Swan-Sein, Aubrie PhD, EdM; Mellman, Lisa MD; Balmer, Dorene F. PhD; Richards, Boyd F. PhD
Advisory dean programs are a relatively recent phenomenon in medical education and are growing in popularity.1–3 Columbia University College of Physicians and Surgeons (P&S) initiated its advisory dean program in 20031 after consulting with other advising program pioneers at Duke University School of Medicine2 and the School of Medicine and Dentistry at the University of Rochester.3
The goals of advisory dean programs generally focus on academic and career counseling but may include other goals, such as fostering professionalism and communication, guidance with personal issues, and role modeling. The importance of advisory dean programs in medical education has increased over the years not only to meet accreditation standards of the Liaison Committee on Medical Education but also to help students navigate the complexities of becoming members of the medical profession.
The current literature on advisory dean programs includes descriptive articles focusing on the why, what, how, and who of establishing such programs.1,2 It also reports on learning communities.4,5 Although there are some similarities between medical school learning communities and advisory dean programs (e.g., both seek to foster a sense of belonging to a small community and to mentor students), the types of programs vary in purpose and execution by school. Although the current literature is helpful, it no longer tells enough of the whole story; it is missing important ideas and strategies for sustaining advisory dean programs over time, especially in evolving education environments common in medical schools today.
In response to this gap in the literature, we report the results of a reflective analysis we conducted to identify key factors specific to sustaining an advisory dean program. We modeled our reflective analysis on the program evaluation methodology of evaluative inquiry, in which individuals identify and learn about a topic and then apply this learning back to the organization. Individuals learn by engaging in dialogue, reflection, asking questions, and thinking through values, beliefs, assumptions, and knowledge about the topic or program, with attention to the institutional contexts of culture, leadership, communication, and systems.6 We offer the insights we gained from our reflective analysis as a resource for others who are working to keep similar programs relevant and useful for their students.
We adopted the Bolman and Deal7 four-frame conceptual model of organizational functioning to shape our data interpretation and analysis. This model has been used as a guiding conceptual framework in a variety of studies pertaining to organizations and leadership in education settings,8 including an analysis of leadership strategies used by college presidents to advance campus diversity.9 The four frames represent distinct dimensions that make up an organization's inputs, processes, and outcomes: structural, human resource, political, and symbolic. Table 1 presents a definition of each frame and corresponding features from our program at P&S.
The four of us met regularly during a one-year period (2010–2011) to review relevant literature, discuss existing evaluation data, and discuss issues relevant to each Bolman and Deal frame. We used three existing evaluation data sources in our review of the program: transcripts from in-depth interviews with past and present advisory deans, results from an annual evaluation survey of student perceptions of the advisory dean program, and agendas from the twice-monthly dean meetings. We reviewed deidentified transcripts from semistructured interviews with eight advisory deans in the spring of 2010 (interviews were recorded, transcribed, and coded as part of a separate IRB-approved qualitative study10), using the transcripts as a source of examples and quotations. We reviewed the annual survey of student perceptions of the advisory dean program and of their advisory deans (typically a 90% annual response rate) for student views of specific aspects of the program. Finally, we reviewed and classified the topics of advisory dean meeting agendas from 2005 to 2010 into the four Bolman and Deal frames and calculated the frequency of topics by frame.
Ultimately, we sought to identify and understand more clearly the program's successes and challenges and to summarize important lessons learned for the benefit of others with similar programs. Our discussions alternated between broad consideration about the relationship between the frames over time and specific reflections on issues within each frame. For example, early deliberations heightened our realization of the natural inclination for program leadership (the senior associate dean for student affairs and the chair of the program) to focus on issues within the structural frame because these issues tend to be relatively more concrete and urgent. However, when motivated by a deliberate effort to consider all four frames, we repeatedly gained insight about gaps and opportunities for improvement within the other frames, as presented in the Results section. We conducted a “member check” of our findings by sharing them with the advisory deans at one of their meetings. This member check helped ensure the fidelity of our analysis presented in this report.
We found the Bolman and Deal conceptual framework useful for understanding the program leaders' approaches to maintaining the advisory dean program. Careful consideration of the frames—together and individually—helped us to gain useful insight about the relative importance of activities and interventions that occurred in the process of sustaining the program over time. Reflections specific to each frame led to insights about what mattered most in the past and/or areas of greatest growth potential for the future. They also shed light on areas that, in retrospect, would have benefited from greater attention at the time.
