Competence vs. Identity, Trainees vs. Physicians: How COVID-19 Has Highlighted Role Confusion in Residency Training
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COMMENTARY
Competence vs. Identity, Trainees vs. Physicians: How COVID-19 Has Highlighted Role Confusion in Residency Training Michael A. Shapiro 1 Received: 14 August 2020 / Accepted: 15 October 2020 # Academic Psychiatry 2020
The idea for this paper occurred much prior to the COVID-19 pandemic. It was supposed to be a more light-hearted and cheekier take on how residents are the “teenagers” of medical education: almost grown-up, but not quite. The initial intent was to highlight how sometimes residents are viewed as having all the responsibility of being full-grown “adult” doctors, while at other times needing to be protected and/or controlled, enjoying very few privileges of autonomous physicians. The COVID-19 pandemic and response have obviously required swift changes to medical education, but have only further highlighted the mixed messaging and treatment that U.S. residents face during training. Prior to COVID-19, almost the entirety of this paper was going to be an examination of Erik Erickson’s Psychosocial Stages of Development [1], how they relate to educational level, and whether a competency-based evaluation system is sufficient for individuals who are also starting professional identity formation. I will try to do this briefly, then move on to how the current COVID-19 crisis has served to amplify these points for psychiatry residents.
Competence vs. Identity Erickson was a child psychoanalyst who developed a list of psychosocial stages, where each stage represents “an unavoidable encounter between the environment and the developing person who is driven by instinctual energy and developing awareness” and results in a corresponding “crisis” that needs to be navigated to resolve the conflict [2]. The crisis or conflict of Erickson’s 4th stage is Industry vs. Inferiority, the successful navigation of which leads to the virtue of competence. Competency-based evaluations have become commonplace in medical schools and residency training programs [3, 4]. * Michael A. Shapiro [email protected] 1
University of Florida, College of Medicine, Gainesville, FL, USA
Although this has led to improved consistency across schools and programs on how students and trainees are evaluated, the risk of students and residents not being able to successfully navigate this stage cannot be ignored. Competition among medical school classmates to prove their superiority over each other for coveted positions in medical honor societies and residency positions has led to such detrimental perfectionism and increased stress levels that many medical schools have made the pre-clinical curriculum pass/fail [4]. This sense of competition and fear of inferiority can also mark this stage and partly explains why in typical development, self-esteem takes a dip in middle childhood [5]—and perhaps medical school. Although residency training still focuses on competency and skill development, residents have already started to embark on the next stage. Residents need to fulfill the expectations that are eventually required to be called a “surgeon,
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