Role modeling is a widely recognized element of medical education and is associated with a number of beneficial outcomes for medical students, such as promoting the development of professional identity and a sense of belonging. However, for students who are underrepresented in medicine by race and ethnicity (URiM), identification with clinical role models may not be self-evident because they do not share a common racial background as a basis for social comparison. This study aimed to learn more about the role models URIM students have in medical school and the added value of representative role models.
In this qualitative study, we used a conceptual approach to explore URiM graduates’ experiences with role models in medical school. We conducted semi-structured interviews with 10 URiM alumni to learn about their perceptions of role models, who their own role models were during medical school, and why they consider these individuals to be role models. Sensitive concepts determined the list of themes, interview questions, and ultimately deductive codes for the first round of coding.
Participants were given time to think about what a role model is and who their own role models are. The presence of role models was not self-evident as they had never thought about it before, and participants appeared hesitant and awkward when discussing representative role models. Ultimately, all participants chose multiple people rather than just one person as role models. These role models serve a different function: role models from outside medical school, such as parents, who inspire them to work hard. There are fewer clinical role models who serve primarily as models of professional behavior. A lack of representation among members is not a lack of role models.
This research gives us three ways to rethink role models in medical education. First, it is culturally embedded: having a role model is not as self-evident as in the existing literature on role models, which is largely based on research conducted in the United States. Second, as a cognitive structure: participants engaged in selective imitation, in which they did not have a typical clinical role model, but rather viewed the role model as a mosaic of elements from different people. Third, role models have not only behavioral but also symbolic value, the latter being particularly important for URIM students as it relies more on social comparison.
The student body of Dutch medical schools is becoming increasingly ethnically diverse [1, 2], but students from underrepresented groups in medicine (URiM) receive lower clinical grades than most ethnic groups [1, 3, 4]. Additionally, URiM students are less likely to progress into medicine (the so-called “leaky medicine pipeline” [5, 6]) and they experience uncertainty and isolation [1, 3]. These patterns are not unique to the Netherlands: the literature reports that URIM students face similar problems in other parts of Europe [7, 8], Australia and the USA [9, 10, 11, 12, 13, 14].
The nursing education literature suggests several interventions to support URIM students, one of which is a “visible minority role model” [15]. For medical students in general, exposure to role models is associated with the development of their professional identity [16, 17], sense of academic belonging [18, 19], insight into the hidden curriculum [20], and choice of clinical pathways. for residency [21,22, 23,24]. Among URIM students in particular, a lack of role models is often cited as a problem or barrier to academic success [15, 23, 25, 26].
Given the challenges that URIM students face and the potential value of role models in overcoming (some of) these challenges, this study aimed to gain insight into the experiences of URIM students and their considerations regarding role models in medical school. In the process, we aim to learn more about the role models of URIM students and the added value of representative role models.
Role modeling is considered an important learning strategy in medical education [27, 28, 29]. Role models are one of the most powerful factors “influencing […] the professional identity of doctors” and, therefore, “the basis of socialization” [16]. They provide “a source of learning, motivation, self-determination and career guidance” [30] and facilitate the acquisition of tacit knowledge and “movement from the periphery to the center of the community” that students and residents wish to join [16] . If racially and ethnically underrepresented medical students are less likely to find role models in medical school, this may hinder their professional identity development.
Most studies of clinical role models have examined the qualities of good clinical educators, meaning that the more boxes a physician checks, the more likely he is to serve as a role model for medical students [31,32,33,34]. The result has been a largely descriptive body of knowledge about clinical educators as behavioral models of skills acquired through observation, leaving room for knowledge about how medical students identify their role models and why role models are important.
Medical education scholars widely recognize the importance of role models in the professional development of medical students. Gaining a deeper understanding of the processes underlying role models is complicated by a lack of consensus on definitions and inconsistent use of study designs [ 35 , 36 ], outcome variables, methods, and context [ 31 , 37 , 38 ]. However, it is generally accepted that the two main theoretical elements for understanding the process of role modeling are social learning and role identification [30]. The first, social learning, is based on Bandura’s theory that people learn through observation and modeling [36]. The second, role identification, refers to “an individual’s attraction to people with whom they perceive similarities” [30].
In the career development field, significant progress has been made in describing the process of role modeling. Donald Gibson distinguished role models from the closely related and often interchangeable terms “behavioral model” and “mentor,” assigning different developmental goals to behavioral models and mentors [30]. Behavioral models are oriented toward observation and learning, mentors are characterized by involvement and interaction, and role models inspire through identification and social comparison. In this article, we have chosen to use (and develop) Gibson’s definition of a role model: “a cognitive structure based on the characteristics of people occupying social roles that a person believes to be in some way similar to himself, and hopefully increasing the perceived similarity by modeling these attributes” [30]. This definition highlights the importance of social identity and perceived similarity, two potential barriers for URIM students in finding role models.
