Teachers and Role Models: Characteristics of Effective Clinical Educators

“Have no teaching without the patient for a text, and the best teaching is often that taught by the patient himself.” William Osler (1903)

In 1993, Charles Barkley starred in a television advertisement for Nike that began with the words “I am not a role model.”¹ Barkley’s statements created controversy when the advertisement first aired, with public figures taking sides for or against his position. Since then, he has continued to make the case that parents, not sports figures, are ultimately responsible for modelling appropriate behavior.^2-3 Instructors and practitioners who supervise and train O&P residents may also have different perspectives about how responsibility for the professional development of students and residents should be allocated. What level of instruction and role modelling should O&P students and residents expect as part of their academic programs and residencies? How should educators in each of these contexts view their responsibilities?

O&P education often begins with shadowing or employment in entry-level technical or clinical positions, involves the completion of a graduate degree, and progresses through a structured residency. The instruction that occurs in an academic program is by necessity introductory and intended to prepare graduates for subsequent educational experiences. Whether completing a traditional or integrated residency, the resident trainee is expected to demonstrate increasing levels of skill and independence as a practitioner, culminating in successful completion of certification exams that demonstrates entry-level clinical competence.

Just as instructors in academic programs must strive toward clinical relevance, clinical supervisors must understand and embrace their responsibilities as educators.

Good Clinical Teachers

In 2008, Sutkin et al. published a literature review to answer the question “What makes a good clinical teacher in medicine?”⁶ The authors used this definition of clinical teaching: “the teaching/learning interaction…that normally occurs in the proximity of a patient and focuses on either the patient or a clinical phenomenon that concerns a patient or a class of patients.”⁶ The fact that many crucial aspects of this interaction cannot be replicated in a classroom setting, even when individuals with amputations and other impairments serve as models, highlights the necessity of education during residency. Prior to conducting the review, two of the researchers discussed their “most influential clinical teachers in medicine and their most effective teaching characteristics” and distinguished between cognitive and noncognitive traits.⁶ They “defined ‘noncognitive’ characteristics as those involving relationship skills, emotional states, and personality types, and ‘cognitive’ characteristics as those involving perception, memory, judgment, reasoning, and procedural skills.”⁶ The articles reviewed included many from the early 20th century (all but one of which were essays), and those published after 1973 “incorporated a wide array of methodologies, including surveys, interviews, and observations of faculty teaching.”⁶

The authors identified 480 descriptors in the 68 articles they reviewed, grouped them into 49 themes, and organized them further into “three main categories: physician, teacher, and human characteristics.”⁶ They reported that “33 (67 percent) of these themes and 301 (63 percent) of these descriptions were classified as noncognitive. Sixteen themes (33 percent) and 162 descriptions (34 percent) were described as cognitive.”⁶ The themes reported most often in the articles are listed in Table 1, along with the number of times each theme was identified in the articles. The authors expressed surprise “that there were no articles that mentioned such characteristics as aggressive, challenging, or demanding, because some of our favorite teachers exhibited these very characteristics.”⁶ They write that these terms “may have negative connotations for many, and authors, survey respondents, observers, etc., may have avoided them in seeking to characterize excellent teachers.”⁶

Good Role Models

After the release of Barkley’s Nike advertisement, Utah Jazz star Karl Malone expressed a different opinion about whether sports figures are role models. “Charles, you can deny being a role model all you want, but I don’t think it’s your decision to make. We don’t choose to be role models, we are chosen. Our only choice is whether to be a good role model or a bad one.”⁷

Jochemsen-van der Leeuw et al. performed a review to investigate role modelling in medical education, and explained that “although the differences among teaching, mentoring, and role modeling are often thought to be unclear due to overlap in daily practice, role modeling is the most implicit (i.e., also occurs when the clinical trainer’s focus is on other, not trainee-related, tasks).”⁸ The researchers defined a role model as “a person considered to demonstrate a standard of excellence to be imitated.”⁸ These researchers reviewed 17 articles reporting on original studies (ten quantitative and seven qualitative) to determine “the attributes characterizing clinical trainers as positive and negative role models.”⁸ They divided the positive attributes described in the articles “into three categories: patient care qualities, teaching qualities, and personal qualities.”⁸ Negative attributes were described in six of the studies, and the authors organized these using the same three categories.

