Wright, Scott M. MD; Carrese, Joseph A. MD, MPH
Diversity in the medical profession is believed to be critical to improving the health care delivery system in the United States.1 Many efforts and strategies, such as the Association of American Medical Colleges' Project 3000 by 2000,2 have attempted to increase the number of underrepresented-minority medical students. While the racial and ethnic diversity among medical students has improved in the last decade,3,4,5 the majority of medical school faculty members continue to be white men. The educational impact of this mismatch between medical trainees (with larger numbers of minority and female learners) and faculty is not known.
Because of the recognition that communication and relationships between people from different cultures may be challenging and require specific training, educators have developed many curricula to teach medical learners to interact and communicate effectively with diverse patient populations.6,7,8 To our knowledge, there has been little effort devoted to helping attending physicians relate to and work successfully with a diverse population of medical learners.
Role modeling is known to be an important educational method for instilling the attitudes, behaviors, ethics, and professional values of medicine to trainees.9,10,11,12,13,14,15 We conducted a qualitative study to analyze the perspectives of outstanding attending physician role models about teaching and serving as role models for medical learners who are different from them.
Setting and Sampling
Sampling for this study followed a purposive strategy of identifying informants who could be regarded as especially knowledgeable about role modeling.16 We identified these informants as part of a previous study on this topic and information related to their selection has been previously reported.17 Twenty-nine of the 30 (97%) most highly regarded role models within the department of medicine, as judged by the medical house officers at two large teaching hospitals in Baltimore, Maryland (Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center), participated in the study. One physician had left the institution and could not be interviewed. These attending physicians were named as excellent role models by five or more house officers (mean = 12.3, range 5–43). The housestaff were provided with a general definition of a role model as defined by Webster's Dictionary, “a person considered as a standard of excellence to be imitated,”18 to allow for identification of a wide range of attending physicians.
Interviews lasting approximately 30 minutes were conducted primarily in the offices of the role model informants between September and November 2000. One of us (SMW) conducted all 29 interviews using an interview guide with follow-up questions for clarification and to explore concepts. Below are the interview questions related to the results presented in this paper:
Before we contacted you to set up this meeting, were you aware of the fact that you are considered to be an excellent role model by the house officers?
Do you ever consciously think about being a role model?
In your experience as a medical educator, have the issues of gender, age, race, culture, or diversity come up in any way as they relate to role modeling?
Are there any ways in which you are different in trying to serve as a role model for medical learners who are from a different culture than your own?
All interviews were audiotaped and transcribed verbatim.
An “editing analysis style” was used.19 We carefully read, interpreted, and independently coded the transcripts. Coding led to the identification of preliminary categories and subcategories, which were reviewed and revised, ultimately resulting in the findings presented here. All decisions about coding and naming of categories were made by consensus. Similarly, we jointly selected quotations presented in this paper. The quotations and presentation of the data were selected to represent the variety of views expressed by the informants. Finally, we presented the study's findings to more than half of the informants, who verified that our interpretation of the data was appropriate.
Twenty-six (90%) of the 29 attending physicians were men. The informants' mean age was 48.1 years (range 35–75 years). With respect to academic rank, one of the attending physician role models (3%) was an instructor, seven (24%) were assistant professors, 12 (42%) were associate professors, and nine (31%) were professors. Six physicians (21%) were from the Cardiology Divisions at the two Hospital Centers, five (17%) were from the Divisions of General Internal Medicine, four (14%) each were from the Divisions of Gastroenterology and Pulmonary, three (10%) were from the Division of Infectious Diseases, two (7%) each were from the Divisions of Geriatrics, Hematology/Oncology, and Rheumatology, and one (3%) was from the Division of Endocrinology. Three informants (10%) were female physicians and three (10%) were nonwhite physicians: one Chinese American, one Indian (East) American, and one Japanese American.
A majority of the informants (19/29, 66%) were aware that they were considered to be role models by the house officers, and most (20/29, 69%) consciously thought about being role models when interacting with medical trainees. In contrast, a minority of the informants (12/29, 41%) believed or acknowledged that role modeling for learners from different cultures is complex and represents a challenge for medical educators.
Analysis of the transcripts identified several domains that were related to effective role modeling by attending physicians for a diverse population of medical learners. All of the comments and opinions on this subject fell into one of three domains: similarity facilitates role modeling, role modeling when physician–teachers and learners are different, or approaches to differences between physician–teachers and learners. (See List 1.)
Similarity Facilitates Role modeling
The subcategories in this domain are supported by the idea that people can best relate to other individuals who are similar to them and to those who can understand their perspective.
Learners prefer role models similar to them
Physician informants contended that learners favor role models who are similar to them. One infectious disease specialist reported his experiences:
I think I'm a role model primarily for white males. Women do talk to me but they often don't do what I say. And there are aspects of black culture that I have absolutely no knowledge of.
A pulmonologist commented:
I think people tend to pick role models that look and act like themselves.
Other physicians echoed the unique needs of trainees from diverse backgrounds:
I think that for somebody to say that they're able to serve as a role model for all different people is naive. I think housestaff want role models who are representative of their own particular group.
