The role of self-concept in medical education

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The role of self-concept in medicaleducationAlexander Seeshing Yeunga, Bingyi Lia, Ian Wilsona & Rhonda G.Cravena

a University of Western Sydney, Sydney, Australia.Published online: 04 Mar 2013.

To cite this article: Alexander Seeshing Yeung, Bingyi Li, Ian Wilson & Rhonda G. Craven (2014) Therole of self-concept in medical education, Journal of Further and Higher Education, 38:6, 794-812,DOI: 10.1080/0309877X.2013.765944

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The role of self-concept in medical education

Alexander Seeshing Yeung*, Bingyi Li, Ian Wilson and Rhonda G. Craven

University of Western Sydney, Sydney, Australia

(Received 28 May 2012; final version received 28 September 2012)

Much research has acknowledged the importance of self-concept foradolescents’ academic behaviour, motivation and aspiration, but little isknown about the role of self-concept underpinning the motivation andaspiration of higher education students in a specialised field such asmedical education. This article draws upon a programme of researchundertaken over the past three years examining the psychosocialdeterminants of success in educating home-grown doctors for regionalcommunities. Interviews conducted with Australian medical studentsfound that self-concept is a dynamic and multidimensional phenomenonthat emerges through social activity and plays a crucial role in shapingtheir motivation and aspirations. For these students in a specialised fieldin higher education, self-concept not only influences their study perfor-mance, but also forms part of their personal and career development.Because of the significant level of interaction between the self and thesocial environment, the development of self-concept through a holisticand systemic facilitation of essential psychosocial drivers of success isessential in higher education.

Keywords: self-concept; motivation; medical education; highereducation; aspiration

Introduction

Psychological factors such as motivation, self-concept and persistence inlearning and career aspirations have been emphasised as crucial in highereducation (Gillory and Wolverton 2008; Ostrove, Stewart, and Curtin 2011).These factors are important for students’ academic achievement and wellbe-ing irrespective of their background (Ostrove, Stewart, and Curtin 2011), andare probably equally important for medical students. According to Dyrbye,Thomas, and Shanafelt (2006, 354), the goal of medical education is to ‘trainknowledgeable, competent and professional doctors equipped to care for thenation’s sick, advance the science of medicine, and promote public health’.However, the history of medical education research has observed that medi-cal students and doctors experience high rates of psychological morbidity in

*Corresponding author. Email: [email protected]

Journal of Further and Higher Education, 2014Vol. 38, No. 6, 794–812, http://dx.doi.org/10.1080/0309877X.2013.765944

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the process of achieving these goals (Dahlin, Joneborg, and Runeson 2007).Dyrbye, Thomas, and Shanafelt (2006, 354) reviewed 40 articles on psycho-logical factors influencing medical students and found that the ‘current edu-cational process may have an inadvertent negative effect on students’ mentalhealth, with a high frequency of depression, anxiety, and stress among medi-cal students’. Furthermore, Leahy et al. (2010, 611) found that psychologicaldistress in medical students varied between year levels, with year 5 medicalstudents having ‘the highest proportion of psychologically distressed’. Thesenegative psychological variables may adversely influence medical students’academic performance and professional development. It is therefore essentialto understand the barriers and facilitating factors that may affect the successof medical education. The purpose of the present investigation is to identifycrucial psychosocial factors that are likely to facilitate the aspiration andwellbeing of pre-service doctors in medical education.

Besides the obvious negative psychological impacts which medicaleducation may have on medical students (e.g., stress, burnout, depression),some medical education research has focused on psychological variables thatmay aid in the selection of students, one of which is personality (Plaisantet al. 2011). These more stable, genetic psychological variables are,nevertheless, not seen as ideal targets of intervention, due to their overallpermanency. Hence the mastery of variables other than personality ‘trait’ ismore likely to benefit medical students.

In medical education, little research has sought to understand the positiveimpact of psychological variables upon medical education outcomes – inparticular, psychological variables that have been shown to be successful inenhancing student resilience, mental health, and performance in other disci-plines (Adcroft 2011; Marsh and Craven 2006; Yeung 2011). For example,something notably missing from medical education research is the identifica-tion of psychological variables that may moderate or buffer the effect ofstress on medical students’ academic and clinical performance. As Hojatet al. (1993, 348) argue, there is a need for:

A broad research agenda on the possible link between gender, relevantpsychosocial attributes and outcome measures… [And this] will produce avibrant field of inquiry that may ultimately lead to discoveries with importantimplications in medical students’ counselling, and in medical education andmedical practice.

