Hatem, Charles J. MD; Lown, Beth A. MD; Newman, Lori R. MEd
Faculty development is increasingly recognized as necessary and central to the academic medical enterprise,1 and teaching and educational scholarship enjoy growing appreciation as appropriate academic currency for promotion. Along with these developments, a number of intensive faculty development programs, including fellowships in medical education (defined by Searle et al1 as single cohorts of medical teaching faculty who participate in extended faculty development activity), have successfully emerged.2–14
In response to growing faculty interest and institutional commitment to teaching as a career focus, we have established three medical education fellowships. During the past decade (1998–2008), 97 Harvard Medical School faculty have graduated from the Rabkin Fellowship in Medical Education at the Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center, the Mount Auburn Fellowship in Medical Education, Mount Auburn Hospital, and the Harvard Medical School Academy Fellowship in Medical Education, Harvard Medical School, all of which are codirected by one or more of us. We have previously published information concerning the funding, selection of fellows, and logistics of the programs.15
These fellowships aim to develop faculty as educators, provide opportunities for scholarly research in medical education, support fellows as leaders and agents of change within their organizations, and create a community of medical educators dedicated to supporting each other as well as the system at large. Supported by philanthropic and institutional/departmental funding, the fellowships permit the fellows to continue performing their responsibilities save for a 20% effort they devote to the program. The core curriculum focuses on understanding the historical context of medical education's funding and current challenges; constructing, implementing, and evaluating curricula; applying adult learning principles to specific clinical settings (including the bedside and ambulatory arenas); teaching small and large groups; doing research in medical education; recognizing the relevance of the humanities to teaching; demonstrating leadership skills; and practicing self-reflection in professional development. Our initial assumptions about curricular domains have remained valid; however, qawe modify content and implementation strategies annually to meet the educational needs of each new cohort of fellows. Fully appreciating that a curriculum is never finished, we provide a recent complete version of the fellowship curriculum online.16
This article presents our reflections on the evolution of the fellowship programs during the past decade. The joy and challenges of bringing a curriculum to life demand continued attention to process—the details essential for ensuring successful seminars and learning experiences. The process strategies derive from our own extensive experience as teachers, knowledge of the literature, consultation with colleagues, input from fellows, and ultimately from conducting “educational experiments.” We have tried various approaches—some successful, some not, but all of which have yielded insights that contribute to the success of these fellowships. We offer here the process strategies we've learned in the hope that they will be useful as a starting point from which curricula elsewhere can be adapted and implemented.
A central and challenging question remains, “Have these fellowships achieved their stated goals?” We will report our evaluation studies separately, but we summarize the major outcomes here under Strategy #9. Our findings demonstrate that the fellowships have strongly influenced the fellows' career trajectories and largely achieved the fundamental educational program outcomes.
The Ten Strategies
Strategy 1: Define an operating philosophy, values, and goals for the fellowship
We believe that enhancing a faculty's educational skills improves both teaching and learning, and that this, in turn, results in better, more effective patient care. We also believe that an ongoing opportunity to develop teaching skills bolsters professional and personal satisfaction, facilitates mastery of training-related core competencies, and contributes to the teamwork vital for coordinated patient care.
The fellowships' original goal remains in place: to develop a community of skillful medical educators devoted to educational scholarship who serve as educational leaders and agents of change. We begin each program year by establishing an educational contract between the fellowship leaders and fellows. The topics and strategies presented in the initial seminars promulgate the philosophy, values, and goals of the fellowship. The participants
* present and discuss personal written philosophies of education (which are compared with new iterations at the end of the fellowship year);
* discuss stories of exceptional teachers who demonstrated core values of teaching and commitment to learners;
* discuss historical material covering the evolution of medical education in the United States in the 20th century17 to understand the current context of academic medicine;
* demonstrate, discuss, and employ the skills of reflective listening and being mindful with attention to both verbal and nonverbal communication;
* establish trust within the group;
* discuss and employ the basic tenets of effective educational and institutional planning (“What am I attempting to do?” “How will I do it?” “How will I know that I've accomplished my goals?”);
* recognize the parallels between effective doctoring and effective teaching;
* understand the importance of self-reflection as essential to growth as an educator; and
* conduct each session with attention to humanism and kindness.
Strategy 2: Establish a curriculum that reflects the roles and responsibilities of fellows
When, more than a decade ago, we fashioned our initial fellowship, our motivating question was, “What educational skill set do faculty who teach need to learn and develop?” The answer produced a curriculum that has remained largely intact, but one that acknowledges that details and experiences differ each time the program is presented. Thus, the curriculum has naturally accommodated fellows' clinical roles and teaching settings. We have, for example, designed sessions on teaching in the operating room, subspecialty clinic, and emergency department. The basic topics of the fellowship curriculum are outlined in List 1.
