A Developmental Framework of Professional Identity Formation in Trainees for Low-resource Settings: A Qualitative Study

A Developmental Framework of Professional Identity Formation in Trainees for Low-resource Settings: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Developmental Framework of Professional Identity Formation in Trainees for Low-resource Settings: A Qualitative Study Yilin Chen, Peixin Lin, Hengshun Du, Jiaxin Wu, Xuanhua Zheng, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9406027/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Professional Identity Formation (PIF) is a dynamic and context-dependent socialisation process; while existing research identifies various influencing factors, there is a paucity of cohesive frameworks that capture the sequential internalisation of identity elements within practice. This gap is particularly salient in low-resource settings, such as China’s Rural-Streamed Medical Education Programme (RMEP), where substantial turnover and tenuous professional identity among trainees present significant challenges. Drawing upon the Ring Theory of Personhood (RToP) as a theoretical lens, this study aims to construct a developmental framework for understanding PIF among RMEP trainees to inform more effective retention strategies. Method Informed by a pragmatic paradigm, nine focus groups were conducted with 42 RMEP trainees across various training stages in China. Drawing upon the RToP as a theoretical lens, data were analysed using inductive thematic analysis to construct a developmental framework. Results A framework comprising 11 themes was constructed across three dimensions: the Societal Ring, encompassing working conditions, policies, attitudes of others, formal teaching and discipline development; the Relational Ring, including relationships with role models, close ones, patients, and peers; and the Individual Ring, incorporating reflective experience, personal character and values. This framework emphasises the dynamic interaction of these themes and the developmental trajectory of PIF, highlighting a shift from external to internal elements while also acknowledging the transformative impact of early external experiences in low-resource settings. Conclusions By proposing a developmental framework that maps PIF across different training stages, this study provides valuable insights for strengthening PIF and refining retention strategies for healthcare professionals in low-resource settings. Professional Identity Formation Low Resource Settings Focus Groups Medical Education General Practitioners Figures Figure 1 1. Introduction Professional Identity Formation (PIF) is inherently a socialisation-driven process of identity development( 1 ). Individuals enter the field of medicine with their own unique, pre-existing personal identities. Through ongoing socialisation, they continuously negotiate between internal self-awareness and external experiences, thereby co-constructing both their personal and professional identities( 2 , 3 ). Currently, medical educators are actively developing strategies to support PIF throughout medical training. Research into the drivers, components, and impacts of PIF has become increasingly robust, with the factors influencing PIF having been extensively explored and integrated into comprehensive frameworks( 2 , 4 ). Nevertheless, as identity formation is context-dependent and dynamic( 4 ), how individuals perceive these factors and the sequential evolution in practice remain insufficiently understood, leading to gaps in these frameworks’ ability to effectively guiding practice( 5 , 6 ). Concurrently, PIF research has predominantly focused on developed regions, with a scarcity of exploration in low-resource settings, which have been characterised by nine dimensions of deficiency, including infrastructure, education, and geographical conditions( 7 , 8 ). Healthcare professionals in these regions frequently encounter difficulties, such as inadequate guidance, heavy workloads, and diminished self-esteem, all of which contribute to workforce attrition and the compromised quality of patient care( 8 , 9 ). Amidst ongoing efforts to identify strategies for workforce retention in these settings, the strengthening of PIF is regarded as vital for addressing current challenges( 10 – 12 ). In 2010, the Chinese government launched the Rural-Streamed Medical Education Programme (RMEP) to cultivate a substantial workforce of general practitioners (GPs) for service in rural areas ( 13 , 14 ). While RMEP trainees (hereafter referred to as trainees in this paper), positioned as the primary workforce in China’s low-resource settings, currently achieve a compliance rate of approximately 70% during the service period, fewer than 20% intend to remain in these positions long-term, citing significant challenges to their PIF( 15 ). Current research has explored various factors influencing the PIF of these trainees; however, a comprehensive framework for understanding this process remains elusive ( 16 , 17 ). Theoretical Framework While research on PIF has expanded, a cohesive theoretical understanding remains underdeveloped, with few studies adequately addressing the contextually grounded perspectives of individual changes along with the sequential transformations( 8 , 18 ).Ring Theory of Personhood (RToP), originally applied in palliative care to examine personality changes influenced by familial factors, is particularly relevant to PIF due to its emphasis on the evolving nature of the self and the diverse sources that shape an individual’s self-concept ( 19 , 20 ). Emerging studies have applied this theory to PIF research, categorising influences into Individual, Relational, and Societal dimensions, and providing valuable insights into the interrelationships between these factors( 4 , 8 ). By employing the RToP as a theoretical lens, this study aims to develop a framework to explore how individuals in low-resource settings integrate external factors into their identity, and how these perceptions dynamically evolve across different training stages, offering insights to enhance PIF and refine retention strategies for healthcare professionals in these settings. 2. Method 2.1 Study Design This study was adopted a pragmatic paradigm and employed a qualitative design( 21 , 22 ). Semi-structured focus groups were conducted with RMEP trainees across different stages of training in China, with reporting guided by the Standards for Reporting Qualitative Research (SRQR) to ensure methodological transparency and rigour ( 23 ). 2.2 Participant Recruitment The RMEP in China requires trainees to complete five years of undergraduate education, comprising three years of theoretical study at medical school followed by two years of hospital-based clinical placements. Upon graduation, trainees are required to serve as GPs for six years in designated settings, including three years of standardised residency training in hospitals followed by three years of rural practice. Service locations are allocated based on local needs or academic performance. Participants in this study were recruited via purposive sampling from a university in southern China, where a researcher liaised with the RMEP coordinator to invite trainees across various stages. Ethical approval was granted by the Research Ethics Committee of Shantou University Medical College (Approval No. SUMC-JGLL202205), and all procedures performed were in accordance with the ethical standards of the respective institutions, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Prior to discussions, all trainees provided written informed consent, acknowledging their voluntary involvement. All data were anonymised and managed according to institutional protocols. The participants comprised undergraduate students from the target university and graduates serving in different hospitals and rural settings. To account for regional variability in the clinical environments across China( 24 ), graduates from various geographic regions were included to maintain a balanced ratio between southern, central, and northern regions. Focus groups were conducted at either university or clinical settings, depending on their geographical proximity; meanwhile, due to logistical constraints, several graduates participated in discussions via online platforms. 2.3 Research Team Preparation The research team comprised seven members (four men and three women). All members were affiliated with a medical school or its associated hospitals, and were trained in qualitative research. The lead researcher (PhD) was responsible for the overall study design and team training. To ensure procedural rigour and data quality, two core members with prior experience in conducting focus groups within general practice and primary care education served as primary facilitators. Furthermore, all members participated in weekly training sessions on qualitative methodology and focus group facilitation over six months, ensuring a shared understanding of methodological principles. 2.4 Data Collection Data collection was conducted between December 2024 and February 2025. Each focus group lasted 60 to 90 minutes and comprised two parts: a briefing and the core discussion. Each session was moderated by one primary facilitator, supported by other team members who took field notes and documented the proceedings. No prior relationship existed between the researchers and the trainees, and only the research team and trainees were present during the sessions. Each session commenced with a 10-minute briefing to outline the study’s aims and procedures, ensuring that trainees clearly understood their roles. During the core discussion, researchers adopted a facilitatory yet non-directive role to mitigate social desirability bias and power dynamics ( 25 ). The focus group guide (Supplementary Table 1) featured open-ended questions to encourage dialogue, avoiding the constraint of responses within predefined themes. All sessions were audio-recorded, transcribed verbatim, and securely archived. Field notes were documented and summarised in Excel spreadsheets. No further interviews were conducted, in line with the predefined scope of data collection. 2.5 Data Analysis The focus group recordings were transcribed verbatim by two researchers within 24 hours. Transcripts were subsequently reviewed by three on-site researchers to ensure the fidelity of the accounts and linguistic integrity. To establish credibility, transcripts were returned to trainees for member reflections; once confirmed, they were imported into Nvivo (Release 1.2) to facilitate analysis. Consistent with a pragmatic approach, an inductive thematic analysis was conducted( 22 ). The analysis commenced with open coding to identify recurring patterns, which were classified into codes and then interpreted, compared, and matched with the original content. While the coding was primarily inductive, the existing theoretical framework served as a sensitising concept to help contextualise and refine the themes( 26 ). To ensure analytical rigour, foster reflexive dialogue and enrich data interpretation, the lead researcher and one primary facilitator engaged in collaborative coding. Regular peer-debriefing sessions were convened to facilitate collaborative sense-making, ensuring a nuanced exploration of diverse perspectives. Data from all focus groups were analysed; through an iterative process of ongoing thematic review, data saturation was considered achieved after the sixth focus group, as no novel themes were identified( 27 ). Following the analysis, two primary facilitators conducted a comprehensive review to develop the framework. During the translation of findings from Chinese to English, key nuances were preserved to enhance fidelity to the original data; to maintain conceptual consistency, the translated segments were back-translated into Chinese for cross-verification. Trustworthiness was further enhanced through in-depth discussions on the coding and themes with researchers possessing long-term international study experience and relevant research backgrounds. Throughout the research process, the researchers' reflections on their perspectives and potential influences were systematically documented and reviewed. This practice promoted transparency and reflexivity, ensuring that the researchers' potential biases and perspectives were critically acknowledged and that interpretations remained grounded in the trainees' experiences ( 28 , 29 ). 