The doctor I want to be: professional self-image in Brazil and Portugal

This qualitative study evaluated the perception of academics about their self-image as future doctors and the factors that influenced the construction of their professional identity. Thirty-two sixth-year medical students in Brazil and Portugal were interviewed. Content analysis in the thematic modality and Goffman’s dramaturgy were used for data analysis and interpretation. The idealized self-image was revealed in two themes: the doctor centered on himself and the one who values the interpersonal relationship. A third theme showed the influence of the University and of elements brought a priori in the doctor’s identity. The results indicate the influence of the hidden curriculum in the construction of professional identity and reinforce the importance of social and humanistic aspects in medical education.


Introduction
The 20th century was marked by three generations of educational reforms with a large impact on medical training: science-based learning, which promoted the integration of science with university curricula and contributed to the technological evolution of medicine; problem-based learning and integrated curricula, which strengthened the doctor-patient relationship and multidisciplinarity; and health systems-based learning, which emphasized the competency-based curriculum, interprofessional education, learning supported by information technology, and leadership and management skills 1 .
Additionally to acquiring knowledge and skills, medical education is an experience of professional socialization, involving development of values, attitudes, and behaviors that define professional identity, which corresponds to the future physician's way of being [2][3][4][5] .
The building of professional identities has its essence in social interaction. However, the influence of social aspects is not explicit in the formal curriculum, encompassing what the literature presents as informal or hidden curriculum 6,7 . Cruess et al. 8 suggests including it in the explicit curriculum objectives, in order to make students and teachers aware of the concepts of identity, professionalism, and socialization, as well as to favor the development of the characteristics of a good professional.
The scientific literature is full of studies about the profile of the "good" physician 5,[9][10][11][12][13] , uniting values and attitudes to clinical skills and theoretical knowledge. It is therefore justified to research the idealized professional profile from the interviewee point of view.
The study aimed to evaluate the perception of students about their ideal self-image as physicians and the factors influencing its construction throughout the course. This knowledge will bring important contributions to the curricula, in order to propose strategies that favor students' development in social and humanistic aspects, focusing on professional identity.

