How clinical teachers perceive the doctor-patient relationship and themselves as role models

It Is Never Too Early to Start: Educating Health Science Students to Become Future Educators

Teachers lead, learn, and live as they walk through the journey of education, experiencing humanity in and outside their classrooms. No task is small when it comes to teaching; it is a craftsmanship that takes years to develop, and never too early to get started. In this commentary, the authors extract thoughtful viewpoints from years of teaching experience regarding how to inspire and engage more students to become educators. After all, nothing is more exciting and rewarding for a teacher than to make more and better teachers.

Role modelling in professional identity formation: a systematic scoping review

BACKGROUND

Role modelling's pivotal part in the nurturing of a physician's professional identity remains poorly understood. To overcome these gaps, this review posits that as part of the mentoring spectrum, role modelling should be considered in tandem with mentoring, supervision, coaching, tutoring and advising. This provides a clinically relevant notion of role modelling whilst its effects upon a physician's thinking, practice and conduct may be visualised using the Ring Theory of Personhood (RToP).

METHODS

A Systematic Evidence Based Approach guided systematic scoping review was conducted on articles published between 1 January 2000 to 31 December 2021 in the PubMed, Scopus, Cochrane, and ERIC databases. This review focused on the experiences of medical students and physicians in training (learners) given their similar exposure to training environments and practices.

RESULTS

12,201 articles were identified, 271 articles were evaluated, and 145 articles were included. Concurrent independent thematic and content analysis revealed five domains: existing theories, definitions, indications, characteristics, and the impact of role modelling upon the four rings of the RToP. This highlights dissonance between the introduced and regnant beliefs and spotlights the influence of the learner's narratives, cognitive base, clinical insight, contextual considerations and belief system on their ability to detect, address and adapt to role modelling experiences.

CONCLUSION

Role modelling's ability to introduce and integrate beliefs, values and principles into a physician's belief system underscores its effects upon professional identity formation. Yet, these effects depend on contextual, structural, cultural and organisational influences as well as tutor and learner characteristics and the nature of their learner-tutor relationship. The RToP allows appreciation of these variations on the efficacy of role modelling and may help direct personalised and longitudinal support for learners.

Optimal training in communication model (OPTiCOM): A programmatic roadmap

OBJECTIVES

Teaching primary care residents patient communication skills is essential, complex, and impeded by barriers. We find no models guiding faculty how to train residents in the workplace that integrate necessary system components, the science of physician-patient communication training and competency-based medical education. The aim of this project is to create such a model.

METHODS

We created OPTiCOM using four steps: (1) communication educator interviews, analysis and theme development; (2) initial model construction; (3) model refinement using expert feedback; (4) structured literature review to validate, refine and finalize the model.

RESULTS

Our model contains ten interdependent building blocks organized into four developmental tiers. The Foundational value tier has one building block Naming relationship as a core value. The Expertize and resources tier includes four building blocks addressing: Curricular expertize, Curricular content, Leadership, and Time. The four building blocks in the Application and development tier are Observation form, Faculty development, Technology, and Formative assessment. The Language and culture tier identifies the final building block, Culture promoting continuous improvement in teaching communication.

CONCLUSIONS

OPTiCOM organizes ten interdependent systems building blocks to maximize and sustain resident learning of communication skills. Practice Implications Residency faculty can use OPTiCOM for self-assessment, program creation and revision.

A multisite randomized trial of implicit versus explicit modeling in clinical teaching

PURPOSE

Faculty modeling of desired behaviors has historically been a part of the apprenticeship model of clinical teaching, yet little is known about best practices for modeling. This study compared the educational impact of implicitly versus explicitly modeled communication skills among U.S. medical students.

METHOD

Fourth-year medical students from six U.S. academic medical centers were randomly assigned one simulated clinical encounter in which faculty provided either implicit or explicit modeling of important communication skills. Outcomes were assessed by electronic surveys immediately before and after the simulations. Students were blinded to the purpose of the study.

RESULTS

Students in the explicit arm were more likely to correctly cite two of the three key specific communication elements modeled by faculty: deliberate body position (53.3% vs. 18.6%, p < 0.001) and summarizing patient understanding (62.2% vs. 11.6%, p < 0.001). More students in the explicit study arm reported faculty 'demonstrated a key behavior that they wanted me to be able to perform in the future' (93.2% versus 62.8%, p = 0.002). Participating faculty stated they would modify their teaching approach in response to their experiences in the study.

CONCLUSIONS

In a multi-center randomized trial, explicit faculty role-modeling led to greater uptake of communication knowledge, greater recognition of skills, and a greater sense that faculty expected these skills to be adopted by students. These results must be considered in the context, however, of a simulated environment and a short timeframe for assessing learning with students who volunteered for a simulated experience.

Collaborators as a key to survival: an ethnographic study on newly graduated doctors' collaboration with colleagues

BACKGROUND

Newly graduated doctors find their first months of practice challenging and overwhelming. As the newly graduated doctors need help to survive this period, collaborators such as peers, senior doctors, registered nurses and other junior doctors are crucial. However, little is known about what characterise these collaborations, and how much is at stake when newly graduated doctors are striving to establish and maintain them. This study aims to describe and explore the collaborations in depth from the newly graduated doctors' point of view.

METHODS

We conducted 135 h of participant observations among newly graduated doctors (n = 11), where the doctors were observed throughout their working hours at various times of the day and the week. Furthermore, six semi-structured interviews (four group interviews and two individual) were carried out. The data was analysed thematically.

RESULTS

Newly graduated doctors consulted different collaborators (peers, senior doctors, registered nurses, and other junior doctors) dependent on the challenge at hand, and they used different strategies to get help and secure good relationships with their collaborators: 1) displaying competence; 2) appearing humble; and 3) playing the game. Their use of different strategies shows how they are committed to engage in these collaborations, and how much is at stake.

CONCLUSIONS

Newly graduated doctors rely on building relationships with different collaborators in order to survive their first months of practice. We argue that the collaboration with peer NGDs and registered nurses has not received the attention it deserves when working with the transition from medical school. We highlight how it is important to focus on these and other collaborators and discuss different work-agendas, mutual expectations, and interdependence. This could be addressed in the introduction period and be one way to ensure a better learning environment and a respectful interprofessional culture.

