Kumagai, Arno K. MD; White, Casey B. PhD; Ross, Paula T. MA; Perlman, Rachel L. MD; Fantone, Joseph C. MD
Modern medicine is practiced in a high-pressure environment caused by increased emphasis on clinical productivity, ever-increasing administrative responsibilities, concerns over medical errors and litigation, and societal expectations that physicians listen to, and communicate effectively with, their patients. Consequently, the topic of physician “burnout” on the one hand, and that of professional fulfillment and satisfaction on the other, have become the subjects of much discussion both in the public domain1,2 and in the literature of academic medicine.3–10
Several studies have investigated the factors underlying professional satisfaction among clinicians;3,6,11–13 however, to our knowledge, only a few studies have directly explored the impact of teaching on professional identity and well-being.14–16 Two previous studies6,7 have suggested that development of self-awareness and reflective practices are associated with satisfaction with work, and factors such as helping relationships, powerful experiences, and opportunities for self-reflection lead to professional satisfaction and personal growth.6,7 On the basis of these studies, we propose that teaching and discussions of the doctor–patient relationship and psychosocial aspects of medicine are likely to enhance clinician–teacher self-reflection and professional development. Recently, we and others have investigated the impact of such discussions on medical student attitudes toward medicine and patient care.17–20 In the current study, we investigated the effects that facilitating small-group discussions on these themes had on the personal and professional development of faculty facilitators.
As part of a major revision of undergraduate medical education at the University of Michigan Medical School in the fall of 2003, we implemented a required two-year longitudinal small-group-based activity, the Family Centered Experience (FCE). The primary aim of the FCE is to enable students to use patient narratives and home visits with individuals with chronic illness as a means of understanding the experience of illness and of fostering reflective judgment and empathic communication skills. The home visits, as well as student-led small-group discussions, readings, reflective written assignments, and interpretive projects, serve as a foundation for the students to explore the experience of chronic illness and its care from the patient’s perspective.19–21 In the FCE, as well as in a companion small-group-based course, Longitudinal Case Studies (LCs), semistructured discussions of a variety of issues in medical ethics, multiculturalism, and the doctor–patient relationship allow each student to bring his or her own personal background and experiences into the learning environment and engage in an exploration of their own, each other’s, and society’s values, biases, and perspectives. Together, the FCE and LCs are designed to complement the biomedical training that students receive during their first two years in medical school and, ultimately, to train physicians who are skilled in understanding both the complexities of clinical medicine and the personal, psychosocial, and cultural aspects of illness and its care.
The small groups of the FCE and LCs are facilitated by faculty clinician–educators. To develop a sense of community and safety necessary for challenging discussions on psychosocial themes in medicine, the FCE/LC small groups have been designed to consist of 10 to 12 students who work with the same faculty clinician–educator for the two-year program. Because of these longitudinal interactions, facilitators are able to provide ongoing feedback and serve as mentors and physician role models for members of the group. To enhance their work, facilitators are provided with individualized observation and feedback as well as frequent faculty development workshops (between 6 and 8 hours annually) on subjects such active learning techniques, student feedback and evaluations, and facilitating discussions on potentially contentious topics involving race, religion, gender, class, and sexual orientation.22 The medical school contributes 10% of the facilitators’ salaries to release them from clinical productivity expectations during the time spent in educational activities.
The FCE/LC small groups were intended, as are all curricular innovations, to enhance the experience of the students. But how does the experience affect the faculty facilitators? In the current study, we used in-depth, face-to-face interviews and qualitative methods to explore the impact of discussions about the experience of illness, the doctor–patient relationship, and psychosocial issues in medicine on the faculty facilitators’ identities and activities as teachers and clinicians.
In the summer of 2006, all faculty facilitators who had taught in the FCE/LC small groups for at least one year (n = 30) were contacted by e-mail and invited to participate in the study. Before participation, the faculty facilitators were informed that their identities would be withheld and that their responses would be masked from the other investigators, and informed consent was obtained.