“Seven studies (41 percent) reported attributes considered the least important in identifying a clinical trainer as a positive role model…. These include stimulating the trainee’s interest in research or assisting the trainee with finding and completing research, being the author of numerous publications, having a national or international reputation, or having received honors and awards. Whether the clinical trainer has management or presentation skills or attends also has little importance.”⁸ This should be encouraging for O&P clinical supervisors. Our profession is relatively small and narrow in scope, and opportunities to develop research skills and participate in research projects are much more limited than within medicine in general. Clinicians in small, isolated practices can develop the skills most important to effective clinical education.

In language reminiscent of Karl Malone’s opinions, these authors state that “a good clinical trainer should be aware of his or her role model status because heightened awareness of role modeling may lead the trainer to seek the opportunity to demonstrate behavior, to comment on what was done, and to explain what was done.”⁸ They also recommend that clinical trainers should make their “implicit behavior as a role model explicit to the trainee. This would help the trainee pay attention, retain what the trainer is modeling, become motivated, and use the modeled behavior as a guide for the trainee’s own actions.”⁸

Clinical Educators in Allied Health

A group of Australian dieticians published a review of 18 quantitative, 26 qualitative, and one mixed-method study “to identify and synthesize the skills and qualities of clinical educators [CEs] in allied health and their effect on student learning and patient care.”⁹ The professions of physical therapy, occupational therapy, and dietetics accounted for 31 of the 43 studies reviewed. The researchers reported that “clinical educators who were role models and proficient in their job were regarded as having desirable qualities.”⁹ The researchers identified “seven educator skills and qualities: (i) intrinsic and personal attributes of clinical educators; (ii) provision of skillful feedback; (iii) teaching skills; (iv) fostering collaborative learning; (v) understanding expectations; (vi) organization and planning; and (vii) clinical educators in their professional role. The concept of taking time to perform the clinical educator role underpinned all skills and qualities.”⁹ They found “few differences between the different professions. All allied groups appeared to value the skills and qualities identified in the thematic analysis.”⁹

According to the authors of the review, “across all the themes were the concept of time and the importance of CEs taking time to develop relationships and nurture learning. Also acknowledged within the included studies was the importance of time to prepare students for potentially stressful learning encounters, and time for reflection and discussion.”⁹ Feedback skills were identified as important in most of the studies reviewed. “Feedback was regarded as effective when it was constructive, regular, prompt, and not degrading. Feedback as a reciprocal relationship impressed students, in that CEs were open to improving themselves and valued the input of students in patient care.”⁹ “Providing appropriate challenges for students and fostering a culture of independence” were also identified as important skills.⁹ The authors found that “an important distinction in the findings of this review compared with those in medical education was the importance of treating students as future colleagues and supporting the development of professional identity. Allied health groups are smaller, and students may lack understanding of professional roles until they are on placement, so CEs play a valuable role in establishing this identity.”⁹

Impact on Learning and Patient Care

Most of the research on this topic involves surveys of or rankings of attributes by clinical trainees or trainers. There does not appear to be research reporting how the traits, skills, or attributes of trainers affect learning or patient care. Sutkin et al. reported that they “found more opinions than empirical data about good teaching, especially data relating student performance to distinguishable and measurable teaching behaviors.”⁶ Although a few of the studies they reviewed “demonstrated a positive correlation between some teaching behaviors and student performance, the effect was either small or inconsistent across various measures of student performance.”⁶ In their research on CEs in allied health professions, Gibson et al. found that “no objective learning outcomes, student success, or patient care parameters were measured in any of the studies.”⁹ Outcomes in the studies were based on “CE and student descriptions of characteristics and attributes; how behaviors were perceived to influence learning and make students feel engaged; and perceptions of the distinguishing features of excellent CEs.”⁹ In this way, O&P education matches clinical practice—much of what we do in both arenas is based on experience and intuition.