Marsh, Hau, and Craven (2004) found that 11 different dimensions ofself-concept were significantly and negatively related to psychological stress-ors in a competitive environment. Their results suggested that targeting rele-vant psychosocial attributes, such as various facets of self-concept, forintervention may prove highly effective. As such, medical educationresearch may benefit from embracing a multidimensional perspective that

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has been productive in other areas of psychology. Hence, concurring withHojat et al. (1993) and consistent with Marsh, Hau, and Craven (2004),through a broadening of the research agenda to enable the understanding oftheir psychosocial attributes, students will benefit from better medical educa-tion and improved psychological wellbeing.

In this article, we report findings from interviews with students in a med-ical education programme. This programme corresponded to the urgent needfor high-quality Australian doctors in Greater Western Sydney, where 10 outof the 14 local government areas are known to be disadvantaged (ABS2006). This programme aims to produce a new kind of home-grown doctor –doctors who have a clear understanding of and empathy for the health chal-lenges facing Australians, particularly those living in disadvantaged andIndigenous communities. The medical school is expected to be a significantboost for the much-needed recruitment of extra GPs and specialists to workacross Western Sydney’s hospitals and health services in order to keep pacewith a rapidly growing population in these disadvantaged areas (UWS2006). The development of the newly introduced programme provides anopportunity to conduct a research project with the aim of identifying thepsychosocial determinants that seed success in educating home-grown doc-tors for regional communities. Arising from this initiative is the question ofhow to educate home-grown doctors most effectively in order to close theshortage gap in disadvantaged areas.

In addition to the programme development, we have been involved inthis programme from the perspective of educational psychology researchwith a focus on self-concept and motivation, concerned with students’ per-formance and outcomes. In both areas of our work – concern for medicalstudents’ self-concept and this self-concept’s impact on their study perfor-mance – we have found ourselves moving to a more holistic and systemicposition. In short, it no longer seems very productive or intellectuallydefensible to separate medical students’ psychosocial aspects from theirachievement, retention and commitment to practice in underserved commu-nities. Hence our recent research on medical students includes psychosocialvariables as drivers of successful performance.

Why psychosocial research?

Some researchers consider psychology to be a broad discipline, but ‘veryfuzzy at the edges where it merges with sociology, biology, brain scienceand the humanities, and just as much a discursive construction as any otherarea of knowledge’ (Frosh 2003, 1546). In contrast, Lucey, Melody, andWalkerdine (2003, 286) argue,

... along with a growing body of researchers across a number of social sciencedisciplines … that to get beyond conscious, rational explanations to a greater

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understanding of the influences and behaviours of ourselves, both the psychicand social processes of how they have come about need to be investigated.

Frosh (2003, 1547) sees the psychosocial ‘as a seamless entity, as a spacein which notions that are conventionally distinguished –“individual” and“society” being the main ones – are instead thought of together, as inti-mately connected or possibly even the same thing.’ The gradual emergenceof the approach to social and psychological research termed psychosocialstudies has ‘created an opportunity for the re-insertion of psychoanalysisinto the social sciences’ (Frosh and Baraitser 2008, 346–7). Psychosocialstudy emphasises the idea that personality is intrinsically social and thatindividualising tendencies are influenced by how people relate to others.The concern of psychosocial studies with the interplay between what areconventionally thought of as ‘external’ social and ‘internal’ psychic forma-tions might offer convincing explanations of how the ‘out there’ gets ‘inhere’ and vice versa, especially through concepts such as self-concept andmotivation (Frosh and Baraitser 2008, 347).

