which highlight these aspects, including the psychosocial,12–14 sociocultural,15–17 performative18 and discursive19 perspectives. 

IDENTITY: A BRIEF OVERVIEW

정체성확립은 스스로의 세계관을 형성해나가는 인지적, 사회적 과정이다. 한 개인으로서, 그리고 집단의 구성원으로서 스스로에 대한 다차원적인 분류를 하는 것이기도 하다.

Identification comprises basic cognitive and social processes through which we make sense of and organise our human world. It includes things that go on in our minds as we create a complex multidimensional classification of our places in the world as individuals and members of collectives.20

따라서 이러한 정체성확립의 과정은 의학교육에서 핵심적이며, 의과대학생들은 학문적, 임상적 환경에서 의사가 되는 방법을 배워야 한다.

Thus this basic and essential process of identification is central to medical education: medical students are learning to become doctors in academic and clinical settings.

Identification comprises basic cognitive and social processes through which we make sense of and organise our human world. It includes things that go on in our minds as we create a complex multi- dimensional classification of our places in the world as individuals and members of collectives.20 This self- categorisation process occurs within a social world through interactional relationships and in the con- text of social institutions with established ways of doing things.2 Thus this basic and essential process of identification is central to medical education: medi- cal students are learning to become doctors in academic and clinical settings.

EMBODIED INDIVIDUALS

정체성확립에 대해서 가장 중요하게 가져야 할 개념은, 이것이 양방향 과정이라는 것이다. 즉, 말과 행동을 통해 스스로 생각하는 자신의 모습,  다른 사람에 의해서 정의되는 자신의 모습을 합병해나가는 과정이다. 이 과정을 통해서 스스로가 누군지를 깨달을 뿐만 아니라, '내가 아닌 것'에 대해서도 생각해 볼 수 있다. 정체성은 '나와 다른 것'에 대해 주의를 기울이는 과정을 통해 확립된다.

The most important concept to hold is that identification is a two-way process which occurs during the simultaneous amalgamation of self-definition (who I think I am: internal) and the definitions of oneself as presented by others (who I think you think I am: external) through language and artefacts.2,15–17 Through this self-categorisation process, we not only identify who we are, but we also say something about who we are not: identities are constructed through attending to difference.

The most important concept to hold is that identifi- cation is a two-way process which occurs during the simultaneous amalgamation of self-definition (who I think I am: internal) and the definitions of oneself as presented by others (who I think you think I am: external) through language and artefacts.2,15–17 Through this self-categorisation process, we not only identify who we are, but we also say something about who we are not: identities are constructed through attending to difference.

Primary identifications

정체성은 어린시절에 다른사람과 나를 분리하고 말을 할 수 있게 되면서 확립된다. 정체성확립이 내적-외적인 양방향 프로세스이지만 초기에는 주로 외적인 요소의 영향을 많이 받는다. 어릴 적에 외부에 의해 결정된 정체성은 더 영향력이 강하고 내적인 저항이 적기 때문에, 후에 그것이 없어지거나 변화되는 경우가 적다. 

Identity formation begins in early childhood through the recognition of the separation of self and significant others and the development of language. Although identification is a two-way internal–external process, early on it is dominated by external factors.2 These early prescripted identities are therefore more authoritative and develop through weak internal responses, so rejection or modification is low: they become more accepted as how things are and more resistant to change.2 

성별이 가장 대표적이며, 성별과 마찬가지로 인종이나 사회적 지위도 마찬가지로 고정된 것은 아니더라도 나중에 성인이 되어 생긴 정체성에 비해서 잘 변하지 않는다.

Along with gender, ethnicity and social class can be considered as primary, embodied identifications which, although not fixed, may be less malleable than identities developed later in life.

여기서 가장 중요한 결론은 초기에 형성된 정체성이 후에 형성될 정체성을 촉진하거나 억제할 수도 있다는 것이다. 또한 다양한 정체성을 어떻게 주관적으로 표현하느냐에 따라서 다른 사람과의 관계가 달라질 수 있다.

