Kumagai, Arno K. MD
Dr. Kumagai is associate professor, Departments of Internal Medicine and Medical Education, Office of Medical Student Education, University of Michigan Medical School, Ann Arbor, Michigan.
Editor's Note: This is a commentary on Westerman M, Teunissen PW, van der Vleuten CPM, et al. Understanding the transition from resident to attending physician: A transdisciplinary, qualitative study. Acad Med. 2010;85:1914–1919
Correspondence should be addressed to Dr. Kumagai, 3901 Learning Resource Center #0726, University of Michigan Medical School, Ann Arbor, MI 48109-0726; telephone: (734) 615-4886; fax: (734) 936-2236; e-mail: firstname.lastname@example.org.
The dynamic influences underlying the development of the professional identity of physicians are not completely understood; however, one can easily imagine that the transition from the supervised work of the resident to the relative autonomy and increased authority of the attending physician is a watershed moment in this developmental process. In this issue of Academic Medicine, Westerman and colleagues present a qualitative, interview-based study exploring the experiences of newly appointed attending physicians during this transition, and from the participants' responses, they construct a conceptual model in which the new attending physicians' attempts to understand and cope with novel disruptive elements (i.e., new and unfamiliar tasks, roles, and settings) eventually give rise to a sense of mastery and personal and professional development. Although the authors use the literature of transition psychology and organizational social theory to support their model, valuable lessons may be learned from looking at the processes from an educational perspective as well. The disruptions which the authors describe find resonance in Piaget's state of “cognitive disequilibrium” or Dewey's “forked road situation,” both of which link the experience of challenging or ambiguous situations with the act of reflection. Disruptive influences may stimulate explorations of self, others, and the world during this critical transition, and educational efforts in mentorship and in the creation of thoughtful discourse about these critical explorations may ultimately contribute to the development of a reflective professional self.
In his Poetics (parts X and XI), Aristotle1 describes the dramatic structure of tragedy as involving a situation, reversal, and recognition: The protagonist, taking action in a specific situation, achieves the opposite of what he or she intends, and this reversal is accompanied by or results in recognition—that is, new knowledge—of self and others. Such it is with life itself. Major life transitions frequently involve periods of uncertainty and self-doubt, and out of these moments arise a new understanding of both self and environment.
In a fascinating new qualitative study, Westerman and colleagues2 use grounded theory to analyze interviews with 14 newly appointed attending physicians in general internal medicine and obstetrics–gynecology, and from the themes arising out of the interviews, they construct a conceptual framework describing the transition from resident to attending physician and the acquisition of new professional skills and identities. They describe three influences that interact in a longitudinal manner during this transition: first, novel disruptive elements (i.e., new and unfamiliar tasks, responsibilities, roles, and environments that the participants encounter as attending physicians); second, the participants' actions in coping with these aspects of their new lives; and third, how, out of the first two influences, there arises a third process—personal development and professional maturity. Even though the authors describe these elements as though they exist in a discrete sequential order, they acknowledge that the elements continually and dialectically interact to foster further personal and professional growth.
The authors draw from literature in transition psychology as well as organizational social theory to support their conceptual model; however, from an educational perspective, one can easily find support from learning theory as well. For example, in his studies of cognitive development in children, Piaget3 introduces the concept of “cognitive disequilibrium” as a central influence in intellectual maturation. Piaget posits that preceding a transition from a less to a more mature cognitive level, a child enters into a state of cognitive disequilibrium in which he or she encounters new and unfamiliar experiences, things, perspectives, or people, and these encounters spur new directions of thought and development. This concept does not apply only to children; it applies to adult learners as well, and as a learning process, it is intimately connected with the concept of reflection. In discussing reflection, Dewey4 states,
Thinking begins in what fairly enough may be called a forked road situation, a situation which is ambiguous, which presents a dilemma, which proposes alternatives. As long as our activity glides smoothly along from one thing to another, or as long as we permit our imagination to entertain fancies at pleasure, there is no call for reflection. Difficulty or obstruction in the way of reaching a belief brings us, however, to a pause. In the suspense of uncertainty, we metaphorically climb a tree; we try to find some standpoint from which we may survey additional facts and, getting a more commanding view of the situation, may decide how the facts stand related to one another.
