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| Journal of the New Zealand Medical Association,
04-May-2007, Vol 120 No 1253
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For better or worse: role models for New Zealand
house officers
Rosemary Wyber, Tony Egan
The Medical Council of New Zealand (MCNZ) Intern Handbook is
distributed to senior clinicians who supervise house officers. It outlines the
desired characteristics and influence of role models in New Zealand.
A growing body of academic literature suggests that role
models are inescapable mediators of medical socialisation and professional
development.1–7 Research indicates their
influence over specialty selection,8–10
ethics,10,11
professionalism,12 and the patient-doctor
relationship.13,14 Theorists suggest that these
influences can be moderated by awareness of role modelling
process.15 It is unclear whether the importance
of role modelling is as well recognised in the wards where it occurs.
This research was conducted to establish the nature of role
modelling experiences for New Zealand house officers over the last decades to
the present day. Retrospective accounts were provided by current general
practitioners, which limits generalisability to other specialties. However,
details of contemporary role modelling were provided by PGY1 and PGY2 doctors
without speciality bias.
Examining these formative working years is important; house
surgery represents the first time that many young doctors have been outside
formal, full-time education, and may be marked by a loss of the structure and
support associated with the student years. The experiences of junior doctors are
also an important barometer of the professional and medical culture in New
Zealand hospitals.
MethodsIn November 2004, interviews were held with a
convenience sample of six male and six female general practitioners (GPs) from
the urban Dunedin area who completed their house surgery years in New Zealand
and were provisionally registered at least ten years ago (Group
1).16
GPs are in an ideal position to reflect on their house
office years with limited subsequent exposure to hospital culture. After
training and a practise interview with the second author, the medical student
first author conducted the interviews. The semi-structured interview, lasting
about half an hour, was conducted in person at practice rooms around the city.
The interviews began with the volunteers providing an example of ‘an
experience, person or incident’ that they considered represented positive,
and then negative, role modelling during their house officer years.
The third part of the interview covered reflection and
consciousness of role modelling during and after the events. In December 2005 a
convenience sample of 3 male, and 10 female, current house officers at Dunedin
Public Hospital (Group 2) participated in interviews using the same
probes.17 These participants were PGY1 and PGY2
doctors with standard house officer rotations in medicine, surgery, and
specialties.
The interviews were held in person, most at the Dunedin
Public Hospital while the house officers were on duty. In general, the second
round of interviews was shorter and slightly less structured than the first. All
interviews were taped, independently transcribed, and underwent multiple
readings by the first author to identify key themes. These themes, and samples
from the transcripts, were regularly discussed with the second author throughout
coding and analysis. Themes are illustrated with verbatim quotes in the results
section; numbers in parenthesis refer to individual respondents.
Ethics approval was granted by the University of Otago
Ethics Committee under the auspices of the Hidden Curriculum Project.
ResultsIdentity of role modelsParticipants were initially asked to identify a person or
incident which they considered an instance of positive role modelling. Senior
teaching clinicians, specifically registrars and consultants, were the vast
majority of positive models. A small number of participants also identified
nurses, and and/or their peers, as positive role models. Most volunteers
identified a number of positive role models, although group two seemed more
aware of having multiple models.
In the second part of the interview, participants were asked
to describe a negative role model. Volunteers from Group 1 generally identified
consultants as negative models. Participants from Group 2 seemed reluctant to
clearly identify individuals that they did not want to emulate. Instead, they
spoke about broad categories—superiors, consultants, and
supervisors—not single clinicians. When the information was volunteered,
consultants and registrars were the most frequent negative role models.
Characteristics of role modelsAnalysis revealed three relationships which house officers
in this study seem to use for identifying role models:
Relationship between house officer
and role model—Participants from both groups identified
supportiveness as the most important trait of their positive role models. They
also described senior clinicians who were ‘nice’, generous with
their time, engaging, patient, accessible for questions, and easy to work with..
