探討臺灣實習醫學生及醫師專業認同之相關因素

Factors Influencing Professional Identity Formation of Medical Students and Physicians in Taiwan

醫學專業精神是醫學教育的核心能力，醫師被要求需展現淵博的醫學知識、醫術精湛，且能善盡照護病人職責，因此在醫師的養成過程，除需培養醫學專業能力，更要提升以病人福祉為中心的態度和行為，重視倫理操守及社會責任核心價值的醫學專業認同（medical professional identity）。而醫學專業認同形成（Professional Identity Formation, PIF）是一種持續動態的變化過程，由於探討PIF的相關因素研究鮮少，是以，本研究目的在探討臺灣醫學生、住院醫師和主治醫師PIF的現況及比較形成PIF的相關因素。本橫斷式研究以中部某醫學大學及其附設醫院的實習醫學生及醫師為對象，使用日本學者Tagawa於2019年發展與效化的中譯本，量測醫學生、住院醫師和主治醫師PIF的四個階段（imperial/SAS-2、interpersonal/SAS-3，institutional/SAS-4及inter-individual/SAS-H）。本研究以便利取樣選取182份有效問卷，填答醫學專業認同特定屬性量表中譯本，再以描述性統計、t檢定、單因子變異數及Spearman相關進行資料分析。結果顯示，SAS-4的平均分數最高，顯示整體研究對象呈現高階專業認同。在高階認同中，男性的得分顯著高於女性；專業認同隨著年齡的增長而增加，36歲以上年齡組在高層次認同表現顯著高於30歲以下年齡組。執業經歷階段分析顯示，在SAS-4及SAS-H階段，新進住院醫師（PGY1和PGY2）的專業認同得分顯著低於實習醫學生、資深住院醫師及主治醫師。本研究發現有助於醫療體系瞭解臺灣醫師專業認同養成的現狀，呼籲應對新進住院醫師及女醫師積極建構有效的輔導與支持系統，可供未來進一步研究參考。

Background and Purpose

Professional identity formation (PIF) is the process by which individuals internalize the values, behaviors, and ethical standards of the medical profession, and– together with clinical competence– it is regarded as a foundational pillar of medical education. In Taiwan, where medical training is shaped by intense academic pressure and hierarchical clinical settings, nurturing a stable, reflective professional identity is especially critical. The 2003 SARS outbreak prompted the launch of a nationwide Post-Graduate Year (PGY) program to remedy gaps in generalist knowledge and skills among young doctors and specialists. A subsequent reform in 2013 shortened undergraduate medical education from seven to six years; within this structure, the 2 years PGY training ensures that every medical graduate can manage undifferentiated patients before entering specialty training. Nevertheless, early-career physicians often experience identity instability as they shift abruptly from student clerkships to licensed PGY doctors in non-structured and fragmented support systems. Because PIF influences how practitioners interpret their roles, engage with patients and colleagues, and resolve ethical dilemmas, understanding its development trajectory is essential. Yet, despite growing global interest in developmental and socialization perspectives, empirical studies on career stage-based identity progression and demographic moderators remain scarce in Taiwan. This study therefore examines PIF among medical clerks and physicians at different career stages and analyses how identity stage correlates with gender, age, and clinical experience.

Literature Review

PIF in medicine is a dynamic, lifelong endeavor shaped by both individual development and the psychosocial context. Classical frameworks– Piaget’s cognitive development, Kohlberg’s moral reasoning, and Erikson’s psychosocial stages– conceive identity as a progression toward ever-more complex understandings of self and others. Kegan’s constructive-developmental theory extends this tradition, portraying adulthood as a series of qualitatively distinct meaning-making structures. Based on Kegan’s model, Tagawa (2019) created the Stage-specific Attribute Scales (SASs), which capture four successive levels of medical professional identity: SAS-2 (imperial balance), SAS-3 (interpersonal balance), SAS-4 (institutional balance), and SAS-H (inter-individual balance). These stages trace a trajectory from rule-bound conformity to the internalization of values and the reflective integration of multiple perspectives. The SASs have been employed in East-Asian settings such as Japan, illuminating how learners negotiate professional roles amid distinctive cultural expectations. Whereas Western models often foreground autonomy and individualism, East-Asian contexts must reconcile collectivist values with entrenched institutional hierarchies. Preliminary studies suggest that gender, age, and clinical experience influence identity growth; yet Taiwanese data remain sparse. In particular, the role conflicts encountered by female trainees and the transition stress of early-stage PGY physicians are under-explored. A culturally attuned understanding of PIF is therefore essential for guiding research, curriculum design, and support systems in Taiwan’s medical education.

Methods

A cross-sectional survey was administered to 182 participants drawn from a medical university and its affiliated teaching hospital in central Taiwan. The participants comprised fifth- and sixth-year medical students (medical clerks), PGY 1-2 residents, senior residents (R3–fellows), and attending physicians. All participants completed the Chinese version of the Stage-specific Attribute Scales (SASs)– 27 items that gauge identity attributes across four developmental stages– using a seven-point Likert scale. The stage with the highest mean score was taken as each respondent’s dominant identity level. Data analysis included descriptive statistics; repeated-measures ANOVA to compare stage scores within individuals; independent-sample t tests and one-way ANOVA for between-group differences; and Spearman correlations to explore associations between background variables and identity scores. Construct validity was evaluated via confirmatory factor analysis (CFA). The study protocol received Institutional Review Board approval, and written informed consent was obtained from all participants.

Results

(1) Stage profile. Mean scores peaked at the institutional balance level (SAS-4, M = 5.66), followed by SAS-3 and SAS-H, whereas the imperial balance stage (SAS-2, M = 4.27) was lowest. This pattern indicates that most respondents have progressed beyond ego-centered rule compliance.

(2) Gender. Male participants scored significantly higher than females on both SAS-4 and SAS-H (p < .05), implying that current clinical structures may pose greater barriers to advanced identity integration for female trainees.

(3) Age. Respondents aged ≥ 36 years outperformed those < 30 on SAS-4 and SAS-H (p < .01), suggesting a positive association between age, accumulated life experience, and professional maturity.

(4) Career stage. PGY 1-2 residents recorded significantly lower SAS-4 and SAS-H scores than both medical clerks and attending physicians, pointing to possible identity regression or instability during early postgraduate training.

Discussion and Recommendations

This study confirms that professional identity formation (PIF) is a staged, yet nonlinear journey shaped by both personal characteristics and contextual forces. Although increased age and clinical exposure are linked to higher-level identity stages, the gender gap and the dip in identity strength among early postgraduate residents reveal structural and psychosocial shortcomings in Taiwan’s training system. For PGY-1-2 doctors, the abrupt shift from student clerk to fully accountable practitioner can create dissonance between clinical workload, external expectations and internal readiness, underscoring the need for strengthened transitional scaffolding. Similarly, the lower scores among female participants may reflect implicit bias, role conflict, or a lack of gender-responsive mentorship within clinical environments.

To foster identity development across the career continuum, educators and institutions should adopt stage-specific strategies– structured mentoring, interprofessional learning, narrative-medicine workshops, and reflective-practice groups– while ensuring regular formative feedback. Support programs for early-career residents should emphasize emotional resilience, role clarity, and opportunities for self-assessment. At the policy level, accreditation bodies could embed identity formation explicitly into competency-based medical education frameworks and audit the availability of supportive structures. Creating learning environments that are inclusive, supportive, and developmentally responsive is essential for sustainable professional growth. Future research should employ longitudinal and mixed methods designs to trace identity trajectories and to examine how sociocultural values interact with professional development in diverse medical contexts.