To understand the Osler Fellows' experiences and perceptions, we conducted a qualitative descriptive study18 in the Faculty of Medicine of McGill University in the winter of 2008. The primary method of data collection was semistructured interviews.
We sent an e-mail invitation to all 29 of the 32 Osler Fellows who had participated in the faculty development component of the fellowship, requesting their participation in an interview at a time and location convenient to them. We followed up with nonresponders via a telephone call. Of the 29 Osler Fellows, 23 (79%) participated in the interviews. The six who did not participate were unavailable during the study period (November 2007 to February 2008); no one refused to participate. At the time of the study, the Osler Fellows and their students were midway through the third year of the four-year program.
The Osler Fellows whom we interviewed came from the following disciplines: family medicine, emergency medicine, pediatrics, surgery, medicine, psychiatry, diagnostic radiology, neurology and neurosurgery, palliative care, rheumatology, obstetrics–gynecology, and urology. Nine (40%) of the Osler Fellows we interviewed were female, and all had an appointment at McGill University. The interviewees had been on staff for 5 to 22 years (with a mean of 11 years). Of the 23 interviewed, 17 (approximately 74%) had attended other faculty development activities at McGill. Those who did not participate in the interviews were similar with respect to gender, departmental affiliation, years on staff, and previous attendance at faculty development programs.
A research assistant with experience in qualitative research who was not associated with the Osler Fellowship conducted all of the interviews. The interview questions were pilot tested with members of the Centre for Medical Education and tapped three major areas of inquiry:
* What motivated clinical teachers to accept the invitation to be Osler Fellows?
* What was it like to be an Osler Fellow, and what was the impact of this experience?
* What were the Osler Fellows' perceptions of the faculty development component of the Osler Fellowship, and how did this program differ from other faculty development initiatives in which they had participated?
Most questions were open-ended to enable participants to talk freely about the issues. Probes accompanied each question to stimulate thinking, to encourage detailed, expansive responses, and to solicit examples of more general observations. During the face-to-face interviews, which lasted 30 to 45 minutes, the interviewer took minimal field notes; he wrote more extensive field notes within 24 hours of the session to capture main themes and preliminary impressions. The interview questions evolved slightly as the process unfolded; when salient issues emerged in one interview, the interviewer reiterated them in subsequent conversations to test for relevancy.
The McGill institutional review board (IRB) approved this study. Participants did not give written consent because the IRB deemed such consent unnecessary. However, the interviewer began each session by stating that the session would be audiotaped and that names would remain confidential in the reporting of results. The interviewer also allowed participants to request that their contribution not be recorded. All of the interviewees agreed to the audiotaping of their interviews.
Following a recognized qualitative descriptive methodology,18 we transcribed all interviews using standard rules of transcription. We removed identifiers and names from the final transcripts and checked each transcript for accuracy. Thematic content analysis guided the data analysis.19 Two of us (Y.S. and D.B.) independently read all transcripts, identified recurrent themes through multiple, close readings, and agreed on the final themes by consensus. We noted similar themes across transcripts, assembling and analyzing these together. A third investigator (M.B.) read a third of the transcripts to contribute to the confirmation and refinement of the emerging themes; no new themes were added. The final step in the analysis included developing major themes and their component subthemes as well as identifying exemplar quotations to illustrate each theme.
For the purpose of this report, we grouped our findings according to the three areas of inquiry listed above.
A. Why clinical teachers accepted the invitation to be Osler Fellows
Three themes emerged in response to the question of why teachers accepted the invitation to be an Osler Fellow: (1) the honor and recognition of being chosen, (2) the perceived “match” between the goals of the course and personal and professional values, of which one was “to make a difference,” and (3) the desire “to connect” with students.
The honor of being chosen.
Faculty members appreciated both the letter of invitation from the dean and the course director and the sense of recognition that accompanied this request, as noted by a senior physician:
It was put to us as something very special, as recognition of our histories and our track records as teachers and educators.
A younger colleague observed the following:
It hasn't given me any prestige in terms of my colleagues … but there is a quiet, internal recognition that somebody […] thought that I'd be a good teacher and a good person to be part of the initial program.
