Learning by example

It is not only what we teach that matters ± how we teach and the atmosphere we create when teaching can have a profound effect on our students and juniors. In a recent issue of the New England Journal of Medicine, Scott Wright and his colleagues at Johns Hopkins University School of Medicine in Baltimore, US, raised some interesting thoughts about medical teachers and the importance of their behaviour in shaping the perceptions of young doctors. They asked 188 members of the internal medicine house staff at four teaching hospitals to identify clinicians whom they considered to be excellent role models. Each member of the house staff identi®ed at least one clinician, although the average was three. One hundred and sixty-®ve clinicians (40% of the total teaching staff) were identi®ed. The remaining clinicians (those not identi®ed as excellent role models) acted as controls for a subsequent study. The study used a 55-item questionnaire to collect data on a range of teaching-related matters, including time spent with house staff beyond that already scheduled; teaching style and methods; attitudes towards teaching; activities aimed at building relationships with house staff, and career characteristics and achievements. Generalists were more likely than specialists to be identi®ed as excellent role models and, overall, those clinicians identi®ed as excellent role models were more likely to have received teaching awards. The attributes associated with excellence identi®ed in the study included: emphasizing the importance of the doctor±patient relationship and of the psychosocial perspective in clinical care, teaching for a greater proportion of time than colleagues (including time beyond scheduled teaching assignments), combining teaching with clinical activities such as ward rounds, and providing more feedback to learners. The excellent teachers identi®ed in the study also enjoyed teaching more than the control group. They were more likely to have been trained in teaching methods, and they had more positive images of themselves as role models for junior staff. They were also more likely to engage in building relationships with their juniors by, for example, arranging end-ofattachment dinners, sharing their professional and personal experiences and demonstrating an interest in the lives of their house staff. In an accompanying editorial, Kelley Skeff and Sunita Mutha discuss some of the implications of the study both for the development of teaching skills in the hospital setting and for academic institutions that demand greater ef®ciency in patient care and in teaching. They point to the central role that staff development can play in the development of teaching skills and emphasize its importance even for experienced teachers. This is especially so for those whose unwitting behaviour may not re ̄ect their belief in the cultural and philosophical values of the medical school. The higher percentage of generalists amongst the pre-eminent teacher cadre may re ̄ect the extent of national and private investment in their educational training, but does not mean that other specialists do not have the desire or the ability to teach well. Indeed, Skeff and Mutha comment that survey respondents were more likely to see clinicians working with patients than those who are predominantly involved in research or laboratory work, and therefore are more likely to model themselves on clinicians whose work most closely matches the current focus of house staff. The importance of teachers being able to broaden the learning horizons of their students beyond the familiar is described in the editorial as engendering a `need to learn'. Previous studies have demonstrated the importance of clinician role models on career choice and professional values and behaviour. Personal qualities, clinical skill and teaching skills (in contrast to research, speciality or title) have emerged as more important characteristics of clinician role models. Particular abilities include explaining dif®cult material and ensuring learning is both stimulating and exciting. In addition, the ability to promote interest in research, enthusiasm about his or her own work and interactions between the teacher and patients, house staff and other health care workers rank higher than technical skills, number of publications or general appearance, as traits considered important in role model clinicians by junior staff. Recently, Janet Grant wrote that medical education `is about learning to be a doctor by being a doctor; caring for patients under controlled conditions of safety and care'. Learning through caring means using clinical contact as the prime element of the educational process ± in this way we cannot avoid learning from example. Wright's paper suggests that we need to examine the impact of role models on our students and junior staff, and be prepared to recognize and respond to the wide variety of professional behaviour that exists in our hospitals and practices.