However, a psychosocial perspective has remained relativelyunderdeveloped in the field of medical education (Redman 2005). Thedilemma of psychosocial study is whether an issue can be resolved from a‘social’ or a ‘psychological’ perspective. Jefferson (2008) reviews previouspsychosocial research and comments on where the real issue lies. First, heargues that ‘some sociological questions require psychological answers’(Jefferson 2008, 370). It does not make sense to analyse a person separatelyfrom social structure, culture and social behaviour. The individual psychic-motivation consideration benefits from the consideration of other factors.Second, the psyche dynamically changes with what is imposed upon it bysociety (Jefferson 2008). Psychologically, the development of personality, forexample, is the result of a dynamic interplay between conscious and uncon-scious factors. Sociologically, an individual’s behaviour and attitude aredetermined by how the psyche responds to social pressures, whether cultural,economic or political. Therefore, a ‘reciprocal alignment of sociological andpsychological analyses requires that they occur at similar levels of abstrac-tion’ (Jefferson 2008, 372). This implies that both social and psychologicalfactors should be considered when examining a group of similarly situatedindividuals. Thus, ‘[w]hen particular individuals appear as objects of analy-sis, they usually serve as exemplars of social group characteristics, often inthe form of ideal-type constructs that facilitate the larger analysis’ (Cavalletto2007). Hence psychosocial study provides an explanation for the behaviourof the mind of an individual in a particular section of society or in the societyas a whole.

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Self-concept and motivation as influential psychosocial variables

Gecas (2003) argues that individuals are products of social and physicalforces, and self-concept plays an important role in the construction ofindividuals and their environments within such forces. Self-concept is both acause and an effect of achievement, because it influences subsequentachievement beyond the effects of prior achievement (Marsh and Craven2006). Self-concept is increasingly important within both psychological andsocial disciplines. Its importance lies in its role ‘both as an outcome and asa mediating variable that helps to explain other outcomes’ (Marsh andCraven 2006, 135). It is perceived as ‘the cornerstone of both social andemotional development’ (Marsh and Craven 2006, 141). Sociology tends tofocus on the antecedents of self-concept within patterns of social interaction.Conversely, psychology tends to focus on the consequences of self-concept,especially related behaviour (Gecas 1982). In a sense, ‘sociology and psy-chology have complementary biases regarding the self-concept’ (Gecas1982, 2). If the ‘fundamental attribution bias’ of psychologists is an overly‘internal’ view of the causes of behaviour, the attribution bias of sociologistsis a tendency to look for the causes of behaviour outside the individual,such as in culture, social structure or social situation (Gecas 1982, 2). Froma psychosocial perspective, self-concept can be viewed as ‘a theory that aperson holds about himself as an experiencing, functioning being in interac-tion with the world’ (Gecas 1982, 3). Self-concept can then be conceptua-lised as ‘an organisation (structure) of various identities and attributes, andtheir evaluations, developed out of the individual’s reflexive, social, andsymbolic activities’ (Gecas 1982, 4).

However, the conceptualisation of self-concept can range from the sourceand dimension of self-concept (Bennett 2009; Marsh 2007) to the content ofself-concept (Guay, Marsh, and Boivin 2003). Elliott (2001, 13) argues thatself-concept is ‘the source of personal motivations that exert a powerfulinfluence on social behavior’. Motivation generally refers to ‘a goal-driven,purposeful action and behaviour’ (Koiranen 2007, 120) – seemingly theinternal state, condition or process resulting in behaviour directed toward aspecific goal. However, motivation is not synonymous with ‘cause’ or with‘reasons’ for the behaviour, because ‘identify[ing] the motivation for a par-ticular action is to largely explain why the action occurred’ (Gecas 1991,172).

Self-concept is an appropriate locus for developing motivation because‘the self is a social product, emerging out of and dependent on social inter-action’ (Gecas 1991, 173). Once the self-concept begins to form anddevelop, it takes on motivational properties. Having a self-concept, the indi-vidual is motivated to maintain and enhance it, to conceive of it as effica-cious and consequential and to experience it as meaningful and real.

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Gecas (1991) proposes three major motives associated with self-concept:self-efficacy, authenticity and self-esteem. There are positive and negativestates associated with each motive. An individual essentially strives toestablish or increase the positive condition and avoid the negative condition.Of the various components of self-concept, none is more important than‘people’s beliefs in their causative and agentic capabilities, that is, in theirself-efficacy’ (Gecas 2003, 370).

Self-efficacy

This is an aspect of self-concept critically relevant to agency and motiva-tion. It refers to ‘the perception of oneself as a causal agent in one’s envi-ronment, as having some control over one’s circumstances, and beingcapable of carrying out actions to produce intended effects’ (Gecas 2003,370). It is consistent with the latest findings of Arens et al. (2011) differen-tiating the competence and affect components of an individual’s self-con-cept in academic settings, with self-efficacy representing the competencecomponent.

