How do mandatory emergency medicine rotations contribute to the junior residents’ professional identity formation: a qualitative study | BMC Medical Education

We interviewed ten junior residents at Okinawa Chubu Hospital; eight were male, and two were female. All interviewees were Japanese; one graduated from medical school abroad, and the others graduated from medical schools in Japan. They all started junior residency in April 2020. Their desired specialties for the future varied, including acute care surgery, cardiovascular surgery, critical care medicine, emergency medicine, hand surgery, internal medicine, palliative care medicine, paediatrics, family medicine, and child and adolescent psychiatry.

Forty-two codes were generated and grouped into four main themes: patient care, teamwork, role models, and colleagues.

Patient care

Delivering patient care in the emergency department critically influenced professional identity formation. Junior residents identified five subthemes related to patient care: patient-centred care, patient care ownership, the gap between ideal practice and actual practice, difficult patients, and the importance of patient contact for future careers.

Patient-centred care

Patients visited the emergency department for a variety of reasons. Junior residents talk about how they have tried to diagnose and treat patients’ diseases. However, even when they reached a correct diagnosis, they realised this was not enough. They also talk about the need for patient-centred attitudes:

Comparing before and after the training in emergency medicine, a significant change has occurred in myself because I realised that just diagnosing the disease is not enough to work in the emergency department. I saw patients who seemed to just want me to listen to their complaints, and I came to believe that this might be the best way to help them. Personally, that is what I learned the most. It feels like if I did not meet their needs, I could not send them home. (Interview 6)

Junior residents must pay attention to different kinds of problems. Patients presenting to the emergency department suffer from various social and public health problems, as well as medical problems. The opportunities to take care of these patients made residents realise the importance of patient-centred care:

I often saw patients who could go home but were not allowed to due to social problems. Therefore, I think it is good that I have changed or diversified my perspective from the past so that I can notice patients’ problems from various angles. (Interview 4)

Patient care ownership

Patient care ownership was related to professional identity formation, especially when junior residents felt personal responsibility for their patients’ management. Junior residents tried to deliver patient care to the best of their ability, though they acknowledged their lack of experience. This led to reflection and learning:

I often wonder if it would have been better if I had noticed it myself initially. Later [after the patient was taken over], I often reviewed the patient’s chart and checked how the patient was managed. Then, I realised that I should have done this from the beginning. (Interview 2)

Autonomy enhanced the sense of patient care ownership. Junior residents described situations where they acted autonomously as experiences that made them feel most like physicians:

When I’m seeing patients myself, there’s a certain enjoyment in it. Listening to patients’ complaints, how can I put this? It may feel insufficient, but I do what I know I should, and that kind of experience is enjoyable to me. There’s something satisfying about it, a feeling of “I’m a real physician.” (Interview 2).

Junior residents’ sense of responsibility was seen in their efforts to avoid misdiagnosis and ensure patient safety. Being in charge of patient care meant they had to take responsibility for their decisions, which could directly affect patient outcomes. Potentially critically ill patients occasionally visit the emergency department without evident symptoms. Handling these cases was challenging. Failing to accurately estimate severity and make correct diagnoses can mislead physicians’ management plans and result in the worst outcomes.:

If I made a diagnostic error, I would feel very sorry. After all, this is my job, and I am in the position of a physician despite my limited experience. I’m still in my first year, but I am the first physician to see the patient. (Interview 10)

The gap between ideal practice and actual practice

Practice in emergency medicine requires quickness and efficiency. Multitasking is necessary, and physicians are often pressed for time to perform several tasks simultaneously. The time available per patient is limited. While junior residents understand the characteristics of practice in emergency medicine, the gap between their image of ideal practice and actual practice led to some discomfort:

I think there’s a difference between practice in emergency medicine and outpatient clinics. In emergency medicine, diseases are diagnosed quickly within a short period of time. […]Personally, I tend to take more time to listen to what patients complain about. […]I cannot truly provide patient care that quickly, that makes it hard for me every time. (Interview 4)

Over time, junior residents seemed to become accustomed to the practice and environment of emergency medicine. They sometimes lose interest in ordinary cases and non-urgent patients. They mentioned that some other residents treated those patients impolitely or disrespectfully, which resulted in unprofessional behaviour:

It makes me wonder, to treat the noncritical patients in a, how should I put it, rough way, that kind of spirit, or sense of un… unprofessionalism, must have a reason for it to occur. I suppose one of the reasons is, well, frankly, we lost that sense of tension and became numb to work. (Interview 5)

Difficult patients

Residents sometimes encounter challenging patient-physician encounters in the emergency department. These encounters provoke adverse emotional reactions toward patients, which conflict with their perception of professional behaviour. One resident noted, “I tend to raise my voice a little…not so much that I raise my voice, but I find myself speaking a little too strongly. In addition, when I do that, it sometimes feels that I’m doing something wrong” (Interview 10).

