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Educating for Professionalism: Creating a Culture of Humanism in Medical Education
Abstract
An inspirational work that will give medical educators many ideas and will stimulate some substantial changes in education about service and community activism. Joseph F. O'Donnell, senior advising dean and director of community programs, Dartmouth Medical School -The authors offer timely, reflective analyses of the work and opportunities facing medical education if doctors are to win back public trust. The thirteen essays in Educating for Professionalism examine the often conflicting ethical, social, emotional, and intellectual messages that medical institutions send to students about what it means to be a doctor. Because this disconnection between what medical educators profess and what students experience is partly to blame for the current crisis in medical professionalism, the authors offer timely, reflective analyses of the work and opportunities facing medical education if doctors are to win public trust. In their drive to improve medical professionalism within the world of academic medicine, editors Delese Wear and Janet Bickel have assembled thought-provoking essays that elucidate the many facets of teaching, valuing, and maintaining medical professionalism in the middle of the myriad challenges facing medicine at the dawn of the twenty-first century. The collection traces how the values of altruism and service can influence not only mission statements and admission policies but also the content of medical school ethics courses, student-led task forces, and mentoring programs, along with larger environmental issues in medical schools and the communities they serve.
... As Hafferty and others have observed, formally raising issues of professionalism may cause a "values conundrum" for students. 10 We speculate that our cases make some students newly aware that unprofessional behaviors are common among preclinical students (e.g. disrespect to faculty and peers, cheating and not keeping commitments). ...
... In addition, they may be immunized against the intense pressure "not to reflect 'too much' on what is happening around them" that many see as a hidden but potent message in medical training environments. 10 As we have seen, and has been noted at other institutions, students are willing to participate in peer assessment if given support and guidelines. 14 Students have been a driving force behind this curriculum. ...
Background:
Medical schools must address the fact that students embarking on careers in medicine are idealistic but have a vague understanding of the values and characteristics that define medical professionalism. Traditionally, we have relied primarily on unsystematic role modeling and lectures or seminars on related topics to teach professionalism.
Methods:
A committee of students and a faculty advisor created a curriculum, based on a needs assessment of the targeted learners, to raise students' awareness of professional tenets and provide them with the skills to recognize and analyze conflicts between the values of professionalism and the daily pressures of medical school training. The student-run professionalism curriculum begins during medical school orientation and is followed by three student-facilitated case-based workshops over the next two years. All of the workshops involve small group discussions led by trained upperclass student facilitators. The workshops address the application of professional values to both the preclinical and clinical situations and prepare students for self-reflection, self-assessment and peer evaluation. We evaluated students' satisfaction following each workshop and pre/post attitudes for the first workshop.
Results:
Twenty five upper-class student facilitators were trained in the first year. Student attendance ranged from 80-100% of the class (N=160), the proportion of students who agreed or strongly agreed that the workshops were educationally useful ranged from 60-75% for each workshop. Certain student attitudes improved immediately after the first workshop. These workshops continue annually.
Conclusions:
Students have been a driving force behind this curriculum, which is a model for professionalism education. It was accepted by students and, although somewhat controversial, created a level of awareness and discussion regarding professional behavior in medical school that had previously been absent.
... Paying attention to their emotions can also enhance their future performance through the hidden curriculum (56). Hidden curriculum is one of the most vital issues to be considered. ...
Background: Professionalism means understanding a profession and introducing it to the society through professional behaviors. In particular in clinical settings, constructive feedback is provided in education to create professional behaviors.
Objectives: This study aimed to investigate giving feedback on professionalism in clinical education.
Methods: A narrative review was conducted in PubMed and Google Scholar on the publications over the last 10 years. Eight hundred twenty-six articles were found in the first step, among which 30 were handed over to the expert panel. Fifteen of
30 articles were finally selected.
Results: The data of the studies were in four categories: feedback techniques, feedback in. curriculum, the scope of feedback, and feedback outcome. Feedback on professionalism was mostly presented through online services, portfolio, video-based systems, by a preceptor or peers, longitudinally in internship courses, and Multi Source Feedback (360 degree). In a study, feedback on professionalism was considered formally in the curriculum. Educational experts give both formative and summative feedback (most of which were formative). Based on the literature, feedback can enhance learning professionalism, curriculum reforms, system support, student comfort, evaluations, and efficacy of professionalism.
Conclusion: Multi-Source feedback assessment was the most used tool for giving feedback in professionalism, and the most popular form was informal-formative feedback. Since professionalism is a multidimensional concept related to personal communication, multi-source tools have been the most commonly used in the literature.
... Students should be supported in finding the right balance between professional distance and empathy. Seminars teaching strategies on how to handle negative emotions and difficult patient-physician contacts could buffer the negative impact of this kind of stress on empathy and help prevent students' burn-outs [61][62][63][64][65][66][67][68]. Self-awareness trainings or Balint groups increase empathy and personal development, while reducing stress [28,68,69]. ...
Background:
Empathy is beneficial for patients and physicians. It facilitates treatment and improves physical and psychosocial outcomes. The therapeutic relevance of empathy emphasizes the need to help medical students develop their empathic abilities. Our study aimed to identify factors which promote or hinder the development and expression of empathy in medical students during the course of their studies.
Methods:
We interviewed 24 medical students (six male and six female students in their 6th semester as well as six male and six female students in their final clinical year) using semi-structured interviews. The interviews were recorded, transcribed verbatim and analyzed using Braun & Clarke's thematic analysis.
Results:
We identified four main themes influencing the development and expression of empathy. 1) Course of studies: hands-on-experience, role models, science and theory, and emphasis on the importance of empathy; 2) students: insecurities and lack of routine, increasing professionalism, previous work experiences, professional distance, mood, maturity, and personal level of empathy; 3) patients: "easy" and "difficult" patients including their state of health; and 4) surrounding conditions: time pressure/stress, work environment, and job dissatisfaction.
Conclusions:
The development and use of empathy could be promoted by increasing: hands-on-experiences, possibilities to experience the patient's point of view and offering patient contact early in the curriculum. Students need support in reflecting on their actions, behavior and experiences with patients. Instructors need time and opportunities to reflect on their own communication with and treatment of patients, on their teaching behavior, and on their function as role models for treating patients empathically and preventing stress. Practical experiences should be made less stressful for students. The current changes implemented in some medical school curriculums (e.g., in Germany) seem to go in the right direction by integrating patient contact early on in the curriculum and focusing more on teaching adequate communication and interaction behaviors.
