Rheuminations: The Evolution of Identity Over Time

This sounds incredibly stupid, but I never thought I would celebrate my 40th birthday. It’s not like I believed I would never reach the age of 40, but the idea that I would ever see that many candles on my birthday cake had always seemed remote, until maybe a month ago. In fact, by the time you are reading this column, chances are that remote reality will already be a memory. Regardless, it’s an opportune time to reflect on the concept of personal and professional identities, their evolution and growth over time, and the confluence of individuality that makes up our sense of collective identity. What does this 40-year-old rheumatologist mean? Let’s rheuminate!

Professional Identity Formation

Before anything else, let’s talk about a term that has been growing exponentially in the literature over the past decade: Professional identity formation (PIF).¹ PIF refers to the internalization of core values, behaviors and sense of purpose associated with a given profession. For physicians, especially rheuma­tologists, this process shapes not only how we practice medicine, but how we see ourselves in relation to patients, colleagues, institutions and society. Almost imperceptibly, as we acquire knowledge and hone our skills, we modify our perspectives and become slightly different people.

It may sound strange to talk so frankly about PIF, but PIF matters because it anchors us in our key sense of purpose. In rheumatology, which is marked by ambiguity and nuance, having a stable, evolving professional identity helps us navigate ethical and diagnostic dilemmas, communicate with patients with empathy and make peace with ever-present uncertainty. Without that identity, our work feels disjointed, counterproductive and even demoralizing.

It is vital to remember that PIF is not an accidental process that just happens.² Our professional identities can be intentionally crafted through reflective practices that start in training. Papers have been written that document and assess such activities as writing and small-group discussions to foster PIF, but this is likely just the tip of the iceberg. Whenever we engage in intentional reflection, we crystallize identity.

This also means that when we mindlessly go through the motions of being a rheumatologist without thinking about what we are doing, we are actually missing opportunities to form our identity. It sounds counterintuitive and heretical, but it is possible for a 25-year-old rheumatologist to have a more secure sense of identity as a rheumatologist than a 75-year-old one, especially if they are more devoted to, and more intentional in, exploring that sense of identity.

As I turn 40, I’ll rededicate myself to my identity formation and continue to reflect frequently and periodically about what it means to be a 40-year-old rheuma­tologist in the year 2025. But to do so, I’ll have to engage in the process of rediscovering who I am.

Identity & Self-Concept

Identity formation is deeply and intimately intertwined with self-concept. Although the term professional identity formation is relatively new, there’s an older theory that helps describe the creation of self-concept. In 1902, the sociologist Charles Horton Cooley proposed the theory of the “looking glass self.”³ According to Dr. Cooley’s theory, we see ourselves as we imagine others see us. That may sound abstract and self-referential, but it has very practical ramifications on identity formation. In the context of professional identity formation, the looking glass self suggests our identity as rheumatologists is deeply influenced by how others, including patients, peers and mentors, perceive us.

This is why it’s crucial to surround ourselves with people who see the inalienable good in us. According to the proponents of the looking glass self, love, respect and esteem flow like currents through social groups. The more we share these authentically positive self-images of one another and the more we open ourselves to seeing the good in one another, the more our self-concept and our identity evolve toward goodness itself. At its best, identity formation can be thought of as a kaleidoscopic, multidirectional and relational process of affirmation and aspiration.

Even if the looking glass self and professional identity formation seem unfamiliar to you, I am sure you have experienced this throughout your career. Mentorship, sponsorship, coaching and role modeling are all practical manifestations of this mutualistic relationship between self-concept and identify formation. When a trainee sees their mentor listening deeply, demonstrating humility or admitting uncertainty, they internalize those behaviors as part of their own professional identity. Likewise, when a mentor sees their mentee receptive to growth, it fosters a sense of reciprocation within the mentor to become humble and listen deeply, ultimately nurturing the affinity of the relationship between both the mentor and the mentee.²

Terror Management Theory

Of course, the looking glass self is only one theory that helps us contextualize the formation of our identity. Another, very different, theory that seems to go against the looking glass self is terror management theory (TMT).⁴ Unlike the theory of the looking glass self, TMT is a psychological framework that suggests much of human behavior is driven by a desire to buffer ourselves against the fear of death. We manage this existential terror by aligning with cultural worldviews and striving for symbolic immortality, like legacies, reputations and contributions that endure after we’re gone. Unlike the looking glass self, the audience that sees us in TMT is situated in the future, coolly and inertly judging us, rather than interacting with us in the present.