The impact of role modelling on the future general practitioner workforce: a systematic review

Role modelling has been identified as an important phenomenon in medical education. Key reports have highlighted the ability of role modelling to support medical students towards careers in family medicine although the literature of specific relevance to role modelling in speciality has not been systematically explored. This systematic review aimed to fill this evidence gap by assimilating the worldwide literature on the impact of role modelling on the future general practitioner (GP) workforce. A systematic search was conducted in Medline, Embase, Scopus, Web of Science, Cochrane, ERIC and CINAHL, and all authors were involved in the article screening process. A review protocol determined those articles selected for inclusion, which were then quality assessed, coded and thematically analysed. Forty-six articles were included which generated four broad themes: the identity of role models in general practice, role modelling and becoming a doctor, the impact of role modelling on attitudes towards the speciality, and the subsequent influence on behaviours/career choice. Our systematic review confirmed that role modelling in both primary and secondary care has a crucial impact on the future GP workforce, with the potential to shape perceptions, to attract and deter individuals from the career, and to support their development as professionals. Role modelling must be consciously employed and supported as an educational strategy to facilitate the training of future GPs.

School connection through engagement associated with grade scores and emotions of adolescents: four factors to build engagement in schools

This study investigated school connectedness, student engagement, academic grades, and student affect. Factor analyses of 331 adolescent students (Years 7, 9, and 11 in Australia), validated a four-factor model of school engagement. The factors revealed in the analyses were described as (1) future and task focus, (2) planning and motivation, (3) positive roles and models, and (4) positive social engagement. Cluster analyses revealed two typologies of students: a thriving group scoring significantly higher on all four factors than a striving group. There was a consistent number of students in each group across Years 7, 9 and 11. Compared to students in the striving group, on average, students in the thriving group scored significantly higher on grades (i.e., mathematics and English). Moreover, students in the thriving group were significantly higher on content and excited affects, and significantly less depressed and distressed compared to the students in the striving group. Limitations and implications for research and practice are discussed.

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.

The use of text mining to detect key shifts in Japanese first-year medical student professional identity formation through early exposure to non-healthcare hospital staff

BACKGROUND

Professional identity formation is nurtured through socialization, driven by interaction with role models, and supported through early clinical exposure (ECE) programmes. Non-healthcare professionals form part of the hospital community but are external to the culture of medicine, with their potential as role models unexplored. We employed text mining of student reflective assignments to explore the impact of socialization with non-healthcare professionals during ECE.

METHODS

Assignments from 259 first-year medical students at Fukushima Medical University, Japan, underwent hierarchical cluster analysis. Interrelationships between the most-frequently-occurring words were analysed to create coding rules, which were applied to elucidate underlying themes.

RESULTS

A shift in terms describing professional characteristics was detected, from "knowledge/skill" towards "pride [in one's work]" and "responsibility". Seven themes emerged: contribution of non-healthcare professionals, diversity of occupation, pride, responsibility, teamwork, patient care and gratitude. Students mentioning 'contribution of non-healthcare professionals' spoke of altruistic dedication and strong sense of purpose. These students expressed gratitude towards non-healthcare professionals for supporting clinical work, from a doctor's perspective.

CONCLUSION

Socialization with non-healthcare professionals provides important insights into the hospital working environment and cultural working norms. Through role modelling altruism and responsibility, non-healthcare professionals positively influenced student professional identity formation, promoting self-conceptualisation as a doctor.

Key tips for teaching in the clinical setting

Teaching with real patients in the clinical setting lies at the heart of health professional education, providing an essential component to clinical training. This is true of all the health disciplines - particularly medicine, nursing, dentistry, physiotherapy, and dietetics. Clinical tutorials orientate students to the culture and social aspects of the healthcare environment, and shape their professional values as they prepare for practice. These patient-based tutorials introduce students to the clinical environment in a supervised and structured manner, providing opportunities to participate in communication skills, history taking, physical examination, clinical reasoning, diagnosis and management. It is only through participation that new practices are learnt, and progressively, new tasks are undertaken. The aim of this paper is to provide health professional students and early career health professionals involved in peer and near peer teaching, with an overview of approaches and key tips for teaching in the clinical setting. Although there are many competencies developed by students in the clinical setting, our tips for teaching focus on the domains of medical knowledge, interpersonal and communication skills, and professionalism.

Barriers to teaching communication skills in Spanish medical schools: a qualitative study with academic leaders

BACKGROUND

In recent years, Spanish medical schools (MSs) have incorporated training in communication skills (CS), but how this training is being carried out has not yet been evaluated.

OBJECTIVE

To identify the barriers to the introduction and development of CS teaching in Spanish MSs.

METHODS

In a previous study, 34 MSs (83% of all MSs in Spain) were invited to participate in a study that explored the factual aspects of teaching CS in these schools. The person responsible for teaching CS at each school was contacted again for this study and asked to respond to a single open-ended question. Two researchers independently conducted a thematic analysis of the responses.

RESULTS

We received responses from 30 MSs (85.7% of those contacted and 73% of all MSs in Spain). Five main thematic areas were identified, each with different sub-areas: negative attitudes of teachers and academic leaders; organisation, structure and presence of CS training in the curriculum; negative attitudes of students; a lack of trained teachers; and problems linked to teaching methods and necessary educational logistics.

CONCLUSIONS

The identified barriers and problems indicate that there are areas for improvement in teaching CS in most Spanish MSs. There seems to be a vicious circle based on the dynamic relationship and interdependence of all these problems that should be faced with different strategies and that requires a significant cultural shift as well as decisive institutional support at the local and national levels. The incorporation of CS training into MS curricula represents a major challenge that must be addressed for students to learn CS more effectively and avoid negative attitudes towards learning CS.