... De entre estas, as que conferem competências transversais na formação nas áreas da saúde são hoje reconhecidamente as que mais enriquecem os curricula atuais na formação dos profissionais de saúde. [10][11][12][13][14][15][16][17] Nas áreas das Ciências da Saúde em geral e na Medicina em especial, a evolução dos conhecimentos e o contexto de mudança que enformam os cursos de Medicina, tornam ainda mais crítica a decisão sobre a seleção e modo de organização de um conjunto de conteúdos e do modo do seu desenvolvimento que assegurem a formação nuclear da educação médica pré-graduada. ...
Os recentes debates sobre o papel da Medicina na Sociedade, têm evidenciado uma grande complexidade na adequação das novas referências no Ensino Superior à formação dos futuros profissionais de saúde. O quadro internacional de referência da educação médica tem sido alvo, nos últimos anos, de uma (re)estruturação que se pretende compatibilizar com a evolução das tecnologias na área da saúde e com os novos referenciais de formação integral dos futuros profissionais, onde emerge a necessidade de abordagem da área das humanidades. Como paradigma de referência para a educação médica do século XXI é hoje amplamente adotado o modelo de competências. O modelo pedagógico deve ser inovador sendo: (a) inspirado no modo como trabalham os grupos de investigação; (b) fortemente assente em práticas de colaboração; (c) baseado na cultura profissional; (d) potenciado pela valorização das dimensões experienciais. Apresenta-se um cenário de novas estratégias educativas, a redefinição do perfil do docente e a nova revolução da Medicina, com a dualidade da tecnologia e das humanidades como um recurso atitudinal na educação profissional em saúde, para a aquisição de competências transversais e “transferíveis”, competências humanísticas, capacidade de autoconhecimento e competências de reflexão crítica e profissional.
... Students who complete the ALC should be conversant with techniques for advocating within the patient, institutional, and community/population spheres (though they may have had practical experience in only one or two of the spheres). The ALC is also intended to combat the sense of helplessness and cynicism that many medical students begin to feel throughout their education (Wear & Bickel, 2009; by helping students to continue to see the "big picture" throughout medical school, demystifying the hierarchies and structures that determine the clinical environment, and, most importantly, giving them the tools they need to actually make systemic change happen and help individual patients. The Committee on the Accreditation of Canadian Medical Schools (CACMS) requires Canadian medical schools to teach students the critical skills required "to solve problems of health and illness" (CACMS, 2015). ...
Physician advocacy and leadership is increasingly recognized as an important part of our social responsibility. Frameworks, such as CanMEDS, have set out definitions of health advocacy and leadership for medical education. Despite calls for mandatory advocacy and leadership teaching and potential wellness benefits, presently medical curricula do not usually teach practical advocacy and leadership skills to learners. There is also a demonstrated disconnect between staff and resident perceptions of advocacy. Our group set out to create an innovative Advocacy and Leadership Curriculum (ALC) to fill this gap. A collaboration of over twenty medical students and professors from across Canada and the U.S worked over the past year to survey students, conduct curriculum mapping, examine current literature and practices in order to inform the creation of an ALC. A competency- and milestone-based ALC was created based on this data and reviewed by experts in medical education and/or physician advocacy. This ALC addresses three spheres of advocacy: the Patient level, the Institutional level, and the Population level (which includes the Community). A guiding principle of the ALC is to form positive working partnerships with communities and patients and to collaborate with other health professionals to advocate with, and on behalf of, patients. CanMEDS-based Learning Objectives, divided into theoretical, skills-based, and application-based categories, form the core of the program. The curriculum prepares learners for real-world advocacy through longitudinal projects, interdisciplinary work, and community-based service learning. Novel engagement of other professionals and physician advocates to act as advocacy preceptors is central to the curriculum. Innovative assessment techniques- such as advocacy simulations, longitudinal study of physician advocacy activity, and focus on attitudes and behaviour as well as knowledge and practical advocacy skills- are introduced. The ALC serves as an adaptable model for the training of socially responsible medical learners who are conversant in advocacy techniques and able to advocate with patients, within institutions, and with populations. Projects resulting from the ALC will improve medical school social accountability.
... 53 When practiced, humanism in medicine promotes compassionate, empathetic relationships with patients and other caregivers. 54,55 It also envisions behaviors and attitudes that are sensitive to the values and culture of others while respecting their autonomy. 56 It has been suggested that even though the terms professionalism and humanism each have their own definition, both are inseparably interwoven into the practice and art of "medicine." ...
This paper reviews the origins of the learned professions, the foundational concepts of professionalism, and the common elements within various healer's oaths. It then reveals the development of the Murdoch Chiropractic Graduate Pledge.
A committee comprised of three Murdoch academics performed literature searches on the topic of professionalism and healer's oaths and utilized the Quaker consensus process to develop the Murdoch Chiropractic Graduate Pledge.
The committee in its deliberations utilized over 200 relevant papers and textbooks to formulate the Murdoch Chiropractic Graduate Pledge that was administered to the 2010 Murdoch School of Chiropractic and Sports Science graduates. The School of Chiropractic and Sports Science included professionalism as one of its strategic goals and began the process of curriculum review to align it with the goal of providing a curriculum that recognizes and emphasizes the development of professionalism.
The reciting of a healer's oath such as the Hippocratic Oath is widely considered to be the first step in a new doctor's career. It is seen as the affirmation that a newly trained health care provider will use his or her newfound knowledge and skill exclusively for the benefit of mankind in an ethical manner. Born from the very meaning of the word profession, the tradition of recitation of a healer's oath is resurgent in health care. It is important for health care instructors to understand that the curriculum must be such that it contributes positively to the students' professional development.
... Findings overall seem to support calls for 'a culture of humanism' in medicine, 21 and to invest such concepts as 'continuity of care' with meaning, by displaying their purpose. In addition, we suggest that the data offer a clear sense that the participating GPs have the intelligence, insight and sensibility to be touched and changed by their patients. ...
The concept of the 'heartsink patient' is well known and much used when talking about general practice. The opposite of this type of patient, however, has been little explored.
To identify patient characteristics valued by GPs.
