Role models--guiding the future of medicine

Moral Elevation, Physician Role Models, and Selected Markers of Professional Identity Formation and Well-Being: A Secondary Analysis from Two National Surveys

OBJECTIVES

Moral elevation is the underlying emotion that arises when witnessing admirable acts, and it is theorized to be the psychological mechanism driving the impact that positive clinical role models have on medical students' professional identity formation (eg, growth in professional virtues, higher sense of meaning, and well-being). This proof-of-concept study explores the development of the Moral Elevation Scale in Medicine by testing the association of moral elevation with various markers of professional identity formation.

METHODS

A secondary data analysis of two nationally representative samples of 960 medical students and 2000 physicians was performed. Respondents completed validated measures of moral elevation as well as markers of professional identity formation, including patient-centered virtues (empathic compassion, interpersonal generosity, mindfulness) and measures of well-being (life meaning, life satisfaction, spirituality, burnout).

RESULTS

The study obtained adjusted response rates of 56.2% (1047/1863, physician survey) and 48.7% (448/919, student survey). The national estimates for mean moral elevation in medical students and physicians are 4.34/5.00 and 4.22/5.00, respectively. In medical students and physicians, high moral elevation was associated with higher empathic compassion (student odds ratio [OR] 1.30, 95% confidence interval [CI] 1.02-1.67; physician OR 1.22, 95% CI 1.23-1.65) and, similarly, generosity. In addition, higher moral elevation in the physician cohort was associated with greater life meaning (OR 2.03, 95% CI 1.25-3.32) and similarly spirituality.

CONCLUSIONS

In medical students and practicing physicians, self-reported experiences of high moral elevation with physician role models were associated with higher self-reported measures of patient-centered virtues, spirituality, and life meaning. Our Moral Elevation Scale in Medicine demonstrates preliminary promise as a measure to assess environmental precursors needed for virtue development in professional identity formation, but further reliability and validity testing of this measure is needed.

Communication skills learning through role models in Nepal; what are medical students really learning? A qualitative study

BACKGROUND

Communication skills (CS) are important and teachable, however, many Asian medical schools' curricula do not incorporate them. Patan Academy of Health Sciences in Nepal identifies CS within its' aims and curriculum. CS are taught from commencement of medical school and re-emphasised throughout preclinical learning (first 2 years). There is no explicit CS teaching in clinical years but placements allow students to learn through observation. These 'role-modelling' interactions form part of CS learning and development.

METHODS

This study is a qualitative evaluation of CS learning in PAHS, through participants' experiences. Through purposive sampling, twenty medical students from 2nd, 4th and Intern years were selected for inclusion. Data were collected via audio recorded, semi-structured interviews, employing a piloted schedule. Transcripts were manually coded and analysed thematically. Codes were organised into themes and subthemes. This paper discusses themes related to role-modelling.

RESULTS

The majority of participants described role-modelling in CS learning, recounting both positive and negative incidents, reflected in the themes of; Positive and Negative experiences. Subthemes of Personal Qualities and Inspiring, emerged from positive experiences, describing students' desire to imitate or aspire to be like their role models. Learners reported predominantly negative experiences and interns exclusively so. From these emerged subthemes of; Good doctors but.., Contradictory messages, How not to behave, Unprofessional behaviour and Affect-Emotional Distress. Learners received conflicting messages from observing behaviour contradictory to explicit CS teaching. Many identified learning "how not to behave" from such incidents, however, several described feeling distressed.

DISCUSSION

Role-modelling is a powerful and important CS learning tool, seen as positively reinforcing or negatively contradicting explicit CS teaching. Negative modelling created internal conflict, confusion and distress amongst learners, despite its' potential for positive learning. The worldwide problem of negative role-modelling is also prevalent in Nepal. Medical educators need to ensure the explicit curriculum aligns with implicit learning. Clinical tutors must be alerted to their powerful role-model position and supported in developing intentional modelling skills. Learners' reflections upon their experiences should be facilitated, enabling them to critically evaluate observations and hence consciously adopt or reject role-modelled behaviour and attitudes.

Teaching medical professionalism: a qualitative exploration of persuasive communication as an educational strategy

BACKGROUND

Across the world, local standards provide doctors with a backbone of professional attitudes that must be embodied across their practice. However, educational approaches to develop attitudes are undermined by the lack of a theoretical framework. Our research explored the ways in which the General Medical Council's (GMC) programme of preventative educational workshops (the Duties of a Doctor programme) attempted to influence doctors' professional attitudes and examined how persuasive communication theory can advance understandings of professionalism education.

METHODS

This qualitative study comprised 15 ethnographic observations of the GMC's programme of preventative educational workshops at seven locations across England, as well as qualitative interviews with 55 postgraduate doctors ranging in experience from junior trainees to senior consultants. The sample was purposefully chosen to include various geographic locations, different programme facilitators and doctors, who varied by seniority. Data collection occurred between March to December 2017. Thematic analysis was undertaken inductively, with meaning flowing from the data, and deductively, guided by persuasive communication theory.

RESULTS

The source (educator); the message (content); and the audience (participants) were revealed as key influences on the persuasiveness of the intervention. Educators established a high degree of credibility amongst doctors and worked to build rapport. Their message was persuasive, in that it drew on rational and emotional communicative techniques and made use of both statistical and narrative evidence. Importantly, the workshops were interactive, which allowed doctors to engage with the message and thus increased its persuasiveness.

CONCLUSIONS

This study extends the literature by providing a theoretically-informed understanding of an educational intervention aimed at promoting professionalism, examining it through the lens of persuasive communication. Within the context of interactive programmes that allow doctors to discuss real life examples of professional dilemmas, educators can impact on doctors' professional attitudes by drawing on persuasive communication techniques to enhance their credibility to demonstrate expertise, by building rapport and by making use of rational and emotional appeals.

