Branch, William T. Jr MD; Frankel, Richard PhD; Gracey, Catherine F. MD; Haidet, Paul M. MD, MPH; Weissmann, Peter F. MD; Cantey, Paul MD, MPH; Mitchell, Gary A. MD; Inui, Thomas S. MD, ScM
Humanism and professionalism have long been emphasized in medical education. Efforts have been redoubled in the past 10 years. In 1999, the Accreditation Council for Graduate Medical Education announced required competencies in professionalism, compassionate care, and humanistic values. All accredited residency programs are now held accountable.1,2 Likewise, all 24 member boards of the American Board of Medical Specialties are accountable in these areas.3,4 The Liaison Committee on Medical Education requires the demonstration of professional behavior by students at all medical schools.5,6
Even so, this does not ensure that all clinical teachers are proficient in modeling the values of humanistic care. Most medical educators would agree that it is extremely important to influence positively the developing personal and professional identities of budding young doctors, yet most would also agree that we have much to learn about the application and effectiveness of educational programs that accomplish those goals. Although many educators would say we teach humanism through faculty role modeling,7–10 this answer leaves largely unaddressed the methods needed to develop truly outstanding faculty role models and to maximize their effectiveness as humanistic teachers.
We previously defined several approaches to teaching humanism through a consensus method and, later, a qualitative analysis of teaching encounters involving widely admired faculty role models.11–13 We have since postulated that a longitudinal faculty development program, using those and other teaching approaches that favorably influence role modeling behaviors, would have a sustained positive impact on faculty modeling of humanistic care. To test the generalizability of our hypothesis, we formed faculty development groups that applied our teaching methods during 18 months at five medical schools. Below, we describe the longitudinal faculty development programs and our assessment of their effectiveness. We compared the humanistic teaching qualities of participants in the longitudinal faculty development programs with those qualities of nonparticipating faculty engaged in similar teaching activities at the five schools.
Expert facilitators for the faculty development groups at five medical schools (Emory University School of Medicine, Indiana University School of Medicine, the University of Rochester School of Medicine, Baylor College of Medicine, and the University of Minnesota Medical School) were drawn from a group that has engaged in studying and teaching the human dimensions of care. The group had formed at a workshop at an American Academy on Communication in Health Care summer course in Worcester, Massachusetts, in June 1999. The facilitators, one of whom was the principal investigator (W.T.B.) for the present study, were also designated as site leaders, responsible for implementation and partial design of the curriculum, selection of participants, and organization of the faculty development programs at their respective institutions.
Program participants were selected by the facilitators (site leaders) at each of the schools. Selection was open to faculty from all departments. All served as teaching attendings on inpatient services or preceptors in teaching clinics. An effort was made within and across sites to achieve diversity by age and gender. In addition to being willing to participate, the main criterion used for selecting participants was that the individuals were considered promising as teachers and role models in the clinical setting. The faculty development group at each school included at least 8 but no more than 12 participants. Occasionally, chief residents were chosen, but they were not included in the evaluation.
The faculty development programs were designed to meet several criteria. Each program had to (1) be longitudinal across 18 months to develop a supportive group process conducive to reflective learning, (2) incorporate experiential learning to practice the skills that we had previously identified as useful in role modeling the human dimensions of care, and (3) alternate sessions for practicing skills with reflective learning sessions to address participants’ attitudes and values. Reflective exercises included discussions, narrative writing exercises, Balint groups, and similar formats.
Groups met at least twice monthly beginning September 1, 2004, during the first 6 months and at least monthly during the remaining 12 months of the curriculum, until March 1, 2006. A formal “core” curriculum was developed by consensus of the site leaders. The format of the core curriculum consisted of goals and objectives, teaching methods, and reading materials for each of the topics. The core curriculum covered the first 6 months of the faculty development workshops. Curricula for the remaining 12 months were designed to meet the individual needs of participants at each of the schools. Site leaders (R.F., C.F.G., P.H., P.F.W., G.A.M.), evaluators (T.S.I., R.F., P.C.), and the principal investigator (W.T.B.) participated in regular conference calls to coordinate their efforts.
