Authors: Swayamjyoti Ray
Publication date: 31 Mar 2010
Swayamjyoti Ray looks at how role models can teach professionalism to medical students and junior doctors
Society expects doctors to act professionally. In 2005, the Royal College of Physicians defined medical professionalism as “a set of values, behaviours, and relationships that underpins the trust the public has in doctors.”
The General Medical Council elaborated on this in 2006 in their publication of Duties of a doctor. By “set of values and behaviours” the council meant:
Making the care of the patient the first concern
Protecting and promoting the health of patients and the public
Providing a good standard of practice and care
Treating patients as individuals and respecting their dignity
Working in partnership with patients
Being honest and open and acting with integrity.
Hilton and Slotnick believe that a good professional is a reflective practitioner who acts ethically, and Stern thought professionalism meant having accountability, altruism, humanism, an excellent understanding of ethical and legal matters, communication skills, and clinical competence.
Studies have shown, however, that with time medical students’ cynicism increases and their humanitarianism decreases. As a consequence, the development of appropriate attitudes in medical students is vital because it affects future practice,  and it affects the doctor-patient relationship, the quality of care, and the outcome of health and illness. Is it possible to learn or to teach professionalism? If so, do role models have a part to play?
Role models: who are they?
Role models are people who are admired for the way they act and for their professionalism, and whose behaviour is considered as a standard of excellence to aspire to.  They are the people in positions that we would like to reach; they possess qualities that we would like to have; and they are people with whon we can identify.
Desirable and undesirable qualities of a role model
Three basic patterns of modelling have been identified:
Active identification (classic modelling)—Students become similar to the role models at the end of socialisation, or they copy their role model. This classic modelling was noticed to be the most common student-physician interaction
Active rejection—Students had totally different views from the role models and did not want to replicate their model (anti-models)
Inactive orientation—There was no change in the students after a period of socialisation with a model.
Wright and colleagues asked medical students what they looked for in their ideal role model.  Clinical skills, personality, and teaching ability were rated the three most important factors in selecting a senior doctor as a role model. Research activities and academic status scored less. Ninety per cent of the medical students identified one or more physician role models during their third and fourth years of medical school, and on average each student identified three to seven doctors as role models. The most important finding of this study was evidence of a strong connection between exposure to role models and a medical student’s choice of clinical field for higher training. Students identified doctors from the department of internal medicine as the most likely candidates for being ideal role models.
Cruess and coworkers have provided examples of unprofessional behaviour using role modelling vignettes. This included a consultant who was angry that a junior doctor called in the middle of the night and a doctor describing a patient in derogatory terms. Another study mentioned that students who reported witnessing unethical behaviour were more likely to report having done something unethical themselves.
Benno tries to raise awareness of problem behaviour in medical students outside the learning environment, and he suggests possible solutions. Evidence suggests that in practising doctors, a history of unprofessional behaviour during undergraduate medical training is strongly associated with disciplinary action by medical boards.
How do role models teach professional values?
Students learn how to act professionally when they interact with their role models. Role models can be health professionals or people from other walks of life ; however, physician teachers have been regarded as the principal models for medical students. The process of modelling goes through the stages of active observation; making the unconscious conscious; reflection and abstraction; translating insights into principles and actions; and generalisation and behaviour change.
Various people have suggested that role modelling should be an integral component of medical education.  Role models affect the attitude, behaviour, and ethics of medical students and cultivate professional values in trainees. They tend to influence the career choices of students, and they function in the formal, the informal, and the hidden curriculums.
The formal curriculum provides details about what faculty members believe that they are teaching; the conduct of the medical teacher at this level can have a profound effect on trainees. The informal curriculum is an unplanned, unscripted, and highly interpersonal form of teaching and learning. It is very powerful, although most harmful role modelling is experienced here. The hidden curriculum has a great effect on the professional development of students, and it functions at the level of the organisational culture and structure of the institution. Cruess and colleagues give an example of an institutional culture that promotes other work and leaves insufficient time to demonstrate good clinical practice to students.
How can we improve role modelling?
Excellent role models will always inspire and teach by example, but being self-critical and wanting to perform better are the first steps in improving role modelling. Two levels of self-awareness that have been identified are the personal level (where we analyse our own strengths and weaknesses) and the institutional level (where we look at the impact of the institutional culture). 
Some of the strategies that can help to improve personal performances include improving teaching skills, attending courses as a part of continuous professional development, making time to teach despite the challenges of busy clinical commitments, and becoming aware of being a role model. It is also vitally important to reflect on our behaviour and to make changes wherever necessary. Some institutions have started rewarding faculty members who model commendable professional behaviour, such as the “national humanism award in medicine” given by the Healthcare Foundation of New Jersey in the United States.
Working to improve the institutional culture is equally important. Methods such as encouraging dialogue with colleagues, raising awareness, pointing out deficiencies, and reinforcing strengths are some of the suggestions that may create an environment that supports positive role modelling.
Alternative methods in teaching professionalism
Paice and colleagues believe that ethics and professional behaviour should be taught through peer group discussions. The discussion group should also include the views of people outside medicine, and it should have access to trained mentors.
Most of the medical schools in the United Kingdom and the United States train medical students in professionalism. Modules on medical ethics, medical sociology, medical law, and public health are all part of the core curriculum in the undergraduate medical course.
Professional development is a process that is at the core of medical training. The learning environment, hidden and formal, must support rather than demoralise the development of professional qualities. Learning from role models is a complex mixture of conscious and unconscious activities, which occur through observation and reflection. Professionalism needs to be fostered as an integral part of medical training, rooted in experience and associated practices. Improving role modelling will help to enhance practice, and proper assessment of professionalism will help to ensure that students display the essential values, attitudes, and behaviour that are expected of doctors.
In the words of Albert Schweitzer, “Example is not the main thing in influencing others, it is the only thing.”
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Swayamjyoti Ray specialist registrar, surgery
Ninewells Hospital, Dundee