Doctor role modelling in medical education: BEME Guide No. 27

Figures & data

Table

Practice points

Clinical teachers can enhance their status as role models. To be an effective role model, clinical teachers must be encouraged to develop a conscious awareness of role modelling, in which they specifically think about being role models when interacting with learners. Role modelling should be explicit in clinical teaching, as it is important for teachers to make an intentional effort to articulate what aspects they are modelling. Clinical teachers need to be aware of the profound influence they exert on recruitment to specialities and that the level of enthusiasm they display for their job is a compelling factor. Medical leaders need to develop strategies to ensure the organisational structure supports a culture of excellence in doctor role modelling. This will involve developing innovative faculty development initiatives and may require establishing valid methods of evaluating the performance of faculty in addition to the provision of opportunities for self-improvement through faculty development. Medical educators worldwide need to collaborate and share ideas to develop excellence in role modelling; as this in turn will ensure high standards of patient care.

Figure 1. Flow diagram of search process.

Table 1  Summary of the main themes and associated references

Theme	Theme	Papers
1	Attributes of positive role models	Wright, 1996; Wright et al. 1998; Althouse et al. 1999; Cote and Leclere, 2000; Matthews, 2000; Elzubeir and Rizk et al. 2001; Wright and Carrese, 2001; Wright and Carrese, 2002; Mclean, 2004b; Joubert et al. 2006; Weismann et al. 2006; Yazigi et al. 2006; Mclean, 2006; Wyber and Egan, 2007; Lynoe et al. 2008; Lombarts et al. 2010.
2	The personality profiles of positive role models	Magee and Hojat, 1998; Hojat et al. 1999.
3	Influence of positive role models on student's career choice	Henderson et al. 1996; Wright et al. 1997; Ambrozy et al. 1997; Watts et al. 1998; Basco and Reigart, 2001, Drouin et al. 2006; Berman et al. 2008; Ravindra and Fizgerald, 2011.
4	The process of positive role modelling	Jones et al. 2004; Thiedke et al. 2004;Balmer et al. 2007; Taylor et al. 2009; Park et al. 2010; Curry et al. 2011; Thiedke et al. 2004.
5	The influence of negative role modelling	Murakami et al. 2009; Wear et al. 2009; White et al. 2009.
6	The influence of culture, diversity and gender in the choice of role models.	Neumayer et al. 1993; Wright and Carrese, 2003; Mclean, 2004a; Shortell and Cook, 2008.

Table A1  Search strategy

Database	Search Strategy
PubMed	((“physicians"[MeSH Terms] OR “physicians"[All Fields] OR “doctor"[All Fields]) OR “physician"[All Fields])) AND (role model[All Fields] OR role modeled[All Fields] OR role modeling[All Fields] OR role modelled[All Fields] OR role modelling[All Fields] OR role models[All Fields]) AND (“education, medical"[MeSH Terms] OR (“education"[All Fields] AND “medical"[All Fields]) OR “medical education"[All Fields] OR (“medical"[All Fields] AND “education"[All Fields]))
Embase	1 role model*.mp. 2 role.mp. 3 model.mp. 4 2 and 3 5 1 or 4 6 medical education.mp. or exp medical education/ 7 doctor.mp. or physician/ 8 5 and 6 and 7
PsycInfo	all(role model* OR (role AND model*)) AND all(doctor* OR physician*) AND all(medical education)
Education Research Complete	(role model* or (role and model*)) AND (doctor* or physician*) AND medical education
Web of Knowledge	Title = (role model* or (role and model*)) AND Topic = (doctor* or physician*) AND Topic = (medical education)
ERIC	all(role model* OR (role AND model*)) AND all(doctor* OR physician*) AND all(medical education)
British Education Index	(role model* OR (role AND model*)) AND (doctor* OR physician*) AND (medical education)

Table

Quality Indicator	Score = 0 or 1	Summary
1. Research Question
2. Study Subjects
3. Data Collection Methods
4. Completeness of Data
5. Control of Confounding
6. Analysis of Results
7. Conclusions
8. Reproducibility
9. Prospective
10. Ethical Issues
11. Triangulation

