Fellowship programs in medical education are defined as single cohorts of medical teaching faculty who participate in extended faculty development activity.1 Offered by almost half of U.S. medical schools, fellowship programs focus on enhancing teaching skills, scholarly dissemination, and curriculum design.2 Despite their growing prevalence, the evaluation of program impact remains limited. Participant satisfaction is the most common form of program evaluation; less than 40% complete peer observations or review portfolios. Although longitudinal inquiries suggest changes in participants’ knowledge, skills, self-perceptions, and social networks, the assessment of the quantity and quality of subsequent educational projects, leadership positions, and scholarship is lacking.1–4
Most fellowship programs require completion of a scholarly project. These are commonly the development of specific curricular material or innovative institutional programs that contribute to quality improvement and patient safety.4 Few fellowship programs require specific activities of faculty postprogram completion. Less than one-quarter require completion of a career development plan or any other longitudinally focused activity.2 Literature outside of medicine advises that the impact of development programs aimed at building skills and changing behaviors is enhanced by individual plan development at completion, followed by implementation experiences with subsequent coaching and reflection through journaling and discussion.5–7
In this article, we describe the development of faculty members’ postfellowship leadership development plans and a structured process to support plan implementation. We compare the implementation results of two cohorts: one that participated in monthly reciprocal peer coaching followed by journaling and quarterly interviews, and a second cohort that received no structured process supporting the implementation of their plans. We provide the participants’ descriptions of the implementation process, its challenges, and its success factors. Finally, we discuss the contributions of each element of the structured process to plan implementation.
The Need to Support Postprogram Completion Activities
Since 2007, the participants in the Master Teacher Leadership Development Program (hereafter, Master Teacher program), which is the faculty medical education fellowship program of the George Washington University School of Medicine and Health Sciences, developed a leadership development plan as their final assignment in the last of six courses. Faculty outline a plan for the completion of a small number of initiatives aimed at enhancing their teaching, educational leadership, and/or educational scholarship (the tripartite goals of the Master Teacher program). Examples of initiatives include changing lecture courses to active learning courses, developing a new curriculum, leading a task force or committee, and completing a research study. Plan templates and guidance are provided by the course leader, who is also the program director (E.G.). The plans identify the steps and timing required to complete the initiatives as well as the evaluation mechanisms and resources required. Faculty meet with their supervisors, department chairs, and dean to review plan content and revise as needed.
For most faculty in the Master Teacher program, the development of a plan with a detailed implementation schedule is a new activity. Faculty require assistance focusing their plans on a few initiatives and differentiating objectives, initiatives, and tasks. The original assignment called for three-year plans to be developed; however, it became apparent that this was too ambitious, and the time frames of the plans were scaled back to one year. Faculty are also encouraged to integrate their leadership development plans with their annual goals and objectives. The process of developing those goals and objectives varies across the four institutions that faculty in the Master Teacher program work in, and faculty members’ experience with goal setting also varies. Although those of us who administer the Master Teacher program cannot control the institutional processes, we do counsel faculty to work with their supervisors to ensure that the initiatives in their leadership development plans are reasonable, given their other annual goals and objectives.
After three years of informal discussion with program graduates, it became apparent that faculty could benefit from support in implementing their plans. Many initiatives were being delayed; some were not started. Faculty who were implementing changes to their own teaching and conducting scholarly initiatives reported doing so in their “spare” time and said that it required determination to complete their initiatives. Those attempting to implement curricular changes reported numerous challenges. Despite earlier approvals, some departments blocked initiatives; promised resources were not made available, priorities were changed, and faculty were given other assignments that used their time. Discussion with several program graduates, the decanal liaison for the Master Teacher program (Y.H.) and the program director led to a review of the literature on plan implementation and the development of a process to support the fellowship graduates.
A Structured Process of Implementation Support
The program director, while facilitating the development of leadership development plans, presented the process depicted in Figure 1 to the current cohort. The cohort agreed to participate. The process called for three distinct structured activities: reciprocal peer coaching, journaling, and interview-based discussion. (Years of participation are not provided because this information could inadvertently lead to the identification of the participants.)
