Physician Role Models Research Articles

If Role Models Do Model Roles

Medicine has traditionally relied on senior physicians to impart values and attitudes to the upcoming generation of physicians through their actions and behavior. In a recent issue of the British Medical Journal, three investigators reviewed existing research on the traits medical students and clinicians look for in senior physician role models, whether they find the traits they seek, and whether they, in fact, adopt the traits they claim to seek.1

When do medical students identify career-influencing physician role models?

To identify when medical students gain physician role models relative to when they make their specialty choices. The 1998 graduating class of one medical school was surveyed about when and where they had made contact with their role models and whether they had made contact before or after making their specialty choices. Students also provided data about their demographics, curriculum pathways (problem-based or traditional), and specialty choices at matriculation and graduation. Of the 89 graduating seniors who responded (62%), 21 had role models they had known prior to matriculation, 51 had encountered their role models in medical school, and 51 had met their role models before making their specialty choices. Of the 51 students who had encountered their role models in medical school, 33 (65%) had done so before making their specialty choices. The mean time from matriculation to meeting a role model was 24.9 +/- 11.6 months, and students on the problem-based learning pathway had met their role models earlier than had students on the traditional pathway. Most medical students have physician role models at graduation, and many of these students identify their physician role models at a point when the interactions can influence their specialty choices.

The Interdisciplinary Generalist Curriculum Project at Nova Southeastern University College of Osteopathic Medicine.

Nova Southeastern University College of Osteopathic Medicine (Nova Southeastern) proposed for its IGC Project to match students with community-based generalist physician role models through partnership with a managed care organization (MCO). An unanticipated corporate merger between the initial managed care partner and another health plan resulted in Nova Southeastern's negotiating training partnerships with multiple MCOS: Other program elements that differed from what was originally proposed include provision of an interactive utilization management session at a hospital or skilled nursing facility, rather than a headquarters-based utilization management rotation; combining multiple learning experiences for students within a single MCO session; having a portion of the training take place at field-based sites outside MCO headquarters or after normal business hours (i.e., MCO physician committee meetings); and recruitment of physician mentors through a variety of means and not just through MCOS: The current goals emphasize preparing students to have a working knowledge of managed care principles and practice that can be applied in any medical field and setting. This goal contrasts with the original goal of preparing students for jobs "within" managed care. The IGC Project is viewed at Nova Southeastern as the flagship of interdisciplinary curricular changes in the training of tomorrow's physicians.

Physician profiling using data envelopment analysis: a case study

As an alternative to existing physician profiling methods, we used DEA to evaluate the efficiency of primary care physicians from a managed care organisation. Taking a case study approach, we discuss how data collected by this organisation regarding resource utilisation, cost, and quality can be used in various DEA models to determine physician efficiency. We consider several decisions regarding the selection of the DEA models and data to be used in these models. We introduce a guided stepwise method to determine a small, but relevant, set of input and output variables. Physicians were analysed on the basis of both in-patient and out-patient performance. DEA not only provided measures of physician efficiency, but also identified a small set of reference groups to serve as role models for non-efficient physicians.

Acute hospital medicine in Ireland — past, present and future

The twentieth century has seen enormous changes in the practice of medicine, and as it becomes ever more successful, demand for acute hospital treatment can only increase. For political reasons the growth of Ireland's hospital service has been erratic and poorly planned. There are, therefore, still Irish hospitals in which acute general medicine is practised without subspeciality support by a dwindling number of general physicians. These physicians and their medical units care for more than half of the 140 000 acute medical admissions/year to Irish hospitals. Most Irish general medical units are efficient with short length of stays compared with other specialities, and low levels of inappropriate admissions by international standards. However, fundamental problems have developed in Irish post-graduate medical education, which are presently seriously lowering morale throughout the profession. Although the number of hours worked has recently been decreased considerably, the proportion of hours spent doing nonmedical menial and clerical work has increased, with a corresponding decline in the number of hours spent in productive patient-related training. As a result, clinical training has become far less satisfying at every level: professional, educational and emotional. Despite the fact that manpower statistics predict an oversupply in the near future, young Irish physicians still continue to seek subspeciality training and show little interest in acute hospital medicine. A major cause of this paradox is the lack of general physician role models in Irish academic centres. The provision of medical service to the population at large is the medical problem of our age: it is undoubtedly true that in the past, many physicians acquired much of their skill by a process of trial and error, often at the expense of their patients. The challenge for the future will be how to recruit and train the next generation of general physicians safely and appropriately.

