We become what we do: a qualitative exploration of professional identity formation in postgraduate fellowships

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Transitions are vulnerable periods in PI formation (PIF). Existing research focuses on transition from lay person to physician. Little is known about PIF of advanced learners. The objective of this study is to explore key factors that influence PIF in postgraduate fellows. Method This was a qualitative study using a constructivist research paradigm. Subjects (current fellows or recent graduates and fellowship leaders of emergency medicine fellowships) were recruited via email by modified Dillman method, using purposive maximum variation sampling to ensure generalizability: gender, race/ethnicity, geography, fellowship type. Socialization theory (ST) informed interview guide development, code scaffold, and iterative code book modifications. Interviews were conducted between June 2023 to January 2024 remotely and were audio recorded, de-identified, and professionally transcribed. Directed transcript analysis with ST explored identity before, during, and after fellowship. Results We conducted 15 interviews with fellows and 11 with fellowship leaders. We constructed 2 identity theme clusters: 1. Society integration: Self-actualization (clarity of purpose); Disillusionment (expectations vs. reality); Integrated Growth (reflect on PI journey including trauma incurred during training, often requiring mental health support). 2. Subspecialty integration: Systems-based Practice (navigation of healthcare infrastructure; often without deliberate guidance); Mentorship archetypes (mentor processes; often outside of fellowship); Subspecialty Mastery Learning (niche development). An omnibus theme, conflation of personal and professional identities, bridged both clusters. Conclusion Key factors that contribute to fellowship PIF include reflective practices, mentorship community, subspecialty content, communities of practice, and the health care system. PIF would be enhanced in fellowship by deliberate structuring of guidance for system-based practice with focus on community and mentorship. Clinical trial registration Clinical trial number: not applicable. medical education professional identity formation fellowship training reflective practice graduate medical education Figures Figure 1 Figure 2 Figure 3 Introduction The transition from resident to subspecialty expert occurs during postgraduate fellowship training, involving a process of acknowledging, developing, and adopting a new professional identity (PI). Professional identity formation (PIF) is “a representation of self, achieved in stages over time, during which the characteristics, values, and norms of the medical profession are internalized” 1 . PIF occurs most intensely during periods of transition, which mark periods of immense opportunity and vulnerability 2 . Fellows navigate an ill-defined identity of trainee and supervisor; a phase in which Gordon et al described as “betwixt and between” exemplifying the liminality in development of fellowship trainees 3 . Existing research on PIF focuses on undergraduate medical education (UME) where the transition between layperson to physician occurs 4 – 6 . This initial transition represents the first step on a lifelong journey. PIF continuously evolves, including in postgraduate fellowship, where physicians transition to independent practitioners, cultivate subspecialty knowledge, and develop leadership in their area. While there is robust guidance in the early stages of PIF, advanced learners and their mentors lack similar transitional structures and must often create their own developmental strategies and resources 2 . The theory of PIF aligns with Robert Kegan’s adult development theory 7 . Six developmental stages describe the evolution of the “self” through increasing internalization of external perspectives, from early childhood through adulthood. To understand the transformation of laymen to medical professionals, Bebeau adapted Kegan’s stages of PIF for medical education (ME); just as in personal identity formation, PIF progresses through stages to become full practicing professionals who have internalized the values and behaviors of the profession 8 – 10 . This transformation is facilitated by a process known as socialization , which shifts learners from peripheral participation to independent practice 2 , 11 , 12 . Socialization represents the transitional mechanism by which learners progress from one developmental stage to the next. Cruess utilized socialization theory to describe a schema of PIF for UME, which emphasized clinical and non-clinical (e.g., didactics) aspects of medical training (Fig. 1 ). Since little is known about the socialization process of advanced learners, we do not know if the same factors crucial for UME may apply to fellows. Understanding the socialization of fellows will have both practical and theoretical significance. Fellows will gain an understanding of the challenges they face in their transformation. Fellowship directors will have an improved understanding of factors required to guide the fellowship transition. From a theoretical perspective, a better understanding in the PIF of the fellow will contribute to a more holistic view of the medical socialization process, one that incorporates advanced stages across ME. The objective of our study is to discover key factors that inform PIF in postgraduate Emergency Medicine (EM) fellows’ acquisition of subspecialty knowledge, skills, and professional development. Methods Design Our qualitative grounded theory study employs a constructivist paradigm, informed by theories of socialization and adult development. Context Many residency graduates choose to pursue fellowship training. They often function as attendings in the clinical space while developing subspecialty expertise. EM fellows may enter fellowship upon completion of an EM or other eligible residency. Fellowships may be accredited by the Accreditation Council for Graduate Medical Education (ACGME) or other external bodies. Sampling strategy: We conducted purposive stratified maximum variation sampling to ensure representation from a diverse study population (Fig. 2 ). Subjects were recruited via publicly available information from the Society for Academic Emergency Medicine (SAEM) Fellowship Database and Directory. We targeted 3 subject groups; current fellows, recent graduates (< 2 years), fellowship leaders. Both current fellows and recent graduates were considered part of the fellows cohort. Potential subjects were sent recruitment emails and a REDCap (RC) survey to collect demographic information. Interview invitations were based on our a priori purposive stratification model to maximize representation (fellowship category, gender, ethnic/racial identity, geography) until thematic sufficiency across groups was determined during data analysis. Each subject was assigned an RC number and was offered a $ 50 Amazon gift card for participating. Data collection and instruments: We (DC, JT, DR, WCC) developed interview guides based on Creuss’ socialization theory framework for both groups (supplemental material). We piloted and refined them using fellows and fellowship directors not participating in the study. From June - September 2023, JT conducted semi-structured interviews with fellows and recent fellowship graduates. From October 2023 -January 2024, DR conducted semi-structured interviews with fellowship leaders. Since fellowship leaders were interviewed after the fellows, we presented some preliminary themes derived from fellows’ interviews as a form of member checking at the conclusion of their formal interviews. Consent to record interviews was obtained verbally. Interviews were audio recorded and professionally transcribed ( https://datalyst.com/ ). Transcripts were de-identified and uploaded with their corresponding RC number to Dedoose Version 9.2.22b (2023. Los Angeles, CA: SocioCultural Research Consultants, LLC) for analysis. Data analysis Our coding framework was based on socialization theory. Four team members (DC, JT, DR, and WCC) coded independently adding new codes within the established framework for the first 4 transcripts. We met to collapse and split codes to create a common code book. New codes for subsequent transcripts were agreed upon through group discussion. All team members coded all transcripts and memoed throughout the coding process to record insights and themes. We met regularly to discuss coding and conducted thematic analysis via both deductive and inductive reasoning in an iterative fashion applying the constant comparison method. Coding and thematic analysis occurred concurrently with interviews and determined the number of total interviews conducted. Interviews were continued until thematic sufficiency was reached for both subject groups. Researcher reflexivity The research team consisted of 3 current or former fellowship program directors (DC, DR, and WCC) and an undergraduate director (JT). JT conducted interviews with fellows or recent fellowship graduates to avoid the appearance of coercion. TH contributed abstemious reflection informed by concurrent work in PIF from the program director perspective. Ethics This study was reviewed by the institutional review board (IRB) at Columbia University Medical Center (IRB # AAAU5023) and determined to be Exempt. Results Study subjects: 53 fellows and fellow leadership personnel completed RedCAP demographic surveys. We completed 15 interviews with fellows and 11 with fellowship leaders. Interviewee characteristics can be found in Tables 1 and 2 . Table 1 Characteristics of fellows and recent graduates interviewed Fellowship Category n, % Simulation 2, 13% Emergency medical services 1, 7% Ultrasound 2, 13% Pediatric Emergency Medicine 3, 20% Toxicology 2, 13% Research 1, 7% Critical Care 1, 7% Gender Identity Female 9, 60% Ethnic/Racial Identity Asian 2, 13% Black/African American 1, 7% White 9, 60% More than 1 race/ethnicity 1, 7% Did not wish to disclose 2, 13% Geographic