Sternszus, Robert MD; Cruess, Sylvia MD; Cruess, Richard MD; Young, Meredith PhD; Steinert, Yvonne PhD
A medical educator has previously defined a role model as “someone who is an example, whose behaviors serve as an ideal for the student to pattern their own behaviors after, or is seen by the student as an exemplary model for their own growth and development.”1 A large body of literature focuses on both the medical student and the resident as a learner in the role modeling relationship.2–9 The current literature reveals that exposure to role models in a particular specialty is strongly associated with a medical student’s decision to pursue a career in that same specialty.8 Moreover, this literature on both residents and students has identified three types of factors (defined by Wright and colleagues8) that are most important in selecting physician role models: teaching skills, clinical competence, and personal qualities.5,7–9 Previous research has suggested and investigated specific attributes within these overarching factor types that are most important in the selection of a role model. Such attributes include the following: demonstrating excellent knowledge and clinical skill, being respectful of students and residents, making time for teaching, and being compassionate and caring.2,8
In addition to their role as learners, residents serve as teachers and, perhaps, role models. Residents spend approximately 25% of their time teaching students, and previous research indicates that both groups—students as well as residents—tend to enjoy those experiences.10 In some of the earliest work on role modeling, 35% of students reported that at least one of their role models was a resident8; however, research specifically investigating residents as role models remains sparse. For example, two recently published articles about the influence of surgical residents on the career choice of medical students both suggest that working with surgical residents whom students rate highly on evaluations influences students to pursue surgical careers themselves.11,12 However, to our knowledge, no current studies have investigated the overall importance of resident role models throughout undergraduate medical education.
We conducted this present study to accomplish three main objectives: (1) to investigate the possible importance of resident role models to the education and career choices of graduating medical students at McGill University, (2) to examine the types of factors that students judge to be the most important in selecting a resident role model, and, finally, (3) to evaluate the specific attributes (within each of these factor types) that students perceive to be the most important in selecting a resident role model, and to compare these attributes with those previously published on physician role models.2–9
Study design and questionnaire development
We employed a cross-sectional, survey-based study design. We developed a 16-item questionnaire to investigate the influence of resident role models in undergraduate medical education. Given that we believe this to be the first study designed specifically to examine residents as role models, previously validated questionnaires were not available for us to use. However, in order to ensure the questionnaire’s clarity, we conducted a pilot study with a group of residents at the Montreal Children’s Hospital, and we adjusted questionnaire items, for clarity only, based on those residents’ suggestions.
We based the structure of the current survey on an unpublished questionnaire previously used in conducting a similar study on physician role models8 (provided to us by Dr. Wright). The cover page of the questionnaire provided the Webster’s dictionary definition of a role model, “a person considered as a standard of excellence to be imitated.”13 The survey itself included five sections.
The first section addressed participant demographics (e.g., gender, age, previous training, and first choice of residency program). The second section focused on the importance of resident role models. This section included items that required students to rate the importance of resident and attending staff role models to their education and career choice on a seven-point Likert-type scale (1 = not all important, 7 = extremely important). For example, one question read, “How important were resident role models to your educational experience at McGill?” This section also required respondents to select who was most important to both their education and their career choice from a provided list of possible responses. Participants could choose only one of the following: attending staff, residents, other health care professionals, parents/family/friends, basic scientists, and “other.” An empty space for a free-text comment encouraged an explanation for the choice of other.
The purpose of the third section was to evaluate the importance of certain types of factors in selecting a resident role model. Based both on the factor types published by Wright and collaborators and on subsequent publications about physician role models,2–9 we included eight broad factor types: approachability, teaching skills, intellectual abilities, research and scientific interests, clinical competence, reputation, seniority, and personal qualities. We asked participants to rate the importance of each of these factor types on a seven-point Likert-type scale (1 = not important, 7 = of utmost importance).