One important implication here is that our unique mix of primary identities may facilitate or constrain the development of existing and newly developing identities.6 Additionally, our subjective representations of these multiple identities, how (or indeed, whether) we synergise these identities, can have important implications. These implications include the way we relate to other people (so-called ‘in-group’ or ‘out-group’ relations).

Identity formation begins in early childhood through the recognition of the separation of self and signif- icant others and the development of language. Although identification is a two-way internal–external process, early on it is dominated by external factors.2 These early prescripted identities are there- fore more authoritative and develop through weak internal responses, so rejection or modification is low: they become more accepted as how things are and more resistant to change.2 For example, gender identity begins early, through artefacts (clothes, toys) our caregivers create a gendered identity which is responded to by others and which we embody.

 

Along with gender, ethnicity and social class can be considered as primary, embodied identifications which, although not fixed, may be less malleable than identities developed later in life. One important implication here is that our unique mix of primary identities may facilitate or constrain the development of existing and newly developing identities.6 These implications include the way we relate to other people (so-called ‘in-group’ or ‘out-group’ relations).

Identity dissonance

새로운 전문직업적 정체성을 개인적 정체성에 통합시키는 과정이 사람에 따라 쉬울 수도 있지만 트라우마가 될 수도 있고, 이럴 때 '정체성 충돌'이 일어났다고 한다.

identity dissonance: ‘integrating new professional identities into personal identities is an easy process for people whose personal identities are consonant with their new professional role, but traumatic for those whose personal identities are dissonant with it’6 (my emphasis)

Costello는 정체성 충돌을 겪는 학생들은 감정적인 혼란을 겪으면서 스스로의 가치, 꿈, 능력, 친밀감, 자아존중감에 대해 불확실한 마음을 가지면서 바람직하지 못한 대응 기전을 만들어간다는 것을 밝혔다.

Costello6 found that students with identity dissonance experienced powerful emotional disruptions that included uncertainty about their own ‘values, ambitions, abilities, affinities, and their very self-worth’ and developed haphazard coping mechanisms.

이러한 바람직하지 못한 대응 기전에는 다음의 것들이 있다.

These coping mechanisms included the outright rejection of the professional role (e.g. consciously dropping out of the programme), displaying aspects of identity that conflict with the professional role (e.g. inappropriatedress), and avoiding professional school-setting interactions whenever possible, and when not possible, ‘role playing’ in professional situations.

일부 연구들은 여학생들이 더 높은 수준의 불안감과, 낮은 수준의 자신감을 갖는다은 것도 보여주고 있으며, 스스로의 의과대학생으로서, 의사로서의 태도에 확신을 가지지 못하는 학생들 또한 정체성 혼란을 겪고는 한다.

Finally, some work has highlighted aspects such as female students reporting (and being independently scored for) higher anxiety and lower self-confidence than male counterparts during standardised patient interactions23 and students’ uncertainties about their own aptitude as medical students and future doctors, 24 which reflect aspects of Costello’s identity dissonance. 

일부 의과대학 학생들이 의사로서 발전해나가는데 어려움을 겪고 있다고 할 때, 의과대학 학생들의 정체성확립과 이것이 어떻게 스트레스나 낮은 수행능력과 관련이 되는가를 연구하는 것이 중요하다.

Given that we know some medical students struggle with their developing roles as doctors, research that considers medical students’ identification and how this relates to stress and underperformance is crucial for the development of our curricula and to facilitate students’ identity formation.

Costello found that women, members of lower socio-demographic classes and non-Whites under- perform at professional schools and that one of the reasons for this is that they suffer from identity dissonance: ‘integrating new professional identities into personal identities is an easy process for people whose personal identities are consonant with their new professional role, but traumatic for those whose personal identities are dissonant with it’6 (my emphasis).