Location West Coast 3, 20% Midwest 6, 40% Great Plains 1, 7% Mid-Atlantic 5, 33% Table 2 Characteristics of fellowship leaders interviewed Fellowship Category n, % Administration 1, 9.1% Medical Education 1, 9.1% Toxicology 1, 9.1% Research 3, 27.3% Global Health 1, 9.1% Simulation 1, 9.1% Emergency Medical Services 1, 9.1% Ultrasound 2, 18.2% Gender Identity Women 2, 18.2 Not specified/other 9, 81.8% Ethnic/Racial Identity White 10, 90.9% More than one race 1, 9.1% Geographic Location West Coast 5, 45.5% Midwest 1, 9.1% Great Plains 2, 18.2% Mid-Atlantic 3, 27.3% Themes: We constructed two thematic clusters from the transcripts. The first cluster relates to the fellows’ exploration of their place within society: society integration . Themes include integrated growth, disillusionment, and self-actualization. The second cluster relates to their budding relationship with their subspecialty niche: subspecialty integration . Themes include systems-based practice, mentorship archetypes, and mastery learning. One overarching theme bridged both clusters: conflation of personal and PIs. We present representative quotes for each theme that includes both fellows’ and fellowship directors’ perspectives. Comprehensive quotations from transcripts mapped to themes can be found in supplemental materials. Society integration cluster: Holistic development This theme refers to the reflective practice expressed by our participants. For many, fellowship allowed the dedicated time, space, and psychological safety to reflect on their prior training including a significant amount of perceived trauma incurred. Many participants disclosed the pursuit of aid from mental health professionals I got keyed in with a therapist and a psychiatrist… and I don’t know if it’s the medic[ation] or my circumstances, or my outlook, but whatever it is, it’s really working, and I don’t feel like I have to fake it. I am back to being authentically this way instead of forced to be this way.” RC36 (fellow) " There was a little bit of a health issue that he's having to sort out that's adjusted some of our plans and scheduling already… being able to be adaptable, flexible, and then making sure that we're supportive of him and making sure that the department has mobilized resources to help him however we can ” RC43 (fellowship director) Disillusionment: Fellows noted a mismatch between their expectations and reality. This perception, mainly of the medical system, led many to develop cynical outlooks on health care. “Taking advantage of altruism is how the American medical system stays afloat.” RC44 (fellow) “ I see people immediately coming into residency, I see burnout. In fellowship, I also see burnout, and I see this sort of like, I need to find another way. ” RC 17 (fellowship director) Self-actualization: Despite some degree of cynicism, many fellows emerged from fellowship with a heightened sense of self and a clearer vision of the overall trajectory for their life. “I think I have learned a lot. There's been a lot of bumps in the road, but it's been a good growth experience for me in understanding what I want to do in my future." RC13 (fellow) " They certainly don't feel like a toxicologist when they walk in. I think they probably feel like a toxicologist when they walk out, but with all of the imposter syndrome that we all have. " RC16 (fellowship director) Subspecialty integration cluster: System based practice: Fellows developed a greater awareness of the health care ecosystem beyond the medical knowledge required for direct patient care. The initial clinical transition from resident to attending proved to be challenging for many. I think as I've gone through [fellowship]…I think of it more as like team sports than I think I ever did. I consider my colleagues everyone from the janitorial staff up to the CEO of the hospital, and I consider them all sort of equally, which I think has been a little bit of a transition from residency... I think we're all sort of in the same trenches together.” RC18 (fellow) “ They do have all the typical things that I would joke around called New Attending Syndrome...I probably figured it was three years or so before I finally said, Well, anything could walk through the door and be like, I got it. I have an answer for everything, even if I don't know what I'm doing .” RC17 (fellowship director) In addition to adapting to more complex systems based practice as well as responsibilities, many fellows found themselves adapting to new cultures of clinical practice: “I had a really hard time adjusting to fellowship here…I felt very much that culture shock of the difference from a very large hospital with innumerate resources to a much smaller hospital with limited resources, and that was a hard adjustment for my practice… I found myself having to learn a lot of workarounds.” RC36 (fellow) Mentorship archetypes of fellowship directors: There was a dichotomy of mentorship provided by fellowship directors as perceived by the fellows as well as affirmed by fellowship directors themselves. Many fellowship directors function more as administrators than mentors in the traditional understanding, which led fellows to seek mentorship outside of their program. " Probably people from my residency, honestly, my residency leadership. [in reference to mentors] I'm new here so I haven't really identified a mentor. " RC22 (fellow) “ My role specifically ends up being a little bit more logistical… quarterly meetings to make sure that we're meeting fellows' expectations and fellows meeting our expectations, identifying areas for improvement. And then a lot of the time it's just working to identify mentors and making sure that mentors are holding up their end of the bargain as well and helping to develop the fellow. ” RC43 (fellowship director) Few fellowship directors saw their role as a mentor to guide their fellows in their PI development. The solitary exception is as follows: “ My number one – I want to launch their career. I want them to see this career longevity in emergency medicine; whether it’s academics or whether it’s in the community. I want them to feel like this is their identity and this is their career and it’s going to—they are going to bring expertise that’s going to be rewarded with either more money or buydown or other leadership positions in the hospital… it’s really a combination of creating future leaders not just in [redacted] but in health care. ” RC14 (fellowship director) Mastery learning Fellows and fellowship directors reflected on their investment into their specific niche describing the dedication required to develop the skills for their subspecialty. “ I've changed in the sense of learning. I'm still figuring that out. And relearning how to learn again… I've changed in that, my brain feels very plastic right now. ” RC42 (fellow) I think it’s really fun to have that professional identity start to kick in during fellowship and say, “When you finish this fellowship, everyone is going to be looking at you as the voice of reason” RC14 (fellowship director) Conflation of personal and professional identities: When asked about their personal identities, fellows usually answered with components of their professional identity. In fact, their personal and PIs seemed intertwined and interdependent, suggesting a merger of these two previously separate identities. This fellow suggests that their happiness is contingent on their profession. " I would just become happier since fellowship because this is exactly what I want to do in life. " RC26 (fellow) It is unclear at what point in training the two identities become entwined. [in reference to personal identity] “ I’m sure maybe without me even knowing it, probably, it’s intertwined... I’m very lucky, very lucky that I love going to work. Even when I sometimes don’t want to go to work and I am tired, but I really enjoy what I do. ” RC36 (fellow) Conceptual understanding of fellows’ professional identity We mapped our current themes to the Cruess’ framework of socialization for UME (Fig. 3 ). Discussion This study explored factors that shape PIF among postgraduate EM fellows. Drawing from socialization theory and themes identified from fellow and fellowship director interviews, we developed a novel socialization model for postgraduate fellowship training that extends Cruess’ framework for UME (Fig. 3 ). Our findings reveal two key insights that distinguish fellowship-level PIF from earlier stages of medical training. First, fellows enter training with established PIs that become increasingly intertwined with their personal identities. Second, the socialization process operatives through two distinct, but interconnected domains: societal and subspecialty integration. These domains shape how fellows negotiate their evolving sense of self while developing expertise in their chosen field. Thematic discussion Societal integration Several aspects of the fellowship socialization process make the blending of personal and PIs problematic. First, the overwhelming expression of disillusionment with the health care system described by participants evinced a cynical outlook on the medical profession and clinical care. PIF is inherently a disruptive process as one negotiates between existing identities and shifts into an identity that one must adopt 13 . Competing healthcare system priorities (e.g., patient- or institution-centeredness of care) place significant demands on trainees, further complicating the integration of personal and PIs. This tension was mitigated by the opportunity for reflection during fellowship and facilitated holistic development. While reflection is widely recognized as an essential component of professional development 14 – 16 , much of the reflective work undertaken during fellowship centers on processing the traumatic aspects of prior medical training. A notable proportion of fellows within our cohort actively sought mental health support. Our findings likely underestimate the true prevalence of mental health needs among physicians, especially those early in their career, given existing literature