Clinical sympathy: the important role of affectivity in clinical practice

Bioethics has begun to see the revaluation of affects in medical practice, but not all of them, and not necessarily in the sense of affects as we know them. Empathy has been accepted as important for good medical practice, but only in a way that strips it of its affectivity and thus prevents other affects, like sympathy, from being accepted. As part of a larger project that aims at revaluing the importance of affectivity in medical practice, the purpose of this paper is to develop a clinical sympathy that can serve as a trainable skill for medical professionals. While everyday sympathy may be problematic as a professional skill for physicians, this does not imply that sympathy should be entirely rejected. As a natural part of our moral psychology, sympathy is an intersubjective affect that aids in our interactions with others and our decision-making abilities. I present here a theory of clinical sympathy as an affective response to patients, in which physicians are both attuned to their affective response and understand how their affects are influencing their beliefs and judgments. In this way, clinical sympathy serves as a trainable skill that can aid physicians in their interactions with their patients.

Specialty-specific reduction in opioid prescribing after common pediatric surgical operations

BACKGROUND

Opioid misuse has reached epidemic proportions, and postoperative opioids have been linked to overdose, diversion, and dependency. We recently found our opioid prescribing practices following common pediatric operations to be inconsistent and excessive. In this study, we evaluate the efficacy of an educational intervention on opioid prescriptions following tonsillectomy and hernia repair.

METHODS

Retrospective chart review of prescriptions following outpatient tonsillectomies and hernia repairs at a single institution before and after an educational intervention was performed. The intervention consisted of a single campus-wide grand rounds presentation detailing the surgeon's role in the opioid epidemic.

RESULTS

Postoperative opioid prescriptions were significantly reduced for hernia repair following the educational intervention: 4.2 ± 2.9 vs 2.7 ± 2.6 days' supply (p = 0.004). Such a reduction was not observed for post-tonsillectomy opioid prescriptions: 6.3 ± 4.4 vs 5.4 ± 3.0 days' supply (p = 0.226). A greater decrease in interprovider variation was observed for hernia providers after the educational intervention than for tonsillectomy providers, though significant variation continued to be present for both procedures after the intervention.

CONCLUSIONS

The efficacy of an educational intervention at reducing postoperative pediatric opioid prescribing may be tied to the specialty-specific role model relationship of the educator to the prescriber.

TYPE OF STUDY

retrospective comparative chart review.

LEVEL OF EVIDENCE

IV.

Role modelling in the training of hospital-based medical specialists: a validation study of the Role Model Apperception Tool (RoMAT)

INTRODUCTION

Role modelling is a key component in the training of doctors that influences professional behaviour, identity and career choices. Clinical teachers and residents are often unaware of this, thereby risking transmission of negative behaviour. On the other hand, awareness positively affects role model behaviour. To assess role model behaviour, the Role Model Apperception Tool (RoMAT) was developed and validated in general practice training. The aim of the current study was to validate the RoMAT in the hospital-based training setting.

METHODS

The authors asked first to last year residents, regardless of their specialty, to participate after written approval from their clinical teachers. The tool was completed online in 2017. The authors performed a principal component analysis and investigated internal consistency, construct validity, inter-rater reliability, known-groups comparisons and floor and ceiling effects.

RESULTS

Of the 473 residents contacted, 187 (40%) completed the questionnaire. As in the primary validation study, the authors extracted two components: 'Caring Attitude' and 'Effectiveness', explaining 67% of the variation with a Cronbach's alpha of 0.94 and 0.93 respectively. Evidence for construct validity was found and there were no floor or ceiling effects, but inter-rater reliability was low.

DISCUSSION

The RoMAT was internally consistent and valid to assess role model behaviour of the clinical teacher towards the resident in the hospital-based training of medical specialists. The poor inter-rater reliability, most likely due to homogeneous RoMAT responses, should be borne in mind when evaluating RoMAT scores on individual clinical teachers.

Twelve tips to promote a feedback culture with a growth mind-set: Swinging the feedback pendulum from recipes to relationships

Feedback in medical education has traditionally showcased techniques and skills of giving feedback, and models used in staff development have focused on feedback providers (teachers) not receivers (learners). More recent definitions have questioned this approach, arguing that the impact of feedback lies in learner acceptance and assimilation of feedback with improvement in practice and professional growth. Over the last decade, research findings have emphasized that feedback conversations are complex interpersonal interactions influenced by a multitude of sociocultural factors. However, feedback culture is a concept that is challenging to define, thus strategies to enhance culture are difficult to pin down. In this twelve tips paper, we have attempted to define elements that constitute a feedback culture from four different perspectives and describe distinct strategies that can be used to foster a learning culture with a growth mind-set.

A Professionalism and Mentoring Curriculum for Pathology Residents in Training

Professionalism is a core Accreditation Council for Graduate Medical Education competency. The Mentoring and Professionalism in Training Program was developed to promote humanism in health-care professionals in our health system. A modified version was implemented in the pathology residency program for professionalism competency. Twenty-one trainees were divided into 3 groups, with a facilitator who was a graduate of the system Mentoring and Professionalism in Training Program. Five sessions included topics on appreciative inquiry, active role modeling, conflict resolution, team building, feedback, mindfulness, and physician well-being. Participants completed pre- and postsurveys. Qualitative responses were very positive, for example, one participant felt the sessions helped “understand intricacies of workplace relationships and ways of effective, respectful, communication.” The Mentoring and Professionalism in Training is a curriculum that teaches team building, conflict resolution, and feedback along with strategies to balance well-being with professional commitments and growth. It is an effective educational tool that can satisfy the Accreditation Council for Graduate Medical Education professionalism curriculum.

Role models and professional development in dentistry: an important resource: The views of early career stage dentists at one academic health science centre in England

BACKGROUND

The importance of role models, and their differing influence in early, mid- and late careers, has been identified in the process of professional development of medical doctors. There is a paucity of evidence within dentistry on role models and their attributes.

AIM

To explore the views of early career dentists on positive and negative role models across key phases of professional development, together with role models' attributes and perceived influence.

METHODS

This is a phenomenological study collecting qualitative data through semi-structured interviews based on a topic guide. Dentists in junior (core training) hospital posts in one academic health science centre were all invited to participate. Interviews were recorded, transcribed verbatim and analysed using framework analysis.

RESULTS

Twelve early career stage dentists, 10 of whom were female, reported having role models, mainly positive, in their undergraduate and early career phases. Participants defined role models' attributes in relation to three distinct domains: clinical attributes, personal qualities and teaching skills. Positive role models were described as "prioritising the patient's best interests", "delivering learner-centred teaching and training" and "exhibiting a positive personality", whilst negative role models demonstrated the converse. Early career dentists reported having largely positive dentist role models during- and post-dental school and report their impact on professional values and aspirations, learning outcomes and career choice.