Structured interview to collect narratives from GPs of individual patients, analysed qualitatively through thematic analysis and word frequency.
Primary Care in Ireland.
GP trainers.
Emergent themes from four lead questions: Tell me about a patient you like, Tell me about the patient's personality, What have you learned about yourself as a GP?, What is different about being a GP as opposed to any other kind of doctor? In addition, a corpus linguistic analysis of word frequencies disclosed further themes, not identifiable on the surface of discourse.
Ten themes were identified: GPs valued patients who were likeable, a challenge, involved them in negotiation of the doctor-patient relationship, were interesting or virtuous and had a positive effect. GPs valued their profession in that they were facilitators, gave and elicited loyalty, formed personal attachments and had a different perspective.
'Heartlift patients' may be a robust concept, to counterbalance heartsink patients. Data collected are suitable for training, and could help GPs enhance a sense of vocation.
This study reports on work undertaken by the Interactive Studies Unit (ISU), University of Birmingham. A total of 727 doctors were referred to the ISU for one-to-one remedial support in a variety of non-clinical areas between 2010 and 2018. The close-in scrutiny which one-to-one support offers provides an opportunity to study and reflect on such issues as values and professionalism, which are notoriously difficult to define or reach objective judgments about. There are fundamental difficulties, in particular, in inferring underlying values from an individual’s behavior. The basic taxonomy of referrals the ISU works with, and which echoes those developed elsewhere, considers problems as being at the level of the self, interactions with others, or working in an institutional or societal context. Six common generic problems are identified, and presented and discussed as generic cases. These are designed to be representative of the complex manner in which behavior and values interact, and problems at the three levels above impinge on each other. All cases are accompanied by details of suggested educational activities.
Internationally, academic hospitals are giving increasing attention to diversity management. This paper sheds light on the actual praxis of cultural diversity management by professionals in workplace interactions. An ethnographic study in a Dutch academic hospital showed that normalization practices were obscuring diversity issues and obstructing inclusion of cultural minority professionals. The normalization of professionalism-as-neutral and equality-as-sameness informed the unequal distribution of privilege and disadvantage among professionals and left no room to question this distribution. Majority and minority professionals disciplined themselves and each other in (re)producing an ideal worker norm, essentialized difference and sameness, and explained away the structural hierarchy involved. To create space for cultural diversity in healthcare organizations in the Netherlands and beyond, we need to challenge normalization practices.
Not available.Journal of Kathmandu Medical College, Vol. 4, No. 1, Issue 11, Jan.-Mar., 2015
Introduction:
We undertook a systematic review and narrative synthesis of the literature to identify how professionalism is defined in the medical education literature.
Methods:
Eligible studies included any articles published between 1999 and 2009 inclusive presenting viewpoints, opinions, or empirical research on defining medical professionalism.
Results:
We identified 195 papers on the topic of definition of professionalism in medicine. Of these, we rated 26 as high quality and included these in the narrative synthesis.
Conclusion:
As yet there is no overarching conceptual context of medical professionalism that is universally agreed upon. The continually shifting nature of the organizational and social milieu in which medicine operates creates a dynamic situation where no definition has yet taken hold as definitive.
The resurgence of interest in professionalism necessarily focuses us on the moral core of medicine and the character of the good doctor. While medical education reform projects aimed at educating for professionalism are replete with lists of laudable virtues necessary for the doctor, we have made little progress in mapping those character traits, values and behaviors to admission procedures, curricular reform and faculty development. If educating for professionalism is to be effective, medicine must re-claim the moral core of professionalism and identify clearly the fundamental traits, values and virtues necessary for good medical practice in the twenty-first century.
A number of significant international reports and journal articles have begun to refer to the importance of non-sectarian, spiritual values in educational planning (Carr, 1999; Rogers & Dantley, 2001). The writer firstly considers how the notion of secular spirituality might be understood and outlines some possible reasons for its upsurgeance. The potential for secular spiritual development from both global and international perspectives is explored with a particular focus upon cultural implications. The conclusion is drawn that communities need to be cautious about accepting at face value globalised notions of spirituality in educational development and that educators need to adopt an international perspective, characterised by ‘bottom-up’ community based initiatives.
With the creation of the Gold Humanism Honor Society (GHHS) in 2002, the Arnold P. Gold Foundation established a mechanism for recognizing medical students who demonstrate exemplary humanism/professionalism/communication skills. Currently, 80 medical schools have GHHS chapters. Selection is based on peer nomination using a validated tool. The objective of this survey was to assess the percentage of residency program directors (PDs) who are aware of and are using GHHS membership as a residency selection tool.
Surgery (SURG) and internal medicine (IM) PDs in 4 United States regions were surveyed for familiarity with GHHS and perceived rank of GHHS membership relative to Alpha Omega Alpha (AOA) membership, class rank, medical student performance evaluation (MSPE), clerkship grade, and United States Medical Licensing Examination (USMLE) score, in evaluating an applicant's humanism/professionalism, service orientation, and fit with their program. Program demographics and familiarity with GHHS were also surveyed.
The response rate was 56% (149 respondents). IM PDs rated GHHS membership higher than did SURG PDs when evaluating professionalism/humanism and service orientation. PDs familiar with GHHS ranked membership higher when considering professionalism/humanism (4.1 vs 3.2; p < 0.05) and service orientation (4.1 vs 2.9; p < 0.01). Familiarity with GHHS correlated with being an IM PD, residency based at teaching hospital, large residency program, knowledge of residents who were GHHS members, and having a GHHS chapter at their school (p < 0.01). Familiarity with GHHS was related to rankings of GHHS (professionalism/humanism F = 3.36; p < 0.05; service orientation F = 3.86; p < 0.05) more than the PDs' specialty was. In all, 157 GHHS students (from all 4 United States regions) were also surveyed about the 1197 interviews they had with residency PDs. They reported that although a few PDs were aware of GHHS, PDs of core medical specialties were more aware of GHHS than SURG PDs.
IM PDs were more aware of GHHS (70%) than SURG PDs (30%). Awareness was related to the favorable ranking of GHHS as a selection criterion for humanism/professionalism/service orientation. PDs familiar with GHHS were from larger programs, were likely to know residents who were members, and were likely to think that GHHS membership predicted humanistic care. Membership in GHHS may set candidates apart from their peers and allow PDs to distinguish objectively the candidates who demonstrate compassionate medical care. Increased knowledge about the GHHS may therefore serve to be a useful adjunct for PDs when selecting medical students for their residency programs.