indicating that physicians are generally reluctant to seek such care 17 , 18 . The relative distance from the clinical environment afforded by fellowship—combined with a smaller, supportive community of practice—may have created the psychological safety net that enabled many to engage in this essential step toward healing 19 . A concurrent concern is that physicians who have not chosen to pursue fellowship may lack similar structural support; they may not have comparable opportunities for reflection and recovery. Cruess also emphasized this salient subject: “health care systems also can impact the learning environment, for example by leaving too little time for teaching or reflection. Providing an opportunity for learners to reflect on such issues during their formative years can foster their awareness of the potential impact of the health care environment on their PIF and can encourage them to cultivate a conscious framing of their own responses to it” 12 . Those in fellowship, who have the infrastructure for supported reflection, can better reconcile with their past trauma and develop a positive sense of self and vision of their future. We found the clinical transition to be one of the most challenging aspects of postgraduate fellows’ socialization. Many described difficulty adapting to complex systems-based practices from which they were largely shielded during residency. As fellows adapt to their new roles, they enter a community of practice that may differ culturally from their prior training environment, adding another layer of complexity to the clinical transition 20 . Unsurprisingly, this challenge is not unique to fellowship training, but prevalent amongst the initial transition to independent practice for junior faculty and underscores the importance of purposeful “legitimate peripheral participation” throughout training 12 , 15 , 21 . These challenges, when unmitigated, can lead to isolation and burnout 22 . Fellowship provides a unique opportunity to optimize the deliberate integration into a smaller subspecialty community of practice. Its primary purpose is to foster development of one’s niche through mastery learning while cultivating deeper relationships on a smaller scale with likeminded individuals. There is an intrinsic platform to develop and showcase one’s skillset and this provides an opportunity to fulfill the dual need to both “fit in” and “stand out” 22 . When effectively implemented, a robust fellowship curricular and social infrastructure may serve as a “vaccine” for this vulnerable period of transition. Mentors broker the negotiation between subspecialty niche development and adapting to new systems-based clinical practice, thus mentorship remains as crucial a component of PIF in fellowship as it was in UME. Per Cruess, mentors facilitate learner transition to become an accepted member of a community of practice: “Becoming like them in action, appearance, and beliefs facilitates the move from the periphery towards the center of the community” 12 . We were surprised to find the fellowship-director-as-mentor paradigm was uncommon, despite the obvious infrastructure that could favor this structure. Instead, fellows primarily sought mentorship outside of their fellowship program, and many directors viewed their role as more administrative than developmental. Mentors influence trainees through two primary mechanisms: conscious passage of knowledge and skills through guided reflection and experiential learning; and unconscious role modeling of behavior and values that mentees internalize over time 12 . Our fellowship directors, by their own description, appeared not to fulfill either of these paradigms. It is likely that some did not receive adequate mentorship throughout their fellowship and therefore lacked a clear model for how to engage in mentorship. This insight may reflect a broader issue - the absence of structured, deliberate mentorship after early formalized ME 23 . Furthermore, both mentorship and menteeship are active processes that require intentional effort and cultivation 24 . Like any meaningful relationship, the mentor-mentee dyad depends on compatibility, shared expectations, and mutual engagement 25 . Consequently, the disconnect between fellows and their program directors as potential mentors may highlight both a lack of formal preparation in mentorship and menteeship in the postgraduate setting. This finding highlights the complex and multifactorial dynamics that underpin successful mentoring relationships. Theoretical implications Although the final framework resembles the same external structure as those for UME as proposed by Cruess, the study revealed remarkably different contributing factors. The framework’s starting point initiates the divergence. Students in Cruess’ framework start only with a personal identity. Our framework begins with both existing personal as well as PI developed through years of medical training. Little people, little problems; big people, bigger problems. The struggles of disillusionment and self-actualization become commensurate with increasingly complex involvement of the trainee/fellow with the vast and flawed healthcare system. Unlike UME, fellowship trains physicians not only for clinical practice, but to become leaders in subspecialty fields. Instead of the “clinical” and “non-clinical/classroom” facets of UME, fellows’ PIF developmental domains involve societal and subspecialty assimilation. To our surprise, the framework culminates in the merger of personal and PIs. Whereas the output of the UME PIF framework establishes novel personal and nascent PIs, the postgraduate socialization process intertwines the two into one. Our initial reaction was tempered by review of known concepts in personal identity development as ”aspects of an individual’s identity are relatively stable throughout life” 12 . Given that fellows typically begin training in adulthood—a period during which personal identity is largely established and remains relatively stable—it is reasonable to infer that the omnipresent development of PI during fellowship increasingly intermixes with existing personal identity. Furthermore, Cruess notes that “an individual’s vocation is a stabilizing and integrative force [on] personal identity” 12 . The interplay between personal and PIs is both natural and mutually reinforcing. This dynamic is an inherent aspect of professional engagement and, in itself, does not imply a detrimental impact on the individual. Practical implications: Our findings suggest several implications for fellowship training programs. First, programs should embed structured support for PIF in the fellowship curriculum. This includes longitudinal initiatives, such as facilitated reflection sessions, narrative medicine workshops, and periodic self-evaluations. Having entered subspecialty training with established PIs, fellows require deliberate opportunities to navigate this evolution in identity 1 , 14 , 15 . Second, programs should prioritize protected time for both program directors and fellows dedicated to reflection, mentorship, and scholarly growth. PI is constructed not only through experience but also through deliberate meaning-making and dialogue 13 , 26 . Without dedicated time and facilitated reflection opportunities, fellows may be forced into a transactional rather than developmental approach to training. Third, fellowship curricula should integrate explicit training in systems-based practice, leadership, and adaptive expertise 27 – 29 . As fellows navigate increasingly complex healthcare environments, these competencies become essential not only for subspecialty practice but also career sustainability. This aligns with adult development theories, which emphasize the importance of adaptive growth in navigating complex environments 7 . Limitations We recognize our interviews were conducted during the post-COVID-19 pandemic period with elevated levels of uncertainty within academic medicine. However, factors such as heightened stress and opportunities for introspection may have offered a more raw insight into personal and PIs. How the pandemic influenced applications to fellowships or fellowship acceptance was not within the scope of this manuscript. How these PIF factors may change over time during periods of relative stability remains unknown. Furthermore, the study focused on EM fellowships so these findings may not be transferable to other specialty fellowships. This limitation reveals the need for further research exploring PIF across broader and multidisciplinary contexts Future directions Our work opens several avenues for further investigation. First, comparison with Cruess’ framework highlighted that it does not account for students entering ME with pre-existing PI from prior careers. While many students enter UME immediately after completing an undergraduate degree, “non-traditional” students exist who have had prior careers- either outside or within the field of medicine. Understanding how pre-existing non-physician PI influence socialization into medicine and subsequent subspecialty training merits investigation. Secondly, the mentorship archetypes identified warrants further exploration. What factors determine whether fellowship directors adopt mentor versus administrator roles? How do different mentorship structures influence PIF? What training or support might enable more directors to serve as effective mentors? Lastly, comparative studies examining PIF in fellows versus junior attending physicians who did not pursue fellowship could illuminate the unique contributions of fellowship training to professional development and identify whether non-fellowship pathways provide adequate support for this critical transition. Conclusions This study addresses a significant gap in understanding PIF during postgraduate fellowship training. Our findings demonstrate that fellowship-level socialization differs fundamentally from earlier stages of ME in both process and outcome. Fellows enter training with established PIs that merge with personal identity through experiences