CONCLUSION

The findings suggest that these early career dentists in junior hospital posts have largely experienced and benefitted from positive role models, notably dentists, perceived as playing an important and creative influence promoting professionalism and shaping the career choices of early career stage dentists.

Assessing the Culture of Residency Using the C - Change Resident Survey: Validity Evidence in 34 U.S. Residency Programs

BACKGROUND

A practical instrument is needed to reliably measure the clinical learning environment and professionalism for residents.

OBJECTIVE

To develop and present evidence of validity of an instrument to assess the culture of residency programs and the clinical learning environment.

DESIGN

During 2014-2015, we surveyed residents using the C - Change Resident Survey to assess residents' perceptions of the culture in their programs.

PARTICIPANTS

Residents in all years of training in 34 programs in internal medicine, pediatrics, and general surgery in 14 geographically diverse public and private academic health systems.

MAIN MEASURES

The C - Change Resident Survey assessed residents' perceptions of 13 dimensions of the culture: Vitality, Self-Efficacy, Institutional Support, Relationships/Inclusion, Values Alignment, Ethical/Moral Distress, Respect, Mentoring, Work-Life Integration, Gender Equity, Racial/Ethnic Minority Equity, and self-assessed Competencies. We measured the internal reliability of each of the 13 dimensions and evaluated response process, content validity, and construct-related evidence validity by assessing relationships predicted by our conceptual model and prior research. We also assessed whether the measurements were sensitive to differences in specialty and across institutions.

KEY RESULTS

A total of 1708 residents completed the survey [internal medicine: n = 956, pediatrics: n = 411, general surgery: n = 311 (51% women; 16% underrepresented in medicine minority)], with a response rate of 70% (range across programs, 51-87%). Internal consistency of each dimension was high (Cronbach α: 0.73-0.90). The instrument was able to detect significant differences in the learning environment across programs and sites. Evidence of validity was supported by a good response process and the demonstration of several relationships predicted by our conceptual model.

CONCLUSIONS

The C - Change Resident Survey assesses the clinical learning environment for residents, and we encourage further study of validity in different contexts. Results could be used to facilitate and monitor improvements in the clinical learning environment and resident well-being.

Empathizing with patients: the role of interaction and narratives in providing better patient care

Recent studies have revealed a drop in the ability of physicians to empathize with their patients. It is argued that empathy training needs to be provided to both medical students and physicians in order to improve patient care. While it may be true that empathy would lead to better patient care, it is important that the right theory of empathy is being encouraged. This paper examines and critiques the prominent explanation of empathy being used in medicine. Focusing on the component of empathy that allows us to understand others, it is argued that this understanding is accomplished through a simulation. However, simulation theory is not the best explanation of empathy for medicine, since it involves a limited perspective in which to understand the patient. In response to the limitations and objections to simulation theory, interaction theory is presented as a promising alternative. This theory explains the physicians understanding of patients from diverse backgrounds as an ability to learn and apply narratives. By explaining how we understand others, without limiting our ability to understand various others, interaction theory is more likely than simulation theory to provide better patient care, and therefore is a better theory of empathy for the medical field.

Factors associated with students' perceptions of role modelling

OBJECTIVES

To determine which professional and humanistic attributes demonstrated by teachers in the health disciplines caused them to be perceived by students as positive or negative role models.

METHODS

Quantitative empirical data were gathered using a self-administered questionnaire by graduating students in medical, dentistry, and pharmacy schools at Kerman University of Medical Sciences. A total of 3 graduating cohorts, comprising about 220 students, were selected for this study. Surveys were distributed during January-March 2013.

RESULTS

In total, 183 students participated in the study. Altogether, students considered 504 and 473 academic staff as positive and negative role models (PRMs and NRMs), respectively. Women were considered more negatively than men (mean scores: -12.13 vs. -11.6, p=0.04). While clinicians were considered more positively than basic scientists (mean scores: 12.65 vs. 10.67, p=0.001), dentists received higher positive scores than physicians or pharmacists (average scores: 13.27 vs. 12.99 and 9.82). There was a significant relationship between the personality of the students and the overall characteristics of their perceived role models (β for PRMs=0.35, p<0.0001; and β for NRMs= 0.20, p= 0.039).

CONCLUSIONS

Humanistic and professional attributes were proposed as major components of personal traits in perceived role models. Demonstration of humanistic attributes by teachers was strongly correlated with the students' perception of the role models. It is suggested that the role of humanistic and professional attributes should be highlighted across medical disciplines in an effort to develop or improve role modelling by academic staff.

At sea with disability! Transformative learning in medical undergraduates voyaging with disabled sailors

CONTEXT

Attitudinal objectives are difficult to formulate, teach and assess; yet good attitudes are fundamental to good practice. For instance, studies highlight negative attitudes to disability in the medical student community that contrast with the self-conceptions of disabled persons. This study was designed to better understand attitudinal learning, inadequately addressed by contemporary programmes, through the application of Mezirow's 'transformative learning theory' (TLT) to a novel educational intervention.

METHODS

Participating students went to sea, for voyages of 5-7 days, in tall ships operated by the Jubilee Sailing Trust. Each student was buddied with another sailor living with disability. Disabilities included cerebral palsy, loss of sight, loss of limbs and paraplegia. Students recorded their experiences using audio diaries, written logs, formal voyage reports and art work and in post-voyage seminars. The data were analysed using interpretive phenomenological analysis, and the results are considered under five themes suggested by Mezirow.

RESULTS

Sixteen students were recruited, with four students sailing on each of four separate voyages. Each student recorded audio-diary entries, which had a total duration of between 10 and 212 minutes. For seven of the 16 students, the five key elements of TLT were demonstrable, suggesting that transformative learning, as described by Mezirow, was occurring. Drawing on diverse qualitative data, insights into different aspects of this transformation are provided.

CONCLUSIONS

TLT can be used to characterise, and thus design, educational interventions to meet attitudinal learning objectives. Students can be helped to discover their less helpful frames of reference. In safe environments these frames can be challenged and subjected to personal and communal reflection. Drawing on audio diaries and other evidence, and in answer to critiques of contemporary medical teaching on disability, we demonstrate such transformation in students 'at sea with disability', highlighting elements that could potentially be transferred to the mainstream curriculum.