3. Results 3.1 Focus Groups Profile A total of 42 trainees participated in nine focus groups (FGs), grouped by their stage of learning and comparable age (Table 1 ). Analysis indicated that trainees' clinical involvement played a pivotal role in their responses, with post-clinical trainees articulating relatively concrete and consolidated conceptualisations of professional identity, while pre-clinical trainees without clinical involvement primarily shared aspirational projections or uncertainties regarding their professional futures, with their reflections appearing more abstract. Given these thematic differences between the two cohorts, a stratified exploration was adopted, whereby FG1-3 represent pre-clinical trainees and FG4-9 comprise post-clinical trainees. Table 1 Characteristics of the trainees Stage of Study Focus Groups No. of Trainees Age Range Clinical involvement Research Background Undergraduate FG1, FG2, FG3 17 19ཞ21 N N Undergraduate FG4 4 21ཞ24 Y N Resident FG5, FG6 11 23ཞ41 Y N Resident FG7, FG8, FG9 10 22ཞ38 Y Y 3.2 Themes Constructed in the Framework Qualitative analysis identified 11 themes, which were organised into a framework based on the three dimensions of the RToP. Illustrative quotes for each theme are provided in Table 2 . Table 2 Themes with representative quotes Dimensions Themes Quotes from pre-clinical trainees Quotes from post-clinical trainees Societal Ring Working Conditions "I think salary is really important, as it reflects the hospital's valuation of you, the perks, and whether promotion opportunities are on par with those of other doctors." (FG2, P4) [employment benefits] "During my last visit, the doctors appeared rushed and careless. I worry that my future workplace may encounter similar issues, which I find quite demoralising." (FG2, P1) [work environment] "If you think a certain medication could help a patient recover, but you can’t prescribe it because you don’t have the authority…That really undermines one’s professional identity." (FG1, P2) [work environment] "If the job mainly involves tasks like guiding patients, I don’t think I’d feel a sense of accomplishment in that role." (FG2, P2) [work content] "Honestly, GPs don't earn as much as most specialists. It might be better in some areas, but it's not the place we will go in the future." (FG8, P1) [employment benefits] "Some of the medications were unavailable…The team there also couldn’t compare to the one in the CCU." (FG9, P1) [work environment] "I’ve heard of places where GPs focus on paper work and have no patient-facing opportunities…What’s the point of being in a place like that?" (FG6, P1) [work content] Policies "The government is really focused on us and has provided substantial support, including waiving tuition fees, accommodation fees, and even offering a monthly stipend." (FG1, P1) "One thing that challenges my professional identity is that I have to stay there for six years. I feel like, after finishing, my age will make it harder for me to develop elsewhere." (FG2, P6) "Many well-intentioned policies often fail in smaller cities due to a lack of funding, turning into tick-box exercises." (FG6, P2) "The policy seems focused on quickly meeting government targets by bringing people from other industries into general practice. It feels unfair, as others can easily obtain certification through alternative routes." (FG6, P4) "The job satisfaction for GPs in big cities is definitely higher than in rural areas because the perks are better, and the work is more diverse… In rural areas, though, you end up doing less, and everything feels much slower. " (FG9, P2) Attitude of others "I often scroll through social media and see GPs sharing their experiences…There are pros and cons." (FG1, P1) "Some professors may favour specialty students, viewing general practice as too broad and shallow in content." (FG8, P3) "In this field, you’ll hear a lot of different opinions…While they can have some impact, they don’t affect me much." (FG8, P2) "We're both graduates, but I'm a GP working in primary care, while other clinical students have better opportunities. This is somewhat disappointing to me." (FG6, P2) Formal Teaching "Take the clinical skills course we’re taking now, for example. It’s more hands-on. When you actually get to practice, you feel a sense of accomplishment and excitement. " (FG1, P2) "You only understand and know if you love general practice after working in the community or related institutions." (FG8, P2) Discipline Development "It seems like there are more and more candidates applying for our specialised programme these days, and we can see that the scores keep going up every year." (FG1, P1) "I think the future of general practice looks promising, especially with China’s aging population." (FG4, P3) "General practice needs a stronger disciplinary system. Both the public and even GPs don't fully understand it currently." (FG7, P4) Relational Ring Relationship with Role Models "There’s a GP on the volunteer team who spoke about visiting homebound patients… Their ability to provide such care is truly inspiring to me." (FG1, P5) "My tutor has been pivotal in shaping my professional identity, with his patience and care for patients deeply impacting me." (FG6, P1) Relationship with Close Ones "My family has quite traditional and simple views, and they think it's good enough for me to be a generalist in all subjects. " (FG3, P2) "My relatives and friends often say, 'As a GP, you learn a lot, but you never truly specialize." (FG1, P4) "My family sees it as a great opportunity because it offers a stable job with no tuition. At the time, I had just finished the college entrance exam and was unsure about my options, but I found it appealing, so I applied." (FG6, P3) "After learning more about general practice from me, my family now sees it as the right path. I've truly changed their perspective." (FG7, P2) Relationship with Patients "Real interactions, such as taking blood pressure for elderly patients or visiting the palliative care centre, are far more valuable than merely observing activities." (FG3, P3) "The strong rapport GPs had with the villagers left a lasting impression, inspiring me to continue in this profession." (FG6, P2) "Hospital patients often show appreciation for doctors' efforts, but GPs in rural areas rarely get such feedback and are often overlooked. " (FG7, P2) "GPs may lack the specialised skills to treat certain illnesses due to the large number of cases they handle, leading to frustration. Meanwhile, this can cause patients to perceive the doctor as incompetent, which may result in a lack of respect." (FG8, P3) Relationship with Peers “Maybe comparing myself to students in higher-paying majors, like dentistry, makes me feel a bit down.” (FG1, G4) "I find the discussions between GPs really interesting. It's something I've personally experienced in the general practice department." (FG6, P5) "At academic conferences, I meet like-minded people, reinforcing that this profession is worth pursuing." (FG7, P2) "I have classmates who don’t put in much effort, and when they underperform, people label them as 'just a GP…If I’m next, they might apply the same preconceived notions to me." (FG9, P1) Individual Ring Reflective Experience "Negative experiences with community healthcare, like high fees… If I become a GP, I will make sure to avoid that." (FG2, P1) "I envision my future career in a small clinic, like the one downstairs from my house. It’s closely connected to my life, and I can work in a stable environment." (FG1, P4) "I believe that with some clinical experience and a solid understanding of textbooks and guidelines, you'll have a much clearer grasp of general practice." (FG7, P3) "Overcoming the challenges I encounter in practice inspires me to consider research, and seeing other GPs succeed boosts my confidence." (FG9, P1) Personal Character and Values “To be honest, I don’t quite get what GP is yet.” (FG2, P2) "I used to be impatient, but becoming a GP has taught me patience and calmness." (FG6, P1) "I used to work in the CCU, which was much more fast-paced, but I consider myself a laid-back person. This experience made me want to be a doctor who takes the time to communicate with patients and provide warmth." (FG9, P1) 3.2.1 Societal Ring Working Conditions Trainees articulated how perceived working conditions shaped their professional identity, focusing on three primary areas: employment benefits, work environment, and work content. Regarding employment benefits, trainees highlighted salary, promotion opportunities, and external exchange opportunities. There was a perception that these benefits were not comparable to those available to hospital-based specialists, which left them feeling disheartened. The work environment encompassed both the working atmosphere and the objective environment. The former was valued for its suitability for learning and professional development, while the latter pertained to aspects such as the availability of medical equipment and medications. The majority of trainees' concerns were informed by prior negative experiences or observations. Finally, concerning work content, while pre-clinical trainees expressed a desire for more challenging tasks, post-clinical trainees found that a significant proportion of GPs' work comprised routine, repetitive tasks, leading to feelings of disappointment. Policies Irrespective of whether trainees had entered clinical practice, they generally expressed a positive attitude towards the policy formulation, both in relation to the RMEP specifically and to the broader context of general practice. However, several trainees indicated that certain aspects of the current policy, such as the compulsory six-year service requirement, led to perceptions that their future development was constrained. Concurrently, they perceived a sense of inequity, particularly in comparison to other trainees who received less specialised training yet benefitted from supportive policies for career mobility. Additionally, post-clinical trainees observed regional and urban-rural disparities in policy implementation, noting that the discrepancy between policy mandates and local execution notably affected their professional motivation. Attitude of Others This theme encompassed evaluations of the status of GPs within society and the healthcare system from various sources, including online media, career lectures and social interactions. Pre-clinical trainees reported that their understanding of GPs’ status was primarily shaped by perceptions encountered through media and social interactions. In contrast, post-clinical trainees often indicated that such appraisals had a limited influence on them. A notable aspect of their experience was interacting with colleagues from other disciplines in social settings, where comparisons between general practice and other fields frequently led to a sense of disparity and a diminished sense of professional identity. Formal Teaching Formal teaching referred to the courses organised by medical schools and hospitals, encompassing both theoretical and practical components. While trainees acknowledged that theoretical courses provided foundational knowledge, they perceived practical courses as playing a more central role. Pre-clinical trainees regarded the practical one as novel, while post-clinical trainees recognised the value of GPs through direct exposure to their work. Discipline Development Discipline development encompassed the current state and future prospects of general practice in China. As post-clinical trainees gained clinical experience, they frequently engaged in in-depth reflections on these issues, recognising the field as both vibrant and challenging. 3.2.2 Relational Ring Role Models Interactions with role models within general practice had a profound influence on trainees at both pre- and post-clinical stages. Comparatively, post-clinical trainees provided more nuanced descriptions, including guidance from their mentors on general practice knowledge and skills, career progression, and even aspects of personality. Close Ones Regarding close relationships, most trainees reported that their initial decision to pursue general practice was influenced by their parents, who held the belief that one should seek a stable and relatively less strenuous job, rather than stemming from a genuine interest in the field. Additionally, some trainees noted that their family members did not view general practice favourably due to limited opportunities for career progression. However, as trainees' understanding of general practice deepened, post-clinical trainees reported that the influence of close ones gradually diminished, with some even describing instances where they, in turn, reshaped the perspectives of those around them. Patients Pre-clinical trainees mainly interacted with patients through volunteer outreach, such as community clinics. However, these opportunities were limited by time and settings, and only those who engaged in meaningful interactions found them beneficial to their professional identity. Post-clinical trainees noted that positive interactions between GPs and patients fostered professional aspirations and increased their willingness to establish similar connections as future GPs. In contrast, some post-clinical trainees indicated that the professional identity could be undermined by the variability in health literacy and the reasons for consultation among primary care patients. Moreover, they expressed concerns that they might face greater challenges in managing doctor–patient relationships when navigating clinical uncertainty without the structured knowledge framework typical of specialist fields. Peers This theme addressed daily communication with peers, as well as giving and receiving support during critical moments. Post-clinical trainees provided more extensive descriptions related to the relationships with peers, particularly emphasising the deeper insights they gained into general practice and a stronger sense of group belonging, which they attributed to discussions and exchanges with their colleagues. However, one trainee mentioned that if the peers performed poorly, it would affect how others in their local area perceived them, thereby reducing their professional identity. 