spanning two interconnected domains: societal integration and subspecialty integration. Key factors influencing PIF in fellowship include integrated growth, disillusionment, self-actualization, system based practice, mentorship community, and mastery learning. PIF would be enhanced in fellowship by deliberate structuring of guidance and time for reflection, system-based practice with focus on community, and dedicated mentorship. Our study serves as a call to action and demonstrates that supported reflective processes are essential to the development of PI, not only during early years of ME, but also during fellowship, and continuing professional education; it is a critical consideration for departmental and institutional leadership in supporting faculty throughout career transitions. Declarations Conflict of Interest Disclosure: None Funding Sources /Disclosures: This study was sponsored by the Society of Academic Emergency Medicine Education Project Grant Author Contribution D.C., J.T., D.R., and W.C. made substantial contributions to the conception and design of the study and to the acquisition of data. D.C., J.T., D.R., W.C., and T.H. contributed to data analysis and interpretation. D.C., J.T., D.R., W.C., and T.H. drafted the manuscript and critically revised it for important intellectual content, and T.H. provided additional expertise in methodology and subject matter. All authors approved the final version of the manuscript and agree to be accountable for their respective contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Data Availability The authors confirm that all data collected or analyzed for this study are included in the article as published. References Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. Acad Med J Assoc Am Med Coll. 2014;89(11):1446–51. 10.1097/ACM.0000000000000427 . Cruess RL, Cruess SR, Steinert Y, editors. Teaching Medical Professionalism: Supporting the Development of a Professional Identity. 2nd ed. Cambridge University Press; 2016. 10.1017/CBO9781316178485 . 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Characteristics of successful and failed mentoring relationships: a qualitative study across two academic health centers. Acad Med J Assoc Am Med Coll. 2013;88(1):82–9. 10.1097/ACM.0b013e31827647a0 . McOwen KS. Cheating is a professional identity formation problem. Med Educ. 2024;58(5):486–7. 10.1111/medu.15317 . Cantaert GR, Pype P, Valcke M, Lauwerier E. Interprofessional Identity in Health and Social Care: Analysis and Synthesis of the Assumptions and Conceptions in the Literature. Int J Environ Res Public Health. 2022;19(22):14799. 10.3390/ijerph192214799 . Wenger-Trayner E, Wenger-Trayner B. Learning in a landscape of practice: A framework. Learning in Landscapes of Practice. Routledge; 2014. Ng SL, Forsey J, Boyd VA, et al. Combining adaptive expertise and (critically) reflective practice to support the development of knowledge, skill, and society. Adv Health Sci Educ Theory Pract. 2022;27(5):1265–81. 10.1007/s10459-022-10178-8 . Additional Declarations No competing interests reported. Supplementary Files IRBapprovedInterviewGuide.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 07 May, 2026 Editor assigned by journal 26 Mar, 2026 Editor invited by journal 20 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 19 Mar, 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9033047","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":641587023,"identity":"66b2871d-11d3-4414-96ca-f4acfee086db","order_by":0,"name":"Di Coneybeare","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYDCCw8wHwLQBCVrYEkjVcoDHgEQtfMd5Pn74uMMmcTt787MPHxi2yRHUInmYd7PkzDNpiTt7jhnPnMFw25igFoPDvNuYedsOJ264kWDMzMNwO7GBsBaeZ0At/xM33H/+mfkPw+16YrSwAbUcANrCY8zMwHA7gQi/sBlLzmxLNt7Zk1PM2GNw25CgLXznDz/88LHNTnY7+/HNDD8qbssTtAUGHCGGkxChDPYkqB0Fo2AUjIKRBgBSPUAWFVYrEAAAAABJRU5ErkJggg==","orcid":"","institution":"Columbia University Irving Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Di","middleName":"","lastName":"Coneybeare","suffix":""},{"id":641587027,"identity":"389166c9-9e1c-48fa-b278-61e8a6b971ed","order_by":1,"name":"Jimmy Truong","email":"","orcid":"","institution":"Columbia University Irving Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Jimmy","middleName":"","lastName":"Truong","suffix":""},{"id":641587035,"identity":"dbd6ef2f-02c5-44ca-bef0-588d9e162770","order_by":2,"name":"Daniel Runde","email":"","orcid":"","institution":"University of Iowa Carver College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Runde","suffix":""},{"id":641587042,"identity":"3172de4d-b095-4e32-84ce-2fb481a013a4","order_by":3,"name":"Timothy Horeczko","email":"","orcid":"","institution":"Los Angeles County-Harbor-UCLA Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Timothy","middleName":"","lastName":"Horeczko","suffix":""},{"id":641587046,"identity":"59a3d0f6-0538-45d9-9f2a-dad1eb175c96","order_by":4,"name":"Wendy Coates","email":"","orcid":"","institution":"University of California, Los Angeles","correspondingAuthor":false,"prefix":"","firstName":"Wendy","middleName":"","lastName":"Coates","suffix":""}],"badges":[],"createdAt":"2026-03-04 18:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9033047/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9033047/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109442238,"identity":"709bca78-9120-4ce9-bfc2-3a24331f6a5c","added_by":"auto","created_at":"2026-05-18 07:28:28","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":169004,"visible":true,"origin":"","legend":"\u003cp\u003eCruess’ schemata of professional identity formation for undergraduate medical education adapted from Cruess et al 2015\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9033047/v1/0fbeebb3187eaa799812c7a3.jpg"},{"id":109759224,"identity":"07c10259-6b58-4963-804b-a60bff9ec3dc","added_by":"auto","created_at":"2026-05-22 07:26:11","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59808,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of recruitment process\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9033047/v1/5218f2a647fb2976b4978b87.jpg"},{"id":109442240,"identity":"54a9c169-fd22-4215-976d-36f4516ae0c5","added_by":"auto","created_at":"2026-05-18 07:28:28","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":75382,"visible":true,"origin":"","legend":"\u003cp\u003eA novel socialization model for postgraduate fellows\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9033047/v1/9744a1064b148ccde06e9622.jpg"},{"id":109763727,"identity":"60876128-2f25-42f3-a528-4b00f53e42bd","added_by":"auto","created_at":"2026-05-22 07:35:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":550274,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9033047/v1/3cbedf09-8b77-4c79-ab9c-58bfed10b9b4.pdf"},{"id":109442237,"identity":"e5e7991c-af88-47a4-b82b-1458856c4b29","added_by":"auto","created_at":"2026-05-18 07:28:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":50475,"visible":true,"origin":"","legend":"","description":"","filename":"IRBapprovedInterviewGuide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9033047/v1/53d58c6d6f7f04d09231e563.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"We become what we do: a qualitative exploration of professional identity formation in postgraduate fellowships","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe transition from resident to subspecialty expert occurs during postgraduate fellowship training, involving a process of acknowledging, developing, and adopting a new professional identity (PI). Professional identity formation (PIF) is \u0026ldquo;a representation of self, achieved in stages over time, during which the characteristics, values, and norms of the medical profession are internalized\u0026rdquo;\u003csup\u003e1\u003c/sup\u003e. PIF occurs most intensely during periods of transition, which mark periods of immense opportunity and vulnerability\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Fellows navigate an ill-defined identity of trainee and supervisor; a phase in which Gordon et al described as \u0026ldquo;betwixt and between\u0026rdquo; exemplifying the liminality in development of fellowship trainees\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eExisting research on PIF focuses on undergraduate medical education (UME) where the transition between layperson to physician occurs\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. This initial transition represents the first step on a lifelong journey. PIF continuously evolves, including in postgraduate fellowship, where physicians transition to independent practitioners, cultivate subspecialty knowledge, and develop leadership in their area. While there is robust guidance in the early stages of PIF, advanced learners and their mentors lack similar transitional structures and must often create their own developmental strategies and resources\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe theory of PIF aligns with Robert Kegan\u0026rsquo;s adult development theory\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Six developmental stages describe the evolution of the \u0026ldquo;self\u0026rdquo; through increasing internalization of external perspectives, from early childhood through adulthood. To understand the transformation of laymen to medical professionals, Bebeau adapted Kegan\u0026rsquo;s stages of PIF for medical education (ME); just as in \u003cem\u003epersonal\u003c/em\u003e identity formation, PIF progresses through stages to become full practicing professionals who have internalized the values and behaviors of the profession\u003csup\u003e\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis transformation is facilitated by a process known as \u003cem\u003esocialization\u003c/em\u003e, which shifts learners from peripheral participation to independent practice\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Socialization represents the transitional mechanism by which learners progress from one developmental stage to the next. Cruess utilized socialization theory to describe a schema of PIF for UME, which emphasized clinical and non-clinical (e.g., didactics) aspects of medical training (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSince little is known about the socialization process of advanced learners, we do not know if the same factors crucial for UME may apply to fellows. Understanding the socialization of fellows will have both practical and theoretical significance. Fellows will gain an understanding of the challenges they face in their transformation. Fellowship directors will have an improved understanding of factors required to guide the fellowship transition. From a theoretical perspective, a better understanding in the PIF of the fellow will contribute to a more holistic view of the medical socialization process, one that incorporates advanced stages across ME. The objective of our study is to discover key factors that inform PIF in postgraduate Emergency Medicine (EM) fellows\u0026rsquo; acquisition of subspecialty knowledge, skills, and professional development.