Graduates’ Reflections on Professionalism and Identity: Intersections of Race, Gender, and Activism

Abstract

Phenomenon: Professionalism as a construct is weaponized to police and punish those who do not fit the norm of what a medical professional should look like or behave, more so when medical professionals in training engage in protests for social justice. In addition, professionalism silences trainees, forcing them not to question anything that looks or feels wrong in their eyes. Socialization in medicine, in both the undergraduate and postgraduate training spaces, poses challenges for contemporary medical professionals who are expected to fit the shape of the ‘right kind of doctor.’ Intersectionality seems to impact how medical trainees experience professionalism, be it intersections of gender, race, how they dress or adorn themselves, how they carry themselves and who they identify as. Although there is literature on the challenges pertaining to professionalism, not much has been written about the weaponization of professionalism in medical training, particularly in the South African context. There is also a paucity of data on experiences of professionalism during or after social upheaval. Approach: This is part of a study that explored the experiences of professionalism of five medical trainees during protests and after protests, extending into their postgraduate training. The main study had 13 participants, eight students and five graduates, who were all interviewed in 2020, five years after the #FeesMustFall protests. For the five postgraduate participants, we looked at how gender, race, hairstyles, adornment, and protests played out in the experiences of professionalism as medical trainees at a South African university. We employed a qualitative phenomenological approach. An intersectional analytical lens was used in analyzing the transcripts of the five graduate participants. Each transcript was translated as the story of that participant. These stories were compared, looking for commonalities and differences in terms of their experiences. Findings: The participants, four males (three Black and one white) and one Black female, were victimized or judged based on their activism for social justice, gender, and race. They were made to feel that having African hairstyles or piercings was not professional. Insights: Society and the medical profession has a narrow view of what a doctor should look like and behave – it should not be someone who wears their hair in locks, has body piercing, or is an activist, least of all if she is a woman, as professionalism is used as a weapon against all these characteristics. Inclusivity should be the norm in medical education.

Keywords:

• Professionalism
• identity
• weaponization
• intersectionality
• racism
• gender
• African hairstyles

Introduction

Professionalism is not a universal construct and varies across cultures.¹ However, regardless of cultural context, the conceptualization of the ideal doctor is based on the western view of professionalism, which excludes people who do not conform to its rigid prescriptions. An increase in literature shows that professionalism is weaponized against medical trainees and used as a means to promote conformity.^2–6 The western view of the ideal doctor is reinforced through racial discrimination in medical organization’s professional policies,³ and is being weaponized against non-conforming individuals with body piercing, tattoos, or dreadlocks.^3,6,7 For example, while the medical education fraternity aspires to promote equity and academic freedom, the western notion of professionalism looks down on those who dare to be different or are different.³ They experience discrimination and frequent reminders that they must be obedient to western notions of what it means to be a doctor. In an effort to continue to catalogue and illustrate the challenges trainees face, this study narrates the stories of five participants involved in a national effort at creating social change in South Africa (SA). These five graduates were part of a sample of thirteen participants involved in this effort and were chosen because their stories illustrate how race and gender play out in medical education as well as the importance of context, geographical and cultural considerations in the conceptualization of professionalism.¹

Professionalism

The concept of professionalism remains ill-defined in the published literature. Ong et al.⁸ found 58 definitions of professionalism within 162 articles on the topic. Despite its widespread use, there is no universal agreement about what professionalism means, but most scholars agree that it encompasses humanism, altruism, excellence, and accountability, with a strong foundation of clinical competence, communication skills, ethics and legal understanding.^7,9,10 Professionalism is frequently found evident in various characteristics, including virtues, aspirations, and humanistic actions, or within a set of skills that could be assessed to demonstrate competence or a process of identity formation in a particular community of practice.^1,11

How professionalism develops in individuals is also a contested topic, evidenced in the multiple theories describing the way it develops. Development includes literature from value-ethics and morality, professional identity formation, and sociological theory.^1,11 In each case, these theories focus on the professional and their relationship to patients. Rarely, if ever, do these theories include influences from the communities from which the patient comes or their cultural background.¹² However, the development of professionalism may be influenced by interconnected factors, such as race, gender, and social class, which may lead to diverse processes of development and identity formation.^10,13 Research indicates nurturing professionalism in young professionals is likely dependent on employing a culturally appropriate foundation, an aspect that has not received a lot of attention.⁸ For example, Ong et al (2020), define professionalism as ‘an evolving, socio-culturally informed, multidimensional construct’,^8(p.636) which positions intersectionality as an important aspect of professionalism and professional identity formation. This is in contrast to the western definition of professionalism, which focuses primacy on patient welfare and autonomy. Such definitions place patients’ interests above those of the physician. It refers to social justice, but fails to consider the intersection of cultural and contextual issues in the development of professionalism.¹⁴ Such intersections and dimensions of professionalism may be particularly important in the context of SA, given the history of discrimination based on race, as well as other cultural dimensions, such as the expectation that women should be subservient to men. More to the point, professionalism in SA may be affected by larger sociohistorical contexts, such as the legacy of apartheid and its aftermath.¹

