Jochemsen-van der Leeuw, H.G.A. Ria MD; van Dijk, Nynke MD, PhD; van Etten-Jamaludin, Faridi S.; Wieringa-de Waard, Margreet MD, PhD
Being a competent, professional doctor is a prerequisite for providing high-quality care to patients.1,2 Medical educators, especially those involved in the clinical training of interns and residents (hereafter called trainees), therefore need to prepare trainees to meet this requirement. According to Bandura’s3 social learning theory, trainees learn essential professional competencies by observing a role model—defined in the medical literature as a person considered to demonstrate a standard of excellence to be imitated.4–8 Bandura3 also indicates that attention, retention, reproduction, and motivation are necessary for effective observational learning; this process is reciprocally influenced by environmental, behavioral, and personal factors (Figure 1). Thus, role modeling is a powerful strategy by which to instill professional behavior in young doctors through learning by observation.6,8–11
In graduate medical education, the clinical trainer—that is, any physician who supervises the trainee in clinical practice—serves as the role model for the trainee. Consequently, the clinical trainer’s display of professional behavior may positively affect the trainee, whereas the trainer’s display of unprofessional behavior may have a negative effect.5,12–15 To help ensure that trainees imitate the behavior that is appropriate for their future role,9 trainees, trainers, and medical educators need to be aware of the key attributes of role models. Such awareness makes it possible to distinguish by apperception between positive and negative role modeling.16
Multiple instruments have been developed to assess clinical trainers and provide feedback on their clinical teaching.17–19 Some tools20–22 address whether the clinical trainer should be considered a role model but do not discriminate between positive and negative role modeling or identify the specific aspects of the clinical trainer’s performance that represent the correct professional behavior to imitate. We believe that these instruments need to be extended to include items on specific aspects of role modeling to reduce the risk that trainees will imitate unprofessional clinical behavior23 and to improve the quality of trainers’ role modeling.
In response to this need, we conducted a systematic review of the medical and medical education literature to identify the attributes that characterize positive and negative role models in clinical practice. Our research question was, which attributes characterize the clinical trainer as a positive and negative role model for the trainee?
Using a search strategy developed by a clinical librarian (F.S.v.E.-J.), we systematically searched the MEDLINE, EMBASE, ERIC, and PsycINFO databases via Ovid for articles published in any language, from each database’s earliest available date through the day of the search, May 5, 2011. Search terms included combinations and alternatives of the following key terms: graduate medical education, residency, clinical trainer or teacher or medical teacher, clinical and family or general practice, role model or modeling, and preceptor and professional role (for the complete search strategy, see Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A111). We performed additional manual searches by reviewing the references of retrieved articles as well as the content of four medical education journals (Academic Medicine, Journal of Postgraduate Medicine, Medical Education, Medical Teacher) published within the year prior to the search. We also reviewed titles and abstracts of articles cited in the reference lists of papers presented on March 22, 2011, at a meeting in Utrecht on the topic of our review that was attended by national experts in the field and organized by the Netherlands Association for Medical Education.
We included original studies, both qualitative and quantitative, that described attributes of the clinical trainer as a role model for the trainee in graduate medical education, in the hospital or in primary care. We excluded duplicates, articles that did not report original studies, and studies describing medical students, medical education before medical school graduation, specialty choice, or the role of the clinical trainer as a teacher or mentor rather than as a role model.
We conducted the selection process during May to September 2011 (Figure 2). Two of us (H.J.-v.d.L., N.v.D.) independently reviewed the titles and abstracts of all unique articles identified in the search. We were able to eliminate many articles after screening their titles and abstracts because our search strategy was broad and identified articles with wide-ranging descriptions of role modeling. We resolved any disagreements through discussion until we reached consensus.
After the initial screening, we retrieved the full text of the publications we considered to be potentially relevant. We (H.J.-v.d.L., N.v.D.) read each of these articles independently and used a form that we had pilot-tested to assess whether they met inclusion criteria. One publication was not available, so we obtained it from its author. We discussed any doubts about particular studies until we reached consensus.
