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Opinion |
1 Department of Pediatric Radiology, Indiana University School of Medicine, 702 N. Barnhill Dr., Rm. 1053, Indianapolis, IN 46202.
Received December 7, 2001;
accepted after revision February 11, 2002.
Address correspondence to R. B. Gunderman.
Introduction
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Be virtuous and good yourselves, and the examples you set will impress themselves on your pupils' memories, and in due season will enter their hearts. [1]
Many important lessons in the education of radiologists are not well conveyed by lectures, books, and electronic media including goal setting, work ethic, patient interaction, consultation, and coping with uncertainty and failure. Whether we recognize it or not, each of us manifests patterns of behavior in these areas, and these habits exert a formative influence on learners such as medical students and residents. Learning is not merely the memorization of facts, but also the adoption—often subconscious—of attitudes and approaches to daily work. One of the most rewarding experiences for any radiology educator is to see learners incorporate elements of the educator's style into their own practice. Of course, if the habit in question is a regrettable one, this experience can also prove mortifying. In either case, however, a crucial component of learning is emulation. In reflecting back over their careers, most successful radiologists can think of an individual or two who exerted a particularly important formative influence on their own development [2].
Emulation can take one of two fundamentally different forms: constructive or destructive. Constructive emulation occurs when learners function more effectively and efficiently as a result of the attitudes and approaches they adopt. For example, a resident who acquires the habit of taking a few minutes each morning to outline key objectives for the workday is likely to be more productive than one who does not. By contrast, destructive emulation occurs when learners adopt habits that make them less effective. Consider a resident who, as a result of working with a cynical and disgruntled faculty member, falls into the habit of criticizing colleagues behind their backs, thereby undermining collegiality and respect in the department. One goal of radiology education should be to increase opportunities for constructive emulation and decrease the probability of its destructive counterpart. Education leaders need to consider not only what learners are being taught, but also by whom and with what effect. One way of enhancing educators' effectiveness as role models is to strengthen their understanding of this vital but frequently overlooked aspect of education [3].
Programs in the education of radiologists provide learners with both formal and informal curricula [4]. Elements of the formal curriculum include stated learning objectives, reading assignments, and the material represented on examinations. Elements of the informal curriculum include learners' observations of how radiologists speak and act. Models for conduct include not only direct superiors, such as members of the faculty, but also peers and subordinates. For example, medical students learn many of their most important lessons from residents, and junior residents learn many of their most important lessons from senior residents. In short, some of the most influential models for this learning are not identified members of the teaching faculty. Educators of radiologists should spend as much time attending to their informal curriculum as their formal curriculum to ensure that learners' experiences in both areas serve the program's overall goals. Efforts to improve an education program for radiologists should not ignore opportunities to improve the informal curriculum.
Individuals who serve as good role models perform three functions [5]. First, their behavior reinforces constructive behavior in others. A medical student's commitment to patient communication is enhanced by spending time with an outstanding communicator. Second, their conduct strengthens the learners' resistance to adopting destructive behaviors. A medical student sees a resident remain calm under difficult circumstances when others might have lashed out in anger, which reinforces his commitment to avoid abusive behavior. Third, learners develop new habits as a result of what they see. A resident develops a new approach to sharing bad news with patients after seeing a faculty member do it well. Members of the faculty do not cease being educators the moment they walk out the classroom door, and many nonfaculty members of a radiology department exert a greater formative influence on learners than they realize. By educating the educators, it is possible to enhance their performance as role models.
For learners to benefit from good role models, at least three conditions must be met [6]. First, learners must pay attention to their role models. Models who are perceived as irrelevant, perhaps because their spheres of concern and activity are too far removed from the learners, are unlikely to be effective. If residents never see faculty radiologists using medical physics in their daily practice, residents may pay little heed to physics teachers in the formal curriculum. Moreover, learners must view models as credible and worthy of emulation. A radiology educator whose clinical skills are not admired is unlikely to exert much positive influence. People learn little from role models they do not respect. Finally, learners must harbor uncertainty about the material they are attempting to understand. Learners who think they already know everything are unlikely to benefit substantially from working side by side with good role models. Taken together, these conditions make it important to provide learners opportunities to recognize what they do not know, to appreciate its importance, and to interact with individuals who do a good job of modeling that knowledge in daily practice.
