Role Modeling in Medical Education: A Twenty-First Century Learner’s Perspective

Abstract

Traditional role modeling is a complex process of observation and emulation delivered by experienced senior physicians with an unknown outcome. Role modeling through organized modalities has been utilized as an educational tool in medical school for years. However, effects of parenting, near peers, gender, race, and social media on role modeling in medical education have not been well characterized yet play a significant role in the development of modern clinicians. The aim of this paper is to encourage students as future medical and clinical educators through an in-depth analysis of role modeling, with the goal of improving their “role modeling consciousness.”

Introduction

There are a wide variety of techniques used to motivate and recruit medical students as future educators. Electives on medical education are common, in which students focus on educational theory and practice didactics [1]. Objective Structured Teaching Evaluations (OSTE’s) and medical education research projects in which students collaborate with faculty are other methods that can be used to motivate and encourage future educators [2]. In both activities, the learner must make a deliberate choice to engage. Furthermore, these activities are explicit and time-bound, involve curriculum development, and encompass faculty actively involved in teaching and mentoring. Another important technique to engage and recruit students as future educators is role modeling [3]. Contrary to the methods above, it is not time-bound and specific courses and curricula are not developed for it. Often, faculty and students are also unaware that they participate in it. In education, role modeling is defined as a “purposeful activity that demonstrates the knowledge, skills, attitudes, and behaviors that students should acquire” [4]. Role modeling is a complex phenomenon whose outcome is not easily recognized. As over 90% of students identify one or more physician role models in their medical school training, it is important to understand role modeling in its entirety to determine its fullest effect [5]. The aim of this paper is to offer a reflection on why role modeling is crucial to encouraging and motivating future educators in the twenty-first century. The term “future educators” in this paper refers to both medical educators who enhance learning outcomes in an educational setting as well as clinical educators who engage in scholarly practice in the clinical setting. Which elements of role modeling should receive more attention? How can these elements encourage learners to become future educators? By elaborating on these aspects, future educators and supervising clinicians can serve as better role models for learners.

Why Is Role Modeling a Suitable Technique to Support Medical Students as Future Educators?

A significant amount of learning in medical school occurs through role modeling. Even prior to medical school, students are encouraged to take part in observational learning processes such as shadowing to gain greater experience in the medical field. As role modeling is a process familiar to all medical students, it is vital that medical students understand how to carefully weigh and incorporate the practices they observe as they step into their own role as future educators.

Traditional Role Modeling

Role modeling is a historic practice that allows individuals to emulate and learn from the actions of another. The practice of role modeling has roots in Bandura’s Social Learning theory which states that children are constantly being influenced by their surroundings [6]. Through the observation of others’ actions, children encode and imitate others’ behaviors. This process occurs to a greater degree in people whom the child feels are most similar to them. Positive and negative reinforcement over time then strengthens or weakens learned behavior. This process, also called observational learning, is the foundation for role modeling. It is important to note that this is not simply limited to familial settings but also takes place in educational and social settings throughout one's life for competency development, such as in medical education [6].

The current view of role modeling in medical education ranges from positive to negative. In general, a positive role model is one who encourages the learner to act in a manner similar to them to elicit a positive outcome, while a negative role model is one who encourages the learner to act in a manner opposite to them to prevent a negative outcome [7]. The impact of positive and negative role models is generally believed to be dichotomous (Table 1).

Table 1.

Attributes of positive and negative medical and clinical role models [4, 9, 11, 13, 20–23]

Positive role model	Negative role model
Clearly articulates roles and responsibilities with clarification as necessary	Poor communication with patients and/ or students
Attempts to connect with patients on multiple levels	Lacks empathy for patients
Readily offers clear, constructive feedback	Fails to offer feedback or provides insufficient/ ambiguous feedback
Provides encouragement and professional support to students	Humiliates or bullies their students
Enthusiastic about medicine and teaching	Unfamiliar with recent advances in the field, unwilling to share their clinical reasoning
Clinically competent	Incompetent history or physical exam skills, poor decision-making skills, poor bedside manner
Demonstrates professionalism in all settings	Acts unprofessionally in formal and/or informal settings
Engages in self-reflection	Fails to reflect on their role in various clinical outcomes
Promotes a healthy lifestyle and demonstrates healthy behaviors	Does not demonstrate healthy work-life balance

Types of Role Modeling

Positive Role Models

The most important characteristics of positive clinician role models are threefold: clinical excellence, strong teaching skills, and humanistic personality traits [8–11]. These qualities are not only highly valued in Western medical education but also in Eastern countries [12]. Qualities that are less valued are clinical reputation, number of publications, and research expertise [13]. These studies reveal that students largely value the way physicians practice medicine, rather than the persona that they exhibit.

Positive role models can influence specialty choice [14]. Medical students in Jordan were polled on why they chose their specialty of interest. 41.8% cited the desire to “emulate a physician” as an influential factor in their decision [15]. This phenomenon is especially evident in the so-called lifestyle specialties such as radiology, ophthalmology, anesthesiology, and dermatology (ROAD) which have fewer residency spots and are therefore more competitive. A 2018 study of students across 24 US allopathic medical schools found that progression to ROAD specialties was strongly correlated with role model exposure [16]. This may be because physicians in these fields are more likely to be satisfied with their day-to-day practice and less likely to remark on and react to the potential negative aspects of their chosen specialty.