Reciprocal peer coaching
Peer coaching has been used for the past 25 years in educational settings to provide feedback to graduate students, improve teaching techniques of new and highly experienced teachers, and address the development of specific skills.8 It is here that reciprocal peer coaching—where peers observe, give feedback, and coach each other—had its origins.9
In health care, peer coaching is identified as providing great potential for nurses’ clinical development and is used to promote teaching excellence and scholarship in nursing.10–12 Medicine uses peer coaching to enhance clinical teaching while adopting more traditional mentoring of a junior faculty member by an experienced colleague to encourage scholarship.13–18
Coaching related to leadership development is widely used in business to help individuals enhance specific skills, reinforce learning of leadership programs, build confidence and self-awareness, and improve performance.19 In the little that has been published about peer coaching,19 it is reported to be less threatening than coaching by an external expert and is credited with providing psychological support and leading to real change. A study of middle managers attending a university-based leadership development program found progressive increases in leadership competencies when the program included strategies of goal-setting, experiential learning, reciprocal peer coaching, and reflective journaling.20 Core elements for successful peer coaching include voluntary participation, training in coaching, selection of one’s own coach, coachees’ decisions as to what to work on, face-to-face contact, a culture of trust, reflection, feedback, and ongoing participation.19 All of these factors were present in the plan-implementation support process.
Reciprocal peer coaching for the cohort began during the leadership development plan conceptualization, when members formed coaching dyads to help each other. Some members preferred peers within the same specialty or organization; others preferred those with different backgrounds and/or outside their work environment. Training in coaching was provided by the program director, included techniques of active listening and prompts for exploration, and was practiced in the classroom.
While this was taking place, further discussion between the program director and the decanal liaison led to the design of a static-group comparison study, with the cohort approaching graduation receiving the structured process of implementation support and the cohort that graduated the prior year receiving no support (the historical standard).21 The two cohorts were similar in size and variety of participants’ specialties; the curricula they received were identical. We decided to compare the implementation progress of the initiatives in the leadership development plans of the two cohorts after one year using a Web-based survey; we received institutional review board (IRB) approval for the study. This added a fourth activity—the survey—to the process depicted in Figure 1. Study start-up activities necessitated the addition of an initial interview (Interview 1) with the program director, where each participant’s consent was obtained and the process re-reviewed. Per Figure 1, reciprocal peer coaching then proceeded on a monthly basis. Instructions were similar to the in-class practice and are provided in Appendix 1.
The second activity in the structured process of support was journaling. This was included to provide faculty an opportunity to reflect on the implementation of their plans and on the reciprocal coaching process.5–7,19 Questions were provided to prompt reflection and are listed in Appendix 1. Faculty were encouraged to journal as soon as possible after their coaching sessions to maximize recall. Journals were forwarded to the program director as data.
The third activity in the structured process of support was an interview-based discussion with the program director. This was done to provide feedback and additional support.19 The intention was that these sessions take place with other members of the research team. However, time constraints and a preference by faculty to be interviewed by someone they knew led to the program director conducting all of these sessions. The discussion was unstructured. Prompts are stated in Appendix 1. Each audio-taped session was approximately 30 to 45 minutes in duration and professionally transcribed.
The added fourth activity in the structured process of support was the completion of an online survey given about one year after the implementation of participants’ plans. The cohort receiving no support took the survey as soon as IRB approval was granted, just over one year after they completed the program.
Comparison of the Cohorts’ Implementation Progress
All 10 faculty of the cohort participating in the structured process of support (the “coaching cohort”) and 9 of 11 faculty of the cohort receiving no support (the “standard cohort”) completed the survey. Faculty accessed survey questions through individual Web addresses, with a statement of consent at the onset. Each survey was preloaded with the individual’s leadership development plan initiatives. For each initiative, a series of questions were asked to ascertain the status of its implementation. Questions are provided in Appendix 1.