To keep our report from being overlong, we have limited the description of our findings to the two or three insights and conclusions within each frame that we believe will be most useful to those who have similar programs facing similar challenges.
When interviewed, one dean captured the essence of the program leaders' early experience with establishing and structuring the advisory dean program.
We didn't know what worked, what the students wanted to hear, and I think that as the years went on and we helped each other, we were much more strategic about how we conducted the [student lunch] meetings—what we introduced and when.
According to our classification of program agenda topics, by far the majority of the discussions at the twice-monthly meetings focused on structural issues. We discuss two of the most salient issues here: (1) the need to articulate and align program goals and program activities and (2) the need to meet the needs of students given time and effort constraints.
Articulating and aligning program goals and program activities.
From the beginning, program leaders were interested in providing high-quality advising and mentoring to students. Over time, there was increased awareness by program leaders that the original intentions of the program were somewhat different from what was realized. Consequently, program goals were codified and aligned with program activities, and some activities were modified to better match these goals.
Most notably, the intention that advisory deans provide “one-stop shopping” for career advising and student counseling was modified. When the advisory dean program was initiated, each advisory dean was supposed to learn about a few residency specialties so that each of the specialties would be covered by at least one dean. Prompted by the lower-than-desired ratings on surveys of students regarding their satisfaction with career advising, an important structural change was made in which a few faculty members from each major specialty were recruited and trained to serve as specialty residency advisors to whom the advisory deans could refer students.
Similarly, the deans became increasingly aware of other student support services and deliberately worked to avoid duplication of efforts by coordinating activities with these other entities to achieve their goals to promote student health and well-being (e.g., Center for Student Wellness), to encourage extracurricular opportunities for relaxation and enrichment (e.g., P&S Club, cultural offerings of New York City), and to facilitate the development of additional faculty–student relationships (e.g., faculty-led small-group doctoring course sessions, research mentors). Now all of these programs collaborate to make formal and informal resources available to students, which has had a positive impact on student ratings of satisfaction.
In comparison, alignment of curriculum-oriented goals has remained relatively stable with less need for change because of ongoing communication with course directors about areas of shared interest. For example, the course director of the doctoring course meets periodically with the advisory deans to review topics common to both programs such as professionalism and humanism.
Meeting the needs of students, given time and effort constraints.
Given Columbia's class size, and based on conversations with other programs, five deans seemed like a functional as well as an affordable number to initiate the program with. Nevertheless, data from students' annual surveys and the in-depth interviews with advisory deans repeatedly revealed that this relatively high student-to-dean ratio did not consistently meet all students' individual needs. As one advisory dean mentioned, “It's a little frustrating for me because I want to get to know them all but you can't get to know all 120 of them well.”
In response, three changes were implemented. First, during the first month of medical school, students now meet with their advisory deans on a weekly basis, and in smaller groups, to give the deans a better opportunity to build relationships with individual students. Second, deans are now required to meet individually with students at least twice during the first two and half years of medical school. Third, when the class size increased from 153 to 163 in the fall of 2010, an additional advisory dean position was created, thus reducing the student-to-dean ratio modestly.
As structural adjustments were made, like the ones mentioned above, program leaders monitored their impact using a variety of quantitative and qualitative evaluation measures. In some cases, data reveal increases across time, such as reports of students' satisfaction with career advising reported on the Association of American Medical Colleges Graduation Questionnaire (from a mean of 2.7 on a 5-point satisfaction scale in 2004 to 3.6 in 2011). In other cases the increases are more modest, such as the percentage of second-year students' reporting on the annual advisory dean program survey that the program meets their expectations for helping them manage stress (88% in 2008 to 93% in 2011) or the percentage of first-year students reporting that the program meets their expectations for academic support (89% in 2008 to 96% in 2011). Students' comments frequently provide useful insights that help interpret such ratings. For example, a final report from the 2010 student survey states in part:
Positive comments clustered around different dimensions of advice/guidance. Students often mentioned that speakers invited to present to advisory dean groups imparted targeted expertise and career advice.
Human resource frame
Once the program established a reliable structure with goals and student instructional activities, efforts to sustain the program expanded to include the human resource frame. Our classification of the program leaders and deans' twice-monthly meeting topics revealed that the human resource issues were the second-most-common topic, albeit much less frequently discussed. Over time, program leaders discovered the challenges of empowering, assessing, and sustaining a cohort of advisors who live very busy academic lives as researchers, teachers, and clinicians. Below, we discuss three of the most salient human resource issues: (1) selecting new deans, (2) training new deans, and (3) providing ongoing skill-building opportunities.