URiM students may be disadvantaged by definition: because they belong to a minority group, they have fewer “people like them” than minority students, so they may have fewer potential role models. As a result, “minority youth may often have role models who are not relevant to their career goals” [39]. Numerous studies suggest that demographic similarity (shared social identity, such as race) may be more important for URIM students than for most students. The added value of representative role models first becomes apparent when URIM students consider applying to medical school: social comparison with representative role models leads them to believe that “people in their environment” can succeed [40]. In general, minority students who have at least one representative role model demonstrate “significantly higher academic performance” than students who have no role models or only out-group role models [41]. While most students in science, technology, engineering, and mathematics are motivated by minority and majority role models, minority students are at risk of being demotivated by majority role models [42]. The lack of similarity between minority students and out-group role models means that they cannot “provide young people with specific information about their capabilities as members of a particular social group” [41].
The research question for this study was: Who were the role models for URiM graduates during medical school? We will divide this problem into the following subtasks:
We decided to conduct a qualitative study to facilitate the exploratory nature of our research goal, which was to learn more about who URiM graduates are and why these individuals serve as role models. Our concept guidance approach [43] first articulates concepts that increase sensitivity by making visible prior knowledge and conceptual frameworks that influence researchers’ perceptions [44]. Following Dorevaard [45], the concept of sensitization then determined a list of themes, questions for semi-structured interviews and finally as deductive codes in the first stage of coding. In contrast to Dorevaard’s strictly deductive analysis, we entered an iterative analysis phase, complementing the deductive codes with inductive data codes (see Figure 1. Framework for a concept-based study).
The study was conducted among URiM graduates at the University Medical Center Utrecht (UMC Utrecht) in the Netherlands. The Utrecht University Medical Center estimates that currently less than 20% of medical students are of non-Western immigrant origin.
We define URiM graduates as graduates from major ethnic groups that have historically been underrepresented in the Netherlands. Despite acknowledging their different racial backgrounds, “racial underrepresentation in medical schools” remains a common theme.
We interviewed alumni rather than students because alumni can provide a retrospective perspective that allows them to reflect on their experiences during medical school, and because they are no longer in training, they can speak freely. We also wanted to avoid placing unreasonably high demands on URIM students at our university in terms of participation in research about URIM students. Experience has taught us that conversations with URIM students can be very sensitive. Therefore, we prioritized secure and confidential one-on-one interviews where participants could speak freely over triangulating data through other methods such as focus groups.
The sample was evenly represented by male and female participants from historically underrepresented major ethnic groups in the Netherlands. At the time of the interview, all participants had graduated from medical school between 1 and 15 years ago and were currently either residents or working as medical specialists.
Using purposive snowball sampling, the first author contacted 15 URiM alumni who had not previously collaborated with UMC Utrecht by email, 10 of whom agreed to be interviewed. Finding graduates from an already small community willing to participate in this study was challenging. Five graduates said they did not want to be interviewed as minorities. The first author conducted individual interviews at the UMC Utrecht or at the graduates’ workplaces. A list of themes (see Figure 1: Concept-Driven Research Design) structured the interviews, leaving room for participants to develop new themes and ask questions. Interviews lasted on average about sixty minutes.
We asked participants about their role models at the beginning of the first interviews and observed that the presence and discussion of representative role models was not self-evident and was more sensitive than we expected. To build rapport (“an important component of an interview” involving “trust and respect for the interviewee and the information they are sharing”) [46], we added the topic of “self-description” at the beginning of the interview. This will allow for some conversation and create a relaxed atmosphere between the interviewer and the other person before we move on to more sensitive topics.
After ten interviews, we completed data collection. The exploratory nature of this study makes it difficult to determine the exact point of data saturation. However, due in part to the list of topics, recurring responses became clear to the interviewing authors early on. After discussing the first eight interviews with the third and fourth authors, it was decided to conduct two more interviews, but this did not yield any new ideas. We used audio recordings to transcribe the interviews verbatim—the recordings were not returned to the participants.
Participants were assigned code names (R1 to R10) to pseudonymize the data. Transcripts are analyzed in three rounds:
First, we organized the data by interview topic, which was easy because the sensitivity, interview topics, and interview questions were the same. This resulted in eight sections containing each participant’s comments on the topic.
