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Role Modeling: A Precious Heritage in Medical Education / Učenje po modelu: dragoceno nasleđe u medicinskom obrazovanju

Role Modeling: A Precious Heritage in Medical Education / Učenje po modelu: dragoceno nasleđe u... ACTA FACULTATIS MEDICAE NAISSENSIS DOI: 10.1515/afmnai-2015-0003 UDC: 159.953:61 Role Modeling: A Precious Heritage in Medical Education Amir Mirhaghi1, Hossein Karimi Moonaghi2, Simin Sharafi3, Amir Emami Zeydi1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran Department of Medical Education, School of Medicine, and Evidence - Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran SUMMARY Role modeling is a powerful form of learning and an integral part of medical education. Although role modeling has a longstanding history, it has not received enough attention in medical education. The aim of this study was to present a comprehensive of the literature to describe dimensions of role modeling in medical education. of the literature was undertaken using the international databases with the following search terms or their combinations: "role modeling", "observational learning" and "medical education" up to September 2014. Relevant articles were retrieved. A total of 39 articles were included in this . The results showed that clinical excellence, humanistic personality and excellence in teaching composed three essential elements of role modeling. Basic outcomes of role modeling in medical education are humanism and professionalism. In conclusion, role modeling as an outstanding educational approach has been recommended for enhancing humanism and professionalism in medical education. Key words: role modeling, observational learning, medical education Corresponding author: Amir Emami Zeydi phone: +989355952357 e-mail: emamiza911@mums.ac.ir Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 INTRODUCTION A role model is an individual whose behavior is admired or imitated by others. This process is interpreted as role modeling (1). In educational pedagogy, role modeling is a unique teaching method for transferring the knowledge, skills, and values of the medical profession (2) as well as promoting educational achievement (3). The idea that humans can learn from the way that other people behave has historical roots in Plato and Aristotle. Aristotle said that "we learn through practice and the best practice is to follow an individual who is a characteristic model" (4). In ancient times, the best role models were chosen for students to be followed. The most characteristic of them are observed to be imitated. In fact, this naturalistic approach had been common for many centuries (5). In the mid-nineteenth century, this cognitive paradigm was challenged by the behaviorists like Pavlov, Thorndike and Skinner. Several animal experiments have indicated that learning happens through direct experience, not indirect one, and it is a product of the stimulusresponse process that is expressed as conditioning (6). However, it did not take long that Miller, Dollard and Bandura explained the observational learning (modeling) as a behavior that was learned from observation and expressed the originality of cognitive processes in learning psychology (7). A new beginning for looking at the concept of role modeling was started with the opinions of Dollard and Miller who considered intimated behavior as a kind of conditioning behavior which includes the same behavior, copying behavior and matched dependent behavior. They explained the role of the individuals in the learning habits and their interactions with the environment (8). However, Bandura criticized the neglect of cognitive processes. He defined learning as an internal cognitive process that may occur as immediate or late behavioral changes (9). He considered four distinct components including attention, retention, motor reproduction, and motivational processes in observational learning (10). All of these recognized the originality of cognitive processes in learning which provides theoretical support for the role modeling. While training students without the institutionalization of professional moral values is a major criticism to the medical education (11), the role modeling has been recognized as a distinguished educational method to convey attitudes, behaviors, values and professional ethics to the students (12-14). Role modeling actually forms the core characters of the learners and has a unique power to transmit the values of medical profession and provide outstanding behavioral patterns for future health care providers to be trained (15). In spite of weak planning for the education through the role modeling, students implicitly and traditionally reproduce communication behaviors of faculty and clinical staff (16, 17). Therefore, developing role modeling capabilities in medical education and confronting with the relevant challenges in this regard are essential. The aim of this study was to present a comprehensive of the literature in order to describe dimensions of role modeling in medical education. METHODS A systematic search of the relevant literature was performed within international databases including PubMed/Medline, Scopus, Educational Resources Information Centre (ERIC), ProQuest as well as Google Scholar search engine using the following search terms or their combinations: "role modeling", "role model", "observational learning" and "medical education" The search was limited to the English languages. Without time limit, all articles having the selected keywords in the title, abstract and text, including quantitative as well as approaches, up to September 2014 were included and evaluated. The eligibility of each study was assessed based on relevancy to the role modeling in medical education. Authors collaboratively discussed to reach consensus through selection process. Studies were excluded from final analysis if access to the full text articles were not available. Also, non-English language articles, as well as articles with weak methodology were excluded from this study. Reference lists of the included studies were