Role Models: Their importance and their development

1
Role ModelsTheir importance and their
development

• Scott Wright, MD
• Arnold P. Gold Foundation Assistant Professor of
  Medicine
• Johns Hopkins University

2

• Websters Dictionary
• Role Model (definition)
• A person considered as a standard of excellence
  to be imitated.

3
Clarification

• Teacher (defn) one who imparts knowledge or
  skill to others by lessons and instruction
• Mentor (origin) In The Odyssey by Homer,
  Odysseus chose his trusted friend Mentor to
  educate and guide his son , Telemachus.
• (defn) a wise and loyal advisor.

4
Outline

• Review early evidence for learning by observation
• Share examples of role models (20)
• Review of studies related to role models in
  medical education
• - Who are the role models?
• - What trainees can learn from role models
• - Trainee attitudes about learning from role
  models
• Implications of this work and issues specific to
  community-based settings and physicians

5
Two of my role role models

• Grandpa Sol
• My father-in-law, Ted

6
Observational Learning

• Imitation as an Instinct
• Early psychologists (Morgan, 1896 Baldwin, 1906)
  suggested that people and animals have an innate
  propensity to imitate behaviors they see.

7
Thorpes categories of observational learning
(1963)

• Social facilitation behavior of one individual
  prompts similar behavior from another (behavior
  not new to imitator)
• Example (Wyrwicka 1978) Trained mother cats to
  eat unusual food (e.g. bananas) and their kittens
  began to eat these foods.
• Local enhancement behavior of a model is copied,
  such that the behavior is learned quicker than
  would have occurred by trial error.
• Example (Bullock, 1977) Pigeons could learn to
  hit buttons in a specific order by observing a
  human hand demonstrate the correct sequence.

8
Thorpes categories of observational learning
(1963) (continued)

• True imitation refers to imitation of a behavior
  that is very unusual for the species
• Example 1 (Fisher, 1949) Birds, of many
  species, began piercing the covers of milk
  bottles left on doorsteps.
• Example 2 (Kuwa, 1965) On an island near Japan,
  grains of wheat were spread along beach and
  monkeys would pick them out one by one. One smart
  monkey learned to separate the wheat from the
  sand more efficiently by picking up a handful and
  throwing it in the water (sand sinks and wheat
  floats). Soon many other monkeys were imitating.

9
Human example

• Meltzoff and Moore (1977) found a reliable
  tendency for infants (12-21 days old) to imitate
  a specific behavior they had just seen
• Humans and animals have the ability to learn
  through observation
• Tendency to imitate is seen at a very young age
  in most species

10
Factors that affect the likelihood of imitation
(Banduras work with elementary school children,
1960s)

• Characteristics of the model
• Those who act in a nurturant manner
• Those who will have a long term relationship with
  the individual
• Those who have dominance within a group
• Those who are more similar to the learner
• Those who appear sincere

11
Factors that affect the likelihood of imitation
(Banduras work with elementary school children,
1960s) continued

• Characteristics of the learner
• Boys imitate aggression more than girls
• Individuals that are unsure of their own
  behaviors and those with less self-esteem are
  more likely to imitate the behaviors of others

12
Factors that affect the likelihood of imitation
(Banduras work with elementary school children,
1960s) continued

• Characteristics of the situation
• People are more likely to imitate when they are
  uncertain of the correct behavior
• The difficulty of the task has an effect on
  imitation
• (the most imitation was seen on tasks of
  intermediate difficulty)

13
What can be learned through observation
(Banduras work with elementary school children,
1960s)

• Almost anything
• Including personality traits, problem solving
  skills, aesthetic preferences, phobias,
  addictions, cognitive development, moral
  judgments and moral behavior

14
One of my earliest recollections of role modeling

• Driving with my father to his workplace

15
Definition of mentor and role model in medical
education Reuler and Nardone, WJM, 1999

• Mentors
• Faculty who take more junior colleagues under
  their wings and encourage and support their
  careers and growth
• Relationship is continuous and complex
• Help proteges to find good opportunities, clarify
  expectations and develop strategies for
  advancement, provide vision...
• Role Models
• Teach primarily by example and help to shape the
  professional identity and commitment of learners
  by promoting observation
• May only have brief contact with learners and do
  not so much deliberately mold students as inspire
  them by their own conduct

