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The question for us as teachers is not whether but how we influence our students. It is a question about relationship: where are our students going and who are we for them on their journey?1
Introduction
Role models and mentors are frequently spoken of in the same breath. Both play important roles in helping new and “becoming” members to develop and navigate their journey into the profession. Indeed, it might be argued that the influence of role models and mentors extends from well before the time one enters professional studies, right through a practice lifetime. There are clearly articulated differences between the roles and processes of mentor and role model. However, they are related functions, and may grow from similar philosophical positions. Both processes are dynamic and reciprocal, involving interactions and adaptive changes occurring in the developing professional.
Certain assumptions inform our exploration of these two processes. First, we have chosen a constructivist approach to understand both role modeling and mentoring. Constructivism refers to the way in which individuals build their own understanding and knowledge of the world through direct experience and reflection on experience. Constructivism focuses on meaning-making, on “making sense” both individually and collectively of our world.2 Such meaning-making is essential to our development as professionals. The processes of learning through role modeling and mentoring are not passive; in both, the learner actively forms an understanding of his or her own developing identity.
Our goals for this chapter are to:
Explore the processes of role modeling and mentoring, to understand how they contribute to the formation of professional identity;
Describe, based on the literature, how current understandings have evolved and how they align with understandings of how learning occurs; and
Suggest and consider implications of the literature for educators, teachers, and learners, to enhance, support, and grow through these processes.
Two important shifts have occurred in the field of medical education, both of which highlight the importance of role modeling and mentoring. The first shift concerns what many would consider the core of our educational mission: creating the “professional” who, in addition to acquiring necessary skills and knowledge, will also adopt the values of the profession and enact them in an ethical, competent, and professional manner, based in mutually respectful interactions in the context of practice.
The ideas of professionalism and how it is best taught and learned have challenged educators – definitions of professionalism; whether it is an innate characteristic (a trait of the individual) or constructed in interaction with others; whether it can be taught or learned; and how it can be demonstrated and assessed have all been the subject of much scholarly consideration.3 One major approach has been to link professionalism to certain observable behaviors that can be taken as indicators of underlying beliefs and values. Over the last decade, leading scholars in medical education have begun to refocus the conversation at a deeper level.4,5 This focus emphasizes the development not of a set of behaviors but of a professional identity, “a way of being a physician,” which embodies the desired attributes, which in turn gives rise to professional behavior.
The second significant shift concerns our understandings of how learning occurs, which have been enriched and broadened by contributions from the disciplines of sociology and anthropology. Sfard6 has described two metaphors for learning that illustrate that change: acquisition and participation. The acquisition metaphor describes learning as the acquisition of knowledge, skills, and abilities. These are seen as attributes of the individual, which can then be applied to the problems of professional practice. In the participation metaphor, we recognize that learning occurs not only through individual acquisition; it is also developed through active participation in the practices of the community. The participation metaphor reminds us that learning is always “situated” and inseparably linked to the context in which it is learned.
Of these two important influences for change, the first has led to the writing of this book. The second shift has implications for understanding the influence of role models and mentors as an integral part of the context and culture of the learning environment. We turn now to explore how role models and mentors contribute to the formation of professional identity.
Understanding the influence of role modeling and mentoring on professional identity formation
Though curricula change, whether by evolution or revolution, the influence of role models remains a central contributor to the formation of physicians. Learners at all levels, and of diverse backgrounds, report that role models play an important part in their education, and educators continue to cite role modeling as the way in which much of clinical learning occurs.7–10 Similarly, mentors have played a consistently important role in the socialization of new professionals, guiding and advising their junior colleagues and providing a “scaffolding for the learning process.”11
Learning from role models and mentors can be understood through various theoretical and conceptual perspectives. In keeping with our constructivist view, these can be grouped into those theories that address how individuals learn and develop as they make meaning of their experience and those that emphasize the importance of social, cultural, and environmental influences on learning and development. Jarvis-Selinger et al.12 write of professional identity formation in medicine as an adaptive process occurring at two levels: the individual level of psychological development, which occurs largely within the person; and the collective level, whereby the individual learns through interaction in the social context about the roles he or she may play, and how he or she may participate in the work of the community of practice (in our case the profession of medicine).
Theories of identity formation are addressed in greater depth in Chapter 3 of this book. For our purposes, we have selected theories that can both illuminate the process and also suggest implications for us as teachers.