Strategy 3: Establish and employ a basic approach to adult learning
Early in the fellowship seminars, we discuss an approach to the essential elements of teaching and learning that includes getting to know the learner, establishing an educational contract, employing effective methods of questioning and responding, creating a safe environment, and establishing a learning community (List 2). We both teach and model these elements throughout the curriculum.
To best know and understand the learning needs of the fellows, we limit their number to six per program. Our experience has been that, while four fellows in a class are too few and eight too many to permit the experiential aspects of the curriculum, having six fellows in a group gives them sufficient time to practice skills and receive feedback, to discuss the topics in our weekly seminars, and to meet individually with their career advisors and project mentors.
The fellows learn about educational contracts not only from the relevant literature18 but also by engaging early on in the process of constructing and adhering to such contracts with each other and with the fellowship faculty. They soon realize that the key elements elaborated in the contract—expectations, needs, content, relationships, and provision for feedback—are essential in almost all teaching domains. It has been our experience that the fellows, if they do not already use the concept of an educational contract in their teaching, quickly incorporate this strategy into their own work. Moreover, as the fellowship progresses and the needs of the fellows more clearly emerge, the curriculum changes accordingly, tangibly pointing to the organic nature of educational contracts.
Reflective teachers question, listen, and respond effectively.19 The fellowship explores in depth the use of effective questioning and various taxonomies for constructing questions.20 These types of questions elicit analytic and synthetic insights from learners at many levels of development. This taxonomy of questioning is consciously and consistently used in the faculty's facilitation of the weekly seminars as we explore basic teaching approaches to lecturing, case-based discussions, or bedside attending rounds.
Through consistent attention to knowing their learners, establishing educational contracts, and using effective patterns of questioning and responding—a template rooted in respect for the individual—teachers establish an atmosphere of trust and respect and a safe learning environment. Safety provides a space to admit mistakes or knowledge deficits to the group. As facilitators, we model this by saying, “I don't know,” revealing our own mistakes, and supporting each other. When fellows finally “break the ice” and share critical teaching incidents, we know that the group has arrived in “a safe place,” one of mutual trust. The reality of a learning community then appears, one in which fellows acknowledge their colleagues' valued contributions to the seminar, mindfully critique the fellowship projects, provide thoughtful feedback to each other on their teaching skills, and bring their educational dilemmas to the group. These are the conditions that allow curiosity to exist and flourish.
Strategy 4: Strive to achieve a balance between meeting the seminar's stated objectives and staying open to discussion
Whitehead21 wrote about “the rhythmic claims of freedom and discipline,” an issue small-group discussion leaders confront regularly. The central challenge of any discussion-based format lies in the attempt to balance the “discipline” of meeting a seminar's particular goals with the “freedom” to explore the issues of the moment. The pitfalls in any given seminar range from faculty-dominated discussion that tries to cover all of the material to open-ended group dialogue that leads far afield. The right balance can only be judged within the intellectual and emotional context of the moment. As seminar facilitators, we pay explicit attention to the basic process issues needed for the effective conduct of the sessions (List 3).
Strategy 5: Create optimal learning opportunities for the fellows to acquire and practice the skills of the curriculum
Theory without practice is often a sterile exercise. Learning teaching skills involves assigned readings, demonstration of the technique by faculty, discussion, and practice followed by reflection and group feedback. Examples include
* Lecturing: Fellows present 8- to 10-minute practice lectures, after which they receive feedback from the group.
* Small-group discussion: Fellows prepare cases from their disciplines and teach them to the group with reflection and comment.
* Peer review: In pairs, fellows observe each other teaching in a variety of venues, reflect with each other, and present process findings to the group.
* Educational project: Fellows prepare and present project-management worksheets based on a well-known educational template.22 Each fellow's educational project is a learning laboratory within which many aspects of the curriculum are practiced and applied. These skills include developing curricula, demonstrating the leadership and organizational know-how to elicit “buy-in” to educational innovations, designing and evaluating educational research, mastering various teaching methods, and disseminating information through such media as posters, abstracts, oral presentations, and articles for publication.
* Intensive medical education research workshops: Fellows learn research strategies, study design, survey construction, and the process of submitting applications to internal review boards. They prepare and present research prospectuses for commentary from faculty and peers.
* Teaching procedural skills: Fellows demonstrate how to teach a procedure from their own discipline. Creative and memorable recent examples include using common household items to find the epidural space, perform punch biopsies, or tap a swollen knee.
* Using narrative to teach: Fellows write and read aloud narratives about memorable teachers and patients. These stories are often profoundly moving and are exquisite reminders of those who have taught us. It is notable how often the memorable teacher is one from grammar or high school. These recollections poignantly and uniquely illustrate the formative power of teaching.