hand-searched to ensure completeness of the search. RESULTS The search strategy generated 1.067 titles and abstracts. After initial screening and evaluation, 957 articles were excluded. Removing duplicates and Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 using secondary screening resulted in 32 articles to be included for the . Also, a manual search of article references added seven further papers. In total, 39 articles were eligible for final inclusion (Figure 1), of which 16 were quantitative, 11 were and remaining were articles. All articles included in this were published between 1992 and 2014 and originated from peer-ed journals. Figure 1: Literature search and retrieval flow diagram The results showed that the role modeling in medical education is contributed with clinical excellence, ethics and teaching skills. Related functions were humanism and professionalism. A role model is defined by clinical excellence (15, 18-24) and humanistic personality (15, 19, 20, 22, 24), as well as effective teaching skills (21, 26). Clinical excellence: clinical excellence and competency (15, 18-24) are essential elements of role modeling. Clinical competency is defined as well qualified clinical practice for the diagnosis and appropriate interventions for the patient and family as well as possessing required knowledge, skills, decision making ability, clinical reasoning and effective communication skills with patients and staff (15, 19, 22-24). Humanistic personality: It is an important character for a role model (15, 19, 20, 22, 24). Personal qualities for a role model include interpersonal skills, positive outlook, commitment to excellence and growth, integrity and leadership (20, 24, 25) and also characteristics like passion, integrity and good interpersonal communication, passion for the practice and teaching as well as consistent improvement (15,19, 22). The significance of human character is that, if a person has a non-cooperative and inhumane attitude, it can turn him into an inappropriate model (21). Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Effective teaching skills: Teaching skills include developing an understanding among learners, developing novel teaching methods and commitment to the empowerment of learning (21, 26), effective communication, providing feedback and reflective opportunities for student-centered learning (15, 19, 22, 23, 27). It has been reported that being a role model has strong relationship with significant teaching responsibilities, involving more than 25% of the time or 25 hours per week in teaching, holding the morning report as an attending physician, with the emphasis on the physician-patient's relationship (15,28), teaching psychosocial aspects of medicine and being senior resident (15). Some personality traits including non-participatory and inhumane attitude formed a hated character (21). Other barriers are being hasty, selfish and rigid, silent, unable to remember people and having broad and multiple responsibilities (20). A Canadian study reported that more than half of all medical students, according to professors, are indifferent about the anxiety of patients and their need to communicate that had negative effect on students (29). Studies also revealed that students who have immoral teachers, more repeatedly found themselves in immoral situations (30). Therefore, it can be said that the relationship between the role model and the patient plays an important role for students to select teachers as role models. A phenomenological study revealed that nurses who were known as the role model had five characteristics, including attention to the details, ability to establish communication and sincere attitude, being model and accepting others the way they are (31). Role modeling functions: humanism and professionalism have been introduced as role modeling functions. Role modeling can cause developing humanism and professionalism. The human-centered approach is the core of practice in medicine (32) and teachers believe that students recognize, learn and utilize their humanistic behaviors. Reflective discussions were reported to be very helpful for explaining their behaviors. Students imitated verbal and nonverbal behaviors such as the face to face look, respect for the patients and their preferences, personal relationships with patients regarding their cultural background, and considering the patient's emotional responses to diseases. This is due to the fact that clinical teachers are conscious of their role in transmitting humanistic behaviors, so role modeling is recognized as effective way to teach humanistic values to the students (33, 34). While physicians want to be known as humanistic persons, patients are more satisfied and reached better health outcomes (35). Studies regarding physician-patient relationship showed that the more role models share their experiences with the students, the more improvement will be achieved in students' skills (32). Besides, it has been reported that ignoring patients as humans could present teachers as inappropriate role models (21). Role modeling is known as one of the most effective ways to promote professionalism in the medicine that can shape students' professional character (25, 36). Kolhan said that the first necessary thing to do for students to become professional is a significant focus on medical doctors who attribute the best professional characteristics (37). Professionalism is a concept that has been discussed from different aspects, providing good clinical care, maintaining good medical practice and education along with good communication with patients and colleagues based on human dignity (38). Professionalism also includes altruism, accountability, excellence, responsibility, honor and respect (39) or a set of values, behaviors and relationships that are associated with the field of public trust in profession in which people are committed to discipline through integrity, passion, dedication, continuous improvement, teamwork and excellence (40). Role modeling greatly facilitate the transmission characteristics of the desired features. Table 1 outlines the main characteristics of a role model. Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Table 1. The main characteristics of a role model Main elements Clinical excellence Descriptions Having competence at the bedside Interpersonal skills Positive outlook Humanistic personality Commitment to excellence and growth Integration Details Expertise, skills, and knowledge in identifying appropriate interventions for patients and families Philanthropist and honest, supportive, considerate and respectful approach Enthusiastic, friendly, comfortable, and satisfied with job Work and commitment to accountability, high standards; multiple talents Being a model is a general feature Ability to inspire, emphasis on team building, strength Characteristics of leadership and pride, excellent communication skills, influencing others without judging attitude Understanding and cooperation Acceptance, interest in students Student-centered, interaction between teacher and Effective teaching skills Special teaching methods and philosophy student, encouraging self-awareness, sense of responsibility for students Commitment to the development of learners Conscious counselor, respect for learners` self-esteem Table 2 outlines the basic features of the research articles included in the . DISCUSSION Role modeling consists of basic elements, including clinical excellence, humanistic personality and effective teaching skills. These elements have been reported in numerous studies that originate from well-known higher education systems. Role modeling as a value-based education is unique (15, 18-24). However, it is worth to mention that culture plays a central role in role modeling education. It has been reported that similarities between the student and the teacher can facilitate role modeling process. Medical students from ethnic minorities are eager to follow teachers who are from their own ethnicity. In contrast, if students and teachers have multiple personality differences, greater effort is necessary to achieve the goals. Thus, differences between teacher and student should be accepted with open arms; also, the impact of differences should be minimized (26). It should be noted that there are several concepts closely related to the role modeling that must be distinguished. Mentoring is a progressive process involving reflection, reframing and problemsolving (41). It can be said that the mentor is a person with experience in the organization that supports and encourages younger students giving his/her advice. Mentor as a friend and job advisor Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 helps students in research and educational activities, and also is a reliable source of information for them. Mentor is a good character who helps the student to achieve personal growth and personal development and facilitates their transition (42, 43). A mentor can also be a role consultant; however, the consultant plays a very limited consulting relationship with a student compared to a mentor whose role is limited to counseling (44). In this regard, the preceptor teaches his/her skills to the novice nursing students in order to prepare them for performing outstanding care. Preceptor helps nurses daily to enter the profession of nursing and clinical care efficiently (45). The concept of role playing education belongs to the social learning models which is different from role modeling. Role playing includes four-stages preparation and explanation of the work that is done, student preparation for the activity and discussion to clarify the roles (46). Hence, it becomes clear that role playing is much more limited than role modeling which is a method for students to be familiar about the feelings and attitudes of an individual; for example, teachers can use role playing to teach the concept of pain. CONCLUSION Role modeling approach has theoretical and practical background in medical education. Unique functions of role modeling include professionalism and humanism in education, and its role in the educational process is outstanding. Despite the challenges that are expected for role modeling, the central benefit of the transferring professional ethical values ensures professional services to the community. Finally, role modeling is recommended as a superior approach to improve the quality of education provided in medical education. Table 2: Summary of the basic features of the research articles that were included in the Author (Year) Lublin (1992) Country Australia Method Main findings regarding role modeling Good personality, teaching ability, skillfulness and being knowledgeable are the most important characteristics of a role model Interacts skillfully with patients, providing supervision and demonstrating expertise at the bedside, self-criticism, assuming responsibility, recognizing limitations, humility, respect, and sensitivity for patients and trainees, and a wholesome sense of humor were the characteristics of role models. Clinical skills, personality, and teaching ability were rated the three most important factors in selecting a staff physician as a role model. Clinical reasoning was considered the most important characteristic of a role model as well as enthusiasm and love for their work. Personality, clinical skills, competence, and teaching ability were most important in the selection of a role model. Teachers displayed the humanistic characteristics of interest. Having greater assigned teaching responsibilities; spending more than 25 percent of one's time teaching; spending 25 or more hours per week teaching; conducting rounds when serving as an attending physician; stressing the importance of the doctor-patient relationship in one's teaching; teaching the psychosocial aspects of medicine and having served as a chief resident were considered as the most important characteristics of a role model. Reuler&Nardone (1994) Wright (1996) Ambrozyet al. (1997) Wright (1997) Beaudoinet al. (1998) Wright et al. (1998) Case-control Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Magee &Hojat (1998) Althouseet al. (1999) Hojat et al. (1999) Matthews (2000) Saudi Arabia