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They Like Me, They Like Me Not? Attaining Trust from Residents and Medical Teams during the Clinical Rotation of a Medical Student

Trust between students and their inter-disciplinary team is key to an effective clinical education in a patient care environment. Medical students desire to gain trust and autonomy from their teams and are constantly trying to fit into the clinical hierarchy and organized chaos that predominate teaching hospitals. There is an inadequate amount of research regarding the engenderment of trust and autonomy in medical schools. We conducted a narrative literature review in the English language regarding the topic and analyzed the literature from the last two decades. We concluded that besides the factors which one requires to be good at any job (be on time, having adequate knowledge, etc.), there are certain unexpected factors which allow medical students to build trust during their clinical clerkships: (1) fostering a positive relationship with other medical students throughout clinical education, (2) being autonomously motivated.


Introduction
Trust is a core value in life: in marriage, in elections, in organizations, but it is especially important in medicine, as it is the intrinsic value of patient-doctor relationships (Pearson, 2000). Trust allows patients to seek care willingly, to be adherent to recommendations and treatment, and to reveal sensitive information (Hall, Dugan et al. 2001). Building a trusting relationship between the student learner and the supervising physician has far reaching positive effects. Medical students often try to fit into the clinical hierarchy and organized chaos of academic medical centers while they gain their clinical experience. As residents strive to gain trust and autonomy from their attending Gao X, Manjunath M, Mookerjee A, Rajput V MedEdPublish https://doi.org/10. 15694/mep.2019.000064.1 Page | 2 physicians during their postgraduate training, medical students try to do the same with their residents and the rest of the multi-interdisciplinary team. We explore the concept of entrustment of medical students within their medical teams in this era of inter-professional clinical care. Students need to practice and portray certain qualities that help them build trust during their clinical years.
The ability to achieve trust is a quality that every medical student should acquire before entering residency. It is not easy, and it requires training and personal development. We evaluate the factors that enhance students' abilities to gain trust between their residents and attendings, as well as patients.

Summary of work
We conducted a narrative review in the English language regarding trust and autonomy in medical education. We analyzed literature from the last two decades and explored the role of entrustment in medical students. Narrative experiences and observation during clinical clerkships were evaluated for factors that enhance the engenderment of trust. Overall, there are two components to trust which an individual must possess to truly be trusted by someone else. One component is based on the warmth and friendliness of a person, which represents trustworthiness, and another is how competent someone is, which represents capacity (Fiske, 2014). When a student is knowledgeable but unfriendly and difficult to approach, it may not seem problematic until one recalls that communicator credibility requires not just expertise but also trustworthiness. Vice versa, a student can be overwhelmingly friendly and warmth, but with unreliable knowledge, he is deemed incapable, and therefore untrustworthy. These components were known from the period of Aristotle. He once said, communication is logic and knowledge, combined with emotion and values. Modern days, scientists and educators often earn respect of people, but not their trust (Fiske, 2014).
Fostering positive relationships is an intuitive process during clinical clerkships. However, the ability to build these relationships with other medical students over the duration of medical school may not be an obvious or encouraged trait. In fact, students enter medical school with the idea that they must be better than everyone else surrounding them. Therefore, these positive relationships are diminished and threatened due to this tension.
Dr. Suraiya Rahman, an instructor for small group study sessions at University of Southern California, states that many times she found fourth-year students sitting with their fellow students in complete silence despite knowing each other for the past four years. She contends that the most formative moments in medical education doesn't occur in the library or in a lecture hall but rather when a student lifts their head from a book and realizes that the person next to them is in distress and they are compelled, obligated and beholden to take care of their fellow student in the same way that the student would have wanted support in that moment (Rahman, 2013). Fostering a positive relationship with other medical students throughout clinical education, demonstrating an ability to be dependable and a willingness to work hard, and communicating effectively within the medical team had a collective positive impact on the entrustment of medical students by their supervising residents and attendings during their clerkships.
It is hypothesized that the inability to foster positive relationships between medical students is precipitated by the competition readily available in medical schools. In the article "How Medical Students Perceive their Quality of Life," competition was ranked as the number five negative aspect of a medical student's life right after fear/insecurity and lifestyle changes (Enns, 2016).