The hidden process of positive doctor role modelling

BACKGROUND

Role modelling is highlighted as an important phenomenon. The aim of this research study was to explore the process of positive doctor role modelling.

METHODS

This study used focus group interviews with 52 medical students, semi-structured interviews with 25 consultants and interviews after clinics with five consultants and five medical students. A qualitative methodology using the grounded theory inquiry approach of Strauss and Corbin was then used to generate an explanation of the process of modelling.

RESULTS

Role modelling is a process that involves conscious and subconscious elements and consists of an exposure phase followed by an evolution phase: The exposure phase involves demonstration of the attributes by the doctor role models. The evolution phase begins with observation of the role model, following which the modellee makes a judgement whether to trial the observed behaviours; when the decision to trial is reached, this then leads to a model-trialling cycle.

CONCLUSION

This research study generated a detailed explanation of the process of doctor role modelling. It is aspired that this can now be incorporated into medical curricula worldwide to enhance the development of the doctor role model and the professional development of the modellee.

Preceptors' understanding and use of role modeling to develop the CanMEDS competencies in residents

PURPOSE

Role modeling by preceptors is a key strategy for training residents in the competencies defined within the CanMEDS conceptual framework. However, little is known about the extent to which preceptors are aware of the importance of role modeling or how they perceive and enact it in their daily interactions with residents. The purpose of this study was to describe how preceptors understand and use role modeling to develop CanMEDS competencies in residents.

METHOD

In 2010, the authors conducted a descriptive qualitative study with preceptors in medical, surgical, and laboratory specialties who supervised residents on a regular basis at the Université Laval Faculty of Medicine (Québec, Canada). Respondents participated in semistructured, individual interviews. An inductive thematic analysis of interview transcripts was conducted using triangulation.

RESULTS

Most participants highlighted the importance of role modeling to support residents' development of the CanMEDS competencies, particularly communication, collaboration, and professionalism, which preceptors perceived as "less scientific" and the most difficult to teach. Although most participants reported using an implicit, unstructured role modeling process, some described more explicit strategies. Eight types of educational challenges in role modeling the CanMEDS competencies were identified, including encouraging reflective practice, understanding the competencies and their importance in one's specialty, and being aware of one's strengths and weaknesses as a clinical teacher.

CONCLUSIONS

Preceptors are aware of the importance of role modeling competencies for residents, but many do so only implicitly. This study's findings are important for improving strategies for role modeling and for the professional development of preceptors.

Role modeling in medical education: the importance of a reflective imitation

The medical literature almost uniformly addresses the positive aspects of role modeling. Still, some authors have questioned its educational value, a disagreement that is probably due to differing definitions of role modeling. If defined as demonstration of skills, provision of feedback, and emulation of specific professional behaviors, then role modeling is an important component of clinical training. However, if it is defined as a learner's unselective imitation of role models and uncritical adoption of the messages of the learning environment, then the benefits of role modeling should be weighed against its unintended harm.In this Perspective, the author argues that imitation of role models may initially help students adapt to the clinical environment. However, if sustained, imitation may perpetuate undesirable practices, such as doctor-centered patient interviewing, and unintended institutional norms, such as discrimination between private and public patients. The author suggests that the value of role modeling can be advanced not only by targeting role models and improving faculty performance but also by enhancing students' reflective assessment of their preceptors' behaviors, especially so that they can better discern those that are worth imitating. This student-centered approach may be accomplished by first, warning students against uncritically imitating preceptors who are perceived as role models; second, showing students that their preceptors share their doubts and uncertainties; third, gaining an insight into possible undesirable messages of the learning environment; and finally, developing policies for faculty recruitment and promotion that consider whether a clinical preceptor is a role model.

Clinicians should be aware of their responsibilities as role models: a case report on the impact of poor role modeling

BACKGROUND

Role modeling is an important and valuable educational method. It is predominant throughout (under-)graduate medical education, and attributes of exemplary medical role models are manifold.

AIM

This article describes the impact of poor role modeling on medical students' professional and personal development on the basis of a singular incident at an associated teaching hospital. In addition, scientific literature studying the effect of and the reasons behind poor role modeling in undergraduate and graduate medical education is analyzed and discussed.

RESULTS

To maximize the educational potential of clinical role modeling, medical schools have to consider strategies both on the individual as well as on the institutional level. Several suggestions are offered on both levels.

DISCUSSION/CONCLUSION

Based on a case report of significantly poor role modeling, this article outlines strategies through which academic medical institutions may maximize the educational potential of role modeling and lastingly enhance teaching proficiency of clinical faculty.

Knowing and acting in the clinical workplace: trainees' perspectives on modelling and feedback

In this article we discuss clinical workplace learning using a dual approach: a theoretical one and an empirical one. Drawing on the philosophical work of Aristotle, Polanyi and Schön we posit that the 'knowing and acting' underpinning day-to-day medical practice is personal and embraces by nature a tacit dimension. Consequently, imparting and acquiring this knowledge type necessitates personal interaction between trainer and trainee. The tacit dimension particularly influences modelling and feedback. In our empirical exploration we explore these educational routes in two disparate disciplines: surgery and paediatrics. We use a longitudinal design with in-depth interviewing. Our conclusion on modelling is: modelling is a dynamic and fragmented process reflecting discipline bound characteristics and working styles. On feedback it is: 'feedback' serves as vehicle for three distinctive forms of commenting on performance, each holding a specific power of expression for learning. We propose to view clinical workplace learning as: an interactive master-apprenticeship model encompassing modelling and feedback as natural educational routes. We conceptualise modelling and feedback as 'function' of interaction (developing grounded theory). Modelling function and feedback function may serve to study these routes as didactical components of ongoing interaction between trainer and trainee rather than an educator-driven series of unrelated events.

Doctor role modelling in medical education: BEME Guide No. 27

AIM

The aim of this review is to summarise the evidence currently available on role modelling by doctors in medical education.

METHODS

A systematic search of electronic databases was conducted (PubMed, Psyc- Info, Embase, Education Research Complete, Web of Knowledge, ERIC and British Education Index) from January 1990 to February 2012. Data extraction was completed by two independent reviewers and included a quality assessment of each paper. A thematic analysis was conducted on all the included papers.