Educational roles as a continuum of mentoring's role in medicine - a systematic review and thematic analysis of educational studies from 2000 to 2018

BACKGROUND

Recent studies have gone to great lengths to differentiate mentoring from teaching, tutoring, role modelling, coaching and supervision in efforts to better understand mentoring processes. This review seeks to evaluate the notion that teaching, tutoring, role modelling, coaching and supervision may in fact all be part of the mentoring process. To evaluate this theory, this review scrutinizes current literature on teaching, tutoring, role modelling, coaching and supervision to evaluate their commonalities with prevailing concepts of novice mentoring.

METHODS

A three staged approach is adopted to evaluate this premise. Stage one involves four systematic reviews on one-to-one learning interactions in teaching, tutoring, role modelling, coaching and supervision within Internal Medicine, published between 1st January 2000 and 31st December 2018. Braun and Clarke's (2006) approach to thematic analysis was used to identify key elements within these approaches and facilitate comparisons between them. Stage two provides an updated view of one-to-one mentoring between a senior physician and a medical student or junior doctor to contextualise the discussion. Stage three infuses mentoring into the findings delineated in stage one.

RESULTS

Seventeen thousand four hundred ninety-nine citations were reviewed, 235 full-text articles were reviewed, and 104 articles were thematically analysed. Four themes were identified - characteristics, processes, nature of relationship, and problems faced in each of the four educational roles.

CONCLUSIONS

Role modelling, teaching and tutoring, coaching and supervision lie within a mentoring spectrum of increasingly structured interactions, assisted by assessments, feedback and personalised support that culminate with a mentoring approach. Still requiring validation, these findings necessitate a reconceptualization of mentoring and changes to mentor training programs and how mentoring is assessed and supported.

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.

Clinical teachers as positive and negative role models: an explanatory sequential mixed method design

Today, role modeling is an essential component of medical education that facilitates the students' learning and affects their attitudes and behaviors. Hence, this study aimed to examine the characteristics of positive and negative role models using a mixed method approach. In the quantitative part, data were collected using a questionnaire with 24 items. The research population included medical students who were in their clinical period between May 2017 and December 2018 at Shiraz University of Medical Sciences (n = 750). A total of 282 questionnaires were completed by these students, and in the qualitative part, 26 semi-structured interviews were conducted with them.

The most important components of role modeling for students included: individual characteristics, clinical skills and competence, teaching skills and professionalism, in that order. The qualitative analysis confirmed the results of the quantitative analysis. The findings showed that the characteristics of a negative role model can also be classified in four main components. The results demonstrated that 46.8% of the students identified one or more medical teachers as negative models.

Students paid attention to not only the positive characteristics of their teachers, but also their negative features, stating that they had been influenced by both. Therefore, it can be concluded that clinical teachers should improve their performance as positive role models through reducing these negative effects and reinforcing positive characteristics.

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.

Talking About Professionalism Through the Lens of Professional Identity

Professionalism is one of the Accreditation Council for Graduate Medical Education's (ACGME) Core Competencies, but the breadth of its content often makes this a difficult topic, both in remedial counseling and when presenting the topic to medical trainees and practicing clinicians. Physician professionalism encompasses both clinical competence and the virtues that comprise the physician's social contract. This difficult subject may best be approached tangentially, through the lens of professional identity. Professional identity describes clinicians' affinity for, acculturation into, and identification with the practice of medicine. One method to highlight the benefits that individuals accrue by adopting professionalism's elements is to pose questions that optimize listeners' self-reflection about their lives and aspirations-in essence, their professional identity. Discussing professionalism this way often yields in-depth discussions of how trainees believe their professional identity was formed and will impact their long-term goals. Both in teaching and in counseling, educators can frame their discussions using professionalism and professional identity's overlapping and reinforcing elements to show listeners how to advance their personal and professional goals and avoid the short- and long-term consequences of unprofessional behavior. To engage the audience, educators and supervisors can emphasize how adhering to the elements of professionalism may determine their career opportunities, the professional respect they receive, and their career fulfillment and, ultimately, longevity. In this way, educators can better guide trainees and clinicians to understand their personal reasons for acting professionally, that is, doing the right thing, at the right time, in the right way, and for the right reason.

Medical students' professional identity development from being actors in an objective structured teaching exercise

INTRODUCTION

Medical students develop professional identity through structured activities and impromptu interactions in various settings. We explored if contributing to an Objective Structured Teaching Exercise (OSTE) influenced students' professional identity development.

METHODS

University clinical faculty members participated in a faculty development program on clinical supervision. Medical students who participated in OSTEs as simulated residents were interviewed in focus groups about what they learnt from the experience and how the experience influenced their vision of learning and teaching. Transcripts were analyzed using the Goldie's personality and social structure perspective model.

RESULTS

Twenty-five medical students out of 32 students involved in OSTEs participated. On an institutional level, students developed a feeling of belonging to the institution. At an interactional level, students realized they could influence the teaching interaction by actively seeking or giving feedback. On the personal level, students realized that errors could become sources of learning and felt better prepared to receive faculty feedback.

CONCLUSION

Taking part in OSTEs as a simulated resident has a positive impact on students' vision regarding the institution as a learning environment and their own role by actively seeking or giving feedback. OSTEs support their professional identity development regarding learning and teaching while sustaining faculty development.

Supervised workplace learning in postgraduate training: a realist synthesis

Context

This paper presents a realist synthesis of the literature that began with the objective of developing a theory of workplace learning specific to postgraduate medical education (PME). As the review progressed, we focused on informal learning between trainee and senior doctor or supervisor, asking what mechanisms occur between trainee and senior doctor that lead to the outcomes of PME, and what contexts shape the operation of these mechanisms and the outcomes they produce?

Methods

We followed the procedures outlined in the RAMESES Publication Standards for Realist Synthesis. We searched the English‐language literature published between 1995 and 2017 for empirical papers related to informal workplace learning between supervisor and trainee, excluding formal interventions such as workplace‐based assessment. We made a pragmatic decision to exclude general practice training to keep the review within manageable limits.

Results

We reviewed 5197 papers and selected 90. Synthesis revealed three workplace learning processes occurring between supervisors and trainees, each underpinned by a pair of mechanisms: supervised participation in practice (entrustment and support seeking); mutual observation of practice (monitoring and modelling), and dialogue during practice (meaning making and feedback). These mechanisms result in outcomes of PME, including safe participation in practice, learning skills, attitudes and behaviours and professional identity development. Contexts shaping the outcomes of these mechanisms were identified at individual, interpersonal, local and systems levels.