The core curriculum included one or several sessions addressing skills such as (1) providing feedback, (2) dealing with difficult learners, (3) role modeling humanism in clinical settings, (4) the application of experiential learning to clinical settings, and (5) teaching caring attitudes.14–30 The reflective learning sessions employed one or more combinations of (1) writing and discussing critical incidents and/or appreciative inquiry narratives (stories of success in teaching, learning, and/or patient care), (2) discussing one’s goals and processes for teaching and learning in the faculty development groups, (3) Balint-type groups (facilitated case discussions), and (4) renewal and meaning in our professional lives.31–42
We employed a quasi-experimental design to prospectively study learners’ perceptions of faculty participants who had completed the program. After completing the curriculum, each faculty participant was compared with one or two nonparticipating faculty control teachers in the final six months of the two-year project until September 1, 2006. An effort was made to select controls who were similar to participants regarding gender, specialty (internal medicine versus noninternal medicine), and years of experience (defined as fewer than five years versus five or more years after completion of residency training). Because no previously validated instrument to measure humanistic teaching practices existed, our group developed the Humanistic Teaching Practices Effectiveness (HTPE) Questionnaire. Using an iterative consensus development process that involved the evaluators, principal investigator, and site leaders, we identified themes and domains of humanism to be used in the questionnaire from the narratives we collected as part of our previous project focused on teaching humanism,11,12 as well as from narratives collected from early faculty development sessions in the current project.
The HTPE Questionnaire was piloted with groups of faculty and residents and was revised repeatedly until all authors agreed that the language was as simple as possible, explicit and understandable, and that the items on the questionnaire reflected humanistic qualities of a teacher. The HTPE questionnaire was administered in 2006 to medical students and residents on clinical inpatient or outpatient rotations on which they were taught by participant or control faculty members. Only those students or residents who had spent at least two weeks with a participant or control teacher were eligible to complete the questionnaire. We mostly used faculty who had been assigned as attendings on the inpatient wards. In cases where the participant faculty member did not attend on the inpatient wards during the data collection phase, we collected data from residents and students for the participant and matched controls in outpatient precepting environments. For data analysis in the evaluation, we considered inpatient and outpatient settings to be equally valid sources of measurement. The residents and medical students were told that the HTPE questionnaire would not be included in the official evaluation of the teacher by the medical school or residency program.
For purposes of illustrating the learning experience, we collected narratives (critical incident reports and/or appreciative inquiry narratives) from the participating faculty members at the beginning and in later stages of the faculty development process.
The HTPE questionnaire included items listed further on to measure 10 qualities of humanistic teachers. The attending physicians were rated by their learners on these qualities as demonstrating “none at all” to “completely” on a linear analog scale. Raw scores were determined by the actual length of the line created when the learners marked an “X” on the line between the two endpoints for each the 10 statements in the questionnaire. We then converted all raw scores to percentage scores (percent of the total line length) and group item means to compare the study group with the control group. Data from the five schools were analyzed by the principal investigator and his colleague (P.C.) at Emory University School of Medicine. We will perform a qualitative analysis of all of the narratives in a later publication. We have quoted from three of the narratives further on in this report to illustrate the influences of the faculty development process on participants’ teaching skills and attitudes.
The data were analyzed using SAS 9.1 statistical software (Cary, North Carolina). Normality of evaluation data was determined by examining skewness and kurtosis in the participant and control groups. Additionally, normality plots were used to assess for normality and symmetry. Finally, the P value for the Shapiro-Wilk test of normality was examined. Because the distributions of the data for all 10 questions were determined to be nonnormal, the Wilcoxon rank-sum test was used to test for differences between the participants and controls for all 10 questions on the evaluation. Differences were determined to be statistically significant if the Wilcoxon two-tailed values were less than 0.05. Additionally gender, specialty (internal medicine versus noninternal medicine), and years of experience (defined as fewer than five years versus five or more years postcompletion of residency training) were compared between the two groups (controls and participants) using a chi-square test or Fisher exact test.
Finally, an overall evaluation score for each participant and control was created by calculating an unweighted mean for all 10 evaluation question scores. This overall evaluation score was analyzed as described above for the individual evaluation scores. Additionally, an analysis of variance (ANOVA) was used to test for overall differences in the overall evaluation score between locations (five sites plus the control). After the ANOVA, each site was compared with the control using Dunnett’s test.