RESULTS

Thirty-nine studies fulfilled the inclusion criteria for the review. Six main themes emerged from the content of high and medium quality papers: 1) the attributes of positive doctor role models; 2) the personality profiles of positive role models; 3) the influence of positive role models on students' career choice; 4) the process of positive role modelling; 5) the influence of negative role modelling; 6) the influence of culture, diversity and gender in the choice of role model.

CONCLUSIONS

This systematic review highlights role modelling as an important process for the professional development of learners. Excellence in role modelling involves demonstration of high standards of clinical competence, excellence in clinical teaching skills and humanistic personal qualities. Positive role models not only help to shape the professional development of our future physicians, they also influence their career choices. This review has highlighted two main challenges in doctor role modelling: the first challenge lies in our lack of understanding of the complex phenomenon of role modelling. Second, the literature draws attention to negative role modelling and this negative influence requires deeper exploration to identify ways to mitigate adverse effects. This BEME review offers a preliminary guide to future discovery and progress in the area of doctor role modelling.

Factors influencing residents' evaluations of clinical faculty member teaching qualities and role model status

OBJECTIVES

  Evaluations of faculty members are widely used to identify excellent or substandard teaching performance. In order to enable such evaluations to be properly interpreted and used in faculty development, it is essential to understand the factors that influence resident doctors' (residents) evaluations of the teaching qualities of faculty members and their perceptions of faculty members as role-model specialists.

METHODS

  We carried out a cross-sectional survey within a longitudinal study of the System for Evaluation of Teaching Qualities (SETQ) of clinical teachers. The study sample included 889 residents and 1014 faculty members in 61 teaching programmes spanning 22 specialties in 20 hospitals in the Netherlands. Main outcome measures included residents' (i) global and (ii) specific ratings of faculty member teaching qualities, and (iii) global ratings of faculty members as role-model specialists. Statistical analysis was conducted using adjusted multivariable logistic generalised estimating equations.

RESULTS

  In total, 690 residents (77.6%) completed 6485 evaluations of 962 faculty members, 848 (83.6%) of whom also self-evaluated. More recently certified faculty members, those who had attended a teacher training programme, and those who spent more time teaching than seeing patients or conducting research were more likely to score highly on most teaching qualities. However, faculty members who had undergone teacher training were less likely to be seen as role models (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.59-0.88). In addition, faculty members were evaluated slightly higher by male than female residents on core teaching domains and overall teaching quality, but were less likely to be seen as role models by male residents (OR 0.80, 95% CI 0.67-0.97). Lastly, faculty members had higher odds of receiving top scores in specific teaching domains from residents in the first 4 years of residency and were less likely to be considered as role models by more senior residents.

CONCLUSIONS

  Younger faculty members who dedicated more time to teaching, had attended a teacher training programme, and were evaluated by male residents in the early years of residency were more likely to receive higher scores for teaching performance.

The devil is in the third year: a longitudinal study of erosion of empathy in medical school

PURPOSE

This longitudinal study was designed to examine changes in medical students' empathy during medical school and to determine when the most significant changes occur.

METHOD

Four hundred fifty-six students who entered Jefferson Medical College in 2002 (n = 227) and 2004 (n = 229) completed the Jefferson Scale of Physician Empathy at five different times: at entry into medical school on orientation day and subsequently at the end of each academic year. Statistical analyses were performed for the entire cohort, as well as for the "matched" cohort (participants who identified themselves at all five test administrations) and the "unmatched" cohort (participants who did not identify themselves in all five test administrations).

RESULTS

Statistical analyses showed that empathy scores did not change significantly during the first two years of medical school. However, a significant decline in empathy scores was observed at the end of the third year which persisted until graduation. Findings were similar for the matched cohort (n = 121) and for the rest of the sample (unmatched cohort, n = 335). Patterns of decline in empathy scores were similar for men and women and across specialties.

CONCLUSIONS

It is concluded that a significant decline in empathy occurs during the third year of medical school. It is ironic that the erosion of empathy occurs during a time when the curriculum is shifting toward patient-care activities; this is when empathy is most essential. Implications for retaining and enhancing empathy are discussed.

A proposal for overcoming problems in teaching interviewing skills to medical students

The objective of this paper is to draw attention to four features that distinguish the pedagogy of patient interviewing from the teaching of other clinical skills: (a) students are not naïve to the skill to be learned, (b) they encounter role models with a wide variability in interviewing styles, (c) clinical teachers are not usually specialists in the behavioral sciences, including patient interviewing, and (d) the validity of the methods used for assessment of interviewing skills is uncertain. We propose to adjust the teaching of patient interviewing to these features by (a) gaining an insight into the students' views and using these views as a point of departure for discussions of patient interviewing; (b) helping students to understand why different clinicians use different communication styles; (c) providing the clinical tutors with additional training that will help them function as both specialists who share their expertise with the students and facilitators of small-group learning; and (d) using assessment methods that encourage joint deliberation by the learner and the examiner, rather than a judgmental right-wrong dualism by the examiner alone. The teaching approach that we suggest is consistent with current theories of adult learning, and it occurs in an egalitarian rather than a hierarchical environment. Hopefully, students will also adopt such egalitarian attitudes toward patients, thereby reducing the tendency to a paternalistic communication style.

Teacher perceptions of desired qualities, competencies and strategies for clinical skills teachers

INTRODUCTION

Clinical skills centres (or Skillslabs) prepare students for patient-encounters. Evidence on teaching skills in these centres is lacking. What teaching skills do teachers view as effective in supporting the acquisition of physical examination skills in undergraduate medical training?

METHOD

Structured interviews of 10 teachers (1/3 of staff of Maastricht University, Skillslab) were conducted. Selection was based on even representation of age, years teaching experience, gender and previous experience at Maastricht University. A topic grid was used to ensure comparability. Interviews (average 70 min, range 33-95 min) were recorded and transcripts were analyzed independently by two researchers.

RESULTS

Teaching skills identified include the ability to adapt content of the training, level of depth and teaching method according to the needs of any particular group. Thorough comprehension of students' context (level of knowledge,prior experience and insight in the curriculum) is considered helpful. Explicitly inviting students to ask questions and providing relevant literature is seen to stimulate learning. Providing constructive feedback is essential, as is linking physical examination skills training to clinical situations. The ideal attitude includes appropriate dress and behaviour, as well as the use of humour. Affinity for teaching is regarded as the most important reason to work as a teacher.