A crucial component of learner effectiveness is clarity about goals. Every academic radiologist knows what it is like to have medical students on service who are uncertain about what they are trying to learn. Without substantial prodding, these students are likely to hover in the background, merely putting in their time and allowing a good learning opportunity to be wasted. These students are not necessarily unmotivated or unintelligent. They simply do not know what they want to gain from their experience in radiology. As a result, they fail to recognize and capitalize on opportunities to learn. By contrast, students with a clear sense of purpose, including knowledge and skills they want to develop, tend to learn more. The challenge to educators is to move students from the first group into the second by fostering a clearer sense of learning objectives. Educators can do learners a service by helping them assume an active role in setting learning objectives and by helping them structure their experience in a way that promotes achievement. A simple question can get the ball rolling: "What do you hope to learn during this rotation?"
Learners alter their conduct based on two sorts of consequences: vicarious and self-generated [7]. Vicarious consequences are learned through the observation of others. For example, a resident who sees colleagues who volunteer to discuss cases repeatedly humiliated by a particular faculty member is less likely to volunteer as a result. All punishment is not bad, however. For example, seeing a colleague reproved for failing to detect a lesion may improve performance as long as the observer regards the skill as both important and achievable. In some cases, failure to punish poor behavior can prove damaging to learners, just as tacit acceptance of lax work habits or dishonest conduct lowers their standards. Educators should bear in mind that the way they treat an individual learner frequently influences not only that particular learner, but others as well. Even if an interaction is not witnessed by others, the information can be rapidly disseminated through casual conversation. In some cases, stories may be passed down from generation to generation of learners and become part of the folklore of an educational program.
Self-generated consequences, those that are independent of the social environment, are even more important modifiers of conduct. Sometimes we modify our conduct based on self-examination, not because someone else suggested the modification or told us to change. For medical students and residents to become excellent physicians, they must learn to regulate their conduct not only according to how others reward or punish them, but also based on their own internal moral compass. Otherwise, the only thing preventing destructive conduct is the fear of detection, embarrassment, and punishment. In this situation, individuals may choose to engage in proscribed behaviors to the degree that they think they can get away with them. Seeing others behave badly can damage the character of learners by leading them to believe that such behavior is acceptable. The need to develop a moral compass renders it vital that learners regularly encounter good role models.
To help learners attend to and accurately perceive good habits of conduct, educational programs should validate good habits by incorporating them into the formal curriculum. The noninterpretive skills program of the Association of Program Directors in Radiology and the American College of Radiology represents an important step for residency programs in this regard [8]. Learners must appreciate that ethical conduct constitutes just as important a learning objective as lesion detection and differential diagnosis. Including these parameters in algorithms for evaluation of medical students and residents is vital. When done well, it validates the importance of conduct, provides appropriate reinforcement, and helps to foster the development of positive internal goals and standards. Practical exercises in areas such as obtaining informed consent and communicating bad news can be helpful because these experiences enable learners to rehearse and receive feedback about these frequently underrated aspects of their performance.
One way to enhance the role of emulation in radiology education is to develop a mentorship program. Derived from the name of a character in Homer's epics who served as Odysseus' friend and advisor, a mentor is less a teacher than an advisor, role model, and coach. A mentor can serve as an official representative of the informal curriculum of radiology education, giving learners someone they can call on for advice and counsel. The particular subspecialty of a radiology mentor is less important than the mentor's ability to serve as a model of a successful radiologist. During informal conversation, perhaps over a meal, learners feel more comfortable raising issues such as difficulties they are encountering in training, balancing personal and professional life, and the choice between different career paths. It can be helpful to learners if mentors share their experiences, including difficulties they have encountered and how they coped with them. In the best of all possible worlds, each radiology resident would have two mentors—one a more senior resident and the other a member of the faculty. Similarly, more radiology faculty members would play a prominent mentorship role for medical students.