The cachet of Osler's name also played a role in this sentiment of honor and recognition, as noted by an experienced teacher:
McGill doesn't allow the name of Osler to be attached to very many things…. I thought that was a sign that the university is really putting its weight and its belief behind the program.
The match between program goals and personal/professional values.
A number of the Osler Fellows commented that the renewed curriculum matched their personal and professional interests (e.g., an emphasis on professionalism), and they saw their involvement as an opportunity to reconnect to the faculty of medicine, to get to know the students, and to make a difference in medical education by focusing on the physician as healer and professional, a value they considered missing from the previous curriculum. Others commented that it was their “obligation” to participate, especially as the direction of the renewed curriculum was too important to ignore.
There was something about the physicianship program that talked about professionalism and healing. And it's that healing element that I've always been looking for; for a long time I felt that this was missing from medicine and from medical education.
The connection with students.
Related to the sentiment of making a difference was a desire to nurture and mentor students, to feel their “excitement and sense of idealism,” and to play an important role in their lives.
I think there is an opportunity, as one of the early Osler Fellows, to actually shape this curriculum and make it better … and to make a difference in the lives of our students.
B. Perceptions on being an Osler Fellow
The notion of connection and reconnection emerged as a major theme in the Osler Fellows' descriptions of their experiences. This theme included four subthemes: (1) the joy of working with students (and in the process reconnecting with the rewards of teaching), (2) the desire to make a difference (and in the process reconnecting with medical education), (3) the process of reflection and renewal (and in the process reconnecting with core values), and (4) the building of community (and in the process reconnecting with colleagues).
The joy of working with students.
Most of the Osler Fellows commented on the joy of working with students, watching them “grow and develop” over time, and helping them in the “journey” of becoming a physician. Many of the Osler Fellows likened their role to that of a parent and, in so doing, identified a sense of satisfaction that came with making a difference in someone's life, honing skills, and having an impact on the future.
What has been overwhelmingly positive has been to watch these six youngsters change over time and see how they've changed. They are in their third year now, my little cohort…. It's like when a bunch of parents, a bunch of mothers, take their kids to the playground. You get the sense that those mothers are collectively looking after those kids. So this is a group that is collectively trying to do something for the next generation.
You are taking them from day one, and you are following them to year four, and so, you really kind of get to hone … not just their interview skills but also their physicianship skills throughout their entire training. And it's like seeing your children grow up.
The desire to make a difference.
In describing their experiences, the Osler Fellows highlighted their desire to make a difference in medical education and their students' lives by addressing core values (e.g., the physician as healer and professional), by “saving” or “restoring” medical education (and in so doing, returning something that was lost), and by teaching students how to be physicians.
The language of medical education is changing, and we are being taught skills about encouraging aspects of physicianship which have been neglected. And I like that. I want to be a part of that.
We want to be a constant reminder that there is a dimension which isn't in the books [but] which is underlying everything that they'll do throughout their career[s].
The process of reflection and renewal.
In diverse ways, the Osler Fellows saw this experience as an opportunity to reflect, to confirm or restore their values, and to “feel again.” In fact, many saw this as an occasion for renewal—as both clinicians and teachers. As clinicians, the Osler Fellows commented on how working with students “forced” them to reflect on their own behaviors and look at themselves “through their students' eyes.” As teachers, they felt that their experiences as Osler Fellows had an impact when teaching other students or residents in the clinical setting. For some, this process was “confirmatory”; for others, it was “rejuvenating.”
I never considered myself […] a jaded doctor [who] lost sight of the big picture. But it's kind of like falling in love with your wife or your spouse or your significant other again because, as I say, this program on a personal level brought back all of the things that I [had] initially fallen in love with … what [it is] to be a physician exactly.
Sometimes I catch myself (with my patients) and say “Well, I'm not doing what I taught them to do last week.”… And they rejuvenate you because they see this as the reason you went into it, into your career to start with, and why you really got turned on by medicine.
A number of the Osler Fellows also commented that this experience, that is, working with students and participating in the faculty development workshops, had an impact on them personally and professionally.
It's making me a better teacher. It's making me a better physician, and I'd even go so far as to say it's making me a better person.