Total Score = /11

Table A2  Summary table of included papers

Author; Title	Aim	Year	Country	Method	Results	Conclusions	Theme	Score
Althouse et al. Attitudes and approaches of influential role models in clinical education.	To determine the characteristics and teaching methods associated with positive role modelling.	1999	USA	Semi structured interviews with 10 role models. 4 role models observed.	5 themes emerged: role models approaches to their teaching; their attitudes towards teaching and learning; clinical competence; external roles and general affect.	Role models were attentive to the needs of students and adapted their teaching accordingly. They provided plenty of patient interaction and demonstrated the rewards of being a physician. Quality more important than quantity.	1	8
Ambrozy et al. Role models’ perceptions of themselves and their influence on students’ speciality choices.	To examine the perceptions of the faculty role models and to learn if their perceptions of role models’ behaviours are congruent with those of their students.	1997	USA	Mailed questionnaire to 210 student identified role models.	177/210 response = 84%. The role models agreed with the students about what it is important to model.	Role models did not intentionally try to recruit students but felt that demonstrating enthusiasm and a sincere love for what they did has a strong influence. The role models agreed with their students what is important to model.	3	8
Balmer et al. Learning behind the scenes: Perceptions and observations of role modelling in paediatric community clinic.	To analyse what and how paediatric residents learn through role modelling during their continuity experience.	2007	USA	Interviews and observations with 10 residents and 10 faculty.	Role modelling was an implicit and intentional learning strategy.	Role modelling is a deliberate learning strategy. Need clarification of definitions.	4	8
Basco & Reigert. When do medical students identify career-influencing physician role models?	To identify when med students gain physician role models relative to when they make speciality choices.	2001	USA	Questionnaire survey to Medical Students.	89/144 = 62% response rate. Most students met role models from third year.	Most medical students have physician role models at graduation, with most identified in 3^rd year before making speciality choice.	3	9
Berman et al. Attracting surgical clerks to surgical careers: role models, mentoring and engagement in the Operating Room	To identify those aspects of the surgical clerkship that are associated with medical students’ experiencing an interest in surgery.	2008	USA	Online questionnaire survey to 131 medical students.	116/131 = 89% response. Students who have positive role models and participate actively in operations will consider surgery as option.	It is important to encourage meaningful and active involvement of students.	3	7
Cote & Leclere. How clinical teachers perceive the doctor –patient relationship and themselves as role models.	To describe how clinicians who teach clerks and residents represent the doctor – patient relationship and how they see themselves as role models for this relationship.	2000	Canada	Semi structured interviews with 28 clinical teachers.	Most of the teachers had difficulty in describing behaviours or situations in which they modelled the doctor-patient relationship.	Being a role model requires a fairly precise idea of what one is modelling and what one wants the trainee to understand about the relationship.	1	8
Curry et al. Role modelling in the operating room: medical student observations of exemplary behaviour.	The aim of this research was to determine and thematically define the exemplary professional behaviours that med students observe in the operating room.	2011	USA	286 medical students recorded one exemplary and one lapse in operating room.	Themes were interaction with patient (calm, communication, comforting); with one another (teamwork, respect); and with medical students (teaching).	This classification of exemplary behaviours contributes to our understanding of how professional behaviour is viewed and potentially emulated by medical students.	4	8
Drouin et al. Medical students as teachers and role models for their future colleagues	The authors describe the role of junior medical students in recruitment.	2006	Canada	The medical students designed workshops. Evaluation is by questionnaire, focus groups and admission statistics.	Attendees give positive evaluations highlighting the importance of role modelling.	Allowing junior doctors to act as teachers and role models for high school and university students during recruitment activity can be useful strategy for institutions.	3	6
Elzubeir & Rizk. Identifying the characteristics that students, interns and residents look for in their role models.	To identify the characteristics that students, interns and residents look for in their role models.	2001	UAE	Questionnaire was sent to medical students, interns and residents.	N = 96, response rate = 80% Personality, teaching and clinical skills were the top three factors identified.	Knowing the characteristics of excellent role models should help medical educators to formulate strategies to recruit, retain and develop them.	1	8