3.2.3 Individual Ring Reflective Experience Reflective experiences catalysed trainees’ contemplation of their future roles as GPs. These insights were derived from clinical encounters, involvement in research, various educational activities, and their personal experiences as patients seeking care. For pre-clinical trainees, observational placements in community hospitals and their experiences as patients had a notable influence in aiding the formation of an initial understanding of GPs. For post-clinical trainees, clinical experience had a more immediate and profound impact on the development of their professional identity. Additionally, these trainees demonstrated a more sophisticated understanding and greater critical thinking regarding general practice, actively exploring solutions to current issues in the field. Consequently, their engagement in academic research served as a pivotal influence in shaping their professional identity. Personal Character and Values While pre-clinical trainees appeared to have a limited awareness of how their character and values influenced their professional identity, the majority of post-clinical trainees engaged in active reflection within this theme. They contemplated whether their inherent characteristics were compatible with the role of a GP and how their character had been shaped or transformed during their training. Furthermore, they developed a deeper understanding of the values and principles underlying general practice. 3.3 The Developmental Framework of PIF 3.3.1 Inter-thematic Relationships within the Same Stage As illustrated in Fig. 1 , at any specific juncture, the elements within the three rings are not independent; rather, they exist in a nested hierarchy, operating within distinct focal domains while maintaining interdimensional connectivity. In this study, the Individual Ring emphasises subjective, agentic behaviours, which are frequently informed by experiences derived from themes within the Societal and Relational Rings. The Relational Ring highlights the influence of close personal relationships on the individual, where perspectives are often mediated by themes within the Societal Ring. The Societal Ring focuses on broader relationships and the effects of the perceived environment. Notably, the Relational Ring often serves as a conduit for individuals' understanding of and engagement with this societal environment. Consequently, the specific emphasis of each dimension varies according to these distinct focal points, collectively contributing to the professional identity of each trainee. 3.3.2 Thematic Development across Stages Figure 1 illustrates the dynamic evolution of PIF across distinct stages. Notably, the third ring representing ‘healthcare professionals’ does not signify a static or predefined endpoint. Instead, it denotes a developmental trajectory where trainees increasingly align with the professional identity of their specific field as their identities mature. Our findings suggest that post-clinical trainees reported a limited influence from the attitudes of others and the opinions of close individuals, contrasting with pre-clinical trainees, for whom these themes were central to their PIF during the initial stages of their training. Concurrently, themes such as discipline development, relationships with peers and patients, as well as personal characteristics and values became more pronounced among post-clinical cohorts, whereas pre-clinical trainees demonstrated limited awareness of these themes. Moreover, as post-clinical trainees recognised the increasing importance of discipline development and relationships with peers and patients in shaping their PIF, they often associated this shift with an enhanced awareness of their values and characteristics. This shift may suggest that as clinical training progresses, elements within the Individual Ring assume an increasingly central role in the PIF process. 3.3.3 Early Community Involvement as the Critical Catalyst Initially, we anticipated that clinical experience would diversify with increasing seniority, assuming that hospital-based placements would exert the primary influence on trainees' PIF. However, during the discussions, trainees consistently emphasised the formative impact of their two-week community involvement on shaping their professional identity, which nearly all had completed at accredited primary care institutions prior to their hospital placements. "Those two weeks gave me a real sense of what being a GP is all about... I thought GPs are amazing, and at that moment, I knew I wanted to become a GP like that in the future.” (FG6, P3) In contrast, while hospital placements such as weekly half-day attendances during pre-clinical years and full-time hospital placements may be beneficial for doctors' professional identity, they appear to have a minimal effect on GP PIF. This distinction underscores that structured community involvement, rather than traditional hospital placements, serves as the critical catalyst for GP PIF. 4. Discussions This study employed focus groups with 42 trainees to construct a developmental framework for the PIF in low-resource settings. The findings elucidate how specific themes influence PIF at various stages of training, while also emphasising the Individual Ring and key catalytic events that warrant attention, offering insights to foster PIF and refine retention strategies for healthcare professionals in low-resource settings. The results revealed that the influence of themes varied across different stages, aligning with the dynamic nature emphasised in Kegan’s framework and the evolutionary character of the RToP( 2 , 19 , 20 ). This suggests that the stages of PIF are dynamic, with each stage prioritising different attributes and challenges. Our study found that, while the themes from the Relational and Societal Rings may initially dominate trainees' identity negotiation, themes within the Individual Ring become increasingly prominent as clinical immersion deepens( 20 , 30 ). This shift potentially accompanies the development of personal awareness, echoing the work of Tsang et al., which suggests that educational interventions focused on value guidance and reflective environments are essential to accelerate the maturation of these themes( 31 ). Although the trainees in our study did not report undergoing specific reflective training, an observable trend was noted: those with a more mature professional identity were more likely to describe their reflections on practice and demonstrate insights into their personal characteristics and values. This aligns with previous studies emphasising narrative reflection, as it deepens the processing of experiences and fosters critical thinking, thereby providing space for identity development( 3 ). Guiding such behaviours may be an effective method for accelerating the formation of the themes within the Individual Ring, a notion further supported by Jia Yin Lim et al. in the Krishna Model of Reflective Writing( 19 , 32 ). Beyond the Individual Ring, creating an environment during the early stages of PIF conducive to reflection through the Relational and Societal Rings is also critical. While previous research has identified the provision of role models and clinical experiences as two of the most significant factors in facilitating PIF( 2 , 3 ), our study suggests that, in low-resource settings, the challenges associated with implementing these factors may be more complex than anticipated. The influence of role models, traditionally regarded as positive, has recently come under scrutiny in studies documenting their negative impacts and the burden placed on trainees in their absence( 1 ). In our study, most trainees lacked dedicated mentors and sought guidance from other groups. Unfortunately, these "role models" were often perceived to have a negative effect, trainees reported that some specialists treated them with indifference compared with specialty-track students. Furthermore, during case discussions, GPs often assumed a secondary role. While the situation may be more pronounced in certain groups including GPs and psychiatrists, and has been previously characterised in the literature as "stigmatisation", the common lack of mentorship in low-resource might lead to a fragmented construction of professional identity, ultimately leaving students uncertain regarding their future roles during the critical early stages of their training. ( 33 , 34 ) Additionally, we identified early community involvement provided by formal teaching as a critical catalyst for trainees in our study. Unlike the standard Chinese curriculum where community engagement commences in the eighth year, the innovative two-week experience at the end of their third year triggered significant reflective practice. Trainees utilised these early encounters to navigate their perceptions of GPs before their re-entry into the field. Previous studies have characterised these significant transformations as pivotal transitions in PIF( 5 , 35 ). Regrettably, many low-resource settings fail to provide the necessary conditions for such transitions, which consequently impedes early integration and a sense of belonging, both of which are essential for PIF( 5 ). Given that current PIF research predominantly originates from developed regions, this study’s framework provides a vital pathway for educational reforms in low-resource contexts, facilitating targeted interventions across various stages( 8 , 36 , 37 ). Given the current lack of evidence for instruments that can effectively and reliably assess medical students' PIF( 38 ), we propose the use of flexible assessment tools to capture shifts in the attributes and challenges prioritised at each stage. For example, Tagawa’s stage-specific attribute scale, grounded in Kegan’s framework, targets professionals at four distinct developmental stages( 37 ), offering valuable insights into longitudinal research regarding the evolution of focal dimensions and their relative weightings. The framework developed in this study also possesses the potential to be operationalised into quantitative assessment instruments. Its flexibility allows it to guide educational reforms in general practice, while offering interdisciplinary applicability to monitor trainees' PIF in low-resource regions and provide constructive feedback for continuous improvement. While the long-term impact of early interventions on retention remains unclear, proactively addressing these themes may alleviate uncertainty and foster a robust professional identity; this is a process that necessitates ongoing collaboration between educators, practitioners, and researchers to effectively capture the multifaceted nature of PIF across diverse clinical contexts. Limitations Several limitations warrant acknowledgement. Firstly, while baseline consistency was noted across the RMEP institutions at entry, longitudinal research is required to fully clarify the trajectory of PIF. Secondly, the study focused on trainees within the RMEP pathway, which represents a structured and policy-driven training model. Consequently, the findings may not fully capture the experiences of other training pathways or independent healthcare professionals, limiting broader applicability. Thirdly, the perspectives of educators and key stakeholders within low-resource settings—particularly rural supervisors, frontline general practitioners, and policymakers—were not included. Given their critical role in shaping training environments and PIF, future research incorporating multi-stakeholder perspectives is needed to enhance the ecological credibility of the framework. Finally, although participants were recruited from multiple regions, the study was not designed to systematically compare geographic or healthcare settings. Importantly, thematic saturation was achieved, and no substantial divergence in core themes was observed across participants, suggesting relative conceptual consistency. However, further studies are warranted to explore how specific contextual factors may shape PIF in greater depth, thereby further assessing the and adaptability of the proposed framework. 