Negative Role Models

The impact of negative role models may unfortunately be greater than that of positive role models simply based on many negative role models present in clinical settings. A study of 750 Iranian medical students found that 46.8% of the students identified one or more medical teachers as negative models [17]. This may be because physicians may not be aware that they are potential role models for students. To improve student learning, all clinical teachers should recognize their position as role models and act accordingly [18]. Conversely to positive role models, negative interactions with role models in specific specialties have the potential to hinder students from pursuing those specialties. A study conducted at Oregon Health Sciences University, Portland, found that 33% of students who chose to pursue emergency medicine or anesthesiology did so only because they had an exceedingly negative interaction with an internal medicine physician that dissuaded them from pursuing internal medicine [19]. Role models must be made aware that no matter how brief their interaction with a student may be, they may have an enormous long-term impact.

Which Elements of Role Modeling Require More Attention in the Twenty-First Century?

Role modeling as it is practiced today encompasses various aspects that are not actively emphasized in medical education but are important to learners. Compared to the nineteenth and early twentieth centuries in which most learners grew up in “traditional” nuclear households, nowadays, the diversity in types of households has increased [24]. The attention to diversity, equity, and inclusion has impacted the discussion around gender and race. Social media has broadened this discussion and amplified previously minimized voices. Over time, the role of peers in medical education has received more attention, especially in the context of changing medical curricula. These five factors heavily impact role modeling today. To effectively utilize role modeling as an educational tool in the twenty-first century, understanding the effects of (a) family, (b) peers, (c) gender, (d) race, and (e) social media on traditional role modeling is critical. The impact of these aspects is in addition to the effects of positive and negative role models as delineated above.

Professional Identity Formation: The Influence of Family as Role Models

The earliest role modeling that a child experiences is that of their parents or guardians [25]. Parents can influence children’s diet [26], their romantic relationships [27], and even their mobile phone usage [28]. More importantly, parents guide children’s morals and intellectual prowess [29]. They may influence their child’s desire to pursue a certain career or higher education. A child with parents who work or are educated in a specific field has a higher probability of making a similar educational choice [30]. For this reason, parental role modeling is thought to be particularly influential during a person’s young adulthood and adolescence by helping shape work ethic and career aspirations [31].

Similarly, grandparents offer emotional support, promote well-being, encourage certain behaviors, and educate on social norms [32, 33]. Grandparents teach children about humanistic values such as empathy, compassion, and altruism and help facilitate character development in children [34]. In contrast to parental role modeling, grandparental role modeling is most influential at an earlier stage particularly when children are in elementary and middle school. At this point, grandparents may have more influence on a child than even his or her peers [35]. However, not all children grow up under the influence of grandparents, and this disparity may be even more pronounced when comparing various cultural and ethnic groups where multi-generational living may be the norm. Exploring these cultural differences and understanding how multi-generational living impacts role model exposure and child development may be especially pertinent in the coming years.

For future educators and medical students alike, it is important to understand where one’s personal values and norms originate from, what values are carried into medical school, and how this may affect one’s current and future teaching. Thinking about the role models in one’s family might help make these values and norms more explicit. Reflecting on family role models may help students as future educators understand (a) how their guardians may have role modeled these values for them and how they can use it in teaching and (b) how family role models impact the type of role model that they as teachers respond to. Having this fundamental understanding will help guide students to possible clinician-teacher role models that they may resonate best with in the future.

Shift from Traditional to Problem-Based Curricula: Peer Role Models

Peers are extremely important in preparing students as future educators, especially as medical school curricula gradually transition from traditional to problem-based learning. Initiatives to prepare students as future educators involve peer-assisted learning strategies (PALS), including direct peer-to-peer teaching and near-peer teaching [36]. While direct peer-to-peer relationships have the advantage of promoting a sense of belonging within a cohort and can have many of the benefits of other mentor relationships, near peers differ in that they are often characterized by either a small age or hierarchical gap [37]. Near peers have a significant influence on the development of professional identity for students while in medical school [38, 39]. When near peers had the opportunity to instruct small groups, they uniformly received positive feedback from learners [40]. Near-peer medical educators have the potential to not only effectively teach basic science and clinical skills to younger medical students [41], but also contribute to their humanistic development by encouraging introspection and self-feedback [42]. Furthermore, by engaging in humanistic practice, near peers also improved their teaching skills with many stating an increased desire to be involved in teaching in the future [43].

Self-feedback is crucial for one’s own personal development and for the development of teaching skills. As students teach, it is vital that they introspect and recognize their own strengths and weaknesses. This is especially important as peers are taking greater responsibility in the modern educational setting and may be even more influential than traditional role models [44]. For medical students as future educators, it is also vital to look outwards and observe both their direct and near peers while teaching. Specifically, it will be important to note what aspects of teaching improve didactical activities such as instruction, lecturing, or providing feedback, as well as what manners of teaching should be avoided. Students as future educators ought to be cognizant of the impact they have on their peers. They should begin the practice of role modeling early in their career and continue in a conscientious manner.