In late 2007, the American College of Clinical Pharmacy (ACCP) charged their National StuNet Advisory Committee to formulate tenets of professionalism, with the primary goal of introducing students to essential attitudes and behaviors of professionalism. The committee's list of tenets served as a working document for the development of this White Paper. This collaborative effort of the ACCP Board of Regents and the National StuNet Advisory Committee sought to complement other published documents addressing student professionalism. The purpose of this White Paper is to enhance student understanding of professionalism, emphasizing the importance of the covenantal or "fiducial" relationship between the patient and the pharmacist. This fiducial relationship is the essence of professionalism and is a relationship between the patient and the pharmacist built on trust. This White Paper also outlines the traits of professionalism, which were developed after an extensive review of the literature on professionalism in medicine and pharmacy. The traits of professionalism identified here are responsibility, commitment to excellence, respect for others, honesty and integrity, and care and compassion. It is from these traits that student actions and behaviors should emanate. Students, pharmacy practitioners, and faculty have a responsibility to each other, to society as a whole, and to individual patients whom they serve to ensure that their words and actions uphold the highest standards of professional behavior.
Prospective, ongoing faculty development programs are important in the initial orientation and short- and long-term development of faculty in higher education. Pharmacy practice faculty are likely to benefit from a comprehensive faculty development program due to the complex nature of their positions, incomplete training in select areas, and multiple demands on their time. The need for faculty development programs is supported by the increased need for pharmacy practice faculty due to the increased number of colleges and schools of pharmacy, expanding enrollment in existing colleges and schools, and loss of existing senior faculty to retirement or other opportunities within or outside the academy. This White Paper describes a comprehensive faculty development program that is designed to enhance the satisfaction, retention, and productivity of new and existing pharmacy practice faculty. A comprehensive faculty development program will facilitate growth throughout a faculty member's career in pertinent areas. The structure of such a program includes an orientation program to provide an overview of responsibilities and abilities, a mentoring program to provide one-on-one guidance from a mentor, and a sustained faculty development program to provide targeted development based on individual and career needs. The content areas to be covered in each component include the institution (e.g., culture, structure, roles, responsibilities), student-related activities, teaching abilities, scholarship and research abilities, practice abilities and the practice site, and professional abilities (e.g., leadership, career planning, balancing responsibilities). A general framework for a comprehensive pharmacy practice faculty development program is provided to guide each college, school, department, and division in the design and delivery of a program that meets the needs and desires of the institution and its faculty.
The authors propose that professionalism, rather than being left to the chance that students will model themselves on ideal physicians or somehow be permeable to other elements of professionalism, is fostered by students' engagement with significant, integrated experiences with certain kinds of content. Like clinical reasoning, which cannot occur in a vacuum but must be built on particular knowledge, methods, and the development of skills, professionalism cannot flourish without its necessary basis of knowledge, methods, and skills. The authors present the need for an intellectual widening of the medical curriculum, so that students acquire not only the necessary tools of scientific and clinical knowledge, methods, and skills but also other relevant tools for professional development that can be provided only by particular knowledge, methods, and skills outside bioscience domains. Medical students have little opportunity to engage any body of knowledge not gained through bioscientific/empirical methods. Yet other bodies of knowledge-philosophy, sociology, literature, spirituality, and aesthetics are often the ones where compassion, communication, and social responsibility are addressed, illuminated, practiced, and learned. To educate broadly educated physicians who develop professionalism throughout their education and their careers requires a full-spectrum curriculum and the processes to support it. The authors sketch the ways in which admission, the curriculum (particularly promoting a sociologic consciousness, interdisciplinary thinking, and understanding of the economic/ political dimensions of health care), and assessment and licensure would function.
This guide is intended to inform medical teachers about the use of portfolios for student assessment. It provides a background to the topic, reviews the range of assessment purposes for which portfolios have been used, identifies possible portfolio contents and outlines the advantages of portfolio assessment with particular focus on assessing professionalism. The experience of one medical school, the University of Dundee, is presented as a case study. The current state of understanding of the technical, psychometric issues relating to portfolio assessment is clarified. The final part of the paper provides a practical guide for those wishing to design and implement portfolio assessment in their own institutions. Five steps in the portfolio assessment process are identified: documentation, reflection, evaluation, defence and decision. It is concluded that portfolio assessment is an important addition to the assessor's toolkit. Reasons for using portfolios for assessment purposes include the impact that they have in driving student learning and their ability to measure outcomes such as professionalism that are difficult to assess using traditional methods.
Physicians associate empathy with benevolent emotions and with developing a shared understanding with patients. While there have been many articles on managing "difficult" patients, little attention has been paid to the challenges physicians face during conflicts with patients, especially when both parties are angry and yet empathy is still needed. This topic is especially important in light of recent studies showing that practicing medicine increasingly requires physicians to manage their own feelings of anger and frustration. This article seeks to describe how physicians can learn to empathize with patients even when they are both subject to emotions that lead to interpersonal distancing. Empathy is defined as engaged curiosity about another's particular emotional perspective. Five specific ways for physicians to foster empathy during conflict are described: recognizing one's own emotions, attending to negative emotions over time, attuning to patients' verbal and nonverbal emotional messages, and becoming receptive to negative feedback. Importantly, physicians who learn to empathize with patients during emotionally charged interactions can reduce anger and frustration and also increase their therapeutic impact.
Faculty development includes those activities that are designed to renew or assist faculty in their different roles. As such, it encompasses a wide variety of interventions to help individual faculty members improve their skills. However, it can also be used as a tool to engage faculty in the process of institutional change. The Faculty of Medicine at McGill University determined that such a change was necessary to effectively teach and evaluate professionalism at the undergraduate level, and a faculty development program on professionalism helped to bring about the desired curricular change. The authors describe that program to illustrate how faculty development can serve as a useful instrument in the process of change. The ongoing program, established in 1997, consists of medical education rounds and "think tanks" to promote faculty consensus and buy-in, and diverse faculty-wide and departmental workshops to convey core content, examine teaching and evaluation strategies, and promote reflection and self-awareness. To analyze the approach used and the results achieved, the authors applied a well-known model by J.P. Kotter for implementing change that consists of the following phases: establishing a sense of urgency, forming a powerful guiding coalition, creating a vision, communicating the vision, empowering others to act on the vision, generating short-term wins, consolidating gains and producing more change, and anchoring new approaches in the culture. The authors hope that their school's experience will be useful to others who seek institutional change via faculty development.