5. Conclusion This study constructs a developmental framework comprising 11 themes across three interconnected dimensions, providing a nuanced understanding of PIF in low-resource settings. By applying the RToP, the findings elucidate the dynamic trajectory of PIF, characterised by a progressive shift from externally mediated influences towards internally integrated identity elements, while underscoring the critical role of early contextual experiences as formative catalysts. These insights extend existing conceptualisations of PIF by offering a context-sensitive framework that can inform the design of targeted educational strategies and support more sustainable workforce retention in underserved settings. Abbreviations PIF Professional Identity Formation GPs General Practitioners RMEP Rural-Streamed Medical Education Programme RToP Ring Theory of Personhood Declarations Ethical approval and consent to participate: Ethical approval for this study was granted by the Research Ethics Committee of Shantou University Medical College (Approval No. SUMC-JGLL202205). All procedures performed were in accordance with the ethical standards of the respective institutions, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all participates. Data were anonymised and managed according to institutional protocols. Availability of data and materials: All data generated or analysed during this study is included in this published article. The datasets analysed are open to the corresponding author on reasonable request. Consent to publish: Explicit written informed consent for publication was obtained from the trainees (or their legal guardians) for the use of their clinical details and/or records in this study. All personal identifiers have been removed or altered to ensure privacy and confidentiality. Author Contributions: Y.C. and P.L. led the study design and data collection. K.L. secured funding and ethical approval. P.L., H.D. and J.W. handled the initial transcription of audio recordings, while Y.C. and X.Z. reviewed the accuracy of the transcription. Y.C., P.L. and X.Z. contributed to the data analysis. K.L. and M.Y. provided expertise in the development of the group guide, data analysis, and framework. M.Y. and K.L. coordinated the overall research project, overseeing data analysis and guiding the interpretation of findings. Y.C. and P.L. drafted the manuscript. All authors reviewed and approved the final manuscript. Funding Statement: This study was supported by the Teaching Reform Project for “New Medical Sciences” (Notice on the Announcement of the 2023 Teaching Reform Project List by the Guangdong Provincial "New Medical Sciences" Construction Steering Committee-No. 126), the Teaching Reform and Research Project of Shantou University Medical College (SUMC [2025] No. SUMC-JG202529 and No. SUMC-JG202553), and the Medical Science and Technology Research Fund Project of Guangdong Province (A2023422). Conflicts of Interest: The authors declare that there are no conflicts of interest regarding the publication of this paper, including any financial or other potential conflicts that could influence or bias the results of this study. Acknowledgements: The authors would like to express their sincere gratitude to all members of the focus groups for their valuable contributions. References Sternszus R, Steinert Y, Razack S, Boudreau JD, Snell L, Cruess RL. Being, becoming, and belonging: reconceptualizing professional identity formation in medicine. Front Med. 2024;11. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A Schematic Representation of the Professional Identity Formation and Socialization of Medical Students and Residents: A Guide for Medical Educators. Acad Med. 2015;90(6):718–25. Scholz E, Trede F. Veterinary professional identity: Conceptual analysis and location in a practice theory framework. Front Veterinary Sci. 2023;Volume 10–2023. Sarraf-Yazdi S, Teo YN, How AEH, Teo YH, Goh S, Kow CS, et al. A Scoping Review of Professional Identity Formation in Undergraduate Medical Education. J Gen Intern Med. 2021;36(11):3511–21. Vaa Stelling BE, Andersen CA, Suarez DA, Nordhues HC, Hafferty FW, Beckman TJ et al. Fitting In While Standing Out: Professional Identity Formation, Imposter Syndrome, and Burnout in Early-Career Faculty Physicians. Acad Med. 2023;98(4). Barnhoorn PC, Houtlosser M, Ottenhoff-de Jonge MW, Essers GTJM, Numans ME, Kramer AWM. A practical framework for remediating unprofessional behavior and for developing professionalism competencies and a professional identity. Med Teach. 2019;41(3):303–8. Chanel van Z, Marelise B, Susan H, Martin H. Unravelling 'low-resource settings': a systematic scoping review with qualitative content analysis. BMJ Global Health. 2021;6(6):e005190. Sarraf-Yazdi S, Pisupati A, Goh CK, Ong YT, Toh YR, Goh SPL, et al. A scoping review and theory-informed conceptual model of professional identity formation in medical education. Med Educ. 2024;58(10):1151–65. Mbalinda SN, Najjuma JN, Gonzaga AM, Livingstone K, Musoke D. Understanding and barriers of professional identity formation among current students and recent graduates in nursing and midwifery in low resource settings in two universities: a qualitative study. BMC Nurs. 2024;23(1):146. Li M, Tang H, Zheng H, Tian Y, Cheng X, Cheng H, et al. Supporting and retaining competent primary care workforce in low-resource settings: lessons learned from a prospective cohort study. Family Med Community Health. 2023;11(4):e002421. Organization WH. WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas Geneva, 2021 [. Krishnan A. Community medicine in India - Which way forward? Indian J Community Med. 2016;41(1). Jing F, Xin S, Yong G. Turnover intention and its influencing factors among general practitioners in the Eastern, Central and Western China. Chin J Public Health. 2021;37(11):1635–40. China, MoEotPsRo. China MoHotPsRo. Several Opinions of the Ministry of Education and the Ministry of Health on Strengthening Medical Education and Improving the Quality of Medical Education. Health Vocat Educ. 2009;27(10):5–6. Xiaoxue H. Meta-analysis of the Performance Status and RelatedInfluencing Factors of China's Order-oriented MedicalStudents [Master]. Guilin Medical University; 2025. Dong-ying Z, Chan-jiao Z, Xiang H, Xiu-juan L, Hua-jie Y, Zhi-zhe L, et al. Research of factors affecting professional identity of general practitioner and strategy. Chin J Gen Pract. 2014;12(11):1836–8. Xue Q, Yongtian Y, Wenjun L, Yinghui L, Jinguang Y, Jingwei L, et al. Root Cause Analysis of the Influencing Factors of Professional Identity in Rural Order-orientedMedical Students: a Qualitative Research. Chin Gen Pract. 2024;27(22):2752–8. Cornett M, Palermo C, Ash S. Professional identity research in the health professions—a scoping review. Adv Health Sci Educ. 2023;28(2):589–642. Radha Krishna LK, Alsuwaigh R. Understanding the Fluid Nature of Personhood – the Ring Theory of Personhood. Bioethics. 2015;29(3):171–81. Krishna LKR, Kwek SY. The changing face of personhood at the end of life: The ring theory of personhood. Palliat Supportive Care. 2015;13(4):1123–9. John W, Creswell CNP, editors. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 4th edition.: Sage Publications; 2017. Guest G, MacQueen K, Namey E. Applied Thematic Analysis. Thousand Oaks, California: SAGE Publications, Inc.; 2012. Available from: https://methods.sagepub.com/book/mono/applied-thematic-analysis/toc O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Acad Med. 2014;89(9). Zhiyang L, Hongyan L, Chuanghao Y. Distribution Characteristics and Equilibrium of General Practitioners among Provinces in China. Chin Gen Pract. 2025;28(16):1992–2000. Coldron J, Smith R. Active location in teachers' construction of their professional identities. J Curriculum Stud. 1999;31(6):711–26. Varpio L, Paradis E, Uijtdehaage S, Young M. The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework. Acad Med. 2020;95(7). Hennink MM, Kaiser BN, Weber MB. What Influences Saturation? Estimating Sample Sizes in Focus Group Research. Qual Health Res. 2019;29(10):1483–96. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Res Sport Exerc Health. 2019;11(4):589–97. Olmos-Vega FM, Stalmeijer RE, Varpio L, Kahlke R. A practical guide to reflexivity in qualitative research: AMEE Guide 149. Med Teach. 2023;45(3):241–51. Sawatsky AP, Santivasi WL, Nordhues HC, Vaa BE, Ratelle JT, Beckman TJ, et al. Autonomy and professional identity formation in residency training: A qualitative study. Med Educ. 2020;54(7):616–27. Tsang L, Ong S, Goh K, Ng C, Ho C. General practitioner professional identity formation: Much needed, (still) oft forgotten. Australian J Gen Practitioners. 2024;53:128–31. Lim JY, Ong SYK, Ng CYH, Chan KLE, Wu SYEA, So WZ, et al. A systematic scoping review of reflective writing in medical education. BMC Med Educ. 2023;23(1):12. Viani Walsh D, Murphy N, Evans S, Murphy KC, Guerandel A, Doherty AM, et al. The impact of badmouthing of medical specialities to medical students. Ir J Psychol Med. 2024;41(3):354–61. Merrett A, Jones D, Sein K, Green T, Macleod U. Attitudes of newly qualified doctors towards a career in general practice: a qualitative focus group study. Br J Gen Pract. 2017;67(657):e253. Kruskie ME, Frankel RM, Isaacson JH, Mehta N, Byram JN. Investigating feelings of imposterism in first-year medical student narratives. Med Educ. 2025;59(3):318–27. Kiyimba B, Atulinda L, Nalunkuma R, Asasira I, Kabunga J, Banturaki D, et al. Research involvement among undergraduate health profession students in a resource-limited setting: awareness, attitude, motivators and barriers. BMC Med Educ. 2022;22(1):249. Tagawa M. Scales to evaluate developmental stage and professional identity formation in medical students, residents, and experienced doctors. BMC Med Educ. 2020;20(1):40. Toben D, Mak-van der Vossen M, Wouters A, Kusurkar RA. Validation of the professional identity questionnaire among medical students. BMC Med Educ. 2021;21(1):359. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 19 May, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers invited by journal 23 Apr, 2026 Editor invited by journal 15 Apr, 2026 Editor assigned by journal 14 Apr, 2026 Submission checks completed at journal 14 Apr, 2026 First submitted to journal 13 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9406027","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633784250,"identity":"f4036935-ad22-40a1-a004-96aec01f2af4","order_by":0,"name":"Yilin Chen","email":"","orcid":"","institution":"Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Yilin","middleName":"","lastName":"Chen","suffix":""},{"id":633784251,"identity":"a0b64095-8939-4fae-b471-400332140338","order_by":1,"name":"Peixin Lin","email":"","orcid":"","institution":"Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Peixin","middleName":"","lastName":"Lin","suffix":""},{"id":633784252,"identity":"5037b77b-6710-4f04-8cf5-6377275c7175","order_by":2,"name":"Hengshun Du","email":"","orcid":"","institution":"Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Hengshun","middleName":"","lastName":"Du","suffix":""},{"id":633784253,"identity":"ec1a5c1d-1057-4d81-aab0-ddcf7903b278","order_by":3,"name":"Jiaxin Wu","email":"","orcid":"","institution":"Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Jiaxin","middleName":"","lastName":"Wu","suffix":""},{"id":633784254,"identity":"904650b7-2611-4798-9dd5-9fe97fa43628","order_by":4,"name":"Xuanhua Zheng","email":"","orcid":"","institution":"Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xuanhua","middleName":"","lastName":"Zheng","suffix":""},{"id":633784255,"identity":"0fa6bc97-d80b-42f5-971b-f332628b66aa","order_by":5,"name":"Mi Yao","email":"","orcid":"","institution":"Peking University First Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mi","middleName":"","lastName":"Yao","suffix":""},{"id":633784256,"identity":"0cefe1d5-a57a-480e-b6d0-e825d9247dae","order_by":6,"name":"Kai Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYBACCXbGBoYPFVAOcVqYGRsYZ5yBqCZWCwMDM28bKVokm5nbHvDOq6szOMB88DYPg10eQS3SzIztBpLbDksYHGBLtuZhSC4mqEWOmbFNwnDbAaAWHjNpHoYDiQ1EaUmcUwfUwv+NOC3SIC0HG5hBtrARp0WymbFNsuHYYcmZh9mMLecYJBPWInG8/Zn0n5o6fr7jzQ9vvKmwI6wFAZhBhAHx6kfBKBgFo2AU4AEATL8y92qRqaUAAAAASUVORK5CYII=","orcid":"","institution":"First Affiliated Hospital of Shantou University Medical College","correspondingAuthor":true,"prefix":"","firstName":"Kai","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2026-04-13 15:24:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9406027/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9406027/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108822431,"identity":"262fee1b-61f4-4d47-81e6-0041f28c61f4","added_by":"auto","created_at":"2026-05-08 16:48:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":129323,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Developmental Framework of PIF: An RToP Perspective\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9406027/v1/6cb86de7854a9f49157f20ed.png"},{"id":108823118,"identity":"76d4da47-38e6-4250-9670-5bcff33254ed","added_by":"auto","created_at":"2026-05-08 16:52:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":444192,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9406027/v1/5a3bb47b-40fd-4988-9b30-b07a08bd12a8.pdf"},{"id":108821161,"identity":"e9504279-7d52-4f06-a24b-23aa32dd3d94","added_by":"auto","created_at":"2026-05-08 16:44:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":21435,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9406027/v1/c7977a3e021cfec765bd93b6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Developmental Framework of Professional Identity Formation in Trainees for Low-resource Settings: A Qualitative Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eProfessional Identity Formation (PIF) is inherently a socialisation-driven process of identity development(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Individuals enter the field of medicine with their own unique, pre-existing personal identities. Through