Lown, Beth A. MD; Newman, Lori R. MEd; Hatem, Charles J. MD
Academic health centers in the United States have as their primary mission the fostering of excellence in scientific research, clinical care, and medical education. Faculty development has become increasingly important as academic communities recognize that a mastery of scientific content, research, and clinical skills does not in itself necessarily translate into educational expertise and desired learning outcomes.1 Educators have developed several strategies to meet the need for such expertise and learning outcomes, including longitudinal medical education fellowships and immersion experiences.2–14
The Rabkin and Mount Auburn fellowships in medical education were established at two Harvard teaching hospitals—Beth Israel Deaconess Medical Center in 1998 and Mount Auburn Hospital in 1999—to prepare faculty for academic careers in medical education. These fellowships, described earlier2 and in another article in this issue of the journal,15 are grounded in the principles of adult and experiential learning, reflective practice, and humanistic philosophy.16–20 The goals of the fellowships are to help faculty develop and enhance their skills as educators, to provide faculty with an opportunity to conduct research or an educational project, to support the Fellows as educational leaders and change agents, and to create a community of committed medical educators. The Fellows at each site meet weekly for two-hour seminars during the academic year to discuss topics and practice skills related to medical education and medical education leadership.21 In addition, the Fellows are expected to develop, implement, and evaluate a medical education project. All Fellows attend sessions together on medical education evaluation and research.
The authors initiated the evaluation of the fellowships, being mindful of our own goals and the calls of education researchers to evaluate programmatic outcomes beyond participant satisfaction1,22 by using models such as that of Kirkpatrick23 to evaluate attitudes, knowledge, behaviors, learning outcomes, and institutional changes. Faculty development leaders elsewhere have responded with a variety of evaluation methods, including surveying participants, analyzing graduates' productivity by an analysis of their curricula vitae,24 and creating programmatic curricula vitae.4 Nevertheless, information remains sparse on the impact on teaching faculty of faculty development offerings in general and of medical education fellowships in particular. Although there have been recent attempts to evaluate these offerings,3–11,13,14 little has been published on the perspectives of the graduates of medical education fellowship programs, particularly with respect to their personal development.
Important questions remain. Palmer25 suggests that “we teach who we are.” If so, what is the impact of faculty development, not only on outcomes and what graduates do, but on whom they become as persons and how they view themselves as educators and their interactions with their students? Do faculty development programs change participants' self-perceptions and behaviors? How do learning communities affect the development of the medical educator? What are the key elements of faculty development programs that foster personal and professional change? Because these important process questions are directly related to the goals of these two fellowships in medical education, we included them as components of programmatic evaluation.
We initiated qualitative and quantitative analyses of our fellowship programs in 2004; quantitative findings will be reported separately. We report here the qualitative analysis of semistructured interviews with seven classes of Fellowship graduates. In this research, we explored the Fellows' perspectives on their skills, their self-perceptions (including identity, self as change agent, and confidence), their participation in learning communities, the evolution of their projects, and their reflective practices. In short, we examined how and why a fellowship in medical education affected graduates' development, both personal and professional.
Study Participants and the Recruitment Process
All of the 43 physicians who had graduated from either the Rabkin or Mount Auburn fellowship from 1999 to 2005 were eligible to participate in this study. The study was approved by the institutional review boards of the Beth Israel Deaconess Medical Center and the Mount Auburn Hospital. A letter of invitation and description of the study were sent by postal mail to eligible faculty. We were unable to locate one former Fellow. A follow-up inquiry was e-mailed to nonresponders one month later. Forty-two Fellows consented to participate in a telephone interview, but two were unavailable at the time of the scheduled telephone interview. Therefore, 40 of the 43 fellowship graduates participated in the semistructured interviews, which were conducted between June 2005 and February 2006.
Faculty members affiliated with Harvard Medical School are selected for one of the fellowships through a competitive application process that attracts persons from a variety of disciplines. Fifty-six percent of the 43 Fellows who graduated between 1999 and 2005 were women; 80% self-identified as Caucasian, 16% as Asian, 2% as Latino, and 2% as African American.