Ongoing work with first and second-year medical students suggests that American medical culture is characterized by a juxtaposition of notions of "competence" and "caring," and that the training of students to be competent physicians requires a reconstruction of "common sense" views of the patient, of sickness, and of the personal boundaries of the medical student. Contradictions that arise from efforts to maintain qualities of caring while undergoing these changes are highlighted.
Bandura's theory of self-efficacy has been applied in many areas of health education including smoking cessation, pain control, eating problems, cardiac rehabilitation, and adherence to regimens. Consequently, self-efficacy has emerged as an important concept with which health educators should be familiar. Self-efficacy refers to one's belief in the ability to do a specific behavior. Self-efficacy is a principle connection between knowledge and action since the belief that one can do a behavior usually occurs before one actually attempts the behavior. Self-efficacy also affects the choice of behavior, settings in which behaviors are performed, and the amount of effort and persistence to be spent on performance of a specific task. This article will examine self-efficacy theory, describe sources of self-efficacy, and present applications of self-efficacy theory.
Postulating that a program integrating language skills with other aspects of cultural knowledge could assist in developing medical students' ability to work in cross-cultural situations and that partnership with targeted communities was key to developing an effective program, a medical school and two organizations with strong community ties joined forces to develop a Spanish Language and Hispanic Cultural Competence Project. Medical student participants in the program improved their language skills and knowledge of cultural issues, and a partnership with community organizations provided context and resources to supplement more traditional modes of medical education.
A community-based course for 2nd-year medical students is described, with an evaluation of its effectiveness. The course is organized around pivotal agencies, defined as community-based programmes or services, in which students propose and complete research projects related to the interaction of a health problem and a social issue. Students choose a placement from a list of agencies associated with their hospital-based academy, or a self-initiated pivotal agency placement with the approval of their academy coordinators. Students present their project to faculty members, community agency personnel and peers. Evaluation data are reported for three student cohorts. Eighty per cent of students rated their pivotal agencies as excellent and/or very good. Over 90% of agencies indicated that the projects met agency expectations, that they were relevant to the mission and role of the agencies, and that they benefited from the projects. Issues of improving student acceptance of the course, staff development and continued agency involvement are discussed.
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Duncan DE. Residents: The Perils and Promise of Educating Young Doctors . New York, NY: Scribner; 1996.
Research into the processes by which medical students selectively acquire the attitudes and values of the medical profession falls into two general categories: (1) in vestigations which conceive of the medical school as a whole environment or social system, (2) studies which focus on the social psychology of particular attitudes. Both types have been concerned to a large extent with the problem of students' attitudes toward human relations. Factual evidence appears to indicate that such attitudes change in the direction of what has been labeled "cynicism." Interpreted within the full context of the student's experience, however, apparent cynicism can be regarded as a form of training in detachment which is an important attribute of the doctor's role. An important theoretical problem which has emerged from studies of attitudinal learning is whether student development is in contest with or in collaboration with the medical faculty. From the standpoint of sociology, the school environment is a vitally important influence on the development of the student into a professional. Investigations lend support to the proposi tion that adult socialization is important in the career of the professional.
A PRIMARY concern of medical ethicists for some time has been the absence of any meaningful analysis of the impact of health care delivery marketplace changes and current legislative reforms on the essential tenets of the physician-patient relationship. Although President Clinton's original reform proposal addressed in broad terms the ethical imperatives supporting universal access, it left virtually unexamined the more fundamental question of the role of the physician in a reformed system in which the incentives are dramatically changed and budgets determine the amount of health care spending and services.See also pp 323 and 338.In June 1990, the Council issued a report, "Financial Incentives to Limit Care: Financial Implications for HMOs and IPAs,"1 which described the financial incentives that managed care plans offer physicians to limit their provision of care. The report concluded that patient welfare must remain the first concern of physicians working in health maintenance
The idea of making the practice of medicine dependent on a license, a certificate issued by a competent body testifying that the bearer has undergone a training considered adequate, is an idea that originated in the Middle Ages. The European Middle Ages created an institution that was modified in the course of time but survived in its basic idea to the present day. The idea of licensing the medical profession resulted from the general structure of medieval society, which was strictly organized according to status, crafts, trades and professions. Each such vocational group had regulations, standard-setting codes, guaranteeing highly qualified services to society. It was recognized that such standards were particularly important in the case of the medical profession. In no other profession is lack of knowledge so serious in its consequences as in medicine. A wrong legal judgment can be corrected by a higher court. A wrong diagnosis or
The topic most discussed by physicians today is the increasing percentage of US health care being taken over by managed care organizations.1 While physicians in practice are struggling to interpret the requirements and implications of contracts with emerging or established health care systems,2 many academic medical centers have also joined the "dance of vertical integration."3,4 What has not emerged from the ofttimes emotional discussions is a cogent examination of the impact of the transformation of medical practice from a cottage industry to a corporate enterprise on how we deliver care, assess and improve the quality of care, and educate future physicians. It is an urgent matter, then, for the medical profession to address the ethical principles that will preserve a sound physician-patient relationship within this rapidly changing environment.
See also pp 323 and 330.
To address the ethics of the physician-patient relationship in managed care realistically and
Dissecting a human cadaver is an important step in the professionalization of medical students, but its transformative aspects (e.g., the potential to teach detached concern, empathy, compassion, and peer accountability) are rarely considered in medical curricula. At SUNY Stony Brook we begin our 4‐year medical humanities curriculum by focusing on systematic reflection about dissection. For their first paper in the Medicine in Contemporary Society course, students write a three‐ to five‐page narrative, recounting either their personal response to dissection (essay) or an imagined life story of their cadaver (fiction). The assignment includes two sequential versions of the paper, each critiqued by faculty and peers, and ends with small‐group discussion. In the first 2 years, narratives were almost evenly split between essay and fiction. Seven themes categorized most student responses: initial apprehension; detachment; curiosity about the cadaver's person; the need for student‐cadaver connection; self‐questioning about the motivation to donate one's body; gratitude; and religious or existential reflection. In writing a narrative about their cadavers, students were able to explore their experience of personal change and articulate goals for professional development. Consistent with our emphasis on problem‐based learning, this exercise allows students, in a sense, to fashion their own curriculum while modeling peer evaluation and accountability.