Côté&Leclère (2000) Elzubeir&Rizk (2001) UAE Wright &Carrese (2002) Paiceet al. (2002) Wright &Carrese (2003) Kenny et al. (2003) McLean (2004) Yazigiet al. (2006) Weissmannet al. (2006) Jouertet al. (2006) UK South Africa Lebanon South Africa Characteristics of a role model includes conscientiousness, striving for achievement, competence, dutifulness, trust, assertiveness, and altruism. The role models' approaches to teaching, their attitudes towards teaching and learning, their emphasis on clinical competence in their teaching, their roles external to their specific responsibilities, and their general affect are prominent. To be attentive, to have deeper intellectual curiosity, to have higher aspiration levels, to have more vivid imaginations, to be more receptive to their emotions, to be interested in mental stimulation, and to think carefully before acting were the most important characteristic of a role model. Positive behavior towards patients, positive behavior towards junior colleagues, suboptimal skills of subject content presentation, and insufficient encouragement for trainees to actively participate in patient management were the most important characteristic of a role model. The ability to conduct interviews effectively and politely, ability to understand and involve the patient, and, in some cases, the ability to handle emotionally-charged situations were considered the most important characteristics of a role model. Personality and teaching and clinical skills were ranked as the top three factors for a role model. Personal qualities included interpersonal skills, a positive outlook, a commitment to excellence and growth, integrity and leadership. Teaching included establishing rapport with learners, developing specific teaching philosophies and methods, and being committed to the growth of learners. Being a strong clinician was regarded as necessary but not sufficient for being an exemplary physician role model. Enthusiasm, compassion, openness, integrity, and good relationships with patients as attributes they seek in their role models. Learners prefer role models similar to them. Necessity of professional character formation. Role models should match the student profile. Clinical skills in positive role models versus inadequate humanistic and collaborative attitudes in negative models. Clinical teachers did not typically address the human dimensions of care overtly. Their idea of a good role model is a clinically and academically competent doctor who cares about patients, has good interpersonal skills, and who can inspire students. Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Clinical competence encompasses knowledge and skills, communication with patients and staff, and sound clinical reasoning and decision making. Teaching skills are the tools required to transmit clinical competence. A student-centered approach in corporating effective communication, feedback, and opportunities for reflection is essential to effective role modeling. Personal qualities include attributes that promote healing, such as compassion, honesty, and integrity. Physicians involved in the education of medical students seem to teach medical ethics as role models. Physician, teacher, and human characteristics have been mentioned. The themes of attending to the little things, making connections, maintaining a light-hearted attitude, modeling, and affirming others are presented. `Feedback', `a professional attitude towards residents' and `creating a positive learning climate'. A need for a greater representation of minority teachers. To be a good teacher or supervisor focuses on students' learning or growth. Someone who conveys knowledge or shows how things are done. Someone who responds to students' content requests in a partially student-centered perspective. Students identified role modeling as the single most important aspect of professionalism. Patient care qualities, teaching qualities, and personal qualities. Demonstration of high standards of clinical competence, excellence in clinical teaching skills and humanistic personal qualities. Medical trainees also need reliable tools that will help them develop a familiar and lasting critical thinking process for decisions about novel professional and ethical dilemmas throughout their careers. Personal professional characteristics like being a role model and having an open and enthusiastic attitude. They all thought that having a specific knowledge base was essential for teaching as well as learner-centered environment. "Effort for humanistic and professional growth of students," "individual and managerial empowerment of instructor," "instructor and student's modeling," "motivation and effort of student," "strategies governing the education system," and "appropriate facilities and equipment,". An equal number of items addressing personal (Heart), teaching (Head), and clinical (Hands-on) qualities, thus demonstrating that competence in the "3Hs" is a condition for positive role modeling. Cruesset al. (2008) Lynoeet al. (2008) Sutkinet al. (2008) Perry (2009) Lombarts (2010) Rezai-Rashtiet al. (2010) Stenfors-Hayes et al. (2011) Byszewskiet al. (2012) Jochemsen-van der Leeuw (2013) Passi et al (2013) Sweden Netherlands Narrative Sweden Netherlands UK Freed & Franks (2013) Narrative Van Roermundet al. (2014) Netherlands MokhtariNouriet al. (2014) Iran Jochemsen-van der Leeuw (2014) Netherlands Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Benbassat (2014) Israel Balintet al. (2014) Hungary Experimental Martinez et al. (2014) The author suggests that the value of role modeling can be advanced not only by targeting role models and improving faculty performance but also by enhancing students' reflective assessment of their preceptors' behaviors, especially so that they can better discern those that are worth imitating. Negative role-models and female role-models induced higher levels of mentalization compared to positive and male role-models. Exposure to role-modeling predicts trainees' attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Acta Facultatis Medicae Naissensis de Gruyter

