Professional identity formation of medical students in relation to the care of older persons: a review of the literature

ABSTRACT With the growing population of older persons, medical students have to be well prepared for older persons’ health care during medical school. Becoming a doctor is an interplay of building competencies and developing a professional identity. Professional identity formation of medical students is a relatively new educational concept in geriatric medical education. This review aims to explore the concept of professional identity formation of undergraduate medical students in relation to the care of older persons. Twenty-three peer-reviewed studies were included and summarized narratively. Patient-centeredness, caring and compassion, collaboration and holistic care are characteristics of the doctor’s professional identity in relation to the care of older persons. Participating in the context of older persons’ health care contributes to the becoming of a doctor in general. In this context, the building of relationships with older persons, participating in their lives and role models are important influencers of professional identity formation. Furthermore, the perceptions and expectations medical students have of future doctoring influence their feelings about the care of older persons. To prepare medical students for older persons’ health care, professional identity formation seems to be a relevant educational concept.


Introduction
Worldwide, the population aged 65 years or above is expected to rise to 1.5 billion in 2050, an increase from 9.3% in 2020 to 16.0% in 2050.(United Nations Department of Economic and Social Affairs, 2020) Health problems in older age differ from those of younger patients and are characterized by multimorbidity, chronic illnesses, atypical presentations, psychosocial and functional problems, ethical dilemmas and increasing dependency.(Abdi, Spann, Borilovic, de Witte, & Hawley, 2019;Banerjee, 2015;Kogan, Wilber, & Mosqueda, 2016;Limpawattana, Phungoen, Mitsungnern, Laosuangkoon, & Tansangworn, 2016;Longino, 1997) With this growing population of older persons, future medical doctors will face these health-care challenges regardless of their chosen medical specialties.Educators in medical school, therefore, have to prepare all medical used and interventions to improve geriatric competencies of undergraduate medical students.(Masud et al., 2022;Tullo, Spencer, & Allan, 2010) The concept of PIF, however, is not described in these reviews.
PIF of medical students is described as a major goal of medical education.(Cruess, Cruess, & Steinert, 2019) To prepare medical students for older persons' health care, it is essential that they develop an appropriate professional identity for the care of older persons.Medical educators should be aware of PIF as this will further enhance geriatric medical education.Since PIF is not described as an educational concept in the literature on undergraduate geriatric medical education, we explored the available literature, in our current systematic review with qualitative data synthesis, to focus on the research question: "what is known about PIF of undergraduate medical students in relation to the care of older persons?"

Search strategy
Given that knowledge on the concept of PIF of undergraduate medical students as an educational concept for geriatric medical education is scarce, we conducted a systematic review with qualitative data synthesis to explore this topic.In collaboration with a trained information specialist, a detailed search strategy was composed on the 21 st of January 2022.The following databases were searched: PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, EmCare, ERIC, Academic Search Premier and PsycINFO.The query consisted of the combination of terms related to "professional identity," "medical student" and "older person" (see Box 1).
Box 1. Query used for this review consisting of the combination of terms related to 'professional identity', 'medical student' and 'older person'.

Selection criteria
No restriction was made to the year of publication, language or design.Only peer-reviewed journal articles were selected.Publications that met the combination of the following criteria were included: (1) related to PIF or to PIF-related topics i.e. values, norms, beliefs, reflections or socialization; (2) related to undergraduate medical students or undergraduate medical education and (3) related to geriatric medicine or older persons.We excluded studies that (1) did not relate to PIF or PIF-related topics; (2) were related to postgraduate medical education or other health-care students; (3) did not relate to geriatric medicine or older persons.References were scrutinized for additional publications, which were then checked for relevance using the same criteria.

Study selection
Three researchers (AM, KL and WT) independently screened all titles, abstracts and the full-text articles for inclusion.Disagreements were resolved through extensive discussion between them or if disagreement still persisted through the involvement of researcher AK.

Data synthesis
A thematic approach was used to synthesize the data.The three researchers (AM, WT and KL) read and analyzed the included articles on topics that were described as relevant to the PIF of undergraduate medical students in relation to the care of older persons.Together the researchers (AM, WT and KL) discussed these topics and identified major themes and subthemes relevant to the subject, which were approved by the other research team members (TM, AK and WA) and summarized narratively.

Results
The search generated 966 publications in total.The selection procedure allowed for the inclusion of 23 selected articles (see Figure 1).These articles were mainly from the Global North and most studies used qualitative research methods (17) or mixed-methods (5).One study used a quantitative method.
Almost half of the articles (10) described reflections of preclinical medical students, particularly on one-day experiences with older patients and in nursing attachments but also on a contact with one older patient over a longer period of time and a geriatric course.The other articles (13) described reflections of medical students in their clinical years, mainly on one-day experiences with older patients but also on experiences during an internal medicine clerkship, a geriatric clerkship, and a geriatric curriculum.
We identified three major themes in the articles: (1) characteristics of the doctor's professional identity in relation to the care of older persons; (2) the relevance of the care of older persons to the PIF of medical students and the care of all patients and (3) external factors in the context of the care of older persons that influence the PIF of medical students.

