This article is part of the Dialogue series which features transcriptions of e-mail discussions focused on a current issue in the field held by two scholars who have approached the issue from different perspectives (for further details, see the editorial published in Med Educ 2012;46(9):826–7). In this contribution to the series, Lynn Monrouxe (Director of Medical Education Research and the School of Medicine at Cardiff University, Wales) and Gary Poole (Associate Professor in the School of Population and Public Health at the University of British Columbia, Canada) discuss their evolving perspectives on identity (i.e., individuals’ conceptions and expressions of their individuality and group affiliations) as it pertains to health professional training. The biggest question I am presently grappling with concerns the concept of identity. What does an identity look like and how can we research it? Of course, across the behavioural and social sciences, the concept of identity and identities has been hotly debated and there is no single idea of what this (or these) are.1 But from a personal perspective, I’m still oscillating between the seductive notion of an individual’s identity being something internal to one’s self that can be a measurable and known entity2 and the thinking that identities are co-constructed through interaction in social settings.3 I guess my biggest issue is my personal desire to measure identity within individuals (e.g. moral identity) and relate that back to personal actions. But at the same time, my own research clearly demonstrates that identities (in the plural) are enacted interactionally and are highly fluid and contextual.4 What do you think? I first became interested in the concept of identity when a nursing student in one of my classes decided to drop out of the programme because, in her words, she could not see herself as a nurse. I believe that, in order to make this important decision, this student needed to have an identity that was, as you so clearly put it, internal to herself. Further, the student compared this internal representation with what she was seeing in her practicum work and found an intolerable mismatch. Thus, I approach the study of identity as being internal, captured within a ‘self-schema’. I also see identity development as a process by which people are making the kinds of comparisons that nursing student made – between that self-schema and the person they are being asked to be, or perhaps could be. Identity development, then, also requires a consideration of ‘possible selves’– the people we could perhaps see ourselves becoming.5 In medical students, I see identity development as a process, at least in part, of trying on these possible selves. This is why I am in favour of self-directed project work for our students because it represents an opportunity to take some control over the trying on of possible selves. All this said, I have no trouble acknowledging that identity can be socially constructed. There is longstanding research to indicate that we become the person others expect us to become.6, 7 Furthermore, the identities we construct of others are necessarily oversimplified constructions of who they really are. I believe that people’s full identities are too complex to be stored intact in our memories, so we work to construct identities for others that are more stable than the real thing. With all this in mind, we return to your provocative question: ‘What does an identity look like and how can we research it?’ At this point, identity for me looks like a file stored in memory. Self-schemas are stored for ourselves and person schemas are stored for others. Your comments made me think about a number of issues, some of which I had not anticipated. Again, the concept of cognitive schemas is familiar to me. This resonates with my earlier thinking as a cognitive psychologist and was my personal way of knowing the world as I entered into the field of medical education a decade ago. I think your narrative of the nursing student is a classic example. With my cognitive psychological hat on, I would agree that she is comparing her personal schema of ‘what a nurse is’ with her self-schema, and seeing a mismatch. The logical conclusion therefore is that she is not, and cannot be, a nurse. I guess this fits with other cognitive theories such as deductive logic, which would state: ‘All nurses are X. I am not X, nor will I be X. Therefore, I am not a nurse, nor will I be a nurse.’ But how much of our own thinking and reasoning about the social world is a construct of our education? As cognitive psychologists, we would think identities are schemas/categories, wouldn’t we? But someone with a different background might see the same thing and think identities are quite different. Certainly, I’ve changed my thinking over time and that’s due to my engagement in medical education and the influences of people around me and the literature I have read. And so I think that the concept of identities as being ‘files stored in memory’ could be too constrictive a concept when we look at how people are categorised and constructed within interactional space.8, 9 And what of these self- and person schemas? How are they formed? How does the identity schema of a nurse come to be? Through ‘prototypes’? ‘Typical features’? ‘Exemplars’?10, 11 The other issue your thoughts raise for me is the age-old matter of interdisciplinary communication, in which we use the same terminology but mean different things. So ‘identity as being socially constructed’ means something entirely different when thinking cognitively than it does when thinking within a social constructivist perspective. From the former perspective, it still comes down to cognitively stored schemata (albeit simplistic constructions) derived from language and interaction (so: what language and interaction does to us). But from the latter perspective it is more about what we do with language and artefacts within interactions. So my last point brings me back to the question of what