Introduction of a new teaching method to support Professional Identify Formation in medical students

Professional Identify Formation is regarded as fundamental to medical education. It involves a process of socialisation where knowledge is often acquired unconsciously via social interaction. Concrete teachings to support and mediate this socialisation process are difficult to implement, because of the implicit nature of the transferred knowledge. Before effective reflection can start, the implicit knowledge has to become explicit. The authors argue that training based on the Systemic Constellation method may be a promising way to support Professional Identify Formation among medical students, by increasing students’ awareness of their own socialisation process and the implicit knowledge that they have acquired. By visualising their social context with a group of students, the method is effective in making explicit the social context and the values, beliefs, perspectives that are present. This creates the possibility to discuss these values, beliefs, perspectives and explore differences, and stimulates individual and group reflection. The method is already widely used in business settings, but not yet in the medical education setting. This article presents how this new training method was implemented in the undergraduate medical curriculum of the University of Groningen, the Netherlands, and discusses its feasibility, acceptance and perceived usefulness by medical students.


Introduction
Professional Identify Formation (PIF) is regarded to be a fundamental aspect of medical education (Cooke et al., 2010;Cruess et al., 2015;Jarvis-Selinger et al., 2012) . Where identity formation is a continuous process that happens in medical school, during residency and beyond (Hafferty & Franks, 1994;Leedham-Green et al., 2019;Witman, 2014), for medical students to develop a Professional Identity, support in this process is desired and education is one of the important tools in this process (Cruess et al., 2015;Goldie, 2012).
Professional identify formation is a process achieved through socialisation, which is often an unconscious process within a social context (Cruess et al., 2015). Much of the knowledge essential to develop a Professional Identify is therefore tacit knowledge (Cruess et al., 2015;Cruess et al., 2019). Tacit knowledge can be defined as the collective, implicit knowledge, that consists of habits, beliefs, values, social structures, and 'how we do things here' (Lam, 2000;Sturmberg & Martin, 2008). While the establishment of a cognitive knowledge base on PIF among learners is relatively easy to implement in medical education, supporting and mediating the acquisition of the tacit knowledge that shapes the professional identify is more difficult, because of the implicit nature of this type of knowledge (Lam, 2000).
Literature suggests the use of experiential learning and guided reflection with mentors and role models as effective means to influence PIF in an educational setting (Goldie, 2012;Wald, 2015;Cruess et al., 2019;Yazdani et al., 2019). However, before learners can reflect on their professional identify, teaching must first allow a learner to become consciously aware of their socialisation process and the tacit knowledge that they have 5 already acquired unconsciously in this context (and are still acquiring). The implicit knowledge needs to become explicit. Up to now, concrete, practical examples of implementation of such teachings are scarce. Without good teaching methods that address the tacit aspects, the process of PIF might develop in a suboptimal way.
A promising teaching method to make learners more aware about their tacit knowledge of their social context and socialisation is the Systemic Constellation method (Arnold & Prescher, 2017;Burchardt, 2015;Kopp & Martinuzzi, 2013;Weinhold et al., 2014). This experiential learning method in groups stimulates reflection for the individual and the group (more details on the method will follow). The method is based on a process of zooming out from the individual level to the larger social system level and encompasses a live visualisation of the elements of a social system in a spatial way. Through the visualisation of a social context with a group, the method is effective in making explicit the social context and the values, beliefs, habits, perspectives that are present. This creates the possibility of discussing these values, beliefs, habits, perspectives and of exploring differences. A systemic constellation training is often performed with a group of 10-30 learners led by a trained facilitator. The method is already widely used in business settings for transformation processes, team development, and leadership training (Burchardt, 2015;Weinhold et al., 2014) and has also been applied in education (Kopp & Martinuzzi, 2013).
We adapted the method into a form that would fit within the medical education setting.
From 2017 we offered training using the Systemic Constellation method in the medical curriculum of the University of Groningen, the Netherlands, as part of an educational track on leadership development (Fleer et al., 2017). Because it has been emphasised to 6 start education addressing PIF early in the curriculum (Cruess et al., 2019), we started with undergraduate medical students. To our knowledge, the Systemic Constellation method has currently not yet been used in undergraduate or graduate medical curricula.
In this article, we propose the Systemic Constellation method as a teaching method to support PIF, discuss implementation of the method in a large group of undergraduate medical students and provide practical details about the training for teachers. In addition, we reflect on our evaluation with the students to gain more insight in the application of this new method in the medical education setting.