Characteristics of the doctor's professional identity in relation to the care of older persons
Patient-centeredness, caring and compassion, collaboration, and holistic care are mentioned as characteristics of the doctor who takes care of older persons.A patientcentered doctor is described as a doctor who sees the older patient as unique, as an expert of his or her life and as part of the health-care team.The patients' life experiences, perspectives and autonomy guide the doctors' decision-making in which the patients' views are respected and taken into account.(Davis et al., 2021;Denton et al., 2009;Helmich et al., 2010;van de Pol et al., 2018;Yoshimura, Saiki, Imafuku, Fujisaki, & Suzuki, 2020) In one study students emphasized the importance of listening to the story of the older patient and working together with this patient to provide care.They acknowledged that the patients' life experiences gained through living were helpful in the patients' understanding of their needs and expectations of healthcare.(Davis et al., 2021) The doctor who takes care of older patients is also described as caring and compassionate through taking time, having empathy and humanity.(Abbey, Willett, Selby-Penczak, & McKnight, 2010;Camp, Jeon-Slaughter, Johnson, & Sadler, 2018;Goldman & Trommer, 2019;Helmich, Bolhuis, Prins, Laan, & Koopmans, 2011;Strano-Paul, Lane, Lu, & Chandran, 2015;Wilson, Warmington, & Johansen, 2019;Yuen et al., 2006) Students who observed the doctor during home visits described the doctor as dedicated and the doctor-and-patient interaction as genuine and personal.(Abbey, Willett, Selby-Penczak, & McKnight, 2010) Furthermore, the ability to give holistic care is described as a characteristic of the doctor in relation to the care of older persons.To accomplish this, the doctor has to know the whole life of the patient, understand the impact of the disease and treatment on this life and must also be able to tailor the care to this life.(Goldman & Trommer, 2019;Jentoft, 2021;Yoshimura, Saiki, Imafuku, Fujisaki, & Suzuki, 2020;Yuen et al., 2006) After having contact with older patients at home during one day, medical students emphasized the importance of knowing the social context, the home environment and the family of the patient to give good care.(Yoshimura, Saiki, Imafuku, Fujisaki, & Suzuki, 2020;Yuen et al., 2006) Additionally, a doctor who is able to collaborate with other health-care professionals is described as essential in giving holistic care.Through teamwork and multidisciplinary thinking, different perspectives are taken into account resulting in care that is not only focused on the disease but also on functional and psychosocial needs.(Jentoft, 2021;Strano-Paul, Lane, Lu, & Chandran, 2015;Yoshimura, Saiki, Imafuku, Fujisaki, & Suzuki, 2020)

The relevance of the care of older persons to the PIF of medical students and the care of all patients
Several articles described the relevance of the participation of medical students in older persons' health care to graduating into a doctor in general.(Helmich et al., 2010;Huls, Rooij, Diepstraten, Koopmans, & Helmich, 2015;Shield, Farrell, Campbell, Nanda, & Wetle, 2015;Shield, Farrell, Nanda, Campbell, & Wetle, 2012) During a geriatric course in the first 2 years of medical school, medical students reflected on caring for older patients and their professional development.They shared that older patients have specific challenges, like hearing problems, complex conditions, fragility, limited mobility and end-of-life questions, which made them develop professional skills like physical examination, communication skills and interprofessional collaboration.They experienced a growing sense of confidence in becoming a doctor and shared that their interaction with older patients would benefit all their patients.(Shield, Farrell, Campbell, Nanda, & Wetle, 2015) Furthermore, the nursing home is described as a suitable context for medical students to develop patientcentered, collaborative and communication skills as well as empathetic behavior.(Helmich et al., 2010;Helmich, Bolhuis, Dornan, Laan, & Koopmans, 2012;Huls, Rooij, Diepstraten, Koopmans, & Helmich, 2015) During a geriatric clerkship in the nursing home, medical students experienced collaboration in a multidisciplinary team and shared they worked together with other health professionals more often than during other clerkships in the hospital.(Huls, Rooij, Diepstraten, Koopmans, & Helmich, 2015) Besides these aspects, various research described that contact with older patients can elicit emotions.(Bagri & Tiberius, 2010;Goldman & Trommer, 2019;Strano-Paul, Lane, Lu, & Chandran, 2015;Wang, Swinton, & You, 2019;Wilson, Warmington, & Johansen, 2019) Medical students experienced sadness when watching the dementia progress of the patient they took care of.(Goldman & Trommer, 2019) In another study, the students were shocked by the death of a patient.(Yoshimura, Saiki, Imafuku, Fujisaki, & Suzuki, 2020) Acknowledgement of emotions by supervisors and role models can help medical students in dealing with such feelings.This acknowledgment and the reflection on feelings and thoughts contribute to the becoming of a doctor in general.(Dornan, Pearson, Carson, Helmich, & Bundy, 2015)