It has made me more confident in the presence of other physicians when trying to do the right thing…. I feel much more confident and I now stand up and say, “No, that's not right.”
The building of community.
Finally, the majority of the Osler Fellows valued the sense of community and collegiality that had developed among them:
It's a group of people with shared values and beliefs who come together to discuss those and try to teach others and propagate the belief…. And I guess what makes the community mature is that you start to understand each other's strengths.
In part, this sense of community was due to a sharing of common goals and values; in part, it was due to a sense of “mission” and newly shared experiences, including the faculty development program that brought them together on a regular basis.
I'd say it's a community because we are all focused on teaching a certain thing, on finding meaning in the teaching…. When I meet up with Osler Fellows in the hospital, or cross paths with them, I certainly feel like there is a connection.
C. Perceptions of the faculty development component of the Osler Fellowship
In discussing the faculty development workshops, the Osler Fellows highlighted five aspects that they found particularly valuable: (1) a focus on a common purpose, (2) a “different” kind of content, (3) a sense of continuity, (4) the opportunity for peer mentorship, and (5) belonging to a community. A number of the Osler Fellows also commented that these activities were different from the “usual” faculty development workshops at our university.
A focus on a common purpose.
Most of the Osler Fellows commented that they valued the fact that they were all “in the same boat” and had similar goals and expectations. They particularly appreciated the fact that the workshop objectives were relevant to their needs, that the content was immediately applicable, and that the activities gave them a “head start” in working with their students.
These workshops focused on what we are supposed to be doing…. There is an immediate application.
Here there is a job that you are doing…. You are together because you have a job.
A “different” kind of content.
The Osler Fellows also observed that the content in these faculty development sessions was different than what they were used to. In part, they saw the emphasis on narrative medicine and reflective practice as “thinking outside the box;” some also saw the content, with the emphasis on healing and professionalism, as a positive value.
It has another level of meaning which is deeper than some of the other faculty development workshops I've been to. When I usually go to faculty development, it's much more cut and dry about how you teach a procedure, how you show a student how to search the Internet, how you guide someone through the critical appraisal of a study; there is very little that deals with the art of medicine. It's all about the science….
I guess it's the material we are focusing on, the physician as professional and healer and the transition from layman to physician. Just the definition of those things—healing and professionalism—these are value laden, as opposed to [workshops such as] “teaching when there is no time to teach.”
A sense of continuity.
The Osler Fellows valued the feeling of continuity that they experienced—with each other, with the faculty developers, and with the content that ran through the sessions. A number of the Osler Fellows highlighted continuity as a distinct difference when comparing these workshops with more traditional faculty development activities.
In Osler workshops it's always the same group, so we get to know each other….
We get to feel more at ease at challenging and being challenged because you get to know the people who are there.
For faculty development you usually come for a one-time session; you want to learn something and then you leave…. The Osler Fellowship is like, you leave, and you have to use what you have learned with your group, and you come back another time, and [you] exchange based on what you just did.
An opportunity for peer mentorship.
The opportunity to exchange information with colleagues was identified as one of the most helpful aspects of these faculty development workshops. Moreover, the chance to discuss ideas, experiences, and information had the noted benefits of “reassuring” the fellows that they were on the right track and helping them to remain “grounded.” In many ways this sharing of experiences and collective problem-solving was considered more valuable than the transfer of information, though most felt that one would not have happened without the other. As two junior colleagues noted,
I learned things, but I've enjoyed the social aspect more. Hearing [the other Osler Fellows'] thoughts, hearing their problems, hearing their conclusions of how things are going…. That was more important than the activities.
So the transfer of information has been very useful. But I think secondly and possibly more importantly, has been meeting with other fellows and talking to them and seeing how they are doing their part, how they are setting up their meetings, seeing that they are experiencing some of the same challenges that I'm experiencing. That's been a very valuable experience.
A number of the Osler Fellows likened this experience to a peer mentorship. They felt that the group often guided them, and that they were learning about mentoring through role modeling—that is, by watching their peers and the group facilitators. The Osler Fellows also identified the notion of being treated with respect—and the sense of recognition that resulted from this respect—as an important aspect of this faculty development initiative.
