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SMJ // Article
Original Article
Developing the Good Physician: The Influence of Role Models in the Development of Virtues and Flourishing in Medical Students
Abstract
Objectives: A virtues-based model of character development for training future physicians may lead to increased flourishing in medical students through the influence of exemplary role models. This study aimed to analyze the association between caring virtues and measures of flourishing and to identify facilitators of physician flourishing.Methods: The authors used data from a 2011 nationally representative sample of 605 US medical students in which caring virtues (mindfulness, empathic compassion, and generosity) were measured using scales at two time points during the students’ clinical years. Hypothesizing a mediated influence of role models in students’ generosity and flourishing, the authors explored the interrelationship between measures of mindfulness, empathic compassion, and generosity, using latent variables within a structural equation model. Built into the model were paths to determine mechanisms by which virtues and flourishing are facilitated and/or inhibited.
Results: Analyses supported the interrelationship between physician-specific measures of mindfulness, empathic compassion, and generosity. Findings were generally consistent with the hypothesized direction of relationships between these virtues of medical care and the effect of role models on student generosity and sense of calling. Experiences of positive character feedback from a supervisor did not directly predict the generous behavior of medical students as hypothesized, but there appeared to be an indirect effect on generosity through increased vocational satisfaction. When moral elevation was added to the structural model, data offered further support for mentors inspiring caring behavior. Findings from this study provide continued evidence in support of a virtues-based model of character education in medicine that theorizes the influence of role modeling on virtues development and flourishing, including evidence for moral elevation as a potential psychological mechanism.
Conclusions: Medical schools may consider adopting a virtues-based model of character education in which supervisors are selected based on their capacity to exemplify virtuous care in their professional life.
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References
1. Leffel GM, Oakes Mueller RA, Curlin FA, et al. Relevance of the rationalist-intuitionist debate for ethics and professionalism in medical education. Adv Health Sci Educ Theory Pract 2015;20:1371-1383.
2. Arthur J, Kristjánsson K, Thomas H, et al. Virtuous medical practice. https://www.jubileecentre.ac.uk/wp-content/uploads/2023/08/Virtuous_Medical_Practice.pdf. Published 2015. Accessed December 24, 2024.
3. Cruess SR, Cruess RL, Steinert Y. Role modelling—making the most of a powerful teaching strategy. BMJ 2008;336:718-721.
4. Passi V, Johnson S, Peile E, et al. Doctor role modelling in medical education: BEME Guide No. 27. Med Teach 2013;35:e1422-1436.
5. Passi V, Johnson N. The impact of positive doctor role modeling. Med Teach. 2016;38(11): 1139-1145. doi:10.3109/0142159X.2016.1170780.
6. Passi V, Johnson N. The hidden process of positive doctor role modelling. Med Teach 2016; 38:700-707. .
7. Yoon JD, Ham SA, Reddy ST, et al. Role models' influence on specialty choice for residency training: a national longitudinal study. J Grad Med Educ 2018;10:149-154.
8. Frei E, Stamm M, Buddeberg-Fischer B. Mentoring programs for medical students—a review of the PubMed literature 2000-2008. BMC Med Educ 2010;10:32.
9. Haidt J. Elevation and the positive psychology of morality. In: Keyes CLM, Haidt J, eds. Flourishing: Positive Psychology and the Life Well-Lived. Washington DC: American Psychological Association; 2003:275-289.
10. Haidt J. The positive emotion of elevation. Prevent Treat 2000;3:3c.
11. Pohling R, Diessner R. Moral elevation and moral beauty: a review of the empirical literature. Rev Gen Psychol 2016;20:412-425.
12. Franzen AB, Clifton T. Influence of role models and unstructured relationship on changes in medical student character, medical-specific empathy, and general empathy. Med Res Arch 2023;11:7.1.
13. Erickson TM, Abelson JL. Even the downhearted may be uplifted: moral elevation in the daily life of clinically depressed and anxious adults. J Soc Clin Psychol 2012;31:707-728.
14. Zagzebski L. Exemplarist Moral Theory. New York: Oxford University Press; 2017.
15. Zagzebski L. Moral exemplars in theory and practice. Theory Res Educ 2013;11:193-206.
16. Paton A, Kotzee B. The fundamental role of storytelling and practical wisdom in facilitating the ethics education of junior doctors. Health (London) 2021;25:417-433.
17. Dobie S. Viewpoint: reflections on a well-traveled path: self-awareness, mindful practice, and relationship-centered care as foundations for medical education. Acad Med 2007;82:422-427.
