STUDENT PERSPECTIVES ON THE ANTI-ROLE MODEL: WHAT THEY LEARN, HOW THEY LEARN, AND HOW THEY COPE

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1 STUDENT PERSPECTIVES ON THE ANTI-ROLE MODEL: WHAT THEY LEARN, HOW THEY LEARN, AND HOW THEY COPE Jennifer Quaintance, PhD and Louise Arnold, PhD University of Missouri-Kansas City

2 Background Role models influence medical students professional behavior 1-10 Students regularly witness unprofessional behavior 8,11-17 Students learn from both positive and negative models 1,4,7-9 Gaps in the literature

3 Research Questions What do medical students learn from negative role models? What processes and circumstances affect the influence of negative models? What coping strategies do students use when faced with negative role models?

4 Methods Setting 2 mid-western schools 6-year BA/MD program, clinical focus 4-year MD program, research focus Participants (n=24) 17 from 6-year program; 7 from 4-year program 13 preclinical; 11 clinical 14 women; 10 men

5 Methods Data Collection Semi-structured interviews minutes in duration Audio recorded and transcribed Data Analysis Open-coding using the constant comparison method 2 coders Iterative process involving independent coding and discussion

6 Results 4 macro-themes What students learned from negative role models Processes that affected learning from negative role models Circumstances that influence the impact of negative role models Strategies students used to cope with negative role models

7 What did students learn from negative role models? you ll hear about your classmates who just don t pull their weight on something, or don t show up to the hospital session, or didn t dress up when they re supposed to which is unfortunate that you tend to hear the bad more than the good but those are the things that tend to be [talked about], so you kind of know, you learn what you should do by knowing what you shouldn t do.

8 What did students learn from negative role models? Some of the residents, and I am starting to acquire this, have a tendency to just want to be so frustrated with the patients who are just coming in to get a warm meal or a place to stay or who will come in with whatever and get treatment, then go back out and get drunk and come back to the hospital. And it gets very very very frustrating. And so the residents have a tendency to want to vent. And of course, all of us will band up together because we re all in the healthcare team.there s a lot of frustration towards the patients. And we will verbalize that. And I think that there s pressure there for me, too, when I go in the patient s room the next morning, to not give them the time of day.

9 What did students learn from negative role models? Even if you can kind of reject the bad example I think being around negative examples has somewhat of a negative impact on you. If nothing else, even just getting morale down or [you] being mad at them for the way they treat people, or whatever, I think it will negatively affect you in some way.

10 What processes affected learning from negative role models? I don t want to be that doctor. I don t want to be the one who leaves the room, and the patient s sitting there confused and not knowing what s going on. If you see a positive example and you see a colleague or a physician who does it very well, then you ll be able to apply those same things. If you see someone who does it very poorly, you might not be able to learn as much because sure, you can see that technique doesn t work, but you don t necessarily know what technique does work.

11 What processes affected learning from negative role models? I remember the example of a resident who slammed the phone and kicked the trash can after this guy left the room everyone was just kind of silent because they were so surprised this happened and then there was some sort of discussion between all the people who were still in the room It makes you think about how you would conduct yourself in that situation and I think that helps to shape your behavior in the future. It shapes how you look at other people s behavior.

12 What processes affected learning from negative role models? You see the negative impact that the bad professionalism has on the patient...and you see the effect, the ripple effect that their actions have on the floor or the staff, the hospital, in general, then you see that one bad apple can truly mess everything up. Only if I fail to recognize that it is a bad example. If I don t recognize it as a bad example and actually do it myself later on, yeah, that had a pretty negative effect on me that night So yeah, it could really harm you if you don t know that it is a bad example

13 What circumstances influenced the impact of negative role models? I think that really gets down to what you came in with. It really does boil down to what level of integrity what you came in with and what sort of a person you were when you started this. Did you come in with the idea that being a jerk is all right, or did you come in with the idea that being a jerk is bad? Some people just don t have that they can t monitor themselves, and they can t, I think they know right from wrong, but they don t always think about it, and so I think if they some in that way sometimes they ll just go with it.

14 What circumstances influenced the impact of negative role models? That s a negative influence because then you think that s acceptable behavior, and then you start taking it on. I think anytime you re surrounded by negative behavior you can t help sometimes but take it on, and think it s okay. And it s the norm. Seeing other people s reactions who have maybe been in for longer than you have I think is really valuable because it gives you an idea of what s acceptable and what s not. You d think it would be obvious, but coming into this sort of strange field of medicine, it s not always obvious what s okay and what s not.

15 What circumstances influenced the impact of negative role models? I m just thinking on one of my recent rotations when my attending was very difficult to get positive feedback from and it seemed like the people that she responded to favorably on the team were those who would make jokes about patients or complain Since this attending was the person grading me, there was a real impetus to start acting like that, and I m sarcastic by nature, and it s something I have to suppress in the hospital. So it was just letting myself be my sarcastic self It wasn t outwardly spoken, but as medical students we re always trying to figure out how to get in good with the attending. And also it made it better in the OR because I got more teaching because she wouldn t ignore me and she would let me do things in surgery And then I got teaching and she would let me do stuff that intern level stuff, resident level stuff that I wouldn t have gotten to do necessarily otherwise.

16 What strategies did students use to cope with negative role models? I don t participate in [the unprofessional behavior]. Like if there s [unprofessional behavior] I ll go to a different room. If people are having a conversation around me that I don t find professional, I don t join in. I don t laugh at unprofessional jokes. I mean, I remember a couple of months ago I was in. a non-patient care area To another doctor a resident made a really inappropriate, really childish comment about a part of that patient s body, and I was just horrified by it, and I didn t laugh. It totally turned me off. I didn t want to work with that resident again, so I just tried to avoid him, and I didn t laugh at his joke, and I didn t give into that.

17 What strategies did students use to cope with negative role models? I think that knowing that you d be out of the situation soon and that you d be able to go back to being yourself and not be uncomfortable is important as well. It s just something that you have to do in order to survive the situation.i don t think that you can just be this solid rock. You look at it and you say, within a storm, what s going to survive, the bamboo that bends or the oak tree that stands straight? And the bamboo that bends is going to survive the storm and the oak tree that stands straight and is like the professional...is going to fall. So you have to, to some degree, do that bending.

18 What strategies did students use to cope with negative role models?.they talk about patients. They disregard what patients are telling them And I understand they know better. But it still kind of hurts the patients when they are not being listened to.i am not going to say they are totally unprofessional, that they are jerks or whatever. They are not. They are nice people., I think they do have a good foundation to what professionalism is. They just sometimes choose to turn it on and off. It is the do as I say, not as I do kinda principle. And you go ahead and go do it. And I guess it s kind of a hypocritical stance on things because I am sure whatever those people are doing, they wouldn t want a medical student to do or to emulate later on.

19 Discussion Students learned how to act professionally and unprofessionally Bandura s Reciprocal Determinism 18 Additional psychological and social processes that support social learning Practical Implications Faculty Development Support for Students Admissions Decisions

20 Limitations Generalizability Small sample Representativeness? Student Perspectives vs Actual Behavior

21 Conclusions Expanded on previous findings Identified specific processes and contextual elements Offered theoretical and practical implications across the continuum of medical education

22 THANK YOU FOR YOUR TIME AND ATTENTION

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