The evolution of South African society has been heavily influenced by the inequity put in place by apartheid. It is continuing to transform itself into a greater axis of a democracy where equal opportunities exist for all members of society, but, with an entrenched system of inequity, it is not there yet. Modiri^, argues that there are multiple complex inequalities with ripple effects that are still felt and perceived 20 years post-apartheid, strongly supporting the notion that ‘critical race theory still matters in examining SA’. ^15(p.410) Even in the post-apartheid period, there are still structural (the intersection of unequal social groups) and political (intersection of political agendas and projects) aspects that influence the oppression of some individuals. Modiri¹⁵ and Crenshaw,^16,17 noted how intersectional forces can have negative implications for higher education. Intersectionality, first coined by Crenshaw,^16,17 describes the complex, cumulative way in which the effects of multiple forms of discrimination (sexism, racism, and classism) combine, overlap, or intersect in the experiences of marginalized individuals or groups. The construct intersectionality has come to mean ways in which multiple identities intersect and interact with each other.¹⁶ It is about the interlocking systems of oppression that act on someone to mitigate or enhance their oppression.¹⁶ Intersectionality refers to different axes of oppression that act on the personal, social, the institutional and the structural, and which might affect the individual negatively or positively.¹⁶ As a construct, intersectionality recognizes the importance of multidimensional facets of identity encompassing cultural, historical, and structural factors.¹⁸ One aspect of resistance to apartheid was the SA student protests in 2015-2016 under the Twitter handle #FeesMustFall movement.

In October 2015, the Fees Must Fall protests, using the Twitter handle #FeesMustFall, spread through the institutions of higher learning as students fought for a reduction in tuition fees, among other social issues. Some of these issues included decolonization, transformation, and the insourcing of workers, as the current government promised free education for all when it was put into power in 1994.^19,20 The aim for #FeesMustFall was to make “quality education affordable and accessible to poor Black students”^{20 (p.xii-xiii)} and “remains a watershed in SA higher education” to this day.^{21 (p.6)} Intersections played a major role in how students experienced #FeesMustFall protests. Being queer, a woman, or Black led to different experiences in these protests, namely marginalization. White students initially did not understand or endorse the protests, whereas, for Black students, the protests ignited the pain of being overlooked by a government that promised free education.²¹ These type of protests, in which social media is used to promote their case, has become a global phenomenon, even evidenced in the US during unrest emanating from inequities affecting people on the margins of society.¹⁸ It is crucial for medical educators to understand how interlocking identities impact trainees’ individual experiences.¹⁸ The South African experience of the interlocking nature of oppression is enhanced by the country’s history of segregation based on color and race, including discrimination based on gender.²²

The South African historical perspective in medical education

A former white institution in SA, in reflecting on its role during apartheid, conducted a study exploring the experiences of Black alumni trained from 1945–1994.²³ The themes identified manifested in three ways, discrimination and its impact on medical training, perceived attitudes of white staff and students, and Black students’ resistance to discrimination.²³ Before 1985, this institution required Black students to sign a document stating that their clinical training was not guaranteed and that they should “agree to excuse themselves from any class, clinic or demonstration where a white patient (or even dead body) was present’, making Black students ‘agents of their own exclusion”.^23(p575) According to the participants in this study, white academic staff were silent when they could have done more.²³ It is important to add that, despite possible punishment, these Black students resisted by entering into spaces from which they were banned.²³ These findings were similar to findings from another former white university.²⁴ Though established as the Black section for medical training in 1951, the Durban Medical School perpetuated apartheid’s racism and discrimination in academic teaching.²⁵ Given the history of SA, critical lenses, including feminist and critical race theory, the latter nuanced to fit post-apartheid SA, as argued by Modiri¹⁵, are crucial in analyzing matters of socialization in different situations in SA. ^22,26 Therefore, using critical theory, particularly lenses focusing on race and feminism, may reveal or illuminate a completely different definition of what professionalism is, leading to a different socialization into the professional identity formation process. This study explores graduates’ experiences of professionalism during the #FeesMustFall protests, the post-protest period, and experiences during their postgraduate training. We chose postgraduate trainees (interns or residents) because they have experiences of socialization as medical students and experiences as postgraduate trainees who are being incorporated into the community of practice. The authorial team is centering the first author’s (MM) voice, by using “I, me, and my” and the use of “we or our” denotes the authorial team’s voice.

