Role Models: Their importance and their development

1. Role Models:Their importance and their development Scott Wright, MD Arnold P. Gold Foundation Assistant Professor of Medicine Johns Hopkins University

2. Webster’s 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. Thorpe’s 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. Thorpe’s 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 (Bandura’s work with elementary school children, 1960’s) 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 (Bandura’s work with elementary school children, 1960’s) [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 (Bandura’s work with elementary school children, 1960’s) [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 (Bandura’s work with elementary school children, 1960’s) • 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

17. ‘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).

18. ‘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

19. My Charismatic Model

20. 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 1970’s: - 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.

21. 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 managementAPDIM, 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 MedicineLinzer 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.

24. “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

25. Senior residents’ views on the meaning of professionalism and how they learn about itBrownell 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.

26. Surgeons swear when operating: fact or mythPalazzo 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; sh*t, p*ss ..., 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

28. 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?

29. 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

31. 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.

32. 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 studentsWright, 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).

35. 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%

36. 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).

37. 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.

38. Results (continued) Factors most important in selecting role model (1 = most important, 6 = least important) MEDIANMEAN 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.

40. Yet another example of role modeling • Our Department of Medicine Chairman at medical grand rounds a few weeks ago

41. 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.

42. Attributes of excellent role models: A case-control studySM 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

43. Case Identification

44. Frequency with which role models were namedby the housestaff Number of attendings Median : 3 Range: 1 - 43

45. 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. 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) Association of exposure with being named as a role model

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