Diversity, Equity, and Inclusion: Gender and Race in Role Modeling

As the proportion of women in the medical field continues to rise, the importance and necessity for role models supporting women in medicine become even more apparent. Because of the gender disparity for some specialties such as family medicine [45] or surgery [46], it is harder for women in medicine to find role models and mentorships compared to their male counterparts. In surgery, this is especially problematic as male surgeons undergo different experiences and therefore may be ineffective role models. Women often feel a stronger personal and societal pressure to bear and support their children and families, which, for many, becomes a deciding factor in career choice. Anecdotally, many women are discouraged from pursuing surgical specialties, especially highly competitive subspecialties like neurosurgery, cardiac surgery, and orthopedic surgery. However, as social media continues to be utilized as a tool to promote and connect individuals in medicine, it is now being used to a greater extent to help other women in medicine make informed and unbiased career decisions [47].

While women in medicine occupy a unique space in the medical field, Black and other minority group women in medicine face their own set of unique challenges. Perhaps chief among this underrepresented group in medicine are Black women, who in 2022 represented a mere 9.4% of women in medical school—an improvement from previous years. A literature review by Sharp et al. concluded that the demographic of Black women is largely neglected, often overlooked, in favor of promoting the inclusion of white women and Black men [48]. Despite the growing presence of Black women in medicine, a massive bias still exists. One proposed solution may be encouraging Black female physicians to utilize their platforms to promote wider distribution, promotion, and celebration of their stories in hopes that it will encourage more robust discussion and in turn, provide more resources to support this group. Due to a recent greater push for diversity, equity, and inclusion in medical education, it is increasingly important to pay attention to role model inclusivity and to consider what can be learned not only from those with similar demographics, but also those from different gender and ethnic groups to promote increasing cultural sensitivity.

The Rise of Social Media and Technology: The Med-Influencer

For physician role models on social media, one of the primary positives is increased exposure, both personally and professionally. In recent years, the title “med-influencer” has surfaced to describe medical professionals who offer advice, paid or unpaid, to current or hopeful medical students and professionals. Prior to this, the word “influencer” was often associated with celebrities or public figures, often prioritizing monetary gain over mentorship. The rise of the “med influencer,” although positive in many ways, raises concerns. The glamorization of medical school and life as a medical professional on social media may usher young people into the field under possible false pretenses. Even worse, seeing influencers project highly curated versions of themselves on social media may lead medical professionals and students to feel more alone in their experiences and hardships. The largely unregulated domain of social media allows med influencers to share information however they please, forcing learners to judge whether the source is trustworthy and ultimately undermining the role modeling relationship [49].

With the increased prevalence of technology, the integration of new modes for learning is moving faster than corresponding rules and regulations. In a study by Kron et al., medical students had a largely positive attitude toward technology such as videogames for role playing in medical education [50]. By using some of these advanced simulation technologies, students may make more informed decisions about which specialty to pursue. However, with the growth of technology as a teaching tool comes a lack of interpersonal interaction with clinician role models. This calls for an intentional step to be taken by those in medical education to compensate for the integration of technology by recruiting role models in medical school and residency programs. Moving forward, due to the increasingly important role that role models serve in residency, role modeling as a practice should be further highlighted in the Accreditation Council for Graduate Medical Education (ACGME) core competencies [51]. Furthermore, there should be widespread implementation of social media education to minimize and prevent inappropriate social media use.

Moving Forward

The impact of the following five trends in medical education: (a) family, (b) peers, (c) gender, (d) race, and (e) social media on role modeling are often overlooked but demand more attention. The term “role model” continues to grow and evolve, especially with changing technologies and with a multicultural pluralistic society. Role modeling is a practice that occurs at an early age and continues throughout life, continually modified by the setting that it is practiced in. Being aware of the traits that lend themselves to being a positive role model as well as negative is equally important, as both types of role models reveal vital truths of what not to do or pass on.

Evidence has shown that physicians who actively consider their position as role models while interacting with students are ultimately described as being better role models. This process is vital to effective role modeling and is termed “role model consciousness” [52]. Moving forward, it will be up to medical schools, hospitals, and residency programs to make an intentional effort to recruit physicians who actively practice “role model consciousness.” It must be emphasized in the ACGME guidelines that providing mentorship and serving as a positive role model are an invaluable part of the medical career.

It is imperative that medical students be aware of factors that influence their established and developing identities. Future educators need to learn how best to utilize these factors to ultimately improve how they serve as role models for learners to come.

Author Contribution

Raina Patel is the first author, responsible for tables, literature review, and manuscript writing. Jacqueline Mirza is the second author and is responsible for literature review and manuscript writing. Corresponding author Vijay Rajput and supplemental author J.M. Monica van de Ridder gave input to the outline and editing of various drafts of the manuscript.

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The authors declare no competing interests.