Scripted success, unscripted consequences: How assessments in undergraduate medical education shape physician...

Professional identity formation (PIF) is increasingly understood not only as becoming a physician but as a matter of being and belonging within the profession. The development of a holistic professional identity can enhance a physician's confidence, wellbeing and performance. Assessment is a central site of the socialisation through which PIF occurs, yet how learners experience assessment when it is felt to be biassed or exclusionary, and what this means for their identity formation, is not well understood. We aimed to explore if and how medical students experience identity-related challenges, including microaggressions, through assessment and how these experiences shape their developing professional identities.

We conducted a constructivist qualitative study using semi-structured interviews, analysed through reflexive thematic analysis. Medical students at a single Canadian institution who self-identified in response to an emailed invitation as having had uncomfortable, unsettling or identity-related experiences with assessment were interviewed. Interpretation was guided by identity-threat and identity-safety as sensitising concepts and by an intersectional reading of participants' accounts.

We interviewed 22 students (16 pre-clerkship and 6 clerkship), 18 of whom identified as members of underrepresented communities. Participants described assessment as an identity-laden encounter that could threaten belonging and shape professional identity formation. Students from underrepresented communities described experiencing microaggressions through assessment. However, even participants who did not report microaggressions described negative assessment experiences that eroded their sense of belonging. Participants also described how assessment could reinforce harmful biases with the potential to affect patient care.

Negative experiences with assessment may be a barrier to trainees' socialisation into the medical profession and can affect patient care through reinforcing harmful stereotypes. Education about microaggressions, professional development on constructing assessment and structuring feedback, access to mentors and safe spaces to debrief may help mitigate these impacts on professional identity formation.