The initiatives were coded by the program director as to their type (teaching enhancement, new curriculum, educational leadership, and educational scholarship) and checked by another author (O.K.). The median number of initiatives per faculty in both cohorts was five; the range was four to six for the standard cohort and three to seven for the coaching cohort. Developing a new curriculum was the major focus of both cohorts and of over one-third of all initiatives. All initiatives related to teaching accounted for 54% to 58% of each cohort’s total initiatives. The coaching cohort had two times as many initiatives related to educational leadership as did the standard cohort; initiatives related to educational scholarship were equal in number. No attempt was made to evaluate the potential ease or difficulty of the initiatives; the nature of the initiatives appeared to be similar across the two cohorts.
Table 1 shows the stage of completion of each intuitive as reported by the faculty. The standard cohort collectively had 40 initiatives, of which 20 were completed or were on schedule (some initiatives required more than one year to complete; those are reported in the table under the heading “No. on schedule or completed”). The coaching cohort collectively had 48 initiatives, of which 35, or almost 73%, were completed. In addition to completing fewer initiatives, the standard cohort had not started significantly more initiatives than the coaching cohort had not started. Implementation progress also varied with the type of initiative. The standard cohort completed only 28.5% of their initiatives related to a new curriculum, whereas the coaching cohort completed 77.8%. The standard cohort did not start half their new curriculum initiatives.
Comments related to implementing the initiatives were summarized (by O.K.) and analyzed (by O.K., M.W., and Y.H.). The coaching cohort reported making more modifications to their initiatives as they were implemented than did the standard cohort. Modifications ranged from clarifying objectives to refocusing and reducing the scope of activity.
List 1 presents comments describing the implementation process. There were few comments regarding the initiatives not started or behind schedule, and what was said was similar to comments regarding the completed initiatives. The comments did not vary by cohort, although the coaching cohort generally provided more verbiage and made a greater number of positive comments. “Challenging” and “frustrating” were terms used to describe implementation of every type of initiative. Specific challenges related to lack of time and/or resources, competing priorities, and—with initiatives related to new curriculum and leadership—lack of support (including active resistance) within and outside of the department. Positive terms were used to describe all types of implementation but were less frequently mentioned in relationship to educational scholarship.
The two main factors needed to help faculty implement initiatives were time and money. In response to the question regarding success factors, faculty indicated how they knew the initiative was successful and also what caused implementation to be successful. Feedback from learners and the excitement of colleagues buoyed the faculty. Leadership, administrative and financial support, and the use of publicly available materials contributed to implementation success.
Contributions of the Support Mechanisms
Identification of themes
The journals and interview transcripts provided an understanding of the value received from the elements of the structured process of support. These were analyzed together using phenomenological techniques.22 One of us (M.W.) read the data multiple times, identified relevant comments of each faculty member in chronological order, and entered them verbatim on forms. She also made notes of her emerging thoughts. This process was repeated for the coaching peer and then for the other sets of peer coaches. The program director reviewed the data summaries to ensure credibility.23 Three of us (E.G., M.W., O.K.) independently identified themes from the data summary and then collectively discussed them. These were codified in writing and sent to all members of the coaching cohort as member checks. Faculty concurred that the themes were accurate. Themes that relate to the structural elements of the process are reported below. All are reported in male gender to protect participant identities.
Themes related to the structure of the process
The reciprocal peer coaching provided emotional, functional, and developmental support. The emotional support was therapeutic. One faculty member said that “it’s a great avenue by which you can vent … it’s cathartic in that regard.” Functional support included ideas and different perspectives. Another faculty member said of his coach that “he is able to see around my obstacles … suggested a few things I’ve been able to try.” Developmental support included building self-confidence to address barriers and helping to clarify issues. One faculty member stated, “I felt more confident and organized after our discussion.” Another described it as “mind-opening,” indicating that a similar situation relayed by his peer and how he handled it were “encouraging to hear and gives me confidence in taking the next step.”
