Many of the most important lessons in the education of physicians are not well conveyed by lectures, books, and electronic media. These lessons touch on such topics as work ethic, goal setting, patient interaction, consultation, and coping with uncertainty and failure. Whether we are aware of it or not, each medical educator manifests characteristic patterns of conduct in these areas, and these habits exert a formative influence on medical students, residents, and other learners. It is a mistake to conceptualize learning as the mere memorization of facts. It also involves the adoption of attitudes and patterned approaches to daily work, and this adoption often takes place at a subconscious level.
In reflecting back over our careers, many of us can easily call to mind a few individuals whose habits of practice exerted a particularly formative influence on our own development, people who stand out as role models. One of the most rewarding experiences for any medical educator is to see learners incorporate elements of our style into their own approach to practice. Needless to say, if the attitude or conduct is a poor one, this can also prove one of the most mortifying of experiences. In either case, however, medical educators need to pay more attention to emulation.
As we have seen, emulation can take one of two fundamentally different forms: constructive or destructive. Constructive emulation occurs when learners adopt attitudes and patterns of conduct that enable them to perform better as physicians. For example, a resident might, as a result of working with a particularly well-organized faculty physician, develop the habit of taking a few minutes each morning to outline key objectives for the workday. A resident who does so is more likely to be productive than one who does not, and this could be one of the most important lessons the resident learns over many years of training.
By contrast, destructive emulation occurs when learners adopt habits that undermine their excellence. Consider a disgruntled and frankly cynical faculty member, whose residents tend to develop such habits as criticizing colleagues behind their backs, thereby corroding collegiality and mutual respect within the department. One goal of all medical educators should be to cultivate opportunities for constructive emulation and reduce opportunities for destructive emulation. We need to consider not only the content of the formal curriculum, but that of the informal and even hidden curriculum, as well. With whom are learners working, and to what effect? One way of enhancing our educational effectiveness as role models is to strengthen our understanding of this vital but often overlooked aspect of education.
First, we must recognize that each one of us, whether we are on the faculty or not, is a role model. Peers and even subordinates influence how learners develop. For example, residents learn many of their most important lessons from other residents, and medical students learn many of their most important lessons from other medical students. I have certainly learned a great deal from residents and medical students I worked with as a faculty member. Once we become aware that our conduct exerts a wider influence than our formal authority might suggest, we can take better care to ensure that we are projecting a worthy image. We do not cease being educators the second we walk out the classroom door, and some nonfaculty colleagues exert even greater formative influence than some members of the faculty. For example, medical students frequently learn more about how to be a physician from the house staff than from the faculty.
What are the functions of people whose attitudes and conduct constitute a worthy example for others? First,they reinforce and augment constructive behavior in others. A medical student's commitment to communicating well with patients is strengthened by working with a physician who places a high priority on effective communication. Second, the conduct of good role models tends to inhibit the development of destructive patterns of conduct. A medical student who witnesses a resident remain calm in circumstances where many others would have lost their cool glimpses firsthand the benefits of keeping one's temper in check. Such experiences send the subtle but important message that abusive behavior is simply not okay. Third, learners emulate new habits that make them better physicians. When we offer a good example of how to obtain informed consent for medical procedures,learners are more likely to do it well themselves.
For learners to grow and develop as excellent physicians as least three conditions must be met. First, learners need to be paying attention to their role models. Potential role models who are not even noticed are unlikely to exert much influence. Similarly, role models who are regarded as irrelevant because they are viewed as insufficiently engaged are unlikely to offer much. To be an effective role model, we need to be close to learners and actively exhibiting attitudes and patterns of conduct to which learners need to attend. We also need to be credible and worthy of emulation. If our clinical skills are perceived as inadequate, learners will not look up to us. Finally, learners must not have definite and inflexible attitudes toward what we do. If they think they already know everything, they are unlikely to benefit from working side by side with us. We need to afford learners an opportunity to recognize what they do not know, to appreciate its importance, and to interact with individuals who exhibit the appropriate attitudes and patterns of conduct.
One area in which we can provide an important example to learners is clarity about goals. If medical students, residents, and even colleagues do not see clearly what they are trying to learn, they are unlikely to seize important learning opportunities. The problem is not that these learners are unmotivated or unintelligent. They simply do not know what they are trying to learn, and as a result, learn less than they could. By helping learners develop a clearer sense of purpose, we can help them learn more. We can help them by modeling how we form our own learning objectives and structuring our own workday so that we are always trying to learn.