18. Program on Medicine and Religion. Project on the Good Physician. https://pmr.uchicago.edu/projects/project-on-the-good-physician/. Accessed November 20, 2023.
19. Leffel GM, Oakes Mueller RA, Ham SA, et al. Project on the Good Physician: a proposal for a moral intuitionist model of virtuous caring. Teach Learn Med 2017;29:75-84.
20. Leffel GM, Oakes Mueller RA, Ham SA, et al. Project on the Good Physician: further evidence for the validity of a moral intuitionist model of virtuous caring. Teach Learn Med 2018;30:303-316.
21. Farb NA, Anderson AK, Segal ZV. The mindful brain and emotion regulation in mood disorders. Can J Psychiatry 2012;57:70-77.
22. Baer RA, Smith GT, Lykins E, et al. Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment 2008;15:329-342.
23. Goetz JL, Keltner D, Simon-Thomas E. Compassion: an evolutionary analysis and empirical review. Psychol Bull 2010;136:351-374.
24. Spreng RN, McKinnon MC, Mar RA, et al. The Toronto Empathy Questionnaire: scale development and initial validation of a factor-analytic solution to multiple empathy measures. J Pers Assess 2009;91:62-71.
25. Hojat M, Mangione S, Nasca TJ, et al. The Jefferson Scale of Physician Empathy: development and preliminary psychometric data. Educ Psychol Meas 2001;61:349-365.
26. Smith C, Hill J. Toward the measurement of interpersonal generosity (IG): an IG scale conceptualized, tested, and validated. https://generosityresearch.nd.edu/assets/13798/ig_paper_smith_hill_rev.pdf. Published 2009. Accessed December 24, 2024.
27. Bendapudi NM, Berry LL, Frey KA, et al. Patients' perspectives on ideal physician behaviors. Mayo Clin Proc 2006;81:338-344.
28. Steger MF, Frazier P, Oishi S, et al. The Meaning in Life Questionnaire: assessing the presence of and search for meaning in life. J Couns Psychol 2006;53:80-93.
29. Diener E, Emmons RA, Larsen RJ, et al. The Satisfaction With Life Scale. J Pers Assess 1985; 49:71-75. .
30. Dik B, Eldridge B, Steger M, et al. Development and validation of the Calling and Vocation Questionnaire (CVQ) and Brief Calling Scale (BCS). J Career Assess 2012;20:242-263.
31. Dreher D, Holloway K, Schoenfelder E. The Vocational Identity Questionnaire: measuring the sense of calling. Res Soc Sci Study Religion 2007;18:99-120.
32. Vianello M, Galliani EM, Haidt J. Elevation at work: the effects of leaders’ moral excellence. J Positive Psychol 2010;5:390-411.
33. Huang SX, Ham SA, Varghese M, et al. Moral elevation, physician role models, and selected markers of professional identity formation and well-being: a secondary analysis from two national surveys. South Med J 2022;115:129-135.
34. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
35. West CP, Dyrbye LN, Sloan JA, et al. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med 2009;24:1318-1321.
36. Shepherd AM, Schnitker SS, Leffel GM, et al. Developing the good physician: spirituality affects the development of virtues and moral intuitions in medical students. J Positive Psychol 2018;13:143-154.
37. Dienstbier RA, Hillman D, Lehnhoff J, et al. An emotion-attribution approach to moral behavior: interfacing cognitive and avoidance theories of moral development. Psychol Rev 1975;82:299-315.
38. Grusec JE, Chaparro MP, Johnston M, et al. The development of moral behavior from a socialization perspective. In: Killen M, Smetana JG, eds., Handbook of Moral Development, 2nd ed. New York: Psychology Press; 2014:113-134.
39. Grusec JE, Kuczynski L, Rushton JP, et al. Modeling, direct instruction, and attributions: effects on altruism. Dev Psychol 1978;14:51-57.
40. Blasi A. Moral cognition and moral action: a theoretical perspective. Dev Rev 1983;3: 178-210.
41. Blasi A. Moral functioning: moral understanding and personality. In: Lapsley DK, Narvaez D, eds., Moral Development, Self, and Identity. Mahwah, NJ: Lawrence Erlbaum Associates; 2004:335-347.
42. Hardy SA, Carlo G. Moral identity: What is it, how does it develop, and is it linked to moral action? Child Dev Perspect 2011;5:212-218.
43. Zagzebski L. Exemplarist virtue theory. Metaphilosophy 2010;41:41-57.
44. Algoe SB, Haidt J. Witnessing excellence in action: the 'other-praising' emotions of elevation, gratitude, and admiration. J Posit Psychol 2009;4:105-127.