16
Becoming Professional, Chapter 5 Role models
and self-evaluation Bucher R and Stelling J,
1977

• Ways in which trainees were noted to use staff as
  models
• 1. Partial Models most frequent
• trainees select particular characteristics and
  traits that they admire and seek to emulate
• learner identifies specific attributes from a
  number of individuals rather than a person to
  serve as a global model
• Trainees would emulate characteristic if
• a. they believed the acquisition could be
  successful, AND
• b. it fit with their projected professional image

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• Chapter 5 Role models and self-evaluation
• Ways in which trainees were noted to use staff as
  models
• 2. Charismatic Models
• highly idealized global models who inspire
  tremendous enthusiasm and awe in the trainee
• 3. Stage Models
• help trainee to understand what to expect at some
  later stage of development and how to deal with
  practical problems.
• 4. Option Models least frequent
• used by trainee to gain information on
  alternative or deviant career path, (e.g. faculty
  who successfully balanced career and family).

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• Chapter 5 Role models and self-evaluation
• Ways in which trainees were noted to use staff as
  models
• 5. Negative Models
• a variant of the previous types
• most frequent were negative partial models

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My Charismatic Model
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The Role of Models in Professional
SocializationShuval and Adler, Soc Sci Med 1980

• Objective To describe how medical students
  relate to their teachers
• Findings based on the longitudinal study of 2
  medical school classes in the early 1970s
• - Students are exposed to many varieties of
  models.
• - Most students pick and choose selectively.
  characteristics from several models.
• - Three patterns of modeling emerged without
  any evidence for 1 dominant type.

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The Role of Models in Professional
SocializationShuval and Adler, Soc Sci Med 1980
(continued)

• Interactions with models include
• 1. Active identification classic modeling,
  learners move towards modes
• 2. Active rejection learners move further away
  from models
• 3. Inactive orientation no change in the student
• a. reinforcement students and model are
  similar
• b. oblivion students and model are different
  yet there is no influence on the learners

22
Stress and impairment during residency training
Strategies for reduction, identification, and
management APDIM, Ann Int Med 1988

• Recommendation for helping residents deal with
  professional stress
• 1. Program directors should encourage and reward
  faculty who are role models and exemplify the
  highest standards of medical practice.
• 2. A system is needed to evaluate and monitor the
  faculty in this regard.
• 3.Physicians who are not good role models should
  not be given teaching assignments.
• 4. Faculty development programs should be
  developed to improve role modeling skills.

23
The SGIM Task Force on Career Choice in Primary
Care and Internal Medicine Linzer M et al,
JGIM 1994

• Training teaching physicians to be effective role
  models will become particularly important.
• Mentors and role models have been shown to be
  among the most important factors influencing
  career selection of medical students.

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• Role modeling of humanistic attitudes and
  behaviors by faculty is seen as the most
  influential teaching method for imparting
  humanism to learners in clinical settings
• American Board of Internal Medicine, Subcommittee
  on Humanistic Qualities
• Professionalism defines the physician. Medical
  students and residents expect faculty to serve as
  role models for professionalism.
• Association of Professors of Medicine

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Senior residents views on the meaning of
professionalism and how they learn about
it Brownell and Cote, Acad Med 2001
Objective To determine senior residents views
on the meaning of professionalism and how they
learned about it. Design Surveyed all (533)
senior residents at 2 medical schools in
Canada. Select Results 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.
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Surgeons swear when operating fact or
myth Palazzo and Warner, BMJ 1999

• Objective To characterize and quantify foul
  language use by surgeons in the operating room.
• Methods Anesthesiologist kept track of profanity
  use by surgeons during 100 consecutive
  operations. A profanity classification was
  developed (1 point God, blood hell,
• 2 points bodily products sht, pss ..., 3
  points four letter words).
• Results Swearing rates for an 8-hour operating
  day
• - Orthopedic surgeons 16.5 swearing points
• - General surgeons 10.6 swearing points
• - Ob / Gyn surgeons 10 swearing points
• - Urologists 3.1 swearing points
• - ENT surgeons 1 swearing point