Methodological Path
Considering that the object of the research relates to the interpretation of the meaning that students give to their idealized image as future physicians 4 , the study was designed as qualitative.
Thirty-two participants were selected from the universe of students from two universities, one Brazilian and one Portuguese. The definition of the institutions considered the cultural proximity between the countries, the frequent migration of Brazilian doctors to Portugal and the interest in carrying out the study by the medical course managers.
The inclusion criterion was to be in the last year of medical school; and the exclusion criterion was to be over 25 years of age, guaranteeing a sample of graduates who entered as adolescents, according to the profile of entrants compared to this group in other pieces of this study.
There was no previous definition of the number of participants, using the criterion of saturation of responses to interrupt the collection when frequent repetition of the speeches was observed. The sample was selected by convenience, consulting the participants about their interest in participating, and including them after signing the Free and Informed Consent Form. The participants' characteristics are shown in Table 1. Regarding the administrative nature of the institutions, the courses included in the study, private in Brazil and public in Portugal, present important differences.
In Brazil, the Medicine Course at the University of Fortaleza (UNIFOR) implemented in 2006 has a modular curriculum integrating theory and practice from the beginning. The insertion in healthcare settings takes place in the first semester and in the last two years, students develop autonomy in patient care in hospital wards, outpatient clinics and urgent and emergency services in supervised internship rotations.
In Portugal, the University of Porto Medical School (FMUP) has a centennial disciplinary curriculum, updated in 2013, integrating disciplinary areas in the three initial theoretical years and transversal areas in the last three years that make up the clinical cycle. In the clinical cycle, practical activities are preceded by theoretical activities, and students' participation in health services is mainly as observers of medical care.
Both medical schools have in common an excellent external evaluation and humanistic training in their pedagogical projects. The main difference is the teaching model. At FMUP (Portugal), science-based learning, with a focus on content, prevails. At UNIFOR (Brazil), learning is problem-based and the integrated curriculum is student-centered, focused on the acquisition of competencies.
Data collection occurred through semi-structured interviews. Initially, the participant was asked to imagine himself as a doctor and to develop a drawing that represented the doctor he wants to be, imagining all the aspects involved in this performance: scenario, audience, relationship with this audience and with the health team.
The participants were shy to share their drawings, but all agreed to participate after being informed that they would not be analyzed or published.
The purpose of the drawing was to allow students to look back at themselves and the relationships established during the course, and to facilitate reflection on the ideal image or performance of the physician they intend to be. The use of drawings in research can stimulate the emotional and psychological dimensions, which are not emphasized by rational methods 14,15 . Interviews are more in-depth when subjective information is sought from the subject's reflection about his or her reality 16 .
Once the drawing was completed, the participant was invited to explain it, starting with the triggering question: "Describe this drawing to me, showing in which scenario you will be acting, the public you will be serving, your relationship with this public and with the health team", and then the following questions were answered: "In this context, what is the most important element for your professional performance? "When you entered the course, did you have this same perception, or did it change over time?"; "What changed?"; "What remained?"; "To what factors do you attribute the changes and persistence?"; "How did the University and the practice environments interfere so that your perceptions changed or remained?" Considering that the Brazilian researchers were professors and manager of the medical course at the time of collection, data collection in Brazil was conducted by students of the Research Initiation Program from April to May 2018, and in Portugal, by the Brazilian researchers in April 2019. The interviews took place at the University, in reserved rooms, being guaranteed the necessary comfort and privacy for data collection.
The interviews, after the drawing was completed, lasted an average of 11 minutes, were recorded and transcribed, so as to include the interviewees' opinions and the drawings were kept, respecting their integrity.
In order to protect the identities of the participants, the letter "C" (concluders), and the letter "B" (Brazil), or "P" (Portugal) were adopted; and numbers representing each participant.
The content analysis in thematic mode 17,18 began with an in-depth reading of the statements, searching for the meanings manifested, relating the semantic structures (signifiers) with the sociological structures (meanings) emerging from the material, extracting the associated ideas that converged on six nuclei of meaning and three thematic categories.
The themes were interpreted in the light of Goffman's Dramaturgy, an approach that uses theater concepts to explain the way individuals present and interact, making a representation of themselves, divided into two fundamental roles: actor and character. In this conception, the world is a stage and the interaction between people occurs under the reciprocal influence of individuals over their actions when they are physically in front of each other 19,20 .
The perception of self-image and the idealization of professional performance are closely related to the model of professional performance and social interactions that this student will have when becoming a physician, justifying the choice of this theoretical reference for the analysis of the results in this study.
The study was approved by the Research Ethics Committee of the University of Fortaleza (opinion 3.954.616) and by the Ethics Committee of the Complexo Hospitalar Universitário de São João/ Faculdade de Medicina da Universidade do Porto.

Results and discussion
From the perceptions of the interviewed concluders, three central themes emerged, interpreted in the light of Goffman's dramaturgy: monologue, interactive theater and backstage 20 , expressed in Table 2. Table 2. Interpretative network of the analysis by central themes and cores of meaning.

Monologue
The specialist as a scenario 4 0 The prioritization of knowledge over interpersonal relationships 5 0

Interactive Theater
The centrality of relationships in the description of the scenario 17 11 The construction of the character centered on the audience 16 11 Backstage Elements brought in a priori 5 1 Influence of the University 10 16 In analogy with any theatrical performance 20 , the stage is the setting where the concluder imagines her/himself acting; the actor is the student; the character is the physician she/he intends to be; and the attributes demonstrated in the performance are the important elements in the construction of the character in the actors' perception. Behind the scenes are elements that contribute to the acting of the character. The patient is played by the audience, and the staff members participate in the acting cast.

Monologue -the self-centered character
Of Greek origin, monologue means "the one who speaks alone." In theater, monologue is the representation made only by an actor or actress who reports to himself 21 . In this study, we classified as monologues the nuclei of meaning that refer to the scenario and the self-centered character: the specialist as a scenario and the prioritization of knowledge over interpersonal relationships.
This thematic axis, present only in the narratives of the Portuguese, may be associated with the traditional teaching model focused on content, composed of a predominantly theoretical workload and the role of observers in practical activities.