Henderson et al. General internists influence students to choose primary care careers: the power of role modelling.	To determine whether med students supervised by general internists are more likely to choose primary care careers.	1996	USA	Questionnaire survey to Medical Students pre and post clerkships and at graduation.	Both pre and post clerkship questionnaires were completed by 138/144 = 96%. Graduation survey completed by 137/188 = 73%	Role modelling appears important in choosing general internist medicine.	3	9
Hojat et al. A comparison of the personality profiles of internal medicine residents, physician role models and the general population.	To compare personality profiles of internal medicine residents with those of the general population and positive role models in medicine.	1999	USA	Neo Personality Inventory to 104 residents and 188 role models.	The internal medicine residents were more likely to be attentive, to have deeper curiosity, higher aspirations and be more receptive to emotions. Medical residents were less eager to face challenges, less able to control their impulses, less able to cope with adversity, less relaxed and less easy going.	Understanding the more distinct qualities of successful physicians helpful in career counselling of students and young physicians.	2	8
Jones et al. An intentional modelling process to teach professional behaviours: Students’ Clinical Observations Of Preceptors	The authors describe an innovative process called SCOOP.	2004	USA	The authors describe the SCOOP process. 93 med students completed at least 1 SCOOP.	83% of students found SCOOP a positive experience for modelling professionalism	The SCOOP provides explicit framework to optimise modelling of professionalism.	4	5
Joubert et al. Medical students on the value of role models for developing ‘soft skills’ – ‘that's the way you do it.’	To study the importance that medical students attach to role models in the development of soft skills.	2006	Africa	91 medical students. Interviews and focus groups.	The students idea of a good role model was a clinically and academically competent doctor that cared about patients, had good interpersonal skills and who could inspire students.	Medical schools need to be consciously aware of the importance of positive and negative role models. Students needed role models to develop own soft skills.	1	8
Lombarts et al. Good clinical teachers likely to be specialist role models.	To examine whether teaching qualities of faculty were associated with their being seen as specialist role models.	2010	Holland	Questionnaire survey to 549 residents of 36 teaching programmes in 15 hospitals.	407 residents completed. 4123 evaluations of 662 faculty = 71% response rate.	Top 3 qualities were –those that rated highly on feedback; a professional attitude towards residents and creating a positive learning climate. Good clinical educators more likely to be seen as specialist role models.	1	8
Lynoe et al. Teaching medical ethics: what is the impact of role models?	The aim of the study was to elucidate what influences medical students’ attitudes and interest in medical ethics.	2007	Sweden	Questionnaire to 409 medical students from 6 schools.	Average response rate 36%.	An increased interest in medical ethics is mainly by encountering good role models in medical school.	1	6
Magee & Hojat. Personality profiles of male and female positive role models in medicine.	To investigate the personality profiles of positive role models in medicine in comparison to the general population.	1998	USA	188 physician role models nominated by CEO completed the NEO Personality Inventory.	188 = 80% response. 164 men 24 women.	Role models scored higher on conscientiousness factor, achievement striving, activity, competence, dutifulness, trust, assertiveness versus the general population.	2	9
Mathews. Role modelling: how does it influence teaching in family medicine?	To explore the influence of role modelling on teaching in family medicine.	2000	S.Arabia	9 semi structured interviews with faculty. Questionnaire to 28 residents.	27/28 response = 97%. 4 remembered teacher behaviours described.	Agreement between faculty and residents with regard to the important aspects to model.	1	6
McLean. Is culture important in the choice of role models?	To investigate the importance that students’ ascribe to culture in their choice of role model.	2004a	Africa	Questionnaire to medical students.	No response rate given. 40.7% felt culture was important in the choice of a role model.	The need for staff training in culture, diversity and tolerance. Cultural diversity training is important in curriculum.	6	6
Mclean. The choice of role models by students at a culturally diverse South African School	The objectives of the study were to ascertain where students sought role models and the characteristic of the role models.	2004b	Africa	Questionnaire to 824 medical students	Response = 97.5%. 64% of students considered having a role model important.	The findings are considered in the light of global medical training and the need for faculties to provide appropriate role models for students.	1	5