Training the trainers: substance abuse screening and intervention.

Screening and brief intervention for substance abuse is effective yet underutilized by primary care physicians. This article reports on Project SAEFP (Substance Abuse Education for Family Physicians), which aimed to enhance the clinical and teaching skills and activities of U.S. family practice residency faculty. Ten five-day workshops were designed and administered for 165 participants. Evaluation data included measures of participant satisfaction and pre-workshop and twelve-month post-workshop measures of the frequency of teaching, consulting, and clinical activities, and the attainment of self-identified teaching goals. The participants were very satisfied with the workshops. They improved significantly in the key outcome measures. Several workshops may have contributed to the apparent success of Project SAEFP. Attributes of the workshops which might have facilitated their success were their duration, funding, frequency of offering, collegial learning environment, opportunities for active learning, emotionally moving exposure to recovering individuals, focus on how to modify curriculum at participant residency programs, availability of family physician role models as faculty, and readily usable instructional materials. Planners of interventions for physician educators might profit from similar attention to these attributes.

Evaluating the Use of a Multimedia Approach to Teaching Nutrition in Medical School

Barriers to medical students receiving nutrition education exist and use of multimedia programs has been suggested as one solution. However, evaluation strategies to determine the effectiveness of this approach are lacking. The experience of 140 medical students using a nutrition multimedia program and the strategies used to assess student attitudes toward this independent learning strategy are reported. Their performance in counseling standardized patients after studying the program was evaluated. The use of multimedia technology to provide appropriate physician role models teaching nutrition assessment and counseling has promise.

The impact of role models on medical students.

To explore the relationship between exposure to clinical role models during medical school and the students' choice of clinical field for residency training, and to estimate the strength of this association. Cross-section study. McGill University School of Medicine, Montreal, Canada. Of the 146 graduating medical students in the class of 1995, 136 participated. Clinical field chosen by students for residency training and the students' assessment of their exposure to and interaction with physician role models were the main measurements. Ninety percent of graduating students had identified a role model or models during medical school. Personality, clinical skills and competence, and teaching ability were most important in the selection of a role model, while research achievements and academic position were least important. Odds ratios between interacting with "sufficient" role models in a given clinical field and choosing that same clinical field for residency were 12.8 for pediatrics, 5.1 for family medicine, 4.7 for internal medicine, and 3.6 for surgery. Most students (63%) received career counseling and advice from their role models. Exposure to role models in a particular clinical field is strongly associated with medical students' choice of clinical field for residency training. Knowing which characteristics students look for in their role models should help identify the physicians who may be most influential in medical students' career choice.

Undying Care for Terminal Patients

With regard to the article by Hill¹in the June 26, 1995, issue of theARCHIVES, I wish to comment. To use the existence of a specific course or rotation on the care of the dying is a poor indicator of training programs that reliably turn out physicians who are more attentive to, or comfortable with, terminal patients. A much more important determinant is the individual personality of each medical student or house officer and his/her personal values, beliefs, and attitudes. To the extent that training can have influence in this area, I believe physician educators and role models are much more important. And this goes deeper than just the willingness of faculty members to teach pertinent courses or be active in a local hospice program. The attending physician's demeanor and behavior toward terminal patients and his/her genuine concern for patients as persons rather than repositories of disease speak

Teaching and learning in ambulatory care settings: a thematic review of the literature.