Conclusions

Our realist theory of workplace learning between supervisors and trainees is informed by theory and empirical research. It highlights the two‐way nature of supervision, the importance of trainees’ agency in their own learning and the deleterious effect of fragmented working patterns on supervisor–trainee learning mechanisms. Further empirical research is required to test and refine this theory. In the meantime, it provides a useful framework for the design of supportive learning environments and for the preparation of supervisors and trainees for their roles in workplace learning.

The authors describe a realist theory of learning between supervisor and postgraduate trainee in the workplace, emphasising the role of individual, interpersonal, local and systems contexts in shaping key mechanisms and their outcomes.

"The Longest Way Round Is The Shortest Way Home": An Overhaul of Surgical Ward Rounds

Background

Ward rounds, a keystone of hospital surgical practice, have recently been under the spotlight. Poor-quality ward rounds can lead to a greater number of adverse events, thereby cascading to an increased financial strain on our already burdened healthcare systems. Faced with mounting pressures from both outside and inside health organizations, concerted efforts are required to restore it back into prominence where it can no longer take a backseat to the other duties of a surgeon.

Methods

The nucleus of this narrative review is derived from an extensive literature search on surgical ward rounds.

Results

In this review, we focus on the need for reforms, current characteristics of surgical ward rounds, obstacles encountered by competing interests and proposed solutions in delivery of effective ward rounds that can meet with newly laid guidelines.

Conclusion

Ward rounds should be standardized and prioritized to improve patient care.

Teaching professionalism: some features in Canadian physiotherapy programs

The role of "professionalism" is core to many health professions including Physical Therapy (PT), and the development of competence in professionalism is a key requirement of entry-to-practice PT programs. However, the actual curriculum, teaching methodologies, and evaluation methods currently used to develop professional competence during PT training programs in Canada are unclear. This study explored current teaching practices, evaluation and curricular content related to professionalism in Canadian entry-to-practice PT programs. Results showed that teaching practices related to professionalism were not necessarily congruent with methods promulgated by educational theory and relied heavily on lecture, while more appropriate strategies such as simulation and role play were under-utilized. The numbers of different teaching methods utilized for specific aspects of professionalism were variable. Emphasis on different curricular areas related to professionalism also varied: communication was given the most emphasis while change management was under-represented. It is posited that teaching methods related to professionalism could be improved and curricular content and emphasis should also be reconsidered.

Developing skilled doctor-patient communication in the workplace: a qualitative study of the experiences of trainees and clinical supervisors

To inform the development of recommendations to facilitate learning of skilled doctor-patient communication in the workplace, this qualitative study explores experiences of trainees and supervisors regarding how trainees learn communication and how supervisors support trainees' learning in the workplace. We conducted a qualitative study in a general practice training setting, triangulating various sources of data to obtain a rich understanding of trainees and supervisors' experiences: three focus group discussions, five discussions during training sessions and five individual interviews. Thematic network analysis was performed during an iterative process of data collection and analysis. We identified a communication learning cycle consisting of six phases: impactful experience, change in frame of reference, identification of communication strategies, experimentation with strategies, evaluation of strategies and incorporation into personal repertoire. Supervisors supported trainees throughout this process by creating challenges, confronting trainees with their behaviour and helping them reflect on its underlying mechanisms, exploring and demonstrating communication strategies, giving concrete practice assignments, creating safety, exploring the effect of strategies and facilitating repeated practice and reflection. Based on the experiences of trainees and supervisors, we conclude that skilled communication involves the development of a personal communication repertoire from which learners are able to apply strategies that fit the context and their personal style. After further validation of our findings, it may be recommended to give learners concrete examples, opportunities for repeated practise and reflection on personal frames of reference and the effect of strategies, as well as space for authenticity and flexibility. In the workplace, the clinical supervisor is able to facilitate all these essential conditions to support his/her trainee in becoming a skilled communicator.

Dis-integration of communication in healthcare education: Workplace learning challenges and opportunities

The purpose of this paper, based on a 2016 Heidelberg International Conference on Communication in Healthcare (ICCH) plenary presentation, is to examine a key problem in communication skills training for health professional learners. Studies have pointed to a decline in medical students' communication skills and attitudes as they proceed through their education, particularly during their clinical workplace training experiences. This paper explores some of the key factors in this disintegration, drawing on selected literature and highlighting some curriculum efforts and research conducted at the University of Iowa Carver College of Medicine as a case study of these issues. Five key factors contributing to the disintegration of communication skills and attitudes are presented including: 1) lack of formal communication skills training during clinical clerkships; 2) informal workplace teaching failing to explicitly address learner clinical communication skills; 3) emphasizing content over process in relation to clinician-patient interactions; 4) the relationship between ideal communication models and the realities of clinical practice; and 5) clinical teachers' lack of knowledge and skills to effectively teach about communication in the clinical workplace. Within this discussion, potential practical responses by individual clinical teachers and broader curricular and faculty development efforts to address each of these factors are presented.

The impact of positive doctor role modeling

BACKGROUND

Role modeling has been highlighted as an important teaching and learning strategy. The aim of this research study was to explore the influences and impact of positive doctor role modelling in twenty-first century medical education.

METHODS

This study was part of a larger study investigating the process of positive doctor role modeling in medical education. 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 approach of Strauss and Corbin was then used to explore the impact of modeling in medical education.

RESULTS

Three main outcomes of role modeling were identified - the development of professional behaviors, the development of professional identity, and the shaping of career aspirations.

CONCLUSION

This study illustrates the powerful, often subconscious impact of doctor role modeling in medical education. This research illustrates that role models are critically important in the professional development, character development, and career development of the modelees. In this way, role modeling effectively enhances the transformation of the student to a doctor.

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.

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.