As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the ‘informal curriculum’ that is so central to the moral development of medical students and residents.
A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting ‘the unwritten code’ for medical students on a surgical clerkship and the senior residents' informal ways of producing a ‘practical ethics of conduct’ that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.
Although students bring to medical school a fairly well established value system, the potential for moral growth through the medical school environment and experience is substantial. The educational environment poses a succession of developmental and adaptive tasks to be accomplished. Several of these tasks are discussed here, tasks that are value-laden and involve, directly or indirectly, the interplay of ethical theory and practice. During the past quarter century, the two influences that have had the greatest impact on the moral growth and moral reasoning capacity of medical students have been the incorporation into the medical school curriculum of courses in medical humanities and the admission to medical school of an increasing number of female students. The female students have brought to medical school a level or dimension of moral reasoning (morality as care or responsibility for others) to augment the male students' focus on rights and justice considerations.
During medical training students and residents reconstruct their view of the world. Patients become bodies; both the faults and the virtues of the medical profession become exaggerated. This reconstruction has moral relevance: it is in part a moral blindness. The pain of medical training, together with its narrowness, contributes substantially to these faulty reconstructions. Possible improvements include teaching more social science, selecting chief residents and faculty for their attitudes, helping students acquire communication skills, and helping them deal with their own pain. Most importantly, clearer moral vision requires time and scope for reflection.
Abundant evidence that medicine is in trouble includes serious career dissatisfaction among practicing and would-be physicians as well as steeply declining interest in generalist careers, especially internal medicine. Medicine is threatened by ever-rising health care expenditures and ineffectual but vexing administrative efforts to contain them. Additional problems challenge internal medicine in particular: the clinical complexity of practice, lower income potential, and incomplete clinical experiences for medical students. Yet, in the past 25 years, spectacular advances in science and technology enabled improved patient care and outcomes; more women and minorities entering the profession brought it into better demographic balance; relative physician incomes rose; and access to physician services improved with Medicare and Medicaid and the desegregation of southern hospitals. Despite an unfinished agenda, never before has medicine held so much promise for improving the health of the public. Despite various professional problems, no other career offers the unique blend of state-of-the-art science and humanism that epitomizes internal medicine--medicine's integrating specialty.
No abstract available. (C) 1992 Association of American Medical Colleges
There is no human endeavor or organization in which perfection is achieved even when it is assiduously sought. More than most, the medical profession, because of its unique role and the consequences of base behavior, has traditionally striven to instill in its practitioners a strong sense of duty and professionalism, but it would be foolhardy to assume that all physicians are ethical, honest, or competent. It is always easy to spotlight anecdotal cases of deviant behavior: good news doesn't sell newspapers! So, we are bombarded with accounts of gross incompetence, greed, and fraud against both patients and institutions. Attempts to quantify the extent of such behavior, although frequently attempted by extrapolation, are nonetheless fraught with so many difficulties that they probably cannot be successful. Obviously, the medical profession would like to assume that the numbers are minimal.
That assumption, however, begs the question. If physicians are
The essence of professionalism is self-governance. Central to self-governance is self-criticism.1 The public trusts medical professionals to be honest with themselves, with each other, and with them. Honesty is exemplified in quality assurance activities within organizations. These are based on the recognition of problem areas, identification of errors when they occur, and institution of corrective actions. The responsible action taken by the faculty and staff at the Beth Israel Hospital in Boston, Mass, and reported elsewhere in this issue in the article by Bedell and colleagues2 should be lauded and considered a model for other institutions interested in ensuring quality.
The editors of The Journal have chosen to publish a number of challenging articles of this nature. For example, the April 24, 1991, JAMA included two research papers on the frequency of substance abuse among resident physicians and medical students3,4 and a remarkably candid Special Communication, "Do
A study assessed the effect of incorporating medical ethics into the medical curriculum and the relative effects of two methods of implementing that curriculum, namely, lecture and case-study discussions. Results indicate a statistically significant increase (p less than or equal to .0001) in the level of moral reasoning of students exposed to the medical ethics course, regardless of format. Moreover, the unadjusted posttest scores indicated that the case-study method was significantly (p less than or equal to .03) more effective than the lecture method in increasing students' level of moral reasoning. When adjustment were made for the pretest scores, however, this difference was not statistically significant (p less than or equal to .18). Regression analysis by linear panel techniques revealed that age, gender, undergraduate grade-point average, and scores on the Medical College Admission Test were not related to the changes in moral-reasoning scores. All of the variance that could be explained was due to the students' being in one of the two experimental groups. In comparison with the control group, the change associated with each experimental format was statistically significant (lecture, p less than or equal to .004; case study, p less than or equal to .0001). Various explanations for these findings and their implications are given.
Academic medicine is entrusted by society with the responsibility to undertake several important social missions toward improving the health of the public, including education, patient care, and research. This trust is given implicit authority by generous public funding and considerable autonomy. Medical academia can take pride in its successes, manifested by a premier scientific establishment, the development and use of sophisticated medical technologies and drugs, and the recent dramatic declines in death rates from heart disease and stroke. Academic medicine, however, has been relatively unresponsive to a number of vexing public problems, including skyrocketing expenditures for medical care, substandard indexes of population health, uneven quality of care, an unfavorable geographic and specialty mix of physicians, and widespread disability from long-term medical and psychiatric problems. Although there are many cogent reasons why academic medicine has chosen to define its task relatively narrowly (the nature of its funding successes, the intractability of the social problems, and the attractiveness of the biomedical model), the central issue is how well academic medicine is fulfilling its responsibilities to the public. To the degree that academic medicine defines its central mission narrowly, it may violate its implicit social contract and jeopardize its primary source of financial support. Alternatively, in recognition of its public responsibilities, academic medicine can choose to expand its current activities to be more responsive to the health concerns of the general population.