* Fellows as agents of change: Fellows discuss readings on leadership skills, negotiation strategies, and becoming an agent of change. Our institutions' CEOs facilitate a number of these seminars, bringing real-world advice to bear and providing opportunities for them to get to know the fellows. The fellows bring their leadership dilemmas to the group for consultation and engage in challenging negotiation role-plays. Becoming an agent of change does not simply happen. We have found that mentoring relationships are important catalysts in this equation and that the fellows often return for advice from program directors, former fellows, or other mentors in the system.
* Prior fellows as seminar facilitators: Fellowship graduates return to lead selected seminars as a way to refine and receive feedback on their teaching skills and reinforce a sense of community.
The fellowship is designed as a 20% time commitment. This permits fellows to continue their institutional work, yet allows them to practice new or refined skills as the fellowship progresses.
Strategy 6: Foster interdisciplinary communication, team development, and the creation of a learning community
The conduct and success of any fellowship rest on the selection and commitment of the fellows themselves. We seek colleagues from the Harvard hospitals who are committed to refining their teaching skills, dedicated to completing their required fellowship projects, and determined to become educational agents of change within the system. We ensure diversity of the group by admitting faculty from different specialties, institutions, and levels of academic advancement. Each specialty brings its own educational questions and contextual dilemmas to the seminars, and the interdisciplinary nature of the fellowship enhances institutional understanding and gives participants insights into the constraints that their colleagues regularly face in practice. We have made the fellowship available to faculty who are still early in their careers as well as those with considerable experience. This rich mix and the fruitful dynamic it creates within the seminars contribute enormously to the success of the program.
In the Mt. Auburn fellowship, we have included up to two colleagues from other professions. To date, these colleagues have been from the fields of psychology, advanced practice nursing, and most recently, chief residents in internal medicine. These fellows bring unique perspectives to discussions, greatly contributing to understanding professional roles, scope of practice, and team formation. Given the diversity of the fellows, we are sensitive to the use of teaching examples and techniques beyond internal medicine, the primary discipline of two of the authors (C.H., B.L.). Opening up the fellowship to large segments of the academic health center may call on resources and space not readily available. Nonetheless, the success of these early initiatives has convinced us of the need to continue and to expand this approach.
A central challenge in a system as diverse as ours is maintaining connections among former fellows as they migrate back to their institutions. Within one's own institution, one often does not know colleagues in other departments (or one's own if large enough). The problem is even more substantial across multiple institutions. As one solution, we gather our community of present and graduate fellows several times each academic year for Building Bridges sessions, discussions facilitated by fellowship faculty, visiting professors, or other influential members of the medical school about broad issues in medical education or educational dilemmas faced by the fellows. We also invite newly appointed fellows to attend the graduating fellows' end-of-the-year project presentations, giving fellowship classes a chance to connect and disseminate the medical education work accomplished to date. Lastly, fellows post bio-sketches and project titles on their institutions' Web sites as an additional means of communicating with the faculty-at-large.
Strategy 7: Develop mindfulness and the discipline of “critical self-reflection”
Langer,23 who has written much about mindfulness, explains that “a mindful approach to any activity has three characteristics: the continuous creation of new categories; openness to new information; and an implicit awareness of more than one perspective.” This framework is as powerful for the educator as it is for the clinician. During the fellowship, we explicitly draw parallels between doctoring and teaching: Both require eliciting different needs (doctor/patient; teacher/student) and using this information as the central basis for action and assessment. We have found that using the existing familiar clinical skills of the faculty and identifying the parallel skills of effective educational practice facilitate the development of the clinician-educator. Epstein24 advises that, in clinical care, the “process of critical self-reflection depends on the presence of mindfulness.” This process, in turn, enables “good practice.” Similarly, we believe that mindfulness enables good teaching practice, and we intentionally bring this perspective to the fellowship. Reflection thus becomes a crucial skill. Following Shön's25 work, we ask the fellows to assume reflection-in-action and reflection-on-action perspectives when conducting and refining a teaching encounter. We ask fellows to keep journals of their teaching sessions and to reflect on each experience. The fellows learn quickly that reflection, so used, is powerful in the improvement of their teaching.26,27
Strategy 8: Systematically review the structure and process issues of each seminar and of the curriculum as a whole
The fellowship faculty debrief after each session, and they scrutinize the curriculum from a broader perspective at the beginning, middle, and end of the academic year. We also ask the fellows to review the curriculum and suggest new material for discussion. To accommodate these requests, we leave seminar topics open in the second half of the year. We have, for example, fashioned “toolbox” sessions in response to fellows' requests to learn about the internal review board process and effective strategies to search the medical education literature.