Methods

This qualitative study explored students’ lived experiences of medical training between 2015 and 2020,²¹ and was located at the University of the Witwatersrand, SA. We used an interpretive phenomenological enquiry to understand the meaning of students’ encounters in a clinical space, rather than a descriptive phenomenological approach which requires bracketing.^27–30 Participants and I (MM) co-created the initial interpretations, followed by an additional interpretation by the authorial team (LG, AG, and AK).²¹

A purposive sample was drawn from senior clinical (final year) students and recent graduates (called interns in SA or residents in USA), followed by a snowballing sampling technique. The participants had been in their first to fourth (MBBCh 1-4) years of the medical program during the #FeesMustFall 2015/2016 protests.²¹

Thirteen semi-structured interviews were conducted in 2020, of which five were recent graduates and eight were students in their final year. This paper will concentrate on the five recent graduate participants (Table 1). I (MM) chose the five recent graduates because their experiences as pre-clinical undergraduates during #FeesMustFall, students in their clinical years and interns (residents) would provide a robust picture of their experiences across their medical training. I asked participants to reflect on their experiences in the medical program and work experience during their internship. An interview guide allowed me to probe their experiences of professionalism and how #FeesMustFall protests impacted their professional identity development.

Table 1. Summary of participants.

Participant’s pseudonym	Pseudonym origin	Title of participant’s story
Zwonaka	Traditional African ‘Beautiful’	Black woman with dreadlocks and a nose ring
Peter	Biblical ‘The Rock’	White, progressive man with an unconventional hairstyle
Asinamali	SA historic protest name. ‘We don’t have money’	Black man from the missing middle during #FeesMustFall
Nyakallo	Traditional African ‘Believes in dressing professionally’	Black man, an activist and a mentor who believes in dressing the part
Moitseki	Traditional African ‘Activist’	Black man, an activist with an African hairstyle

Positionality

Intersections of race, gender, and disability played out in my (MM) career as a doctor in various forms. First, in an ageist, gender-based way. For example, during postgraduate training in a consulting room, a question would be asked, ‘Nurse, where is the doctor; is he still coming?’ Second, in a racist way, when an Afrikaner man wearing a safari suit (a matching jacket and trousers originally worn on safaris in the African bush, but commonly worn by Afrikaner men in the 1970s and 1980s),³¹ long socks, with a gun in his sock, refused to allow me to treat his comatose teenage son. Eighteen years after practicing as a pediatrician, I went into full-time teaching as an academic at the University of the Witwatersrand, my alma mater, the medical school where I trained as an undergraduate. Nearly several decades later, I still had to navigate through discrimination and sometimes heavy-handed power dynamics. Through these intersections, being a woman who is Black with a different ability, I learnt to embrace everyone I met.

Two members of the authorial team (AG and LGT) are colored (of mixed race) ² South Africans, non-physician, and physician faculty members, respectively, of my generation. The other two members of the authorial team (AK and TW) are North American collaborators, whose role is to position my South African work in the international literature by suggesting non-South African ways of looking at the data for positioning in the international context.

Analysis

This is my analysis with the support of the authorial team. I (MM) tried to relay the participants’ stories as they experienced them, rather than interpreting them through a particular lens. Although the analysis could have examined these students’ stories through multiple layers of oppression including individual, social, structural, and institutional, the focus of this paper is on the experiences of these recent graduates based on different intersections of their identities, not necessarily on different layers of power. I chose this form of analysis because I believe that the layers of power they experienced are already intertwined in the institutional, structural, and sociohistorical aspects of their identities. I looked for content in the participants’ experiences that speaks to transgressions of professionalism as they might be viewed by the medical education fraternity. These transgressions might be in the form of appearance that is likely not deemed appropriate by the profession. I also looked for instances where their identities might be muted in some way, where they may be silenced because of their gender, color, activism, or lack of funding.