One of the investigators (P.T.R.), who had no connection with the course, conducted individual, face-to-face interviews using an open-ended protocol to explore the overarching research question, “What impact did facilitating small-group discussions of the patient’s experience with chronic illness, the physician–patient relationship, and doctoring have on your attitudes and perspectives regarding medicine in general and, in particular, your work as a clinician and teacher?” Open-ended questions were asked to elicit the facilitators’ thoughts and insights regarding specific topics, such as the impact of the small-group discussions on the facilitators’ views of the doctor–patient relationship, teaching, and professional goals. The interview format was deliberately kept open to encourage in-depth exploration of the facilitators’ perspectives and experiences. Interviews were audiotaped and transcribed, and identifying information was omitted before distributing the transcripts to the other investigators. In cases where the participant identified him- or herself indirectly through disclosure of information about department or type or place of practice, that portion of the transcript was sent to the respondent for review and for permission to use the information in the analysis. In the event of a respondent’s declining to give permission, the information was deleted before distribution to the other investigators.
For thematic analysis of the transcripts, we used a grounded theory approach.23–25 Grounded theory involves the close analysis of primary data (e.g., interview transcripts, journals, written reflections, or other means of expression) to develop an overall theoretical construct of the meanings that a particular experience has had for the individual participants. The themes on which this construct is based emerge from—are “grounded in”—the participants’ words, and the final product of this analysis often takes the form of a theoretical schema in which the structural relationships between the emerging themes are described.23–25 In this study, all investigators read each transcript, and two investigators (A.K.K. and J.C.F.) independently performed the coding. Using a “line-by-line” analysis of the transcripts, we identified open codes (i.e., general thematic categories). We then met and, through discussion, comparisons, and repeated return to the original transcripts, agreed on open codes. Open coding was then followed by axial coding, in which each investigator returned to the data to explore the connections between general thematic categories and the variations of responses (subcategories) that comprised the general themes.23 Each step in this process was reiterated three to four times per transcript and involved independent reading of the transcripts and discussion to reach consensus among the investigators. Throughout the process, we ensured validation of the approach (i.e., assurance that the codes represented the authentic expression of the participants) through repeated contextual reading of the original transcripts. Saturation of codes was achieved when repeated analysis of the data revealed no new information.23 We summarized thematic categories and subcategories, and we shared the summary with the study participants to solicit comments, additional reflections, and suggestions. All aspects of the study received approval by the medical school’s institutional review board.
Eighteen facilitators (60% of the 30 invited) agreed to participate in the interviews; all were full-time faculty members of the medical school and were from a variety of clinical departments, including internal medicine, family medicine, pediatrics, obstetrics–gynecology, psychiatry, physical medicine and rehabilitation, and emergency medicine. Three of the faculty members (17%) were on the instructional or tenure track; the remainder (83%) were on the clinical track. In terms of ethnicity and gender, the facilitators who were interviewed reflected the diversity and characteristics of the entire group of 30 faculty facilitators of the FCE/LC. The interviews averaged approximately 40 minutes in length, with a range of 30 to 90 minutes.
Analysis of the participants’ responses revealed four major thematic categories (open codes) and subcategories, which are discussed in detail below.
Facilitation of small-group discussions of psychosocial issues in medicine led to reflective approaches to patient care
This influence was often seen not as something new but, rather, as an affirmation or reinforcement of humanistic values and perspectives that the facilitators already possessed. For some facilitators, the discussions led to a heightened awareness of the patient’s perspective and allowed them to approach patient care with a “deeper degree of understanding and compassion.”
I think it’s reminded me to walk in my patients’ shoes, more than anything…. It’s a recurrent theme, and … one of the biggest things I stress with the students is, if you can’t walk in their shoes, it’s going to be hard to connect with them and figure out where they are in order to meet them so you can actually make some progress with whatever needs to be done.
Facilitators spoke of learning from the patient volunteers’ stories along with their students: “I think it’s been eye-opening for those of us who are faculty as much as for the students, through the stories that the students relay back to us.” Several facilitators remarked that discussions on the doctor–patient relationship stimulated reflection on their own approach to patient care and made unconscious habits more conscious and reflective:
I think I’ve seen patients long enough … so it doesn’t always get as much conscious thought…. But working with the students, what it’s clearly done is put it in the front of my thought very often, even during my clinical day when I’m not teaching. To reflect on something in class and just ask yourself, “Are you doing this the way you would want to tell your students you’re doing it?” So I think it’s taken it from a subconscious to a conscious level on many interactions.
Personal reflections and discussion of the doctor–patient relationship and the experience of illness also led to identifiable changes in clinical practice, such as spending more time listening to patients and answering their questions, paying more attention to patients’ support systems or their desire for meaning, taking the time to learn the process that a patient goes through to set up an appointment, or making occasional home visits to patients and their families for the first time in the clinician’s career.