27
Which values do attending physicians try to pass
on to house officers? Wright and Carrese,
Medical Education 2001

• 265 (78) faculty shared the single value that
  they try to pass onto residents.
• The responses fell into 4 main categories
• 1. Empathy / Caring / Understanding
• 2. Respect
• 3. Communication Skills / Listening
• 4. Trust / Honesty

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Physicians that have been role models for
you (sponsored by Old Bay)

• Please consider (if you can) a physician with
  whom you have worked that you consider as a
  standard of excellence to be imitated? (No need
  to name names)
• What was it about that individual (skills,
  knowledge, attitude, personal qualities...) that
  made her / him a role model in your eyes?

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Faculty and house staff as role modelsFicklin et
al, J Med Educ 1988

• Indiana University School of Medicine convened a
  conference that focused on role modeling.
• Key points
• 1. Students emulating their teachers is an
  important part of medical education.
• 2. Different types / styles of role models are
  desirable.
• 3. Role models can have positive or negative
  effects.
• 4. House staff are important role models for
  medical students.
• 5. Educational institutions should recognize and
  reward faculty and house officers who are
  effective role models.

30
Medical student attitudes about internal
medicine A study of US medical school seniors
in 1988 Babbott et al, Ann Intern Med 1991
Objective To determine the attitudes of medical
students towards careers in internal
medicine. Design Cross-sectional national survey
of medical school seniors (over 10,000
respondents). Results Most important factors in
selecting internal medicine 1. Intellectual
content 2. Diagnostic challenges Most important
factors in selecting another field 1. Patient
population 2. Role models
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Attractiveness of Internal Medicine A
qualitative analysis of the experiences of male
and female medical students McMurray et al,
Ann Intern Med 1993

• Objective To better understand the decline in
  medical student interest in Internal Medicine.
• Design Qualitative analysis of 500 essays from
  medical school graduates (class of 1990).
• One of the key findings
• A lack of positive role models in internal
  medicine may be contributing to the falling
  number of students choosing it as a career.

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Brief interactive interlude

• Consider the individuals that you will be shown
• Do you think they are role models?
• What characteristics make them special such that
  others might wish to emulate them?

33
Examining what residents look for in their role
models Wright, Acad Med 1996
Objective To determine the characteristics that
were deemed most important by residents regarding
physician role models. Design Surveyed house
staff at McGill University, (85 response rate).
Select Results 1. Most residents (74) were
satisfied with the proportion of positive role
models in their residency training program. 2.
Clinical skills, personality, and teaching
ability were judged to be the most important
factors in identifying and selecting role
models.
34
The impact of role models on medical
students Wright, Wong, Newill JGIM 1997

• Objectives
• To explore the relationship between exposure to
  role models during medical school and the
  students choice of clinical field for residency
  training.
• To identify the specific attributes felt to be
  most important to students in selecting their
  role models.
• Design
• Cross-sectional study, questionnaire given McGill
  University School of Medicine graduates (Class of
  1995).

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Results

• Response rate 93 (136/146)
• Average age 25.4 years
• Female 43
• Choice of clinical field for residency training
• Internal medicine 23 Surgery 22
• Family medicine 14 Pediatrics 9
• Obstetrics/Gynecology 5 Psychiatry 4
• Other 18

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Results (continued)

• 90 identified 1 or more role models during
  medical school.
• For 35 of the students, at least one of their
  role models was a resident.
• For 85 of the male students, a male physician
  served as the role model.
• For 41 of the female students, a female
  physician served as the role model, (noteworthy
  since female physicians comprised 28 of faculty).

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Results (continued)

• 89 of medical students identified their role
  model during the clinical years 11 did so
  during the first 2 years.
• 63 received advice regarding future direction
  from these role models.
• 61 stated that the relationship with their role
  model resulted in personal growth and
  development.
• 57 acknowledged that their role model was
  influential in their choice of residency.