His manner was kind and warm
and uncritical and he was always very approachable, always very very helpful,
never made you feel as a learning house surgeon as though you were stupid or you
made a foolish error (Group 1, 1)
Poor support, or poor communication, typified the
relationship with senior clinicians who were negative role models. The incidents
reported by Group 1 participants were generally more serious.
I had to ring someone at
home one night and they were just really horrible and unhelpful and I just sort
of found that quite negative (Group 2, 3)
...I rang him up about a
baby who had been sent in and I started doing the presentation as I’d been
taught to do and he sort of interrupted me and said ‘What the f--k are you
telling me this for?’ That is something that certainly stuck in my mind
(Group 1, 2)
Relationship between role model and
patients—Senior clinicians who demonstrated a good relationship
with their patients were widely admired by participants from both groups. These
doctors were described as being compassionate, caring, and engaging.
He was a registrar and he
was just really good with patients...he always used their name, always made a
joke, or would take their hand, or he might just pop his hand on their knee or
leg, or something, so he made patient contact really well. He really engaged the
patient. (Group 2, 9)
Negative role models who had poor relationships with
patients were described as uncaring and disinterested. Interviewees expressed
frustration, anger, and disbelief at the treatment of some patients. A
significant number of participants in Group 2 described their attempts to make
up for poor communication by their consultants.
... if my consultant had
gone around in the morning and was being really rude to the patients, then I
would often go back and clarify what was going on for patients... often they
didn’t realise what was happening, or understand what the consultant was
saying (Group 2, 2)
I do find myself as a house
surgeon going back and doing a second ward round sometimes...and actually going
through things [explanations to patients] in a bit more depth and detail (Group
2, 5)
Relationship between role model and
medicine—Several participants described and admired their
positive role models for enjoying their job or having maintained interests
outside medicine. Recent graduates in Group 2 seemed particularly reassured that
positive role models had retained an enthusiasm for medicine.
...it can be done.
They’re happy. (Group 2, 1)
Contrastingly, doctors who were bitter or cynical in their
relationship with medicine were identified as negative role models by both
groups, particularly Group 1.
I think in hindsight
definitely the registrars and consultants I didn’t like were basically the
people who didn’t enjoy the job and you did sort of wonder why they were
in medicine actually (Group 1, 10)
Role models also demonstrated a relationship with their
specialty. Participants from both groups felt that role models had been
influential in their thinking about specialty selection, mainly in a negative
sense.
He was vitriolic of them in
his condemnation of [the] GP and always about, you know, the crap and the dross
that was referred...and why was this patient in, and why was that patient
in...and stupid GP didn’t see this, and stupid GP didn’t notice
that. And that was enormously destructive (Group 1, 1)
Invariably, surgery was identified as a specialty with many
negative role models. Some participants described choosing runs to work with
consultants they liked and avoiding supervisors who were difficult to work for.
This may bias graduates towards experiences in certain specialties.
Consciousness—Most interviewees said
that they were aware whether other clinicians were ‘good’ or
‘bad’ while watching them on rounds. The vast majority of Group 1
participants could discuss who, why, and how they had been influenced by their
interaction with senior doctors. They described a superficial awareness of role
models during their house officer years, but growing reflection and
consciousness over time.
But when you think back
from... however many years later I am now, 12 or 13, I guess...I do remember
individuals and they do start to stick out as a sort of positive role model
(Group 1, 10)
In contrast, current house officers found it more difficult
to single out individual doctors who had influenced them. They tended to
identify a wide range of positive and negative models who had helped to shape
their professional style.
Both groups confirmed that house officers talk about their
colleagues and senior clinicians. These discussions rarely focused on the
clinician as a role model. Instead, house officers shared information about the
idiosyncrasies of senior clinicians, or informally debriefed after negative
experiences.
A significant number of participants in Group 1 provided
unprompted explanation for poor behaviour by negative models. They cited
external stress, exhaustion, bureaucracy, and family pressures as factors
contributing to unprofessional behaviour by their superiors.