I regarded the interview transcripts for each of the five participants as narratives of the participants’ personal stories.^32,33 After reading each story and distilling the main elements, then using intersectionality as an analytical lens, I compared the stories with each other through constant comparative analysis. I chose an intersectional lens to see how race and other multiple identities of these participants intersected.¹⁶ I read each story several times and then the meaning of each sentence or paragraph was analyzed looking for transgressions or participants feeling of being muted. Intersectionality-informed analysis allowed me to perceive how the multiple socially constructed identities interrelate.³ The SA sociohistorical context feeds into how their experiences played out because of the legacy of apartheid that is intertwined in SA society.²¹ I tried to understand how participants resisted hegemonic norms of professionalism that may be unique to SA, the tension they encountered in their training and the intersections with power, especially discrimination based on race and gender.^34,35 To engage in member checking, I sent each of the five participants their relevant part of the article and asked them to comment on whether their story was accurately portrayed. I then incorporated their feedback into their story in the article. I told each of the five stories appropriately, interspersing quotes from the participant’s transcript to highlight the findings.

I (MM) used pseudonyms to avoid making participants identifiable. Each pseudonym was part of the analysis in that the names that I chose were part of my analytical process. Reading these stories took me through a journey of the SA history of protests that included theater, music, dance, poetry, literature, and how people adorned themselves. I personally wore dreadlocks as a budding neonatologist as a form of defiance (transgression) against the prevailing notions of professionalism. I waited until I qualified as a pediatrician before I wore my hair in locks as I feared being victimized (being muted). This defiance opened a door for younger doctors and nurses in our unit and the rest of the hospital to wear their hair in this way. The stories of these participants took me back to instances when I felt excluded either as a woman with a different ability or being Black. For these participants, I chose mainly cultural names that may not necessarily be obvious to the global reader but are an essential part of their story. The South African reader will understand these pseudonyms, but I will expand on them in the discussion for the Western or Northern Global reader. The study was approved by the University of Witwatersrand Human Research Ethics Committee (HREC Medical) (Clearance Certificate Number: M180864).

Findings

In these transcripts I saw professionalism issues relating to appearance, including references to how an ideal doctor should look. This led to participants being judged for appearing different from the norm, such as wearing unconventional hairstyles. It was not only the participants that were on the receiving end of doctors’ prejudice but patients who looked different from the medical professionals or those who could not express themselves in the Queen’s language, i.e., English. I also saw the participants’ identities muted in several ways, such as not being allowed to embrace their activism, being accepted with what they bring, i.e., their ‘African-ness’ into the training spaces or being muted because they were forced to leave the university during the #FeesMustFall protests.

Participants described experiencing higher education as an alienating space, particularly the institutions at which their training took place. They found their training environments oppressive, and rife with widespread discrimination based on both race and gender. Below are the participants’ stories and the ways their experiences intersected with professionalism. The stories include quotes (in quotation marks if less than 40 words) from their transcripts.

Zwonaka, a Black woman with dreadlocks and a nose ring

Zwonaka’s parents decided she should study medicine, and she was content with this decision because she wanted to help people. However, two of her family members had studied at her alma mater before her, and they had found it extremely racist. She was reminded of this when she saw students who were activists during the Fees Must Fall protests being victimized. She recalled a Black registrar in training saying to her,

I hope you’re not a Fees Must Fall person. I just hope you don’t have that attitude, and if you do, don’t put it on Twitter, don’t even go liking those pages. Keep it in your house because you will not progress.

She knew during #FeesMustFall, if one is at the forefront of the protests, medical educators in the clinical space will “chop off your head”. As such, on all her rotations, Black registrars in training would warn her “not to be a difficult person” if she wanted to succeed in the program. She was always alerted about the underlying racism in some rotations: “These people grew up in a certain world, they can’t see the world for what it really is. They only see the world for what they’ve grown up to believe it is.” For Zwonaka, being Black and a woman brought a great deal of heaviness, which was an “unnecessary invisible load” to carry. She alluded to the fact that racism was overt during apartheid and her experiences resonated with the feeling that post-1994, the “invisibleness cuts deeper and you have to deal with it in an invisible way”.^21(p.3) Victimization of friends who were speaking out against “the hierarchy and racism in medicine” made her question her chosen profession, which she felt is “meant to heal” but does the opposite.

During her internship, she saw whiteness and being male as privilege and entitlement, as one of her peers was getting away with unprofessional behavior. According to Zwonaka, white interns were “given the benefit of the doubt but interns of other races were not afforded the same treatment.” She perceived failing to fail as a western notion of professionalism where students, especially white ones, are allowed to proceed despite unprofessional behavior, leading to communities facing the consequences of the students’ failure to fail.