Semistructured interview process
We developed nine questions to explore Fellows' perceptions of the extent to which the goals of the fellowship had affected their personal and professional development (List 1). A trained research assistant conducted audiotaped, standardized, semistructured interviews; each interview took approximately 30 minutes. The audiotapes were transcribed and deidentified.
We used qualitative, grounded theory methods to analyze and code the data and to build a theory from the data.26 We undertook multiple cycles of reading the transcripts, using the constant comparative method to group concepts within themes and to clarify and rename each theme until the data were fully described and categorized. Each author then independently coded all transcripts. We discussed coding discrepancies and revised the themes and their descriptions to better represent the data. Two of us (B.A.L. and L.R.N.) then independently recoded, discussed, and reached consensus on all 40 transcripts. We then entered the data into a qualitative analysis software program (HyperRESEARCH, version 2.6.1; ResearchWare, Randolph, Mass) to generate reports and to perform theme frequency counts. The themes are described in the Results section.
We used three methods to ensure the trustworthiness of our research.27 First, we conducted deliberate searches for positive and negative examples of each theme and coded these accordingly. For example, within the theme, “Role models and mentoring,” we identified 77 quotes in the transcripts that we coded as “Perceived support and examples” and 6 quotes that we coded as “Wished for more mentoring” (Table 1). Second, we conducted an external audit of the data by randomly selecting 25% of the transcripts for independent review. A qualitative researcher with no role in the fellowships reviewed and coded this subset by using the final list of described themes. Third, we performed a literature review to compare our study's themes with those of other qualitative researchers who had analyzed outcomes of faculty development in medical education. The search strategy and results are described in Appendix 1 and Appendix 2, respectively. During the final analysis process, we examined the relationships between our themes and compared our themes with those of previous investigators to build a grounded theory about the results.
We identified 11 themes in our analysis of the 40 transcripts: (1) the understanding and application of concepts and skills, (2) identity, (3) general comments or suggestions for change, (4) community, (5) reflective practice, (6) confidence, (7) career development, (8) role models and mentoring, (9) perceptions of others, (10) time, and (11) project evolution. These themes are described in Table 1. Agreement between the research team's coding and that of the external research auditor was 99%.
The understanding and application of concepts and skills
The most commonly coded theme was the understanding and application of concepts and skills. Fellows spoke about the importance of learning the historical context of medical education, the principles of adult learning, the language and vocabulary of education, and specific educational strategies and teaching skills. Their comments demonstrated their understanding of the centrality of learner-centered teaching. One Fellow wrote, “[I]t's really a structure of trying to find where my learners are … on what level I'm going to need to teach them, find the teachable moment, provide them with a little bit of evaluation, and then [provide] some feedback on how they're doing.”
Participants mentioned learning specific skills practiced in the fellowship, such as lecturing, creating educational contracts, teaching at the bedside, providing feedback, developing curriculum, and leading small-group discussions. Some also described learning the meta-cognitive skills necessary to become a “participant-observer” in order to reflect during the act of teaching—skills emphasized throughout the fellowship. One Fellow wrote, “[T]oday, whenever I'm in a teaching encounter, I'm not just thinking about what I'm teaching, but I'm thinking about how I'm teaching…. I'm much more conscious of the process, which [is] very different than when I started.”
Several Fellows commented that the lessons learned can be broadly applied, including in their clinical, administrative, and leadership roles. One Fellow wrote, “[T]here are things about team dynamics, about being a good listener, being a good communicator, knowing when to intervene, knowing how to manage conflict, that came out of the Fellowship [and] that I still use today.” At the same time, some Fellows had difficulty distinguishing between what was attributable to the fellowship and what was attributable to other significant faculty development activities.