ongoing socialisation, they continuously negotiate between internal self-awareness and external experiences, thereby co-constructing both their personal and professional identities(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Currently, medical educators are actively developing strategies to support PIF throughout medical training. Research into the drivers, components, and impacts of PIF has become increasingly robust, with the factors influencing PIF having been extensively explored and integrated into comprehensive frameworks(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Nevertheless, as identity formation is context-dependent and dynamic(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), how individuals perceive these factors and the sequential evolution in practice remain insufficiently understood, leading to gaps in these frameworks\u0026rsquo; ability to effectively guiding practice(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConcurrently, PIF research has predominantly focused on developed regions, with a scarcity of exploration in low-resource settings, which have been characterised by nine dimensions of deficiency, including infrastructure, education, and geographical conditions(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Healthcare professionals in these regions frequently encounter difficulties, such as inadequate guidance, heavy workloads, and diminished self-esteem, all of which contribute to workforce attrition and the compromised quality of patient care(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Amidst ongoing efforts to identify strategies for workforce retention in these settings, the strengthening of PIF is regarded as vital for addressing current challenges(\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2010, the Chinese government launched the Rural-Streamed Medical Education Programme (RMEP) to cultivate a substantial workforce of general practitioners (GPs) for service in rural areas (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). While RMEP trainees (hereafter referred to as trainees in this paper), positioned as the primary workforce in China\u0026rsquo;s low-resource settings, currently achieve a compliance rate of approximately 70% during the service period, fewer than 20% intend to remain in these positions long-term, citing significant challenges to their PIF(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Current research has explored various factors influencing the PIF of these trainees; however, a comprehensive framework for understanding this process remains elusive (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheoretical Framework\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhile research on PIF has expanded, a cohesive theoretical understanding remains underdeveloped, with few studies adequately addressing the contextually grounded perspectives of individual changes along with the sequential transformations(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).Ring Theory of Personhood (RToP), originally applied in palliative care to examine personality changes influenced by familial factors, is particularly relevant to PIF due to its emphasis on the evolving nature of the self and the diverse sources that shape an individual\u0026rsquo;s self-concept (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Emerging studies have applied this theory to PIF research, categorising influences into Individual, Relational, and Societal dimensions, and providing valuable insights into the interrelationships between these factors(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBy employing the RToP as a theoretical lens, this study aims to develop a framework to explore how individuals in low-resource settings integrate external factors into their identity, and how these perceptions dynamically evolve across different training stages, offering insights to enhance PIF and refine retention strategies for healthcare professionals in these settings.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eThis study was adopted a pragmatic paradigm and employed a qualitative design(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Semi-structured focus groups were conducted with RMEP trainees across different stages of training in China, with reporting guided by the Standards for Reporting Qualitative Research (SRQR) to ensure methodological transparency and rigour (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Participant Recruitment\u003c/h2\u003e \u003cp\u003eThe RMEP in China requires trainees to complete five years of undergraduate education, comprising three years of theoretical study at medical school followed by two years of hospital-based clinical placements. Upon graduation, trainees are required to serve as GPs for six years in designated settings, including three years of standardised residency training in hospitals followed by three years of rural practice. Service locations are allocated based on local needs or academic performance.\u003c/p\u003e \u003cp\u003eParticipants in this study were recruited via purposive sampling from a university in southern China, where a researcher liaised with the RMEP coordinator to invite trainees across various stages. Ethical approval was granted by the Research Ethics Committee of Shantou University Medical College (Approval No. SUMC-JGLL202205), and all procedures performed were in accordance with the ethical standards of the respective institutions, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Prior to discussions, all trainees provided written informed consent, acknowledging their voluntary involvement. All data were anonymised and managed according to institutional protocols.\u003c/p\u003e \u003cp\u003eThe participants comprised undergraduate students from the target university and graduates serving in different hospitals and rural settings. To account for regional variability in the clinical environments across China(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), graduates from various geographic regions were included to maintain a balanced ratio between southern, central, and northern regions. Focus groups were conducted at either university or clinical settings, depending on their geographical proximity; meanwhile, due to logistical constraints, several graduates participated in discussions via online platforms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Research Team Preparation\u003c/h2\u003e \u003cp\u003eThe research team comprised seven members (four men and three women). All members were affiliated with a medical school or its associated hospitals, and were trained in qualitative research. The lead researcher (PhD) was responsible for the overall study design and team training. To ensure procedural rigour and data quality, two core members with prior experience in conducting focus groups within general practice and primary care education served as primary facilitators. Furthermore, all members participated in weekly training sessions on qualitative methodology and focus group facilitation over six months, ensuring a shared understanding of methodological principles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Collection\u003c/h2\u003e \u003cp\u003eData collection was conducted between December 2024 and February 2025. Each focus group lasted 60 to 90 minutes and comprised two parts: a briefing and the core discussion. Each session was moderated by one primary facilitator, supported by other team members who took field notes and documented the proceedings. No prior relationship existed between the researchers and the trainees, and only the research team and trainees were present during the sessions.\u003c/p\u003e \u003cp\u003eEach session commenced with a 10-minute briefing to outline the study\u0026rsquo;s aims and procedures, ensuring that trainees clearly understood their roles. During the core discussion, researchers adopted a facilitatory yet non-directive role to mitigate social desirability bias and power dynamics (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The focus group guide (Supplementary Table\u0026nbsp;1) featured open-ended questions to encourage dialogue, avoiding the constraint of responses within predefined themes. All sessions were audio-recorded, transcribed verbatim, and securely archived. Field notes were documented and summarised in Excel spreadsheets. No further interviews were conducted, in line with the predefined scope of data collection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Analysis\u003c/h2\u003e \u003cp\u003eThe focus group recordings were transcribed verbatim by two researchers within 24 hours. Transcripts were subsequently reviewed by three on-site researchers to ensure the fidelity of the accounts and linguistic integrity. To establish credibility, transcripts were returned to trainees for member reflections; once confirmed, they were imported into Nvivo (Release 1.2) to facilitate analysis.\u003c/p\u003e \u003cp\u003eConsistent with a pragmatic approach, an inductive thematic analysis was conducted(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The analysis commenced with open coding to identify recurring patterns, which were classified into codes and then interpreted, compared, and matched with the original content. While the coding was primarily inductive, the existing theoretical framework served as a sensitising concept to help contextualise and refine the themes(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo ensure analytical rigour, foster reflexive dialogue and enrich data interpretation, the lead researcher and one primary facilitator engaged in collaborative coding. Regular peer-debriefing sessions were convened to facilitate collaborative sense-making, ensuring a nuanced exploration of diverse perspectives. Data from all focus groups were analysed; through an iterative process of ongoing thematic review, data saturation was considered achieved after the sixth focus group, as no novel themes were identified(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFollowing the analysis, two primary facilitators conducted a comprehensive review to develop the framework. During the translation of findings from Chinese to English, key nuances were preserved to enhance fidelity to the original data; to maintain conceptual consistency, the translated segments were back-translated into Chinese for cross-verification. Trustworthiness was further enhanced through in-depth discussions on the coding and themes with researchers possessing long-term international study experience and relevant research backgrounds. Throughout the research process, the researchers' reflections on their perspectives and potential influences were systematically documented and reviewed. This practice promoted transparency and reflexivity, ensuring that the researchers' potential biases and perspectives were critically acknowledged and that interpretations remained grounded in the trainees' experiences (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Focus Groups Profile\u003c/h2\u003e \u003cp\u003eA total of 42 trainees participated in nine focus groups (FGs), grouped by their stage of learning and comparable age (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Analysis indicated that trainees' clinical involvement played a pivotal role in their responses, with post-clinical trainees articulating relatively concrete and consolidated conceptualisations of professional identity, while pre-clinical trainees without clinical involvement primarily shared aspirational projections or uncertainties regarding their professional futures, with their reflections appearing more abstract. Given these thematic differences between the two cohorts, a stratified exploration was adopted, whereby FG1-3 represent pre-clinical trainees and FG4-9 comprise post-clinical trainees.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the trainees\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage of Study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFocus Groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo. of Trainees\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge Range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical involvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eResearch Background\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFG1, FG2, FG3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19ཞ21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFG4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21ཞ24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFG5, FG6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23ཞ41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFG7, FG8, FG9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22ཞ38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Themes Constructed in the Framework\u003c/h2\u003e \u003cp\u003eQualitative analysis identified 11 themes, which were organised into a framework based on the three dimensions of the RToP. Illustrative quotes for each theme are provided in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes with representative quotes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimensions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuotes from pre-clinical trainees\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuotes from post-clinical trainees\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocietal Ring\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking Conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"I think salary is really important, as it reflects the hospital's valuation of you, the perks, and whether promotion opportunities are on par with those of other doctors.