I pay much more attention to patients’ social situations, whether they’re married, they’re single, they’re divorced, whether they have kids, where do they live…. When they teach you to do a history, most of it is focused on physical exam and past medical history and surgical history … but the social history is really the interesting part. It’s actually the part where you … connect with the patient and figure out what their barriers are.
One faculty instructor described how it made her a “better doctor” by reinforcing those humanistic practices and by pushing her to be “a person worthy of being a role model.”
Small-group teaching fostered reflection and skill development in teaching that was often applied to other domains of educational and professional activity
Faculty facilitators were challenged by, and learned from, their roles as small-group facilitators, and this experience fostered reflection on their skills and identities as teachers. Because the emphasis in learning in the small groups was on facilitation rather than lecturing and on process (i.e., development of critical skills, reflective thinking, independent learning, teamwork and collaboration, etc.) rather than content, the style of teaching was very different from the traditional, lecture-style or expert/novice approaches with which the faculty were familiar. A common theme among the facilitators was recalling a certain amount of apprehension when beginning this new style of teaching: “it’s putting me out there in a situation in a place where I haven’t been, and that’s always a little scary for most people.” Others noted that it “constantly teaches you as the teacher.” The small-group discussions, as well as faculty development activities, allowed facilitators to “get inside a learner’s head” and to learn to “be present and provide direction,” rather than to lecture the students.
I’ve come to … realize that it’s not for me as the teacher to know all the answers, and it’s not for me to be prepared to answer any question that the students deliver. And it’s much more for me to be present and give direction than it is to give answers … it’s much better to have them explore and question why things are the way they are or what the answers have been in the past so that they can learn to ask better questions in the future.
Another instructor commented,
I’m much more likely to probe and see what the [student] thinks as opposed to just getting an answer. I’m much more likely to give direct, concrete feedback, which is something that I think I’ve learned to do through this.
Faculty expressed that the skills in teaching and facilitation they acquired in small-group facilitation enhanced their work in other areas of educational and administrative activities, such as medical students teaching during clerkships, house officer teaching in clinic or on the wards, or facilitation of staff meetings and clinic administration. One of the facilitators, a medical director of an outpatient clinic, remarked,
I started doing this medical director job at the same time that I started doing the FCE and … a lot of the skills that are required to be a good facilitator and a good medical director are the same in terms of getting people to identify their own weaknesses, facilitating groups. It’s all the stuff that’s in the business literature that we get no training in at all that I actually got some formal training through the FCE.
Facilitation of discussions of psychosocial issues in medicine also stimulated facilitators’ willingness to raise these issues during clinical case discussions with students and residents. One instructor noted,
Thinking about patients’ impact on their illness, on their social circumstances, on what else are they going through, I realize that I was never verbal about that. It’s something that I did all the time, but I never said, “Okay, let’s go into a room and talk to Mrs. Jones about this because I think this is important to what’s going on.” So I think that’s changed—it’s changed my clinical teaching in a positive way.
Small-group teaching allowed expanded interpersonal connections with faculty, students, and patients
Longitudinal exposure to small groups of students fostered bonds between facilitators and students, as well as the facilitators’ sense of personal responsibility and investment in the students’ development and success as physicians. Facilitators spoke of “learning from their students” and of the “emotional power” of getting to know someone better, and they expressed a belief that “working with students is an empathy builder in and of itself.” Faculty also spoke of the program’s impact in developing a sense of community and collegiality among faculty facilitators who shared similar teaching experiences and goals and of the program’s helping them to develop closer ties with their own patients in getting to know them more as individuals. One instructor noted,
Working with students this closely, you really get to know them as people, where they can really come to you with issues and problems … just helps build those skills in all of us. We have to be empathic, not only to our patients and families, but to our colleagues, to our students, to other people we work with, and I think anything that allows interpersonal exchange on more emotional material helps build those skills in all of us.
Small-group teaching acted as a source of personal and professional fulfillment and renewal among faculty facilitators
Faculty facilitators described their work in small groups as providing “a balance” with the constant demands and pressures of patient care and allowing them to “step back” from the “grind” or “treadmill” and “think about what you’re doing.” The facilitators described their appreciation of affecting their students’ development and perspectives of medicine at a very early stage in professional training. One instructor remarked,
Unlike an organized lecture … this is an opportunity to bring your perspective, yourself, some mentoring … I very much like seeing young people who don’t know where they’re going yet … and helping them start to get on that track. I just find it fun. I find it rewarding, I guess, personally and professionally, to see them grow up.