Quality assessment and data extraction
Two of us (H.J.-v.d.L., N.v.D.) used the validated Medical Education Research Study Quality Instrument (MERSQI)24 to independently assess the methodological quality of each of the studies selected for inclusion. We reached agreement on scores through discussion. The possible MERSQI score for quantitative studies ranges between 5 and 18, with higher scores indicating higher quality. However, some MERSQI items are not valid for qualitative studies, so we omitted them when assessing such studies. This resulted in a maximum possible score of 15 for qualitative studies.
We (H.J.-v.d.L., N.v.D.) independently abstracted data from each included study using the Best Evidence Medical Education (BEME) Collaboration systematic review data extraction form,25 which we modified to also fit qualitative research by adding tables to record reported attributes. Any disagreements were discussed until consensus was reached. For each included study, we extracted the following information: study design; country of origin; types and numbers of participants; specialty; most important and least important attributes of positive role models; and attributes of negative role models. We determined an attribute’s importance by the number of studies in which it was mentioned, combined (if available) with its relative importance as reported by the trainees participating in that study.
Our literature search yielded 4,955 unique articles (Figure 2). After screening all titles and abstracts, we excluded 4,882 articles. We retrieved the full text of 73 studies and reviewed them against our inclusion and exclusion criteria. Of these articles, 17 met our inclusion criteria.
Characteristics and quality of included studies
Table 1 presents the characteristics of and results of the quality assessment of the 17 studies4–8,26–37 included in this systematic review. The mean MERSQI score for the 10 quantitative-design studies (59%)4,6–8,30,32,33,35–37 was 9.7 (range: 7.5–11; maximum possible score = 18). For the 7 (41%) qualitative-design studies,5,26–29,31,34 the mean MERSQI score was 8.1 (range: 6–11; maximum possible score = 15).
Most important attributes of positive role models
We determined that the attributes of positive role models (Table 2) can be divided into three main categories: patient care qualities, teaching qualities, and personal qualities. This is the same classification Wright8 found in 1996.
Patient care qualities.
First, a positive role model is a competent specialist6 with up-to-date knowledge.26,30,34 He or she is an experienced34,37 and strong clinician5 with a commitment to excellence and growth,5 effective diagnostic6,8 and therapeutic skills,30,33 and sound clinical reasoning.6,30 Furthermore, a positive role model is compassionate,8,29 caring, engaging,29 and empathic to patients6,31 and is able to build a personal connection with them.7,28,29,31 He or she is dedicated to the quality of patient care5,6 and centers the care he or she provides on the patient rather than the illness.37 A positive role model communicates well with patients and their relatives,6,8,26,31 shows respect to patients,31 has a humanistic attitude toward patients,26,30,37 and educates and fully informs patients.6 In addition, he or she has respect for and gives recognition to others,6 resulting in positive interactions with other health care workers.6,8,30,37
Moreover, a positive role model displays a high degree of professionalism,26,27 assumes responsibility in difficult clinical situations,5 and is able to cope with adversity.35,36 In daily life, he or she demonstrates enthusiasm for his or her work,4,8,29 enjoys the job,28,29 and displays satisfaction with his or her chosen specialty.7,29
As a clinical educator, a positive role model employs a humanistic style of teaching,26 establishes rapport with learners,5 tailors his or her teaching to learners’ needs,7 creates a safe learning environment,28 and gives learners the autonomy to make independent decisions.32,33 Moreover, a positive role model teaches trainees about the psychological aspects of medicine and the importance of the doctor–patient relationship.7 At the same time, he or she adopts a positive attitude toward trainees,4,6 shows enthusiasm for teaching,6 and makes himself or herself available for trainees4,7 and accessible for questions.29 He or she stimulates critical thinking,32,33 makes learning exciting,8 and is inspirational.28 Finally, a positive role model is aware of the importance of his or her role model status for medical education5,7,31 and, therefore, acts as a dedicated and active role model,34 encouraging the trainee to adopt similar behavior.27
A positive role model is patient,6,8,29 has self-confidence30,34 and self-esteem,35,36 and displays honesty and integrity.4–6 He or she is easy to work with29 and cooperative,35,36 shows humility and humanism,26,30,37 and has leadership ability.5,7,30
Least important attributes of positive role models
Seven (41%) studies4,6–8,30,32,33 reported attributes considered the least important in identifying a clinical trainer as a positive role model (Table 2). These include stimulating the trainee’s interest in research or assisting the trainee with finding and completing research,6,30,32,33 being the author of numerous publications,4,6,8 having a national or international reputation,4,30 or having received honors and awards.4 Whether the clinical trainer has management30 or presentation skills6 or attends conferences6,32,33 also has little importance. The clinical trainer’s general physical appearance4,6,8,30 is reported as having little influence, as are the trainer’s sharing of interests with the trainee outside medicine,6,8 spending time with trainees and learning about their personal lives,7 or participating in community affairs.6
Attributes of negative role models
Six (35%)5,27–30,34 of the 17 studies reported attributes of negative role models (Table 2). These characteristics can also be divided into the categories of patient care qualities, teaching qualities, and personal qualities.