Discussion
It is evident that many students enter the field knowing that they need to be competitive and therefore, there is an urge to do better than their peers. Thus, their social interactions and relationships with each other begins to diminish during medical school years. The medical schools need to be designed with a curriculum not only concentrated on medical content, but also around a better quality of life for their students. As a result, medical students' social interaction and relationship with each other begins to diminish during medical school years. Studies regarding team work has shown that more self-efficacious team members felt that they had more support from their coworkers (Mierlo, 2006). Translating these findings into the medical education setting, many authors argue that medical schools need to be designed with a curriculum not only concentrated on medical content, but also around a better quality of life for their students. "A greater effort must be made to decrease competitiveness and to fight excessive self-demands. These missions can be achieved through discussion groups, mentoring, and psychological support".
One suggestion for discussion groups was to increase patient encounter sessions. Patient encounters have always been cited as a source of pride and motivation for medical students. Patient-care related activity makes the student feel relevant and decreases their insecurity. Increasing patient interactions and enabling a safe environment that encourages students to discuss patient interactions could profoundly affect the way the students view each other. Perhaps, this method will help them understand that they can work as a team and not individually in the environment where they face similar challenges. If by being friendly to other students is all we need, then the best medical student would be someone with a psychology or sociology major, someone who understands human behavior and knows how to talk to people -but that's not the case. Being able to foster positive relationships with other students is important, but it is also important to be intrinsically motivated to study medicine. Geoffrey Williams describes two different types of self-determined models: autonomous and controlled. (Williams,1998). Medical students who believe learning is autonomous freely choose to read and study because they find the material interesting or important to their identities as physicians. In contrast, medical students who experience controlled sense of motivation study assigned materials because they feel coerced or pressured to do so. Ultimately, it comes down to "I want to learn" compared to "I have to learn." Autonomous motivation rather than self-controlled motivation shows improvement in overall psychological well-being of the student, patient care, and team dynamics. On the other hand, the same author claims that instructors have significant influence on students' motivational pattern.
There has been a substantial amount of research done on autonomous motivation in a clinical setting between physicians and patients. When autonomously motivated, morbidly obese patients attended more weekly visits, lost more weight, and exercised more regularly. In an educational setting, students are like patients. Students can have many different instructors throughout the medical education years, and the instructors can effectively influence their motivation patterns. An instructor who is more controlling will promote a controlled sense of learning into their students versus a teacher who is supportive of a students' sense of autonomy. An autonomy-supportive learning environment encourages students to become autonomously motivated and to feel more competent. (Kusurkar, R. 2012).
Effective communication with the medical team is critical for gaining trust for medical students. In a study concerning common themes across medical courses. Among those, clearly communicated goals and objectives were second only to a well-structured curriculum. The students felt a course had a higher quality if they understood the course goals and objectives and what was taught matched the same course goals and objectives. Now, while this piece of communication benefits a student, it must have a similar effect vice-versa. There should be, at the beginning of each rotation, a chance for a student and resident to establish and exchange expectations.

Conclusion
Establishment of trust within team members will allow students to gain autonomy and strengthen their experience and independence when taking care of patients. These factors demonstrate the willingness to work as a team, enhance the development of a professional identity and positively influence the relationship between students and their residents. Medical education stakeholders should promote these qualities in medical students, particularly in fostering a positive relationship between the students. Emerging research show interpersonal and inter-professional trust is critical in patient-care.

Take Home Messages
The formation of trust between medical students is a characteristic that should be fostered early in medical education. Autonomous motivation can help to develop required skills and behaviors to gain trust with their residents and medical teams.

Notes On Contributors
Xinuo Gao is senior medical student at Ross University School of Medicine. She presented this work at Academcy of Professionalsim in Health Care in Chicago in 2017.
Dr. Madhura Manjunath is third year resident at Berkshire Health System in MA, USA. She worked on this idea and paper while she was senior medical student at Ross University School of Medicine.
Dr. Anuradha Lele Mookerjee, MD is Associate Professor of Medicine and course director for Lifestages in foundation of medicine at Cooepr Medical School of Rowan University, Camden, NJ.
Dr. Vijay Rajput, MD, Professor and chairman of Medicine at Ross University School of Medicine, Miramar, Florida. His area of interest is Humanism, bedside teaching, curriculum devleopment.