Thirty-four of the original 45 enrollees at the five schools (75%) completed the 18-month faculty development program. Table 1 describes characteristics of the faculty participants who completed the program. The majority of participants were male, about two thirds were in internal medicine, and about half fell into the “experienced faculty” category (i.e., five or more years postresidency completion). Although the percentage of participants that completed the program varied across the five schools, a majority completed it at every school. Attendance was less consistent at Baylor and Indiana and was more consistent at Minnesota and Rochester. Between years one and two, there was a change in site leadership at Indiana (due to retirement). Emory had the most consistent attendance, with seven faculty members who completed the program. One Emory participant left the program to take a position at another medical school. Each group at the five schools met at convenient times; some groups met weekly, and others met twice monthly, during the first 6 months. All met at least monthly for the remaining 12 months of the faculty development curriculum. All of the groups chose educational leaders as participants: for example, clerkship directors, residency program directors, associate residency program directors, associate deans for medical education, and directors of ambulatory teaching clinics. Seniority and major leadership responsibilities did not predict completion of the program, because several of the more senior participants were among those who dropped out.
Twenty-nine of the 34 physicians who completed the faculty development programs at the five schools were evaluated after completing the 18-month curriculum. They were compared with 47 peer controls during the same time period. A total of 300 learners (medical students and residents) assigned on clinical rotations to either participant (107) or control (193) teachers completed the HTPE questionnaires. Of the faculty evaluated, eighteen faculty participants (62%) and 27 controls (57%) were male (P = .81). Of the faculty evaluated, eighteen faculty participants (62%) and 32 peer controls (68%) were five or more years postresidency (P = .63). Twenty-two faculty participants (76%) and 36 controls (77%) were internists (P = 1).
Table 2 shows aggregate results for participants versus peer controls on the HTPE questionnaire. Faculty participants outperformed their peer controls on all 10 items on the questionnaire. There was an 8% to 13% increased agreement depending on the question. All differences were statistically significant.
The effects of gender, years of training, and specialty were examined using regression analysis. Except for question two, these demographics had no statistically significant ability to predict scores either independently or in combination. Only one’s status as a faculty participant versus a control had a statistically significant ability to predict scores, with the exception of question two, where internists also received higher scores in both uni- and multivariate analyses.
When the data were broken down by location, all five sites demonstrated superior performance of faculty participants compared with that of controls on all 10 HTPE questions, with two exceptions. At one site, there was no difference between participants and controls on question one (“Listens carefully to connect with others”), and at another site, the participants performed 1% less well than did the controls on question one.
As a check on selection bias, we retrospectively compared the seven program completers at Emory with their 14 peer controls using their standard residency evaluation forms that were available from 2003–2004 before the beginning of the faculty development program. On overall teaching scores and on items related to care/professionalism before the beginning of the faculty development program, there was no educationally meaningful or statistically significant difference between participants (overall score of 3.65 out of 4 and care/professionalism score of 3.79 out of 4) and peer controls (overall score of 3.55 out of 4 and care/professionalism score of 3.67 out of 4). Using the most conservative statistical test, the P value for the overall score is .46, and for the care/professionalism score the P value is .34. Absolute differences were approximately 3%.
The Appendix provides a summary of the required curricular components for the first six months of the program at each medical school. The groups at each school devised different approaches for the remaining 12 months of faculty development. All maintained an emphasis on a reflective learning and supportive group process. At two schools, the groups continued to mix experiential learning of skills with narrative writing and other reflective exercises. At one school, the group primarily employed Balint-type groups after the initial six months. Groups at two schools spent more time in this period discussing issues related to job satisfaction, professional values, meaning and renewal, and their personal goals as teachers and faculty members.
Narratives collected during reflective learning exercises illustrated influences of the faculty development program. About five months into the program, one faculty participant wrote this account of a teaching experience:
Upon my return from clinic, I learned of a reportedly seamless meeting between members of my team and a patient’s family. They decided that no further heroic effort should be made and that the patient’s comfort was the ultimate goal. That evening the patient arrested. Her loved ones immediately panicked and frantically asked to have the “DNR” decision reversed.
Less than five minutes before my next [teaching] session, I decided to teach the team in a completely different way. I sat down and took a deep breath. I shared the case of a patient with a necrotic leg (a case I had as an intern). I explained to the team that this patient was not likely to have a satisfactory outcome, and that a family meeting was needed to discuss this with her loved ones. The catch? I would be playing the role of the patient’s loving daughter, and the fourth-year medical student would play the patient’s loving granddaughter.