Effects of undergraduate medical students' individual attributes on perceptions of encounters with positive and negative role models

BACKGROUND

The use of role models (RMs) is a successful educational strategy. In formal training and other settings during undergraduate education, students have the opportunity to recognize numerous traits and behaviors of their RMs, such as teaching skills, professionalism in the clinical setting, and personal qualities. Encountering both positive and negative RMs allows medical students to learn a variety of professional norms and values. This learning process is likely influenced by a student's developmental status, which itself is related to that student's personal attributes and experiences. The purpose of this study was to examine graduating medical students' perceptions of their RM encounters and their learning processes, and how these perceptions and processes are affected by their own personal attributes.

METHODS

Sixth-year medical students were asked to complete questionnaires in 2013 and 2014 regarding encounters with positive or negative RMs, in terms of patient relationships, clinical expertise, teaching ability, and other factors, during clinical training and other situations. Associations between gender, age, admission status, and recognition of self-achievement and joy of learning in relation to RM encounters were then analyzed.

RESULTS

Among 115 students (75 males, 40 females) who completed the questionnaires, 113 (98.3 %) and 85 (73.9 %) reported encountering positive and negative RMs, respectively. The majority of students reported encountering both positive and negative RMs in terms of relationships with patients, humanity, and teaching ability, and fewer negative RMs in terms of clinical expertise and contributions to the community. Older students, males, and those who had passed an entrance examination for bachelors reported encountering more negative RMs in terms of relationships with patients, humanity, and teaching ability than younger students, females, and general admission students. These results suggested an association between positive and negative RM encounters and recognition of self-achievement and joy of learning in formal clinical training.

CONCLUSIONS

Most medical students encountered both positive and negative RMs during undergraduate medical education. These findings suggest that encounters with not only positive, but also negative RMs might facilitate student learning. Therefore, personal development appears to affect student perception of RMs.

A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators

Recent calls to focus on identity formation in medicine propose that educators establish as a goal of medical education the support and guidance of students and residents as they develop their professional identity. Those entering medical school arrive with a personal identity formed since birth. As they proceed through the educational continuum, they successively develop the identity of a medical student, a resident, and a physician. Each individual's journey from layperson to skilled professional is unique and is affected by "who they are" at the beginning and "who they wish to become."Identity formation is a dynamic process achieved through socialization; it results in individuals joining the medical community of practice. Multiple factors within and outside of the educational system affect the formation of an individual's professional identity. Each learner reacts to different factors in her or his own fashion, with the anticipated outcome being the emergence of a professional identity. However, the inherent logic in the related processes of professional identity formation and socialization may be obscured by their complexity and the large number of factors involved.Drawing on the identity formation and socialization literature, as well as experience gained in teaching professionalism, the authors developed schematic representations of these processes. They adapted them to the medical context to guide educators as they initiate educational interventions, which aim to explicitly support professional identity formation and the ultimate goal of medical education-to ensure that medical students and residents come to "think, act, and feel like a physician."

Third Year Medical School Students' Experiences of Revealing Patients' Stories through Role Playing

OBJECTIVE

Studying medicine is hard and it takes longer time compared to other majors. In addition, medical students find medical education boring. It is now necessary to turn medical education into an enjoyable and interesting way. The aim of this study is to evaluate the impact of an educational program related to how to learn taking medical history and how an effective patient-doctor interview should be. The program is structured in various scenarios, on the students learning skills, by the "role playing" method.

MATERIALS AND METHODS

A scenario prepared by the lecturer was employed in this study. While one of the students acted in a doctor role, the other one played in the role of patient's relative. The lecturer always played in the role of patient. After performing the role playing, students' written and oral feedbacks were gathered. Data were analysed by using SPSS 20.0 program.

RESULTS

A total of 470 feedbacks (51.3% were given by the female students) were taken from the students. Thirty-three volunteer students, nineteen of them were male, took part in the role playing. In the patient-doctor interview, the field that students were best were greeting the patients and dealing only with patients during the examination. The mean scores were 3.81±0.95 and 3.79±0.94 respectively. The ability to "summarize" and to "address the patient with his/her name" had the lowest scores; the mean scores of the students in these areas were 2.94±1.11 and 2.70±1.31, respectively.

CONCLUSION

Medical education is a long and tough process. Therefore, it should be interesting, attention getting and cheerful. Role playing can be effective in meeting that need.

Modelling successful primary care for multimorbidity: a realist synthesis of successes and failures in concurrent learning and healthcare delivery

BACKGROUND

People are increasingly living for longer with multimorbidity. Medical education and healthcare delivery must be re-orientated to meet the societal and individual patient needs that multimorbidity confers. The impact of multimorbidity on the educational needs of doctors is little understood. There has been little critique of how learning alongside healthcare provision is negotiated by patients, general practitioners and trainee doctors. This study asked 'what is known about how and why concurrent healthcare delivery and professional experiential learning interact to generate outcomes, valued by patients, general practitioners and trainees, for patients with multimorbidity in primary care?'

METHODS

This realist synthesis is reported using RAMESES standards. Relationship-centred negotiation of needs-based learning and care was the primary outcome of interest. Healthcare, social science and educational literature were sought as evidence. Data extraction focused on context, mechanism and outcome configurations within studies and on data which might assist understanding and explain; i) these configurations; ii) the relationships between them and; iii) their role and place in evolving programme theories arising from data synthesis. Mind-mapping software and team meetings were used to aid interpretative analysis.

RESULTS

The final synthesis included 141 papers of which 34 contained models for workplace-based experiential learning and/or patient care. Models of experiential learning for practitioners and for patient engagement were congruent, frequently referencing theories of transformation and socio-cultural processes as mechanisms for improving clinical care. Key issues included the perceived impossibility of reconciling personalised concepts of success with measurability of clinical markers or adherence to guidelines, and the need for greater recognition of social dynamics between patients, GPs and trainees including the complexities of shared responsibilities. A model for considering the implications of concurrency for learning and healthcare delivery in the context of multimorbidity in primary care is proposed and supporting evidence is presented.

CONCLUSIONS

This study is novel in considering empirical evidence from patients, GPs and trainees engaged in concurrent learning and healthcare delivery. The findings should inform future interventions designed to produce a medical workforce equipped to provide multimorbidity care.

TRIAL REGISTRATION

PROSPERO International prospective register of systematic reviews CRD42013003862.