To discover that others agree with me, that is very powerful…. I learn a lot from the other Osler Fellows. There are probably two or three of them that come to mind who have participated over the years in many faculty development workshops…. They add a lot for me as a junior Osler Fellow, in how to deal with students and how to teach.
As teachers and as clinicians, we tend to operate in a bit of a vacuum. We sort of do our own thing, and we think we are the only ones facing certain struggles. Within this program, you meet with peers and have an open dialogue about the issues we are facing…. We learn that we are not alone.
Belonging to a community.
As this last quotation suggests, the Osler Fellows developed a sense of collegiality through the faculty development workshops. This sense included the notion of belonging to a community as well as a confirmation, or reinforcement, of shared goals and values. The fellows also iterated the value of collective problem-solving in the context of a community.
There is that common bond. So that set these apart from the other faculty development [activities].
It's a place for us. In the same way that students feel that there is a place for them, this is a place for us.
A number of key themes emerged in this exploration of the Osler Fellowship. First, many of the Osler Fellows reported a sense of recognition and honor that included acknowledgment by the faculty of medicine in being chosen, honor in being named an Osler Fellow, and a feeling of privilege in accompanying students on their journey of discovery. From their perspective, the experience of working with students and watching them develop encompassed the values we try to emphasize in medical education, the idea of “bringing back something which was lost,” and the responsibility of teaching students to be compassionate physicians. The interviews also highlighted the joy of connecting with students, the desire to make a difference, the value of reflection and renewal triggered by the faculty development program and the Osler Fellows' meetings with students, and the building of a sense of community. In many ways, becoming an Osler Fellow helped these faculty members to connect—or reconnect—with the rewards of teaching and core values guiding the profession. The Osler Fellows identified the notion of connection both in their experiences with students as they watched them grow and develop across four years and in their work with colleagues for whom they felt a great sense of admiration and respect. The growth and learning with colleagues also led to a strong sense of community that the faculty development program brought to the fore. This sense of community included the privilege of working with colleagues in a respectful manner, sharing feelings, discovering that colleagues face similar challenges, and watching peers find solutions to common problems. Faculty development for the Osler Fellows, a stable group of participants over time, was also strengthened by a common purpose, content that the teachers could apply immediately, reflection and peer mentorship, and the emergence of a community of practice.
Medical educators often talk about the difficulty of recruiting faculty members for educational tasks or the possibility of burnout secondary to volunteerism.20,21 Surprisingly, neither recruitment nor burnout was a challenge in the Osler Fellowship, and we believe that a number of the lessons learned from our experience may be applicable to other settings. For example, the name, Osler Fellow, endowed the program with a clear sense of value. The faculty members' sense of honor and recognition in participating—as well as their sense of reconnection that accrued over the course of the program—also added value. On the basis of these preliminary findings, we wonder whether medical educators' desire to connect with students and make a difference by contributing to the training of future generations is an aspect that deans and administrators should acknowledge and recognize more frequently in their attempts to recruit and retain faculty members. Although the heritage of Sir William Osler is unique to McGill, every school has its own historic in-house standard of excellence.
The observation that participation in the Osler Fellowship led to a sense of connection and reconnection is also of interest. In a recent study, Steinert and colleagues22 reported a sense of “disconnect” from the faculty of medicine among individuals who did not participate in faculty development activities. The fact that working with students in a program that addressed teachers' intrinsic values helped to mitigate this sense of disconnect merits attention—as do the Osler Fellows' comments regarding the benefit of seeing themselves through students' eyes. Brookfield23 has described the concept of critical reflection, particularly the importance for faculty to see themselves through students' eyes, as vital for renewal. Interestingly, the Osler Fellows highlighted this notion of seeing themselves through “fresh eyes,” and they specifically mentioned how this new perspective influenced them as both teachers and clinicians—making them more reflective, more enthusiastic, and more aware of what they were doing.