Although this may sound bleak, TMT has powerful implications for professional identity. Our choice to become rheumatologists, our drive to teach, research and care for others may, in part, reflect a deep-seated desire to matter and to contribute to something larger and more lasting than ourselves.

In this light, the drive toward a lasting legacy is an essential aspect of identity formation. TMT may help elucidate how we unconsciously shape the field through mentoring, modeling and everyday actions. After all, each decision, no matter how small, makes lasting contributions to the cultural fabric of rheumatology. Through the diligence of our work, we create a sense of permanence and meaning.

At face value, TMT seems entirely irreconcilable with the looking glass self, but that’s not necessarily so. Admittedly, at age 40, I am thinking about my own sense of impermanence. It absolutely does spur me to make the most of each day, whether at work or at home. Yet it also makes me think more carefully about the people that I surround myself with and how I contribute to their identity and self-concept.

Growth Mindset & PIF

No discussion about identity formation would be complete without talking about growth mindset. It’s become popular in recent years due to the work of psychologist Carol Dweck. Her theory of growth mindset emphasizes the belief that abilities and intelligence can be developed through dedication and effort.⁵ This contrasts with a fixed mindset, which assumes these traits are static. Confusing things further is the false growth mindset, which gives lip service to growth but avoids the discomfort that real learning entails.

For rheumatologists and all clinicians for that fact, a true growth mindset is essential. We are constantly learning, not only from the literature, but from our patients, our mistakes and our evolving roles. A growth-oriented identity acknowledges that mastery is a journey, not a destination.

This mindset also upholds our well-being. When we believe our identity and self-concept can change and grow, setbacks seem more temporary blips than fatal failures. This aligns well with the ideals of professional identity formation being less about arriving at competence and more about carefully cultivation of virtue. This orientation is particularly important in a field like rheumatology where the unknown is unescapable; having certainty that we can grow makes all the difference.

Collective Identity of Rheumatology

However you choose to characterize professional identity formation, it is inescapable that our identities are inexorably tied to the identities of others, and so it follows that there is also a sort of collective identity formation. This may seem more ethereal, but it is self-evident that the rheumatology community is akin to a living organism. Like cells, we rheumatologists routinely enter and exit, through training, retirement or other career transitions, but regardless of the exact cellular composition, the field’s identity remains intact.

Even as the demographics shift and the tools of our trade evolve, a core ethos unites us. Whether in private practice or academic settings, in the U.S. or abroad, we are very much defined by our willingness to listen deeply, think expansively and engage humanely. Our collective identity is formed in conferences and clinics, in journals and coffee breaks. It is most definitely affected by new technologies, challenged by the ever-present burnout and refined through continuous medical education. In that sense, our collective identity is more than the sum of our individual identities.

Forty is quite a lot, but it is also a pitifully tiny number. This ambiguity gets to the heart of a major dilemma that people have been trying to grapple with since the beginning of time: Although we can count the number of days that we have lived, we cannot do so with any degree of certainty for the number of days that we will remain on this Earth.

This asymmetry and the anxiety associated with it can easily crowd out our sense of aspiration and ambition. Worse yet, it can compromise our ability to relate to the present. That’s why identity formation is so vital, because it provides a counterbalance to these natural anxieties. Identity formation places a mirror to ourselves so that those asymmetries seem less glaring, and we can return to being fully ourselves in the present, as bridges between the past and the future.

Or I could be completely wrong. Maybe when I am blowing out a half-century’s worth of candles in the year 2035, I’ll look back and say what an idiot I was at age 40 to write such things. Only time will tell whether this column stands the test of time. I for one, am looking forward to the revelation.

Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X (formerly Twitter) @BharatKumarMD.

References

1. Coneybeare D, Truong J, Runde D, Coates W. Professional identity formation: Who am I? Where am I going? AEM Educ Train. 2025 Apr 29;9(Suppl 1):S73–S79.
2. Krishna LKR, Ravindran N, Kwok HYF, et al.The impact of mentoring relationships on professional identity formation in medical education: A systematic review. BMC Med Educ. 2025 Apr 19;25(1):576.
3. Bailey JA 2nd. Self-image, self-concept, and self-identity revisited. J Natl Med Assoc. 2003 May;95(5):383–386.
4. Tan Y, Huang R, Chen Z. How does mindfulness alleviate panic buying: The mediating role of social alienation and death anxiety. Psychol Res Behav Manag. 2025 Apr 9;18:901–915.
5. Linklater-Steele A, Colthorpe K, Ainscough L. Mindset matters: Exploring the link between mindsets, learning intentions, and performance in biomedical science students. Adv Physiol Educ. 2025;49(3):780–788.