CONCLUSION

Desired characteristics for undergraduate skills teachers resemble findings in other teaching roles. Affinity for teaching and flexibility in teaching methods are novel findings.

Role modelling--making the most of a powerful teaching strategy

Teachers need to be aware of the conscious and unconscious components of learning from role modelling, so that the net effect of the process is positive

Factors considered by medical students when formulating their specialty preferences in Japan: findings from a qualitative study

BACKGROUND

Little research addresses how medical students develop their choice of specialty training in Japan. The purpose of this research was to elucidate factors considered by Japanese medical students when formulating their specialty choice.

METHODS

We conducted qualitative interviews with 25 Japanese medical students regarding factors influencing specialty preference and their views on roles of primary versus specialty care. We qualitatively analyzed the data to identify factors students consider when developing specialty preferences, to understand their views about primary and subspecialty care, and to construct models depicting the pathways to specialization.

RESULTS

Students mention factors such as illness in self or close others, respect for family member in the profession, preclinical experiences in the curriculum such as labs and dissection, and aspects of patient care such as the clinical atmosphere, charismatic role models, and doctor-patient communication as influential on their specialty preferences. Participating students could generally distinguish between subspecialty care and primary care, but not primary care and family medicine. Our analysis yields a "Two Career" model depicting how medical graduates can first train for hospital-based specialty practice, and then switch to mixed primary/specialty care outpatient practice years later without any requirement for systematic training in principles of primary care practice.

CONCLUSION

Preclinical and clinical experiences as well as role models are reported by Japanese students as influential factors when formulating their specialty preferences. Student understanding of family medicine as a discipline is low in Japan. Students with ultimate aspirations to practice outpatient primary care medicine do not need to commit to systematic primary care training after graduation. The Two Career model of specialization leaves the door open for medical graduates to enter primary care practice at anytime regardless of post-graduate residency training choice.

Empathy and patient-physician conflicts

Physicians associate empathy with benevolent emotions and with developing a shared understanding with patients. While there have been many articles on managing "difficult" patients, little attention has been paid to the challenges physicians face during conflicts with patients, especially when both parties are angry and yet empathy is still needed. This topic is especially important in light of recent studies showing that practicing medicine increasingly requires physicians to manage their own feelings of anger and frustration. This article seeks to describe how physicians can learn to empathize with patients even when they are both subject to emotions that lead to interpersonal distancing. Empathy is defined as engaged curiosity about another's particular emotional perspective. Five specific ways for physicians to foster empathy during conflict are described: recognizing one's own emotions, attending to negative emotions over time, attuning to patients' verbal and nonverbal emotional messages, and becoming receptive to negative feedback. Importantly, physicians who learn to empathize with patients during emotionally charged interactions can reduce anger and frustration and also increase their therapeutic impact.

Twelve tips for recruiting and retaining facilitators in a problem-based learning programme

Successful curriculum reform requires considerable staff development. It is imperative for management to ensure that its academic staff members are committed to the change. This requires planning and negotiation. As facilitators form the 'teaching' backbone of a problem-based learning programme, faculty management must ensure mechanisms are in place to recruit facilitators, and that once recruited, the experience is sufficiently rewarding personally for their enthusiasm to be sustained. This article offers several solutions to difficulties which many medical schools encounter during the early years of an undergraduate PBL programme which replaces a traditional curriculum. The advice offered ranges from recruiting facilitators from the private sector to encouraging staff to become involved in other areas of curriculum development. Most importantly, however, is the reward and incentive system, which must be well advertised in advance of any programme implementation. The suggestions presented in this article will be useful to faculties planning to implement problem-based learning as well as those who already have a programme in place.

Community paediatrics: soft science or firm foundations?

Community paediatrics strives to integrate the biology of health into the social and psychological worlds within which children grow and develop. Consumer demand for limited community paediatric clinical services is increasing and medico-legal pressures escalate professional and personal concern. Meanwhile, the profession, through training and professional support, has struggled to keep up. Research into community paediatrics and its integration into policy and clinical practice remains limited, raising the perception that it is a 'soft' science. Our viewpoint is that necessary progress in this field requires leadership, apprenticeship and research. We argue that to build firm foundations for the future requires structures to enable clinical specialisation and continuing professional development in this area.

Clinical role models are important in the early years of a problem-based learning curriculum

Following a comprehensive study of the role models identified by the first five years of students in a traditional medical programme, it was hypothesized that with curriculum reform clinical role models would assume greater importance earlier in the undergraduate medical programme. Indeed, when compared with their first- and second-year traditional curriculum colleagues, more problem-based learning students identified role models. Almost four times as many identified faculty role models (largely medically qualified) in comparison with their traditional curriculum counterparts. Concomitant with this increase was a decline in the selection by the PBL students of family members, friends and other students as role models. For all cohorts, however, the mother was the most important role model. Since students in integrated curricula have earlier clinical experience and patient contact, they interact with clinicians in hospitals and clinics as well as in the academic environment of the small-group tutorial and lecture theatres. Academic faculty members, particularly clinicians, need to be aware that students take note of their attitudes and behaviour as members of the medical profession, a profession that students had chosen as a career. Retraining of senior doctors from the traditional curriculum might be necessary to ensure that all clinicians have an equivalent understanding of patient care.

Training in gastrointestinal motility

Gastrointestinal (GI) motility and functional GI disorders are common reasons for patients to see gastroenterologists. Knowledge of the evaluation and treatment of these disorders is important to appropriately care for these patients in clinical practice. Training in GI motility is important to GI fellows and their subsequent role as gastroenterologists. The aim of this paper is to discuss the importance of GI motility disorders for trainees in gastroenterology, provide some suggestions for training activities for GI fellows in GI motility, and discuss ways to address the unmet clinical need for caring for patients with GI motility disorders that gastroenterologists routinely see in their clinical practice.

An empirical study of decline in empathy in medical school

CONTEXT

It has been reported that medical students become more cynical as they progress through medical school. This can lead to a decline in empathy. Empirical research to address this issue is scarce because the definition of empathy lacks clarity, and a tool to measure empathy specifically in medical students and doctors has been unavailable.