Journaling provided an additional reflective opportunity for the half of the coaching cohort who embraced it. Reflections generally concerned the plan implementation process. One faculty member who questioned whether he had progressed in implementation reported that he “went back and looked at everything, and I felt more positive about stuff after actually looking at it and thinking about it.” Another noted that he was “journaling about a lot of things … about how I’m feeling about things and how I’m accomplishing what I want to accomplish … not just work.”
The interview discussions with the program director helped faculty grow as peer coaches and offered the opportunity to make sense of the leadership development plan process. Faculty discussed issues they were encountering with coaching, such as sessions being one-sided (i.e., one faculty member dominating), feeling that they were pressuring their peers when making suggestions, and wondering if they were really providing any help to their peers. Several faculty also discussed changes they thought they should make to their plans but were not sure how to accomplish. Over time, the interview discussions helped faculty optimize the use of their leadership development plans. One faculty member described his learning process:
I wish I had spent more time on my plan in the beginning … putting a lot more thought into it … probably the most beneficial part was laying out the steps and putting dates with them to really learn budgeting my time … the other process feature is that it needs to be a living document … wanting to change it but not wanting to change it too … trying to figure out how much to change it … new things came my way but it’s challenging to remember that they’re going to need to modify the plan … my updating was something I picked up halfway through.
Another faculty member indicating similar benefits reported that he now requires six-month development plans of his residents:
I basically took some of the skeleton of what the leadership plan is and superimposed it upon what used to be our elective day goals and objectives … a good way [for the residents] to crystallize: Hey, these are the things I want to do.
More ambition was expressed by another faculty member:
I need to expand [my plan] for the next five to ten years down the road as to some of the things I want to do.
Other faculty articulated benefits of the entire structured process of support:
It forces you to look at your leadership development plan often.
Left to my own devices inertia would take over…. I would not have accomplished each of the things I have … it’s not because I couldn’t, but because [the plan] just gets lost in the day-to-day activities.
Benefits Beyond the Numbers
We have described a structured process of supporting postfellowship activities. The process quantified the educational projects, leadership positions, and scholarship completion and provided a better understanding of the implementation process. Faculty participating in this process completed 23% more of their planned initiatives than those receiving no support, including 2 times as many educational leadership initiatives and 3.5 times as many initiatives related to developing new curricula, despite similar challenges expressed regarding implementation. We were disappointed that there was no difference in the scholarly activity of the coaching cohort and have recently added resources to support this.
The combination of plan development, reciprocal peer coaching, journaling, and interview discussions provided faculty with focus, structure, and support to improve teaching, develop new curricula, and lead others in educational activities. The adage that “it takes a village” may be appropriate in describing the support required, but it is also true that all involved gained from the process. Faculty not only completed their planned activities but also gained lifelong skills in coaching and in using development plans; some have already passed on these skills to their students. Program administrators are convinced that a postprogram support process is essential. Unfortunately, continued funding for the conduct and transcription of interviews, journal collection, and the analysis of both is not available. Current fellowship program graduates are encouraged to form peer coaching dyads, review their implementation plans on a monthly basis, and keep a journal. The program director offers faculty the opportunity to informally discuss their implementation experiences quarterly with her. A learning community of program graduates has been established and currently meets quarterly to share teaching and curriculum development ideas and implementation progress.
The structured support process we have described here includes a number of resources (coaching guidelines, journaling prompts, interview discussion prompts, and survey questions) that may be useful for other medical school faculty fellowship programs with minimal modifications. Of greater value may be the applicability of completing leadership development plans and providing structured support for their implementation. These concepts may be useful to other faculty development programs and adapted for use with residents and fellows.
Acknowledgments: The authors wish to thank the graduates of the two participating cohorts for their participation in this study.
Funding/Support: This project was made possible in part by funds from the Office of the Dean, George Washington University School of Medicine and Health Sciences Medical School, Washington, DC.
Other disclosures: None.
Ethical approval: This study received approval from the George Washington University institutional review board.
Previous presentations: A description of this process was presented at the Organizational Behavior Teacher’s Conference (of the Organization Behavior Teaching Society) on June 9, 2011, Milwaukee, Wisconsin.
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