 

Costello6 found that students with identity dissonance experienced powerful emotional disruptions that included uncertainty about their own ‘values, ambi- tions, abilities, affinities, and their very self-worth’ and developed haphazard coping mechanisms. These coping mechanisms included the outright rejection of the professional role (e.g. consciously dropping out of the programme), displaying aspects of identity that conflict with the professional role (e.g. inappro- priate dress), and avoiding professional school-setting interactions whenever possible, and when not possible, ‘role playing’ in professional situations.

 

There has been little research undertaken in medical education to directly investigate students’ emotional disruptions from the perspective of identity forma- tion. However, role-playing in professional situations has been reported to represent a coping mechanism for students’ ‘shaky’ professional identities.21 Although numerous studies have demonstrated medical students’ negative coping strategies for stress, including excessive alcohol usage,22 research looking at potential causes of stress have concentrated on factors such as high workloads and have predomi- nately used questionnaire methods of enquiry. Finally, some work has highlighted aspects such as female students reporting (and being independently scored for) higher anxiety and lower self-confidence than male counterparts during standardised patient interactions23 and students’ uncertainties about their own aptitude as medical students and future doc- tors,24 which reflect aspects of Costello’s identity dissonance.

Relationships between multiple identities

스스로의 다양한 정체성을 인지하는 방법에는 다음과 같은 것들이 있다.

It has been proposed that we structure our perception of our own multiple identities according to four different models: intersection, hierarchy, compartmentalisation, and merging. These models reflect different relationships between our multiple identities and have implications for interactions with ingroup and out-group members.13

예) Maria : Black, female and doctor. 

- intersection - single unique identity of a ‘Black female doctor'

- hierarchy of identities - identity as a doctor over that as a woman and over that of being Black.

- dominant identity are considered in-groups. - However, because the representation is hierarchical, Maria will feel closer to other doctors who are female or Black.

- compartmentalisation. - Identities are then activated within different contexts and situations. So, whilst at work Maria will identify with other doctors and will consider everyone else as out-group members.

- The ability to hold a complex representation of identities will lead Maria to develop a merged in-group identity that is highly inclusive and divergent. 

'어떻게 스스로 다양한 정체성을 개념화하고 관리하는가'를 살펴보면, 의사를 어떻게 교육시켜야 하는가에 대해서 시사하는 점이 많다.

The ways in which we conceptualise and manage our multiple identities have profound implications for he education of doctors. 

정체성은 상호작용이 있는 환경에서 다르난다.

For example, identities are played out within interactional settings.One important factor that might differentiate intergroup communication from intragroup communication is individuals’ awareness of their group memberships.

다양한 정체성은 환자 진료에 있어서도 영향을 준다. 환자의 인종, 민족, 사회경제적 지위에 따라서 의사가 그 환자를 어떻게 인지하는지가 달라진다.

Furthermore, the ability to represent complexity within our multiple identities can have implications for patient care. It has been demonstrated that patients receive variable care according to factors such as race, ethnicity and socio-economic status26 and that this is associated strongly with doctors’ implicit perceptions of patients.27 

환자의 정체성 중 인종적인 면이나 민족적인 면만을 강조해서 바라보면, 문화적-사회경제적 고정관념이 강화된다는 연구결과가 있다. 또한 환자의 지적 능력에 대한 의사의 판단은 환자의 인종에 따라 달랐다는 연구결과도 있다.

Reducing patients’ identities to racial or ethnic labels in this way might facilitate cultural or socio-economic stereotyping.28 Indeed, it has been demonstrated that doctors’ perceptions of the intelligence of a patient vary according to factors such as the patient’s race.29

또한 이러한 요소들은 환자에 대한 의사의 연대감(affiliation)에도 영향을 주는 것으로 드러났다.