Authenticity

This refers to ‘the motivation to experience oneself as meaningful, real, andtrue to one’s core values and standards’ (Gecas 2003, 371). Authenticityemphasises beliefs about what is real and what is false as perceived by theindividual and is used as a basis to strive for meaning, coherence and under-standing about the self.

Self-esteem

This refers to the drive to act in such a way as to maintain and enhance anoverall favourable evaluation of oneself (Gecas 2003). It is sometimesreferred to as general or global self-concept. In general, people like feelinggood and dislike feeling bad about themselves; they are therefore motivatedto act to increase the probability of experiencing favourable emotions suchas pride and avoid undesirable emotions such as shame. In essence, in thispaper, we have moved the research further on to investigate distinguishableaspects of self-concept such as sense of competence, authenticity andself-esteem in relation to medical students’ motivation and aspirations.

The present investigation

This paper examines the relations between self-concept, motivation andmedical students’ aspirations in the medical field. Specifically, the researchquestion in relation to medical students’ future practice in regional

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communities is: Do medical students have an established and well-definedmultidimensional structure of self-concept and motivation from a psychoso-cial perspective? Data used in this paper include 11 one-to-one interviewswith medical students from years 2 to 4 in a school of medicine inAustralia.

Research methodology

Following the university ethics procedures for research with human partici-pants, invitation letters were first sent to year 2–4 students enrolled in theparticipating medical school. These students had experienced the transitionfrom classroom-based learning to practical clinical learning in hospitals. Atotal of 11 students from years 2 to 4 (three to four students each)participated in the interviews (seven non-Indigenous and four IndigenousAustralian medical students). The semi-structured interviews aimed toexplore the psychosocial factors that may have influenced the medical stu-dents’ performance, motivation and self-perceptions. Signed active consentwas obtained from the participants before they answered questions relatedto:

• motivation for becoming a doctor;• individual perspectives on educational outcomes;• commitment to practice in disadvantaged and underserved regions; and• self-concept of their competence and skills over time.

These interviews were audio-recorded, transcribed, and then coded usingthe computer software QSR NVivo. The analysis was conducted throughcoding – ‘the process of defining what the data are all about’ (Charmaz1995, 37). The goal of coding was to fracture the data and rearrange theminto categories for facilitating comparison between elements in the same cat-egory (Miles and Huberman 1994). First, open coding transformed the datainto evidentiary constructs. This stage of data analysis involved breakingdown, examining, comparing, conceptualising and categorising data in termsof properties and dimensions. This process generated 51 codes related tomedical students’ perspectives of study goals, motivations, self-concept,association with other students and the medical school environment. Thesecond stage was focused coding – filling in or bridging codes in the analyt-ical structure (Miles and Huberman 1994). Focused coding was moreabstract, general, and incisive for the identification of the motivational com-ponents in the process of self-concept formation. The data analysis had twofocuses: to search for evidence of motivational components for being adoctor to examine the process of self-concept development. Evidence ofmotivational components was categorised as self-efficacy, authenticity, andself-esteem as described by the participants (Table 1). Then the dimensions

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Table

1.Multid

imensional

PsychosocialStructureof

MotivationalCom

ponentsof

Self-concept

Motivationsforbeingadoctor

Motivational

compon

entof

self-

concept

Multidim

ension

alpsychosocialstructure

Individual

agency

Interaction

Environment

support

Beinterested

inhealth,bod

ySelf-efficacy

UTak

echallenge

UBedifferent

UEnjoycommunicatingan

dworkwith

people

U

Helpfamily

mem

ber

from

disease

ULackof

medical

facilityin

country

UPrestigeof

beingdoctor

UHelppeople

Authenticity

UIm

prove

indigenou

shealth

URew

ardto

community

UU

Beingmeaningful

UCon

tinuelearningfrom

previou

sknow

ledge

Self-esteem

U

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of the psychosocial nature of self-concept were identified in terms of howthey were being disseminated. The multidimensional psychosocial structureincludes three dimensions: the first refers to individual agency in choosingvalued goals in a specific context; the second focuses on how individualsinteract with and support each other in an environment; the third relates toassessing the opportunities offered by the learning environment for anindividual’s growth and achievement. For the second focus, self-conceptdevelopment was examined from a psychosocial perspective in terms of themedical students’ ‘Being’ and ‘Doing’ (see Table 2) as they reported theirself-concept of academic outcomes, practice skills and relationships withother students and colleagues.

