Role modelling is seen as an essential component of medical education. It has been nominated as our most powerful tool.
Central to the experience of learners in this complex and challenging terrain is the “modelling of” and “learning how to be” a caregiver and health professional.
But are we the role models our students need, to learn to become the compassionate, caring and competent doctors our profession needs and that we all deserve?
We are well practiced in teaching knowledge and skills, and our students are for the most part experts in learning, interpreting and utilising these facts in a simulated environment. However, it requires personal interaction and role modelling for them to learn to put this together in a competent and caring response to our patients’ needs. Students themselves identify role modelling in all clinical settings as a key component of positive learning.
Role modelling is at the heart of professional character formation. Excellence in professional practice is learned in and through experience, and critical reflection on its expression in the clinical encounter.
Beware the “Hidden Curriculum”
Our profession has been described as lofty, it espouses high ideals. It claims to be humanitarian, compassionate, ethical and even above reproach. If this is so, why do we even recognise and have a title for the “hidden curriculum” and see it as a danger in medical training? Critical observation of role models is a powerful way of learning. What happens when what the students observes and experiences negatively contrasts with the ideals they have brought into Medicine and have been taught in the classroom?
Many are drawn to Medicine by high, possibly unrealistic ideals. Pre-clinical teaching may compound these ideals, meaning students enter the clinical environment unprepared for the reality that is clinical Medicine. Although they may have been given a strong foundation in medical knowledge and skills, they may be unprepared for the hierarchical system they are entering, to deal with the reality of patient suffering, to deal with the inadequacies of patient care and the incongruence between what they have been taught and what they are witness to. They may be completely unprepared to cope with the highly emotionally charged environments they encounter and even less prepared to deal with their own emotional response. Unsupported, this may lead to a loss of idealism and belief in their future in Medicine. Indeed, Beyond Blue(1) and other studies have shown a rise in cynicism and burnout during this phase of medical training.
Yes, the Hidden Curriculum is a danger. It has the potential to destroy the youthful compassion of our young students, those who will be the future of Medicine. It is something we need to be aware of, to remedy and to deeply care about.
The Question Has to be Asked – What are We Role Modelling?
“A View from the Trenches”(2) written from a student perspective, explicitly outlines the deleterious effect of unprofessional behaviour on the development of professionalism amongst students. This paper emphasises the power of positive role modelling and how negative role modelling can arrest the students’ professional growth and worse, contribute to the increasing cynicism seen in students in the later years of their medical training.
The typical medical school Professionalism Curriculum places the patient at the centre of an ethical framework consisting of the virtues of altruism, respect, honour, integrity, excellence, and accountability. Indeed, many clinicians uphold these values and are wonderful examples to our students. However, we are also aware of times when unprofessional behaviour in different arenas is alive and well and therefore teaches opposing sets of values.
We are all able to identify those who become our role models, especially those who stand head and shoulders above the rest. We all have the choice to be positive role models, demonstrating compassionate and effective patient care, or we can be negative role models, possibly lacking insight into the damaging effect this can have on our students.
I remember my most memorable role models as being not only exceptional clinicians but exceptional people, men and women who in their professional behaviour personified all that is good in Medicine, men and women I would have liked to emulate. Not all of these people fulfilled all of the criteria we might see in the perfect physician, but they at least they fulfilled most and for the rest “did no harm”. As students, these were educators who appeared to care about us and were seriously concerned about our development as clinicians.
The Medical Workplace is a Tough Working Environment, but Do We Really Want our Students to Toughen up to Survive?
The medical workplace is a tough learning environment. As students, we were trained to be tough – a very strange way to train us to be compassionate. Our first encounter with “patients” was that first day in the anatomy lab meeting forty pickled cadavers. Having never encountered a dead body before, how were we to cope other than to tough it out with ribald, if inappropriate, humour.
Being a houseman was an ordeal by fire – impossibly long hours, sleep deprivation, inadequate supervision. I can remember “lapses” in professionalism purely due to fatigue and overload. I feel guilty about them, but looking back compassionately at my young inexperienced self, working under often extreme duress in situations I was ill prepared for, both in my knowledge base and certainly in my lack of emotional maturity, I can understand those lapses.
Perhaps until Medicine recognises that doctors are not superhuman and need themselves to be cared for, we are unrealistic in demanding immaculate professionalism from all clinical staff. Doctors are human after all.
If we are to change the face of Medicine, if we are to make compassion its foundation, we need to start by treating our future doctors with understanding, love and compassion from the first day they enter medical school. The medical workplace is a tough working environment but do we really need our students to toughen up to survive? If we do that, what are the consequences?
Can Compassion offer a solution?
What would medical training look like if we made Love and compassion its foundation? What if this started in medical school, where student well-being was given priority over high academic achievement? What if we asked the students themselves what environments best supported their learning AND their well-being? They are tender and beautiful buds of compassion, that through nurturing become the most beautiful of flowers, but deprived of nourishment shrivel and die.
In the end the whole culture of Medicine and clinical care needs to be reviewed. Our patients do not want hardened and distant clinicians, rather they want their needs to be met in an atmosphere of effective clinical care coupled with tender loving kindness. The motto on the RACGP heraldic crest says Cum Scienta Caritas – Science with Compassion.
Too often we forget the importance of compassion in healing. Compassion is learned through being treated with compassion, witnessing compassion and seeing the highest value attributed to compassion. To be true role models, our teaching of the science of medicine needs to be tempered with the art of true compassion, to deliver the whole of medical care.