Zwonaka believed she experiences different challenges being a woman and Black in medicine. In her case, she was policed about her hairstyle, dreadlocks, and body piercings. She was told by someone above her that “it [was] interfering with my beauty, the nose ring specifically.” She experienced not only being judged by the medical team, but by the nursing staff as well, who told Zwonaka to change her looks to find a husband, “this consultant doesn’t have a wife, now he’s not going to think of you as an option because of this nose ring.” The nurses asked her, “why do [you] have dreads, why don’t [you] have a weave?” Medicine left her feeling that a woman is of no value without a man by her side and that it was impossible for her to have one given the ways she chose to present herself, yet she was determined not to succumb to these pressures.

Zwonaka witnessed doctors “shouting at people because they don’t know English properly”, doctors who did not “greet patients”, which was against what they were taught as medical students. She regarded the western notion of professionalism as “barbaric, because people aren’t people, they are just numbers.” She said this notion “doesn’t see context”, “doesn’t understand where this [patient] is going back to”. Zwonaka posited “that Western medicine thing is Sandton-based,³ they don’t understand the people they are treating.” In clinics, doctors were ignoring patients’ backgrounds and were only concerned about pushing the queue to finish seeing many patients on time. She would, therefore, be scolded for taking too long when seeing a patient, which created a great deal of dissonance for her, as she felt that what she was doing for the patient was not being valued by the senior doctors. Professionalism involves a patient feeling positive post-consultation, that their questions have been answered and that the doctor listened to and heard them. “How one treats patients and everyone around them says a lot about their professionalism.”

Zwonaka witnessed widespread bullying, with colleagues and friends being plunged into depression and routinely using antidepressants. Unchecked power trickled down from the most senior academic to the physician-in-training, with the most junior doctors on the receiving end. This bullying was traversing color lines and genders, as she had been on the receiving end from both white and Black women, as well as men. She said that reporting bullying was of no use, as the system would believe the perpetrator who might be a renowned clinician or researcher. What was evident to her is that what was taught in medical school was not apparent in her workspace. She was determined to create a safe space for those that came after her, to be a person they could consult regarding any issues they might have in clinical spaces.

Peter, a white, progressive man with an unconventional hairstyle

Peter experienced growth and a multitude of emotions, which included severe pain, during the #FeesMustFall protests in 2015. To him, it was an “emotional roller-coaster”. For the first time Peter realized what some of his Black friends and classmates were going through when facing financial exclusion from the university. Although he had immersed himself in the #FeesMustFall movement, he felt he remained “an onlooker”, which he described in the following way: “No matter how much I got involved in the protest, the more and more I realized that I was just on the side-lines, that I wasn’t a student who was deeply affected by it.” It was during this period that he “grappled with issues of race like I’ve [he’s] never done before.” From a position of privilege, he was tormented by “how institutions treat poor people, institutions treat Black people, how government treats Black people and poor people.”

Peter felt that the institution, his alma mater, was “oppressive and is out to get people” and he was concerned about those who had less means than he. According to Peter, there were individuals who were trying to make things better for the students, but their efforts were thwarted. To Peter, the institution did not care about poor and Black students. Peter said that, during #FeesMustFall, “Professionalism wasn’t modelled from [sic] the institution or the people that were meant to.” The student leadership had to busy itself with raising funds for students who were not allowed to register unless they paid some of their debt. This reminded Peter of his friend who was self-funding and had to work during weekends to cover his living expenses and tuition fees. This left Peter gutted to the core. According to him, “racism, the sexism that students experience on a day-to-day basis, on every single ward round and every single tutorial, you know, it was palpable.”

Peter recalled that in one of the ward rounds he had an argument with a white physician. This argument started when the physician implied that other physicians had a problem with his hairstyle. This conversation turned into a discussion of #FeesMustFall, where a Black student who was active during the protests was labeled by the physician as trying to “steal [other] people’s education.” Peter’s account indicating victimization of the #FeesMustFall activists correlates with Zwonaka’s experiences. He described how a “student [activist] was victimized as somebody who was derailing the education of white students who are compliant [and] are now not having access to the education that they are paying for based on people like the student [activist].”

Peter saw Black students having to act as interpreters during ward rounds. White physicians assumed that, if the patient is Black, someone who looks like them is bound to know their language, in this case, Black medical students. He used an example involving assessment at another ‘white’ university in SA, describing how, during assessments, particularly practical ones, “Black students would start with a mark below zero and work their way up in contrast to white students who start at a 100% and work their way downwards.”