Results and discussion

The analysis yielded three major findings. Because the patterns found in dif-ferent year groups were very similar, they are reported together anddescribed below.

Motivational components in the process of self-concept formation

Table 1 shows the list of medical students’ motivations for becoming a doc-tor in terms of self-concept and its psychosocial structure in relation to indi-vidual and social levels. Data show that seven response items fall into the‘self-efficacy’ category, which indicates a sense of competence is a criticalaspect relevant to medical students’ motivation for being a doctor. Suchsense of competence reflects the degree to which medical students think ofthemselves as competent, effective and able to control their environment incarrying out actions and producing intended effects. It is well acknowledged

Table 2. Medical Students’ Self-concept in Terms of ‘Being’ and ‘Doing’

Being Doing

Positive Negative Positive NegativeGood at basicphysiology

Lack ofcommunication

Working in a team Not good inwritten exam

Good atcommunication

Less confident Strength in clinicalpractice

Good at peopleskills

Fear Answering randomquestions

Hard working WorryConfident aboutknowledge

Integrity aboutmedicine

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that a sense of competence is a strong indicator influencing one’s ability topursue goals that are valued.

The interviewees primarily showed their sense of self-efficacy in whatthey were able to do, and their self-perception of what they were interestedin. For example, students said:

I am fascinated with the human body, different processes of how the bodyworks… stemming from my background as well, indigenous background,helping the gap that exists between indigenous and non-indigenous as well(Student 1)

I wanted the challenge of being a little bit more broad with my career. (Stu-dent 2)

From the interviews, it seemed that the motivational component of selffacilitated students’ learning and aspiration to accomplish disciplinary goals.The students, as capable agents, enjoyed activities for the pleasure and satis-faction derived from them. Together with a sense of competence involvingestimation of what they can do and the likelihood of successful perfor-mance, the affective element seems to be a strong motivational force drivingthe students to become doctors:

I previously had done a medical science degree, I really loved that. I’ve got areal keen interest for health and I do really enjoy communicating with peopleas well and working with people. I guess that’s why I became a doctor.(Student 2)

In terms of competence, students’ self-perceptions may develop gradu-ally through continued successes and accomplishments. For example, onestudent was quite confident about his interpersonal skills and professionalknowledge, but was concerned with developing his empathy for patientsas a qualified doctor. Conversely, another student showed a lack of con-fidence in being a doctor and realised the need for effort to overcomeher negative self-perceptions. The evidence also showed that medical stu-dents may benefit from evaluating their own attributes in relation to theirwork:

I feel confident that my personal skills and communication skills are fairlywell compared to... It can be adequate for medical practice. I think that in thatterm I would be, hopefully in the future and if I retain these skills, I will bean empathetic and caring and compassionate doctor. (Student 3)

Sometimes I … lack confidence in myself. I’m my own worst critic. But Ihave a lot of support. Especially last year, it’s all new and hard to get into.But I think with one year under my belt I am a little bit more confident.(Student 9)

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One’s sense of competence contributes to one’s agency through thechoices made and actions pursued. Nevertheless, circumstances beyondone’s own control can aid or hinder functioning in seeking to achieve goals.As such, medical students’ sense of competence is established as a result ofa negotiation between themselves and the environment in which they areembedded:

I think specifically in my own family, I’ve seen a lot of ill health; particularlydiabetes. My mother and three sisters and a niece all have diabetes. (Student2)

I’m from the country, so I grew up in a small town – Lightning Ridge – thathad no hospital until about five or six years ago. (Student 1)

Job security and a fairly stable income, that was important as well. (Student10)

The above comments indicate it is important to emphasise the influenceof situation and context upon competence beliefs. An individual’s sense ofcompetence is built upon effective participation and successful interactionwith people significant to them. These students chose to become doctors fora range of reasons, including those related to their family, their communityor, in part, due to the prestige of the job. Their sense of competence makestheir medical students more effective in shaping their circumstances andtheir lives in their intended direction.

As illustrated in Table 1, authenticity is also important in the process ofmedical students’ self-concept formation. Gecas (2003) argues that authentic-ity, as a motivational component, lies in the fact that the individual tends tomaximise meaningfulness in relations with others and minimise meaning-lessness of self. For example, one medical student chose to be a doctor inorder to ‘achieve something meaningful in my life’ (Student 4).