The specialist as a scenario
Despite having been stimulated to include the public served in the scenario, the relationship with the public and health team, four Portuguese students idealized their scenario focused on themselves, without considering patients or the team. I see myself in hospitals, in a hospitalization, where I am with people when they are sick and then I never see them again. (CP9) Another noticeable result in this group is the preference for the hospital, which may be associated with the disease-centered training, with more frequent practical activities in hospital settings. The Portuguese medical course under studied, is inserted in a hospital complex and only a few students experience practical activities in health centers, contradictory to the advance achieved by primary health care (PHC) in Portugal since its reform initiated in 2005 22 .
Our daily routine is mostly in the hospital, so I think we see ourselves more in the hospital than outside. (CP7) Medicine is a science based on social interactions; however, the advancement of technology and the over-specialization of medical practice over time have contributed to the decline of this aspect 23,24 , leading to the self-centered view of the physician.
The absence of interpersonal relationships in the representation of the scenario in this group of graduates leads to reflection on the image of the idealized physician, which disagrees with other studies 5,10-13 , which demonstrated the association between technical and social competences, incompatible with the graduate profile expected for the 21 st century, described based on principles and commitments necessary to build relationships guided by integrity, ethics, social justice, and teamwork, aiming at excellence in professional practice 4 .

Prioritizing knowledge over interpersonal relationships
When asked about the most important element for their professional performance, five Portuguese pointed out knowledge, experience, and self-control, without mentioning social skills or attributes of professionalism, valued in medical education publications 4,25,26 .
Versatility, integration of knowledge and work, and attention to detail. (CP9) Having good training, good theoretical knowledge, and lots of experience. (CP10) The importance of acquiring knowledge by physicians is indisputable. The main characteristic of medicine, described by Freidson in his sociological study on the medical profession, is preeminence, justified by the social prestige associated with the mastery of medical knowledge 27 . However, it is surprising to see knowledge and experience as the only attributes in the representation of a quarter of Portuguese graduates and the absence of these elements that characterize technical competence in almost all Brazilian graduates.
Knowledge is essential, but the real challenge for physicians is to be able to understand the human being and approach their patients, offering understanding and help 4,28 . A recent study on professional image in the perception of medical students in the Northeast of Brazil described the "good doctor" as a professional who maintains a balance between the "human side" and "technical competence" 5 .
The constant evolution of knowledge makes it more relevant for future professionals to learn how to learn, recognizing the importance of the best scientific evidence to solve health problems. Studies have shown the importance of personal and professional development during training, including the acquisition of values, behaviors, and attitudes encompassed by the construct of medical professionalism [1][2][3][4]8,12,23 . There is, however, a gap in this path of transformation of medical education, where many schools still focus on content and prioritize the assessment of knowledge.

Interactive Theater -Valuing interaction on stage
Interactive theater is acting in which the audience is included in the narrative for the purpose of sharing ideas, the performance being only a pretext for a personal experience 29 .
In this study, interactive theater is represented by two nuclei of meaning: the centrality of relationships in the description of the scene and the construction of the character centered on the audience watching.
The setting is everything that is placed to dialogue with the actors in the construction of the scene. About eighty percent of the Portuguese and all the Brazilian concluders brought in the relationships with patients, family and staff to the description of their ideal scene, demonstrating the value of proximity and the construction of bonds with patients.
I imagine myself in a specialty of contact with people, in the health center maybe, because there is a closer follow-up with the patient. (CP8) Even when the medical specialty and the health unit were mentioned, the harmonic and empathic interpersonal relationship was central to the description of the acting scenario.
Health team hand in hand with family and patient, because everyone has to work together. (CB1) I want to be a dermatologist and feel that I am part of the community, feel that I can have a more human relationship. (CP4) Being a doctor requires interpersonal relationship, often in situations of physical tiredness and emotional stress. Being able to keep calm under pressure and establish a good relationship with patients, family members, and the team, recognizing and welcoming the pain of others, are fundamental attributes for the exercise of medicine 10,12,26 .
The process of building the professional identity is based on the numerous interactions experienced throughout life, especially those established during training and professional practice 5 . Leadership and teamwork are essential competencies, valued by international institutions responsible for certifying medical schools in different countries [30][31][32][33] , and they are also present in the national guidelines for medical education in Brazil 34 .
The physician does not work alone; the relationship with the team has to be the best possible one, so that the patient benefits the most. (CB7) Teamwork is a crosscutting issue to all situations, respect and consideration for each other's work, which is different, but not more or less important, it is fundamental. (CP13) Aligned with the scientific literature on teamwork in health services, we observed the acknowledging of interpersonal relationships in the description of the ideal scenario by most of the interviewees. Concerns with relationships based on mutual respect were constant in the narratives, frequently emphasizing the importance of the work of each team member for the doctor's good performance and better results for the patients.

