Understanding Professionalism’s Interplay Between the Profession’s Identity and One’s Professional Identity

DISCUSSION

Welch and colleagues wrote in the 2020 SAC report that “Paramount to the advancement of [professional identity formation] is the need for the profession to evaluate and define the professional identity of the pharmacist.”¹² This could be misinterpreted to mean that work on students’ professional identity formation should wait until a single identity is accepted for the pharmacy profession. Some may feel that for students to successfully form a professional identity, there needs to be a widely accepted definition of a pharmacist and, therefore, a single identity of the profession that all student pharmacists will adopt.

One problem with this interpretation of when students should start forming a professional identity is that the identity of the pharmacy profession has long been the subject of disagreement. Kellar and colleagues outlined five different identities over the past century, each based on the primary (or newest) role of the pharmacist at that point in time.¹⁴ These are apothecary, dispenser, merchandiser, expert advisor, and health care provider. Several of these still describe how pharmacists are identified by patients and/or other health care providers today. Many patients readily think of the pharmacist as a dispenser since they commonly interact with pharmacists at community pharmacies to pick up prescriptions. Yet, to attendees of a national pharmacy organization’s annual meeting who see sessions on practicing at the top of the Doctor of Pharmacy (PharmD) degree, a pharmacist’s identity may be that of an expert advisor or a health care provider. Different views of pharmacists’ identities may be harbored by other health care professionals, who interact with pharmacists based, in part, on the roles they think pharmacists fill, as well as legislators and regulators, who decide what roles pharmacists are allowed based on their own perception of pharmacy.

It seems intuitive that an accepted identity for a profession helps contribute to the development of one’s own professional identity. After having served on both the 2019-2020 and 2020-2021 SAC, I agree with the argument that a widely accepted identity for pharmacy could help student pharmacists better understand the community they are joining. Noble and colleagues reported when students encounter an identity of the pharmacy profession in the classroom that is different from the identity they encounter on experiential rotations, this can slow the development of their professional identities.¹⁵ They mentioned that students were taught in class about the expert adviser identity of pharmacists, but, on many of their rotations, they only saw the roles and responsibilities of a dispenser. A disconnect between what students were taught in class and what they experienced in practice led to confusion about the community they were trying to join and, thus, their place in it. Kellar and colleagues also noted this effect on students, saying that “in many cases, the health provider identity they aspire to during their education is in direct opposition to what they later experience in practice settings.”¹⁴

I agree that a universally accepted identity for pharmacists might also help members of other health care professions better understand what to expect when working with a pharmacist. Moore and colleagues urged that “We need to consciously expand our communication about who pharmacists are and what pharmacists do to those outside of the profession: to those who are not aware; to those who are being educated with future pharmacists; to those in other health care professions. With the requirement of interprofessional education for all health professions, the time is now to educate our colleagues in other professions about the pharmacist role and scope of practice.”¹⁶ A widely accepted identity for pharmacy might enhance that communication and, thus, the integration of pharmacists as members of the health care team, helping achieve the goal stated by previous AACP President Todd Sorenson “that by 2025, 50% of primary care physicians in the U.S. will have a formal relationship with a pharmacist.”¹⁷

I have been in academic pharmacy for 26 years, and in that time, I have worked with and taught many pharmacists. I have seen the transition from pharmaceutical care to medication therapy management and now to the Pharmacists’ Patient Care Process (PPCP), and I have seen the way these changes have affected how pharmacists talk about themselves. I believe that as it has in the past, any future identity of the pharmacy profession will likely focus largely on roles and responsibilities taken on by its members. However, although roles and responsibilities are important, they alone do not define an individual’s professional identity. Being competent at roles and responsibilities can be achieved by thinking and acting like a pharmacist, but this alone does not ensure one has internalized the community’s norms, attitudes, and behaviors and, therefore, feels like a pharmacist. As an oversimplification, a profession’s identity is a sort of brand, making it possible to explain to others what one does. In contrast, having a professional identity means that one describes being a member of that profession as part of who they are. Two pharmacists in different practice environments filling completely different roles can each think, act, and feel like a pharmacist, meaning they have a professional identity. Despite differences in their roles and responsibilities and, perhaps, in how they would each define the identity of the pharmacy profession, they both demonstrate the shared norms, attitudes, and behaviors associated with being a pharmacist.

In the absence of a singular identity for the pharmacy profession, it is worth considering whether the student pharmacists studied by Noble and colleagues would have been as confused about the profession and their place in it if they had been aware of the breadth of practice conditions, roles, and responsibilities they would encounter outside of the classroom. Unless and until there is a widely accepted identity for the pharmacy profession, schools should make clear that pharmacists have roles as dispensers’ as well as expert advisors and health care providers. Preceptors are offered continuing education opportunities by the schools whose students they train, and in return, could provide feedback on the current real-world state of pharmacy, so students do not experience culture shock on rotations. Based on the observations of Nobel and colleagues, this simple awareness could go a long way toward helping student pharmacists develop their professional identities.

Welch and colleagues wrote in the 2019-2020 SAC report of the importance of addressing both the profession’s identity and students’ professional identities.¹² However, the identity of a profession is distinct from an individual’s professional identity, and the two should not be conflated. The identity of the profession can be decided on through a discussion among the various pharmacy stakeholders, including the Academy. This might parallel the process used by the Joint Commission of Pharmacy Practitioners during the development of the PPCP, and it should be driven by pharmacy practitioners both within the Academy and outside it. It is they who develop interprofessional relationships and, thus, benefit from the “brand awareness” of those in other health care professions. It would also help them more clearly communicate with the patients who seek their care and the legislators who regulate the roles and responsibilities of the pharmacist.

In contrast, an individual’s identity, whether personal or professional, is developed over time through interactions with others, and it evolves in response to both internal and external feedback from those interactions. Successful professional identity formation begins as one explores a community, continues as they initiate and then establish a place in that community, and results in being accepted by others in the community and a feeling that one belongs there. For everyone, developing a professional identity involves the teachers, preceptors, patients, and other health care providers with whom they interact throughout their career. The variety of these interactions alone means it will not be possible for schools and colleges to guide their students toward one professional identity that is shared by all.

In addition, we must remember the bidirectional interplay between personal identity and professional identity. One’s professional identity cannot be stable and resilient if there are significant conflicts between it and one’s personal identity, and vice versa. Frost and Regehr wrote that one’s personal and professional identities cannot be completely compartmentalized from each other. They argued that “medical education should be organized and delivered in ways that encourage the incorporation, preservation, and leveraging of students’ idiosyncrasies. If differences are effaced or negated through medical training, then the benefits of admitting diverse students fail to be realized.”¹⁸ The recognition of the impact of the personal identity on the professional identity has also played a role in academic medicine’s move from professionalism to professional identity. As Bhatia-Lin and colleagues wrote, “Physician [professional identity formation] has historically been racialized and gendered to reflect the White male physicians who dominated the occupation and to maintain an overrepresentation among its leadership.”¹⁹ The importance of this cannot be overstated as we work to enhance equity, inclusion, and diversity in our application pipeline and our curricula. It can be easier for individuals to start exploring a place for themselves in a professional community if they can readily see others who seem to share one or more aspects of their personal identity.