Furthermore, authenticity addresses systems of beliefs and values when itdeals with matters of reality and meaning for the individual. Authenticity ismost likely to be considered when a society’s or a group’s norm and beliefsare the main focus of attention (Gecas 2003). Commitment to the communi-ties within which they are embedded leads people to feel a sense of authen-ticity. For our sample, data analysis indicates that helping people gives thissense of authenticity:

in poorer countries. (Student 4)

giv[ing people] a second chance at life that’s really important. (Student 3)

helping people in disadvantaged areas. (Student 5)

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helping [to narrow] the gap that exists between Indigenous and non-Indige-nous. (Student 1)

These students integrated social values as a meaningful choice for pursu-ing their desired goal. In this way, authenticity pertains to the sphere ofwhat ‘ought’ to be, and helps to frame desired states of being that constitutestandards or criteria for making decisions and for justifying behaviour.

Data from Table 1 show that self-esteem does not seem to be as strong amotivational factor as self-efficacy and authenticity. Self-esteem is ‘a per-sonal judgement of worthiness that is expressed into the attitude the individ-ual holds toward himself’ (Earl 2006, 19). Data analysis shows that medicalstudents did not consider self-worth or how good they felt overall when theywere asked about their motivation for becoming doctors. One student com-mented: ‘I previously had done a medical science degree’ (Student 6), whichindicates that he may think of himself as suitable to undertake medicalstudy. It seems that self-esteem is the least motivating factor contributing tothese medical students’ choice to become doctors. This result is consistentwith Marsh and Craven’s (2006) research findings based on their reciprocal-effects model (REM). They suggest that ‘academic achievement is substan-tially related to academic self-concept, but nearly unrelated to self-esteem’(Marsh and Craven 2006, 133). Apparently, self-esteem, as an over-genericperception of the self, does not function as a strong predictor of the morespecific aspiration of being a medical doctor.

So far, we may draw a preliminary conclusion that a sense of compe-tence and feelings of authenticity, but not self-esteem, play important rolesin the process of self-concept formation for medical students. According tothe interview analysis, these future doctors’ senses of competence andauthenticity are consistent with other research in motivation and self-conceptwhich has shown that competence and affect factors should be treated asseparate, although interrelated, components, which may influence individualsin different ways (Arens et al. 2011, 978).

Interaction between self-concept and social factors

Table 1 shows that nine of 12 motivation factors are related to interactionwith the social context, which implies that people, and their motivations,may be better understood within a social structure. The data show the diver-sity of social contexts in which medical students were motivated to pursuetheir aim of becoming doctors. Family, communities, peer groups andschooling are especially important developmental contexts for the medicalstudents’ self-concept development. Initially, the family is likely to be themost important context for self-concept development. Knowledge and com-petencies in many aspects of life develop from family experiences, such as

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knowledge of the physical and social worlds, the rules and values of familyand how to live by them:

I think communicating with family and friends has been a real reality checkbecause particularly my parents, they told me, you don’t have to know every-thing before you finish. You don’t have to have the type of knowledge thatyou think that you must have because I guess I’m comparing myself todoctors. (Student 7)

Parental support and encouragement with the use of inductive control ismost conducive to the development of young adults’ self-concept of being adoctor. In this study, in particular, parents’ expectations of their childrenbecoming medical doctors affected individual behaviour and action in pre-dictable ways. The following comment was made by a medical student whois also a father of three children:

I look in the context of my family. To my boys I’m their role model and sowhat I do is going to influence them and they look to me as someone to guidethem and so in the context of medicine in different scenarios. (Student 7)

The feedback or appraisal that parents give their children regarding theirmastery attempts can build the children’s competence beliefs and confidencein further mastery attempts. Interaction with peers is also an important con-text for the development of the medical students’ self-concept:

I think having good relationships with other students is very beneficialtowards my medical studies, because you have a base and a network to goand shoot ideas off, or learn off, or share with. (Student 6)

Peer interactions, in this study, provided a wide range of positive conse-quences for medical students’ self-concept formation. Friends may extendsupport for learning, as noted by one student:

It’s good to study with, people can motivate you and help you out whenyou’re stuck. (Student 1) Another student indicated the benefit from peerinfluence as follows:

The way I look at it is that you are continually learning as a doctor and devel-oping and progressing, learning new skills and refining procedures and tech-niques. (Student 7)