Patient care qualities.
A negative role model is uncaring29 toward and communicates poorly29,30 with patients, adopts an uncooperative attitude toward health care workers,30 and displays unprofessional attitudes27 and unethical behavior.34 In addition, if the trainer’s knowledge of the field is not up-to-date, the trainee may feel more knowledgeable than the trainer.34
A negative role model teaches the trainee the wrong thing to do and the wrong way to behave,27 gives poor support to learners,27 and rarely provides feedback to trainees.28 He or she practices a sink-or-swim approach from the outset.28 Furthermore, he or she is disinterested8 and has difficulty remembering names and faces.5
A negative role model is cynical,28,29 has a sexist attitude,34 and is impatient, inflexible, and overopinionated.5 He or she may nitpick and be harsh, unfair, or self-serving.34 Finally, a negative role model may lack self-confidence30 or leadership skills30; he or she may be quiet and reserved5 or overextended.5
Discussion and Conclusions
Through our systematic review of the medical and medical education literature on the clinical trainer as a role model for trainees (interns and residents), we have identified extensive lists of attributes that describe positive role models and negative role models. These attributes can be divided into three categories—namely, patient care qualities, teaching qualities, and personal qualities.
Although the differences among teaching,8 mentoring,10,13 and role modeling are often thought to be unclear due to overlap in daily practice, role modeling is the most implicit (i.e., also occurs when the clinical trainer’s focus is on other, not trainee-related, tasks).9,10,13,16 Our findings illustrate this implicit aspect of role modeling: Positive role models were most commonly described as being excellent, experienced clinicians who had empathy for patients and positive interactions with patients, patients’ families, and other health care workers. Positive role models were also frequently described as displaying teaching qualities, including commitment to the growth of learners and a humanistic style of teaching, as well as personal qualities such as enthusiasm. Thus, the literature describes the clinical trainer who is a positive role model as someone who is admired for being, or acting as, a professional,4–8 or as someone who inspires and teaches while carrying out other tasks.10,16
A good clinical trainer should be aware of his or her role model status because heightened awareness of role modeling may lead the trainer to seek the opportunity to demonstrate behavior, to comment on what was done, and to explain what was done.5 Some authors stressed that the clinical trainer should make his or her implicit behavior as a role model explicit to the trainee.9,16 This would help the trainee pay attention, retain what the trainer is modeling, become motivated, and use the modeled behavior as a guide for the trainee’s own actions.
In addition to describing the most important attributes of positive role models, almost half of the studies reviewed reported those attributes considered least important. These included whether the clinical trainer was active in research, published articles, played a management role, had achieved an international or national reputation, or had received awards.4,6,8,30 Furthermore, the clinical trainer’s general physical appearance was not considered to have much influence on his or her performance as a role model.4,6,8,30 This is in contrast with Gurung and Vespia’s38 earlier finding that the teacher’s attractiveness was positively correlated with the student’s perceived learning. The authors of that study,38 however, interpreted “attractiveness” more as “liking” the teacher than as related to the teacher’s physical appearance. Another study that examined the influence of the trainer’s appearance on students’ evaluations of teaching showed that attractiveness had no effect.39 Thus, it seems that the clinical trainer’s behavior—as demonstrated through patient care, personal, and teaching qualities—is more important than the trainer’s appearance or scientific achievements.