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eOur qualitative grounded theory study employs a constructivist paradigm, informed by theories of socialization and adult development.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eContext\u003c/h3\u003e\n\u003cp\u003eMany residency graduates choose to pursue fellowship training. They often function as attendings in the clinical space while developing subspecialty expertise. EM fellows may enter fellowship upon completion of an EM or other eligible residency. Fellowships may be accredited by the Accreditation Council for Graduate Medical Education (ACGME) or other external bodies.\u003c/p\u003e\n\u003ch3\u003eSampling strategy:\u003c/h3\u003e\n\u003cp\u003eWe conducted purposive stratified maximum variation sampling to ensure representation from a diverse study population (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Subjects were recruited via publicly available information from the Society for Academic Emergency Medicine (SAEM) Fellowship Database and Directory.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe targeted 3 subject groups; current fellows, recent graduates (\u0026lt;\u0026thinsp;2 years), fellowship leaders. Both current fellows and recent graduates were considered part of the fellows cohort. Potential subjects were sent recruitment emails and a REDCap (RC) survey to collect demographic information. Interview invitations were based on our \u003cem\u003ea priori\u003c/em\u003e purposive stratification model to maximize representation (fellowship category, gender, ethnic/racial identity, geography) until thematic sufficiency across groups was determined during data analysis. Each subject was assigned an RC number and was offered a \u003cspan\u003e$\u003c/span\u003e50 Amazon gift card for participating.\u003c/p\u003e\n\u003ch3\u003eData collection and instruments:\u003c/h3\u003e\n\u003cp\u003eWe (DC, JT, DR, WCC) developed interview guides based on Creuss\u0026rsquo; socialization theory framework for both groups (supplemental material). We piloted and refined them using fellows and fellowship directors not participating in the study. From June - September 2023, JT conducted semi-structured interviews with fellows and recent fellowship graduates. From October 2023 -January 2024, DR conducted semi-structured interviews with fellowship leaders. Since fellowship leaders were interviewed after the fellows, we presented some preliminary themes derived from fellows\u0026rsquo; interviews as a form of member checking at the conclusion of their formal interviews. Consent to record interviews was obtained verbally. Interviews were audio recorded and professionally transcribed (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://datalyst.com/\u003c/span\u003e\u003cspan address=\"https://datalyst.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Transcripts were de-identified and uploaded with their corresponding RC number to Dedoose Version 9.2.22b (2023. Los Angeles, CA: SocioCultural Research Consultants, LLC) for analysis.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eOur coding framework was based on socialization theory. Four team members (DC, JT, DR, and WCC) coded independently adding new codes within the established framework for the first 4 transcripts. We met to collapse and split codes to create a common code book. New codes for subsequent transcripts were agreed upon through group discussion. All team members coded all transcripts and memoed throughout the coding process to record insights and themes. We met regularly to discuss coding and conducted thematic analysis via both deductive and inductive reasoning in an iterative fashion applying the constant comparison method. Coding and thematic analysis occurred concurrently with interviews and determined the number of total interviews conducted. Interviews were continued until thematic sufficiency was reached for both subject groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResearcher reflexivity\u003c/h2\u003e \u003cp\u003eThe research team consisted of 3 current or former fellowship program directors (DC, DR, and WCC) and an undergraduate director (JT). JT conducted interviews with fellows or recent fellowship graduates to avoid the appearance of coercion. TH contributed abstemious reflection informed by concurrent work in PIF from the program director perspective.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e This study was reviewed by the institutional review board (IRB) at Columbia University Medical Center (IRB # AAAU5023) and determined to be Exempt.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy subjects:\u003c/h2\u003e \u003cp\u003e53 fellows and fellow leadership personnel completed RedCAP demographic surveys. We completed 15 interviews with fellows and 11 with fellowship leaders. Interviewee characteristics can be found in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\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 fellows and recent graduates interviewed\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFellowship Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en, %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSimulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2, 13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency medical services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1, 7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2, 13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric Emergency Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3, 20%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToxicology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2, 13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1, 7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCritical Care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1, 7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender Identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9, 60%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnic/Racial Identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2, 13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack/African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1, 7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9, 60%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 1 race/ethnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1, 7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not wish to disclose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2, 13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic Location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWest Coast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3, 20%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6, 40%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreat Plains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1, 7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMid-Atlantic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5, 33%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\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\u003eCharacteristics of fellowship leaders interviewed\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFellowship Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en, %\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1, 9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1, 9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToxicology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1, 9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResearch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3, 27.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlobal Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1, 9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSimulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1, 9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency Medical Services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1, 9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2, 18.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender Identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2, 18.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot specified/other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9, 81.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnic/Racial Identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10, 90.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than one race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1, 9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographic Location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWest Coast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5, 45.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMidwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1, 9.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreat Plains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2, 18.