\" (FG2, P4) [employment benefits]\u003c/p\u003e \u003cp\u003e\"During my last visit, the doctors appeared rushed and careless. I worry that my future workplace may encounter similar issues, which I find quite demoralising.\" (FG2, P1) [work environment]\u003c/p\u003e \u003cp\u003e\"If you think a certain medication could help a patient recover, but you can\u0026rsquo;t prescribe it because you don\u0026rsquo;t have the authority\u0026hellip;That really undermines one\u0026rsquo;s professional identity.\" (FG1, P2) [work environment]\u003c/p\u003e \u003cp\u003e\"If the job mainly involves tasks like guiding patients, I don\u0026rsquo;t think I\u0026rsquo;d feel a sense of accomplishment in that role.\" (FG2, P2) [work content]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"Honestly, GPs don't earn as much as most specialists. It might be better in some areas, but it's not the place we will go in the future.\" (FG8, P1) [employment benefits]\u003c/p\u003e \u003cp\u003e\"Some of the medications were unavailable\u0026hellip;The team there also couldn\u0026rsquo;t compare to the one in the CCU.\" (FG9, P1) [work environment]\u003c/p\u003e \u003cp\u003e\"I\u0026rsquo;ve heard of places where GPs focus on paper work and have no patient-facing opportunities\u0026hellip;What\u0026rsquo;s the point of being in a place like that?\" (FG6, P1) [work content]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"The government is really focused on us and has provided substantial support, including waiving tuition fees, accommodation fees, and even offering a monthly stipend.\" (FG1, P1)\u003c/p\u003e \u003cp\u003e\"One thing that challenges my professional identity is that I have to stay there for six years. I feel like, after finishing, my age will make it harder for me to develop elsewhere.\" (FG2, P6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"Many well-intentioned policies often fail in smaller cities due to a lack of funding, turning into tick-box exercises.\" (FG6, P2)\u003c/p\u003e \u003cp\u003e\"The policy seems focused on quickly meeting government targets by bringing people from other industries into general practice. It feels unfair, as others can easily obtain certification through alternative routes.\" (FG6, P4)\u003c/p\u003e \u003cp\u003e\"The job satisfaction for GPs in big cities is definitely higher than in rural areas because the perks are better, and the work is more diverse\u0026hellip; In rural areas, though, you end up doing less, and everything feels much slower. \" (FG9, P2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttitude of others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"I often scroll through social media and see GPs sharing their experiences\u0026hellip;There are pros and cons.\" (FG1, P1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"Some professors may favour specialty students, viewing general practice as too broad and shallow in content.\" (FG8, P3)\u003c/p\u003e \u003cp\u003e\"In this field, you\u0026rsquo;ll hear a lot of different opinions\u0026hellip;While they can have some impact, they don\u0026rsquo;t affect me much.\" (FG8, P2)\u003c/p\u003e \u003cp\u003e\"We're both graduates, but I'm a GP working in primary care, while other clinical students have better opportunities. This is somewhat disappointing to me.\" (FG6, P2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormal Teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Take the clinical skills course we\u0026rsquo;re taking now, for example. It\u0026rsquo;s more hands-on. When you actually get to practice, you feel a sense of accomplishment and excitement. \" (FG1, P2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"You only understand and know if you love general practice after working in the community or related institutions.\" (FG8, P2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscipline Development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"It seems like there are more and more candidates applying for our specialised programme these days, and we can see that the scores keep going up every year.\" (FG1, P1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"I think the future of general practice looks promising, especially with China\u0026rsquo;s aging population.\" (FG4, P3)\u003c/p\u003e \u003cp\u003e\"General practice needs a stronger disciplinary system. Both the public and even GPs don't fully understand it currently.\" (FG7, P4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelational Ring\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelationship with Role Models\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"There\u0026rsquo;s a GP on the volunteer team who spoke about visiting homebound patients\u0026hellip; Their ability to provide such care is truly inspiring to me.\" (FG1, P5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"My tutor has been pivotal in shaping my professional identity, with his patience and care for patients deeply impacting me.\" (FG6, P1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelationship with Close Ones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"My family has quite traditional and simple views, and they think it's good enough for me to be a generalist in all subjects. \" (FG3, P2)\u003c/p\u003e \u003cp\u003e\"My relatives and friends often say, 'As a GP, you learn a lot, but you never truly specialize.\" (FG1, P4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"My family sees it as a great opportunity because it offers a stable job with no tuition. At the time, I had just finished the college entrance exam and was unsure about my options, but I found it appealing, so I applied.\" (FG6, P3)\u003c/p\u003e \u003cp\u003e\"After learning more about general practice from me, my family now sees it as the right path. I've truly changed their perspective.\" (FG7, P2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelationship with Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Real interactions, such as taking blood pressure for elderly patients or visiting the palliative care centre, are far more valuable than merely observing activities.\" (FG3, P3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"The strong rapport GPs had with the villagers left a lasting impression, inspiring me to continue in this profession.\" (FG6, P2)\u003c/p\u003e \u003cp\u003e\"Hospital patients often show appreciation for doctors' efforts, but GPs in rural areas rarely get such feedback and are often overlooked. \" (FG7, P2)\u003c/p\u003e \u003cp\u003e\"GPs may lack the specialised skills to treat certain illnesses due to the large number of cases they handle, leading to frustration. Meanwhile, this can cause patients to perceive the doctor as incompetent, which may result in a lack of respect.\" (FG8, P3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelationship with Peers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Maybe comparing myself to students in higher-paying majors, like dentistry, makes me feel a bit down.\u0026rdquo; (FG1, G4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"I find the discussions between GPs really interesting. It's something I've personally experienced in the general practice department.\" (FG6, P5)\u003c/p\u003e \u003cp\u003e\"At academic conferences, I meet like-minded people, reinforcing that this profession is worth pursuing.\" (FG7, P2)\u003c/p\u003e \u003cp\u003e\"I have classmates who don\u0026rsquo;t put in much effort, and when they underperform, people label them as 'just a GP\u0026hellip;If I\u0026rsquo;m next, they might apply the same preconceived notions to me.\" (FG9, P1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndividual Ring\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReflective Experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Negative experiences with community healthcare, like high fees\u0026hellip; If I become a GP, I will make sure to avoid that.\" (FG2, P1)\u003c/p\u003e \u003cp\u003e\"I envision my future career in a small clinic, like the one downstairs from my house. It\u0026rsquo;s closely connected to my life, and I can work in a stable environment.\" (FG1, P4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"I believe that with some clinical experience and a solid understanding of textbooks and guidelines, you'll have a much clearer grasp of general practice.\" (FG7, P3)\u003c/p\u003e \u003cp\u003e\"Overcoming the challenges I encounter in practice inspires me to consider research, and seeing other GPs succeed boosts my confidence.\" (FG9, P1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonal Character and Values\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;To be honest, I don\u0026rsquo;t quite get what GP is yet.\u0026rdquo; (FG2, P2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\"I used to be impatient, but becoming a GP has taught me patience and calmness.\" (FG6, P1)\u003c/p\u003e \u003cp\u003e\"I used to work in the CCU, which was much more fast-paced, but I consider myself a laid-back person. This experience made me want to be a doctor who takes the time to communicate with patients and provide warmth.\" (FG9, P1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Societal Ring\u003c/h2\u003e \u003cp\u003e \u003cb\u003eWorking Conditions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTrainees articulated how perceived working conditions shaped their professional identity, focusing on three primary areas: employment benefits, work environment, and work content.\u003c/p\u003e \u003cp\u003eRegarding employment benefits, trainees highlighted salary, promotion opportunities, and external exchange opportunities. There was a perception that these benefits were not comparable to those available to hospital-based specialists, which left them feeling disheartened.\u003c/p\u003e \u003cp\u003eThe work environment encompassed both the working atmosphere and the objective environment. The former was valued for its suitability for learning and professional development, while the latter pertained to aspects such as the availability of medical equipment and medications. The majority of trainees' concerns were informed by prior negative experiences or observations.\u003c/p\u003e \u003cp\u003eFinally, concerning work content, while pre-clinical trainees expressed a desire for more challenging tasks, post-clinical trainees found that a significant proportion of GPs' work comprised routine, repetitive tasks, leading to feelings of disappointment.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePolicies\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIrrespective of whether trainees had entered clinical practice, they generally expressed a positive attitude towards the policy formulation, both in relation to the RMEP specifically and to the broader context of general practice. However, several trainees indicated that certain aspects of the current policy, such as the compulsory six-year service requirement, led to perceptions that their future development was constrained. Concurrently, they perceived a sense of inequity, particularly in comparison to other trainees who received less specialised training yet benefitted from supportive policies for career mobility.\u003c/p\u003e \u003cp\u003eAdditionally, post-clinical trainees observed regional and urban-rural disparities in policy implementation, noting that the discrepancy between policy mandates and local execution notably affected their professional motivation.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAttitude of Others\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis theme encompassed evaluations of the status of GPs within society and the healthcare system from various sources, including online media, career lectures and social interactions. Pre-clinical trainees reported that their understanding of GPs\u0026rsquo; status was primarily shaped by perceptions encountered through media and social interactions. In contrast, post-clinical trainees often indicated that such appraisals had a limited influence on them.\u003c/p\u003e \u003cp\u003eA notable aspect of their experience was interacting with colleagues from other disciplines in social settings, where comparisons between general practice and other fields frequently led to a sense of disparity and a diminished sense of professional identity.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFormal Teaching\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFormal teaching referred to the courses organised by medical schools and hospitals, encompassing both theoretical and practical components. While trainees acknowledged that theoretical courses provided foundational knowledge, they perceived practical courses as playing a more central role. Pre-clinical trainees regarded the practical one as novel, while post-clinical trainees recognised the value of GPs through direct exposure to their work.