A thematic review was conducted of the 1980-1994 research literature on teaching and learning in ambulatory care settings for both undergraduate and graduate medical education. Included in the review were 101 data-based research articles, along with other articles containing helpful recommendations for improving ambulatory education. The studies suggest that education in ambulatory care clinics is characterized by variability, unpredictability, immediacy, and lack of continuity. Learners often see a narrow range of patient problems in a single clinic and experience limited continuity of care. Few cases are discussed with attending physicians and even fewer are examined by them. Case discussions are short in duration, involve little teaching, and provide virtually no feedback. Excellent teachers are described as physician role models, effective supervisors, dynamic teachers, and supportive persons. Rather than block rotations, students and residents prefer longitudinal teaching programs, which offer continuity-of-care experiences with patients and preceptors. Although little can be concluded about learning outcomes, the studies indicate that some medical students and residents have deficient skills in interviewing, physical examination, and management of psychosocial issues. Based on the reviewed studies, the author recommends facilitating learning by increasing continuity-of-patient-care experiences and contact with faculty members, encouraging collaborative and self-directed learning, providing faculty development, and strengthening assessment and feedback procedures. The author also recommends further research to learn about medical specialties other than internal medicine and family medicine, to describe the knowledge and reasoning of both teachers and learners, and to assess the influences of various educational programs on learning and satisfaction.

The wisdom of Sir William Osler

William Osler (1849–1919) was generally regarded as the greatest and most respected physician of his time. He is still considered by many in these terms. Others have questioned the relevance of Osler's teachings in recent years. This paper describes Osler's life and gives his philosophy and views in his own words. An outstanding clinician who emphasized bedside teaching and observation, he possessed extraordinary charm that inspired many disciples. As Professor of Medicine at 4 institutions in 3 countries, he exerted a profound influence on medical education. He was a prolific writer and his textbook became the most popular and widely read treatise on medicine in the world. He also was a medical historian, a classical scholar, and an avid bibliophile. He emphasized the value of hard work and ongoing education. His compassion and concern for patients and colleagues reflected his personality. Osler's wisdom is as relevant now as in his era. It is likely that he would be in the forefront of medical science if he were alive today. Osler blended the art and science of medicine perhaps better than anyone else and remains a valuable role model for students and physicians more than 75 years after his death.

Specialty Choice Among Students Entering the Fourth Year of Medical School

In this article, the authors explore senior medical students' specialty preferences and investigate factors that influence those preferences. The design of the study was a written questionnaire. The setting was a large, state-supported university-based southern medical school. The patients/participants were students entering the fourth year of medical school. One hundred seventy-six students (97% of the class) completed the questionnaire. Of those students, 12.5% were interested only in primary care, 43.2% were interested in both primary and nonprimary care, and 44.3% were interested in nonprimary care careers. Most students considering both primary and nonprimary care careers were interested in general internal medicine or general pediatrics and subspecialties within those fields. Career choice was influenced most strongly by several factors--clerkship experiences, the fact that it fit with skills/abilities, physician role models, the challenge, and intellectual content. Encouragement from family and other students, prestige, and income potential had the least impact on career choice. Students interested in primary care careers valued providing continuity of care much higher than did those interested in nonprimary care specialties. The authors conclude that students' experiences in medical school, particularly during the clerkships, have a significant impact on their specialty choice.

Compliance with universal precautions in a medical practice with a high rate of HIV infection.

Universal precautions have been recommended to limit occupational exposure to the human immunodeficiency virus (HIV) and other infectious agents, but whether these recommendations have been incorporated into routine practice has not been demonstrated. Using a one-group, before-after design, we assessed the knowledge and attitudes concerning universal precautions and the level of compliance with these recommendations. The health care professionals had various levels of training and worked in an ambulatory practice with a high rate of HIV. A total of 195 procedures involving potential exposure to various body fluids were observed. No improvement in compliance with recommended precautions was observed following a didactic educational program for either latex glove use (44 percent versus 49 percent, chi 2 less than 1, P greater than 0.2) or appropriate use of hand washing (34 percent versus 47 percent, chi 2 = 3.38, P = 0.07). Faculty demonstrated the lowest levels of adherence to universal precautions. While knowledge of precautions was high, staff members at all levels overestimated their own compliance with these recommendations. Although the number of observations limits the conclusions, the results suggest that the basic protective measures included in universal precautions are not being routinely applied in ambulatory medical practice. Furthermore, didactic educational programs might not be sufficient to improve compliance. Finally, faculty in training programs should monitor their own compliance with universal precautions because of their responsibilities as role models for physicians in training.