Looking back you can see
that I am...perhaps a bit sort of softer on them than I perhaps was sometimes at
the time...just because you understand that they were probably under a lot of
stress from all sorts of different things and perhaps were completely unaware of
this house surgeon (Group 1, 4)
In contrast, participants from Group 2 made only very
rudimentary attempts to explain or understand the behaviour of their negative
role models. They occasionally identified that negative models were very busy or
stressed, but were less sympathetic to these demands than Group 1.
DiscussionThe basic characteristics of positive role models have been
described by a number of studies: clinical excellence, good teaching,
compassion, focus on the patient-doctor relationship, and certain elements of
personality. However it is an oversimplification to consider these traits as the
sole criterion for professional excellence. It is rare for students and junior
staff to have global role models who represent the endpoint of all their
professional aspirations.18 Rather, role
modelling is an interactional, transactional process which occurs simultaneously
with multiple models and changes over
time.7,10,19 How young doctors interact with
their role models is better served by examining relationships than lists of
adjectives.
The interviews revealed three broad relationships that house
officers consider important for identifying their role models: the relationship
between house officer and the model; the model’s relationship with
patients; and the model’s relationship with medicine. Clinical skills are
excluded from this discussion because they are generally a poor demarcation
between positive and negative role models.
Relationship between house officer and role
model—Senior clinicians who were supportive towards junior staff
were most often elevated to role model status. Elements of supportiveness have
been described in other studies; senior clinicians who spend non-essential time
with house officers, make an effort to build relationships with them, and have a
positive attitude towards junior staff are most likely to be considered positive
role models.10,20
Being supportive transcends the boundaries of positive role
modelling, encompassing good teaching, and good supervision. In contrast,
negative role models had poor relationships with house officers from both
groups. Participants described senior clinicians who were terse when called for
clinical advice, unreasonable in their expectations, and unsupportive of junior
staff. Negative interactions with senior staff have been identified as one of
the most memorable, stressful, and influential experiences for junior
doctors.21–24 Although gross examples of
student abuse may be becoming less common, it seems that a cycle of poor
relationships between senior doctors and their junior staff still exists.
Relationship between patients and role
model—Consultants who made time to give thorough explanations or
provide reassurance to patients were singled out as role models. Participants
from Group 2, who have been more exposed to the principles of biopsychosocial
medicine, were particularly appreciative of this.
The importance of the patient-doctor relationship is widely
reported in literature on role model selection. Negative role models who display
poor patient-doctor relationships are an unfortunate constant for junior
staff.25
In our study, negative role models who communicated poorly
with patients were discussed by both groups. However, only participants of Group
2 described ‘fixing’ the communication of senior doctors after ward
rounds. Completing a second ward round to clarify the communication of
consultants is a significant investment of time for a house officer. It is
heartening to think that junior doctors are taking positive action to address
perceived deficiencies; however there are questions about the appropriateness
and efficacy of this practice. Junior staff may lack the experience, knowledge,
and insight, to undertake all the intricacies of communicating clinical issues.
Learners need to observe excellent consultants display the subtleties of the
patient-doctor relationship to fully develop their own skills. Understanding why
young doctors seem to be taking on additional responsibility to compensate for
the perceived inadequacies of their seniors should be carefully examined in a
dedicated study.
Relationship between role model and
medicine—Young doctors need reassurance that medicine is
challenging, manageable, and satisfying. These needs are probably greatest in
the midst of the high stress PGY1 year when house officers are vulnerable to
doubts about their clinical abilities and career choices.
Participants from both groups identified positive role
models who were enthusiastic about medicine. Participants from Group 2 also
admired senior clinicians who had maintained outside interests and demonstrated
a work/life balance. This probably represents a wider generational shift towards
career flexibility. Negative role models who had become cynical, disillusioned,
weary, or bored with medicine were also identified.