Peter wondered what “professionalism looks like in a South African context” and felt that “we’ve inherited [a] rigid set of standards from the western environment”. He added that the students’ response through #FeesMustFall showed “another aspect of the attitude of professionalism”.

Asinamali, a Black man from the ‘missing middle’⁴ during #FeesMustFall

In 2015, when #FeesMusFall started, Asinamali lived off-campus due to financial constraints. He could not get funding because this was his second degree, making #FeesMustFall close to his heart. Asinamali felt rejected by the “system and government”, classified as someone who is not poor enough to receive government funding but not rich enough to afford paying for a medical degree. He almost sounded relieved when the term “missing middle” came into use: “I just did not have the word for the missing middle, and I was very glad when later it started coming to the fore and I realized, oh, I was not the only one with that kind of problem.”

When the institution was shut down due to the protests, Asinamali had to move back home as he was self-funding at that time. Reflecting on this period, he felt that the recently qualified medical practitioners did not display advocacy by not supporting the #FeesMustFall movement. Asinamali was expecting this group, students who had experienced similar challenges in the recent past, to show support by vocalizing their discontent. Asinamali is now focused on furthering his career in medicine. Reflecting on this, he posited that the western notion of professionalism had a poor or non-existent advocacy role, saying, “we felt unassisted by other former students,” “people in the professional world, young lawyers, people who graduated as recent as the year before”. He went on to say, “we didn’t see other graduate doctors coming through.” He posits that, “when people move to professional spaces, they behave like those whatever systems they’ve gotten into, as it would have them behave.” He was happy that, through #FeesMustFall, the “plight of students is better understood.”

Nyakallo, a Black man, an activist and a mentor who believes in dressing the part

Growing up in the township, Nyakallo, like most other children, wanted to be a teacher, a police officer, or a nurse, as was common in the townships. A general practitioner (GP) ignited the spirit of healing and leading in Nyakallo, and this GP became his role model. Nyakallo came into medicine wanting to be like that GP, but that was not long-lived. He met an astute professor during a surgical rotation who made him change his mind. This surgeon was an excellent teacher, which swayed Nyakallo into yearning to become a specialist, a surgeon.

During #FeesMustFall, Nyakallo was in the first aid team, in the frontline to assist students who were injured. However, he felt tension during the #FeesMustFall protests, when the student body instructed them that “as medical students you are assisting only students, not security police.” To him, this was uncomfortable, as it ignored the values of the profession, but he had to grudgingly comply as a member of the student body. Nyakallo posited that, during the clinical years, he experienced subtle racism, where Black students were merely called as students (or just pointed at or identified by clothing items - “hey, student wearing a blue shirt, tell us the answer”) despite wearing name tags, whereas white/Indian counterparts were called by their names. This prevented students from experiencing a “sense of belonging.” Students felt excluded on that basis.

During clinical rotations in the fifth and final years, Nyakallo started noticing behaviors that he would not want to replicate as a doctor. He described how the unbecoming behavior of senior medical staff affected him:

[You] go into med[ical] school with this notion of how to be a good doctor, with all the idealistic [notion of] whatever a good doctor is. And then maybe the exposure of a professor talking harshly to a registrar in our presence [or] sometimes it’s directed to us, [the good doctor notion] goes away.

It was during these instances when patients, particularly elderly women patients, would call students, as Nyakallo remembers, and educate them about the principles of ubuntu. They would show them an example of an excellent doctor who embodied ubuntu, an Indian professor in internal medicine, encouraging them to “be like Prof X, [saying] this is how a doctor should behave. This doctor respected them as patients and as human beings. A “doctor who sits down with them” rather than hovering above them when discussing their treatment. A doctor who made them feel that their stories and opinions matter.

However, Nyakallo felt that the negative behaviors of people meant to be their role models became imprinted on the students. The students were imitating their medical seniors’ bad behavior in their workspaces. “This doesn’t just stop in medical school,” Nyakallo said, “you start seeing it beyond medical school.” He provided the following example:

[T]hat is what I just see, it goes away to a point [at which], when you address patients now. I see it with some of my colleagues…so we are very young, you know, young and then an elderly patient comes, and I feel like we still have to address that patient as an elderly patient, you know, besides just treating whatever they have, there’s that respect that one must portray.

