Factors Influencing Professional Identity Formation of Medical Students and Physicians in Taiwan
Author: Ming-Hao Liang (Center for Medical Humanities, Chung Shan Medical University), Chia-Yang Lin (Institute of Medicine, Chung Shan Medical University), Jen-Hung Yang (Center for Medical Humanities, Chung Shan Medical University; Center for General Education, Chung Shan Medical University; Chung Shan Medical University Hospital), Hsiang-Chu Pai (Department of Nursing, Chung Shan Medical University), Zuway-R Hong (Center for General Education, Chung Shan Medical University)
Vol.&No.：Vol. 71, No. 2
Date：June 2026
Pages：171-200
DOI：https://doi.org/10.6209/JORIES.202606_71(2).0006
Abstract：
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.
Keywords：
constructive developmental theory, professional identity formation, medical professionalism, medical education