Lessons Learned from Introducing the Characteristic of an Outstanding Medical Teacher: Its Implication in Role Modeling and Professionalism

Background Role models play a crucial role in determining the professional development of medical trainees. The purpose of this qualitative descriptive study is to gain in-depth understanding of the outstanding qualities of one successful role model in Iran. We described his character, personality and merits as a conceptual framework for role modeling in medical education. Methods Qualitative descriptive study. Inductive content analysis was performed, and data were collected by conducting interviews. The study was done in the school of medicine of Tehran University of Medical Sciences in Iran. Twenty ve medical students, medical graduates and faculty members participated in 25 interviews from April to December 2019. The participants were recruited via purposive sampling. Results Five themes, 13 subthemes, and 46 categories were extracted from the data, and the conceptual framework of role modeling in medical education was developed. Conclusion In this study, we designed a framework for role modeling in medical education Based on this framework, role models in medical education can function as mentors, medical leaders, clinical teachers, and professional instructors. Overall, role modeling is an important concept in medical education, and results of this article contributes to maintain the high quality of medical education. analysis, which provides valuable information about people’s experiences and perceptions of a phenomenon, was performed to collect the data. We used inductive content analysis, dened by Elo and Kyngas (2008), for data analysis. Themes and categories were extracted from the transcribed texts via inductive content analysis, without considering previous theoretical frameworks. All interviews were recorded on videotapes and then audio-transcribed. The transcripts were analyzed by two of the authors of this manuscript, and an agreement was achieved with the research group. This process briey included the following two stages: selection of the analysis unit and understanding the data in the preparation phase; and open coding, formation of categories, and in the organization phase.

modeling in medical education, ve main themes were extracted: characteristics of positive role models for physicians; personality type of positive role models; inspiring impact of positive role models on the students' future career choice; process of positive role modeling; and impact of negative role models [12]. In another study, the majority of medical students believed that observing their role models in uenced their learning more than formal teaching [13].
In Iran, physicians comprise a community of professionals, affecting the health of the public. Therefore, educating medical students for practice in the changing medical environment is of great importance in medical schools.
Since the beginning of a new era in Iranian medical education, professionalism has become a fundamental part of teaching and practicing medicine. In this approach, empirical research on professionalism has attracted major attention to role modeling, which can have a signi cant impact on the development of professional values and competencies of medical students. Some medical schools have also made attempts to nurture this important competency.
One of the famous role models in Iranian medicine is Prof. Alireza Yalda, who was born in 1930. He was accepted into Tehran University of Medical Sciences (TUMS) in 1951 and graduated the university in 1957. He became an infectious diseases specialist in 1960. After completing his internship, he was accepted as a faculty member of TUMS and gradually became a professor. His outstanding research on infectious diseases, great teaching abilities, and ethical behaviors towards patients, colleagues, medical staff, and students made him an unrivaled professor and a great example of excellent morals, humanity, and knowledge.
Prof. Yalda has been awarded over 20 scienti c awards for outstanding scholarly and research activities. He is the rst Iranian physician and professor to be awarded the "Sustain Faces". He is known as a pioneer, a role model, and a mentor, whose professional achievements are known to many.
The purpose of this qualitative descriptive study is to gain in-depth understanding of the outstanding qualities of successful role model that Prof. Yalda provided. We described his character, personality and merits as a role model in medical profession.
It is imperative that culture is considered by its impacts on choice of a medical role model. 14 This paper explores role modeling concept as a way of re ecting upon and sharing diverse cultural experiences.

Methods
In this qualitative descriptive study, inductive content analysis was performed. Data were collected by conducting interviews. This research consisted of three stages. First, we conducted a literature review on the conceptual frameworks of role modeling. Second, we conducted qualitative interviews with faculty members and medical students about the attitude and behaviors of Prof. Yalda as a role model. Finally, in the third stage, a conceptual model was designed based on the previous steps.

Literature review
In the rst stage, we conducted a literature review of the conceptual frameworks of role modeling. We searched the literature published in four databases (Web of Science, MEDLINE, Google Scholar, and Scopus) until May 2019, using the following keywords: "role modeling", "conceptual framework", "academic medicine", and "higher education". By searching the databases, a total of 35 articles were retrieved for review. Twelve studies were of limited relevance or completely irrelevant, 14 were majorly relevant, and nine included information on the conceptual frameworks of role modeling. Twenty-three articles were nally selected for the nal review.