These comments (that the Osler Fellowship had an impact on the participants as clinicians and teachers) are certainly worth examining; to our knowledge, the influence of faculty development on clinical practice has not been reported in the literature to date. The clinical impact of the Osler Fellowship may be due to the nature of the faculty development content (e.g., the physician as healer and professional, narrative medicine, reflective practice, portfolio learning). It may also be the result of participating in a faculty development program while concurrently working with students to address similar goals. Recent advances in medical education have purported the advantages of work-based learning, often defined as learning for work, learning at work, and learning from work.24 In many ways, the faculty development component of the Osler Fellowship is an example of work-based learning,25,26 as exemplified in an earlier quotation: “… you have to use what you have learned […] and you come back another time, and [you] exchange based on what you just did.” The Osler Fellowship is a faculty of medicine program designed for participants to improve their mentoring and teaching skills while they mentor and teach medical students. Although McGill's usual faculty development activities focus on relevant and practical content to enhance instructional effectiveness (e.g., small-group teaching, interactive lecturing, advanced clinical teaching skills), the participants do not usually see their involvement in our workshops as essential to their job success. Moreover, one-time workshops do not usually result in building a sense of community, and we wonder whether this faculty development initiative is, in effect, an example of situated learning in a community of practice.
Situated learning is based on the notion that knowledge is contextually situated and fundamentally influenced by the activity, context, and culture in which it is used.27,28 This view of knowledge as situated in authentic contexts has important implications for our understanding of the faculty development component of the Osler Fellowship, especially as the participants' observations highlight a number of the elements of situated learning: cognitive apprenticeship, reflection, and practice.29
Closely tied to the notion of situated learning are communities of practice. Barab and colleagues30 define a community of practice as a “persistent, sustaining, social network of individuals who share and develop an overlapping knowledge base, set of beliefs, values, history and experiences focused on a common practice and/or mutual enterprise.” Further, Lave and Wenger31 suggest that the success of a community of practice depends on five factors: the existence and sharing of a common goal, the use of knowledge to achieve that goal, the nature and importance of relationships formed among community members, the relationships between the community and those outside it, and the relationship between the work of the community and the value of the activity. Many features of communities of practice, as described by these authors, seem to be implicit in the Osler Fellows' descriptions of their experiences.
The concept of a community of practice is, in part, rooted in a distinguished philosophical tradition dating to the Aristotelian idea of phronesis. Phronesis, often equated to “prudence” in English, has been defined as “practical wisdom in dealing with particular individuals, specific problems and the details of practical cases or actual situations”32—such as in the doctor–patient encounter. Dunne33 has explored the distinction between theoretical knowledge (sophia and episteme) and practical knowledge (techne and phronesis). Although scholars debate the precise difference(s) between the nontheoretical knowledge constructs, techne versus phronesis, and their respective places in medicine, they increasingly recognize the phronetic character of medical practice, most notably in bioethics34 and clinical reasoning.35 MacIntyre,36 a neo-Aristotelian philosopher, has described phronesis as a central intellectual virtue, one that must be acquired through teaching and developed through practice or habitual exercise. He also argued that this intellectual virtue could find its place in the life of a city, or in other words, a political society or community, as well as in individuals. This idea is supportive of the goals of Physician Apprenticeship. MacIntyre's definition of practice is also particularly germane to our discussion: “[Practice is] any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence … with the result that human powers to achieve that excellence and human conceptions of ends and goods involved, are systematically extended.”36(p187) The experience of the Osler Fellows parallels MacIntyre's definition of practice. The deepening and enrichment of professional identity that has occurred by participating in the Osler Fellowship is reflected not only in the Osler Fellows' ongoing work with students but in their clinical practices as well. In the context of Physician Apprenticeship and the Osler Fellowship, the word “goods” refers to purposes or ends, whether external (e.g., meeting the needs of a community—provision of professional, ethical, compassionate medical care) or internal (e.g., nurturing and amplifying personal inclinations and dispositions—self-reflection, renewal, community building). This definition also embraces notions of agency and instrumentality; that is, the agent changes in the act of doing and the practice itself extends the practitioner's excellence.