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMid-Atlantic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3, 27.3%\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=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eThemes:\u003c/h2\u003e \u003cp\u003eWe constructed two thematic clusters from the transcripts. The first cluster relates to the fellows\u0026rsquo; exploration of their place within society: \u003cem\u003esociety integration\u003c/em\u003e. Themes include integrated growth, disillusionment, and self-actualization. The second cluster relates to their budding relationship with their subspecialty niche: \u003cem\u003esubspecialty integration\u003c/em\u003e. Themes include systems-based practice, mentorship archetypes, and mastery learning. One overarching theme bridged both clusters: conflation of personal and PIs. We present representative quotes for each theme that includes both fellows\u0026rsquo; and fellowship directors\u0026rsquo; perspectives. Comprehensive quotations from transcripts mapped to themes can be found in supplemental materials.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSociety integration cluster:\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eHolistic development\u003c/h2\u003e \u003cp\u003eThis theme refers to the reflective practice expressed by our participants. For many, fellowship allowed the dedicated time, space, and psychological safety to reflect on their prior training including a significant amount of perceived trauma incurred. Many participants disclosed the pursuit of aid from mental health professionals\u003c/p\u003e \u003cp\u003e \u003cem\u003eI got keyed in with a therapist and a psychiatrist\u0026hellip; and I don\u0026rsquo;t know if it\u0026rsquo;s the medic[ation] or my circumstances, or my outlook, but whatever it is, it\u0026rsquo;s really working, and I don\u0026rsquo;t feel like I have to fake it. I am back to being authentically this way instead of forced to be this way.\u0026rdquo;\u003c/em\u003e RC36 (fellow)\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eThere was a little bit of a health issue that he's having to sort out that's adjusted some of our plans and scheduling already\u0026hellip; being able to be adaptable, flexible, and then making sure that we're supportive of him and making sure that the department has mobilized resources to help him however we can\u003c/em\u003e\u0026rdquo; RC43 (fellowship director)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDisillusionment:\u003c/h2\u003e \u003cp\u003eFellows noted a mismatch between their expectations and reality. This perception, mainly of the medical system, led many to develop cynical outlooks on health care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Taking advantage of altruism is how the American medical system stays afloat.\u0026rdquo;\u003c/em\u003e RC44 (fellow)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI see people immediately coming into residency, I see burnout. In fellowship, I also see burnout, and I see this sort of like, I need to find another way.\u003c/em\u003e\u0026rdquo; RC 17 (fellowship director)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSelf-actualization:\u003c/h2\u003e \u003cp\u003eDespite some degree of cynicism, many fellows emerged from fellowship with a heightened sense of self and a clearer vision of the overall trajectory for their life.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think I have learned a lot. There's been a lot of bumps in the road, but it's been a good growth experience for me in understanding what I want to do in my future.\"\u003c/em\u003e RC13 (fellow)\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eThey certainly don't feel like a toxicologist when they walk in. I think they probably feel like a toxicologist when they walk out, but with all of the imposter syndrome that we all have.\u003c/em\u003e\" RC16 (fellowship director)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSubspecialty integration cluster:\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eSystem based practice:\u003c/h2\u003e \u003cp\u003eFellows developed a greater awareness of the health care ecosystem beyond the medical knowledge required for direct patient care. The initial clinical transition from resident to attending proved to be challenging for many.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think as I've gone through [fellowship]\u0026hellip;I think of it more as like team sports than I think I ever did. I consider my colleagues everyone from the janitorial staff up to the CEO of the hospital, and I consider them all sort of equally, which I think has been a little bit of a transition from residency... I think we're all sort of in the same trenches together.\u0026rdquo;\u003c/em\u003e RC18 (fellow)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThey do have all the typical things that I would joke around called New Attending Syndrome...I probably figured it was three years or so before I finally said, Well, anything could walk through the door and be like, I got it. I have an answer for everything, even if I don't know what I'm doing\u003c/em\u003e.\u0026rdquo; RC17 (fellowship director)\u003c/p\u003e \u003cp\u003eIn addition to adapting to more complex systems based practice as well as responsibilities, many fellows found themselves adapting to new cultures of clinical practice:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I had a really hard time adjusting to fellowship here\u0026hellip;I felt very much that culture shock of the difference from a very large hospital with innumerate resources to a much smaller hospital with limited resources, and that was a hard adjustment for my practice\u0026hellip; I found myself having to learn a lot of workarounds.\u0026rdquo;\u003c/em\u003e RC36 (fellow)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eMentorship archetypes of fellowship directors:\u003c/h2\u003e \u003cp\u003eThere was a dichotomy of mentorship provided by fellowship directors as perceived by the fellows as well as affirmed by fellowship directors themselves.\u003c/p\u003e \u003cp\u003eMany fellowship directors function more as administrators than mentors in the traditional understanding, which led fellows to seek mentorship outside of their program.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eProbably people from my residency, honestly, my residency leadership. [in reference to mentors] I'm new here so I haven't really identified a mentor.\u003c/em\u003e\" RC22 (fellow)\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMy role specifically ends up being a little bit more logistical\u0026hellip; quarterly meetings to make sure that we're meeting fellows' expectations and fellows meeting our expectations, identifying areas for improvement. And then a lot of the time it's just working to identify mentors and making sure that mentors are holding up their end of the bargain as well and helping to develop the fellow.\u003c/em\u003e\u0026rdquo; RC43 (fellowship director)\u003c/p\u003e \u003cp\u003eFew fellowship directors saw their role as a mentor to guide their fellows in their PI development. The solitary exception is as follows:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMy number one \u0026ndash; I want to launch their career. I want them to see this career longevity in emergency medicine; whether it\u0026rsquo;s academics or whether it\u0026rsquo;s in the community. I want them to feel like this is their identity and this is their career and it\u0026rsquo;s going to\u0026mdash;they are going to bring expertise that\u0026rsquo;s going to be rewarded with either more money or buydown or other leadership positions in the hospital\u0026hellip; it\u0026rsquo;s really a combination of creating future leaders not just in [redacted] but in health care.\u003c/em\u003e\u0026rdquo; RC14 (fellowship director)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMastery learning\u003c/h2\u003e \u003cp\u003eFellows and fellowship directors reflected on their investment into their specific niche describing the dedication required to develop the skills for their subspecialty.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI've changed in the sense of learning. I'm still figuring that out. And relearning how to learn again\u0026hellip; I've changed in that, my brain feels very plastic right now.\u003c/em\u003e\u0026rdquo; RC42 (fellow)\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think it\u0026rsquo;s really fun to have that professional identity start to kick in during fellowship and say, \u0026ldquo;When you finish this fellowship, everyone is going to be looking at you as the voice of reason\u0026rdquo;\u003c/em\u003e RC14 (fellowship director)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eConflation of personal and professional identities:\u003c/h2\u003e \u003cp\u003eWhen asked about their personal identities, fellows usually answered with components of their \u003cem\u003eprofessional\u003c/em\u003e identity. In fact, their personal and PIs seemed intertwined and interdependent, suggesting a merger of these two previously separate identities. This fellow suggests that their happiness is contingent on their profession.\u003c/p\u003e \u003cp\u003e\"\u003cem\u003eI would just become happier since fellowship because this is exactly what I want to do in life.\u003c/em\u003e\" RC26 (fellow)\u003c/p\u003e \u003cp\u003eIt is unclear at what point in training the two identities become entwined.\u003c/p\u003e \u003cp\u003e[in reference to personal identity] \u0026ldquo;\u003cem\u003eI\u0026rsquo;m sure maybe without me even knowing it, probably, it\u0026rsquo;s intertwined... I\u0026rsquo;m very lucky, very lucky that I love going to work. Even when I sometimes don\u0026rsquo;t want to go to work and I am tired, but I really enjoy what I do.