I recognize that there probably aren't enough female role models for female residents and that there are unique aspects of how you deal with being a mother and taking maternity leave. Given that there often are parental issues different for a woman than a man, at times it may be useful to have some gender-specific role models. Role modeling as a physician means not only what happens in the hospital but what happens outside the hospital too.
Role modeling is easier when the learner resembles the teacher
Many physician role models stated that it is less complicated to serve as a role model for medical learners who are like them and conversely that it is more difficult when differences exist.
One gastroenterologist specifically commented on the matter of exchanging ideas:
The more things that people have in common [teacher and learner], the easier it is for them to communicate.
A cardiologist recognized that providing guidance and counseling may be facilitated and most relevant if there are similarities between the parties:
It is perhaps easier to feel that one is able to give advice to somebody who has the same issues.
Another physician understood that his culture and perspectives might restrict his ability to truly serve as a role model for some learners:
One must recognize that there are limitations because of who I am and my own culture and race and identity that may prohibit me from being fully useful to those who are not of my own culture, race, etc.
Minority physicians may be better role models for minority learners
Several physician informants spoke about their abilities to relate to and serve as role models for minority learners, even for those from minority groups different from their own, because of their minority status (including being female in a heavily male-dominated environment). A physician recounted:
There are clearly issues that women face in medicine, that certain minorities face in medicine that I'm not able to address as well as perhaps people of the same gender or the same minority. I do think, however, that being a minority itself is helpful in dealing with gender and other racial minorities. Is it as good as it being the same gender or the same minority as the person I'm trying to be a role model for? Probably not. But I do think it is helpful particularly in our system that continues to be so white-male–dominated.
A female general internist described one of her experiences:
I guess in some sense, being an underrepresented minority in this culture, female, I identify. There was a minority male resident who was really struggling and I was charged with counseling and mentoring this person. I think I could kind of identify with not being like everyone else in the institution.
Role Modeling When Physician–Teachers and Learners are Different
This domain addresses views and feelings of role model physicians related to their experiences working closely with learners from different backgrounds.
Extra effort may be necessary
Physicians believed that working with learners who are different from themselves requires more effort on the part of the teacher. One physician succinctly summarized this point:
I think you have to work at it a little bit harder. You have to be aware of it because another white guy is just easier to interact with. I mean, you just have more things in common.
Success promotes and inspires confidence
Having success with medical learners who are different from the faculty physician promotes self-assurance. A geriatrician commented:
I've had a lot of experience in serving as a role model for a diverse set of learners. My best fellow was from the Middle East and he's now a professor of medicine. So I 'd like to think that I can be a role model for any race, creed, color, persuasion … I think I've been reasonably ecumenical in my approach to race and culture.
A male endocrinologist spoke with confidence about his ability to serve as a role model for a variety of medical learners:
With regard to gender, I'm very pleased that there have been a handful of trainees who are women who have told me that I've been an effective role model for them … Right now we have two fellows who are members of underrepresented minorities. I feel very close to them and I'd be surprised if they didn't feel the same way about me and perhaps in some respect want to have careers that were like mine.
It is an achievable objective and should be pursued
Many role model informants contended that a physician role model can be useful and serve as a positive example for any medical learner.
A general internist proclaimed:
I believe that to a degree that any good teacher can serve as a role model for all cultures, all races and genders.
Another internist asserted:
I think that role modeling can be genderless and can be without race or age but at times I think that they do play a factor.
Approaches to Differences between Physician–Teachers and Learners
The methods and styles used by the physician informants for handling or responding to the differences between themselves and their learners are described in the subcategories below.
Informants recognized that medicine is culturally diverse and believed this to be an asset. A geriatrician spoke about medicine's universality:
Race and cultural diversity come up in the process of whatever we do. There are always cultural differences and the question is whether you take them as something you take joy and pleasure in … I like diversity. I look at it as a great strength.
A general internist recognized the merit of having a varied set of teachers involved in the training of medical learners:
If you had a bunch of me, and you didn't have women and African Americans and Asians and whatever, it would be horrible.
Act as a consultant and refer when necessary
A proposed solution for matching medical learners with similar role models requires that faculty physicians be aware of their physician colleagues with different backgrounds. In these instances, a physician could refer a medical learner to a colleague who may be better equipped to fully understand the needs of the learner. A male general internist explained:
I think with regard to gender issues there are certain things that I can't speak personally to, like being a mother and being a physician. I could tell people what I've learned from others who have been in that position. I can direct those house officers to the faculty who can adequately answer the same things and that's a position I've been in. Race, I can't speak to what it's like to be a minority but again, I would refer people to those than can speak personally to the issue.
Minimize and disregard all differences
In thinking about role modeling for medical learners, a number of physician role models expressed the view that differences were unimportant and that they either ignored or downplayed them. The following sampling of quotations from different physicians reflect this perspective:
A medical learner's age, sex, race, or whatever other humanistic qualities may be present do not really influence me or I barely pay much attention to those things.
I must admit I really don't think about those things. So I'm always a little bit surprised when people raise the gender and racial bias issues.
