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Small-group Teaching Emphasizing Reflection Can Positively Influence Medical Students' Values

Branch, William T. Jr. MD

LETTERS TO THE EDITOR
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Dr. Branch is Carter Smith, Sr., Professor of Medicine, vice chairman for primary care, and director, Division of General Medicine, Emory University School of Medicine, Atlanta, Georgia.

Coulehan and Williams1 have provided a thoughtful framework to explain the widely noted phenomenon whereby medical students lose their idealism as they are socialized into being physicians. Although I don't believe theirs is the whole story, detachment, entitlement, and non-reflective professionalism certainly characterize parts of the professional persona that doctors adopt during clinical training. Young physicians in training also are inculcated with a strong sense of responsibility to provide excellent clinical care to their patients, no matter the long hours and emotionally straining work. One question is whether these two sets of values are tradeoffs. Must the young physician become detached and non-reflective in order to develop his or her sense of responsibility and ability to care for patients?

I do not believe there is necessarily a tradeoff, nor do I think that the solutions suggested by Coulehan and Williams fully take into account the experience and evidence to date regarding solving this problem. They dismiss medical ethics and humanities teaching “in the majority of medical schools” as having generally limited impact. I believe the limited impact results from a lecture-style format, and from timing the courses in the first two years of medical school, not from an inherent impotency of medical education to create a reflective practitioner. Coulehan and Williams embrace the family medicine, primary care, and generalist movements as potentially valuable in maintaining students' commitment to moral and professional values. Here, I agree and would argue that these movements accomplish much chiefly because they often do offer educational interventions aimed at teaching human values during the clinical years.

Coulehan and Williams also discuss managed care and the possibility of more socially relevant clinical experiences as additional antidotes against loss of idealism. Without a long discussion, I would note that managed care is losing some of its impetus at present, and that if its chief impact on physicians is to undermine their professional commitment to taking responsibility for the care of individual patients, then it will be destructive mostly of professionalism in medicine. Socially relevant clinical experiences should be tried, but there are few examples that I know that have been well organized and integrated into the clinical curriculum. Rather, these rotations carry the danger of being “show and tell” experiments at various community facilities.

What I want to get to is the documented impact of educational interventions that occur during the clinical years and are designed to counterbalance the non-reflective aspects of clinical training. Such interventions have been under way for more than ten years.2,3 I believe the common feature of effective intervention in the clinical years is small-group teaching facilitated by highly respected faculty role models that allows students to reflect on their values, beliefs, and experiences in a safe and intimate setting on a regular basis. Most successful programs have combined the opportunities for reflection with learning patient—doctor communication skills. Extensions of these programs beyond medical school into residency training also seem to me to be necessary to achieve their full impact. This educational approach counterbalances non-reflectiveness with reflectiveness. To do so requires the safe, small-group environment so that students or residents can freely express their feelings and concerns regarding patient care in a mutually supportive atmosphere. It is also necessary to reinforce the impact of small-group discussions with highly effective bedside teaching of humanism.4 Evidence suggests that intensive educational interventions such as these improve physicians' abilities to convey fundamental values of the medical profession, such as compassion and respect, to their patients.5–8

My concern is that despite the proven impact of such programs, they continue to be given lip service by the leaders of medical education in most medical schools, who have yet to commit the resources to mount and evaluate large-scale interventions despite clear evidence that there is a problem needing to be addressed and a means available to address it. Furthermore, I fear that emphasis on too many options and alternatives to address the problem of non-reflectiveness and loss of values and idealism will disperse efforts in a non-focused way, leading to the prolongation of impotence in this component of medical education. Thus, I suggest that medical schools commit the needed resources to counteract what Coulehan and Williams so aptly term “vanquishing virtue.”

A final word on the resources needed. There are enough clinical faculty at most medical schools to provide small-group facilitators for medical students and housestaff. The chief lack is the will to implement such programs, and the understanding that untrained faculty require a well-designed faculty development program if they are to be useful guides, role models, facilitators, and mentors for their students and residents.

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References

1. Coulehan J, Williams PC. Vanquishing virtue: the impact of medical education. Acad Med, 2001;76:598–605.
2. Branch WT Jr, Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. Teaching medicine as a human experience: a patient—doctor relationship course for faculty and first-year medical students. Ann Intern Med. 1991;114:482–9.
3. Branch WT Jr, Pels RJ, Calkins D, et al. A new educational approach for supporting the professional development of third year medical students. J Gen Intern Med, 1995;10:691–4.
4. Branch WT, Kern D, Haidet P, et al. Teaching the Human dimensions of care in clinical settings. JAMA. 2001;286,1067–74.
5. Moore GT, Block SD, Briggs-Style C, Mitchell R. The influence of the New Pathway curriculum on Harvard medical students. Acad Med. 1994;69:983–9.
6. Smith RC, Lyles JS, Mettler JA, et al. A strategy for improving patient satisfaction by intensive training of residents in psychosocial medicine: a controlled randomized study. Acad Med. 1995;70:729–32.
7. Smith R, Lyles JS, Mettler J. The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann Intern Med. 1998;128:118–26
8. Maquire P, Booth K, Elliott C, Jones B. Helping health professionals involved in cancer care acquire key interviewing skills—the impact of workshops. Eur J. Cancer. 1996:32A:1486–9.
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