The Systemic Constellation method
The Systemic Constellation method was originally developed in Germany for psychotherapy (focused on the family system) and later applied to other social systems such as organisations (Weinhold et al., 2014). 'Social system' refers to any group of people (e.g. colleagues, team members, organisations). The Systemic Constellation method has a strong basis in social constructionism and assumes that people have a perception of their social reality which results from a largely unconscious socialisation process and is influenced by the social systems which they are part of (Gminder, 2005;Weinhold et al., 2014). In line with the concept of habitus (Bourdieu, 1992)   The method makes learners more aware of their own social context and their tacit knowledge about it, by visualising the social system the learner is part of. To this end, a spatial arrangement of elements (using people or objects) representing elements of the social system is used, also called 'systemic constellations' (Figure 1). Elements can be a person, function or role in the social system (e.g. the supervisor or a nurse), groups or stakeholders (e.g. patients), or concepts or societal aspects (e.g. insurance). In this way, the social system is made visible and tangible. The structures of the social system, the inter-dependencies between different elements and different perspectives (e.g. of the perspective of an external observer or of someone else within the group) are explored with the learner and the group.
This spatial visualisation relies on learners' tacit knowledge about their social systems and makes this implicit knowledge explicit. It makes use of the human ability to interpret social space or interpersonal distance and perceive the social meaning from it (Hall, 1966;Lloyd, 2009). The method is often applied in a workshop setting with 10 to 30 participants and a trained facilitator. The facilitator guides the process and stimulates individual and shared reflection. A detailed procedure is presented in Appendix 1.

Aim of the training
The aim of the training is to support PIF by providing learners an opportunity to increase their: 1) awareness of the tacit source of knowledge that they already have about their social context in general (implicit knowledge becomes explicit); 2) the ability to use this knowledge so that they become more aware of the social context they are currently in and the socialisation processes that are present; 3) the ability to reflect on their socialisation and on their social context (and the beliefs, norms, values that are present) with other students.

Details of the students
The training was offered to about 300 3 rd -year undergraduate medical students. Medical training in the Netherlands lasts 6 years and consists of a three-year bachelor program and a three-year master program. In general, the bachelor has a focus on gaining theoretical knowledge, while the master has a focus on developing skills and consists mainly of internships. Thus, the students in our training had only had a minimum of clinical experience during the training.

Setting and timing
The Systemic Constellation training was held at the medical faculty of the University of Groningen, the University Medical Centre Groningen, the Netherlands over the course of 2 weeks. It took place in regular tutor rooms, where the tables and chairs could be 9 removed. The training was scheduled during the second semester, which is the last semester before the 3 rd -year bachelor students start their medical internships. The training was compulsory and part of the educational track on leadership and professional development.

Trainers
We worked with trainers appointed at the medical faculty and acquainted with the medical education setting, who were trained in the Systemic Constellation method during a 4-day training program at the Bert Hellinger Institute in the Netherlands. Every year, the training was practiced with all trainers during a one-day practice day in which students also participated.

Outline of the training
The 2-hour training was developed in 2017 in cooperation with students, teachers and experts on the Systemic Constellation method from the Bert Hellinger Institute in the Netherlands. To allow the students to link their learnings and insights to their current situation and to increase direct applicability, we focussed the training on a social system that the students were all currently part of, i.e. their research project team. At the time of the training, the students worked in groups of 2-5 students on a research project for a semester. Per training session, 2-4 research project teams were included, leading to in total 10-15 students per session. The training focused on the research project team; no personal issues of the students were addressed during the training sessions. Details of the complete training can be found in Appendix 1. In brief, for each research project team a current social context was visualised, using students representing relevant elements (the constellation). Subsequently, the students of the research project team placed themselves in the constellation, relative to each other and the elements. The group reflected on the constellation as a whole and on the observations and perspective of the persons in it, guided by the trainer. This opened up the students' implicit beliefs associated with the social context and the structures and relations in it. It enabled these beliefs and perspectives to become explicit so that they could be discussed within the group.