Experiences in the program also led to major changes in the ways the faculty viewed their own careers in medicine and fostered a renewed interest in, and commitment to, medical education. Facilitators spoke of a “career shift” in which they transferred (or planned to transfer) effort from research, administrative, or clinical activities to education. These changes took the form of seeking out additional educational activities, pursuing advanced training in higher education, getting involved in curricular development, or reorienting clinical work to accommodate increased teaching responsibilities.
I’m seriously thinking of changing … what I do in the future in terms of my professional goals…. I do a lot of research. I’m still interested in that. I’m thinking of shifting that a lot more to education, becoming more involved with students and residents and fellows. It’s almost like a career shift to some extent.
Finally, there was a sense among many facilitators that their engagement with their students and with the themes of discussion in the small groups occurred on a deeply personal level: “all the things of one’s life are brought to bear in this course.” Several faculty described how much they learned from their students and how exposure to the “innocence,” “energy,” and idealism of beginning medical students helped to “rekindle” humanistic perspectives in themselves. Several faculty facilitators contrasted the openness of beginning medical students with the cynicism of residents and more seasoned clinicians:
It’s kind of refreshing to work with students who are coming in with a fresh slate and don’t have the biases and the burnout that can be associated with residents and people who are farther along in their careers. It’s been very refreshing for me. And it actually kind of reminds me of why I actually did this.
The facilitators’ engagement with their students and in teaching contributed to an overall enhancement in their professional and personal satisfaction. One instructor commented, “It’s been very good for my morale, my overall interest in medicine has gone up … because of it as well.” Another remarked that by allowing the faculty to “open their minds” and reflect on their experience with patient care, the program has changed the faculty as well as their students:
I’m hoping it can change how [we] behave or how [we] deal with patients on a day-to-day basis. So, as much as we say this is for the students I think it’s really going to change us as well in a better way.
In two previous studies, we investigated the impact of the activities of the FCE program on medical students’ perspectives on the experience of illness and its care.19,20 An unexpected outcome of these educational efforts was the impact that the program had on the faculty small-group facilitators. The results of the present study suggest that facilitation of longitudinal small-group discussions on doctoring and psychosocial themes in medicine led to an enhancement of reflective clinical and teaching practices and a sense of personal and professional renewal and fulfillment among faculty clinician–educators.
Several studies have investigated the factors that underlie professional growth and satisfaction among physicians.3,6,26 These factors include personal reflection,6 strengthened doctor–patient relationships,3,6 satisfaction from having a profound impact on the lives of others,3,6 and a sense of control of one’s practice environment.26 Some of these themes are also noted in the present study; however, the in-depth, qualitative approach taken here allows an understanding of what role these factors play in professional and personal growth among faculty facilitators. On the basis of a detailed analysis of the thematic categories emerging from the facilitators’ comments, we would like to propose a general schema of how longitudinal facilitation of small-group discussions of psychosocial themes in medicine, including doctoring, leads to the outcomes hypothesized above (Figure 1).
Facilitation of ongoing small-group discussions of the doctor–patient relationship and the patient’s experience of illness brought tacit, personally held humanistic perspectives and values to conscious awareness among the clinician–educators. The volunteers’ stories (as related by the students), as well as the facilitators’ recall of their own clinical experiences, enhanced self-reflection, perspective taking, and empathy among the faculty and led to specific changes in clinical practice. These changes, such as taking more time to answer patients’ questions, inquiring about support systems and life circumstances, and making visits to their patients’ homes, have at their center the patient-as-person and are accompanied by the ongoing introspection, self-assessment, curiosity, and refining of approaches to doctor–patient interactions that are embodied in the term, “mindful practice.”27 The facilitators reported use of personal stories of prior clinical experiences to enhance their facilitation of small-group discussions on doctoring; in addition, their clinical work was enriched by their own reflections on the art of medicine and their relationships with patients.