A poor relationship with medicine is thought to be an area
of considerable unconscious influence of role models. This may contribute to the
well documented decrease in idealism during student and early clinical
years.6
Specialty selection is an important issue for house officers
and is consciously and unconsciously influenced by role modelling. Volunteers
were conscious of the explicit, personal advice which they had received from
mentors or active role models. They also identified clinicians whose behaviour
and attitudes had made their specialty unappealing. Some also referred to the
influence of casual comments or remarks they had overheard during training.
This ‘badmouthing’ of specialties, by potential
role models, is exceptionally common in medical school and can seriously
undermine learners’ confidence in their career
choices.6,26 A yet more subtle influence occurs
when students and house officers choose runs based on which consultants are
‘nice to work with’. Biased run selection can limit exposure to an
entire field based on negative behavior by a single senior clinician.
The number and constancy of subtle messages about a given
specialty—especially the surgical specialties—could be expected to
have a significant influence on house officers. Analysis of these interviews
indicates that this continues to be the case for modern house officers.
Consciousness—There is significant
misalignment between the qualities learners profess to admire, and the
characteristics they ultimately develop. Junior doctors describe aspiring to
professional ideals of compassion, idealism, and humanism, yet research reliably
indicates that students and young doctors become progressively less
compassionate, idealistic, humanistic and empathetic during their
training.24,27
This change is clearly multifactorial but role models almost
certainly play a part. It is possible that if junior staff were conscious of
this paradox they would be better equipped to deal with the myriad negative
influences which shunt them away from their stated ideal. It makes sense that
students and house officers who can analyse the behaviour of role models are
most likely to benefit from their interactions.
Being conscious of role modelling allows medical learners to
selectively integrate multiple models, and facilitates reflection. This process
can reduce the impact of negative role models, and strengthens the influence of
positive models. In the absence of understanding and appreciation of role
modelling, young doctors passively absorb a multitude of mixed messages about
medicine, patients, communication, and professional
values.15,28
A spectrum of role model consciousness was revealed during
these interviews. All participants could recall encounters which they considered
to be role modelling. Some volunteers displayed deeper insight and went on to
discuss role modelling as an active process, occurring simultaneously with
multiple models. A few identified that most of their colleagues had been
influential in forming their professional style and identity.
For others, role modelling was a novel concept which they
had not really considered prior to these interviews. Awareness of multiple
models was more apparent in Group 2; this was reflected in their tendency to be
vague when identifying or describing single individuals as role models.
Personal reflection on role models and professional
socialization was generally limited. Some of the current house officers from
Group 2 referred to formal team debriefings after traumatic cases; they valued
these forays into a formal reflective process. A few participants described
mulling over the events of their day. Most indicated that these thoughts were an
effort to check that everything had been done, and elements of clinical care had
not been overlooked.
Volunteers generally indicated that surviving the house
surgery experience was a much higher priority than thinking about examples of
good practice. Time and subsequent general practice training seemed to have
increased the reflective abilities of participants from Group 1.
Self-reported discussions between house officers were also
heavily influenced by the time and role demands of house surgery. Conversations
were generally focused on sharing practical information, or tips about working
with a given consultant. Some discussions with peers also serve as an informal
debrief after difficult events.
Discussing negative role models is generally more emotive
than analytical; although recounting a story about what happened on the wards
does force learners to identify and articulate their experiences. Participants
from both groups consistently alluded to the time pressure and clinical demands
which superseded discussion of role models.
In place of constructive, reflective analysis, it seems that
past and present house officers rely on informal storytelling to peers and
friends as a way of coping with the stresses of their role. This should be an
area of consideration, and possible concern, in terms of the wellbeing of junior
doctors.
Inter-group analysis—Decades of
difference in age and experience between the two groups were evident but not
overwhelming. Participants from Group 1 were distinguished by their greater life
experience; they referred to overseas examples, personal research interests,
empathy with consultants, and were generally more opinionated. This group also
expressed a general view that the house surgery experience has changed and is
now less traumatic. There was little evidence that this was the case.