Nyakallo was concerned about what professionalism means to the younger generation. “I’m looking at junior doctors, which is us, we are slowly losing it.” It had become something to which he does not relate. Nyakallo discussed his concern about junior doctors not respecting the profession, as shown by their inappropriate dress code and improper behavior. Junior doctors are seen in the communities inebriated and they appear at work with signs of being intoxicated the night before. Nyakallo had respect for nurses and physiotherapists “because of how they conduct themselves and their dress code,” which is “better than that of most doctors”.

Cultural dimensions of professionalism, in the South African context, “that respect that one must portray” was critical in Nyakallo’s view, to how patients are addressed or treated. To Nyakallo, respect for elders was paramount, irrespective of whether they are patients or not. Nyakallo raised concerns about young doctors who address elderly patients by their first names. This to Nyakallo was a western notion of professionalism, not an African one.

Moitseki, a Black man, an activist with an African hairstyle

Moitseki classified himself as an activist who was in the forefront during #FeesMustFall: “I felt that I was part of the action of Fees Must Fall, rather than Fees Must Fall happening in the space that I existed. “He stated that #FeesMustFall shaped his university experience until he graduated. Prior to entering university, Moitseki had never attended school with white people. Everyone at each of his schools was Black. Moitseki posits that, during #FeesMustFall, as a collective, the students achieved and experienced victories in two parts, the student’s victory, and the worker’s victory. He described how the students’ victories were multifaceted:

There were certain political narratives that were driven. [W]e believe that part of the victory was conscientizing the students of the issues that were there, and the race and power dynamics that existed within that space. So, the first change was the awareness that the movement brought in the student population itself, becoming aware of the power dynamics that were related to race.

Moitseki went on to say that “white students were privy to certain spaces, privy to certain privileges that we were not having precisely because of our color.” He explained how the #FeesMustFall movement also conscientized white students about the body of Black students taking up space and owning alongside them:

[B]oth parties were recognizing that we exist in a space that is competitive racially and the white students had to recognize their privilege, they had to recognize their space and the perpetuation of racial power.

Black students started fighting for space and showing that they belong in spaces where doors were previously shut for people of color. “There was a sudden change in political awareness and consciousness of self in existing within a particular space.” He realized that not only race was being brought to the fore but also gender issues. LGBTQI (Lesbian, Gay, Bisexual, Queer, Questioning and Intersex) groups and women were raising their voices:

LGBTQI groups, so they also found expression[s]. And we were conscientized, all of us were conscientized. [B]y the end of it, when [a] woman stood to speak you would understand that firstly she’s a comrade, and [secondly], she’s an activist at her own right, before you even look at the fact that she’s a woman.

Moitseki reflected on issues that were raised about students feeling the tension of professionalism related to #FeesMustFall. He classified these issues into two groups, a protest part, and a post-protest part, depending on whether they” exhibited a particular behavior during [the] protests” and transitioned seamlessly into the clinical space.

I could make the transition. In the hospital I was never the noisy one, I was never disruptive, I wouldn’t stand up and say that, no, but Black registrars are being disrespected by consultants and so forth. Although that might have been their struggle, I understood that there I was in a professional space where I had to learn, and my responsibility was to patients, and it was a responsibility of learning. But I don’t know, and I’m suspicious that, that transition might have been informed by the fear of victimization.

Moitseki went on to say that, although he became a better advocate after #FeesMustFall, he was still wise, he knew which battles to take on and which battles not to tackle. He felt that #FeesMustFall also gave the students “good arrogance in the clinical space” where one felt that “you can’t look down on me, I belong here”. Moitseki said that #FeesMustFall gave them confidence that “no matter how you can look at me, I belong here” and maintains that it made them better professionals. #FeesMustFall gave them the confidence to resist things they did not like, and this carried through into their work environment.

In Moitseki’s postgraduate training workspace, as an intern, more than 95% of the population was Black. The patient population was Black, and most professionals were black, with whites and Indians in the minority. To Moitseki, the positions were reversed in his workplace, where he did not have to fight for space and a sense of belonging. This contrasts with his colleague, an Indian woman, who did not feel that sense of belonging. He says that most of his Indian friends classify themselves as Black. However, in this workspace, an Indian colleague feels that she was ostracized because of her color. Moitseki went on to say that, for as long as there is structural racism, “Black people are not racist, they are still fighting for space.” He believes that race, “financial muscle” and power are entwined.

He described how the issue of race invoked memories of “a young Black consultant [in the clinical rotations]”, who made them feel “that we belonged in the space”. There was always a sense of belonging, knowing that there was someone in a higher position who looked like them and probably knew and understood their struggles.