identity is and how we can research it. From my perspective, identities are plural and enacted and can be understood through a systematic analysis of language. Coming back to your nurse, I would ask how she attended to issues such as accountability within her interactional narrative with you (accountability to her decision to drop out) and how she narrated her alternative identities within that accountability.12 For she was, after all, not merely reporting a subjective mismatch between her inner schema and an external ‘reality’. She was holding herself accountable to you for her actions. Don’t you think? Was the nursing student just reporting a mismatch between her self-schema and the perceived role of nurse? I have always seen her narrative in this way, but your comments invite me to expand on my understanding of what was going on in my conversation with her. How else might she have portrayed her decision to drop out of the programme, considering her accountability to that programme and to her own life? She might have reported a different mismatch, perhaps between her personal resources and the demands of the role. She might have said: ‘I am not smart enough… confident enough… patient enough…’ As it turns out, she did not say these things. Is this because she accessed her self-schema and decided that she could manage the demands of the role but chose not to because ‘it wasn’t her’? Or was it because the admission of inadequacy would have been much more difficult, given the way we construct conversations of this kind? I truly don’t know. The distinction here is important because, as you imply, the cognitive psychologist will study the role of identity in a case such as this very differently from someone who might adopt a perspective like ‘symbolic interactionism’, in which the self we present is wrapped up in a complex web of beliefs and perceptions about social context, unstated meanings and the perceived purpose of discourse. Relatedly, I agree that identity needs to be understood in the plural. I also agree with those who posit that some people maintain one constant identity across most situations (low self-monitors), while others carry multiple selves that they bring out based on situational demands (high self-monitors).13 From this view, we could say that the nursing student could not expand her numerous selves to include a new one as nurse. As for how she came to understand what a nurse is, as a psychologist, I would return to the concept of possible selves described by Markus and Nurius.5 Those who write about the process of socialising someone into a field like nursing would focus on how norms are communicated, as in: ‘This is what it looks like to be a nurse.’ A more anthropological view would suggest we need to understand rituals in the profession to understand identity. Such analysis has identified therapeutic and occupational rituals in that field.14 All this agrees with your point that our thinking about the social world is a construct of our training. Now we’re broadening our discussion to include a greater number of ways in which we can understand identities ranging from the individual, social, interpersonal and societal perspectives. Out of interest, I wonder just how reductionist we can be with respect to understanding and researching identities: it seems that even neuroscientists are proposing that we can understand identities by examining neurones and neurotransmitters.15 So what can we make of this? Essentially we are all looking at the same phenomena, but with different eyes. It reminds me of an important lesson I learned about science as a psychologist: explanations of the same phenomena that are made at different levels can be equally valid. So perhaps these are not mutually exclusive accounts; rather, they are complementary. And through further searching I have discovered an interesting researcher in the USA called Ken Wilber. He appears to have tried to integrate theoretical perspectives at different levels and suggests that reality comprises four domains – interior individual (first person), interior collective (second person), exterior individual (third person) and exterior collective (third person) – each with its own ‘truth-standard’ validity.16 Now, while I’m not suggesting for a moment that Wilber’s model16 maps onto the variety of levels of explanation we have discussed so far, what I am wondering is whether there is a way to represent our variety of different perspectives and their truth-standards. Such a description might take us beyond my original ‘what is identity and how can we research this?’ question, and into a more sophisticated description of identities, truth-standards, ways of knowing, research methodologies and how they build on one another to provide a more detailed picture of the ways in which identities are formed, co-constructed, stored, retrieved and enacted (and more). Perhaps? I am intrigued by the work you reference in your last message, Lynn. In my own career as a psychologist, I started as an unapologetic reductionist, and still am to a point. However, like so many people from this tradition, I eventually started studying phenomena that either could not be ‘reduced’ or that lost something vital in the process. I think, for example, of our work interviewing immigrant women in a large suburban maternity unit.17 The need to consider multiple perspectives is underscored in research on identity because identities are constructed at multiple levels, as you point out with your use of the word ‘co-constructed’. As a case in point, I hold the view that personality is something that is created by those who perceive us much more than it is by our own brains. We then shape our actions to be consistent with these other-constructed personalities. I believe we can substitute the word ‘identity’ for ‘personality’ in this case. A pragmatic conclusion from this is that research on identity must not just ask ‘Who are you?’ or ‘Who do you think you are?’ but also ‘Who do you think he or she is?’ Well... I see what you mean by suggesting identity and personality can be substituted, although I guess when we’re focusing on how we research this I become a little concerned, mainly because personality research is very much the domain of psychologists and from an individual perspective, although we do talk about certain types of personality in the collective form (authoritarian, for example). I also agree that we often ‘shape our actions to be consistent with these other-constructed personalities’, but let’s not forget that we also resist these ‘other-constructed personalities’. And this happens at the psychological, social and cultural levels (and therefore also at the level of neurones). And in addition to our actions being consistent with how others see us, self-verification theory suggests that we prefer others to view us as we view ourselves – so we try to elicit reactions that back up our own theories of self (e.g. Swann18). So, if we hold positive views of ourselves, we seek to reinforce these, and if we hold negative self-views, we try to reinforce that negativity.19 And this occurs through the interactive process of identity negotiation, which contributes to the process of shaping, preserving and displaying our self and our group identities. And now I wonder about the different terms we use and how these can become confused and confusing when we engage in research. Terms such as ‘self’, ‘identity’, ‘identities’ and ‘personality’ all have distinct research ‘histories’ and rarely overlap. So to use them interchangeably can confuse. Each has been researched using different paradigms. And so the confusion continues. Theories such as narrative identity theory20, 21 use personal stories to understand how individuals construct their identity; self-identification theory uses an experimental approach to understand this concept; personal construct psychology22 uses the ‘repertory grid’ technique, and symbolic interactionism uses ‘naturalistic’ data (e.g. talk in workplace, home and interview settings) to understand the co-construction of identities (e.g. Goffman’s dramaturgical theory23). So the complexity of the issue is great: there are different levels of explanation, different words and concepts (signifiers), and different theories with different ways of researching them. What can we say pragmatically about this, Gary? You explain very nicely the point that different language takes us into different research traditions. To clarify a comment from my previous message, I think ‘identity’ can be inserted for ‘personality’ in some of the work on social perception. However, this is not to say that the terms are synonymous. For me, personality is primarily about a collection of attributes, whereas identity is about much more: roles, nationalities, gender, place… the list goes on. It is interesting to think about how self-verification processes jibe with tendencies to confirm others’ views of us. One important consideration in determining what motive will prevail – confirming self-identity or confirming others’ perceptions of us – refers to the deliberate decisions we make about with whom we interact. To the extent that we can control that, we will look for people who will be sufficiently similar to us to make for viable comparators when we need to use social comparison to test our views of the world, with a bias towards those who confirm rather than disconfirm our views. We will seek those who confirm our sense of self as well. I am also now wondering about the self-serving value of seeking out those who confirm our negative views of self. For medical students, this must be a tricky business. My first guess is that this strategy might be used to protect against being put in situations for which the student does not feel adequately prepared. A supervisor who agrees with a student’s negative assessment of self might not push the student into the situation. Admittedly, this is a speculative example on my part. I really don’t know if this is what happens, though I believe that such events can work to help shape the student’s identity as a practitioner. Again, thank you for such a thought-provoking response. Your comments about seeking out those who confirm our negative self-views reminded me of a paper I’ve just read by Helmich et al.24 Through their analysis of students’ narratives of early clinical attachments, they found an interplay between emotions (negative and positive), meaning and identity and identified four different ‘paradigms’ of students’ experiences: feeling insecure; complying; developing, and participating (which are similar to Marcia’s identity status paradigms2). It is the ‘feeling insecure’ state in which students find it difficult to find their place (or role), and how the ways in which others act towards you can shape your feelings of belonging and your feelings of participating that I feel link with this. There is so much to say and so much to do around the issues of self, identity and identities. And there are so many different ways to address these issues. Once again I come back to what might be considered an ‘onion’ metaphor of identity, in which each layer represents a different level of understanding from the ‘inner-world’ to the ‘outer-world’, although I’m not sure that ‘onion’ is a suitable metaphor when we want to think of interactions! Bringing Marcia’s work2 into the conversation makes sense, especially when considering the possibility that identities are re-formed when we hit ‘rocky bits’– when our confidence is tested if not shattered. It leads me to conclude that identity is ‘rebuilt’ as self-efficacy is solidified ‘after a fall’. I suspect lots of this goes on during clerkships. I will look for the Helmich et al.24 paper. I also really like your onion metaphor and believe we could use it to bring our ideas together meaningfully. Contributors: this manuscript is a transcription of an original e-mail correspondence that took place between LM and GP. Acknowledgements: none. Conflicts of interest: none. Ethical approval: not applicable.