The construction of the character centered on the audience
Caring, empathy, communication, respect, responsibility, compassion, doctor-patient relationship, interpersonal relationship, and teamwork emerged as important elements for professional performance in the perception of the interviewees in both countries.
Knowing how to listen, being understanding and trying to perceive all the nuances of human thought. (CP1) Being empathetic, having social and communicative skills, and working in a team. (CP13) The will to make a difference, to really be there, to care and do my best. These results may relate to curriculum differences, with the prioritization of theoretical activities in Portugal and greater opportunities for practical experiences in Brazil. This difference may provide to the Brazilian interviewees chances for greater interaction with patients and teams in services, primarily in Primary Health Care, favoring the construction of professional identity focused on social interactions and the possible influence of the legacy of Brazilian Public Health Policies developed in the last two decades.

Backstage: the influence behind the scene
Backstage in theater is the place where the elements that contribute to the construction of the scene are located, invisible to the audience, but essential for the success of the representation.
The elements brought in a priori and the influence of the university are the nuclei of meaning of this theme, emerging from the analysis of the answers about the factors influencing the construction of the ideal professional self-image.

Elements brought in a priori
Five Portuguese and one Brazilian graduate believe that the University contributed only to the technical training and that the elements valued by them, related to the social role and the attributes of professionalism, such as empathy, care, respect and teamwork were brought in a priori.
I think it comes from my personality, because since I was a kid, I have this social sense a little bit developed. (CP13) Professionalism has been described as a set of personality traits by authors who believe that these traits are predictors of academic success 37,[39][40][41] . A study of medical students in Ireland showed that personality factors can influence future professional behavior 42 .
The parental education, personal experiences, and activities performed during childhood and adolescence were the other elements brought in a priori in the perception of the participants of this study.
I think that the way I was raised has a lot of influence, and the fact that I joined the Scouting program gave me a vision about humanitarian action. (CP2) According to the French sociologist Pierre Bourdieu, there are constitutive elements of cultural accumulation, transmitted through informal education, especially in the family, which contribute to define the attitudes towards cultural capital and the school institution, causing a strong relationship between performance at school and the students' socioeconomic and cultural origin 43 .
The influence of the family context in structuring behavior has been demonstrated by several studies. By observing family attitudes, the child unconsciously develops a mental model of action and emotion regulation that will guide his interpersonal relationships in the future 44,45 .
The elements mentioned as "brought in a priori" are closely related to the motivation that influenced them in their professional choice and that was maintained throughout the course in the idealized image of "being a doctor".

Influence of the University
The influence of the University in training the "doctor I want to be" was present in the speeches of most of the interviewees, represented by three interconnected aspects: the role of the curricular units, the importance of practical activities, and the influence of people.

The role of the curricular units
The role of the curricular units, was most cited by the Portuguese, who pointed out Humanities in Medicine and Medical Psychology, theoretical and compulsory subjects taken at the beginning of the course, when "they still didn't realize their usefulness".
Some humanities subjects help to give that more human perspective of medicine. (CP20) Subjects that one says, this is not so related to Medicine and I don't like it so much, and that start to make sense when we are finishing the course. (CP6) In the Brazilian subjects, Integrated Actions in Health (AIS in the Portuguese acronym) and Medical Skills Laboratories (LH in the Portuguese acronym) were cited, theoretical-practical modules, present in the curriculum from the first to the fourth year and that address the doctor-patient relationship in different scenarios, including realistic simulation environments, health centers, specialized outpatient clinics, and hospitals.
In AIS we learn the importance of treating not only health, but treating the person and their social bond. (CB9) The role of empathy and the doctor-patient relationship is highly valued at LH, including in the exams and is developed throughout the course. (CB5) The scientific medicine of the 20 th century reached its peak in the 1960s, when it began to be criticized for its dehumanization. Aiming at a more humane medical practice, a set of disciplines called "medical humanities" was created, integrating classical disciplines, such as history, philosophy, ethics and religion with contemporary social sciences, such as anthropology, psychology and sociology; and arts, such as literature, theater and cinema 6,24 .
The comparative analysis between the two countries shows -in the perception of the Portuguese -that the influence of the units mentioned is pinpointed, in theoretical subjects, and studied long before the practice in assistance. Also, the knowledge acquired may or may not be recovered in the last years, when the clinical experience with patients begins. In Brazil, the modules indicated are longitudinal, from the first to the fourth year, combining theory and practice in patient care, where the "human side" of medicine is experienced in the daily interaction in the health services. These interactions are possibly dehumanizing practices and processes; however, they allow the students to reflect about what they see, hear and feel, providing opportunities for more meaningful learning.