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Results (continued)

• Factors most important in selecting role model
• (1 most important, 6 least
  important)
• MEDIAN
  MEAN
• Personality 1 1.7
• Clinical skills competence 2 1.9
• Teaching ability 2 2.2
• Area of specialty 4 4.3
• Research publications 5 5.1
• Position/ academic rank 5 5.2

39
Conclusions

• Exposure to role models in a particular clinical
  field appears to be associated with students
  career choice.
• Personality, clinical skills, and teaching
  ability are most important to students in
  identifying and selecting physician role models.
• It is hoped that attending physicians
• a) can be helped to improve themselves as role
  models.
• b) become more aware of their potential impact
  on students.

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Yet another example of role modeling

• Our Department of Medicine Chairman at medical
  grand rounds a few weeks ago

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The current status of medical grand rounds in the
U.S.A. Hebert and Wright, somewhere 2002
Objective To collect information about the
objectives, structure, quality, attendance, and
funding of grand rounds Design Survey of
Department of Medicine Chairs (77 response rate,
389 surveys returned). Select findings The top 2
objectives of medical grand rounds were 1. To
educate the faculty about clinical topics 2. To
have faculty serve as role models for the
importance of life-long learning.
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Attributes of excellent role models A
case-control study SM Wright, DE Kern, KB
Kolodner, DM Howard, FL Brancati NEJM 1998

• Objective To identify the attributes which set
  the excellent attending physician role models
  apart from their colleagues.
• Methods
• Design Case-control study
• Setting 4 North American teaching hospitals
• Participants 342 medicine attendings
• Measurement Self-administered questionnaire
• Outcome Excellent role models vs. controls
• Analysis Contingency tables, logistic regression

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Case Identification
44
Frequency with which role models were named by
the housestaff

Number of attendings
Median 3 Range 1 - 43
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Control Selection
46
Selected Characteristics of the 341 Attending
Physicians

• Age, yrs 45.8 ( / - 8.9)
• Male 278 (81)
• Specialty
• General Internal Medicine 57 (17)
• Medicine specialties 284 (83)
• Rank
• Professor 68 (20) Associate Professor
  138 (40)
• Assistant Professor / Instructor 135 (40)
• Full Time 289 (84)

47
Association of exposure with being named as a
role model

• Structured exposure
• Precepting in clinic
• Attending on wards
• Attending in units

• Crude Odds Ratio (95 CI)
• 2.3 (1.3-4.3)
• 3.8 (2.1-6.6)
• 2.7 (1.2-6.2)

48
Association of training in teaching with being
named as a role model

• Training
• Any formal training
• Former chief resident
• Faculty development program

Adjusted Odds Ratio (95 CI) 1.9 (1.2-3.0) 2.0
(1.2-3.3) 1.8 (1.0-3.0)
Adjusted for inpatient and outpatient exposure
to housestaff
49
Association of teaching style and method with
being named as a role model

• Teaching methods
• Depth of feedback
• Emphasize psychosocial aspects
• Stress Dr.-Pt relationship

Adjusted Odds Ratio (95 CI) 1.7 (1.1-2.8) 2.0
(1.3-3.0) 2.7 (1.4-5.2)
Adjusted for inpatient and outpatient exposure
to housestaff
50
Association of relationship development with
being named as a role model

• Interactions with housestaff
• Sharing professional experiences
• Sharing personal experiences
• Learning about the house officer
• End of month dinner

Adjusted Odds Ratio (95 CI) 1.7
(1.1-2.7) 1.7 (1.1-2.7) 1.7 (1.1-2.7) 1.9
(1.1-3.5)
Adjusted for inpatient and outpatient exposure
to housestaff
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Association of select other factors with being
named as a role model

• Variable
• Enjoys teaching
• Time spent with learners when attending
• Perceived support

Adjusted Odds Ratio (95 CI) 2.7 (1.6-4.6) 3.1
(1.7-5.8) 1.9 (1.2-3.1)
Adjusted for inpatient and outpatient exposure
to housestaff
52
Five factors independently associated with being
named as a role model

• Variables
• Spending 25h/wk with team when attending
• Former chief resident
• Emphasize psychosocial aspects
• Stress Dr.-Pt relationship
• Spends 25 time teaching

Adjusted Odds Ratio (95 CI) 2.5 (1.2-5.4) 2.1
(1.1-4.0) 2.3 (1.2-4.4) 2.6 (1.1-6.4) 5.1
(1.8-9.9)
Adjusted for assigned teaching responsibilities
and all other variables in the model
53
Select factors not associated with being named
as a role model

• Gender
• Rank
• Full vs. part-time
• Research

• Clinical time
• Learner-centeredness
• Preparation for teaching
• Donuts

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Limitations

• Relied exclusively on self-report
• Personality was not formally assessed.