Qualitative study Setting
The study setting was the School of Medicine of TUMS, which holds comprehensive medical programs, including residency (specialty and subspecialty), fellowship, and MD programs. It also holds different graduate programs in basic sciences (MSc, MPH, and PhD). Generally, faculty members are known as prominent clinicians and scholars not only for didactic training, but also for role-modeling, transfer of clinical skills, and research mentoring. The TUMS School of Medicine is committed to research excellence, ethics, and provision of clinical services, especially in demanding clinical scenarios. Prof. Yalda was a faculty member of the School of Medicine of TUMS.

Recruitment process
We invited 25 participants to this study (see below) from April to December 2018. The participants were recruited via purposive sampling for semi-structured interviews. E-mail invitations for participation in the study described the purpose of the study. None of the contacted candidates refused to participate in the study, but the nal appointment was based on the individual's availability on speci c dates. The participants were recruited from TUMS.

Data collection
Semi-structured interviews were conducted for data collection in order to allow the participants to describe their experiences freely. The interviews started with a general question about the individual's perception of Prof. Yalda as a role model. Some probing questions, such as "How do you de ne a great role model?" were also asked. The probing questions were based on the participants' answers to the general questions. The interviewer encouraged the participants to provide more explanations about the issues.
The participants were also invited to talk about issues, which were not discussed in the interviews. The interviews were conducted in a quiet room and recorded using a tape recorder. Each interview lasted between 35 and 65 minutes. The interviews were immediately transcribed and analyzed. Sampling and data collection continued until data saturation, based on the immediate analysis of data after transcribing the interviews. Data saturation was reached after coding and analyzing 25 interviews.

Data analysis
Qualitative content analysis, which provides valuable information about people's experiences and perceptions of a phenomenon, was performed to collect the data. We used inductive content analysis, de ned by Elo and Kyngas (2008), for data analysis. Themes and categories were extracted from the transcribed texts via inductive content analysis, without considering previous theoretical frameworks. All interviews were recorded on videotapes and then audio-transcribed. The transcripts were analyzed by two of the authors of this manuscript, and an agreement was achieved with the research group. This process brie y included the following two stages: selection of the analysis unit and understanding the data in the preparation phase; and open coding, formation of categories, and abstraction in the organization phase.

Rigor
Peer-checking was performed in the data analysis phase by two peers for ensuring the credibility and trustworthiness of the data.

Ethical considerations
All of the participants were given information about the aims of the study. In addition, the participants were informed that they could withdraw from the study at any time. Written consents were also obtained from the participants. Moreover, permission was obtained for recording the interviews. Con dentiality was maintained in all steps of data collection and analysis.

Results
The study population included 8 (65%) women and 17 (35%) men. Eight participants were medical faculties, seven participant were medical graduate and ten were medical students. The participants' age ranged from 23 to 68 years (mean age: 45.5 years). Five themes, 13 subthemes, and 46 categories were extracted from the data, which are presented in Tables 1-5. The participant's quotes presented in Table 6. The conceptual framework is also demonstrated in Fig. 1.     "All people who were associated with Prof. Yalda recalled his calmness, humility, and dignity. He believed that if we want to succeed in life, we should set aside our pride. By avoiding our instincts, we will be ready to rise up, learn, and evolve." "No one will forget his unique personality, even now that he is gone; his teachings promote spirituality and kindness to people around us. In my opinion, being a human is not about being a physician, a scientist, or a physician. If Prof. Yalda was not a professor or a medical doctor, he would still be a great man. Although he would not be recognized in the medical community, he would still have a positive impact on the society and would be regarded as a valuable asset to the community." Table 6 participant's quotes extracted from qualitative study in sample of subthemes