External factors in the context of the care of older persons that influence the PIF of medical students
Various external factors in the context of the care of older persons are described as influencers of the PIF of medical students.These factors can be summarized by being part of the life of the older patient, role models, the hidden curriculum, and perceptions and expectations.
By being part of the personal life and living environment of the patient during home visits, medical students learn to know the older patient as a person, get to know the life of the patient and experience the impact of a disease or treatment on this life and the family.(Abbey, Willett, Selby-Penczak, & McKnight, 2010;Davis et al., 2021;Denton et al., 2009;Goldman & Trommer, 2019;Strano-Paul, Lane, Lu, & Chandran, 2015;Wilson, Warmington, & Johansen, 2019) In one study medical students observed the commitment and responsibility of caregivers during home visits.(Abbey, Willett, Selby-Penczak, & McKnight, 2010) Role models during educational courses, nursing attachments or clerkships are frequently mentioned as influencers for medical students' learning to become a doctor.(Farrell, Shield, Wetle, Nanda, & Campbell, 2013;Meiboom, de Vries, Hertogh, & Scheele, 2015;Shield, Farrell, Campbell, Nanda, & Wetle, 2015;Shield, Farrell, Nanda, Campbell, & Wetle, 2012;van de Pol et al., 2018;Wang, Swinton, & You, 2019;Wilson, Warmington, & Johansen, 2019) Medical students experienced nurses as positive role models during a nursing attachment.The nurses showed kindness, warmth and empathy to the patient.(Wilson, Warmington, & Johansen, 2019) Care-givers who showed disrespect, frustration, coldness and depersonalization during an internal medicine clerkship were seen as negative role models by the students.(Meiboom, de Vries, Hertogh, & Scheele, 2015;Wang, Swinton, & You, 2019) Role models represent parts of the hidden curriculum.(Borgstrom, Cohn, & Barclay, 2010;Meiboom, de Vries, Hertogh, & Scheele, 2015;van de Pol et al., 2018;Wang, Swinton, & You, 2019) A hidden curriculum refers to the characteristics of an organization or culture that are taken for granted and is communicated through implicit beliefs, messages and expectations.(Hafferty & Franks, 1994) Implicit messages and approaches in relation to older persons will influence the perceptions medical students have of older patients.(Meiboom, de Vries, Hertogh, & Scheele, 2015) It is known that, with traditional training, medical students often perceive that becoming a doctor predominantly means saving lives and curing diseases.(van de Pol et al., 2018) They learn to appreciate diagnostic skills, acute complaints and visible results in the medical profession, which are less common characteristics in geriatrics.On the other hand, aspects of older persons' health care such as psychosocial, chronic and terminal conditions are experienced as being less attractive, boring and time consuming.(Bagri & Tiberius, 2010;Meiboom, de Vries, Soethout, Hertogh, & Scheele, 2018;van de Pol et al., 2018) These perceptions and expectations may negatively influence students' feelings and thoughts about what the care of older persons involves.

Discussion
PIF of medical students is a relatively new educational concept in geriatric medical education.In this review, we explore what is known in the literature about the development of a professional identity of undergraduate medical students in relation to the care of older persons.The majority of articles we have found are qualitative ones from the Global North.The results are particularly based on the experiences of medical students during one-day meetings with older patients or geriatric courses.Some studies described long-term experiences with older patients during a nursing attachment or clerkship.Our exploration gives an overview of the characteristics of the doctor who takes care of the older person.Furthermore, the results emphasize the relevance of caring for older persons to the PIF of medical students and outline the external influencers in the context of older persons' health care on this PIF.
The doctor who takes care of the older patient is characterized by compassion, patientcenteredness, collaboration and giving holistic and personal care.These characteristics are not only relevant to older persons' health care but also to the care of all patients, old and young.This suggests that the professional development of the medical student in the context of the care of older persons is applicable to all patients and relevant to the becoming of a doctor in general.In this context, the building of relationships with older persons, participating in their lives and role models are important influencers of PIF.
The hidden curriculum influences the expectations medical students have of future doctoring as well.The focus of medical school on saving lives and curing diseases can create negative feelings and thoughts about older persons' health care.Moreover, implicit messages and beliefs as a result of ageism among caregivers can induce negative perceptions, stereotypes and prejudices toward older persons in medical students.It is commonly known that age discrimination negatively impacts the health of older persons.(Mikton, de la Fuente-Núñez, Officer, & Krug, 2021)