Nutrition training in graduate medical (residency) education: a survey of selected training programs

Because limited information exists about nutrition training of residents, we studied the teaching practices of nationally recognized nutrition programs. Two hundred thirty-eight nutrition educators and 787 residency-program directors identified 160 institutions with strong nutrition training. The 23 highest-ranked programs were surveyed and 7 were visited. The results showed that 1) clinically active physician-nutritionist role models are the key elements in teaching residents clinical nutrition; 2) multidisciplinary nutrition support teams are valuable learning resources unless they function primarily as technical support services; 3) nutrition elective rotations, although highly effective, are taken by a minority of residents; 4) the nutrition curriculum should include practical learning materials and conferences; and 5) a research environment is important to attract qualified physician-nutritionist role models. A major deficit is teaching nutritionally based approaches to disease prevention in the ambulatory setting. Finally, a shortage of nutrition-oriented physician role models is probably the major constraint in teaching nutrition to residents.

Rurally based education

Skills needed by physicians to address and prevent our communities' leading causes of premature death--injuries, cancer, cardiovascular disease, homicide, and suicide--are not in the typical roster of medical school learning experiences. And traditional, urban, hospital-based venues of medical education scarcely model for students appealing careers in the community. These twin problems are especially severe in rural America. Yet rural training sites are ideal locations for students to confront the array of social, political, and economic forces underlying ill health in our society. If learning in medical schools is to be suitable for rural practice, students must receive early and sustained exposure to rural communities and to rural physician role models. To facilitate this educational redirection, medical schools must (1) sensitize their existing faculty and residents to community health needs via in-service training on community health topics, (2) encourage faculty and residents to provide service and education outreach to rural communities, and (3) promote rural health research. Finally, to prevent the marginalization of rural health concerns within the academic agenda, efforts should be made to develop university-community partnerships in which model rural training practices and a "field" teaching faculty are established and nourished by the medical center.

Moonlighting: Making a Buck, Compassion, and Quality Control

To the Editor.— I simply must respond to the letter about moonlighting by Dr Cohen.1He and his ever-compassionate seem to have calculated a method to make money off the moonlighting activity of the house staff. Apparently, the faculty supervisor is available by beeper or telephone while the house officer stays up all night and does the work. The physician is then paid a commensurate amount for sitting at home and being available. We are constantly hearing pleas for better physician role models for residents and medical students. Is it any wonder that house staff are so cynical when they are so blatantly ripped-off, as in the above scenario? These house officers have a permanent license and in the eyes of the state are permitted to practice medicine on their own. Assuming job performance is not compromised, it is none of the university's business how a resident

Professors of Medicine

To The Editor. —In a recent editorial in theArchives(1983;143:212-213), Landau theorizes that professors of medicine have in some way abandoned their leadership role in medical society. I think this does not represent dereliction, but rather the inevitable consequence of changing referral patterns, and of rapidly advancing technology. Many patients now obtain medical care in their home communities, largely from university-trained physicians, and fewer patients are referred to university hospitals. The new technology has taken away much of the aura of bedside diagnosis. It would be difficult, even for Sir William Osler, to make rounds in this day of computed tomographic scans and other sophisticated diagnostic tests. This has resulted in the virtual extinction of the great clinicians; not a happy occurrence, in my opinion. Dr Landau asks if the real doctors, the community physicians, are expected to become the role models for students and young physicians. The obvious

In search of the biopsychosocial perspective: an experiment with beginning medical students.

The authors assessed the clinical thinking of medical students before, during, and after their first extensive in-hospital learning experience and exposure to physician role models. They found that more than 90% of the students' requests for additional data in response to videotaped simulated patient interviews were for biologic information; approximately 66% of all respondents in six separate trials failed to request a single psychological or social item concerning the patient. The authors discuss the pervasiveness of the biomedical rather than the biopsychosocial mentality and its implications for medical education as well as clinical teaching, decision making, and practice.