Discussion
The proposed framework in this study holistically combines all attributes of role modeling in the context of medical education. Therefore, it provides an important contribution to the theoretical recognition of role modeling research.
Our framework in this research identi ed ve main themes, including "role model as a mentor", "role model as a medical leader", "role model as an expert clinical teacher", "role model as a professional physician", and "role model as a undeniable physician". Based on our results, mentoring is used for guiding and facilitating a learner's, success planning and educational growth. Fowler and O'Gorman in 2019 introduced eight categories of mentoring function: learning facilitation; coaching; personal and emotional guidance; facilitation of career development; advocacy; strategies and systems advice; role modeling; and friendship [15].
The main domains of most mentoring functions are based on a Kram mentoring Theory, which recognized two mentoring function categories: career-related function and psychosocial function. Psychosocial functions, which develop self-con dence and self-esteem, include counseling, friendship, and role modeling. On the other hand, career-related function includes exposure, protection, and sponsorship [16]. The present ndings are consistent with previous research, which showed that with positive role models as mentors, medical students can develop their skills, including professional attitudes and behaviors, and develop their identity as a physician [17][18][19].
Based on our results, a role model is a person who is looked up by other people and whose behaviors and success are copied. A study by Huang et al. (2014) revealed that in the Leader-Member Exchange Theory, leaders are aware of their reputation and work to maintain a positive one in line with the organizational values. They also develop strong relationships with their follower and invest in them. These relationships provide an opportunity for leaders to intentionally act as role models. By relating to others and continuing their communication, leaders help others in order to help themselves [20].
According to a study by Saxena (2014), transformational leaders are unique and exible, take risks, and are tolerant of uncertainty. They are passionate and inspirational, using their in uence to act as role models. In addition to their inspirational role, they show expertise in some technical skills, which can involve people and/or leadership [21]. Chan (2019) believed that leaders, with both expert knowledge and unique access, are accepted as experts in the professional setting. They develop supportive relationships that bene t others because they are willing to lend expertise, access, time, and energy, providing both professional and psychosocial support for others [22]. These attributes can be classi ed into teaching qualities, patient care qualities, and personal qualities. A good clinical trainer needs to be conscious of his/her function as a role model, since development of clinical training skills may be supported by increased awareness of role modeling behaviors [7]. According to some researchers, a clinical trainer as a role model should make his/her behaviors explicit to the trainees in order to increase their attention and motivate them [10].
Based on our results, there is an urgent need for positive role models in medical training. These role models are the most powerful in the formation of professional character. The role models effect the development of professionalism. Positive doctor role models in uence behavior of medical student by demonstrating them 'how to act' professionally with patients and clinical staff. Positive role models also help the medical students cultivate their own 'professional role' in medical practice and in uencing career choices. The professionals highlighted that role modelling is vital as many professional characteristics such as 'integrity' are challenging to teach [23]. Finally the role models are undeniable and persistent in their mind of medical graduate. Role models provide support, protection, re ectiveness, advising, approval, con rmation, and coaching to their medical graduate and can have a great in uence on students' awareness of the excellence of their medical graduate experience.
The ndings of this study are subject to one limitations. The results might not be generalizable to all settings; nonetheless, we studied some frameworks and models of role modeling in our literature review.
The Implication of this study is the necessity of appropriate discussion in medical society about role modeling and how we may ensure that the faculty members are empowered to reach their full potential. This study has shown what is needed to construct an effective role model for medical education. Recognizing the ve elements of effective role modeling based on our framework allows medical teachers to produce powerful form of learning for medical students.

Strengths And Limitations Of This Study
We analysed rich data from, in-depth qualitative interviews conducted among different target groups of participants who have diverse experience and knowledge (Students, faculties and managers).
The study aimed to enhance understanding of role modeling in medical education to improve support for medical students and share good practice.
The study contextualises existing evidence pointing to the characteristics of effective role-modeling and generate a model for how integrate it into the curriculum of medical students, residents, in various domains, include patient care, teaching, communication, and professionalism.
The study presents new and unique data on how role modeling can be considered as a key factor in medical education.
The limitations of the study include the purposeful sampling and focusing on just one university in Iran; caution should be taken when generalising the conclusions to other university of the country or other countries. However, a good level of data saturation was achieved.

Conclusion
This is the rst qualitative study to demonstrate the role modeling framework for medical education. The result of this study show the necessity of organized education and arguments for consensus making in the eld to assist medical educationist in reaching the best plan for role modeling in medical education. All participants were given information about the aims of the study. In addition, participants were informed that they could withdraw from the study at any time without any consequences. Written consent was obtained from all participants. Moreover, permission was obtained for recording interviews. Con dentiality was maintained through all steps of data collection and analysis. The research proposal was submitted to the IRB committee. The committee reviewed the proposal and decided that there was no involvement of human or animal factors in the research and, hence there was no need for ethical approval.

Consent to publish
Not applicable.

Availability of data and materials
Data are available upon reasonable request.

Figure 1
Conceptual Framework for Role Modeling in Medical Education