Medical schools vary by nation and by culture but, for students, the experience appears to be very similar. Also, despite a half-century of radical changes in medical practice, education as a process of socialization for the profession is relatively unchanged. At the same time, medical educators have frequently instituted curricular reforms. To analyse this history of reform without change, this paper first establishes what the content and structure of medical education is, and how it came to be that way; second it traces a process whereby the scientific mission of academic medicine has crowded out its social responsibility to train for society's most basic health-care delivery needs. The main argument is that medical education's manifest humanistic mission is little more than a screen for the research mission that is the major thrust of the institution's social structure.
Using recent first-hand accounts by Klass (1987), Konner (1987), LeBaron (1982), and Reilly (1987), this paper examines "insiders'" experiences of medical school. Medical education emphasizes disease, technical procedures, and technological medicine, with scant attention to "caring" aspects of doctoring. Students struggle to learn medicine and to maintain a humanistic or patient-oriented perspective, but the social environment of medical training militates against humanistic doctoring. Toward the end of medical school, students undergo a transformation by adopting the medical-clinical perspective and shifting their identification from patients to doctors. The doctors who maintain a humanistic orientation to medical care appear to be individuals who had developed this orientation before they arrived at medical school. Thus, to increase the number of humanistic physicians, the best strategy may be to alter medical school recruitment and selection policies.
Medical school deans and faculty members were surveyed by the Association of American Medical Colleges to obtain information on 1984-85 courses designed to improve students' ability to examine their values in relation to those of patients, communicate effectively with patients, or think critically about cultural, social, and ethical issues arising in medical care. Of the 126 deans contacted, 113 supplied course descriptions, and 99 responded to survey questions about the integration of human values programs into students' clinical education. Ninety-five schools reported that at least one human values course was required during the first or second year of the curriculum; 38 schools listed a program as part of the required curriculum for the third or fourth year. The respondents reported several ways in which human values programs were integrated into clinical education. The most frequently mentioned method was reinforcement or addition of human values emphases during medical clerkships. The process considered to be most important by respondents in achieving this integration was a combination of interactions among faculty members, improvement of human values courses, and the support of the dean. The respondents also reported on the characteristics of faculty members who teach such courses, on faculty development efforts, on barriers to the integration of human values teaching into the curriculum, and on the evaluation of such courses.
Being regarded as a professional and having one's occupational group regarded as a profession are often deemed desirable. It is not immediately apparent why this is so. 'Professional' often contrasts simply with 'amateur', and as a label conveys not honor but the recognition that the one so labelled is paid for doing what others do for free. But there is a distinct, honorific sense in which the professional contrasts not with the amateur but with the person who simply has a job rather than a life-long calling. It is in this honorific sense that physicians, attorneys and members of the clergy serve as paradigm professionals. Aspiring professionals in disciplines other than the paradigm ones regard themselves as more nearly like these paradigms than is usually recognized, and this is their claim to recognition as professionals. The paper explores several possible points of similarity by developing an account of the ideal for professionals which has been held in Western society at least since the time of the Hippocratic Oath, which best captures its spirit. As the Oath makes clear, professionals have fiduciary relations with their patients or clients, and provide services of a personal nature. The paper explores the principal demands of this ideal, the principal steps which physicians have taken in pursuit of it, and some of the implications of this ideal for various groups of social scientists associated with medicine. Finally, it recognizes a professional spirit or attitude which transcends occupation.
Contemporary medicine has given little attention to the spiritual dimension of human experience despite its relevance to our fundamental goal of healing. This exploratory work takes the position that this dimension can and should be reintegrated into health care models and practice. After delineating the scope of inquiry and providing some definitions, I draw upon paradigms from psychology and physics to provide a basis for such integration, and then extend the biopsychosocial model to include the spiritual dimension, discussing some ways in which this perspective might affect our thinking about disease and health care.
Medical educators had hoped that increased elective time, decreased night call, ethics courses, and other efforts to address nontechnical issues and reduce stress in medical education would provide student physicians more time and encouragement for personal development and self-scrutiny and would promote the development of more healthy, humanistic, and self-motivated physicians.1 2 3 4 5 6 7 However, despite what many would agree is a richer educational atmosphere, there is little evidence that these and other innovations have had any enduring influence on the character of the physician who is produced by the improved system.7 If anything, many experts are voicing increasing concern about such problems . . .
The purpose of the study presented here was to assess medical students' perceptions of the weight given to scientific and humanistic values in their learning environment and to determine whether students' perceptions in a given school vary according to their level of medical training and personal characteristics. The study was conducted in 1979 via a mail questionnaire sent to a sample of 713 freshmen, juniors, and graduates from three U.S. medical schools; 82.2 percent responded. The results indicated that the students' perceptions of school values varied little according to the students' personal characteristics, such as sociodemographic and educational background, interests before medical training, and expected specialty choice. However, important differences were observed in students' perceptions of values emphasized to them at different schools. Preclinical and clinical students' perceptions of the importance given to scientific values were similar. As for humanistic values, significantly lower ratings were given by clinical students than preclinical students in two of the schools.
Despite growing consumerism and skepticism about authority in the culture as a whole, most patients continue to be pliant. If there is a serious threat to physician autonomy, it is more likely to come from third-party payers and new forms of medical practice, particularly the rise of for-profit hospital chains, than from patients. Though physicians are restless, they will learn to adapt to the new conditions of practice.
The use of informal terms by young physicians to describe patients is analyzed by examining the use of one such term, 'gomer'. Patients labeled gomers by internal medicine housestaff in a university hospital were found to present more difficult diagnostic, therapeutic, and behavioral problems, to suffer more mental decline, to remain in the hospital longer, and to be less able to return to their own homes and usual adult roles. Gomers were no more ill than control patients; however, their problems were more frustrating, engendered disagreement, and aroused uncertainty in the housestaff caring for them. 'Gomerism' is not just a characteristic of patients, but is a phenomenon arising from their interaction with the social system of the hospital and in particular with young physicians in a transitional stage of training. 'Gomerism' reflects larger dilemmas in the health care system and society. Gomers represent the failure of technological medicine to eliminate illness and to heal the aging as well as the failure of society to provide human care for the socially isolated patient whose illness is not tidily resolved by either cure or death.