Implications for medical education
Based on the results of this review, we propose three recommendations for medical education.First, we argue that suitable contexts are essential for medical students to develop an appropriate professional identity for older persons' health care.These contexts have to provide engagement in older persons' lives and reflect the values and norms of patientcentredness, holistic care, compassion and collaboration.Socialization in these contexts will help medical students to focus not only on cure but also on care and quality of life.(Cruess, Cruess, & Steinert, 2018;Cruess, Cruess, Boudreau, Snell, & Steinert, 2014, 2015;Jarvis-Selinger, MacNeil, Costello, Lee, & Holmes, 2019;Jarvis-Selinger, Pratt, & Regehr, 2012;Monrouxe, 2010;van de Pol et al., 2018) The nursing home and the care for older patients at home are described as such suitable contexts.(Helmich et al., 2010;Helmich, Bolhuis, Prins, Laan, & Koopmans, 2011;Huls, Rooij, Diepstraten, Koopmans, & Helmich, 2015;Kanter, 2012;Masud et al., 2022) We recommend that medical schools provide more and more mandatory clinical placements in these contexts.
Second, we want to emphasize that the development of a professional identity with a focus on care and quality of life is important to all patients.Participation of medical students in the context of older persons' health care contributes to the development of a competent and compassionate doctor in general.(Kanter, 2012;Shield, Farrell, Campbell, Nanda, & Wetle, 2015;van de Pol et al., 2018) Therefore curriculum committees should be aware of the value of the learning opportunities of this context.
Furthermore, we realize that medical students have negative perceptions of older persons and experience geriatric medicine as boring, frustrating and complex.This can hinder an appropriate PIF in relation to the care of older persons.(Bagri & Tiberius, 2010;Cruess, Cruess, Boudreau, Snell, & Steinert, 2015;Higashi, Tillack, Steinman, Harper, & Johnston, 2012;Meiboom, de Vries, Hertogh, & Scheele, 2015) Ageism both in medical care and in the living environment of medical students contributes to these perceptions.Education and intergenerational contacts are described as effective interventions to reduce ageism, especially the combination of both interventions.(Burnes et al., 2019;Mikton, de la Fuente-Núñez, Officer, & Krug, 2021) As PIF encompasses professional values, norms and beliefs, we suggest that an appropriate PIF for the care of older persons might help medical students to feel more comfortable with geriatric medicine and reduce negative perceptions.(Cruess, Cruess, & Steinert, 2016;Jarvis-Selinger, Pratt, & Regehr, 2012;Monrouxe, 2010) Therefore, PIF has to be explicitly addressed as an educational objective in medical education.(Cruess, Cruess, & Steinert, 2018, 2019) Faculty development can facilitate medical educators to mentor medical students in this development, in which guided reflections on experiences, emotions and thoughts are essential to make PIF explicit and effective.(Cruess, Cruess, & Steinert, 2019;Cruess, Cruess, Boudreau, Snell, & Steinert, 2015)

Future research
In our opinion, PIF of undergraduate medical students in relation to the care of older persons is a relevant concept for medical education.To better understand this concept we suggest to explore this topic further.A future research area will be the experiences of medical students while caring for older persons over a longer period of time.Furthermore, we want to explore the perspectives of older persons and physicians in older persons' health care on PIF.In the end, we intend to develop educational interventions to encourage PIF of medical students in relation to the care of older persons and evaluate the effect of these interventions on this care.We hope that a better understanding can strengthen the position of geriatric medicine in curriculum development and can facilitate medical educators to help medical students develop an appropriate professional identity.

Limitations
Our review has several limitations.First, to explore the concept of PIF, we included all peer reviewed articles that met our inclusion criteria.We did not assess these articles on design.Second, we could have missed qualitative studies, which are not published in the databases we used.Furthermore, our findings are particularly based on one-day experiences of medical students with older patients.Literature on long-term experiences with older patients are scarce and mainly situated in the pre-clinical years of medical school.Finally, the majority of the included studies are from the Global North.As PIF is related to context, this may limit the generalizability of our findings to medical schools outside this region.

Conclusion
With the growing population of older persons, undergraduate medical students have to be well prepared for older persons' health care during medical school.Becoming a doctor is an interplay and accumulation of building competencies for practice, and developing a professional identity through the internalization of the values and norms of the medical profession.PIF of undergraduate medical students is a subject of significant interest in medical educational research and a relevant educational concept in preparing medical students for the care of older persons.The context of older persons' health care provides relevant learning opportunities for the becoming of a doctor in general.