One harmful habit that many learners develop is stress aversion. Afraid that they will fail, learners become unwilling to try. Even intelligent and capable people may become less and less successful over time because they fear that they will not succeed at certain tasks. Overconfidence is to be avoided, but some degree of self-confidence is a prerequisite for effective learning. Hence, one important function of a radiology educator is to model success in a way that learners can relate to and become energized by. Seeing others succeed enables learners to develop a sense of efficacy, especially if they identify with the persons involved. To foster a willingness to take risks, educators should challenge learners in ways that truly stretch their capabilities but with a substantial probability of success and recognition. If learners never see their teachers cope with failure because they always cover it up before anyone notices, then learners may fail to develop an adequate tolerance for risk taking. Ideally, learners would develop the habit of treating heightened tension as an opportunity to excel, not as a signal to quit.
People who succeed tend to be proficient at constructing their own scenarios of success [9]. They spend time imagining their goals and visualizing themselves achieving them. By contrast, less successful individuals tend not to have a clear sense of goals. Even if they know what their goals are, they cannot envision a path by which to achieve them. They tend to set low goals for themselves, expend less effort in pursing their goals, and give up when they encounter obstacles. When challenged, these individuals retract into their shells. If forced to respond, they frequently proceed in an erratic fashion, taking potshots in the dark. Individuals with high regard for their own efficacy tend to respond differently by analyzing the situation in light of their goals and developing strategies by which to succeed. They aim higher, work harder, and persist longer when faced with difficulties. By encouraging learners to discuss and debate their own visions of success, including the routes they would pursue to achieve them, radiology educators can increase the chances that learners will be able to build fulfilling careers for themselves.
People are limited not only by their capabilities, but also by unduly low estimations of what they are capable of. They avoid new challenges from which they might otherwise learn and grow. The most successful people in a field are not the ones who never make a mistake, but people who manage their risks in a way that enables them to recover when they stumble and, more importantly, who learn from their mistakes. Instead of sitting around ruefully mourning their deficiencies, they seek challenges that ultimately enrich their capabilities. An education program that insulates learners from failure does them no favors because learners fail to develop a capacity for risk taking and do not learn how to fail successfully. By working with role models who know how to fail successfully, learners can learn to stretch themselves to higher levels of excellence.
Throughout most of radiology education, the evaluation of learners is heavily biased in favor of information recall. We tend to evaluate medical students and residents by what they can remember. This bias stems in part from the fact that it is relatively easy to determine whether a learner can recall a certain fact. By contrast, a learner's approach to unfamiliar situations is not easy to observe, objectively describe, or measure. Nevertheless, performance evaluation systems should be expanded beyond what is easiest to measure to encompass what is most important to learn as well. If an educational program fails to evaluate learners according to parameters such as motivation, confidence, and self-regulation of learning, learners are unlikely to cultivate such traits and, as a result, achieve less than they are capable of. The best educators focus not merely on how much information learners have acquired or how competent they have become at particular skills, but also on how effectively they learn and perform in novel situations. How much learners know is ultimately less important than their commitments and capabilities as learners.
There are two great pitfalls that all individuals who may function as role models should strive to avoid. The first is the danger of allowing learners to complete their educational program in an ethical vacuum. Good radiologists bring more than facts and techniques to their professional lives. They bring sound characters and high standards of professional practice as well as strong commitments to the welfare of their patients, colleagues, and institutions. Learners need to see that their teachers care about these matters because while learners are developing technical expertise, they are also developing professional character. The second great pitfall is hypocrisy. After hearing members of the faculty constantly chafe about having to give lectures or the pressures to publish, how seriously will residents consider choosing academic careers? Far more damaging to the development of good character than ethical indifference is the juxtaposition of heavenly words and subterranean conduct.
In sum, what learners deem important to know, how they approach learning, and their ultimate success as learners are all powerfully influenced by the individuals whose attitudes and approaches they emulate. One of the most important services a radiology department can perform for medical students and residents is to put them in daily contact with radiologists worthy of emulation, individuals who not only are avid learners themselves, but whose character embodies responsibility, compassion, and integrity. By their very natures, such individuals tend to exhibit one of the most important traits of successful educators—namely, a sincere commitment to the comprehensive welfare of those they teach.
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