The items in the fourth section probed specific attributes (within three of the factor types) that are important for students when selecting a resident role model. Previous literature had shown teaching skills, clinical competence, and personal qualities to be the most important factor types in selecting physician role models.2–9 Therefore, we subdivided these three into specific attributes, each of which we asked students to rate, consistent with previous studies,2,8 on a three-point Likert-type scale (1 = unimportant, 3 = very important). Later, we qualitatively compared the rank order of these specific attributes with the data published by Wright and colleagues8 on physician role models in 1997. We chose the 1997 study for comparison because it examined a similar population (graduating McGill medical students just prior to their residency match). However, in addition to the specific attributes previously reported by Wright and colleagues, we added and slightly modified certain attributes (e.g., makes time to teach) based on the literature published since that time2–7,9, to ensure completeness and clarity. Therefore, some of the specific attributes are not identical to those presented in the comparator publication.
Finally, the fifth section consisted of two pilot questions on negative role modeling designed to help guide future research. These data are not presented here.
Participants and setting
We conducted the study with graduating students at McGill University’s Faculty of Medicine. McGill medical students encounter residents from a variety of specialties, and from all years of training, in several clinical and educational settings over the course of their two-year clinical clerkship. The academic calendar for medical students and residents is coordinated such that rotations run in the same four-week periods; thus, to the extent possible, medical students work with the same group of one to four residents for at least four weeks during a single rotation. Although the experience medical students have with residents varies among departments, McGill has a long-standing reputation for significantly engaging residents as teachers and leaders of undergraduate trainees. For example, residents play a vital role in orienting students to the clinical setting, leading clinical teams, and conducting bedside teaching and clinical rounds that include third- and fourth-year medical students. Moreover, residents are engaged as small-group leaders and lecturers throughout the undergraduate curriculum.
Timing, procedures, and ethical considerations
We approached the students in the spring of 2011 after they decided on their first-choice residency, but before they received the results of their residency match. We selected this time period because we did not want the results of the residency selection process to influence responses.
During a mandatory session on professionalism, one of the researchers (R.S.) addressed the 2011 graduating McGill medical class, inviting all of the students present (158 of 165) to participate in the survey. We asked those who were willing to complete a paper-and-pencil questionnaire on residents as role models.
On the day of the survey, we provided a brief description of the study. We informed the students—both verbally and in writing—that participation in the study was strictly voluntary, anonymous, and independent of assessment and that all responses would be kept confidential. Subsequently, one member of the research team (R.S.) distributed the questionnaires (each of which was numbered) along with blank envelopes to the students. Each of the study participants completed a copy of the questionnaire and placed it in a box at the front of the classroom in a sealed envelope. All responses were transferred into a spreadsheet for analysis. The McGill University ethics review board approved this study.
We analyzed the data using descriptive statistics; we calculated mean scores for each of the items that used rating scales, and frequencies for those items that required a forced-choice response. We performed repeated measures analysis of variance both to analyze items using scalar responses (Likert-type scales) and to test for between-subjects effects (e.g., gender, previous educational background, first-choice residency).
To rank the eight factor types for selecting a resident role model, we conducted paired comparisons. On the basis of between-subjects effects identified in the analysis of these factor types, post hoc paired comparisons were subsequently performed. Finally, using the ratings of the specific attributes within these factor types, we divided them into three groups, as defined by Wright and colleagues8: more important attributes (mean rating 2.51–3.0), attributes of medium importance (mean rating 2.0–2.5), and less important attributes (1.0–1.99).
We used SPSS 18.0 software (Chicago, Illinois) to conduct all analyses.
Of the 165 graduating students, 158 were present in class and received the invitation to participate. Of those 158 students, 152 completed the questionnaire, resulting in a 96% response rate (representing 92% [152/165] of the graduating class).
The average age of the respondents was 25.2 years. Of the 152 respondents, 78 (51%) had not completed a prior university degree, and 82 (54%) were female (two respondents did not complete this portion of the questionnaire). Respondents reported the following programs as their first choice for residency: 24% (n = 36) family medicine, 20% (n = 31) surgery, 17% (n = 26) internal medicine, 9% (n = 14) pediatrics, 7% (n = 10) obstetrics–gynecology, and 4% (n = 6) psychiatry. Ten percent (n = 16) chose specialties not included in the core clerkship rotations, and 8% (n = 13) did not report a first-choice residency.