\u003c/em\u003e\u0026rdquo; RC36 (fellow)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eConceptual understanding of fellows\u0026rsquo; professional identity\u003c/h2\u003e \u003cp\u003eWe mapped our current themes to the Cruess\u0026rsquo; framework of socialization for UME (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored factors that shape PIF among postgraduate EM fellows. Drawing from socialization theory and themes identified from fellow and fellowship director interviews, we developed a novel socialization model for postgraduate fellowship training that extends Cruess\u0026rsquo; framework for UME (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur findings reveal two key insights that distinguish fellowship-level PIF from earlier stages of medical training. First, fellows enter training with established PIs that become increasingly intertwined with their \u003cem\u003epersonal\u003c/em\u003e identities. Second, the socialization process operatives through two distinct, but interconnected domains: societal and subspecialty integration. These domains shape how fellows negotiate their evolving sense of self while developing expertise in their chosen field.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eThematic discussion\u003c/h2\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eSocietal integration\u003c/h2\u003e \u003cp\u003eSeveral aspects of the fellowship socialization process make the blending of personal and PIs problematic. First, the overwhelming expression of disillusionment with the health care system described by participants evinced a cynical outlook on the medical profession and clinical care. PIF is inherently a disruptive process as one negotiates between existing identities and shifts into an identity that one must adopt\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Competing healthcare system priorities (e.g., patient- or institution-centeredness of care) place significant demands on trainees, further complicating the integration of personal and PIs. This tension was mitigated by the opportunity for reflection during fellowship and facilitated holistic development. While reflection is widely recognized as an essential component of professional development\u003csup\u003e\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, much of the reflective work undertaken during fellowship centers on processing the traumatic aspects of prior medical training. A notable proportion of fellows within our cohort actively sought mental health support.\u003c/p\u003e \u003cp\u003eOur findings likely underestimate the true prevalence of mental health needs among physicians, especially those early in their career, given existing literature indicating that physicians are generally reluctant to seek such care\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The relative distance from the clinical environment afforded by fellowship\u0026mdash;combined with a smaller, supportive community of practice\u0026mdash;may have created the psychological safety net that enabled many to engage in this essential step toward healing\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA concurrent concern is that physicians who have not chosen to pursue fellowship may lack similar structural support; they may not have comparable opportunities for reflection and recovery. Cruess also emphasized this salient subject: \u0026ldquo;health care systems also can impact the learning environment, for example by leaving too little time for teaching or reflection. Providing an opportunity for learners to reflect on such issues during their formative years can foster their awareness of the potential impact of the health care environment on their PIF and can encourage them to cultivate a conscious framing of their own responses to it\u0026rdquo;\u003csup\u003e12\u003c/sup\u003e. Those in fellowship, who have the infrastructure for supported reflection, can better reconcile with their past trauma and develop a positive sense of self and vision of their future.\u003c/p\u003e \u003cp\u003eWe found the clinical transition to be one of the most challenging aspects of postgraduate fellows\u0026rsquo; socialization. Many described difficulty adapting to complex systems-based practices from which they were largely shielded during residency. As fellows adapt to their new roles, they enter a community of practice that may differ culturally from their prior training environment, adding another layer of complexity to the clinical transition\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Unsurprisingly, this challenge is not unique to fellowship training, but prevalent amongst the initial transition to independent practice for junior faculty and underscores the importance of purposeful \u0026ldquo;legitimate peripheral participation\u0026rdquo; throughout training\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. These challenges, when unmitigated, can lead to isolation and burnout\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFellowship provides a unique opportunity to optimize the deliberate integration into a smaller subspecialty community of practice. Its primary purpose is to foster development of one\u0026rsquo;s niche through mastery learning while cultivating deeper relationships on a smaller scale with likeminded individuals. There is an intrinsic platform to develop and showcase one\u0026rsquo;s skillset and this provides an opportunity to fulfill the dual need to both \u0026ldquo;fit in\u0026rdquo; and \u0026ldquo;stand out\u0026rdquo;\u003csup\u003e22\u003c/sup\u003e. When effectively implemented, a robust fellowship curricular and social infrastructure may serve as a \u0026ldquo;vaccine\u0026rdquo; for this vulnerable period of transition.\u003c/p\u003e \u003cp\u003eMentors broker the negotiation between subspecialty niche development and adapting to new systems-based clinical practice, thus mentorship remains as crucial a component of PIF in fellowship as it was in UME. Per Cruess, mentors facilitate learner transition to become an accepted member of a community of practice: \u0026ldquo;Becoming like them in action, appearance, and beliefs facilitates the move from the periphery towards the center of the community\u0026rdquo;\u003csup\u003e12\u003c/sup\u003e. We were surprised to find the fellowship-director-as-mentor paradigm was uncommon, despite the obvious infrastructure that could favor this structure. Instead, fellows primarily sought mentorship outside of their fellowship program, and many directors viewed their role as more administrative than developmental.\u003c/p\u003e \u003cp\u003eMentors influence trainees through two primary mechanisms: conscious passage of knowledge and skills through guided reflection and experiential learning; and unconscious role modeling of behavior and values that mentees internalize over time\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Our fellowship directors, by their own description, appeared not to fulfill either of these paradigms. It is likely that some did not receive adequate mentorship throughout their fellowship and therefore lacked a clear model for how to engage in mentorship. This insight may reflect a broader issue - the absence of structured, deliberate mentorship after early formalized ME\u003csup\u003e23\u003c/sup\u003e. Furthermore, both mentorship and menteeship are active processes that require intentional effort and cultivation\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Like any meaningful relationship, the mentor-mentee dyad depends on compatibility, shared expectations, and mutual engagement\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Consequently, the disconnect between fellows and their program directors as potential mentors may highlight both a lack of formal preparation in mentorship and menteeship in the postgraduate setting. This finding highlights the complex and multifactorial dynamics that underpin successful mentoring relationships.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eTheoretical implications\u003c/h2\u003e \u003cp\u003eAlthough the final framework resembles the same external structure as those for UME as proposed by Cruess, the study revealed remarkably different contributing factors. The framework\u0026rsquo;s starting point initiates the divergence. Students in Cruess\u0026rsquo; framework start only with a personal identity. Our framework begins with both existing personal as well as PI developed through years of medical training.\u003c/p\u003e \u003cp\u003e \u003cem\u003eLittle people, little problems; big people, bigger problems.\u003c/em\u003e The struggles of disillusionment and self-actualization become commensurate with increasingly complex involvement of the trainee/fellow with the vast and flawed healthcare system. Unlike UME, fellowship trains physicians not only for clinical practice, but to become leaders in subspecialty fields. Instead of the \u0026ldquo;clinical\u0026rdquo; and \u0026ldquo;non-clinical/classroom\u0026rdquo; facets of UME, fellows\u0026rsquo; PIF developmental domains involve societal and subspecialty assimilation.\u003c/p\u003e \u003cp\u003eTo our surprise, the framework culminates in the merger of personal and PIs. Whereas the output of the UME PIF framework establishes novel personal and nascent PIs, the postgraduate socialization process intertwines the two into one. Our initial reaction was tempered by review of known concepts in personal identity development as \u0026rdquo;aspects of an individual\u0026rsquo;s identity are relatively stable throughout life\u0026rdquo;\u003csup\u003e12\u003c/sup\u003e. Given that fellows typically begin training in adulthood\u0026mdash;a period during which personal identity is largely established and remains relatively stable\u0026mdash;it is reasonable to infer that the omnipresent development of PI during fellowship increasingly intermixes with existing personal identity. Furthermore, Cruess notes that \u0026ldquo;an individual\u0026rsquo;s vocation is a stabilizing and integrative force [on] personal identity\u0026rdquo;\u003csup\u003e12\u003c/sup\u003e. The interplay between personal and PIs is both natural and mutually reinforcing. This dynamic is an inherent aspect of professional engagement and, in itself, does not imply a detrimental impact on the individual.