Two types of consequences affect learner performance. One type of consequence is vicarious, and the other self-generated. We learn vicariously when we see the consequences that accrue to other learners. For example, if we see a colleague publicly humiliated because of an incorrect response, we may become less inclined to volunteer to answer questions ourselves. This is not to say that all criticism is bad. Failure to point out mistakes can be even worse, and criticism can definitely exert a salutary effect, as long as it encourages learners to improve their performance and provides guidance on how to do so. We need to bear in mind that the way we treat a learner affects not only that individual, but others as well. Even interactions that are not directly witnessed by others are often rapidly spread through informal channels of communication. In some cases, particularly memorable accounts may be passed down from year to year and even generation to generation, becoming part of the folklore of our educational programs.
Self-generated consequences are equally important. These arise independent of the social environment. In some cases, we may modify our attitude and conduct based on our own self-reflection, independent of criticism or praise from others. If we are to become excellent physicians, we need to develop this talent for self-examination, so that we can regulate our own professional trajectory based on our internal moral compass. This provides a more powerful and enduring bulwark against destructive conduct than fear of detection, humiliation, or punishment. By sharing our self-examination with learners and encouraging them to pay attention to their own internal compasses, we can help them to develop fully as excellent physicians.
To highlight the best habits of physicians, we should seek out opportunities to incorporate them into the formal curriculum. We need to make clear to learners that their ethics is no less important than their fund of knowledge and clinical skills. One way to implement this is to ensure that we take character into account in our selection and evaluation processes for medical students and residents. When done well, such programs highlight the importance of character in medicine, provide some encouragement for exemplary conduct, and help to foster the development of constructive internal goals and standards.
One way to foster the quality of emulation in our educational programs is to develop formal mentorship responsibilities. The term mentor is derived from an elderly character in Homer's Odyssey, who serves as a friend and advisor to Odysseus. A mentor is less a teacher than a confidante, role model, and coach. A mentor can serve as a quasi-official representative of the informal curriculum, giving learners someone to call on when they need counsel in the face of uncertainty. Mentorship often works best in an informal environment, such as a meal, where learners may feel more comfortable about raising such issues as interpersonal conflict, balancing personal and professional life, and choosing between different career paths. What difficult decisions have we faced, how did we cope with them, and what did we learn as a result? It is probably wise for learners to have at least two mentors, one on the faculty and one from a slightly more advanced peer group.
We must guard against implicitly encouraging learners to develop an aversion to challenge. It is all too easy for many learners to develop such a fear of failure that they begin to avoid new things. If learners never see us try something new, and never get to see how we handle disappointment, they may develop the disabling view that they, too, should never take risks. If they see us always avoiding failure and covering it up whenever it occurs, they may fail to develop their own ways of coping with and learning from disappointments. Overconfidence is certainly problematic, and we want learners to develop a healthy respect for their own limitations. To foster a willingness to venture into uncharted territory, we need to challenge learners in ways that stretch them beyond their comfort zone yet hold out a reasonable probability of success, so that they develop their sense of personal efficacy. We want learners to regard heightened tension as an opportunity to excel, not a signal to give up.
We need to exemplify how we construct our own scenarios of success. We need to share with learners how we use our time to imagine our goals and visualize ourselves achieving them. Less successful people tend not to have a clear vision of their own goals, and even if they do, they cannot foresee a path by which to reach them. They tend to set lower goals for themselves, expend less effort in their pursuit, and give up more easily when they encounter obstacles. People with a higher sense of personal efficacy tend to analyze new situations in light of their goals and devote considerable energy to developing strategies by which to excel. They aim higher, work harder, and persist longer when faced with obstacles. By encouraging learners to discuss and reflect on their own visions of success and the routes by which they might pursue them, we can increase their ability to fashion rewarding careers for themselves.
Throughout most of medical education, the evaluation of learners is heavily biased in favor of information recall. We tend to evaluate medical students and residents by what they can remember. This bias reflects the fact that it is relatively easy to determine whether learners can recall a particular fact. By contrast, a learner's approach to unfamiliar situations is much more difficult to detect, describe, and measure. Despite this challenge, we need to develop evaluation systems that extend beyond what is easiest to measure and encompass what is most important to learn as well. We need to pay attention to motivation, confidence, self-reflection, and self-regulation of learning. If we do not, learners are likely to achieve less than their potential. To what degree are we assessing our own performance on parameters other than fund of knowledge, and how well are we sharing this perspective with learners?
Above all, it is vital that we bring to the arena of medical education sound characters, high standards of professional conduct, and a deep commitment to the welfare of our patients, our colleagues, and our institutions. Learners need to see that we care about these matters, because they are not only developing their diagnostic and therapeutic acumen, they are also developing their professional character. It is equally important that we guard against hypocrisy. If we constantly chafe about the need to give lectures or publish papers, how seriously will our trainees contemplate academic careers, no matter how much lip service we pay to their importance? Our profession cannot afford to juxtapose heavenly words and subterranean conduct.
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