Individual theories of learning and development
Individuals learn and make meaning of their environment through the mental structures or schemata they develop. As people learn and develop, these schemata become increasingly complex and form the bases for problem-solving, decision-making, judgment, and critical-thinking abilities.13,14 Several important approaches to learning are informed by constructivism, including adult learning principles, reflection, and self-assessment. Development at the individual level has also been seen as a progression through a number of conceptually distinct stages.15,16 Generally, these stages are assumed to follow each other and may require completion of one stage before moving on to the next. Each stage differs from the others in that it reflects the individual’s ability to understand the world in a qualitatively different way.12 Examples of approaches to learning, which are informed by developmental theory, might include motivation of learners, self-directed learning, and moral and ethical decision-making.
Social learning theories
Sociocultural theories of learning extend our thinking beyond the individual (see Chapter 5). Learning and identity development is seen as social, involving the interaction of the individual with society, through participation and practice. Learning happens between people rather than solely within an individual. For our purposes in this chapter, we will focus on four theoretical approaches: social cognitive theory,17 communities of practice,18,19 figured worlds,20 and the hidden curriculum.21 For each, we have briefly described the theory and illustrated its relevance to medical education.
Social cognitive theory
Social cognitive theory (SCT), as described by Bandura,17 brings together individual learning and the influence of the environment. The process of learning includes all of the experience, beliefs, and values that the learner brings to new professional interactions and situations. SCT posits that the developing professional and his or her new environment have continuous, dynamic, reciprocal effects on each other. A second fundamental aspect of SCT is vicarious or observational learning, in which learning occurs powerfully, through observing the actions of others and the consequences of those actions. A third aspect of SCT is self-efficacy, i.e., learners’ perceptions of their capability to perform the roles and tasks they observe as important in the environment. Bandura17 describes vicarious learning as second only to personal experience in its influence on self-efficacy. Learners in medical education observe the actions of others in the learning environment (including more senior members of the profession, peers, and patients) and consider whether they might adopt those ways of acting for themselves. Attitudes and values are also learned vicariously, sometimes without the learner’s awareness. Finally, through observation, learners also form judgments about their own competence as they develop as physicians.
Communities of practice theory
First described by Lave and Wenger18 and further elaborated on by Wenger,19 communities of practice is a second helpful conceptual framework. In this framework, learners enter a community of practice, in this case the profession of medicine, at the periphery. Beginning as newcomers, they gradually move closer to the center in the community as they gain skills and knowledge, become more competent, assume more responsibility, and develop more fully as participating members. Importantly, learning and knowledge are seen as being held not only by the individual but also collectively within and distributed across the community. Role models do not only exert influence as individuals; they also influence learners collectively through their ongoing interactions with each other and their shared values and understandings. Learning is about engaging in and contributing to the practice of the community, in increasingly complex and responsible ways.
Wenger19 describes developing a sense of identity as one of the most important aspects of participation in the community. To Wenger, identity is fluid and continually negotiated and constructed in interaction with the community. Identity is developed through three key processes: imagination, participation, and alignment. Imagination involves learners imagining themselves as a member of the community; participation involves participating actively in the practices of the community, in this case the activities of the profession; and alignment involves uncovering and adopting the values of the community enacted by its members. In all of these processes, both role models and mentors figure significantly.
A second aspect of communities of practice theory can highlight the potential influence of role models and mentors further. Paradigmatic trajectories are visible paths that are provided by members of the community. In any one community, a variety of different career paths may be visible to learners. In the early stages of medical education, perhaps even prior to entering their professional education program, learners may distinguish different trajectories; for example, the trajectory of a surgical career will be different from that of a career in a medical specialty. These different paths shape, and are shaped, as the developing professional finds meaning within his or her community. Similarly, different trajectories can be seen within a specific discipline. Hill and Vaughn22 have described the different trajectories that are available within the discipline of surgery, how the experience of men and women may differ in the trajectories available to them, and how this may affect their career choices.
Hill and Vaughn22 studied medical students’ experiences of surgery and described four ways in which role models influenced both aspiration and understanding: seeing, hearing, doing, and imagining. Seeing and hearing role models enabled newcomers to see who succeeds and what is needed or valued to do so. Doing also enabled an understanding of the culture and how certain roles were enacted. Imagining built on all of this information to stimulate learners to think about identities within that culture and whether these were identities they could imagine themselves assuming.
As Jarvis-Selinger et al.12 note in writing about medical education, we can only know ourselves in relation to the groups with whom we interact and the roles we are given in those groups. Socialization into a community of practice can involve many models; indeed, as learners move from the classroom to the clinical setting, and as they assume increasing responsibility, peers and near-peers may provide important models for them as to how to navigate those transitions.12 Both through their own experience and through observing others in the community, learners gain an understanding of what a community is and its values and of important aspects of practice such as teamwork and interprofessional interactions.
