24. Role modelling in residency education

Introduction

Role modelling has been shown to be one of the most important ways in which residents learn from their supervisors and teach students. Helping clinical teachers and residents to role model effectively, guiding residents to optimize their learning from role models and being a strong positive role model yourself are critical to creating learning environments in which residents and residency programs can thrive. Conversely, role modeling can perpetuate harm to vulnerable medical learners, patients, and communities, often through implicit norms of the “hidden curriculum”.  Reflection with residents on role-modelling must be sensitive to inclusive ways of being and celebrate the value that diverse individuals bring to the profession. Many program directors feel they don’t have a good understanding of role modelling and aren’t sure how to support and promote it and how to do it explicitly themselves. This chapter explores what role modelling is, what its impacts are on residents and residency education, what effective role modelling looks like and how you can make explicit, positive role modelling central in your own program.

Understanding role modelling and why it’s important to residency training

When thinking about role modelling, we tend to imagine people who demonstrate the highest standards of excellence and whom we have aspired or perhaps still aspire to be. In reality, role modelling is simply a process (or teaching strategy) whereby a learner is taught something through demonstration.¹ In other words, it is teaching by showing. When understood in this way, it is easy to see how program directors, clinical teachers and residents are role modelling all of the time. But why is it so important?

Much of its importance comes from the significant role that it plays in the formation of a resident’s professional identity. Professional identity formation is a developmental process that occurs throughout one’s training (and perhaps one’s entire career) where a resident learns to think, act and feel like a specialist or subspecialist by internalizing the knowledge, skills, attitudes, values and norms of that specialty or subspecialty.^2,3

Role modelling is essential to this process and appears to influence it in two very important ways. First, learners will consciously and deliberately learn knowledge and skills (e.g., taking a history) by observing, reflecting on, imitating and practising what their role models have shown them.⁴ This has a significant influence on the development of competence and confidence, which are central to professional identity. Second, learners tend to pattern their professional behaviours and attitudes on those of their role models, as they wish to be seen as a colleague or member of the specialty or subspecialty, which will enable them to more fully participate in the community in which they are training. These attitudes and professional behaviours can be either positive (e.g., being available to support a colleague in need) or negative (e.g., belittling the decisions of colleagues). They are also largely demonstrated and learned in an implicit or unconscious fashion, thereby contributing to the hidden curriculum (i.e., implicit sociocultural norms that residents are taught, often centered on a dominant culture) and resultant learning environments of residency programs.⁵

As a program director, you are responsible not only for the residents in your program, but you are also a key player in influencing the environments in which they learn. Being aware of the importance of role modelling is a critical first step in meeting that responsibility. The next section of this chapter will discuss how that awareness can be used to enhance the effectiveness of teaching and learning through modelling.

Making role modelling more effective

As described above, role modelling is a process. As with any process, it can be helpful to break it down into its component parts. Role modelling begins with what has been described as the exposure phase.⁶ Put simply, this is the phase in which the attitudes, values and behaviours of the model are observed by the learner. The learner then enters what has been described as the evolution phase⁶ whereby they must pass judgment on what they have seen, make sense of it, experiment with it, adapt it to their own style and ultimately decide if they will adopt it.⁶ To make the role modelling that occurs in your program more effective you will need to create an environment where the evolution phase can be more consciously and explicitly supported, while simultaneously communicating the need for critical reflection. How can you do that?

There is no arguing that implicit role modelling is essential and important. However, people who are recognized by learners and their peers as exceptional role models seem to have the unique ability to make their modelling more explicit when it is appropriate to do so.⁷ Here’s how they do it: ^8,9

•  They are aware that they are always role modelling for the people around them. This also applies to residents who are regularly serving as role models for more junior learners.
• They demonstrate positive professional behaviours that are aligned with the values of the specialty or subspecialty, the department and the program.
• They help learners focus on what they are demonstrating.
• They engage learners in reflection on what they have observed. This includes asking them their opinion, reinforcing important points and checking what they have taken away from the experience.
• They observe learners put into practice the things they have seen and provide them with clear feedback on those observations.

Each of the actions apply to all role models, whether they are modelling for one learner or several. Helping teachers in your program incorporate some of these strategies into their role modelling will enhance the impact of positive role modelling in your program. The next section of this chapter offers tips on how to do just that.

Fostering a culture of conscious, explicit, and reflective role modelling

If you want to maximize the impact of positive role modelling in your program, being aware yourself of its importance and influence and being explicit about your own role modelling is an excellent start. However, to foster a culture of conscious, explicit, and reflective role modelling throughout your program you may want to also consider the following tips:

• Be aware of the values of your program and state them explicitly. Your specialty or subspecialty, department and program should have a clear sense of the physicians you want your residents to become and the values you want to instill in them during their training. If you do not already have guiding principles and values, this is a key exercise for your residency program committee to undertake. Once you and your residency program committee have identified these values, make them explicit, demonstrate them and encourage everyone in your program to do so as well. This will help to “un-hide” the hidden curriculum.
• Be approachable with your residents and be aware of the influence you have on them as a role model.  Your residents are watching you, their program director. What you say and do (as well as what you don’t say or do) will provide them with formal and informal guidance on what is expected of them, what is valued and how to respond to various clinical and non-clinical situations that arise. Be approachable, so that they will be comfortable coming to you when they are faced with challenges. Tough situations are ideal times to model the values and behaviours you hope to instill in them.
• Model and promote self-reflection. Residents may witness role modelling that perpetuates harm for medical learners, patients, and communities. Demonstrate a willingness to listen to residents who may be impacted by negative role modelling, and reflect on how you may educate yourself and others on how to contribute to a safer learning environment.
• Incorporate role modelling into your academic half-day. Residents need to learn how to role model for their students and junior colleagues as well as how to learn from their own role models. This training should involve some background information on the importance of role modelling and strategies for making it effective (as described above), and it should also provide them an opportunity to practise. The Royal College of Physicians and Surgeons of Canada has a free resource entitled ”Resident as role model: Capitalizing on a powerful opportunity,”¹⁰ to help support you in implementing this type of training into your academic half-day.
• Incorporate role modelling into faculty development initiatives. Collaborate with the faculty development office at your institution to offer training to your clinical teachers on how to be more explicit and reflective in their role modelling.
• Engage faculty in the direct observation of resident role modelling. Supervisors often witness interactions between residents and students in which role modelling occurs (e.g., patient rounds). Taking the opportunity to deliberately observe those interactions and provide residents with feedback on their modelling can be of great value. A tool to help support these observations (the Direct Observation of Resident Role Modelling rubric) is included in the role modelling resource from the Royal College described above.¹⁰
• Include role modelling on resident and faculty teaching evaluations. Most universities have systems whereby residents can provide feedback on the teaching of their supervisors and students can provide feedback on the teaching of residents. Include questions about role modelling on these evaluations (e.g., Do they demonstrate positive professional behaviours? Do they encourage you to reflect on the clinical interactions they model?). These evaluations can serve as useful triggers for discussion at semi-annual meetings with residents and at annual report discussions with department or division chairs.
• Acknowledge and reward positive role modelling. Whether it be through emails or through an award offered by your local program, shining a light on faculty members and residents who serve as excellent positive role models highlights the importance of role modelling in your program.
• Assist in finding physician or interprofessional role models from a resident’s own community. Beyond mentorship, residents typically seek out and learn from physicians who are part of one or more of their own communities (e.g. gender, sexuality, religion, ‘race’, disability, etc.). Offering to use your networks to make these connections, especially when a resident may not otherwise be exposed to someone like them at your institution, can be invaluable for a resident to share their experiences with.

Conclusion

Role modelling is one of the most important ways in which residents learn from their supervisors and teach students and junior colleagues. It plays a critical role in the professional identity formation of residents and in the hidden curriculum that shapes their learning environments. Although much of role modelling is implicit, one of your fundamental jobs as a program director is to help your residents and faculty to recognize how they have been influenced by their own role models, both positively and negatively, and to give them the reflective tools they need to become better role models themselves.  By investing in this work, you’ll shape the environments in which residents work and learn and the professional identities they form for the better.

Further reading

www.royalcollege.ca/rcsite/canmeds/resident-role-modelling-e

• This website contains all the materials needed to incorporate role modelling training into an academic half-day (AHD). It includes an e-lecture, simulation or role-playing scenarios, a guide for facilitated reflection and other helpful resources.

Passi V, Johnson N. The hidden process of positive doctor role modelling. Med Teach. 2015;38(7):700–707.

• This empirical study uses a grounded theory approach to generate an explanatory model of the process of doctor role modelling. Data are derived from semi-structured interviews, focus groups and observations of medical students and teaching faculty. The exposure and evolution phases of role modelling are derived from this study and described in detail.

Cruess RL, Cruess SR, Steinert Y, eds. Teaching medical professionalism: support the development of a professional identity. 2nd ed. Cambridge (UK): Cambridge University Press; 2016.

• This book provides an in-depth look at how professional identity formation can be supported across the spectrum of medical education. Role modelling features prominently throughout the book because of its central role in identity development.

References

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3. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. Acad Med. 2014;89(11):1446–1451.
4. Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. A schematic representation of the professional identity formation and socialization of medical students and residents: a guide for medical educators. Acad Med. 2015;90(6):718–725.
5. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69(11):861–871.
6. Passi V, Johnson N. The hidden process of positive doctor role modelling. Med Teach. 2015;38(7):700–707.
7. Wright SM, Carrese JA. Excellence in role modelling: insight and perspectives from the pros. CMAJ. 2002;167(6):638–643.
8. Sternszus R, Steiner Y, Bhanji F, Andonian S, Snell L. Evaluating a novel resident role-modelling programme. Clin Teach. 2018;15(3):252–257.
9. Cruess SR, Cruess RL, Steinert Y. Role modelling — making the most of a powerful teaching strategy. 2008; 336:718–721.
10. Royal College of Physicians and Surgeons of Canada. Resident as role model: capitalizing on a powerful opportunity [workshop]. Ottawa: Royal College of Physicians and Surgeons of Canada; 2019. Available from: royalcollege.ca/rcsite/canmeds/resident-role-modelling-e