45. Haidt J. The Righteous Mind: Why Good People Are Divided by Politics and Religion. New York: Vintage; 2013.
46. Aquino K, McFerran B, Laven M. Moral identity and the experience of moral elevation in response to acts of uncommon goodness. J Pers Soc Psychol 2011;100:703-718.
47. Lai CK, Haidt J, Nosek BA. Moral elevation reduces prejudice against gay men. Cogn Emot 2014;28:781-794. .
48. Darnell C, Gulliford L, Kristjánsson K, et al. Phronesis and the knowledge-action gap in moral psychology and moral education: A new synthesis? Hum Dev 2019;62:101-129.
49. Kristjánsson K, Fowers B, Darnell C, et al. Phronesis (practical wisdom) as a type of contextual integrative thinking. Rev Gen Psychol 2021;25:239-257.
50. Lamb M, Brant J, Brooks E. How is virtue cultivated? J Character Educ 2021;17:81-108.
51. Lyon W. Bedside rounds as cultural jig: keeping trainee attention directed. J Grad Med Educ 2023;15:150-151.
52. Kim DT, Applewhite MK, Shelton W. Professional identity formation in medical education: some virtue-based insights. Teach Learn Med 2024;36:399-409.
53. Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA 2001;286:1897-1902.
54. DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Acad Med 2004;79:351-356.
55. Shapiro J, Morrison E, Boker J. Teaching empathy to first year medical students: evaluation of an elective literature and medicine course. Educ Health (Abingdon) 2004;17:73-84.
56. Jenkins TM, Kim J, Hu C, et al. Stressing the journey: using life stories to study medical student wellbeing. Adv Health Sci Educ Theory Pract 2018;23:767-782.
57. Hawking M, Kim J, Jih M, et al. "Can virtue be taught?": a content analysis of medical students' opinions of the professional and ethical challenges to their professional identity formation. BMC Med Educ 2020;20:380.
58. Hyde Park Institute. Scholars in Ethics and Medicine. https://hydeparkinstitute.org/sem/. Accessed August 6, 2022.
59. Lyon W. Virtue and medical ethics education. Philos Ethics Humanit Med 2021;16:2.
60. Arthur J, Harrison T. Transforming the theory and practice of character education: a case study of the Jubilee Centre for Character and Virtues. In: Lovat T, Toomey R, Clement N, et al, eds., Second International Research Handbook on Values Education and Student Wellbeing. New York: Springer; 2023:267-277.
61. Arthur J, Kristjánsson K, Thompson A, et al. The Jubilee Centre framework for virtue-based professional ethics. https://www.jubileecentre.ac.uk/wp-content/uploads/2023/08/Framework_Virtue_Based_Prof_Ethics.pdf. Published 2023. Accessed May 20, 2023.
62. Pavlic A. The Good Doctor Course (Medical College of Wisconsin). 2024. https://www.mcw.edu/education/medical-school/curriculum/mcwfusion-curriculum/learning-communities.
63. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009;302:1284-1293.
64. Schenström A, Rönnberg S, Bodlund O. Mindfulness-based cognitive attitude training for primary care staff: a pilot study. Complement Health Practice Rev 2006;11:144-152.
65. Klimecki OM, Leiberg S, Lamm C, et al. Functional neural plasticity and associated changes in positive affect after compassion training. Cereb Cortex 2013;23:1552-1561.
66. Blanch-Hartigan D, Andrzejewski SA, Hill KM. The effectiveness of training to improve person perception accuracy: a meta-analysis. Basic Appl Soc Psychol 2012;34:483-498.
67. Chunharas A, Hetrakul P, Boonyobol R, et al. Medical students themselves as surrogate patients increased satisfaction, confidence, and performance in practicing injection skill. Med Teach 2013;35:308-313.
68. Kaldjian LC, Yoon J, Ark TK, et al. Practical wisdom in medicine through the eyes of medical students and physicians. Med Educ 2023;57:1219-1229.
69. Kinghorn WA, McEvoy MD, Michel A, et al. Professionalism in modern medicine: does the emperor have any clothes? Acad Med 2007;82:40-45.
70. Duke University School of Medicine. The Project on the Good Surgeon. https://www.thegoodsurgeon.org/. Accessed December 26, 2024.
71. Siscoe W. Flourishing as a physician: Columbia’s character cooperatives. https://socialconcerns.nd.edu/virtues/newsletter-post/flourishing-as-a-physician-columbias-character-cooperatives/. Accessed December 26, 2024.
72. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69:861-871.