Figured worlds theory
Figured worlds, as theorized by Holland,20 is a third and complementary conceptual framework. Through this lens, identity is seen as being constantly negotiated between the individual and society. Identity is fluid; it is a “process of becoming” that changes in response to our interactions as we journey through a social landscape. The individual and society meet and affect each other through interpretations and imaginings that mediate behavior. Meanings draw on history and culture as well as current experience, and they are negotiated through language. As the individual makes meanings and interpretations, the meanings can become internalized as a kind of “inner voice.” Identity formation is “the meaning we make of ourselves,” as we “author ourselves.”
As Dornan et al.23 describe figured worlds in medical education, they note that students may hear many different voices in their world (doctors, nurse, peers, for example); these voices speak about being a doctor in dynamically different, sometimes contradictory, ways. Learners can choose which voices and other aspects of their environment they can use to tell their own stories as they develop. Dornan shows us the rich availability of role models in the environment. In this process, learners have agency; although they may be placed in certain roles in the community, they have the power to creatively improvise and “author” their own identity. As we shall see later in this chapter, a fundamental role of the mentor can be thought of as supporting the learner in this process of self-authoring.
Hidden curriculum
Hidden curriculum, a fourth lens, illuminates another way of understanding how learning may be influenced by role models and mentors. Introduced to medical education in 1994 by Hafferty and Franks,21 the concept of the hidden curriculum provided a way of exploring the reasons for apparent disconnects between espoused values and goals of the formal curriculum and what might be called values-in-action, as seen through the practices of institutions and the individuals who were part of them. The hidden curriculum has been defined as “a set of influences that function at the level of organizational structure and culture” and included “understandings, customs, rituals, and taken-for-granted aspects of what goes on in the life-space we call medical education.”24 (p. 404) The authors suggested that the hidden curriculum of medical education could be uncovered by examining areas such as institutional “slang,” institutional policies, evaluation (assessment) practices, and resource allocation decisions of our institutions.
Scholars have examined the hidden curriculum across many contexts of medical education. More recently, Hafferty and Hafler (p. 17) have described it as “the cultural mores that are transmitted but not openly acknowledged through the formal and informal curriculum.”4 Their analysis focuses not only on the elements of the curriculum and the routines that are taken for granted: it also focuses clearly on role models as those who enact the hidden curriculum. As Bleakley et al.10 also noted, role models enact the values of the institution. In this way, participants both shape and are shaped by their interaction within the institution or setting of their practice. Not all aspects of socialization are explicit. Indeed, as many of the elements of the hidden curriculum are unspoken, socialization through implicit messages is powerful, and individuals can have internalized some particular values and approaches without ever being aware that they have done so. The hidden curriculum may also be transmitted through the student-teacher relationships that learners experience as they are developing.25
Summary
In this section, we have described several conceptual lenses through which to understand learning from role models and mentors and how this learning may influence professional identity formation. While they take different perspectives, there are important congruent messages that emerge: First, learning occurs powerfully from observing others, the roles they play, and the ways in which they enact those roles. Second, through active participation, learners come to understand the values and practices of the community they wish to join, and the meaning of their experience to them as they develop. Third, role models and mentors are important figures in the world which students enter. They influence learning both individually and collectively. They are part of the social landscape, with which students interact as they negotiate their developing identity. Both can help learners to examine how their behaviors align with the emerging identities they are constructing, both at their current level of training and as they work toward developing their identity as a physician.
We turn now to review selected literature related to role models and mentors and their influence on professional identity formation.
What does the literature on role modeling and mentoring tell us?
There is a plethora of literature to inform our thinking about both role models and mentors. We have selected an approach that highlights current thinking and particularly that informs our understanding of professional identity formation.
Role modeling
Role models and their influence on learners have been studied for several decades. The process of role modeling, however, is not fully understood, and there remain some differences of opinion as to how its effect is exerted. Jochemsen-van der Leeuw et al.26 conducted a systematic review including 17 articles in 2013. Positive role models were frequently described as excellent clinicians who were invested in the doctor-patient relationship. They inspired and taught trainees while carrying out other tasks, were patient, and had integrity. Negative role models were described as uncaring toward patients, unsupportive of trainees, cynical, and impatient. The authors suggested that these findings confirmed the implicit nature of role modeling and proposed that it would be helpful to orient students to the characteristics they should imitate.