Selecting new deans.
Turnover of program faculty is a challenge common to academic programs and organizations. In the first seven years of the program, one dean position turned over five times. Informal communications with these departing deans, as well as our more formal in-depth interviews, reveal that turnover tended to be in response to positive career opportunities within or outside of Columbia (e.g., becoming student affairs dean, being promoted, moving to another institution).
The need to respond to higher-than-expected turnover gave program leaders the opportunity to iteratively adjust dean selection criteria in accordance with their emergent understanding of program circumstances and needs. At first, selection criteria focused on identifying mostly senior, charismatic, highly seasoned, and well-known individuals. Over time, the selection began to emphasize diversity, including expanding the diversity of specialties of the deans and considering more junior faculty. One quality of an advisory dean that has remained important over time is for the person to be an active clinical practitioner in his or her field.
Training new deans.
The need to select new deans heightened the leaders' awareness of the need for more formal orientation and training. Training comprises content presented in a packet of orientation materials, one-on-one meetings with program leaders, and meetings with the directors of various curricular and student support offices. When possible, the new advisory dean sits in on the final group meetings with the outgoing dean.
Program leaders' experience suggests that it takes about a year for a new advisory dean to reach the same level of comfort and/or performance that an outgoing dean had. This amount of time is needed to experience a full cycle of the students' curriculum, become familiar with other student support and academic services, and gain students' trust. Recognizing the challenges new advisory deans face to assume their roles, the program leaders have recently provided deans more assistance, such as through designating senior medical students within their group to be “on call” to assist the deans in providing advice for first- or second-year students.
Providing ongoing skill-building activities.
The need for ongoing faculty development in sustaining an effective advisory dean program became apparent from the results of the annual student survey, which revealed that program outcomes for each group were influenced by the strengths of their respective deans. For example, some deans are more expert at running small groups, whereas others excel in one-on-one meetings. Some deans are action-oriented problem solvers, whereas others are more contemplative and reflective. As one dean said, “I think we all have different strengths.”
Program leaders use the twice-monthly meetings to disseminate information and discuss best practices in terms of structural elements, such as appropriate content and visitors for group meetings. These discussions stemmed from an assumption that some differences among groups are inevitable and actually desirable—as long as program goals are met. At the same time, program leaders recognize that additional skill building might be useful to promote consistency among deans in how they run group meetings or work one-on-one with students. This belief has led to the idea to implement a peer mentoring program in which deans are paired, asked to observe each other in group meetings, and then have a reflective discussion of observed similarities and differences in group dynamics, methods used, and outcomes achieved.
Because an advisory dean program requires substantial resources derived from multiple levels in the organization (school, department, individual), the political frame played an important role from the outset of our program. Available feedback shaped initial structural features; this feedback has continued to influence ongoing efforts to maintain a vibrant and successful program, based on student survey results and anecdotes such as those about student inquiries to the admission office about the program. Nevertheless, our classification of twice-monthly meeting topics showed that issues within this area were seldom explicitly addressed. The two most salient issues, which we discuss here, focused on protecting and managing time.
Funding to protect time.
At the outset, the dean of the medical school increased the student affairs budget so that the department of each dean could count on a fixed amount of money in order to protect 20% of the dean's time, regardless of differences in deans' salaries due to specialty and longevity. This level of funding per dean has remained unchanged except for a one-time increase three years into the program. Program leaders have found that maintaining this level of salary support has not been difficult, primarily because of ongoing efforts to share with the dean of the medical school and department chairs the benefits of and students' positive regard for the program.
The annual cost of the program is approximately $280,000. This estimate includes salaries, fringe benefits, and food for students, but it does not include the time the senior associate dean for student affairs or staff spend guiding and supporting the program; these activities overlap with other responsibilities and are not separately budgeted.
Finding and managing the time needed for individual deans to meet program goals is perhaps the most salient issue within the political frame that surfaced during our reflective analysis—at least from the perspective of the deans themselves. Even with a general expectation of 20% protected time, the deans are challenged to manage their busy schedules, juggling specific personal and professional obligations with their advisory dean duties. From the outset of the program, the Office of Student Affairs has scheduled rooms for meetings, ordered lunches, and maintained a general calendar of program-related events. Yet, we noted variable levels of departmental administrative support for other administrative tasks (e.g., arranging guest speakers, scheduling individual appointments). Some deans are able to delegate these tasks to departmental administrators, whereas others perform them on their own. In effect, our reflective analysis increased our awareness of the value of departmental administrators in helping maximize deans' use of their limited time.