McLean. Clinical role models are important in the early years of PBL curriculum.	The study compares the role models identifie by students in the first 2 years of the traditional medical curriculum with that of a PBL programme.	2006	Africa	Questionnaire study to 745 medical students.	90% response rate. PBL students more likely to identify role models.	Faculty need to be aware that they are being assessed as role models and their behaviours must be worthy of emulation at all times. Need exposure to role models in early years.	1	6
Murakami et al. The perception of the hidden curriculum on medical education: an exploratory study	To identify themes pertaining to the students’ perceptions of the hidden curriculum.	2009	Japan	Semi structured interviews with 25 medical students	Seven themes including the prevalence of positive and negative role models.	Some effects of the hidden curriculum likely to exist in Japan and UK despite the differences in their demographic backgrounds, cultures and philosophies.	5	8
Neumayer et al. Female surgeons in the 1990s: academic role models	A survey of female surgeons and their role models.	1993	USA	Questionnaire to 1500 members of the association of female surgeons.	676/1500 = 45% response. 630 believed that female medical students need successful female surgeons as role models.	Need successful female surgeons as role models.	6	6
Park et al. Observation, reflection and reinforcement: faculty members’ and residents’ perceptions.	To explore perceptions of how professionalism is learned in the current academic climate.	2010	Canada	34 semi structured interviews with surgery residents and faculty at 2 institutions.	Participants identified 3 processes - observation, reflection and reinforcement in learning from role models. Role models the most important source of learning professionalism.	This study highlights an active approach to role modelling through intentional and explicit demonstration of behaviours.	4	9
Ravindra & Fitzgerald. Defining surgical role models and their influence on career choice.	To investigate whether identifying role models in surgery influences career choice.	2011	UK	Questionnaire to 320 graduates.	208/320 = 65% response. 131 = 63% were able to identify a role model.	Junior doctors were twice as likely to pursue a surgical career if they identified a positive surgical role model.	3	8
Shortell & Cook. Importance of gender specific role models in vascular surgery	To explore the importance of same gender role models in vascular surgery.	2008	USA	Questionnaire survey to 2389 members of the Society of Vascular Surgeons.	135 respondents = 5.6%. Men and women more likely to find male role models in Medical School.	Lack of female role models during medical school.	6	4
Taylor et al. The influence of mentorship and role modelling on developing physician-leaders	To understand the role and functions of role modelling in developing leaders.	2009	USA	Semi structured interviews with 25 faculty.	3 themes identified: role modelling is different to mentoring; the importance of strategic interactions; emotional support.	Role modelling is different to mentoring and there is an impact of learning from direct observation of leaders.	4	8
Thiedke et al. Students’ observations and ratings of preceptor's interactions with patients: the hidden curriculum.	The study examined first year student observations of community based physician behaviour during a community based clinical experience.	2004	USA	1st year medical student questionnaire regarding physicians’ behaviour with patients.	119 = 87% response rate. Students rated aspects of the physicians demeanour with patients as the highest value.	Community based physicians reinforce many professional values associated with positive role modelling aspects of the physician – patient interaction.	4	7
Watts et al. Undergraduate education in anaesthesia: the influence of role models on skills learnt and career	To investigate the influence of role models on the educational process of anesthetic teaching to undegraduates.	1998	Australia	Questionnaire to 75 directors. Questionnaire to 160 final year medical students.	40/75 faculty response. 101/160 student response. Positive role models were identified by 66% students if they and practical training.	For those students intending a career in anaesthesia (18%); 94% identified a positive role model compared to 65% who did not (P = 0.03).	3	8
Wear et al. Making fun of patients: medical students’ perceptions of the use of derogatory and cynical humour.	To investigate how medical students perceive and use derogatory and cynical humour directed at patients.	2006	USA	5 focus groups with 58 medical students.	5 categories emerged: “Fair game” patients; locations; “Humour game”; not funny humour; motives. Students disappointed by role models displaying derogatory humour. Intergenerational Transmission Model.	Need to use positive role modelling as a specific strategy to develop professionalism. Consider – “Reflections on Doctoring” classes.	5	8