OBJECTIVE

To examine changes in empathy among medical students as they progress through medical school.

MATERIALS AND SUBJECTS

A newly developed scale (Jefferson Scale of Physician Empathy [JSPE], with 20 Likert-type items) was administered to 125 medical students at the beginning (pretest) and end (post-test) of Year 3 of medical school. This scale was specifically developed for measuring empathy in patient care situations and has acceptable psychometric properties.

METHODS

In this prospective longitudinal study, the changes in pretest/post-test empathy scores were examined by using t-test for repeated measure design; the effect size estimates were also calculated.

RESULTS

Statistically significant declines were observed in 5 items (P < 0.01) and the total sores of the JSPE (P < 0.05) between the 2 test administrations.

CONCLUSIONS

Although the decline in empathy was not clinically important for all of the statistically significant findings, the downward trend suggests that empathy could be amenable to change during medical school. Further research is needed to identify factors that contribute to changes in empathy and to examine whether targeted educational programmes can help to retain, reinforce and cultivate empathy among medical students for improving clinical outcomes.

A faculty development program evaluation: from needs assessment to long-term effects, of the teaching skills improvement program

BACKGROUND

We evaluated whether the faculty development program, the Teaching Skills Improvement Program, met medical educators' needs at Hacettepe University Faculty of Medicine, Turkey. In a 1997 needs assessment survey, large proportions of 178 medical educators assessed their knowledge of educational issues and teaching skills as good or excellent. Nonetheless, 86% of the respondents stated they would like to participate in a future training program focused on the content indicated in the survey.

DESCRIPTION AND EVALUATION

In 1998, 83 faculty members took part in the program and expressed a high degree of satisfaction with its content and organization, as well as the course trainers' teaching. Most of the participants got high scores on a test of knowledge related to the course content and performed proficiently in a microteaching session.

CONCLUSION

Six months to a year later, large proportions of the participants reported using many of the training techniques in their teaching program.

What can we learn from facilitator and student perceptions of facilitation skills and roles in the first year of a problem-based learning curriculum?

BACKGROUND

The small group tutorial is a cornerstone of problem-based learning. By implication, the role of the facilitator is of pivotal importance. The present investigation canvassed perceptions of facilitators with differing levels of experience regarding their roles and duties in the tutorial.

METHODS

In January 2002, one year after problem-based learning implementation at the Nelson R. Mandela School of Medicine, facilitators with the following experience were canvassed: trained and about to facilitate, facilitated once only and facilitated more than one six-week theme. Student comments regarding facilitator skills were obtained from a 2001 course survey.

RESULTS

While facilitators generally agreed that the three-day training workshop provided sufficient insight into the facilitation process, they become more comfortable with increasing experience. Many facilitators experienced difficulty not providing content expertise. Again, this improved with increasing experience. Most facilitators saw students as colleagues. They agreed that they should be role models, but were less enthusiastic about being mentors. Students were critical of facilitators who were not up to date with curriculum implementation or who appeared disinterested. While facilitator responses suggest that there was considerable intrinsic motivation, this might in fact not be the case.

CONCLUSIONS

Even if they had facilitated on all six themes, facilitators could still be considered as novices. Faculty support is therefore critical for the first few years of problem-based learning, particularly for those who had facilitated once only. Since student and facilitator expectations in the small group tutorial may differ, roles and duties of facilitators must be explicit for both parties from the outset.

Fostering students' personal and professional development in medicine: a new framework for PPD

CONTEXT

Altruism, accountability, duty, integrity, respect for others and lifelong learning are qualities that have been identified as central to medical professionalism. However, we do not have a systematically developed understanding of what is needed to optimise medical students' personal and professional development (PPD). We need some level of agreement on how to teach and assess PPD, but traditional educational methods may not be strong determinants of students' or graduates' actual behaviour in clinical settings.

AIMS

This paper considers the factors that demonstrably influence doctors' behaviour as a contribution to the development of a model for considering PPD within the broader context of medical practice. The model presented acknowledges that behaviour change comes about through a number of influences including education, feedback, rewards, penalties and participation. These elements can be plotted against the cognitive, affective and metacognitive processes that are intrinsic to learning.

IMPLICATIONS

A framework that promotes the consideration of all of these factors in PPD can provide guidance for schools undergoing curriculum reform and inform further research into one of the most important and challenging aspects of medical education.

Clerkship directors' perceptions of the effects of managed care on medical students' education

PURPOSE

Little is known about the effect of managed care on medical students' education. Because clerkship directors (CDs) are especially well positioned to observe any changes, this study surveyed CDs from six medical specialties about their perceptions of the effects of managed care on medical students' education.

METHOD

Anonymous questionnaires were mailed to 808 CDs from departments of six medical specialties at 125 U.S. allopathic medical schools between October 1997 and March 1998. Among other questions, respondents were asked whether they had observed changes in 19 different aspects of medical students' education, whether these changes were beneficial or detrimental, and whether they believed the changes were due to managed care and/or to other factors. Results were analyzed to determine perceptions of the overall magnitude and source(s) of changes, the perceived positive versus negative effect of managed care, and whether these outcomes were statistically associated with the perceived degree of managed care's market penetration.

RESULTS

Five hundred questionnaires (61.9%) were returned. For full-time and voluntary faculty teaching, faculty availability for educational administration, directors' clinical responsibilities, and quality of professional life, the most common response was that managed care had an adverse effect. For faculty's enthusiasm for teaching, directors' administrative and educational duties, and clerkship training sites, the second most common response after "not changed" was that managed care had a negative effect. The majority of respondents held negative opinions of managed care and thought that medical students did not understand it.

CONCLUSIONS

CDs in six medical specialties perceived that managed care has negatively affected medical students' education. These perceptions may influence medical students' education. Measures must be taken to ensure excellent education through adequate resources and training in the context of high-quality medical care.