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDiscipline Development\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDiscipline development encompassed the current state and future prospects of general practice in China. As post-clinical trainees gained clinical experience, they frequently engaged in in-depth reflections on these issues, recognising the field as both vibrant and challenging.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Relational Ring\u003c/h2\u003e \u003cp\u003e \u003cb\u003eRole Models\u003c/b\u003e \u003c/p\u003e \u003cp\u003eInteractions with role models within general practice had a profound influence on trainees at both pre- and post-clinical stages. Comparatively, post-clinical trainees provided more nuanced descriptions, including guidance from their mentors on general practice knowledge and skills, career progression, and even aspects of personality.\u003c/p\u003e \u003cp\u003e \u003cb\u003eClose Ones\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRegarding close relationships, most trainees reported that their initial decision to pursue general practice was influenced by their parents, who held the belief that one should seek a stable and relatively less strenuous job, rather than stemming from a genuine interest in the field. Additionally, some trainees noted that their family members did not view general practice favourably due to limited opportunities for career progression.\u003c/p\u003e \u003cp\u003eHowever, as trainees' understanding of general practice deepened, post-clinical trainees reported that the influence of close ones gradually diminished, with some even describing instances where they, in turn, reshaped the perspectives of those around them.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePatients\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePre-clinical trainees mainly interacted with patients through volunteer outreach, such as community clinics. However, these opportunities were limited by time and settings, and only those who engaged in meaningful interactions found them beneficial to their professional identity.\u003c/p\u003e \u003cp\u003ePost-clinical trainees noted that positive interactions between GPs and patients fostered professional aspirations and increased their willingness to establish similar connections as future GPs. In contrast, some post-clinical trainees indicated that the professional identity could be undermined by the variability in health literacy and the reasons for consultation among primary care patients. Moreover, they expressed concerns that they might face greater challenges in managing doctor\u0026ndash;patient relationships when navigating clinical uncertainty without the structured knowledge framework typical of specialist fields.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePeers\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis theme addressed daily communication with peers, as well as giving and receiving support during critical moments. Post-clinical trainees provided more extensive descriptions related to the relationships with peers, particularly emphasising the deeper insights they gained into general practice and a stronger sense of group belonging, which they attributed to discussions and exchanges with their colleagues. However, one trainee mentioned that if the peers performed poorly, it would affect how others in their local area perceived them, thereby reducing their professional identity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Individual Ring\u003c/h2\u003e \u003cp\u003e \u003cb\u003eReflective Experience\u003c/b\u003e \u003c/p\u003e \u003cp\u003eReflective experiences catalysed trainees\u0026rsquo; contemplation of their future roles as GPs. These insights were derived from clinical encounters, involvement in research, various educational activities, and their personal experiences as patients seeking care.\u003c/p\u003e \u003cp\u003eFor pre-clinical trainees, observational placements in community hospitals and their experiences as patients had a notable influence in aiding the formation of an initial understanding of GPs. For post-clinical trainees, clinical experience had a more immediate and profound impact on the development of their professional identity. Additionally, these trainees demonstrated a more sophisticated understanding and greater critical thinking regarding general practice, actively exploring solutions to current issues in the field. Consequently, their engagement in academic research served as a pivotal influence in shaping their professional identity.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePersonal Character and Values\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhile pre-clinical trainees appeared to have a limited awareness of how their character and values influenced their professional identity, the majority of post-clinical trainees engaged in active reflection within this theme. They contemplated whether their inherent characteristics were compatible with the role of a GP and how their character had been shaped or transformed during their training. Furthermore, they developed a deeper understanding of the values and principles underlying general practice.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3 The Developmental Framework of PIF\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e\u003cb\u003e3.3.1 Inter-thematic Relationships within the Same Stage\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eAs illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, at any specific juncture, the elements within the three rings are not independent; rather, they exist in a nested hierarchy, operating within distinct focal domains while maintaining interdimensional connectivity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn this study, the Individual Ring emphasises subjective, agentic behaviours, which are frequently informed by experiences derived from themes within the Societal and Relational Rings. The Relational Ring highlights the influence of close personal relationships on the individual, where perspectives are often mediated by themes within the Societal Ring. The Societal Ring focuses on broader relationships and the effects of the perceived environment. Notably, the Relational Ring often serves as a conduit for individuals' understanding of and engagement with this societal environment. Consequently, the specific emphasis of each dimension varies according to these distinct focal points, collectively contributing to the professional identity of each trainee.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Thematic Development across Stages\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the dynamic evolution of PIF across distinct stages. Notably, the third ring representing \u0026lsquo;healthcare professionals\u0026rsquo; does not signify a static or predefined endpoint. Instead, it denotes a developmental trajectory where trainees increasingly align with the professional identity of their specific field as their identities mature.\u003c/p\u003e \u003cp\u003eOur findings suggest that post-clinical trainees reported a limited influence from the attitudes of others and the opinions of close individuals, contrasting with pre-clinical trainees, for whom these themes were central to their PIF during the initial stages of their training. Concurrently, themes such as discipline development, relationships with peers and patients, as well as personal characteristics and values became more pronounced among post-clinical cohorts, whereas pre-clinical trainees demonstrated limited awareness of these themes.\u003c/p\u003e \u003cp\u003eMoreover, as post-clinical trainees recognised the increasing importance of discipline development and relationships with peers and patients in shaping their PIF, they often associated this shift with an enhanced awareness of their values and characteristics. This shift may suggest that as clinical training progresses, elements within the Individual Ring assume an increasingly central role in the PIF process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Early Community Involvement as the Critical Catalyst\u003c/h2\u003e \u003cp\u003eInitially, we anticipated that clinical experience would diversify with increasing seniority, assuming that hospital-based placements would exert the primary influence on trainees' PIF. However, during the discussions, trainees consistently emphasised the formative impact of their two-week community involvement on shaping their professional identity, which nearly all had completed at accredited primary care institutions prior to their hospital placements.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Those two weeks gave me a real sense of what being a GP is all about... I thought GPs are amazing, and at that moment, I knew I wanted to become a GP like that in the future.\u0026rdquo; (FG6, P3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn contrast, while hospital placements such as weekly half-day attendances during pre-clinical years and full-time hospital placements may be beneficial for doctors' professional identity, they appear to have a minimal effect on GP PIF. This distinction underscores that structured community involvement, rather than traditional hospital placements, serves as the critical catalyst for GP PIF.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussions","content":"\u003cp\u003eThis study employed focus groups with 42 trainees to construct a developmental framework for the PIF in low-resource settings. The findings elucidate how specific themes influence PIF at various stages of training, while also emphasising the Individual Ring and key catalytic events that warrant attention, offering insights to foster PIF and refine retention strategies for healthcare professionals in low-resource settings.\u003c/p\u003e \u003cp\u003eThe results revealed that the influence of themes varied across different stages, aligning with the dynamic nature emphasised in Kegan\u0026rsquo;s framework and the evolutionary character of the RToP(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This suggests that the stages of PIF are dynamic, with each stage prioritising different attributes and challenges. Our study found that, while the themes from the Relational and Societal Rings may initially dominate trainees' identity negotiation, themes within the Individual Ring become increasingly prominent as clinical immersion deepens(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). This shift potentially accompanies the development of personal awareness, echoing the work of Tsang et al., which suggests that educational interventions focused on value guidance and reflective environments are essential to accelerate the maturation of these themes(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough the trainees in our study did not report undergoing specific reflective training, an observable trend was noted: those with a more mature professional identity were more likely to describe their reflections on practice and demonstrate insights into their personal characteristics and values. This aligns with previous studies emphasising narrative reflection, as it deepens the processing of experiences and fosters critical thinking, thereby providing space for identity development(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Guiding such behaviours may be an effective method for accelerating the formation of the themes within the Individual Ring, a notion further supported by Jia Yin Lim et al. in the Krishna Model of Reflective Writing(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBeyond the Individual Ring, creating an environment during the early stages of PIF conducive to reflection through the Relational and Societal Rings is also critical. While previous research has identified the provision of role models and clinical experiences as two of the most significant factors in facilitating PIF(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), our study suggests that, in low-resource settings, the challenges associated with implementing these factors may be more complex than anticipated.\u003c/p\u003e \u003cp\u003eThe influence of role models, traditionally regarded as positive, has recently come under scrutiny in studies documenting their negative impacts and the burden placed on trainees in their absence(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In our study, most trainees lacked dedicated mentors and sought guidance from other groups. Unfortunately, these \"role models\" were often perceived to have a negative effect, trainees reported that some specialists treated them with indifference compared with specialty-track students. Furthermore, during case discussions, GPs often assumed a secondary role. While the situation may be more pronounced in certain groups including GPs and psychiatrists, and has been previously characterised in the literature as \"stigmatisation\", the common lack of mentorship in low-resource might lead to a fragmented construction of professional identity, ultimately leaving students uncertain regarding their future roles during the critical early stages of their training. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e Additionally, we identified early community involvement provided by formal teaching as a critical catalyst for trainees in our study. Unlike the standard Chinese curriculum where community engagement commences in the eighth year, the innovative two-week experience at the end of their third year triggered significant reflective practice. Trainees utilised these early encounters to navigate their perceptions of GPs before their re-entry into the field. Previous studies have characterised these significant transformations as pivotal transitions in PIF(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Regrettably, many low-resource settings fail to provide the necessary conditions for such transitions, which consequently impedes early integration and a sense of belonging, both of which are essential for PIF(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven that current PIF research predominantly originates from developed regions, this study\u0026rsquo;s framework provides a vital pathway for educational reforms in low-resource contexts, facilitating targeted interventions across various stages(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Given the current lack of evidence for instruments that can effectively and reliably assess medical students' PIF(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), we propose the use of flexible assessment tools to capture shifts in the attributes and challenges prioritised at each stage. For example, Tagawa\u0026rsquo;s stage-specific attribute scale, grounded in Kegan\u0026rsquo;s framework, targets professionals at four distinct developmental stages(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), offering valuable insights into longitudinal research regarding the evolution of focal dimensions and their relative weightings. The framework developed in this study also possesses the potential to be operationalised into quantitative assessment instruments. Its flexibility allows it to guide educational reforms in general practice, while offering interdisciplinary applicability to monitor trainees' PIF in low-resource regions and provide constructive feedback for continuous improvement. While the long-term impact of early interventions on retention remains unclear, proactively addressing these themes may alleviate uncertainty and foster a robust professional identity; this is a process that necessitates ongoing collaboration between educators, practitioners, and researchers to effectively capture the multifaceted nature of PIF across diverse clinical contexts.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeveral limitations warrant acknowledgement. Firstly, while baseline consistency was noted across the RMEP institutions at entry, longitudinal research is required to fully clarify the trajectory of PIF. Secondly, the study focused on trainees within the RMEP pathway, which represents a structured and policy-driven training model. Consequently, the findings may not fully capture the experiences of other training pathways or independent healthcare professionals, limiting broader applicability.\u003c/p\u003e \u003cp\u003eThirdly, the perspectives of educators and key stakeholders within low-resource settings\u0026mdash;particularly rural supervisors, frontline general practitioners, and policymakers\u0026mdash;were not included. Given their critical role in shaping training environments and PIF, future research incorporating multi-stakeholder perspectives is needed to enhance the ecological credibility of the framework.\u003c/p\u003e \u003cp\u003eFinally, although participants were recruited from multiple regions, the study was not designed to systematically compare geographic or healthcare settings. Importantly, thematic saturation was achieved, and no substantial divergence in core themes was observed across participants, suggesting relative conceptual consistency. However, further studies are warranted to explore how specific contextual factors may shape PIF in greater depth, thereby further assessing the and adaptability of the proposed framework.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study constructs a developmental framework comprising 11 themes across three interconnected dimensions, providing a nuanced understanding of PIF in low-resource settings. By applying the RToP, the findings elucidate the dynamic trajectory of PIF, characterised by a progressive shift from externally mediated influences towards internally integrated identity elements, while underscoring the critical role of early contextual experiences as formative catalysts. These insights extend existing conceptualisations of PIF by offering a context-sensitive framework that can inform the design of targeted educational strategies and support more sustainable workforce retention in underserved settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePIF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProfessional Identity Formation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGPs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Practitioners\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMEP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRural-Streamed Medical Education Programme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRToP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRing Theory of Personhood\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u003c/strong\u003e Ethical approval for this study was granted by the Research Ethics Committee of Shantou University Medical College (Approval No. SUMC-JGLL202205). All procedures performed were in accordance with the ethical standards of the respective institutions, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all participates. Data were anonymised and managed according to institutional protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll data generated or analysed during this study is included in this published article. The datasets analysed are open to the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e Explicit written informed consent for publication was obtained from the\u0026nbsp;trainees\u0026nbsp;(or their legal guardians) for the use of their clinical details and/or records in this study. All personal identifiers have been removed or altered to ensure privacy and confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Y.C. and P.L. led the study design and data collection. K.L. secured funding and ethical approval. P.L., H.D. and J.W. handled the initial transcription of audio recordings, while Y.C. and X.Z. reviewed the accuracy of the transcription. Y.C., P.L. and X.Z. contributed to the data analysis. K.L. and M.Y. provided expertise in the development of the group guide, data analysis, and framework. M.Y. and K.L. coordinated the overall research project, overseeing data analysis and guiding the interpretation of findings. Y.C. and P.L. drafted the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u0026nbsp;\u003c/strong\u003eThis study was supported by the Teaching Reform Project for “New Medical Sciences” (Notice on the Announcement of the 2023 Teaching Reform Project List by the Guangdong Provincial \"New Medical Sciences\" Construction Steering Committee-No. 126), the Teaching Reform and Research Project of Shantou University Medical College (SUMC [2025] No. SUMC-JG202529 and No. SUMC-JG202553), and the Medical Science and Technology Research Fund Project of Guangdong Province (A2023422).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare that there are no conflicts of interest regarding the publication of this paper, including any financial or other potential conflicts that could influence or bias the results of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to express their sincere gratitude to all members of the focus groups for their valuable contributions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSternszus R, Steinert Y, Razack S, Boudreau JD, Snell L, Cruess RL. 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Professional identity research in the health professions\u0026mdash;a scoping review. Adv Health Sci Educ. 2023;28(2):589\u0026ndash;642.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadha Krishna LK, Alsuwaigh R. Understanding the Fluid Nature of Personhood \u0026ndash; the Ring Theory of Personhood. Bioethics. 2015;29(3):171\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrishna LKR, Kwek SY. The changing face of personhood at the end of life: The ring theory of personhood. Palliat Supportive Care. 2015;13(4):1123\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohn W, Creswell CNP, editors. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 4th edition.: Sage Publications; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuest G, MacQueen K, Namey E. Applied Thematic Analysis. Thousand Oaks, California: SAGE Publications, Inc.; 2012. 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Scales to evaluate developmental stage and professional identity formation in medical students, residents, and experienced doctors. BMC Med Educ. 2020;20(1):40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToben D, Mak-van der Vossen M, Wouters A, Kusurkar RA. Validation of the professional identity questionnaire among medical students. BMC Med Educ. 2021;21(1):359.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Professional Identity Formation, Low Resource Settings, Focus Groups, Medical Education, General Practitioners","lastPublishedDoi":"10.21203/rs.3.rs-9406027/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9406027/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eProfessional Identity Formation (PIF) is a dynamic and context-dependent socialisation process; while existing research identifies various influencing factors, there is a paucity of cohesive frameworks that capture the sequential internalisation of identity elements within practice. This gap is particularly salient in low-resource settings, such as China\u0026rsquo;s Rural-Streamed Medical Education Programme (RMEP), where substantial turnover and tenuous professional identity among trainees present significant challenges. Drawing upon the Ring Theory of Personhood (RToP) as a theoretical lens, this study aims to construct a developmental framework for understanding PIF among RMEP trainees to inform more effective retention strategies.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eInformed by a pragmatic paradigm, nine focus groups were conducted with 42 RMEP trainees across various training stages in China. Drawing upon the RToP as a theoretical lens, data were analysed using inductive thematic analysis to construct a developmental framework.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA framework comprising 11 themes was constructed across three dimensions: the Societal Ring, encompassing working conditions, policies, attitudes of others, formal teaching and discipline development; the Relational Ring, including relationships with role models, close ones, patients, and peers; and the Individual Ring, incorporating reflective experience, personal character and values. This framework emphasises the dynamic interaction of these themes and the developmental trajectory of PIF, highlighting a shift from external to internal elements while also acknowledging the transformative impact of early external experiences in low-resource settings.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eBy proposing a developmental framework that maps PIF across different training stages, this study provides valuable insights for strengthening PIF and refining retention strategies for healthcare professionals in low-resource settings.\u003c/p\u003e","manuscriptTitle":"A Developmental Framework of Professional Identity Formation in Trainees for Low-resource Settings: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 16:23:45","doi":"10.21203/rs.3.rs-9406027/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-19T13:53:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308527303085314979878150702181035066187","date":"2026-04-29T13:27:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226954652853581005577085166298327914745","date":"2026-04-24T09:00:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-24T02:04:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-15T14:24:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-14T06:21:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-14T06:20:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-04-13T15:09:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fe7c0d93-f5bf-419b-8515-d82a76d74c2c","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-19T13:53:25+00:00","index":33,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T16:23:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 16:23:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9406027","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9406027","identity":"rs-9406027","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}