Despite political challenges related to the resources of protecting and managing time, interviews with advisory deans have shown that the deans have a sense of privilege and satisfaction working closely with students in this important role. One dean shared, “It's very gratifying to see so many really talented, smart, altruistic students interested in medicine, taking care of patients.”
Given that the symbolic frame tends to focus on implicit meanings, behind elements of the other frames, that communicate values and establish a cultural identity, we are not surprised that it emerged as the least visible of the four frames from an operational perspective, accounting for the smallest portion of topics at twice-monthly meetings. It also developed at a slower pace because “image” and meaning are built over time. Through our reflective analysis, we became much more aware of the need to explicitly recognize and address symbolism at both the implicit and explicit levels.
Our reflective analysis led us to discuss the need to recognize and address the implicit symbolic meanings of a variety of program features and the consequences of those meanings on stakeholders' perceptions. For example, we discussed ways to compensate for the potentially negative messages students may derive from the relatively high student-to-faculty ratio, or ways to optimize the potentially positive messages transmitted by such elements as the annual survey to solicit student perceptions of the program or providing food at meetings.
One of the most obvious manifestations of managing symbolism at the explicit level is including advisory deans in the school's white coat and graduation ceremonies. The meaning of this action has enhanced the perception and stature of the deans themselves and the program overall. In this regard, one dean remarked: “I'd say people respect the role. In a lot of ways, being an advisory dean can make things happen, which is nice.” It is notable that even though the program was developed to meet relatively specific goals, such as student career advising, the program continues to expand as a symbol of the institution's regard for medical student education and for providing a safe place for students to engage faculty in meaningful discussions about topics that may not have a recognized place in the formal curriculum.
Reviewing our advisory dean program using the four frames of Bolman and Deal proved to be a useful exercise that stimulated systematic thinking about why changes had been made in the program and why additional changes were needed. Though program elements and changes were complex and, sometimes did not fit into only one frame, the framework was helpful in making our thinking explicit, organizing our discussions, and enhancing our understanding of the things that mattered most in sustaining an effective program. In summary, as we reflected on the data at hand, aided by Bolman and Deal's conceptual framework, we had the following insights:
* It became clear that the initial focus of efforts to sustain a newly established program centered in the structural frame. After a few years, the program realized it could align its services with the broader array of complementary student support services. This realization also allowed program leaders to better tailor program goals and better define the roles of the deans.
* Issues in the human resource frame became more apparent as program leaders realized differences in the personalities and backgrounds of the deans. With more turnover than anticipated, human resource topics required constant vigilance to ensure effective selection and training of replacement deans. Over time, it became increasingly obvious to program leaders that all the deans benefit from organized efforts to enhance the knowledge, skills, and attitudes for effective group facilitating, individual advising, and promoting student networking.
* Although initial acquisition of resources falls within the political frame, the issues of managing these resources over time did not surface immediately and were overshadowed by the more pressing and ongoing concerns within the structural frame. A greater awareness of issues within the political frame also allowed the program leaders to verify that both deans and their departments are working together to protect and manage the time needed for the deans to achieve program goals.
* The ongoing success of the program heightened the school's ability to use the program as a symbol of its commitment to promoting an environment of medical education that was based on meaningful relationships between faculty and students through which students can find support. Program leaders also began to appreciate the symbolic meaning present in all structural, human resource, and political decisions.
The process of continuing to assess and reflect on the program, including structural, human resource, political, and/or symbolic aspects, is pertinent to the continuous quality improvement and adaption required to optimize program impact. We found that the quality of our reflections was dependent on the data that we were able to bring forward and discuss during our reflective analysis meetings. All the data sources were useful, including executive reports of the annual survey of student perceptions, interviews with past and present advisory deans, and meeting agendas.
Overall, our experience, albeit at a single institution, suggests that engaging program leaders, deans, and evaluation specialists in a reflective analysis, using sound methods (such as evaluative inquiry), an established conceptual framework (such as the Bolman and Deal four-part framework), and available data from stakeholders, is a useful strategy to help sustain an advisory dean program. It is our goal to conduct another reflective analysis in a few years, perhaps with a new framework, to further challenge and broaden our thinking about program effectiveness.
The authors wish to thank Drs. Peter Puchner, William Macaulay, Donald Quest, Joseph Haddad, Mary Sciutto, Emily DiMango, William Turner, and Gwen Nichols for their contributions to the Columbia University College of Physicians and Surgeons Advisory Dean Program and to this report, as well as the thoughtful reviewers and editors of this manuscript.