Developing agency through experiences of misalignment: A path to becoming a physician

INTRODUCTION: How medical students respond to the dissonance that can result from misalignments between personal values and the norms and values of the profession informs their evolving professional identities. But to what extent do medical students have agency to respond intentionally to these experiences? While current literature focuses primarily on agentic constraints (e.g., hierarchy), how medical students enact agency when they perceive the expectations of the clinical environment to be negatively aligned with their own values remains underexplored. This study examines the following research questions: (1) How do medical students perceive their agency when experiencing misalignment between their personal values and the norms and values of the clinical setting? and (2) How do medical students perceive their experiences of agency in the face of misalignment as contributing to their professional identity formation (PIF)? METHODS: This study used interpretive description methodology, with social cognitive theory as a primary theoretical framework. Semi-structured interviews (n = 16) were conducted with third- and fourth-year medical students at McGill University, using rich pictures as an elicitation technique. Interpretive themes were generated iteratively and inductively. RESULTS: Participants reported that agency evolved over time and was shaped by experiences of misalignment. In situations of negative misalignment, the enactment of agency was described as shaped by emotional responses, involving dynamic, often deliberate judgements that weighed internal and external factors. Participants' accounts further suggested that enacting agency in these moments may have informed their future capacity for agency and their PIF. DISCUSSION: This study highlighted how developing and enacting agency in response to misalignment contributes to PIF. By implementing strategies to foster agency, such as guiding reflection on the emotions associated with misalignment, medical educators may be better positioned to help students engage more meaningfully in becoming the physicians they hope to become.