Questionnaire
In 2019, the students evaluated the training by completing an anonymous, digital questionnaire, implemented by using Qualtrics that could be accessed by smartphone, tablet, or laptop. The link to the questionnaire was emailed to the students enrolled for the training, the night before the training. The students were asked to complete the questionnaire directly after the training. All students were informed about the aim of the evaluation and gave informed consent. The evaluation was approved by the Ethical

Results and feedback
The training was attended by 308 students, of whom 223 (72%) completed the evaluation questionnaire. Almost one third of the students was male (31.4%, N=70) and the mean age was 21.3 years (SD=1.6 years). A majority of the students, liked the training (64.1 %, N=143), 17.0% (N=38) was neutral and 18.8% (N=42) disliked the training (Table 1).
The training gave useful insights with regard to their teamwork to 148 students (66.4%) and came at the right moment according to 164 students (77.0%). Overall, satisfaction of the students with the training got a mean score of 67.6 (SD=16.0) on a scale of 0 to 100.
As suggestions for improvement 'Prepare the students better for the training' and 'Explain more about the training' was mentioned most often (Table 2). On the open question 'What did you like about the workshop?' 136 students provided answers. More than half of the students liked the visualisation of the social dynamics, the new insights 12 and new perspectives (54.4%, N=74). Also, the good atmosphere (11.8%, N=16) and the interactive method was appreciated by the students (14.7%, N=20).

Discussion
The implementation of teaching to support and guide PIF can be difficult. PIF builds on tacit knowledge and values that are acquired in an unconscious socialisation process (Cruess et al., 2015). In the socialisation process, knowledge and values are transferred to students from the medical education community. To convert this acquired tacit knowledge into explicit knowledge is key (Yazdani et al., 2019). This article presents a new teaching method, the Systemic Constellation method, to enable students to become aware of their tacit knowledge of their social context. The method could be successfully implemented for undergraduate students with no prior experience with constellations in the medical education setting. The method was accepted and considered as useful by the majority of the students.
To our knowledge, this is the first time that the Systemic Constellation method has been applied in an undergraduate medical education setting. Because of the large number of students and implementation in three successive years, we have gained ample experience with the method.
For most of the students in this sample, the training was a first encounter with experiential learning in general and with the Systemic Constellation method in particular.
As undergraduate students they are used to cognitive learning and often receive teaching in the form of lectures. This might explain the critical appreciation of some of the students, but also their suggestions to explain more about the training. Furthermore, we anticipated that the training might come too early, because the students had no experience with working in the clinical setting yet. However, the majority of the students indicated that the timing of the training was appropriate. This finding supports the idea of starting 14 this type of training in the undergraduate phase, and of linking the training to a social system the students are currently engaged in, i.e. research project team.
With this training, we offered the students a new experience, created a setting for experimenting with different perspectives on their social context and socialisation, and stimulated reflection. A strength of the Systemic Constellation method is that it, literally, makes the social context explicit by visualizing the system using the spatial arrangement of representatives (the other students) (Kopp & Martinuzzi, 2013). This allowed all students to have a look at the same external image of the social context as a representation of their own internal images and view it from different perspectives.
Importantly, it opens up their tacit knowledge attached to this social context. By having the training with other medical students, it was a shared experience which allowed for personal reflection as well as collaborative learning and shared reflection, which are important elements in the process of PIF (Cruess et al., 2019).
The aspect of visualisation and externalising implicit inner images shows resemblance with methods like Soft Systems Methodology, where Rich Picture Building by means of drawing is the first step in exploring the problem (Checkland, 2000). An important difference is that the Systemic Constellation method is focused on the social context of the learners and that it is a shared experience.
The large number of students that reported to have gained useful insights, and the specific appreciation of the visualisation and change of perspective mentioned by various students, supports the assumption that the Systemic Constellation method can be useful for students to get a new view on the social context they are currently in and activate reflection.

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A limitation of the study is that we could only evaluate reactions of the students and not include other levels of training evaluation outcomes (such as effectiveness) and actual contribution to PIF (Arthur. et al, 2003). Via the open questions, we only got a scant view on the reasons behind the level of appreciation and perceived usefulness. Further research is needed to gain more insights into these underlying reasons.
This article presents a new method for developing awareness among medical students of their social context and their socialisation process, and the tacit knowledge that they have of it. It provides a first step to evaluate the acceptability and perceived usefulness of this method in this setting. With the results from this implementation we can proceed with training sessions based on the Systemic Constellation method and have ample starting points for improvement, such as providing students with a preparatory assignment in advance, or explaining more clearly why we offer this training. Now we have a training protocol that is feasible and acceptable, the next step is to set up an in-depth evaluation study to assess outcome effect and contribution to the acquisition of a professional identity. In order to make PIF a conscious process which the student can reflect on, repeated training and connection with the broader medical system is required. (Frenk et al., 2010;Larsen, 2019). Therefore, we aim to embed the training in the medical curriculum at different stages. This way, medical professionals can become equipped from an early stage with an understanding of their social context and the impact of the socialisation process, and develop the reflective attitude essential for PIF.