This article describes an innovative method of teaching and learning in medical education, the Focal Problem Teaching Method, which provides a natural introduction to clinical experience. This format directly simulates the problem-solving character of medical practice in order to explicitly cultivate the skills of medical problem-sohving while simultaneously providing a realistic context for transmitting relevant information and concepts. It is neither discipline-centered nor organ-system based but rather organized around problems which face the medical practitioner. It employs a small-group learning format which provides the opportunity to develop skills of communication, interaction, self- and peer-evaluation. Faculty develop specific objectives for each problem, plan and supervise the discussion of problems, and arrange appropriate study materials. Evaluation of student performance and program through test problems provides data on ability to perform in the clinical or practice setting.
An evaluation survey was undertaken at the Rockford School of Medicine to examine the purpose and quality of the relationship between faculty mentors and students. Both groups strongly endorsed the program. Results of the survey indicated that students needed to put more effort into developing friendships with their mentors and that physicians needed to broaden their focus beyond a concern for the academic performance of their proteges.
This article has no abstract; the first 100 words appear below.
One does not have to be a pessimist or an incurable victim of nostalgia to agree that modern medicine in the Western world is undergoing some form of crisis. One indication of the depth of the crisis is the attention with which thoughtful people are willing to consider seriously almost any criticism of physicians and of the medical establishment — even such absurd critiques as those of Illich,¹ who would have us believe that modern medicine is almost the reincarnation of the Devil himself. Similarly, the proliferation of health cults even within educated and otherwise sophisticated circles bears witness to . . .
Seymour M. Glick, M.D.
Ben-Gurion University of the Negev Health Sciences Center Soroka Medical Center Beer Sheva, Israel
Based on an address delivered by Dr. Glick at the inauguration of the Gussie Krupp Chair in Internal Medicine, September 9, 1980.
The practice of voluntary physician-assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity.
The study of literature encourages the development of otherwise hard-to-teach clinical competencies. It provides access to the values and experiences of physicians, patients, and families; it calls for the exercise of skill in observation and interpretation, develops clinical imagination, and, especially through writing, preserves fluency in ordinary language and promotes clarity of observation, expression, and self-knowledge. Faculty in one-third of U.S. medical schools teach literature in courses that, although concentrated in the preclinical years, range from the first day of school, through residency programs. Once focused on the work of physician-authors and realist fiction about illness that encouraged moral reflection about the practice of medicine, literary study in medicine now encompasses a wide range of literature and narrative types, including the patient history and the clinical case. Literary study is intended not only to enrich students' moral education but also to increase their narrative competence, to foster a tolerance for the uncertainties of clinical practice, and to provide a grounding for empathic attention to patients. Literature may be included in medical humanities courses, and it may provide rich cases for ethics courses or introductions to the patient-physician relationship; it also may be the focus of small, elective, or selective courses, frequently on particular social issues or on the experience of illness. Reading, discussion, writing, and role-play rather than lectures are the methods employed; faculty include those with PhDs in literature and MDs who have strong interests in the contributions of literature to practice.(ABSTRACT TRUNCATED AT 250 WORDS)
Data from the 1993 Matriculating Student Questionnaire (MSQ) and the 1994 Medical School Graduation Questionnaire (GQ) of the Association of American Medical Colleges were investigated for differences in responses between men and women. Notable differences were discovered, particularly with regard to career plans and experiences during medical school. Findings from the GQ include that a higher proportion of women rated curricular coverage of numerous subjects inadequate and that women students more frequently reported mistreatment during medical school. Women were also more likely than men to work in clinics serving the indigent and to complete a primary care clerkship. Over 30% of the 1994 women seniors, compared with 18% of the men, planned to pursue generalist careers. The authors discuss the gender-associated differences, with reference to previous studies, and conclude that medical educators should ensure that women have access to the same skill-development opportunities that men do and to a humane learning environment. Moreover, educators should examine what adaptations can encourage students of both genders to develop an ethic of "social responsibility."
The transformation of U.S. health care is driven by underlying principles. The tensions between what exists now and what will emerge over the next 15 years pervade health care delivery and financing, the doctor-patient relationship, the provider-payer relationship, and the atmosphere within educational institutions for the health professions. The institutions that early on develop the capacity to forge and sustain strategic partnerships will be well positioned to take advantage of the opportunities of a rapidly changing system, but those that do not will risk being isolated without the diversity of resources needed to make meaningful contributions to health care. The tensions also drive major changes in the way health professionals are educated, trained, and deployed. Health care reforms will dramatically change the culture of the medical school in areas of patient care, research, and education programs. These institutions face external pressures to change and internal barriers to change, not the least of which are the lack of sustained leadership and collective vision. Academic medical centers must take active steps now to assess their strengths and weaknesses objectively, look realistically at options, and construct new, mutually beneficial partnerships that will be the keys to success.
Institutions have ethical lives and characters just as their individual members do. Health care organizations must look critically at how professed institutional values can best be realized in day-to-day interactions within the institution and with the wider community.
To initiate an electronic mail (e-mail) program as a supplement to a medical humanities curriculum focusing on ethical and social issues.
In 1991-92 an e-mail track (called NET) was established for second-year students participating in Medicine in Contemporary Society, a four-year curriculum in medical humanities at the State University of New York at Stony Brook School of Medicine. In 1991-92 ten students volunteered to form a NET group; in 1992-93 22 students, forming two groups, were randomly selected from a volunteer pool of 76 students (from a class of 100). In both study years, the NET students analyzed and discussed electronically a series of cases posted sequentially through the academic year. Faculty tutors reviewed the students' responses, interacting with the groups and with individual students by e-mail. NET was evaluated in two ways: at the end of the course, the students completed e-mail questionnaires that included quantitative and qualitative assessments; and throughout the course, the tutors assessed the students' participation, quality of case analysis and discussion, and quality of writing.
The students' assessments indicated that they considered NET to be more educational than the lectures, "live" group discussions, problem-based learning exercises, and formal papers in the medical humanities curriculum; that they made gains in computer literacy; and that NET enhanced their abilities to think about ethical and social issues. The tutors judged that the students had improved their written self-expression as the course progressed.
NET adequately accomplished the goals set for it as an adjunct to the small-group sessions and other components of the medical humanities curriculum.
Role models play an important part in determining how medical trainees mature professionally. Demonstrating clinical skills at the bedside is the most distinctive characteristic of an effective role model. We discuss how role modeling affects professional identity and career choice and offer several suggestions for improving medical education, including the need for leaders to change the educational climate and culture. If implemented, these changes would enhance our ability to provide medical students with positive role models.