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Conclusion
Role models differ from their colleagues in a
variety of ways

• Training in teaching
• Chief resident
• Feel supported
• Enjoy teaching
• Spend more time when teaching

• Provide detailed feedback
• Emphasize psychosocial aspects
• Stress Dr.-Pt relationship
• Share their stories
• Learning about learner

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Implications

• Many of the attributes associated with being
  identified as a role model are modifiable
  behaviors or acquirable skills.
• These results may help programs foster excellence
  in role modeling.

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Brief Videotape

• Depicts two individuals who are exemplary in the
  face of adversity

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Excellence in Role Modeling Insight and
Perspectives from the Pros
Wright and Carrese

• Objective To examine and better understand role
  modeling by drawing on the insights and opinions
  of respected physician role models.
• Methods
• Design Qualitative study
• Setting 2 large teaching hospitals in Baltimore
• Sampling Purposive, 29 of the 30 most highly
  regarded role models within the Department of
  Medicine as judged by the medical house officers
• Data Audiotaped in-depth interviews

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Data Analysis

• Audiotaped interviews were transcribed, read and
  independently coded by two readers
• Coding led to the identification of preliminary
  categories and subcategories
• All decisions were made by consensus
• Categories were organized into a conceptual model

60
Selected Characteristics of the 29 Attending
Physician Role Models
Age, yrs 48 (35 - 75) Male 26
(90) Specialty General Internal Medicine
5 (17) Medicine specialties 24
(83) Rank Professor 9 (31)
Associate Professor 12 (42) Assistant
Professor / Instructor 8 (27) No. of times
named as role model 12 (5 - 43)
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Findings

• Analysis of the transcripts identified several
  domains that were related to role modeling in
  medicine
• Personal qualities
• Teaching skills
• Clinical Attributes
• Barriers to effective role modeling
• Role modeling consciousness
• Value of multiple role models

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Personal Qualities

• Integrity
• A positive outlook
• A commitment to excellence and growth
• Leadership
• Being interpersonally skilled

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Personal Qualities

• Integrity
• Being ethical and principled
• Being true to ones values
• Being genuine

64
Personal Qualities

• A Positive Outlook
• Being friendly
• Demonstrating enthusiasm
• Being easy going
• Having job satisfaction and showing it

65
Teaching

• Establishing rapport with learners
• Being committed to the growth of learners
• Developing specific teaching philosophies
• Relationship between teaching and role modeling

66
Teaching

• Establishing rapport with learners
• Treating house officers as colleagues
• Being approachable
• Being interested in learners as people

67
Teaching

• Relationship between teaching and role modeling
• A lot of overlap
• Role modeling entails a more expansive skill
  set
• Role modeling is felt to be more implicit

68
Clinical Skills

• Being a strong clinician was necessary but not
  sufficient
• High quality care
• Compassion
• Higher order clinical skills are important
• - assuming responsibility in difficult
  situations
• - going the extra mile
• - advocating for patients

69
Barriers to Effective Role Modeling

• Being impatient
• Being overly opinionated
• Being inflexible
• Being quiet and reserved
• Being over-extended
• Having difficulty remembering names and faces

70
Role Modeling Consciousness

• Consciously thinking about being a role model
  when interacting with medical learners.
• Awareness that learners are watching closely,
  constantly.

71
Value of Multiple Role Models
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Conceptual Model

• Threshold level of clinical skill is required
• Role modeling consciousness is helpful
• Proficiencies can compensate for barriers
• Value of multiple role models

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(No Transcript)
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C
B
A
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Conclusion

• Physician role models have a threshold of
  clinical skill and are conscious about
  opportunities for role modeling.
• Role models possess personal qualities, specific
  teaching skills, and higher order clinical skills
  that outweigh their barriers for role modeling.