The importance of practical activities
As per the interviewees, the practical activities and the people exert the greatest influence on the education of the physician. These influences are perceived as opportunities to experience the medical specialties and make their choices. Although practical activities were mentioned in both countries, it can be read between the lines, the differences in the role of students, in Brazil taking the leading role and in Portugal as observers in patient care.
You only really understand when you're living it, when you have the responsibility of "my" patient, I'm the one that has to do it. (CB10) While we are waiting for some doctor to let us watch an office visit, we can see the dynamics between doctors and patients, and what people do well and what they do badly, and that helps us to create an ideal situation. (CP20) The need to include values teaching and attitude assessment in the formal medical school curriculum has been pointed out for some decades. However, in most medical schools, it has not been consistently applied, prevailing lectures and small group sessions in the preclinical years of training 46,47 . In practice settings, learning opportunities provide students with an insight into routine medical work, the importance of teamwork and interpersonal relationships, and play an important role in teaching values, behaviors, and attitudes. However, we emphasize the need for a space for reflection on the interactions experienced and discussion about the roles to be played in the future professional.
The frequent lack of a link between professionals working in clinical settings and universities makes the influence of these interactions on the construction of professional identity unpredictable, requiring close monitoring, frequently absent, by those who manage learning in educational institutions.

The influence of people
In addition to the influence in practice settings, the daily contact with teachers and peers throughout the course proved to be a source of influence and learning in the perception of the participants of this study. The influence of the teacher in the process of professional identity formation is recognized in the perception of medical students in different studies. The students, during their training, learn, besides technical skills, how to be and act as doctors, mirroring the actions of the professionals with whom they interact throughout the course 4,5,48 .
I think it is more in the human part that we realize how we want to deal with the patient and the team. (CP3) Compatible with what is described in the literature 5,10 , it was observed in the analyzed narratives the admiration of the students for teachers and physicians who have a good interpersonal relationship, and show a coherent attitude with what they teach. On the other hand, it can be noticed that students recognize the existence of good and bad examples at the university.
Sometimes the same professor that I lived with during basic, I saw in the hospital doing what he said in class, and that is very nice. (CB9) I had examples of both how I wanted to be and how I didn't want to be. (CB3) Every person, the impression they give us, good or bad, somehow contributes. (CP17) A study conducted in the US revealed that more than half of the 2016 class graduates in the medical school perceived disconnection between what they learned and what they saw demonstrated in the attitude of their professors 49 . In Brazil, a study with newly graduated physicians in different regions, described that the vast majority of participants, about 85%, experienced or witnessed during the course some ethical conduct that they judged inadequate, especially in the relationship with patients in practice settings 50 .
Professors and physicians who accompany students in clinical practice need to be aware of their role in shaping the professional image of the future physician, and the need to follow the ethical principles and fundamental values of the profession, cherishing the moments of interaction as an opportunity for professional, as well as technical, training.

Final considerations
When asked about the ideal image of the "the doctor I want to be", the participants of this study reflected on their training trajectories and were confronted with their professional self-image, prioritizing interpersonal relationships in the practice settings and the construction of a professional identity centered on the patient's needs.
It is perceived that, even with the recognition of the importance of the acquisition of values, attitudes and behaviors in the education of doctors, a large part of the construction of professional identity is derived from the informal curriculum and dependent on the modeling, not controlled by medical schools.
The results of this study reinforce the importance of working on social and humanistic aspects and the need for attention to modeling in practice settings focused on the development of professional identity.
Investing in the self-perception of the students and in the construction of their self-image as a physician, from the beginning of the course, making teachers and students aware of the influence of the hidden curriculum, may contribute to guide the academic path and the future professional trajectory of the physician.
Some limitations of the study may be related to the fact that the participants were self-selected, and it is not possible to rule out the possibility that the sample was composed of students with greater interest in the issues related to the study. It is also