A significant area of distinction was the willingness of
Group 1 to explain, justify, or excuse, the behaviour of negative role models.
This was an unexpected outcome with a number of potential explanations. One
previous study has suggested that students become less critical of faculty as
they gain experience.29
Alternately, their progression through the medical hierarchy
may have provided insight into the pressures experienced by their role models.
This ‘insight’ may be compounded by an alarming normalization of
poor behaviour as house officers progress through medicine. Some participants
identified that their general practice training had emphasised reflective
skills; it is possible that their reflective development enhanced their empathy
with role models.
Maturity and medical experience probably also influenced the
recall of the general practitioners. These elements may explain why current
house officers in Group 2 made little comment about the context of negative role
modelling.
Volunteers from Group 2 seemed somewhat muted in comparison
to Group 1; their interviews were considerably shorter and they were
understandably more self absorbed by their own experiences. Participants who had
had other careers before medicine and those who had been involved in student
medico political activities were exceptions and displayed a wider perspective in
their interviews.
Group 2 participants were more likely to want to
‘fix’ inadequate communication by their supervisors and were more
focused on models with an effective work/life balance. Participants from Group 2
also indirectly displayed a greater awareness of the socialization process; they
stressed that they had multiple models who they emulated to create their own
personal style. It is difficult to know whether this indicates a genuine
awareness of role modelling, or simply an inability to be definitive about the
people and qualities that they admire.
ConclusionThis study adds to our understanding of role modelling for
house officers in the New Zealand health system. It demonstrates the importance
of providing multiple models who excel clinically and in the three relationship
domains that house officers use to identify role models. Awareness,
understanding, and reflection on role modelling was variable in both groups.
However, the majority of participants had a limited appreciation of the
influence of role models.
Methodological weaknesses stem from recall bias, potential
gender selection bias in Group 2, geographic bias, and the single specialty
represented in Group 1. However, qualitative analysis revealed consistent key
themes, and correlates well with other research in role modelling.
A recent paper from the New Zealand Medical Journal
calls for district health boards to take increased responsibility for providing
mentorship for resident doctors.30 A mentoring
program for house officers began recently at Dunedin Public Hospital. This
increasing awareness and support of mentoring is to be applauded. However, even
the most talented of mentors can not hope to single-handedly outweigh the
incidental influence of other clinicians.
Improving the learning environment for junior staff requires
attention to both mentoring and to role modelling. If students and junior staff
could have a greater understanding of socialisation, role modelling, and
mentoring then they would be more equipped to analyse, and benefit, from the
interactions they have with professional colleagues. Clearly this increased
awareness needs to be parallel in senior clinicians.
All members of clinical teams need to view themselves as
role models and appreciate the impact and influence they have on young doctors.
Excellence in teaching, role modelling, and mentoring must be rewarded alongside
research and clinical excellence as criteria for recruitment and promotion.
The values, skills, attitudes, and behaviours which role
models imbue in learners are some of the most important elements of clinical
training. Although this is increasingly recognised by medical councils and
educators, it is not yet common knowledge in wards where role modelling occurs.
Addressing this lack of awareness should be a primary
consideration in order to improve the teaching, socialisation, and professional
development of junior staff in New Zealand hospitals.
Competing interests: None.
Author information: Rosemary Wyber,
5th year Medical Student, Christchurch School
of Medicine and Health Sciences, University of Otago, Christchurch; Tony Egan,
Senior Teaching Fellow, Department of the Dean, Dunedin School of Medicine,
University of Otago, Dunedin
Acknowledgement: This research was
generously supported by summer studentship grants from the Medical Council of
New Zealand in 2004/2005 and 2005/2006.
Correspondence: Rosemary Wyber, c/o
Christchurch School of Medicine, PO Box 4345, Christchurch. Email: rosemary.wyber@gmail.com
References:
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