Everyone got into their characters and it proved to be a very powerful teaching tool. It allowed me to witness the strengths and weaknesses of the house officers. It was interesting to see the threshold of each person’s comfort level with such a hard decision. I learned that my team was uncomfortable giving a clear explanation of what to expect, as well as giving recommendations to family members even when asked.
Her account suggests that the program encouraged her to reflect and then innovate by using an experiential teaching method, and to direct some of her teaching overtly toward humanistic practices. The teaching method described in her vignette was similar to those in the role play exercises used in our faculty development curriculum.
The second narrative selected for quotation below was submitted toward the end of the project, and it illustrates that group process was an important component of our curriculum. Written spontaneously by a participant, the narrative indicates the degree to which his group of fellow participants and his facilitator influenced him. Group support validated his humanistic and professional values:
I just wanted to thank you for leading a very interested and lively discussion today and to thank you again for giving me the opportunity to participate in this group. I had been feeling very frustrated with some things in my job lately…. I hear so many people grabbing on the phrase “patient-centered care” and yet I see no clear evidence that any large health care organization truly values this as a priority. Anyway … once again, I left the group feeling rejuvenated and comforted by the fact that there are others who share similar frustrations and struggles on their jobs, but yet continue to work to improve things.
A third example illustrates that our faculty development program could have larger effects on an institution. Inspired by one of the discussions in his group, a participant developed a new elective course for medical students called Meaning in Medicine:
At the meetings (of the new course) … each student … would tell the story of something that had happened to him/her in either a clinical or educational context which either enhanced or changed his/her sense of what is meaningful about the practice of medicine…. The range, depth, and intensity of the stories … was truly amazing. The experience was evaluated very positively by the students.
This writer applied the narrative writing process used in our faculty development project to generate a successful new course at his medical school. The new course was one component of a psychiatry rotation. The writer states that most faculty members teaching these students on the clinical part of the rotation were highly supportive of the new reflective writing component. A few were not supportive. Students were disappointed by the occasional nonsupportive faculty attitudes. The story suggests that clinical faculty as a whole currently have mixed responses to reflective learning that addresses humanism.
Ours is the first multiinstitutional study of faculty development to improve teaching that has shown a statistically significant and educationally important benefit.43,44 Learners at all five schools perceived that faculty members who participated in our program were superior humanistic teachers and role models. This was despite the fact that the faculty development groups at each school (1) were composed of individuals of different ages, genders, and specialties, (2) modified their curricula to include some different types of sessions, and (3) were led by different facilitators. This uniformly positive outcome suggests common factors in the programs. We speculate that the experiential learning of skills, the longitudinal nature of the experience, a supportive group process, and the engagement of participants in deep personal reflection were positive factors common to all five groups. Whereas these educational methods have strong theoretical underpinnings,45–60 our study supports the theory by demonstrating its effectiveness in faculty development aimed at strengthening humanistic teaching in clinical settings.
Longitudinal faculty development as we designed it proved feasible at all five schools. We judged the completion rate of 75% to be acceptable, given the turnover and competing responsibilities of medical school faculty. Skilled facilitators familiar with and committed to the process undoubtedly contributed to the successes of the groups. The different pathways followed by groups at several schools after completing the required curriculum illustrate the importance of flexibility in addressing issues pertaining to faculty at a school while maintaining a supportive process for reflective learning.