The importance of patient contact for future careers

Junior residents believed that training in emergency medicine would provide them with indispensable knowledge and skills regardless of their future careers. They saw this as an opportunity to acquire the basic competencies needed by all physicians:

Even if it is not your specialty, seeing patients outside of it is still a good idea. It will give you broad knowledge and improve your instinctual and experience-based thinking, which is important for any specialty. (Interview 5)

Teamwork

Teamwork between physicians and nurses is fundamental in the emergency department. Junior residents identified two subthemes related to teamwork: interprofessional collaboration and leadership.

Interprofessional collaboration

Junior residents were required to maintain clear and concise communication with nurses. The interviews showed junior residents prioritised interprofessional collaboration as much as patient care. One resident noted, “I used to think mainly about what I wanted to do for patients, but now I also think about how to work with other professionals and colleagues and how I should work with them” (Interview 5).

The narratives revealed the relationship between nurses and junior residents in the clinical setting. Nurses expected junior residents to work as effectively as other physicians did. However, junior residents recognised and admitted their inability to meet nurses’ expectations due to lack of experience. This gap provoked emotional conflict in their relationships with nurses:

At first, I did not know anything about this or that. I did not know how the emergency department worked, how the nurses worked, and so on, so I often had conflicts with nurses. Nurses got mad at me, which happened a lot. (Interview 6)

Junior residents felt they were being treated unfairly by nurses compared to other physicians, such as senior residents and attending physicians. They felt that nurses regarded them as not qualified to work independently or without supervision from attending physicians. Conflicts with nurses induced negative self-perceptions:

To be honest, I try not to think of it that way, but sometimes I get annoyed or upset. I get irritated when nurses treat me like I cannot do anything without attending physicians, and I become even bossier, which makes me feel bad about myself. In addition, of course, when you behave like that, it amplifies the conflict. (Interview 9)

On the other hand, some junior residents experienced positive effects from working with nurses. They felt helped or supported by experienced nurses.

I was always getting help from the nurses. Many times, they said, ‘Doctor, I think it’s better to order this lab too,’ and I’d just respond, ‘Oh, thank you.’ This happened a lot, … But then, I learned and understood the reasoning behind things myself. I began to understand why we should order specific labs and tests. (Interview 5)

Junior residents recognised the importance of understanding how nurses operate in the emergency department, and they felt that this knowledge facilitated more effective collaboration.

I think it’s pretty important to understand how nurses work and the systems they operate within … Knowing how nurses work and understanding that they need specific instructions from physicians is crucial. … So, I often ask the nurses when I’m unsure because they usually know better. By communicating more and more with nurses, I think it has become easier to work together. (Interview 1)

Leadership

Taking leadership contributed to building confidence in professional identity. Although residents were initially unaccustomed to taking leadership, they seemed to develop self-confidence in leadership roles eventually. Taking on leadership roles seemed to be associated with the feeling of being a physician. Another resident noted, “I think I have become more like a physician; although there are still many things I do not do well, I am not too afraid to give instructions to the nurses anymore” (Interview 8).

Although taking leadership is vital for developing professional identity, some residents are uncomfortable taking the initiative initially. This improves over time when they accumulate experience:

I have never been in a leadership position before. When a patient was brought into the resuscitation room, two nurses asked, “What should we do, doctor?” I would be like, “Uh…” That was when I realised that I should be the one giving them orders. Gradually, I became more accustomed to giving instructions to the staff. (Interview 8)

Role models

Working with role models helped junior residents shape their professional identity. They felt supported when attending physicians helped them establish patient-physician relationships in problematic situations:

… my explanation did not convince the patient, so my attending physician explained his medical condition again. The patient was then convinced and went home without any trouble. I was impressed by my attending physician’s ability to do that; it was one of those specialised, unquantifiable skills physicians have. (Interview 6)

Junior residents paid attention to attending physicians’ attitudes and behaviours.

“Wow, this attending has a broad perspective, that he can notice things that I don’t notice, that he can see things from a higher perspective.” (Interview 8).

Physicians’ commitment to resident education was perceived favourably, and it encouraged junior residents to imitate their behaviour. “I got a lot of advice and feedback on my practice from attending physicians, and I truly feel like I want to become a physician who can support residents like them” (Interview 10).

Peers

In the interviews, junior residents referred to connections with peers and other junior residents. Together, they developed shared values and understanding in the community of practice. They shared and compared their experiences. “I was talking with a colleague about how trust in physicians is important. I thought he had gotten a truly good point (Interview 6).”

Junior residents also felt a sense of competition among their peers while working in the emergency department. They tended to care about external evaluation from their colleagues and attending physicians:

I think this is because we are too concerned about the eyes of our peers, senior residents and attending physicians. For better or worse, there is a sense of competition among peers. The emergency department is where colleagues, senior residents and attending physicians judge whether you are a good or bad worker. I think it is just a disturbing opinion, but you cannot escape from it. (Interview 9)

By training in the same department, opportunities arise to observe the attitudes and behaviours of colleagues. Colleagues sometimes work as negative role models, encouraging junior residents to reflect on their professional attitudes and behaviours:

When I looked at the previous medical charts of the patient who had come to the emergency department frequently, I found the charts written by my colleagues. I found in the description that my colleagues had sent the patient home very impolitely. These kinds of things irritate me a lot. I often see things like my colleagues treating patients disrespectfully or explaining things sloppy. (Interview 3)