Role modelling of clinical tutors: a focus group study among medical students

BACKGROUND

Role modelling by clinicians assists in development of medical students' professional competencies, values and attitudes. Three core characteristics of a positive role model include 1) clinical attributes, 2) teaching skills, and 3) personal qualities. This study was designed to explore medical students' perceptions of their bedside clinical tutors as role models during the first year of a medical program.

METHODS

The study was conducted with one cohort (n = 301) of students who had completed Year 1 of the Sydney Medical Program in 2013. A total of nine focus groups (n = 59) were conducted with medical students following completion of Year 1. Data were transcribed verbatim. Thematic analysis was used to code and categorise data into themes.

RESULTS

Students identified both positive and negative characteristics and behaviour displayed by their clinical tutors. Characteristics and behaviour that students would like to emulate as medical practitioners in the future included: 1) Clinical attributes: a good knowledge base; articulate history taking skills; the ability to explain and demonstrate skills at the appropriate level for students; and empathy, respect and genuine compassion for patients. 2) Teaching skills: development of a rapport with students; provision of time towards the growth of students academically and professionally; provision of a positive learning environment; an understanding of the student curriculum and assessment requirements; immediate and useful feedback; and provision of patient interaction. 3) Personal qualities: respectful interprofessional staff interactions; preparedness for tutorials; demonstration of a passion for teaching; and demonstration of a passion for their career choice.

CONCLUSION

Excellence in role modelling entails demonstration of excellent clinical care, teaching skills and personal characteristics. Our findings reinforce the important function of clinical bedside tutors as role models, which has implications for faculty development and recruitment.

Resident experiences of informal education: how often, from whom, about what and how

CONTEXT

The merits of informal learning have been widely reported and embraced by medical educators. However, research has yet to describe in detail the extent to which informal intraprofessional or informal interprofessional education is part of graduate medical education (GME), and the nature of those informal education experiences. This study seeks to describe: (i) who delivers informal education to residents; (ii) how often they do so; (iii) the content they share; and (iv) the teaching techniques they use.

METHODS

This study describes instances of informal learning in GME captured through non-participant observations in two contexts: a palliative care hospice and a paediatric hospital. Analysis of 60 hours of observation data involved a process of collaborative team consensus to: (i) identify instances of informal intraprofessional and informal interprofessional education, and (ii) categorise these instances by CanMEDS Role and teaching technique.

RESULTS

Findings indicate that 84.8% of GME-level informal education that takes place in these two settings is physician-led and 15.2% is nurse-led. Organised by CanMEDS Role, findings reveal that, although all Roles are addressed by both physicians and nurses, those most commonly addressed are Medical Expert (physicians: 35.7%; nurses: 27.5%) and Communicator (physicians: 22.3%; nurses: 25.0%). Organised by teaching technique, findings reveal that physicians and nurses favour similar techniques.

CONCLUSIONS

Although it is not surprising that informal interprofessional education plays a lesser role than informal intraprofessional education in GME, these findings suggest that the role of informal interprofessional education is worthy of support. Echoing the calls of others, we posit that medical education should recognise and capitalise on the contributions of informal learning, whether it occurs intra- or interprofessionally.

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.

Assessment of the clinical trainer as a role model: a Role Model Apperception Tool (RoMAT)

PURPOSE

Positive role modeling by clinical trainers is important for helping trainees learn professional and competent behavior. The authors developed and validated an instrument to assess clinical trainers as role models: the Role Model Apperception Tool (RoMAT).

METHOD

On the basis of a 2011 systematic review of the literature and through consultation with medical education experts and with clinical trainers and trainees, the authors developed 17 attributes characterizing a role model, to be assessed using a Likert scale. In 2012, general practice (GP) trainees, in their first or third year of postgraduate training, who attended a curriculum day at four institutes in different parts of the Netherlands, completed the RoMAT. The authors performed a principal component analysis on the data that were generated, and they tested the instrument's validity and reliability.

RESULTS

Of 328 potential GP trainees, 279 (85%) participated. Of these, 202 (72%) were female, and 154 (55%) were first-year trainees. The RoMAT demonstrated both content and convergent validity. Two components were extracted: "Caring Attitude" and "Effectiveness." Both components had high reliability scores (0.92 and 0.84, respectively). Less experienced trainees scored their trainers significantly higher on the Caring Attitude component.

CONCLUSIONS

The RoMAT proved to be a valid, reliable instrument for assessing clinical trainers' role-modeling behavior. Both components include an equal number of items addressing personal (Heart), teaching (Head), and clinical (Hands-on) qualities, thus demonstrating that competence in the "3Hs" is a condition for positive role modeling. Educational managers (residency directors) and trainees alike can use the RoMAT.

Role-modeling and medical error disclosure: a national survey of trainees

PURPOSE

To measure trainees' exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees' attitudes and behaviors regarding error disclosure.

METHOD

Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error.

RESULTS

The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P < .001); negative role-modeling had the largest independent, negative effect (standardized effect estimate, -0.26, P < .001). Positive role-modeling had a positive effect on attitudes (standardized effect estimate, 0.26, P < .001). Exposure to negative role-modeling was independently associated with an increased likelihood of trainees' nontransparent behavior in response to an error (OR 1.37, 95% CI 1.15-1.64; P < .001).

CONCLUSIONS

Exposure to role-modeling predicts trainees' attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.

The challenge of promoting professionalism through medical ethics and humanities education

Given recent emphasis on professionalism training in medical schools by accrediting organizations, medical ethics and humanities educators need to develop a comprehensive understanding of this emphasis. To achieve this, the Project to Rebalance and Integrate Medical Education (PRIME) II Workshop (May 2011) enlisted representatives of the three major accreditation organizations to join with a national expert panel of medical educators in ethics, history, literature, and the visual arts. PRIME II faculty engaged in a dialogue on the future of professionalism in medical education. The authors present three overarching themes that resulted from the PRIME II discussions: transformation, question everything, and unity of vision and purpose.The first theme highlights that education toward professionalism requires transformational change, whereby medical ethics and humanities educators would make explicit the centrality of professionalism to the formation of physicians. The second theme emphasizes that the flourishing of professionalism must be based on first addressing the dysfunctional aspects of the current system of health care delivery and financing that undermine the goals of medical education. The third theme focuses on how ethics and humanities educators must have unity of vision and purpose in order to collaborate and identify how their disciplines advance professionalism. These themes should help shape discussions of the future of medical ethics and humanities teaching.The authors argue that improvement of the ethics and humanities-based knowledge, skills, and conduct that fosters professionalism should enhance patient care and be evaluated for its distinctive contributions to educational processes aimed at producing this outcome.