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003ePractical implications:\u003c/h2\u003e \u003cp\u003eOur findings suggest several implications for fellowship training programs. First, programs should embed structured support for PIF in the fellowship curriculum. This includes longitudinal initiatives, such as facilitated reflection sessions, narrative medicine workshops, and periodic self-evaluations. Having entered subspecialty training with established PIs, fellows require deliberate opportunities to navigate this evolution in identity\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSecond, programs should prioritize protected time for both program directors and fellows dedicated to reflection, mentorship, and scholarly growth. PI is constructed not only through experience but also through deliberate meaning-making and dialogue\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Without dedicated time and facilitated reflection opportunities, fellows may be forced into a transactional rather than developmental approach to training.\u003c/p\u003e \u003cp\u003eThird, fellowship curricula should integrate explicit training in systems-based practice, leadership, and adaptive expertise\u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. As fellows navigate increasingly complex healthcare environments, these competencies become essential not only for subspecialty practice but also career sustainability. This aligns with adult development theories, which emphasize the importance of adaptive growth in navigating complex environments\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eWe recognize our interviews were conducted during the post-COVID-19 pandemic period with elevated levels of uncertainty within academic medicine. However, factors such as heightened stress and opportunities for introspection may have offered a more raw insight into personal and PIs. How the pandemic influenced applications to fellowships or fellowship acceptance was not within the scope of this manuscript. How these PIF factors may change over time during periods of relative stability remains unknown. Furthermore, the study focused on EM fellowships so these findings may not be transferable to other specialty fellowships. This limitation reveals the need for further research exploring PIF across broader and multidisciplinary contexts\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eFuture directions\u003c/h2\u003e \u003cp\u003eOur work opens several avenues for further investigation. First, comparison with Cruess\u0026rsquo; framework highlighted that it does not account for students entering ME with pre-existing PI from prior careers. While many students enter UME immediately after completing an undergraduate degree, \u0026ldquo;non-traditional\u0026rdquo; students exist who have had prior careers- either outside or within the field of medicine. Understanding how pre-existing non-physician PI influence socialization into medicine and subsequent subspecialty training merits investigation.\u003c/p\u003e \u003cp\u003eSecondly, the mentorship archetypes identified warrants further exploration. What factors determine whether fellowship directors adopt mentor versus administrator roles? How do different mentorship structures influence PIF? What training or support might enable more directors to serve as effective mentors?\u003c/p\u003e \u003cp\u003eLastly, comparative studies examining PIF in fellows versus junior attending physicians who did not pursue fellowship could illuminate the unique contributions of fellowship training to professional development and identify whether non-fellowship pathways provide adequate support for this critical transition.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study addresses a significant gap in understanding PIF during postgraduate fellowship training. Our findings demonstrate that fellowship-level socialization differs fundamentally from earlier stages of ME in both process and outcome. Fellows enter training with established PIs that merge with personal identity through experiences spanning two interconnected domains: societal integration and subspecialty integration.\u003c/p\u003e \u003cp\u003eKey factors influencing PIF in fellowship include integrated growth, disillusionment, self-actualization, system based practice, mentorship community, and mastery learning. PIF would be enhanced in fellowship by deliberate structuring of guidance and time for reflection, system-based practice with focus on community, and dedicated mentorship.\u003c/p\u003e \u003cp\u003e Our study serves as a call to action and demonstrates that supported reflective processes are essential to the development of PI, not only during early years of ME, but also during fellowship, and continuing professional education; it is a critical consideration for departmental and institutional leadership in supporting faculty throughout career transitions.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of Interest Disclosure:\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding Sources\u003c/h2\u003e \u003cp\u003e/Disclosures:\u003c/p\u003e \u003cp\u003eThis study was sponsored by the Society of Academic Emergency Medicine Education Project Grant\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eD.C., J.T., D.R., and W.C. made substantial contributions to the conception and design of the study and to the acquisition of data. D.C., J.T., D.R., W.C., and T.H. contributed to data analysis and interpretation. D.C., J.T., D.R., W.C., and T.H. drafted the manuscript and critically revised it for important intellectual content, and T.H. provided additional expertise in methodology and subject matter. All authors approved the final version of the manuscript and agree to be accountable for their respective contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe authors confirm that all data collected or analyzed for this study are included in the article as published.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. 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Adv Health Sci Educ Theory Pract. 2022;27(5):1265\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10459-022-10178-8\u003c/span\u003e\u003cspan address=\"10.1007/s10459-022-10178-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\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":"medical education, professional identity formation, fellowship training, reflective practice, graduate medical education","lastPublishedDoi":"10.21203/rs.3.rs-9033047/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9033047/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eResidency graduates transition from novice to expert subspecialists requiring a transformation of professional identity (PI) in fellowship. Transitions are vulnerable periods in PI formation (PIF). Existing research focuses on transition from lay person to physician. Little is known about PIF of advanced learners. The objective of this study is to explore key factors that influence PIF in postgraduate fellows.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis was a qualitative study using a constructivist research paradigm. Subjects (current fellows or recent graduates and fellowship leaders of emergency medicine fellowships) were recruited via email by modified Dillman method, using purposive maximum variation sampling to ensure generalizability: gender, race/ethnicity, geography, fellowship type. Socialization theory (ST) informed interview guide development, code scaffold, and iterative code book modifications. Interviews were conducted between June 2023 to January 2024 remotely and were audio recorded, de-identified, and professionally transcribed. Directed transcript analysis with ST explored identity before, during, and after fellowship.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe conducted 15 interviews with fellows and 11 with fellowship leaders. We constructed 2 identity theme clusters: 1. Society integration: Self-actualization (clarity of purpose); Disillusionment (expectations vs. reality); Integrated Growth (reflect on PI journey including trauma incurred during training, often requiring mental health support). 2. Subspecialty integration: Systems-based Practice (navigation of healthcare infrastructure; often without deliberate guidance); Mentorship archetypes (mentor processes; often outside of fellowship); Subspecialty Mastery Learning (niche development). An omnibus theme, conflation of personal and professional identities, bridged both clusters.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eKey factors that contribute to fellowship PIF include reflective practices, mentorship community, subspecialty content, communities of practice, and the health care system. PIF would be enhanced in fellowship by deliberate structuring of guidance for system-based practice with focus on community and mentorship.\u003c/p\u003e\u003ch2\u003eClinical trial registration\u003c/h2\u003e \u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e","manuscriptTitle":"We become what we do: a qualitative exploration of professional identity formation in postgraduate fellowships","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-18 07:28:24","doi":"10.21203/rs.3.rs-9033047/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-05-07T16:41:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-27T03:33:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-20T13:13:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-19T16:39:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-03-19T15:36:44+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":"5dbb1ddd-1964-40bf-9a30-4c05a93853dd","owner":[],"postedDate":"May 18th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"30","date":"2026-05-07T16:41:40+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T07:28:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-18 07:28:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9033047","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9033047","identity":"rs-9033047","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}