"[They] Assume You Don't Know Things": How Immigrant Status and Language Shape the Professional Identities of...

Professional identity formation (PIF) is the developmental process through which medical trainees transition from laypersons to physicians. While recent scholarship has explored the challenges of a dominant standard influencing the PIF of minoritized students, much of this research employs a single-axis lens, focusing on race/ethnicity or gender in isolation. This study investigates how the intersection of race/ethnicity, immigrant status, and non-English language skills influences PIF among 1.5-generation immigrant medical students and second-generation children of immigrants in the US. This qualitative study was designed using a constructivist grounded theory approach to data collection and analysis. We recruited nine East Asian, 10 South Asian, six Black, and seven Latinx immigrant students in their third and fourth years of medical school. Participants were either foreign-born students who migrated to the US during childhood or adolescence and completed formative schooling in the US or US-born children of immigrants. We interviewed them about their PIF experiences and then analyzed the data iteratively using an intersectional lens. Using open, focused, and theoretical coding, we analyzed each group's PIF experiences then moved to constant comparative analysis to identify themes that cut across groups. Using re-storying, we incorporated common plot points from all four groups to create a collective narrative. Across participants, the dominant narrative reflected experiences of conditional belonging, in which students could be welcomed into medicine when their identities and language skills served institutional needs, but those same identities could also be used to perceive them as less competent, less professional, or less fully belonging. Perceived foreign accents, non-standard English communication styles, and distinct cultural frames of reference were treated as a deficit. However, students also found that their multilinguistic and cultural knowledge, often developed through their immigrant family experiences, were powerful assets in patient care. These assets could also become liabilities when students were pushed into unpaid labor for the institution and their communities. By adopting a multi-axis lens, this study shows conditional belonging is a common narrative that transcends individual racial/ethnic categories, while still taking different forms across groups. Non-English language skills are a core issue used to justify inadequate patient care and question competence across all groups. This key mechanism of marginalization for immigrant students adds nuance not thoroughly addressed in single-axis studies.