In a similar manner, facilitation of the small groups enhanced self-reflection and skill development in teaching among the faculty. Comments from multiple facilitators suggest how this occurs. Facilitators described their sense of being challenged by new approaches to teaching and learning required in the small groups. Facilitation rather than lecturing, and an emphasis on development of reflective and critical thinking rather than information transfer, represented a completely new type of teaching for the facilitators and made the teaching methods they had acquired during their own training problematic in this new environment. From instructor responses, it is apparent that this challenge stimulated reflection on their own perspectives, abilities, and approaches in teaching and learning and led to the development of new teaching practices.
The phenomenon of reflective thought arising from encountering an uncertain or problematic situation—which Piaget terms “cognitive disequilibrium”28—is cited as being a central, core stimulus for reflective thinking by writers as varied as Dewey,29 Piaget,28 Schön,30 Habermas,31 and Mezirow32 and, we believe, acted as the stimulus to the development of new approaches to both teaching and patient care among the faculty facilitators. Furthermore, the application of these skills in facilitation was not confined to the faculty members’ work within the small groups: numerous facilitators reported applying skills in other educational and administrative activities. What is apparent from their comments, however, is that what the facilitators gained from their small-group experiences was not just a set of skills to be applied in other situations but, rather, an orientation that incorporated reflective practices—including introspective self-assessment and improvement, perspective taking, listening, and facilitation—into multiple areas of their professional lives. This orientation enriched their work in numerous domains and had benefits extending far beyond their small groups.
The present study suggests a possible approach to the phenomenon of a “downward spiral of physician satisfaction.”10 The small-group facilitators of the FCE/LC reported that their work in the small groups stimulated renewed enthusiasm and interest in teaching and patient care and a sense of growth as physicians, teachers, and individuals. This overall sense of renewal was particularly salient among the clinician–educators, who described their activities in small groups as a means to “step back and think about what you’re doing.” From their comments, possible causes for this sense of renewal may be identified. Facilitation of stable, small groups of students fostered interpersonal connections between the faculty members and their students, as well as their patients, and colleagues. The interactions between faculty and students exposed the facilitators to the “innocence,” “enthusiasm,” and the “idealism” of medical students at the beginning of their careers and gave the facilitators a sense of influencing the development of these physicians-in-training in a critical, highly personal manner.33 Furthermore, unlike many traditional approaches to teaching in medical education, these activities required that the facilitators engage in teaching, not on just a cognitive or intellectual level but also on an affective and experiential one as well: as one instructor commented, “you bring your whole self into this [experience].” This engagement of the instructor as a whole person in an activity which required reflection on one’s role as a physician and teacher and involved highly personal interactions resulted in both personal and professional growth among the facilitators. This dynamic assists the faculty in fostering the self-awareness, growth, and well-being and a commitment to the humanistic aspects of medical practice7,34 that we seek in graduating medical students.
It is possible that factors other than their discussions in the small groups contributed to the responses we have observed in the faculty facilitators. For example, as part of their activities in the FCE and LCs, facilitators participated in extensive faculty development and were provided with individualized feedback by the course directors and trained staff members after observation of their work in small groups. As a scheduled part of the quarterly faculty meetings of the course, faculty instructors engaged in group problem-solving activities on issues such as facilitating participation in discussion from all students within a small group and handling issues of professionalism arising among small-group members (e.g., disrespectful remarks during discussion, lack of commitment to learning goals, etc.). As was suggested by faculty comments, these activities may have acted synergistically with the faculty’s facilitation of small-group discussions to enhance their reflections on teaching, learning, and clinical practice.
In summary, the present study reports that longitudinal facilitation of small-group discussions on doctoring and psychosocial themes in medicine enhances personal and professional growth among faculty facilitators and renewed interest in teaching and patient care. The facilitators’ comments suggest that this experience has caused a shift in their frame of reference of their professional activities to an orientation that addresses human needs35—their patients’, their students’, and their own. Unlike specialized programs or faculty development sessions specifically devoted to enhancing teacher and/or physician identity and well-being,3,36,37 the activities described in this study have occurred within the context of teaching in a required medical school course. The Brazilian educator Paulo Freire once stated that “it’s impossible to be an educator without the possibility … to be reinvented,”38 and, as suggested in this study, in the context of the FCE, the orientation toward a reflective, humanistic practice of medicine that facilitators have hoped to instill in their students has been reflected in themselves.
The authors would like to acknowledge the efforts of the faculty instructors of the Family Centered Experience and Longitudinal Case Studies courses for their commitment to teaching and learning.
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