Weismann et al. Role modelling humanistic behaviour: learning bedside manner from experts.	To study how excellent teachers impart the behaviours and attitudes consistent with humanistic care to their learners.	2006	USA	12 faculty role models. Observations and interviews.	Clinical teachers taught by role modelling. The teachers identified self-reflection as the method by which they refined their teaching strategies.	Role modelling is the primary method by which excellent clinical teachers try to teach medical residents humanistic aspects of medical care.	1	9
White et al. A qualitative exploration of how the conflict between the formal and informal curriculum influence students values and behaviours	Exploration of the FCE on students’ experiences in the third year clinical clerkship.	2009	USA	Focus groups with 27 3^rd year med students.	Authors categorised students into those whose patient centred values were maintained, compromised or transformed.	Role modelling had a significant influence on consequences related to students’ patient centred values.	5	8
Wright. Examining what residents look for in their role models.	The study aims to determine which characteristics were considered most important by residents regarding their physician role models.	1996	USA	Questionnaire to 195 residents.	195/230 = 85% response. 144 = 74% satisfied with proportion of positive role models. Clinical skills, personality and teaching ability were rated as 3 most important factors.	Knowing what residents look for in their role models should help identify which staff are excellent role models and these staff should be selected as role models.	1	8
Wright et al. The impact of role models on medical students	To explore the relationship between exposure to clinical role models during medical school and the students choice of clinical field for residency training.	1997	USA	Questionnaire to medical students	136/146 graduating students. 90% had identified role model at medical school.	Exposure to role model in clinical field is strongly associated with medical students’ choice in residency.	2	7
Wright et al. Attributes of excellent attending physician role models.	Case control study To identify attributes of excellent attending physician role models.	1998	USA	Case control study. Questionnaire sent to role models and non-role models	341/411 response = 83% Of these 144 = 42% identified as excellent role models Having greater assigned teaching responsibility was important as role model.	Many of the attributes of being an excellent role model are related to skills that can be acquired and to modifiable behaviour.	1	9
Wright & Carrese. Which values do attending physician try to pass on to house officers?	To determine the values and attitudes which attending physicians try to pass on to residents.	2001	USA	Questionnaire study to 41 physicians at 4 universities.	341/411 response = 83% 265 (78%) shared the single value they would pass on. 4 main categories identified: Caring, Respect, Communication, Integrity.	Attending physicians attempt to pass on values and attitudes that they consider important for the professional development of medical trainees.	1	9
Wright & Carrese. Excellence in role modelling: insight and perspectives from the pros	To better understand role modelling by examining the insights of physician role models.	2002	USA	Semi structured interviews with 29 role models identified by house staff.	Categories of identified teaching and personal qualities given for role models. Barriers described. Multiple role models valued	Role Model Consciousness. Highly regarded physicians have personal qualities, teaching abilities and exceptional clinical skills that can be modified and/or acquired. Role modelling is implicit.	1	8
Wright & Carrese. Serving as a Physician role model for diverse population of learners.	The study examined issues related to physicians serving as role models for diverse medical learners.	2003	USA	Semi structured interview with 29 role models.	3 domains identified in the results. Learners prefer role models similar to themselves and role modelling is easier in this situation.	Physicians need to consider a broader range of options for successful interactions with learners different to them.	6	7
Wyber & Egan. For better or worse: role models for New Zealand House Officers	This study examines the positive and negative role modelling experiences of the house officers.	2007	NZ	Semi structured interviews with 12 GPs and 13 house officers.	Relationship of house officer and their role model; relationship of role model and patients; relationship of role model and medicine.	Role modelling is an interactional, transactional process which occurs simultaneously with multiple models and changes over time.	1	8
Yazigi et al. Clinical teachers as role models: perceptions of interns and residents in a Lebanese medical school.	To identify the characteristics and learning impact of role models as perceived by interns and residents.	2006	Lebanon	Questionnaire sent 34 interns and 66 residents.	88 (97%) had positive role models and 87 (96%) had negative role models. Role modelling had positive impact on achievement of improved clinical skills (55%) and humanistic skills (30%).	Role models have a positive impact on the professional learning and career choices of interns and residents. Strategies to reinforce role modelling are required to pass on broad spectrum of professional values to students.	1	7

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