Importance of resident role models
Students felt that resident and attending staff role models were equally important to their education (mean = 5.51, standard deviation [SD] = 1.24 for both residents and attending staff; t = 0.00; P = .99). However, when we examined the overall pattern of ratings, students reported attending staff role models to be significantly more important than resident role models (mean for attending staff = 5.26 versus mean for residents = 5.01; F[1, 148] = 4.43; P < .05). On further analysis, we determined that this difference appeared to be driven by the difference in relative ratings for the importance of attending staff and residents for career choice (mean for attending staff = 4.99 versus mean for residents = 4.61; t = 3.08; P < .002). That is, medical students rated attending staff physicians as more important than residents in choosing a career. Moreover, 36% (54) of respondents identified attending staff as the role models most important in choosing their careers, whereas only 22% (34) identified residents as the most important (see Figure 1).
Finally, participants reported that role models, in general, were significantly more important in their education than in their choice of careers (mean for education = 5.52 versus mean for career choice = 4.80; F[1, 148] = 45.02; P < .0001). We detected no interactions between any of the individual items regarding the importance of resident role models and student gender, degrees awarded to student participants prior to medical school, or students’ first choice of residency program (all F values < 1.985); however, we noticed that women students gave higher ratings than men on all Likert scales measuring the importance of role models (mean = 5.36 [standard error of the mean (SEM) = 0.115] for women, and mean = 4.70 [SEM = 0.126] for men; F(1, 148) = 5.23; P < .03).
Important factors in selecting a resident role model
We found a significant difference among the ratings of the eight types of factors related to selecting a resident role model (F[7, 1022] = 283.00, P < .0001). According to our paired comparisons (see Table 1), the students perceived approachability as significantly more important than all other factor types, whereas having research and scientific interests was significantly less important than all other factor types. We detected no main effects or interactions between factor type ranking and gender or educational background (all F values < 1.5), but there was a significant interaction between the ratings of factor types and reported first choice of residency (F[7, 952] = 1.424, P < .05). However on post hoc analysis, we found that the overall rank order of the factor types was relatively consistent across groups of students by first choice of residency; therefore, we performed no further statistical analyses.
Specific attributes important in selecting a resident role model
Students rated the specific attributes that further defined teaching skills, clinical competence, and personal qualities, and we ordered the mean ratings for each attribute within the three factor types from highest to lowest mean rating. Being “respectful of students” and “mak[ing] time to teach,” received the highest rating of all the attributes (see Table 2). The comparison of our data with that published by Wright and colleagues8 in 1997 (Table 3) revealed that those attributes which our students felt to be the most important for resident role models were similar to the attributes that previous participants felt were the most important for attending staff role models.
Our data illustrate three points that, to our knowledge, are novel to the discussion of residents as role models: (1) Resident role models play an important role in the education and career choice of medical students; (2) resident and attending staff role models are equally important to the education of medical students; however, attending staff role models appear to be more important for the career choice of students; and (3) the types of factors and specific attributes important in selecting resident role models (i.e., respect and taking the time to teach) are consistent with the factor types and specific attributes previously reported as important in selecting physician role models.2–9
First, the idea that residents play an important role in undergraduate training makes sense intuitively; however, we believe that this is the first study to actually document residents’ important contributions as role models. Several fields are useful for contextualizing these findings. One of the most relevant is the research regarding “near-peers,” which focuses primarily on interactions between junior medical students and their more senior colleagues.14–16 Previous research has suggested many reasons to support the benefits of near-peer teaching, three of which we believe are critical to understanding why resident role models are important. The first claims that because near-peers have similar knowledge bases (i.e., cognitive congruence), a near-peer is able to offer an educational experience at the learner’s own cognitive level.15 Students perceive this cognitive congruence with their near-peers during their training and, therefore, identify near-peers as very helpful information providers, role models, and facilitators.14 The second principle is that near-peers appear better able to create comfortable and safe learning environments.15 Finally, near-peers seem better situated to socialize their more junior colleagues to the institutional culture and to act as “peer-models” because they may be more familiar with the hidden curriculum (i.e., implicit rules to survive the institution) than attending staff.15,17 Whereas the near-peer literature is based primarily on interactions between junior and senior medical students, it is reasonable to assume that similar phenomena may be taking place in the context of medical student and resident interactions because residents are simply a few years farther along in their educational pathway.