Several features of this development process, as described by Dunne and MacIntyre, are expressed in the reflections generated in the interviews. The Osler Fellows clearly described a sense of community with shared goals, corresponding to the idea of polis (city state), a community which Aristotle considered an essential ingredient for the expression and development of phronesis. The Osler Fellows also spoke of a “different kind of content,” which is congruent to the idea of the intellectual and character virtues required of individuals who possess practical wisdom. Finally, the Osler Fellows described a sense of “renewal and rejuvenation” through involvement in Physician Apprenticeship, aligning the program with the transformative powers of the human activity of “practice.”
Our findings hold implications for medical educators interested in mounting faculty development programs. Although we tend to rely on workshops, short courses, or longitudinal programs such as teaching scholars programs,37 the literature provides no descriptions of longitudinal, workshop-based faculty development programs.17 We have also not sufficiently explored the value of how faculty development activities can help to build a community of practice, or how belonging to such a community can help to develop medical educators.
This study has several limitations. Twenty-nine (of 32) Osler Fellows participated in the faculty development workshops, and of these, six were not available for interviews during the study period. Thus, we interviewed 23 faculty members in one specific program in a particular medical school; this limits the transferability of our findings to other settings. In addition, the Osler Fellows interviewed for this study were in the third year of the program; they had not completed the four-year mandate with their students. These participants were also the first cohort of Osler Fellows, many of whom saw themselves as cofounders, which gave them a strong sense of ownership of the course. Interestingly, the sense of ownership may partially explain the positive nature of the comments about their experiences. To repeat this study with another cohort of Osler Fellows, and to do so at the end of the course, would therefore be worthwhile. Understanding students' perceptions of this experience and comparing their views with those of their teachers would also be beneficial. To begin to address these questions, we have initiated a multicase study to better understand faculty and student perceptions of Physician Apprenticeship.
Despite this study's limitations, we believe that we have uncovered a number of important implications for both designing and delivering faculty development and student mentoring programs. In a recent workshop, we asked Osler Fellows to characterize the nature of their Physician Apprenticeship small groups. In so doing, they highlighted the following: the social nature of the student groups (and how this leads to the socialization of new physicians), the focus on personal and professional values, and the longitudinal experience that enabled growth and reflection over time. In many ways, these descriptors could also characterize the Osler Fellows' experiences, and we were struck by how the faculty development component mirrored their students' apprenticeship experience. To date, the literature has not highlighted the value of a longitudinal, social experience for faculty members that includes work-related content, peer mentorship, reflection, and exchange. Perhaps we should now examine how such a faculty development program can nurture the socialization of faculty members and the development of a community of practice. In particular, it might be worth exploring the interplay between faculty development and communities of practice, the differential benefits of faculty development, student mentorship and small-group facilitation, the value of this methodology for program evaluation, and the process by which the notions of techne and phronesis play out in faculty development initiatives.
This study, which examines the experiences of clinical teachers in a longitudinal course with students across four years, has shown the value of this program for increasing teachers' perceptions of connection (and reconnection) to teaching, medical education, core professional values, and colleagues. It has also demonstrated the benefits of a longitudinal faculty development course, rooted in both situated and work-based learning, that mirrored the students' experiences and helped to promote a community of practice.
Sir William Osler38 portrayed the professor as a “senior student anxious to help his juniors.” He believed that “When a simple earnest spirit animates a college, there is no appreciable interval between the teacher and the taught—both are in the same class, the one a little more advanced than the others.” In many ways, our Osler Fellows have reinforced this image of the “professor” and the value of an apprenticeship in their own development.
The authors gratefully acknowledge the Osler Fellows who agreed to be interviewed for this study, Dr. Justin Jagosh for his skillful interviewing and assistance with data transcription, and the Max Bell Foundation for its financial support of the Physicianship Program. The research team also thanks the Newell Trust for Research in Medical Education for an educational grant that made this research study possible.
The Max Bell Foundation supported the development and implementation of the Physicianship Program. Support from the Newell Trust for Research in Medical Education allowed us to conduct this study.
The institutional review board of the McGill University Faculty of Medicine approved this study.
Aspects of this study were presented at an invited symposium entitled “A New Perspective on Faculty Development: From Workshops to Communities of Practice” at the annual meeting of the Association for Medical Education in Europe, August 2009, Malaga, Spain.
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