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.

The attributes of the clinical trainer as a role model: a systematic review

PURPOSE

Medical trainees (interns and residents) and their clinical trainers need to be aware of the differences between positive and negative role modeling to ensure that trainees imitate and that trainers demonstrate the professional behavior required to provide high-quality patient care. The authors systematically reviewed the medical and medical education literature to identify the attributes characterizing clinical trainers as positive and negative role models for trainees.

METHOD

The authors searched the MEDLINE, EMBASE, ERIC, and PsycINFO databases from their earliest dates until May 2011. They included quantitative and qualitative original studies, published in any language, on role modeling by clinical trainers for trainees in graduate medical education. They assessed the methodological quality of and extracted data from the included studies, using predefined forms.

RESULTS

Seventeen articles met inclusion criteria. The authors divided attributes of role models into three categories: patient care qualities, teaching qualities, and personal qualities. Positive role models were frequently described as excellent clinicians who were invested in the doctor-patient relationship. They inspired and taught trainees while carrying out other tasks, were patient, and had integrity. These findings confirm the implicit nature of role modeling. Positive role models' appearance and scientific achievements were among their least important attributes. Negative role models were described as uncaring toward patients, unsupportive of trainees, cynical, and impatient.

CONCLUSIONS

The identified attributes may help trainees recognize which aspects of the clinical trainer's professional behavior to imitate, by adding the important step of apperception to the process of learning professional competencies through observation.

General practitioners as supervisors in postgraduate clinical education: an integrative review

CONTEXT

General practice supervisors are said to serve as the cornerstones of general practice postgraduate education and therefore it is important to clearly define their roles and what makes them effective. The commonly used definition of a supervisor is not primarily based on general practice and does not cover aspects predicted to be important according to work-based learning theory.

METHODS

We searched for papers published between 1991 and 2011 inclusive, categorised them according to whether they provided empirical evidence, descriptions or recommendations, open-coded the empirical evidence, and used the resulting coding scheme as an analytic framework within which to present a narrative summary of findings.

RESULTS

Recommendations and descriptions far outweighed empirical evidence, which showed how supervisors intertwined clinical and educational activities and formed educational alliances with resident doctors that provided a foundation for learning. Residents needed a balance of challenge, usually provided by patients, and support, provided by supervisors. Supervisors established learning environments, assessed residents' learning needs, facilitated learning, monitored the content and process of learning and the well-being of residents, and summarised learning in ways that turned 'know that' into 'know how'.

CONCLUSIONS

General practice must be expert in ensuring patients are well cared for 'by proxy' and in giving residents just the right amount of support they need to face the challenges posed by those patients. As general practice responds to contemporary clinical demands and rising numbers of undergraduate medical students, it is essential that the ability of general practice supervisors to develop and sustain supportive supervisory relationships with residents is preserved.

Use of ecological momentary assessment to determine which structural factors impact perceived teaching quality of attending rounds

INTRODUCTION

Providing high-quality teaching to residents during attending rounds is challenging. Reasons include structural factors that affect rounds, which are beyond the attending's teaching style and control.

OBJECTIVE

To develop a new evaluation tool to identify the structural components of ward rounds that most affect teaching quality in an internal medicine (IM) residency program.

METHODS

The authors developed a 10-item Ecological Momentary Assessment (EMA) tool and collected daily evaluations for 18 months from IM residents rotating on inpatient services. Residents ranked the quality of teaching on rounds that day, and questions related to their service (general medicine, medical intensive care unit, and subspecialty services), patient census, absenteeism of team members, call status, and number of teaching methods used by the attending.

RESULTS

Residents completed 488 evaluation cards over 18 months. This found no association between perceived teaching quality and training level, team absenteeism, and call status. We observed differences by service (P < .001) and patient census (P  =  .009). After adjusting for type of service, census was no longer significant. Use of a larger variety of teaching methods was associated with higher perceived teaching quality, regardless of service or census (P for trend < .001).

CONCLUSIONS

The EMA tool successfully identified that higher patient census was associated with lower perceived teaching quality, but the results were also influenced by the type of teaching service. We found that, regardless of census or teaching service, attendings can improve their teaching by diversifying the number of methods used in daily rounds.

[Doctor-patient communication: one of the basic competencies, but different]

Effective communication skills form part of being a good doctor. Today there is solid evidence to support the teaching of effective communication skills in all medical schools. This article describes how communication is different from the other skills that medical students and residents need to learn, how this affects teaching and learning, and the application of these ideas in a Chilean medical school. We describe the premises that need to be taken into consideration when planning teaching communication in medicine and illustrate how these affected the development of our teaching of communication in our undergraduate curriculum. All medical education programmes should include formal teaching on the doctor-patient relationship, but must take into consideration the aspects of communication teaching that make it different from teaching other aspects of medicine.

Assessing the quality of clinical teachers: a systematic review of content and quality of questionnaires for assessing clinical teachers

BACKGROUND

Learning in a clinical environment differs from formal educational settings and provides specific challenges for clinicians who are teachers. Instruments that reflect these challenges are needed to identify the strengths and weaknesses of clinical teachers.

OBJECTIVE

To systematically review the content, validity, and aims of questionnaires used to assess clinical teachers.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO and ERIC from 1976 up to March 2010.

REVIEW METHODS

The searches revealed 54 papers on 32 instruments. Data from these papers were documented by independent researchers, using a structured format that included content of the instrument, validation methods, aims of the instrument, and its setting.