Role Modeling: A Precious Heritage in Medical Education / Učenje po modelu: dragoceno nasleđe u medicinskom obrazovanju

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ACTA FACULTATIS MEDICAE NAISSENSIS DOI: 10.1515/afmnai-2015-0003 UDC: 159.953:61 Role Modeling: A Precious Heritage in Medical Education Amir Mirhaghi1, Hossein Karimi Moonaghi2, Simin Sharafi3, Amir Emami Zeydi1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran Department of Medical Education, School of Medicine, and Evidence - Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran SUMMARY Role modeling is a powerful form of learning and an integral part of medical education. Although role modeling has a longstanding history, it has not received enough attention in medical education. The aim of this study was to present a comprehensive of the literature to describe dimensions of role modeling in medical education. of the literature was undertaken using the international databases with the following search terms or their combinations: "role modeling", "observational learning" and "medical education" up to September 2014. Relevant articles were retrieved. A total of 39 articles were included in this . The results showed that clinical excellence, humanistic personality and excellence in teaching composed three essential elements of role modeling. Basic outcomes of role modeling in medical education are humanism and professionalism. In conclusion, role modeling as an outstanding educational approach has been recommended for enhancing humanism and professionalism in medical education. Key words: role modeling, observational learning, medical education Corresponding author: Amir Emami Zeydi phone: +989355952357 e-mail: emamiza911@mums.ac.ir Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 INTRODUCTION A role model is an individual whose behavior is admired or imitated by others. This process is interpreted as role modeling (1). In educational pedagogy, role modeling is a unique teaching method for transferring the knowledge, skills, and values of the medical profession (2) as well as promoting educational achievement (3). The idea that humans can learn from the way that other people behave has historical roots in Plato and Aristotle. Aristotle said that "we learn through practice and the best practice is to follow an individual who is a characteristic model" (4). In ancient times, the best role models were chosen for students to be followed. The most characteristic of them are observed to be imitated. In fact, this naturalistic approach had been common for many centuries (5). In the mid-nineteenth century, this cognitive paradigm was challenged by the behaviorists like Pavlov, Thorndike and Skinner. Several animal experiments have indicated that learning happens through direct experience, not indirect one, and it is a product of the stimulusresponse process that is expressed as conditioning (6). However, it did not take long that Miller, Dollard and Bandura explained the observational learning (modeling) as a behavior that was learned from observation and expressed the originality of cognitive processes in learning psychology (7). A new beginning for looking at the concept of role modeling was started with the opinions of Dollard and Miller who considered intimated behavior as a kind of conditioning behavior which includes the same behavior, copying behavior and matched dependent behavior. They explained the role of the individuals in the learning habits and their interactions with the environment (8). However, Bandura criticized the neglect of cognitive processes. He defined learning as an internal cognitive process that may occur as immediate or late behavioral changes (9). He considered four distinct components including attention, retention, motor reproduction, and motivational processes in observational learning (10). All of these recognized the originality of cognitive processes in learning which provides theoretical support for the role modeling. While training students without the institutionalization of professional moral values is a major criticism to the medical education (11), the role modeling has been recognized as a distinguished educational method to convey attitudes, behaviors, values and professional ethics to the students (12-14). Role modeling actually forms the core characters of the learners and has a unique power to transmit the values of medical profession and provide outstanding behavioral patterns for future health care providers to be trained (15). In spite of weak planning for the education through the role modeling, students implicitly and traditionally reproduce communication behaviors of faculty and clinical staff (16, 17). Therefore, developing role modeling capabilities in medical education and confronting with the relevant challenges in this regard are essential. The aim of this study was to present a comprehensive of the literature in order to describe dimensions of role modeling in medical education. METHODS A systematic search of the relevant literature was performed within international databases including PubMed/Medline, Scopus, Educational Resources Information Centre (ERIC), ProQuest as well as Google Scholar search engine using the following search terms or their combinations: "role modeling", "role model", "observational learning" and "medical education" The search was limited to the English languages. Without time limit, all articles having the selected keywords in the title, abstract and text, including quantitative as well as approaches, up to September 2014 were included and evaluated. The eligibility of each study was assessed based on relevancy to the role modeling in medical education. Authors collaboratively discussed to reach consensus through selection process. Studies were excluded from final analysis if access to the full text articles were not available. Also, non-English language articles, as well as articles with weak methodology were excluded from this study. Reference lists of the included studies were hand-searched to ensure completeness of the search. RESULTS The search strategy generated 1.067 titles and