A close look at the items on our HTPE questionnaire confirms that the specific skills taught in our faculty development sessions were perceived to be superior in participants compared with their peer controls. This outcome suggests that the skills-learning components of the five programs were successfully accomplished. The effectiveness of skills learning is not surprising, because role play, practice, feedback, and other experiential methods employed by the five programs are known to be more effective than passive lectures or demonstrations.61–65
Of perhaps greater interest is the finding that participants in the faculty development programs were perceived to be more humane and caring physicians than their controls. Several items on the questionnaire pertain to these personal attributes of the teachers. Examples include “listening carefully to connect with others,” “inspiring (a learner) to grow professionally and personally,” and being known as a “caring person.” Such attributes have traditionally been thought to be embedded character traits, not altered by education. In our groups, however, informal observations and the emergent qualitative data as well as the results of the HTPE questionnaire suggest that the programs fostered professional and personal growth in the behaviors that express humanistic qualities of participant teachers. Examining the educational methods employed commonly at all five schools identifies several that we think have a strong theoretical basis for fostering professional and personal growth.54,57–60 Certainly, reflective learning should be at the heart of any educational program designed to foster professional and personal growth in its participants,57,58,66–68 and reflective learning was central in our curriculum. We believe that the aspect of reflective learning leading to professional and personal growth is related to enhanced personal awareness.54,57–59 We further propose that our supportive group process facilitated reflective learning and enhanced personal awareness.69,70
The quotations provided above illustrate the flavor of the group processes in the faculty development programs. The second participant quoted in our Results section went on to say that “the group process empowered the faculty to address issues of professionalism and humanism. It certainly gave me the courage to do so, since I now knew (and didn’t just hope) that I wasn’t the only one who cared about these issues.” These observations are educationally important, because a very similar process of personal development is desirable in young physicians. Young professionals are forming a professional identity.66–68 While doing so, they are influenced by faculty role models. If the faculty role models are perceived to be caring and humanistic, they should positively influence the nascent professional identities of their trainees and medical students. Medicine is an idealistic profession that expects its members to reach a deeply humanistic understanding of their patients.71–77 This can best be achieved if residents and medical students can incorporate humanistic values and attitudes into their professional identities.
Have we influenced the informal curriculum, which has frequently been cited and described in the literature as eroding humanism?73,78 We did not design our study specifically to address this question. We speculate that at least among the medical students and residents taught by our participants, certain aspects of the informal curriculum were positively influenced. Being inspired to grow personally and professionally, using personal and social information about patients, and being inspired to adopt caring attitudes, to cite just 3 of the 10 positive humanistic qualities we evaluated, suggest favorable influences. Nevertheless, a larger study focused on identifying positive changes in residents and medical students will be necessary to demonstrate conclusively that teachers who participate in faculty development processes similar to ours act as effective change agents and favorably influence the informal curriculum.
Our evaluation has several limitations. First, we had small numbers of participants. Despite the small numbers, the effects measured using our HTPE questionnaire reached statistical and practical significance. Second, comparison of the participating physicians and their controls was clearly vulnerable to selection bias. Although we were aware of this potential bias at the outset of the study, we decided that it was best for the project to select promising teachers for enrollment in the faculty development groups and, in an effort to minimize selection bias, to choose superb clinical teachers to serve as peer controls. Analysis did not reveal effects of gender, years of experience, or specialty on our overall results. In addition, comparison of Emory’s faculty participants with their peer controls before enrollment in the study revealed no differences in overall teaching ratings or ratings of teaching related to humanistic qualities in Emory’s standard teaching evaluations. A randomized trial would be needed to definitively exclude selection bias. Although we cannot rule out selection bias as a factor in the superior performance of participating faculty, we think that—taken as a whole—our results suggest that the positive changes we observed are related to the kind of faculty development program we implemented. Finally, the faculty development curricula differed among the five schools, and we presume that facilitators at each school varied somewhat in their approaches. Nevertheless, results at every school favored the participant teachers over the peer controls. As discussed above, common elements of the curricula may have been sufficiently educationally powerful to create a positive impact across all groups.
Longitudinal faculty development using experiential and reflective learning was accomplished successfully and seemed to have a positive impact on participants’ humanistic teaching. This positive impact was detected in all groups despite having different facilitators and, to some extent, different types of sessions at the five schools. Because of this, we conclude that our results are likely to be generalizable to other schools and settings. The qualities that were positively affected in teacher participants included teaching skills and personal and professional attributes. On the basis of the results from this study, we predict that favorable changes in the informal curriculum can be achieved by developing teachers who are more caring persons, better able to connect with and inspire others.
The authors wish to acknowledge Stephen Pierrel, PhD (1948–2008), whose contributions to this project and career in general are exemplars of the practice of humanism in medicine. The authors also thank Kirk Easley, MA, biostatistical consultant, Emory Rollins School of Public Health, for his helpful review of the manuscript’s statistical methods.
The funding support for the work on which our manuscript is based came from a grant given by the Arthur Vining Davis Foundations.
The Arthur Vining Davis Foundations had no role in the design and conduct of the study nor in the collection, management, analysis, and interpretation of the data, and the preparation, review, and approval of the manuscript for publication.
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