The characteristics of negative role models, as reported in the studies reviewed, included being uncaring toward patients as well as having poor relationships with patients and other health care workers. Additionally, negative role models were described as being unsupportive and disinterested toward learners, being cynical and impatient, or having a sexist attitude. These attributes of negative role modeling are in marked contrast to the qualities of positive role modeling described above and, thereby, confirm how important attributes are for characterizing role model behavior. Janssen et al40 similarly described the importance of the attributes of positive role models; they considered positive role modeling a prerequisite for stimulating trainees to provide patients with high-quality care. Kenny23 argued that the impact of negative role modeling may adversely affect the trainee’s establishment of a professional identity, and suggested that there is a need for trainees to be able to discriminate between good and poor role modeling.
This review has a number of limitations. First, although much has been written about the importance of role modeling in medical education, we only found 17 articles based on original studies that met our inclusion criteria. Furthermore, these studies used different methods, techniques, and wording, which prevented us from performing a meta-analysis. Nonetheless, we were able to identify congruent qualities, and three distinguishing categories emerged from our analysis of these data. Second, the 17 studies were conducted in a range of countries and specialties, in different sociocultural and ethnic circumstances, which may have influenced the generalizability of the results. However, we believe that the similarity of the data from these diverse settings suggests that the identified attributes are transferable to other settings.
Implications for medical education and future research
The literature shows that efforts have been made to improve clinical role modeling. For example, Maker et al33 used identified role model criteria as a tool to evaluate and provide feedback to clinical trainers. With these criteria, they could confirm a trainer’s improvement with regard to role modeling after the intervention. Cruess et al16 described additional strategies to improve role modeling using a number of characteristics identified in their review, such as raising the trainer’s awareness of serving as a role model and facilitating reflection on the behaviors that had been modeled.
Such strategies are in line with the recommendations made by Wright and colleagues,5,7 who concluded that the identified attributes of positive role models can be acquired through training, particularly by making clinical trainers aware of their role model function. Such continuous awareness of the role model task is, as Wright and Carrese5 stated, an important attribute of an excellent role model. Thus, we suggest that the most important attributes of positive role models identified in our review could form the foundation of a training course for clinical trainers. They could also be used to develop an instrument for enhancing clinical trainers’ awareness of being a role model and to give trainers feedback on their role-modeling behaviors.
As trainees learn through observation and imitation,3 it is important that they learn to distinguish between positive and negative role modeling to prevent them from unwittingly imitating a trainer’s less desirable behavior.40 Given that the characteristics identified in this review were drawn from studies in clinical settings where multiple clinical trainers were observed and compared, the question arises as to whether trainees in a small hospital or primary care setting with only one or two clinical trainers would be able to distinguish between positive and negative role modeling. This is particularly relevant in situations in which it is not possible to compare the modeled behavior with that of another trainer who may be more professionally competent.40 However, if trainees were to have an objective instrument that they could use to evaluate their clinical trainers, they could identify negative role modeling. Therefore, we recommend incorporating the attributes we identified in this review into a tool to help trainees determine, through apperception, whether to imitate a trainer’s role-modeled behavior. Such a tool would help ensure that trainees learn the professional competencies that will enable them to become doctors capable of providing high-quality patient care.
Further research is necessary, however, to transform the attributes we identified in this review into a validated instrument to assess the clinical trainer as a role model. In addition, such a tool could be used in studying the effect of training courses for clinical trainers to improve role modeling.
Funding/Support: This study was funded by CASH (Committee for Activities to Promote the Education of General Practitioners; http://www.sboh.nl/content.asp?kid=10034714).
Other disclosures: None.
Ethical approval: Not applicable.
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