Identity was the second most commonly coded theme. Most of the Fellows said that the fellowship enhanced their sense of identity as medical educators. For some, the fellowship clarified a nascent or preexisting identification as an educator. Others described a sense of transformation, kindled by the fellowship, that continued to evolve over time. One Fellow wrote, “[T]here's a lot of comforting… inspirational value, actually, to the fellowship…. [T]hose sorts of experiences are really transforming, and… I think several folks who go through the fellowship have a similar kind of slow dawning… as they move forward.”
Most Fellows described a deepened sense of purpose and commitment. They spoke of a renewed passion for their roles and a desire to inspire others. One Fellow wrote,
[W]hat's more important and more difficult to impart… is your own sense of vitality about what you do and your own sense of questioning and growth as a physician and as an educator…. I hope to live up to that … challenge of continuing to improve and inspire and instill.
Many Fellows described a newfound sense of empowerment and self-efficacy. One Fellow wrote, “I'm more willing to start a creative process, thinking that I can do it, having gone through the fellowship, than I would have [been] before.” Another Fellow wrote, “I'm less afraid to … stand up and say, ‘This is what I think is right for the medical students, and I'm going to fight for this because this is what they need and deserve.’” Several Fellows were willing to describe themselves as change agents. One Fellow wrote, “I feel like the fellowship gave me skills and knowledge that have put me in the position where I am [able] to feel like I can be a change agent.” Others were ambivalent about the term “change agent,” describing their role instead as leader, educational innovator, and collaborator.
The Fellows developed a sense of community within the fellowship. They valued the opportunity to meet regularly with like-minded people from other disciplines and institutions. They developed a sense of trust in the fellowship group over time that advanced both their personal and collective learning. One Fellow wrote, “[I]t was helpful to have that reflective mirror held up into one's self with a group of colleagues that you came to know and came to trust, so that your intrinsic strengths and weaknesses were both brought forward.”
The Fellows also described a sense of connection to the larger community of medical educators with whom they shared a common language and interests. For some, this sense of connection provided a sense of support and collegiality, and, for others, it was an “admission ticket” to an academic career and a stimulus to network both locally and nationally. One Fellow wrote, “I have more opportunities to be involved in things, mainly because there's a network now that I feel part of…. [Y]ou're part of a bigger community of medical educators now going towards a common goal.”
The Fellows commented on their wish for more time to connect, noting the difficulties of time constraints and the fact that the other Fellows were working in different institutions. Some Fellows continued to meet regularly after the fellowship year ended.
The Fellows discussed the importance of reflection, not only to facilitate their ongoing learning and improvement, but as an approach to life and self-renewal. This is a quality they wished to model for their learners. One Fellow wrote, “[I]t's one of the more important lessons that I carried away…. The way to sustain yourself through a career is to continually grow, and that growth takes some tending to, and that tending-to really is the practice of reflection on the work that I do.”
The reflective strategy the Fellows used most frequently was to become proactive about seeking feedback. While many didn't necessarily record their own reflections, some have since incorporated into their own curriculum development efforts a requirement for written reflection. One Fellow wrote, “We're just working with this new pilot curriculum, and we've built in monthly self-reflection written pieces as part of a journal or portfolio for the students…. [I]f we're going to build on this concept of lifelong learning, reflection has to be a key component of that.”
Most Fellows expressed a sense of enhanced confidence in their knowledge, abilities, and credibility as medical educators. As evidence of this, they cited their willingness to take on educational challenges or leadership positions, to network nationally with other medical educators, to ask for feedback from learners and peers, to provide educational consultation, and to help others improve their teaching. One Fellow wrote, “I was asked to take over the physiology course at this medical school…. I felt much more confident about doing that, having done this fellowship, than I might have been otherwise. I probably would have pulled back a bit from that kind of a leadership role.”
Confidence evolved over a period of time that varied, depending on the Fellow. One Fellow wrote,
[D]uring the fellowship, I wasn't a very confident participant, and I was often not saying very much…. [I]t wasn't until actually two years later where I started seeing [that] the bits … I had learned and the things that I had practiced in the fellowship really have a lot of relevance in what I was doing in my job…. [I]t sort of all jelled in a delayed fashion.