Career choice influences in Australian anaesthetists

All female members and a randomly selected group of male members of the Australian Society of Anaesthetists (n = 488) were surveyed by questionnaire as part of a broader study of gender issues in anaesthesia. This paper reports on reasons for career choice and the importance of role models. Responses were received from 199 women and 98 men (60.9% of those surveyed), representing all States and one Territory. Most males (95.9%) and a majority of females (55.7%) worked full-time. Reasons for career choice varied with gender, with a significantly greater proportion of women (39.7%) than men (8.7%) choosing anaesthesia because of controllable hours, particularly the ability to work part-time. Experiences in anaesthesia during internship and residency were important for 19.1% of women and 14.1% of men, although very few mentioned undergraduate exposure. Other important factors in career choice were the application of physiology and pharmacology in patient care, practical and procedural aspects of practice, and chance. A majority of women (56%) and men (55%) named specific role models who were influential and encouraging in their choice. These results are similar to those of other studies.

Senior residents' views on the meaning of professionalism and how they learn about it

PURPOSE

To determine senior residents' views on the meaning of professionalism and how they learned about it.

METHOD

By means of a modified Dillman technique, all senior residents at two faculties of medicine (n = 533) were surveyed about professionalism during the 1998-99 academic year. The residents were asked to list attributes of professionalism and to rank methods they found most useful for learning about professionalism, to rate the adequacy and quality of their teaching about professionalism and their comfort in explaining the concept of professionalism to a more junior trainee, to list suggestions about how teaching about professionalism could be improved, and to name the medical organization most concerned with matters of professionalism.

RESULTS

A total of 258 residents (48.4%) responded. They listed 1,052 attributes they associated with professionalism. The three most common attributes, all listed by more than 100 respondents, were respect, competence, and empathy. The respondents had learned the most about professionalism from observing role models, they rated the quantity and quality of teaching about it positively, and they felt comfortable explaining professionalism to a junior resident. Only 56% of the residents correctly identified the Canadian medical organization most concerned with professionalism.

CONCLUSION

Residents' knowledge about professionalism reflects their early stage of development as physicians and their daily activities, where such aspects of professionalism as the social contract, codes of ethics, participation in professional societies, and altruism are not highlighted. Residency programs should develop teaching activities focusing on professionalism that relate to issues residents face in their daily work.

Identifying characteristics that students, interns and residents look for in their role models

OBJECTIVE

To identify characteristics which students, interns and residents look for in their role models.

METHODS

A 45-item self-administered questionnaire was sent to a sample (n=96, response rate 80%) consisting of three groups: (1) students in years 3-6 of the medical curriculum (n=66); (2) interns (n=17) and (3) residents (n=13). The questionnaire contained characteristics that participants might use to describe excellent role models, grouped under five general headings: personality, clinical, research and teaching skills, and community service. Other characteristics mentioned by study subjects were qualitatively analysed using content analysis.

RESULTS

Personality and teaching and clinical skills were ranked as the top three factors, and research skills and community service as the least important factors by 79 (82%) respondents. Qualitative analysis of characteristics described by respondents for their role models yielded 21 characteristics. These were clustered into three main themes: role models as teacher, physician and person. The most frequently mentioned characteristics were personal characteristics such as positive, respectful attitudes toward patients and their families, and staff and colleagues; honesty; politeness; enthusiasm; competence, and knowledge. Females rated nine personal characteristics significantly higher than males (P < 0.05). Interns and residents valued teaching enthusiasm and competence significantly more than students (P=0.01). Role models had a strong influence on the specialty choice of 53 (55%) respondents.

CONCLUSION

Knowing the characteristics of excellent role models should help medical educators to formulate strategies to recruit, retain and develop them. Increasing exposure of a variety of excellent role models to aspiring medical practitioners should be encouraged.

CeMENT: evaluation of a regional development programme integrating hospital and general practice clinical teaching for medical undergraduates. The Community-Based Medical Education in North Thames

OBJECTIVES

To determine the feasibility and effectiveness of shared hospital and general practice clinical teaching for medical undergraduates.

DESIGN

A multifaceted approach employing quantitative and qualitative techniques.

SETTING

All medical schools in North Thames Region.

SUBJECTS

Students, GP tutors and hospital specialists.

RESULTS

The model was successfully adopted in a broad range of clinical specialties in all of the participating medical schools, resulting in a doubling of the involvement of general practice in clinical teaching. Participating students provided an overwhelmingly positive evaluation of the attachments and there was a clear perception of benefit amongst the participating GPs. However, the views of the participating hospital clinicians were less positive and the true nature and extent of the educational impact proved difficult to assess.

CONCLUSIONS

This model of collaborative clinical teaching between hospital and general practice can be implemented in accordance with the project's key aims, but the enthusiastic involvement of hospital clinicians may be difficult to secure.

Quo vadis, psychiatry? Problems and potential for the future of medical student education in psychiatry

Psychiatric education occupies a relatively low status level in most academic departments of psychiatry. This problem may be in part because career teachers rarely generate sustained external grant support. Their salaries may be regarded as perpetual drains on the budgets of department chairs. The author explores a possible relationship between the decline in the emphasis on psychiatric education and the decline in the number of medical students entering psychiatric residency programs. Recommendations for improvement in the support of psychiatric education are made that focus on greater accountability of how tuition fees are distributed to support the salaries of faculty educators. The unique role that consultation-liaison (C-L) psychiatry occupies in psychiatric education, the effects of managed care on C-L psychiatry, and the special problems that C-L psychiatry currently faces with its strong emphasis on non-reimbursable educational activities are discussed. Revitalization of the importance of education in undergraduate medical education is vital for the future of psychiatry.

The collaborative health care team: the role of individual and group expertise

BACKGROUND

Increasing costs of health care and rapid knowledge growth have led to collaboration among health care professionals to share knowledge and skills.

PURPOSES

To characterize the qualitative nature of team interaction and its relation to training health professionals, drawing on theoretical and analytical frameworks from the sociocognitive sciences.

METHODS

Activities in a primary care unit were monitored using observational field notes, hospital documents, and audio recordings of interviews and clinical interactions.

RESULTS

The demarcation of responsibilities and roles of personnel within the team became fuzzy in practice. Continuous care was provided by primary care providers and specialized care by intermittent consultants. The nature of individual expertise required was a function of the patient problem and the interaction goal. These team characteristics contributed to the reduction of unnecessary and redundant interactions.

CONCLUSIONS

Distributed responsibilities allow the team to process massive amounts of patient information, reducing the cognitive load on individuals. The uniqueness of individual professional expertise as it contributes to the accomplishment of team goals is highlighted, suggesting emphasis on conceptual competence in the development of individual professional education programs.