On issues of professionalism in his work environment, Moitseki alludes to patients, particularly African elderly ones, finding it difficult to understand the contemporary dress code and hairstyles of the younger generation of doctors. He talked about how elderly patients had mixed reactions toward him, with respect but also with reservations particularly to his African hairstyle:

I think there’s that generational gap, there’s that expectation from the generation that was trained twenty years ago, [that] a medical doctor should come out like this. Should come out wearing a white coat, with a haircut, combed hair every day, and a tie. And there’s this notion from myself and others that hair doesn’t matter, the politics of black hair shouldn’t be seen in the workspace, I shouldn’t be told to cut my hair. I don’t think we are unprofessional.

Discussion

In this study, I (MM) chose pseudonyms and the titles of the stories to reflect my analysis. Zwonaka means beautiful; I was highlighting the fact that, dreadlocks, nose ring and all, she is beautiful. For Peter, I chose a biblical name as his name is biblical, not necessarily implying that he is religious, but his concern for others showed deep-seated sacrifice. Asinamali means ‘we have no money’ in Isizulu language and was a political slogan in SA through the years of apartheid. Nyakallo, which means ‘happiness’ in the Sesotho language, was appropriate as he is happy to assist and mentor others, as well as strongly believing that professionals should always dress professionally. Moitseki means activist in the Sesotho language, he called himself an activist, saying that #FeesMustFall protests did not just happen in the space he was in, he was involved in instigating the protests. The participants’ stories display two things, firstly, their transgressive approach to ideal professionalism, and, secondly, the muting of their identities.

These participants’ perceived transgressions were committed because they chose to be their authentic selves, which was not part of the norms of medicine. They struggled because society, including the medical fraternity, has a certain image of how a doctor should look, as well as how they should behave, speak, and dress.³⁶ This image does not include individuals who have body piercings, tattoos or dreadlocks, as these are deemed unprofessional.^6,37–39 However, what these experiences are really akin to is discrimination, although it is couched under the concept of medical professionalism . By challenging these norms through African hairstyles, body piercing and speaking out against injustices, participants were subjected to being policed. As such, the concept of professionalism is weaponized instead of being used to affirm one’s identity.⁶

Part of the problem is that current definitions of professionalism do not consider the evolving nature of this construct. The twenty first century doctor continues to be bound by definitions that were penned more than 20 years ago by mostly Western authors⁷ and it is onerous for younger doctors to abide by the rules set by earlier generations.⁴⁰ Despite there being more women, people of color and people who are more open about their gender and sexuality,⁴¹ this study shows they continue to be held to former ideas and norms around professionalism. What makes this particularly challenging is that although in North America scholars suggest that students and staff be trained on how to deal with racism,³⁴ in a country like SA, with a history of apartheid that continues to influence all aspects of society today, how does one challenge racism, which can be subtle and invisible, and therefore difficult to confront? How do these conversations get started to problematize these issues? We argue that it begins by medical doctors telling their stories about what it means to be a professional and where physicians experience tension. In doing so, assumptions around professionalism can be interrogated for the ways in which they exclude some groups, while forwarding others all in the name of the profession.

While we have attempted to tell these stories here, this study is not without limitation. First, the participants largely focused on their physical presence, but there are other aspects of professionalism that might be considered in future work, such as interactions that physicians have with patients that differ from the norm, different approaches to clinical diagnosis and treatment, as well as other deeply embedded expectations for what it means to be a physician. As this is a phenomenological study, we concentrated on what participants feel is their identities and the experiences they had based on those identities.We were also limited to the number of participants in the study and the extent to which they could reflect on their experiences in ways that show how professionalism can be problematic.

Conclusion

The concept of professionalism is used to marginalize certain individuals’ and groups’ experiences to maintain a shared identity within the profession of medicine. However, as new kinds of trainees enter our system, especially those whose ideas and values fall outside the norm, we must reconsider these professionalism definitions to be inclusive of other ways to think about what it means to be a professional.

Disclaimer

This work was prepared by a civilian employee of the US Government as part of the individual’s official duties and therefore is in the public domain. The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense.

Acknowledgements

We acknowledge the participants in this study who were willing to assist in this project by telling their stories.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes

1 https://www.sahistory.org.za/article/history-apartheid-south-africa

2 https://www.sahistory.org.za/article/race-and-ethnicity-south-africa

3 Sandton is an affluent suburb in the north of Johannesburg.

4 Students who were categorised as missing middle were those whose families earned more than R350 000 but less than R600 000 per annum did not qualify to receive Government funding.