Some Fellows cited confidence as a factor that gave them the flexibility to be learner-centered, to share control of the goals and shape of teaching sessions, and to shift course when particular educational strategies weren't working well. One Fellow wrote, “[N]ot only do I feel like I'm a good teacher, but I understand much more of what I'm actually doing. So if something didn't work right, I can sort of adjust it midstream.”
A few Fellows mentioned that their deepened understanding of medical education heightened their sense of how much more there was to know and do. This awareness didn't necessarily increase confidence but, rather, created an acute sense of the need to improve. One Fellow wrote, “I see what I do so acutely that I think I'm beginning to see where I'm kind of bumbling it…. I also know how to just say, ‘You know, that really wasn't very good.’”
The Fellows discussed seeking and being offered new roles and career opportunities. While some described this occurring as a result of the fellowship, others acknowledged that it was difficult to attribute this solely to the fellowship. The types of opportunities mentioned included taking on the directorship of a course, a clerkship, a clinical service, or a graduate medical education program; serving on local or national education committees; developing undergraduate, graduate, and national-society-based curricula; and receiving education research grants.
Some described considering medical education as a viable academic career path for the first time after the fellowship. One Fellow wrote, “[T]here was so much support and [a] clear vision about how promotion paths could be modified and changed at different institutions in order to reflect the value of work that clinician educators do in a similar way as researchers.”
Many commented on the exposure and recognition resulting from the fellowship as a factor that contributed to new career opportunities. Once on this career trajectory, many Fellows described a cycle of increased responsibility and recognition as medical educators. One Fellow wrote,
[I]t's that domino sort of thing. I don't think those things would have happened if I hadn't developed an interest early on, and I don't think any of that would have happened if I hadn't taken on the responsibility, and … it's unlikely that would have happened if it weren't for the fellowship.
Role models and mentoring
Many Fellows described the mentoring activities of the fellowship leaders, including the establishment of expectations coupled with support. The fellowship leaders' modeling of their own continuous learning and of attributes such as kindness and affirmation was also mentioned frequently as a primary take-home lesson of the fellowship. One Fellow wrote,
[T]he factual material and all those sorts of things eventually dribble away, but the encounter with a living, vibrant person who's striving for herself to be better and better, to learn more and more, and to know how to impart learning … that's really what I took away from [the fellowship leaders]…. [T]hose kinds of encounters are pretty rare in life.
The example set by the fellowship leaders strengthened Fellows' belief that a career in which medical education was a significant component was feasible. One Fellow wrote, “For all of us as Fellows, it was more of an eye-opening experience, the introduction to see, ‘Oh, this is something that we actually could do ourselves.’”
Over time, many of the Fellows came to regard each other and former Fellows as important sources of support and collaborative mentoring. One Fellow wrote,
We can think of each other as mentors, we can think of each other as someone we can go to when we have problems, and we also are a part of this extensive network now, so that all of those Fellows who know what my interests are can steer other people toward me and [vice versa].
Perceptions of others
Many Fellows talked about the perceived value of the credential of having completed the fellowship, which they felt made them more widely regarded as education consultants and experts within their departments and nationally. One Fellow wrote, “I think that people look to Rabkin graduates to be the leaders in education at the medical center.”
Many won awards in recognition of their teaching excellence. Fellows' enhanced sense of confidence as educators contributed to the positive perceptions of others, which in turn further enhanced their willingness to voice their thoughts and assume new roles. One Fellow wrote,
[T]he fact that I took this course suddenly made people see me in a different light…. I suddenly had confidence when I was speaking because I felt like I had much more knowledge, plus the fact that I have this credential people can point to, and therefore [they are more likely to suggest me for] these positions.