Peer groups seemed to be an influential context for mastering necessaryknowledge and skills, and particularly for overcoming the stress faced bystudents. School is an important institution providing favourable circum-stances for the emergence of peer groups. It is a setting in which knowledgeand thinking abilities are constantly tested, evaluated and compared with

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those of other students, and is where medical students develop a sense oftheir intellectual self-concept. Many school activities have implications forstudents’ self-concept. One of the most important of these is evaluation oftheir academic performance. The medical students established a sensibleself-concept through evaluation against their previous performances or onthe basis of cooperative activities, rather than simply measuring themselvesagainst their classmates, as they would in high school settings:

It’s not the number, it’s more the amount of knowledge and I think that’s a lotmore important. So whilst comparing test scores might be all fun and well likeit’s a number and it’s exciting to score high. The reality is that it’s our depth ofknowledge that we can pull out of our brains when we see a patient and whenwe are quizzed by doctors and when we are talking to our fellows. (Student 3)

I’m not here to compare myself with others. I’m very much on my own goalsof what I want to achieve. I think the best assessment of a person is how theyare with people in the hospital. How they are with patients. (Student 7)

In the school of medicine, the processes of individual comparison andreflected appraisals did affect self-concept, but mostly in a positive way.Medical students’ judgements regarding how they compared with otherswere based on previous knowledge or practical skills such as clinical prac-tice. Their self-concept is mostly built upon perceptions of themselves ratherthan evaluations against others.

Beyond the peer group and school, community is an important source ofinformation that influences self-concept through conformity to communitynorms, values and ideals. When medical students establish their self-conceptof being a doctor, they link it with opportunities to contribute to the publicgood, such as ‘helping people’ (Student 4) and ‘bridging the gap of healthbetween urban and rural areas’ (Student 1), or with ‘job security and a fairlystable income’ (Student 3).

These social values play an important role in guiding medical students’decisions. Their combined sense of competence and authenticity may leadthem to perceive themselves in the context of the community. Although‘different persons may have very different ways of interpreting ethical ideasincluding those of social justice, and they may even be far from certainabout how to organise their thoughts about it’ (Sen 1999, 261), the commu-nity provides a social context for them to interpret their roles.

Self-concept is the process of development in its social context

The self cannot be understood apart from the activities of people within spe-cific contexts (Raeff 2010). There is also an increasing trend towards analys-ing the self in social and cultural contexts. That is, attention is focused onhow ways of representing oneself are constructed through interactions with

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others in the context of specific social practices (Raeff 2010). The analysisabove has indicated that the formation of self-concept involves a combina-tion of recognising and controlling one’s inner state and a desired orexpected external state, in order to produce a presentation that is consideredappropriate in a given social context.

Here, we argue that the formation of self-concept is a developmental pro-cess that is intertwined with a range of environmental influences. In Table 2,self-concept is analysed by exploring how the medical students recognisedvaluable ways of being and doing as student doctors in previous and currentstudy contexts. ‘Being’ relates to the attributes which help students becomeintellectual, capable of critical thinking and committed to the medical pro-fession. ‘Doing’ refers to the medicine-related activities. Medical students’thinking about their behaviour, perspectives, experiences and characteristicsmay involve remembering past events (being a student doctor) and may alsoinvolve considering future possibilities (being a doctor).

Table 2 presents the ways in which self-concept affects medical students’overall sense of being medical students now and doctors later on. They havethorough and specific perceptions of themselves in terms of their professionalskills and competencies from both positive and negative viewpoints. We haveobserved that self-constructing activities may include talking to others aboutoneself, and positioning oneself in relation to others. For example,

I have some med friends who go and ask the most random of questions and ifI can answer sometimes that question, I guess that I know that I’m on myway, I’m progressing okay. (Student 6)

During PBL [problem-based learning] I feel like if I’m doing good, I’m talk-ing, I’m not relying on my notes and I’m making the links. (Student 10)

The evidence shows that the development of self-concept is social,because interactions with others provide individuals with opportunities topractise professional modes of activity. As they progressed, these medicalstudents realised their weakness as an emergingtheir weakness as an emerg-ing doctor. As such, they reflected during their study and acknowledged thatthe more they learned, the more ignorant they felt. Therefore, the self-con-cept development processes also included the individuals’ ability to directand improve aspects of their own behaviour.