We then coded the data using deductive codes. Data that did not fit the deductive codes were assigned to inductive codes and noted as identified themes in an iterative process [47] in which the first author discussed progress weekly with the third and fourth authors over several months. During these meetings, the authors discussed field notes and cases of ambiguous coding, and also considered issues of selecting inductive codes. As a result, three themes emerged: student life and relocation, bicultural identity, and lack of racial diversity in medical school.
Finally, we summarized the coded sections, added quotes, and organized them thematically. The result was a detailed review that allowed us to find patterns to answer our sub-questions: How do participants identify role models, who were their role models in medical school, and why were these people their role models? Participants did not provide feedback on the survey results.
We interviewed 10 URiM graduates from a medical school in the Netherlands to learn more about their role models during medical school. The results of our analysis are divided into three themes (role model definition, identified role models, and role model capabilities).
The three most common elements in the definition of a role model are: social comparison (the process of finding similarities between a person and their role models), admiration (respect for someone), and imitation (the desire to copy or acquire a certain behavior). or skills)). Below is a quote containing elements of admiration and imitation.
Second, we found that all participants described subjective and dynamic aspects of role modeling. These aspects describe that people do not have one fixed role model, but different people have different role models at different times. Below is a quote from one of the participants describing how role models change as a person develops.
Not a single graduate could immediately think of a role model. When analyzing responses to the question “Who are your role models?”, we found three reasons why they had difficulty naming role models. The first reason most of them give is that they have never thought about who their role models are.
The second reason participants felt was that the term “role model” did not match how others perceived them. Several alumni explained that the “role model” label is too broad and does not apply to anyone because no one is perfect.
“I think it’s very American, it’s more like, ‘This is what I want to be. I want to be Bill Gates, I want to be Steve Jobs. […] So, to be honest, I didn’t really have a role model who was as pompous” [R3].
“I remember that during my internship there were several people whom I wanted to be like, but this was not the case: they were role models” [R7].
The third reason is that participants described role modeling as a subconscious process rather than a conscious or conscious choice that they could easily reflect on.
“I think it’s something you deal with subconsciously. It’s not like, “This is my role model and this is what I want to be,” but I think subconsciously you are influenced by other successful people. Influence”. [R3] .
Participants were significantly more likely to discuss negative role models than to discuss positive role models and to share examples of doctors they would definitely not want to be.
After some initial hesitation, alumni named several people who could be role models in medical school. We divided them into seven categories, as shown in Figure 2. Role model of URiM graduates during medical school.
Most of the identified role models are people from the alumni’s personal lives. To distinguish these role models from medical school role models, we divided role models into two categories: role models inside the medical school (students, faculty, and health care professionals) and role models outside the medical school (public figures, acquaintances , family and health care workers). people in the industry). parents).
In all cases, graduate role models are attractive because they reflect the graduates’ own goals, aspirations, norms and values. For example, one medical student who placed a high value on making time for patients identified a doctor as his role model because he witnessed a doctor making time for his patients.
An analysis of graduates’ role models shows that they do not have a comprehensive role model. Instead, they combine elements of different people to create their own unique, fantasy-like character models. Some alumni only hint at this by naming a few people as role models, but some of them describe it explicitly, as shown in the quotes below.
“I think at the end of the day, your role models are like a mosaic of different people you meet” [R8].
“I think that in every course, in every internship, I met people who supported me, you are really good at what you do, you are a great doctor or you are Great people, otherwise I would really be like someone like you or you are so good coped with the physical that I couldn’t name one.” [R6].
“It’s not like you have a main role model with a name you’ll never forget, it’s more like you see a lot of doctors and establish some kind of general role model for yourself.” [R3]
Participants recognized the importance of similarities between themselves and their role models. Below is an example of a participant who agreed that a certain level of similarity is an important part of role modeling.
We found several examples of similarities that alumni found useful, such as similarities in gender, life experiences, norms and values, goals and aspirations, and personality.
“You don’t have to be physically similar to your role model, but you should have a similar personality” [R2].
“I think it’s important to be the same gender as your role models—women influence me more than men” [R10].
Graduates themselves do not consider common ethnicity as a form of similarity. When asked about the added benefits of sharing a common ethnic background, participants were reluctant and evasive. They emphasize that identity and social comparison have more important foundations than shared ethnicity.
“I think on a subconscious level it helps if you have someone with a similar background: ‘Like attracts like.’ If you have the same experience, you have more in common and you’re likely to be bigger. take someone’s word for it or be more enthusiastic. But I think it doesn’t matter, what matters is what you want to achieve in life” [C3].
Some participants described the added value of having a role model of the same ethnicity as them as “showing that it’s possible” or “giving confidence”:
“Things might be different if they were a non-Western country compared to Western countries, because it shows that it is possible.” [R10]
Post time: Nov-03-2023