Fellows spoke both of the luxury of having protected time in which to learn and reflect with like-minded people and of the wish for more time to meet, read, experience, and digest the lessons of the fellowship. One Fellow wrote, “[Y]ou sort of escape your day-to-day activities and refocus on the topic of education…. Unfortunately, you've got to shift in and shift out…. [T]he trick is trying to incorporate those things into whatever… your real world is.”
For some, the fellowship came at a particularly opportune time in their careers. One Fellow wrote, “[T]he fellowship was a pivotal time in my career [that] provided the support from a group of colleagues [who] viewed medical education as a formal path by which people can receive training, study their work, and evaluate their work.”
The Fellows conduct medical education research or work on an educational project to apply lessons they learned during the fellowship. Their projects reach various stages of evolution over the course of the year. Some complete their projects during the fellowship year, but most continue to develop their projects, sometimes over several years. Some incorporate aspects of their project into new activities. One Fellow wrote, “[My project] evolved pretty dramatically, both in the year of the fellowship and in a few years that followed…. I developed another related curriculum because of my involvement in it. So it was a very powerful vector for a lot of good work.”
Many Fellows noted the difficulty of initiating and sustaining change in their institutions. Factors contributing to this difficulty included the scope of their project as originally conceived and the barriers to accessing necessary resources. One Fellow wrote, “I was hoping to get something done within a six-month time period, and the scope of the project was… just too large… I've since… kept a similar overall goal but have basically lengthened my timescale by… years, rather than months.”
Several Fellows had implemented new curricula at their institutions and described institutional changes that had resulted from their fellowship projects, particularly those linked with hospital quality-improvement efforts. One Fellow wrote, “I evolved the housestaff curriculum for heart failure…. I do think the project had some value because it was folded into some aspects of the care that patients were receiving via the automated order-entry system.”
General comments or suggestions for change
Fellows shared their general reflections and offered suggestions for change, such as implementing project benchmarks, allowing for additional skills practice, focusing more on medical education research design, assigning project mentors, and establishing writing and publication requirements. Most of these suggestions have since been incorporated into the fellowship. Some Fellows wanted more rigor, but others stated that they had difficulty in keeping up with the fellowship requirements, along with their other professional and personal responsibilities. Their comments acknowledged the challenge of balancing the breadth and depth of curriculum. One Fellow wrote,
I wanted a lot more time in several of the areas that we had been through…. [W]hen I got to the end of the course, I said, ‘I'm glad that they didn't listen to me….’ [I]t exposed me to things that I thought were not very useful but [that] became useful because they related in a funny way to something else that was going on.
Several Fellows suggested options for increasing the time spent within the fellowship, including longer or more frequent sessions and increasing the length to two years.
The fellowship graduates in this study reported changes in attitudes, knowledge, behaviors, social networks, self-perception, and others' perceptions of them. We were particularly interested in exploring the fellowship's potential effect on personal development, as reflected in shifts in self-perceptions, including identity, confidence, and leadership capacity. Entering Fellows bring a wide range and length of career experience. Not surprisingly, they described a spectrum of reactions to the impact the fellowship had on their sense of their identity as educators. Some had previously self-identified as educators; many described significant enhancement of this sense of themselves. Others spoke of a transformative experience and a profound shift in their sense of identity and in their career path. Prior research also noted a range of faculty development effects, from career-altering to career-affirming and -expanding and to career-neutral.28 Those Fellows who described a sense of transformation remarked that the fellowship had come at a particularly opportune time in their careers, when they were open to new ways of thinking and being. The Fellows in this study described a sense of empowerment and self-efficacy, which they associated with newly honed knowledge, skills, and confidence and with greater recognition by others. This change is significant because self-efficacy beliefs have been shown to be strongly correlated with motivation and enhancement of the performance of both teachers and learners.29 The Fellows described a deepened sense of mission to inspire and model learning, a greater passion for their roles as educators, and a greater commitment to their learners. Some Fellows were willing to identify themselves as leaders and change agents, whereas others found it difficult to make that claim.