Readings, drawn from a wide range of expertise, emerge from requests to explore new topics or from the directors' constant review of the literature. They are retained, replaced, or removed depending on how well they inform seminar discussions or on direct feedback from the fellows. We are attentive to how our “educational experiments” are received and seek feedback from the fellows about whether these innovations should be retained.
Strategy 9: Evaluate fellowship outcomes
Have the fellowships achieved their stated goals of developing the faculty as educators, promoting educational scholarship, and creating a community of educators who are agents of change? In 2004, we initiated qualitative and quantitative research studies to examine these core questions. Two of these studies will be reported separately, but we present the key findings here. Qualitative analysis of semistructured interviews with fellows suggests that their identity and confidence as educators, built on a foundation of educational knowledge and skills, is enhanced by support from a community of peers and mentors, validation by others' perceptions of them as local experts, and reflective practice and awareness. This personal development, in turn, enhances professional development and affects their career trajectories as medical educators.28
We also used CV analysis to quantitatively evaluate fellowship outcomes in key areas relevant to medical education and academic promotion. We analyzed pre/post fellowship outcomes and also compared the 2004–2005 cohort of 12 fellows with “matched peers.” Our findings showed significant changes in teaching activities, committee work, presentations, leadership, publications, and curricula implemented (manuscript in progress). Both of these approaches—interview and CV analyses— illuminate the impact of the fellowship on the graduates.
Fellowship graduates have also had an impact on their home institutions. Fellows have provided leadership and specific curricular material that have substantially influenced programs across the continuum of undergraduate, graduate, and continuing medical education. They have fashioned innovative institutional programs that have enhanced training and contributed greatly to the goals of quality improvement and patient safety. Many of these contributions stemmed directly from the scholarly projects undertaken during the fellowship year. The fellowship projects are disseminated in abstracts, workshops and other presentations, and publications.
Lastly, our fellowship efforts also impact faculty development at Harvard Medical School. The authors (C.H. and B.L.) offer a program for fellows at The Academy at Harvard Medical School.29
Strategy 10: Plan for the future
The pivotal question is how to sustain the efforts made to date, permit them to grow, and fashion new and creative methods for the continued education and enhancement of the medical educator. The economic challenges of financing faculty development programs in medical education and supporting medical educators are ongoing. We hope that philanthropic monies will be part of a solution, but the educational community must also find budgetary allocations of hard money to support faculty development. Clearly, commitment to the growth of educational talent is essential if teaching is to be truly accepted as an equal and integral part of the mission of the academic medical center.
For those institutions that seek to create a fellowship in medical education, we offer the following general considerations for successful program implementation:
* Leadership must be committed to the necessity of developing skillful educators for the system.
* A recognized, respected leader (whether clinical, research, or education based) should organize, recruit, and facilitate such a program.
* A curriculum and related programmatic strategies must be established or adapted from other sources, such as those offered in this article.
* A program should be implemented that accommodates concomitant faculty responsibilities.
* Opportunities should be created to establish and maintain a community of educators who serve to promote the enhancement of medical education within their institutions.
* Scholarly accomplishments of the fellows should be celebrated and publicized to the wider academic center community.
* Outcome evaluation should be considered from the start of the program's design and development and attended to throughout the fellowship to ensure and demonstrate quality and efficacy to stakeholders.
Funding for both new and established fellowships is, no doubt, an issue. However, it has been our experience that institutional and departmental leaders clearly recognize the value of cultivating local educational leadership and have been willing to readjust productivity expectations. Fellows are paid their full salaries. The 20% devoted to the fellowship is supported in a variety of ways drawing on philanthropic and departmental monies. A requirement of the fellowship application process is an explicit statement by the department/division chief that the fellow, if selected, will have protected time without penalty to participate in the program. It may be that academic systems will have to more specifically identify and support a defined cadre of educators by allocating designated resources to enhance the quality of teaching.
We hope the curricular content and process issues described in this article may be beneficial to institutions that are beginning or considering initiating a fellowship in medical education. We are exquisitely mindful of Schön's30 insight that
learning all forms of professional artistry depends, at least in part, on conditions similar to those created in the studios and conservatories: freedom to learn by doing in a setting relatively low in risk, with access to coaches who initiate students into the “traditions of the calling” and help them, by “the right kind of telling,” to see on their own behalf and in their own way what they need most to see.
Perhaps the key elements in successful educational faculty development and behavioral change are an experience rooted in kindness and safety, and a continued opportunity to practice, under programmatic or peer supervision, the skill set of an effective teacher. The reward of “teaching the teachers” is enormous, and we offer our reflections as an educational resource to our colleagues and those whom they touch.
The authors wish to thank Nancy S. Searle, EdD, program director for faculty development and recognition, Office of Undergraduate Medical Education, Baylor College of Medicine, for her critical review of this manuscript.