Struggling productively with professionalism: Swinging the pendulum between behaviors and identity

Professionalism has long been a contentious and evolving focus in medical education, with a long history of educators grappling with definitions, concepts and frameworks. Drawing on over two decades of scholarship and personal reflection, this article traces the trajectory of professionalism assessment in medicine, using the concept of "productive struggle" as a guiding frame. Initially championing behavioural frameworks as more objective and assessable than character-based definitions, researchers came to recognize the complexity and contextual nature of professional conduct. Both learners and faculty struggle to define and assess which behaviours are most professional, and behaviours alone may be insufficient signals of professionalism without insight into underlying rationales and the environments in which actions occur. As identity formation gained traction-emphasizing internalization of professional values-the pendulum swung away from behaviours. While conceptually appealing, this shift brought its own tensions, including learner resistance, concerns about surveillance and performance of professionalism, and conflicts between personal and professional identities. The author highlights growing discomfort among both learners and supervisors, especially when professionalism is used punitively or when wellness and discomfort are falsely positioned as mutually exclusive. Ultimately, the author promotes a "both-and" approach that integrates behaviours and identity, while acknowledging contextual influences and allowing space for growth. This will hopefully lead to the pendulum swinging in shorter arcs, towards a middle ground. In the meantime, we are faced with eager learners who want to develop as professionals while maintaining their own health and intersecting identities, and faculty who respect this yet are finding it increasingly challenging to promote productive struggle.