Second, as far as we are aware, this study is also the first to compare the importance of resident role models and attending staff role models in the areas of education and career choice. Our medical school respondents rated attending staff and resident role models as equally important for education, but attending staff role models as more important in determining career choice. Given that residency is a transitory phase on route to a medical career, it follows that students would be more likely to look to an attending staff rather than to a resident as a role model for career choice. However, our results also demonstrate that resident and attending staff roles models are less important to a medical student’s choice of career than they are to the student’s education. It may be that students turn to a much more diverse set of influences (e.g., family and friends) when selecting careers (as evidenced by the number of people other than attending and resident physicians whom our students report as influential to their career choice [Figure 1]), whereas attending staff and residents are the primary influences on their education.
Finally, when analyzing the types of factors important in selecting residents as role models, the results illustrate that approachability, teaching skills, personal qualities, clinical competence, and intellectual ability were the most important. This is consistent with previous literature on physician role models.2–9 Further, our relatively large sample size (n = 152), allowed us to generate a defensible rank-list of the above factor types. In addition, ratings of the specific attributes (within the three factor types) also reflected previous findings.2–9 This parallel implies that medical students attend to similar attributes in both resident and attending staff role models. Moreover, the stability in these findings across generations may indicate that what medical students look for in role models may not have changed significantly over the last 16 years. Finally, the similarity in rank order lends further credibility to the importance of the identified factor types and specific attributes studied here.
Our study highlights the importance of residents as role models, and we believe that it is essential to ensure that residents are able to successfully become positive role models for medical students. The literature suggests that residency represents a difficult transitional period for trainees who face many challenges related to balancing a heavy workload, mastering procedures, and navigating a new learning environment.18–22 As such, transition to residency appears to be associated with high levels of stress and negative emotions.22 Therefore, we postulate that the challenges residents face could make being a positive role model difficult for some of them. Although the relationship between resident role models and the stresses of residency have yet to be formally explored, we believe that an emphasis on better supporting residents in their function as role models may enable them to exert an even greater influence than that illustrated in this study.
Because of our large sample size, we have been able to provide support for concepts that have been previously reported in a more descriptive fashion.5–8 However, our study has some limitations. Our study population consists of a single graduating class at McGill University. This population may differ from other medical schools, particularly those in the United States, in which new duty hours restrictions prohibit residents from doing 24-hour shifts. Such restrictions had not yet been implemented at McGill at the time this study was conducted, and, as such, any implications that they may have on the interactions between students and residents would require further investigation. Moreover, the questionnaire used in this study was not formally validated, although it was piloted prior to distribution. Finally, our study did not explore whether medical students’ perceptions of residents as role models were consistent across the various departments and specialties through which medical students rotate, nor did it define at a granular level the educational areas in which resident role models are most important. Future research examining these specifics may enable us to better understand the variables influencing the relationship between medical students and resident role models in specialty-specific contexts.
In summary, our study is the first to illustrate that resident role models are perceived by medical students to be as important as attending physician role models to their education. We therefore believe that further investigation into means of supporting residents in their status as role models would have an important positive impact on undergraduate training. Albert Schweitzer best summarized the importance of such positive examples when he wrote, “Example is not the main thing in influencing others. It is the only thing.”
Acknowledgments: The authors wish to thank Dr. Scott Wright, Dr. Farhan Bhanji, Ms. Lorie Kloda, Dr. Linda Snell, Ms. Deanna Radford, and core faculty members at the Centre for Medical Education at McGill University, for their contributions to this project.
Other disclosures: None.
Ethical approval: The McGill University Faculty of Medicine Institutional Review Board has granted ethical approval to conduct this study.
Previous presentations: The authors presented this research at the Canadian National Pediatric Resident Research Competition in Winnipeg Manitoba, on May 12, 2011.
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