He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all. — Osler⁵

Closing Thoughts

It could be argued that residency education does far more than school to prepare trainees for independent practice. There is no substitute for frequent encounters with patients, something that only a clinical position in the real world can provide. To the extent that clinical supervisors embrace their roles as educators and role models and develop skills viewed as essential to those roles, they will better prepare residents for independent practice. Just as instructors are responsible to teach students more than facts and theory, the clinical educator’s role extends beyond clinical and technical tasks to include modelling how a professional should practice. We are all teachers and role models, whether we accept those responsibilities or not.

To focus educational efforts on clinical content and tasks is understandable, but these reviews show that the noncognitive skills of clinical educators may have an even greater impact on trainee development. According to Sutkin et al., “noncognitive behaviors are both measurable and alterable. Most of them, such as personality typology, emotional states, and relationship predispositions, have underlying neural networks, which are entering our sphere of understanding….”⁶ Jochemsen-van der Leeuw et al. state that “the identified attributes of positive role models can be acquired through training, particularly by making clinical trainers aware of their role model

function. Such continuous awareness of the role model task is…an important attribute of an excellent role model.”⁸ Gibson et al. state: “The personal attributes of CEs were perceived as paramount for providing a safe learning environment…. Professional skills, including self-awareness, are essential for professional practice in healthcare, including clinical education…. There may be a need for those involved in clinical education to examine their personal qualities and identify areas for development….”⁹ The full text of these three reviews is available online at no charge. Reading through the lists of characteristics, attributes, and qualities can provide an opportunity to reflect on our own skills as educators.

Clinical teaching provides many opportunities to impart knowledge, develop skills, and form the professional identities of our trainees. It is also a way to impact the care of many more patients through the care provided by those we’ve trained. Giving careful thought to our roles as models of effective and compassionate clinicians will help us make the most of training opportunities. To quote Sutkin a final time: “The transformation of our students requires the engagement of innovative and outstanding clinician–teachers who not only supervise students in their development of technical skills and applied knowledge but also serve as role models of the values and attributes of the profession and of the life of a professional.”⁶

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an associate professor at Northwestern University Prosthetics-Orthotics Center. He has over 30 years of experience in patient care and education.

References

1. https://www.youtube.com/watch?v=R8vh2MwXZ6o
2. Jeff Eisenberg, Yahoo Sports. 2019. Iconic Sports Commercials: Charles Barkley’s ‘I am not a role model.” https://sports.yahoo.com/iconic-sports-commercials-charles-barkleys-i-am-not-a-role-model-055726035.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAABkQJy7YTgybiyXZZ4wn6U39L_myUSLw34C9RC36jEZ04CQVgSHbbQQWmD2XuIcLLdne_fvHUjCtjVUktPZjreq1Jy6gL2NDk2N4M4T04hRUkSVxoDlkVQevvIgGy7jJ4WdrbpbA9OkSVT0IR4XiRfdWnn0_Z1aDClqm8eVZwJ_C
3. https://www.youtube.com/watch?v=IhSqVGYrvhY&t=38s
4. https://profiles.nlm.nih.gov/spotlight/gf/catalog/nlm:nlmuid-101743406X29-img
5. https://www.acponline.org/about-acp/about-internal-medicine/sir-william-osler-and-internal-medicine
6. Sutkin, G., E. Wagner, I. Harris, and R. Schiffer. 2008. “What makes a good clinical teacher in medicine? A review of the literature.” Academic Medicine 83(5): 452-66.
7. https://vault.si.com/vault/1993/06/14/one-role-model-to-another-whether-he-likes-it-or-not-charles-barkley-sets-an-example-that-many-will-follow
8. Jochemsen-van der Leeuw, HGA Ria, F. van Dijk, F. van Etten-Jamaludin, and M. Wieringa-de Waard. 2013. “The attributes of the clinical trainer as a role model: a systematic review.” Academic Medicine 88(1): 26-34.
9. Gibson, S. J., J. Porter, A. Anderson, A. Bryce, J. Dart, Nicole Kellow, et al. 2019. “Clinical educators’ skills and qualities in allied health: a systematic review.” Medical