In contrast, a systematic review by Passi et al.,9 while acknowledging the informal and unplanned aspects of role modeling, noted other studies that have suggested that the process of learning and teaching through role modeling must be more deliberate. Specifically, surgical residents27 perceived that effective learning from role models involved three components: observation, reflection, and reinforcement of desirable behaviors. A study by Weissmann et al.28 of distinguished teachers identified that those teachers consistently identified the importance of being aware of oneself as a model and mindful in using role modeling as a teaching strategy. The sociology literature describes both “silent” and “articulate” models. The silent model may fulfill only part of the teaching that occurs through role modeling.9 Passi et al.9 suggest that being able to reflect on one’s actions, and to clarify what was intended, is helpful in facilitating learners to consider various models deliberately. Benbassat29 suggests that learners should be encouraged to reflect critically on the positive and negative attributes of the role models they have observed, to examine how these experiences fit with their developing identity and their values and goals. Lastly, Cruess et al.30 described an active, experiential process through which learning from role models occurred.
The literature consistently reports the influence of role models on career choice.31–33 Further, the attributes desired in a role model remain consistent across many surveys and studies over time. Generally, these attributes of desirable models fall into three groups: personal attributes, clinical competence (which includes relationships with patients), and teaching attributes.
Negative role models are less well understood; however, their impact can profoundly affect learners in the development of their professional behaviors.9 Their influence appears most commonly to occur in the informal and hidden curriculum.34 Learners who observe negative behaviors of more senior doctors can experience feelings of powerlessness and of conflict between what they were taught in the classroom and what they see modeled in the clinical environment.9
Mentoring
The literature on mentoring, while plentiful, is less robust in terms of demonstrating its effect. The literature on mentors has been explored in depth in two recent systematic reviews. In 2006, Sambunjak et al.35 reviewed quantitative studies that focused on mentoring outcomes in academic medicine. While mentorship was reported to be perceived as an important influence on personal development, career guidance, career choice, and productivity, experimental studies were lacking. According to the available evidence, fewer than fifty percent of medical students, and in some fields fewer than twenty percent of faculty members, had a mentor. Women appeared to have more difficulty finding mentors than did men.
To gain a deeper understanding, the authors conducted a second systematic review of qualitative research on the meaning and characteristics of mentoring in academic medicine.36 Mentoring emerged as a complex relationship grounded in mutual interests between parties, both professional and personal. Consistent with social learning theory, the mentoring relationship was seen as “inextricably situated in a social context and shaped by institutional culture and climate.”36 (p. 77) The good mentor was sincere in his or her dealing with mentees, created a safe environment, listened actively to understand the needs of the mentees, helped the mentee to clarify feelings, motivated and fostered self-reflection, and was well established within the academic community. An engaged, active mentee was seen as important to the development of effective mentoring relationships, as was a facilitating environment at the institution. Barriers to effective mentoring included personal factors, relational problems, and structural and institutional barriers. There was inconclusive evidence on the importance of gender, race, and ethnic congruence between mentor and mentee, and the sensitivity of the mentor appeared more important than matching on any of these factors. Systems of multiple mentors were recommended as an appropriate response to the challenges of mentoring across difference. Both reviews called for more rigorous research to expand and deepen knowledge. In particular, the authors called for deeper understanding of relational and reciprocal outcomes of mentoring such as personal growth, interdependence, and connectivity.
Scholars of mentoring have recognized a disparity between the importance and utility of mentoring and a paucity of theory development for the construct.37 One reason for this disconnect is the multifaceted nature of the construct, the lack of consensus on “what counts” as mentoring, and how it is distinguished from related functions such as teaching, precepting, and apprenticeship. Many studies fail to clearly define mentoring and instead rely on common understanding. Often a list of attributes suffices for a definition. Darling38 somewhat poetically identified fourteen parameters of the mentor role, including model, envisioner, energizer, investor, supporter, career counselor, standard prodder, teacher, coach, feedback giver, challenger, eye opener, door opener, idea bouncer, and problem solver. Levinson39 names five functions inherent to the mentoring relationship: teaching, sponsoring, guidance, socialization into a profession, and provision of counsel and moral support that allows the mentor to aid the mentee in the realization of dreams. The literature reveals several dualities or tensions in descriptions and discussions of mentoring, among them the following: formal–informal, career–psychosocial, hierarchical–mutual, dyadic–networked, and maintaining status quo versus critical appraisal. Each of these has some relevance to how mentoring might affect professional identity formation. We will explore each very briefly.
Formal–informal
Informal mentoring relationships arise naturally and spontaneously on the basis of shared values, interpersonal comfort, and perceived utility to meet career needs.40 Such relationships are not structured or supported by the institution or other third party. In contrast, formal mentoring relationships are assigned by the institution, and generally involve regularly scheduled meetings and specific productivity goals. There is little evidence as to whether formal or informal mentoring differs in terms of outcomes40 or whether a supervisor can simultaneously be an effective mentor.
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