This factor also affects doctors’ feelings of affiliation towards patients, along with doctors’ beliefs about patients’ likelihood of adherence with medical advice, physical activity preferences and risk-taking behaviour.29,30

tolerance for ambiguity (TfA)는 SP에 대한 의과대학 학생들의 문진 태도, 환자의사 관계, 환자 만족과 연관이 있었다.

tolerance for ambiguity (TfA). Indeed, research has demonstrated that TfA, moderated by empathy, contributes to the prediction of medical students’ performance with standardised patients on history taking, doctor–patient interaction, and patient satisfaction over time: the higher the students’ TfA, the better they performed.31

It has been proposed that we structure our percep- tion of our own multiple identities according to four different models: intersection, hierarchy, compart- mentalisation, and merging. These models reflect different relationships between our multiple identi- ties and have implications for interactions with in- group and out-group members.13

 

The ways in which we conceptualise and manage our multiple identities have profound implications for the education of doctors. For example, identities are played out within interactional settings. Communi- cation in intergroup contexts, such as multi-profes- sional team-working, also involves intragroup communication (e.g. among nursing, medical and social workers). One important factor that might differentiate intergroup communication from intra- group communication is individuals’ awareness of their group memberships. Individuals who construct their identities as complex might demonstrate dif- ferent communicative patterns within interprofes- sional team-working, such as communicating in a manner that manifests less social distance and demonstrates greater acceptance and trust.13

 

Furthermore, the ability to represent complexity within our multiple identities can have implications for patient care. It has been demonstrated that patients receive variable care according to factors such as race, ethnicity and socio-economic status26 and that this is associated strongly with doctors’ implicit perceptions of patients.27 In some medical settings, patients’ race is routinely included at the beginning of case presentations. Although at times this may be useful to the diagnostic process, reducing patients’ identities to racial or ethnic labels in this way might facilitate cultural or socio-economic stereotyping.28 Indeed, it has been demonstrated that doctors’ perceptions of the intelligence of a patient vary according to factors such as the patient’s race.29 This factor also affects doctors’ feelings of affiliation towards patients, along with doctors’ beliefs about patients’ likelihood of adherence with medical advice, physical activity preferences and risk-taking behaviour.29,30 It is therefore easy to see how the way we conceptualise our identities can unconsciously affect the way we relate to others.14

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Med Educ. 2010 Jan;44(1):40-9. doi: 10.1111/j.1365-2923.2009.03440.x.

Identity, identification and medical education: why should we care?

Monrouxe LV.

Source

Division of Medical Education, School of Medicine, Cardiff University, Cardiff, UK. monrouxelv@cardiff.ac.uk

Abstract

CONTEXT:

Medical education is as much about the development of a professional identity as it is about knowledge learning. Professional identities are contested and accepted through the synergistic internal-external process of identification that is constituted in and through language and artefacts within specific institutional sites. The ways in which medical students develop their professional identity and subsequently conceptualise their multiple identities has important implications for their own well-being, as well as for the relationships they form with fellow workers and patients.

OBJECTIVES:

This paper aims to provide an overview of some current thinking about identity and identification with the aim of highlighting some of the core underlying processes that have relevance for medical educationists and researchers. These processes include aspects that occur within embodied individuals (e.g. the development of multiple identities and how these are conceptualised), processes specifically to do with interactional aspects of identity (e.g. how identities are constructed and co-constructed through talk) and institutional processes of identity (e.g. the influence of patterns of behaviour within specific hierarchical settings).

IMPLICATIONS:

Developing a systematic understanding into the processes through which medical students develop their identities will facilitate the development of educational strategies, placing medical students' identification at the core of medical education.

CONCLUSIONS:

Understanding the process through which we develop our identities has profound implications for medical education and entails that we adopt and develop new methods of collecting and analysing data. Embracing this challenge will provide better insights into how we might develop students' learning experiences, facilitating their development of a doctor identity that is more in line with desired policy requirements.

Comment in

• Identities as performances: encouraging visual methodologies in medical education research. [Med Educ. 2010]
• Do you really want to be a doctor? The highs and lows of identity development. [Med Educ. 2012]