I guess it’s a reflection of how you are in the hospital. I think that for me isthe biggest area where you know how well you’re going and where you’vegot gaps in your learning. (Student 7)

With knowledge, I feel like the more you learn the more you find out thatthere is so much else to learn. (Student 11)

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So even though I’ve physically learnt more in an absolute sense, in a relativesense I think I know less and less. (Student 8)

Reflection seems to play an important role in self-concept formation anddevelopment. It enables individuals to construct coherent changes withinthemselves over time. In addition to constructing oneself as continuous withthe past and present, there is construction of possible self-functions toestablish a sense of continuity with the future. The evidence indicates that theconstruction of the future or possible self involves the construction of repre-sentations of what one does and does not want to be and do in the future. Thisis consistent with Ostrove , Stewart and Curtin’s (2011) findings indicating astrong association among factors such as sense of belonging, self-concept andcareer aspirations. A future-oriented self-concept functions to provide a moti-vational framework for setting goals and working towards achieving them.The ongoing self-concept enables people to distance themselves from aspectsof their past so as to create new selves. Self-concept development is thereforea dynamic process through which the self is not perceived merely as a conceptor as an object of self-evaluation, but through ‘the process of assimilation andintegration into a group’s culture by learning and internalizing the group’s val-ues, norms, roles, beliefs, and ways of life’ (Ryan and Brown 2003, 71). Thus,in this view, self-concept is both an inherent tendency and a dynamic, syn-thetic process, which is observable in our sample of medical students.

Conclusion

While much impressive self-concept research has focused on teenagers andhas emphasised the relations between self-concept and achievement scores ina quantitative sense (Marsh and Craven 2006; Yeung 2011), our study onmedical students’ self-concept has gone beyond teenage samples and is notconfined to quantitative achievement outcomes. The study has explored themotivational components of self-concept and examined medical students’ var-ious reasons for becoming doctors from a qualitative research perspective.The students’ self-concept is conceptualised here as a dynamic and multidi-mensional phenomenon that emerges through social activity. It is suggestedthat the self-concept cannot be understood apart from the activities of peoplewithin specific social contexts. Focusing more specifically on self-conceptformation and development activities can provide a way in which to considersome of the complexities of how medical students go about construing andrepresenting their lives, experiences, perspectives, behaviours and characteris-tics to themselves and to others. By understanding how medical students’self-concepts form and how this influences their aspiration and behaviour, wemay be able to master better medical education strategies to benefit futuredoctors and the communities in which they serve. This knowledge may shedlight on ways in which other disciplines may enhance the wellbeing of higher

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education students. It may also shed light on improving medical services inunder-served areas, such as Western Sydney, where this study was conducted.

Limitations

It is important to note some of the limitations in this study. First, the specificcontext within which the findings were interpreted needs to be considered.The dataset is small and is derived from one medical education degree. Assuch, the insights cannot be readily generalised to all medical students inthe programme investigated or to other programmes. Further research with alarger sample would be useful for explicating the role of self-concept bothin the medical-school context and in the context of other disciplines forpositive academic performance. Second, the participants in this study weredrawn from a ‘home-grown’ doctor training programme which aims to buildthe capability of student doctors to practise in their own underserved com-munities. Hence the sample for the present investigation is not likely to berepresentative of all medical students, many of whom may hold other moti-vations for undertaking a medical degree. Despite these limitations, our find-ings may serve as a starting point for further research on how to enhancethe wellbeing of higher education students by considering their self-concept.

AcknowledgementsThis study was supported by the Australian Research Council.

Notes on contributorsAlexander Seeshing Yeung is an associate professor of the Centre for PositivePsychology and Education (CPPE) at the University of Western Sydney. He is aregistered teacher and educational psychologist. He is a productive researcher in theareas of self-concept, motivation, measurement and evaluation, lifelong education,cognition and instruction and research methodology in longitudinal studies.

Bingyi Li is currently a research assistant at the Centrre for Educational Research,University of Western Sydney. She received her PhD in education at the Universityof Western Sydney in 2011. She is interested in students’ outcomes in terms ofsocial equality and self-concept. She also researches the effect of ICT on teachereducation.

Ian Wilson is associate dean (learning and teaching) at the University ofWollongong. At the time of this research he was a professor of medical educationat the University of Western Sydney. His research interests are student developmentand selection.

Rhonda G. Craven is director of the Centre for Positive Psychology and Educationat the University of Western Sydney. She is a highly accomplished researcher,

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having successfully secured more than seven million dollars in nationallycompetitive funding for 45 national research projects.

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