Disruptive situations, including major life transitions, force an individual out of habitual perspectives, behaviors, and ways of thinking and knowing and stimulate reflection on self, others, and the world. In the case of the new attending physicians described in Westerman and colleagues' study, encountering the unfamiliar in new tasks and roles and in the new contexts in which they work and live stimulates self-inquiry and assessment. Significantly, with such uncharted territory also come feelings of incompetence and fear of failure that wane as increasing experience is acquired. From these “disruptions” comes a sense of mastery and personal growth. My colleagues and I5 have recently described a similar process among clinician–educators who are using novel approaches to facilitate medical student small-group discussions on doctoring. By presenting new challenges in teaching and opportunities to reflect on participants' roles and identities as physicians, these small-group discussions enhanced the clinician–educators' own reflective approaches to patient care and teaching and stimulated personal and professional growth and development. The disruptive elements described in Westerman and colleagues' study and our own work challenged the participants not only intellectually but also emotionally. In this sense, the type of reflection in which these individuals were engaged is different than Dewey's perspective from the treetop or Piaget's work with children: The participants were motivated to reflect not only on facts but also on themselves, and the processes engaged them in acts of reflection as individuals on cognitive, affective, and experiential levels. These experiences are indeed transformative and involve fundamental changes in the new attending physicians' perspectives of themselves and their world.6
Westerman and colleagues' study is also an example of a perfect marriage between methodology and subject. Eschewing the a priori hypotheses and categorizations of survey-based methods, the authors used open-ended research questions and a rigorous qualitative approach to explore the experiences of newly appointed attending physicians during their transition from resident to professional. One of the most powerful aspects of qualitative research is its ability to explore, analyze, and document the meaning that individuals give to important experiences and interactions. Thematic analysis and conceptual understandings arise from and are grounded in the actual expressions and interpretations that individuals give to their lives and thoughts. What qualitative approaches lack in statistical generalizability, they more than make up for in authenticity; that is, they may give us a true glimpse of the possible ways in which specific individuals see their world. In Westerman and colleagues' study, it is hard to imagine the authors being able to identify their participants' experiences without this type of approach.
In discussing possible implications of their work, Westerman and colleagues2 state that “it appears to be important to minimize disruptive novel elements in the transition” between residency and practice as attending physicians. Minimizing the emotional trauma involved in such life changes is perfectly reasonable. However, at the risk of endorsing the Nietzschian dictum of “what doesn't kill me will make me stronger,” I would argue that such disruptive changes are inevitable and that the critical reflection engendered from such disruptions should be welcomed in developing thoughtful approaches to patient care. I agree with the authors that opportunities for peer discussions and advice are important in the socialization process that the authors describe; in addition, mentorship is also essential, not only from the standpoint of being a source of practical information but also to facilitate and enhance the process of reflection itself. Supportive environments and safe spaces for reflection and thoughtful discourse are critical components of this transformative learning process and may act as the springboard for ongoing personal and professional growth and development. Ultimately, from an educational perspective, the opportunities provided by the “novel disruptive elements” in this major professional transition should be seized on, for it is from the soil of such reversals and recognition and reflection and discourse that a lifelong orientation to reflective practice may arise.
1 Aristotle. Aristotle's Poetics. Halliwell S, trans. London, UK: Duckworth; 1986.
2 Westerman M, Teunissen PW, van der Vleuten CPM, et al. Understanding the transition from resident to attending physician: A transdisciplinary, qualitative study. Acad Med. 2010;85:1914–1919.
3 Piaget J. The Equilibration of Cognitive Structures: The Central Problem of Intellectual Development. Chicago, Ill: University of Chicago Press; 1985.
4 Dewey J. How We Think. New York, NY: Barnes & Noble; 2005.
5 Kumagai AK, White CB, Ross PT, Perlman RL, Fantone JC. Impact of facilitation of small group discussions of psychosocial topics in medicine on faculty growth and development. Acad Med. 2008;88:973–981.
6 Mezirow J. Transformative Dimensions of Adult Learning. San Francisco, Calif: Jossey-Bass; 1991.