I just treat them all the same … I try to deal with them as people … I try to eliminate all marks of distinction: age, gender, race. I just think of them as a person, either I'm trying to teach them something or they're my patient. But in terms of age, sex, all that stuff, it doesn't matter to me.
In my view, all of us are in medicine for the same purpose … to help sick people deal with their problems, I think that ought to be the common currency and nothing else should really matter … And I think that if you have a group with different backgrounds, it is a mistake to talk about nonmedical things.
It has been established that role models make an important and unique contribution to the education of medical learners.10,11,12 In this study, we present new findings that emerged from the opinions and views of highly regarded physician role models about role modeling for a diverse population of learners. We hope that the results of this study will prompt educators to reflect on their attitudes and approaches to medical learners, particularly learners who are underrepresented minorities.
It is believed that minority role models are essential for the successful maintenance and recruitment of minorities in the “biomedical pipeline.”20,21 This idea is supported by the work of early psychologists who have suggested that people have an innate propensity to imitate behaviors that they see,22 and that similarity between the model and the learner is an important factor that influences the likelihood of imitation.23,24 A study examining barriers in medical education concluded that underrepresented minority students considered the lack of same-race mentors and role models to be important impediments to their professional development.25 Female medical students have been found to be in a similar predicament and have the same concerns.26,27 Meanwhile, reports in the literature have noted that medical school faculty demonstrate low levels of awareness and have limited expertise interacting with women and minority students.28,29 In these studies, some of the faculty members' remarks and behaviors were described as inconsiderate and inappropriate at times. In our study, the comments of some of the informants, who represent the best and most beloved teachers, may also be perceived as insensitive.
The highly regarded faculty role models we interviewed were not of one mind about how to regard differences between themselves and their learners, or how to appropriately respond to such differences when working with learners. Many expressed the view that diversity should be acknowledged, embraced, and given appropriate attention. Some advocated for an increased level of diversity among faculty members who would serve as role models. Yet, others minimized the relevance of differences between faculty role models and learners. To their way of thinking, the significant issues in medical training and learning did not include the sociocultural-ethnic differences between faculty members and learners. Faculty members with the latter perspective may be failing to adequately recognize the needs and interests of their learners.
The demographics of the U.S. population are changing in the direction of increasing diversity. The percentage of underrepresented minority medical school matriculants, while not keeping pace with the percentage of underrepresented minorities in the general U.S. population,30 exceeds considerably the percentage of underrepresented minority faculty members in the nations' schools of medicine.31 In this sense, there exists, and may persist for some time, a “demographic discrepancy” between medical learners and the medical school faculty members who are available to serve as their role models. Thus, any interventions aimed to enhance the experience for underrepresented minority learners (through formal mentoring programs or faculty development programs to heighten the awareness of the faculty) should be considered a worthy investment to address an enduring problem.
In previous work, we reported our informants' views about the importance of every learner's having multiple role models to emulate, each with his or her own particular abilities and strengths.17,32 This finding seems to be especially germane when considering the issue of a mismatch between medical learners and their faculty role models. While a good role model may be effective to some degree for any medical learner, female and minority physician role models may be critical and may offer definite and exclusive advantages for medical learners from the same cohorts. Referring a learner to a faculty colleague who may share sociocultural–ethnic characteristics with that learner is one helpful strategy our informants identified that is almost certainly underused.
Our study had some limitations. Informants interviewed were from two hospitals, but from the same medical school, and they had particular characteristics. These informants were identified by housestaff as the most highly regarded role models and were interviewed for precisely this reason. But their views may not be representative of all faculty role models. Our informants were more likely to be men (90%) and white (97%) than were faculty members in the school of medicine at Johns Hopkins University (69% and 80.3%, respectively)33 or faculty members in U.S. schools of medicine (72% and 83%, respectively).34 This discrepancy is also partly due to the fact that these most highly regarded role models were mostly at the rank of associate professor and professor, ranks that have inadequate female or minority representation.35,36,37 However, the percentages were similar enough that we suspect that the views expressed by our informants will be familiar to many learners and faculty members.
Despite these limitations, there are several important implications of our findings. Academic medical centers must have a comprehensive and sincere commitment to enhancing the educational experience for underrepresented minority learners. To be successful, such efforts must become and remain a high priority for deans, department chairs, and division chiefs. While recruiting minority faculty members is essential, it is also absolutely critical to retain minority faculty members by giving them every opportunity to succeed and rewarding them with leadership positions. Because such changes take time, interim ventures are needed. Structured mentoring programs with the explicit objective of bringing together minority trainees and faculty members of similar backgrounds would be exciting. Faculty development programs that emphasize mentoring and the challenges associated with serving as a role model for a diverse population of medical trainees would also seem to be meaningful and advisable.
Our study shows that while many of the top-rated role models at a leading medical school demonstrated sensitivity to the differences between themselves and their learners, other faculty members either did not recognize these issues or minimized their relevance to medical education. Given current U.S. demographic trends, medical school faculty and administrators should carefully reflect on these issues and their implications. Similarly, this is an important topic for dialogue among and between faculty members and medical learners.
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