abstracts. After initial screening and evaluation, 957 articles were excluded. Removing duplicates and Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 using secondary screening resulted in 32 articles to be included for the . Also, a manual search of article references added seven further papers. In total, 39 articles were eligible for final inclusion (Figure 1), of which 16 were quantitative, 11 were and remaining were articles. All articles included in this were published between 1992 and 2014 and originated from peer-ed journals. Figure 1: Literature search and retrieval flow diagram The results showed that the role modeling in medical education is contributed with clinical excellence, ethics and teaching skills. Related functions were humanism and professionalism. A role model is defined by clinical excellence (15, 18-24) and humanistic personality (15, 19, 20, 22, 24), as well as effective teaching skills (21, 26). Clinical excellence: clinical excellence and competency (15, 18-24) are essential elements of role modeling. Clinical competency is defined as well qualified clinical practice for the diagnosis and appropriate interventions for the patient and family as well as possessing required knowledge, skills, decision making ability, clinical reasoning and effective communication skills with patients and staff (15, 19, 22-24). Humanistic personality: It is an important character for a role model (15, 19, 20, 22, 24). Personal qualities for a role model include interpersonal skills, positive outlook, commitment to excellence and growth, integrity and leadership (20, 24, 25) and also characteristics like passion, integrity and good interpersonal communication, passion for the practice and teaching as well as consistent improvement (15,19, 22). The significance of human character is that, if a person has a non-cooperative and inhumane attitude, it can turn him into an inappropriate model (21). Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Effective teaching skills: Teaching skills include developing an understanding among learners, developing novel teaching methods and commitment to the empowerment of learning (21, 26), effective communication, providing feedback and reflective opportunities for student-centered learning (15, 19, 22, 23, 27). It has been reported that being a role model has strong relationship with significant teaching responsibilities, involving more than 25% of the time or 25 hours per week in teaching, holding the morning report as an attending physician, with the emphasis on the physician-patient's relationship (15,28), teaching psychosocial aspects of medicine and being senior resident (15). Some personality traits including non-participatory and inhumane attitude formed a hated character (21). Other barriers are being hasty, selfish and rigid, silent, unable to remember people and having broad and multiple responsibilities (20). A Canadian study reported that more than half of all medical students, according to professors, are indifferent about the anxiety of patients and their need to communicate that had negative effect on students (29). Studies also revealed that students who have immoral teachers, more repeatedly found themselves in immoral situations (30). Therefore, it can be said that the relationship between the role model and the patient plays an important role for students to select teachers as role models. A phenomenological study revealed that nurses who were known as the role model had five characteristics, including attention to the details, ability to establish communication and sincere attitude, being model and accepting others the way they are (31). Role modeling functions: humanism and professionalism have been introduced as role modeling functions. Role modeling can cause developing humanism and professionalism. The human-centered approach is the core of practice in medicine (32) and teachers believe that students recognize, learn and utilize their humanistic behaviors. Reflective discussions were reported to be very helpful for explaining their behaviors. Students imitated verbal and nonverbal behaviors such as the face to face look, respect for the patients and their preferences, personal relationships with patients regarding their cultural background, and considering the patient's emotional responses to diseases. This is due to the fact that clinical teachers are conscious of their role in transmitting humanistic behaviors, so role modeling is recognized as effective way to teach humanistic values to the students (33, 34). While physicians want to be known as humanistic persons, patients are more satisfied and reached better health outcomes (35). Studies regarding physician-patient relationship showed that the more role models share their experiences with the students, the more improvement will be achieved in students' skills (32). Besides, it has been reported that ignoring patients as humans could present teachers as inappropriate role models (21). Role modeling is known as one of the most effective ways to promote professionalism in the medicine that can shape students' professional character (25, 36). Kolhan said that the first necessary thing to do for students to become professional is a significant focus on medical doctors who attribute the best professional characteristics (37). Professionalism is a concept that has been discussed from different aspects, providing good clinical care, maintaining good medical practice and education along with good communication with patients and colleagues based on human dignity (38). Professionalism also includes altruism, accountability, excellence, responsibility, honor and respect (39) or a set of values, behaviors and relationships that are associated with the field of public trust in profession in which people are committed to discipline through integrity, passion, dedication, continuous improvement, teamwork and excellence (40). Role modeling greatly facilitate the transmission characteristics of the desired features. Table 1 outlines the main characteristics of a role model. Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Table 1. The main characteristics of a role model Main elements Clinical excellence Descriptions Having competence at the bedside Interpersonal skills Positive outlook Humanistic personality Commitment to excellence and growth Integration Details Expertise, skills, and knowledge in identifying appropriate interventions for patients and families Philanthropist and honest, supportive, considerate and respectful approach Enthusiastic, friendly, comfortable, and satisfied with job Work and commitment to accountability, high standards; multiple talents Being a model is a general feature Ability to inspire, emphasis on team building, strength Characteristics of leadership and pride, excellent communication skills, influencing others without judging attitude Understanding and cooperation Acceptance, interest in students Student-centered, interaction between teacher and Effective teaching skills Special teaching methods and philosophy student, encouraging self-awareness, sense of responsibility for students Commitment to the development of learners Conscious counselor, respect for learners` self-esteem Table 2 outlines the basic features of the research articles included in the . DISCUSSION Role modeling consists of basic elements, including clinical excellence, humanistic personality and effective teaching skills. These elements have been reported in numerous studies that originate from well-known higher education systems. Role modeling as a value-based education is unique (15, 18-24). However, it is worth to mention that culture plays a central role in role modeling education. It has been reported that similarities between the student and the teacher can facilitate role modeling process. Medical students from ethnic minorities are eager to follow teachers who are from their own ethnicity. In contrast, if students and teachers have multiple personality differences, greater effort is necessary to achieve the goals. Thus, differences between teacher and student should be accepted with open arms; also, the impact of differences should be minimized (26). It should be noted that there are several concepts closely related to the role modeling that must be distinguished. Mentoring is a progressive process involving reflection, reframing and problemsolving (41). It can be said that the mentor is a person with experience in the organization that supports and encourages younger students giving his/her advice. Mentor as a friend and job advisor Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 helps students in research and educational activities, and also is a reliable source of information for them. Mentor is a good character who helps the student to achieve personal growth and personal development and facilitates their transition (42, 43). A mentor can also be a role consultant; however, the consultant plays a very limited consulting relationship with a student compared to a mentor whose role is limited to counseling (44). In this regard, the preceptor teaches his/her skills to the novice nursing students in order to prepare them for performing outstanding care. Preceptor helps nurses daily to enter the profession of nursing and clinical care efficiently (45). The concept of role playing education belongs to the social learning models which is different from role modeling. Role playing includes four-stages preparation and explanation of the work that is done, student preparation for the activity and discussion to clarify the roles (46). Hence, it becomes clear that role playing is much more limited than role modeling which is a method for students to be familiar about the feelings and attitudes of an individual; for example, teachers can use role playing to teach the concept of pain. CONCLUSION Role modeling approach has theoretical and practical background in medical education. Unique functions of role modeling include professionalism and humanism in education, and its role in the educational process is outstanding. Despite the challenges that are expected for role modeling, the central benefit of the transferring professional ethical values ensures professional services to the community. Finally, role modeling is recommended as a superior approach to improve the quality of education provided in medical education. Table 2: Summary of the basic features of the research articles that were included in the Author (Year) Lublin (1992) Country Australia Method Main findings regarding role modeling Good personality, teaching ability, skillfulness and being knowledgeable are the most important characteristics of a role model Interacts skillfully with patients, providing supervision and demonstrating expertise at the bedside, self-criticism, assuming responsibility, recognizing limitations, humility, respect, and sensitivity for patients and trainees, and a wholesome sense of humor were the characteristics of role models. Clinical skills, personality, and teaching ability were rated the three most important factors in selecting a staff physician as a role model. Clinical reasoning was considered the most important characteristic of a role model as well as enthusiasm and love for their work. Personality, clinical skills, competence, and teaching ability were most important in the selection of a role model. Teachers displayed the humanistic characteristics of interest. Having greater assigned teaching responsibilities; spending more than 25 percent of one's time teaching; spending 25 or more hours per week teaching; conducting rounds when serving as an attending physician; stressing the importance of the doctor-patient relationship in one's teaching; teaching the psychosocial aspects of medicine and having served as a chief resident were considered as the most important characteristics of a role model. Reuler&Nardone (1994) Wright (1996) Ambrozyet al. (1997) Wright (1997) Beaudoinet al. (1998) Wright et al. (1998) Case-control Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Magee &Hojat (1998) Althouseet al. (1999) Hojat et al. (1999) Matthews (2000) Saudi Arabia Côté&Leclère (2000) Elzubeir&Rizk (2001) UAE Wright &Carrese (2002) Paiceet al. (2002) Wright &Carrese (2003) Kenny et al. (2003) McLean (2004) Yazigiet al. (2006) Weissmannet al. (2006) Jouertet al. (2006) UK South Africa Lebanon South Africa Characteristics of a role model includes conscientiousness, striving for achievement, competence, dutifulness, trust, assertiveness, and altruism. The role models' approaches to teaching, their attitudes towards teaching and learning, their emphasis on clinical competence in their teaching, their roles external to their specific responsibilities, and their general affect are prominent. To be attentive, to have deeper intellectual curiosity, to have higher aspiration levels, to have more vivid imaginations, to be more receptive to their emotions, to be interested in mental stimulation, and to think carefully before acting were the most important characteristic of a role model. Positive behavior towards patients, positive behavior towards junior colleagues, suboptimal skills of subject content presentation, and insufficient encouragement for trainees to actively participate in patient management were the most important characteristic of a role model. The ability to conduct interviews effectively and politely, ability to understand and involve the patient, and, in some cases, the ability to handle emotionally-charged situations were considered the most important characteristics of a role model. Personality and teaching and clinical skills were ranked as the top three factors for a role model. Personal qualities included interpersonal skills, a positive outlook, a commitment to excellence and growth, integrity and leadership. Teaching included establishing rapport with learners, developing specific teaching philosophies and methods, and being committed to the growth of learners. Being a strong clinician was regarded as necessary but not sufficient for being an exemplary physician role model. Enthusiasm, compassion, openness, integrity, and good relationships with patients as attributes they seek in their role models. Learners prefer role models similar to them. Necessity of professional character formation. Role models should match the student profile. Clinical skills in positive role models versus inadequate humanistic and collaborative attitudes in negative models. Clinical teachers did not typically address the human dimensions of care overtly. Their idea of a good role model is a clinically and academically competent doctor who cares about patients, has good interpersonal skills, and who can inspire students. Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Clinical competence encompasses knowledge and skills, communication with patients and staff, and sound clinical reasoning and decision making. Teaching skills are the tools required to transmit clinical competence. A student-centered approach in corporating effective communication, feedback, and opportunities for reflection is essential to effective role modeling. Personal qualities include attributes that promote healing, such as compassion, honesty, and integrity. Physicians involved in the education of medical students seem to teach medical ethics as role models. Physician, teacher, and human characteristics have been mentioned. The themes of attending to the little things, making connections, maintaining a light-hearted attitude, modeling, and affirming others are presented. `Feedback', `a professional attitude towards residents' and `creating a positive learning climate'. A need for a greater representation of minority teachers. To be a good teacher or supervisor focuses on students' learning or growth. Someone who conveys knowledge or shows how things are done. Someone who responds to students' content requests in a partially student-centered perspective. Students identified role modeling as the single most important aspect of professionalism. Patient care qualities, teaching qualities, and personal qualities. Demonstration of high standards of clinical competence, excellence in clinical teaching skills and humanistic personal qualities. Medical trainees also need reliable tools that will help them develop a familiar and lasting critical thinking process for decisions about novel professional and ethical dilemmas throughout their careers. Personal professional characteristics like being a role model and having an open and enthusiastic attitude. They all thought that having a specific knowledge base was essential for teaching as well as learner-centered environment. "Effort for humanistic and professional growth of students," "individual and managerial empowerment of instructor," "instructor and student's modeling," "motivation and effort of student," "strategies governing the education system," and "appropriate facilities and equipment,". An equal number of items addressing personal (Heart), teaching (Head), and clinical (Hands-on) qualities, thus demonstrating that competence in the "3Hs" is a condition for positive role modeling. Cruesset al. (2008) Lynoeet al. (2008) Sutkinet al. (2008) Perry (2009) Lombarts (2010) Rezai-Rashtiet al. (2010) Stenfors-Hayes et al. (2011) Byszewskiet al. (2012) Jochemsen-van der Leeuw (2013) Passi et al (2013) Sweden Netherlands Narrative Sweden Netherlands UK Freed & Franks (2013) Narrative Van Roermundet al. (2014) Netherlands MokhtariNouriet al. (2014) Iran Jochemsen-van der Leeuw (2014) Netherlands Scientific Journal of the Faculty of Medicine in Nis 2015;32(1):31-42 Benbassat (2014) Israel Balintet al. (2014) Hungary Experimental Martinez et al. (2014) The author suggests that the value of role modeling can be advanced not only by targeting role models and improving faculty performance but also by enhancing students' reflective assessment of their preceptors' behaviors, especially so that they can better discern those that are worth imitating. Negative role-models and female role-models induced higher levels of mentalization compared to positive and male role-models. Exposure to role-modeling predicts trainees' attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.

Journal

Acta Facultatis Medicae Naissensis – de Gruyter

Published: Mar 1, 2015

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