RESULTS

Aspects covered by the instruments predominantly concerned the use of teaching strategies (included in 30 instruments), supporter role (29), role modeling (27), and feedback (26). Providing opportunities for clinical learning activities was included in 13 instruments. Most studies referred to literature on good clinical teaching, although they failed to provide a clear description of what constitutes a good clinical teacher. Instrument length varied from 1 to 58 items. Except for two instruments, all had to be completed by clerks/residents. Instruments served to provide formative feedback ( instruments) but were also used for resource allocation, promotion, and annual performance review (14 instruments). All but two studies reported on internal consistency and/or reliability; other aspects of validity were examined less frequently.

CONCLUSIONS

No instrument covered all relevant aspects of clinical teaching comprehensively. Validation of the instruments was often limited to assessment of internal consistency and reliability. Available instruments for assessing clinical teachers should be used carefully, especially for consequential decisions. There is a need for more valid comprehensive instruments.

Pedagogical strategies used in clinical medical education: an observational study

BACKGROUND

Clinical teaching is a complex learning situation influenced by the learning content, the setting and the participants' actions and interactions. Few empirical studies have been conducted in order to explore how clinical supervision is carried out in authentic situations. In this study we explore how clinical teaching is carried out in a clinical environment with medical students.

METHODS

Following an ethnographic approach looking for meaning patterns, similarities and differences in how clinical teachers manage clinical teaching; non-participant observations and informal interviews were conducted during a four month period 2004-2005. The setting was at a teaching hospital in Sweden. The participants were clinical teachers and their 4th year medical students taking a course in surgery. The observations were guided by the aim of the study. Observational notes and notes from informal interviews were transcribed after each observation and all data material was analysed qualitatively.

RESULTS

Seven pedagogical strategies were found to be applied, namely: 1) Questions and answers, 2) Lecturing, 3) Piloting, 4) Prompting, 5) Supplementing, 6) Demonstrating, and 7) Intervening.

CONCLUSIONS

This study contributes to previous research in describing a repertoire of pedagogical strategies used in clinical education. The findings showed that three superordinate qualitatively different ways of teaching could be identified that fit Ramsden's model. Each of these pedagogical strategies encompass different focus in teaching; either a focus on the teacher's knowledge and behaviour or the student's behaviour and understanding. We suggest that an increased awareness of the strategies in use will increase clinical teachers' teaching skills and the consequences they will have on the students' ability to learn. The pedagogical strategies need to be considered and scrutinized in further research in order to verify their impact on students' learning.

Teaching and learning professional behavior in practice

This paper is the fourth article in a series on Professionalism and provides an overview of current methods used for teaching and learning about professionalism. The questions "whether" and "how" professionalism can be placed in the formal medical school curricula are addressed, and the informal learning related to professionalism reviewed.

Clinical supervisors' perceived needs for teaching communication skills in clinical practice

BACKGROUND

Lack of faculty training is often cited as the main obstacle to post-graduate teaching in communication skills.

AIMS

To explore clinical supervisors' needs and perceptions regarding their role as communication skills trainers.

METHODS

Four focus group discussions were conducted with clinical supervisors from two in-patient and one out-patient medical services from the Geneva University Hospitals. Focus groups were audio taped, transcribed verbatim and analyzed in a thematic way using Maxqda software for qualitative data analysis.

RESULTS

Clinical supervisors said that they frequently addressed communication issues with residents but tended to intervene as rescuers, clinicians or coaches rather than as formal instructors. They felt their own training did not prepare them to teach communication skills. Other barriers to teach communication skills include lack of time, competing demands, lack of interest and experience on the part of residents, and lack of institutional priority given to communication issues. Respondents expressed a desire for experiential and reflective training in a work-based setting and emphasised the need for a non-judgmental learning atmosphere.

CONCLUSIONS

Results suggest that organisational priorities, culture and climate strongly influence the degree to which clinical supervisors may feel comfortable to teach communication skills to residents. Attention must be given to these contextual factors in the development of an effective communication skills teaching program for clinical supervisors.

Difficulties of residents in training in end-of-life care. A qualitative study

Residents in training are first-line physicians in hospital settings and they are in the process of developing knowledge and mastering clinical skills. They have to confront complex tasks calling upon their personal background, professional identity and relationships with the patients. We conducted a qualitative study investigating the difficulties they perceive in end-of-life care. In all, 24 consecutive residents were presented with a written query asking them to indicate the difficulties they identify in the management of patients hospitalised for end-of-life care. Their responses were submitted to content analysis. Physicians' mean age was 28 +/- 2.2 years, 37% were women, average postgraduate training duration was 2.5 +/- 1.3 years. Content analysis elicited eight categories of difficulties: ability to provide adequate explanations, understand the patients' needs, have sufficient theoretical knowledge, avoid flight, avoid false reassurance, manage provision of time, face one's limits as a physician and be able to help despite everything. Residents' responses showed that they identify the complexity of care in terminally-ill patients early in their training. Their responses pointed to the 'right distance' in-between getting involved and preserving oneself as a dimension of major importance.

What makes a good clinical teacher in medicine? A review of the literature

PURPOSE

The authors perform a review of the literature pertinent to the question, "What makes a good clinical teacher in medicine?"

METHOD

After framing the question, based on discussions of their own experiences with clinical teachers, the authors performed a search of the literature pertinent to the question, "What are the qualities of a good clinical teacher in medicine?" Between July and December, 2006, they reviewed titles from Index Medicus (1909-1966), PubMed (1966 to the present), PubMed Related Articles, and referenced articles. The initial selections were chosen by scanning pre-1966 Index Medicus title lists and post-1966 abstracts. Chosen articles were then read in their entirety, and those which described specific characteristics of clinical teachers were selected for inclusion. Qualitative analysis was used to identify themes.

RESULTS

From 4,914 titles, 68 articles were selected for analysis-26 published before 1966, and 42 published after 1966. Four hundred eighty descriptors were identified and grouped into 49 themes, which were clustered into three main categories: physician, teacher, and human characteristics. Echoing the authors' intuitive descriptions, noncognitive characteristics dominated the descriptions and themes.

CONCLUSIONS

Excellent clinical teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students. Faculty development programs and future research should focus on development of the noncognitive attributes of clinical teachers, as well as the knowledge and skills associated with effective teaching.