76
Role models in books

• Books allow us to emulate characteristics of
  outstanding people without ever meeting them.

77
Factors influencing career development Do men
and women differ? Cohe et al, JAMWA
1988 Study of McMaster University School of
Medicine graduates (176 women and 106
men). Select Results Many women, regardless of
career choice within medicine, reported that the
lack of female role models detracted from career
development.
78
Perceived barriers and biases in the medical
education experience by gender and
race Bright et al, J Natl Med Assoc
1997 Study of 4th year medical students 270
female and 288 male respondents 21 Asian, 13
underrepresented minorities, and 66 white.
Select Results Underrepresented minority
students identified the lack of a same race
mentor (23 for URM versus 4 for whites) and
same race role model (40 for URM versus 1 for
whites) as a large barrier.
79
Serving as a physician role model for a diverse
population of medical learners
Wright and Carrese
Objective To explore and better understand the
issues related to serving as a role model for
medical learners who are different from the
attending physicians. Methods and Data
Analysis Design Qualitative study Sampling
Purposive, 29 of the 30 most highly regarded role
models within the Department of Medicine as
judged by the medical house officers Three
informants (10) were female physicians. Three
informants (10) were non-white physicians, (one
Chinese-American, one Japanese American, one
Indian American).
80
Findings

• Analysis of the transcripts identified several
  domains
• Similarity facilitates role modeling
• Role modeling when physician-teachers and
  learners are different
• Approaches to differences between
  physician-teachers and learners

81
Similarity facilitates role modeling

• Learners prefer role models similar to them
• It is easier to serve as a role model when the
  learner resembles the teacher
• Minority physicians may be better role models for
  minority learners

82

• Role modeling when physician-teachers and
  learners are different

• Extra effort may be necessary
• Success promotes and inspires confidence
• It is an achievable objective that should be
  pursued

83
Approaches to differences between
physician-teachers and learners

• Embrace the diversity
• Act as a consultant and refer when necessary
• Minimize and disregard all differences

84
Select Conclusions

• Although similarities between teaching physicians
  and medical learners are felt to facilitate role
  modeling, differences are not an insurmountable
  obstacle for effective role modeling and a
  commitment of extra effort may be required.
• Because it is known from prior studies that
  disregarding all differences fails to meet the
  needs of learners, individuals relying
  exclusively on this approach may wish to consider
  alternative strategies.

85
3 quotations related to role modeling

• It is by imitation, far more than by precept,
  that we learn everything and what we learn thus,
  we acquire not only more efficiently, but more
  pleasantly. This forms our manners, our opinions,
  our lives.
• Edmund Burke
• True role models dont stand on a pedestal and
  tell you how to climb up they jump down and help
  push you up.
• Carl Polloi
• By three methods we may learn wisdom First, by
  reflection,which is noblest Second, by
  imitation, which is easiest and third by
  experience, which is the bitterest.
• Confucius

86
Role Modeling in medical education Reuler and
Nardone, WJM 1994
Future directions for role modeling in
medicine 1. Figure out who the role models are
and increase the opportunities for learners to
interact with these people. 2. Negative role
models shouldnt be allowed to interact with
learners. 3. Help housestaff to become role
models (among the suggestions was to create a
less stressful environment). 4. Hire and recruit
faculty that are more representative of the
learners (student body)
87
Some ideas about role modeling that are
particularly relevant to community-based (CB)
settings

• Learners working with CB physicians need to
  witness us providing high quality compassionate
  care to our patients
• Show learners see that we enjoy our work
• Insist that all clinic staff and faculty role
  model for the learners the values and missions of
  the clinic / heath center. Challenge students and
  residents to model these philosophies as well.
• Send learners to CB sites where theyll have the
  chance to work with faculty who are similar to
  them.
• Include questions about role modeling on the
  evaluation forms.

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Summary

• Heightened awareness about role modeling
• Be more transparent about role modeling
• When its gone, its very hard to recover
• Role modeling can be taught