Imitation is more than the sincerest form of flattery; it may also explain how medical students select their future careers. When graduating medical students at Baylor College of Medicine described clinical faculty who had "significantly and positively influenced their clinical education,"1 many used epic terms like "folk heroes," "legends," and "Renaissance men [and women]." Many credited their decisions to enter particular specialties to these role models, a finding that has been demonstrated elsewhere.2- 4
Because residents interact with the same attending physicians over several years, one might expect residents to identify more role models from residency than from medical school. However, residents at McGill University reported having encountered more positive role models in medical school than in residency.5 We sought to examine how interns perceived their learning experiences, particularly the influence of role models.
In 1999, we conducted critical incident interviews6 with 10 general surgery residents at our institution, who were selected for diversity in level of training, clinical performance ratings, and academic performance. Each training year was represented.
During audiotaped interviews, residents described specific incidents that either helped or impeded their learning. All described at least 2 positive and 2 negative learning experiences. The transcribed interviews were independently read and coded by both investigators for factors related to resident learning. Intercoder agreement exceeded 95%. Consistent with grounded theory method, interviews continued until analysis of the most recent interview provided no additional data or themes.7
Representative excerpts from the interviews illustrate the central themes about learning during internship. Interns seemed to learn best when faculty, fellows, or senior residents structured and directed their learning: "I learn best by being told what's expected of me. . . . Usually if you teach me how to do something one time, it saves me from trying to learn it on my own . . . several times."
For one intern, directed instruction about Swan-Ganz catheters reduced insecurities about being "left alone" with critically ill patients. Every interviewee recalled incidents during internship when faculty support was critical and empowering. One resident described how a faculty member's stepwise instructions provided the confidence to treat a seriously injured patient: "That's about as scared as I've been in my life. I felt very unsure and very scared that anything I might do—this kid could die. It was a huge responsibility and I didn't feel ready for it, but he was just such a confident, good teacher."
Conversely, novice residents learned little when forced to act autonomously. Without skills or faculty support, interns relied on trial and error learning, which, according to one resident, "produced at least some sort of anxiety." One resident underscored this problem in discussing an overmedication error: "Luckily nothing happened. . . . I'll never make that mistake again, but maybe somebody could have pointed it out to me. . . ."
Lack of faculty support also isolated first-year residents. All residents described their intern experiences with overnight calls in terms such as "being left alone" and having "no backup."
In turn, isolation created anxiety about patient care. Severe anxiety almost paralyzed novice residents, who feared making mistakes with critically ill patients, and generated resentment toward faculty "for not being there."
Our interviewees described faculty members' failure as role models who teach by example. Residents at all training levels perceived that faculty had hindered their learning during internship by delegating too much responsibility and forcing too much autonomy too soon. For most, dependent relationships with faculty and senior residents enabled them as interns to overcome anxiety in decision making and contributed to positive learning experiences. Although our request to describe teachers who had "significantly and positively influenced their clinical education" may have prompted graduating medical students to identify role models,1 we were unable to elicit similar descriptions of role models in this study. Similarly, Wright5 found that surgery residents recalled 4 times the number of positive role models during medical school than during residency. The relative absence of role models deprives interns of learning from example.
As they take their first steps toward clinical independence, interns may be wondering where the role models are who provided the enthusiasm, passion, and support for the specialties they selected. Based on this study, we intend to encourage and reward faculty members who teach and lead by example.
Paukert JL, Hsieh G. From Medical Student to Intern: Where Are the Role Models?. JAMA. 2001;285(21):2781. doi:10.1001/jama.285.21.2781-JMS0606-3-1