Fellows described the development of their self-confidence as evolutionary, based on their personal context, knowledge, ability, and opportunities to apply the lessons of the fellowship. Positive feedback and others' perceptions of them as local experts further enhanced self-confidence. In contrast, for some, self-confidence decreased as their knowledge and self-expectations increased. This progression from what Adams30 called “unconsciously unskilled” to “consciously unskilled” has also been described by other education researchers.31
Feeling connected with a larger community of educators was also instrumental in enhancing Fellows' development. Trust within each fellowship group grew over time and provided a safe haven for expression and experimentation. Self-identification as a member of one of these groups and of a larger “community of practice”32 with similar values and interests provided a sense of validation, as well as career and networking opportunities. Membership in a community of practice is significant, because researchers have found that collegial networks are a significant predictor of academic success.32,33 Protected time to be in community with like-minded individuals and to learn and discuss issues of common interest, separate from the other demands of professional life, provided “a little oasis of reflection” that facilitated all of the processes described above.
The Fellows described the development of skills such as being more flexible while teaching, combining learners' needs with their own knowledge and expectations, and shifting gears in midsession to better meet these needs. This ability to move fluidly between being learner- and teacher-centered during an educational encounter might be called “relationship-centered teaching,” and it represents the integration and synthesis of teachers' and learners' agendas and needs within a given context. The Fellows described this capability as being facilitated by their growing self-confidence and the process of reflection-in-action.
Despite calls for mixed-method analysis of learner and programmatic outcomes of faculty development in medical education, our literature review yielded only five articles with well-described qualitative methods and reporting of themes8,10,34–36 (Appendix 1). Common themes across these studies and ours suggest several factors that contribute to personal and professional development during and after medical education fellowships. Protected time and a supportive learning environment create the conditions necessary to foster faculty development. Our analysis suggests that a key factor in changes in identity and confidence was a Fellow's strong foundation of knowledge of educational principles and applied skills. Other important factors were an enhanced sense of self-efficacy, greater credibility as perceived by others, self-reflection and self-awareness, and support from a community of peers and mentors. Identity was further strengthened by membership in a social group of valued colleagues who are interested in medical education. For most Fellows, this personal development led to professional growth, as they felt enabled and empowered to take on new challenges, to pursue career trajectories in which medical education responsibilities occupied an expanded role, and, in some cases, to effect institutional change.
Our analysis supports the theory that the evolution of personal identity, confidence, and self-efficacy fostered by the common themes mentioned above promotes professional development in a career trajectory that includes medical education as a central focus. We suggest that these common themes constitute “essential elements” in faculty development fellowships in medical education.
This study has both limitations and strengths. Our analysis is based on participants' self-reporting and is not correlated with observed teaching behaviors and learning outcomes. The individuals studied are highly motivated and may have achieved the same degree of professional development without the fellowship, although their comments suggest otherwise. Self-reporting and rich descriptions serve equally as the study's strengths, because they provide windows into the Fellows' perceptions and experiences. The qualitative study design enabled us to identify and examine relationships among significant themes that contribute to the development of medical educators, and to develop a theory about why such development may occur.
We concluded that faculty development programs in medical education would benefit from additional research to deepen the understanding of the processes that enhance their effectiveness, particularly as they correlate with important faculty, learning, and programmatic outcomes.37 The identified “essential element” themes could be used to inform survey instruments that could evaluate outcomes, improve programs, and demonstrate their necessity. Collaboration among institutions to develop, validate, and implement such instruments would simplify evaluation processes, provide common language, and add significantly to our understanding of how adults learn, how best to teach, and how to create communities that foster the personal and professional development of medical educators.
The authors wish to acknowledge the assistance of Dr. Anna Johannson who conducted the external audit of our themes.
All authors receive salary support from the Beth Israel Deaconess Medical Center, where the Rabkin Fellowship is based, and Drs. Lown and Hatem also receive salary support from Mount Auburn Hospital, where the Mount Auburn Fellowship is based.