A map does not just chart, it unlocks and formulates meaning; it forms bridges between here and there, between disparate ideas that we did not know were previously connected.
—Reif Larsen, The Selected Works of T.S. Spivet
Planning the Journey
A map reveals features, contours, and relationships between things; its accuracy and completeness make navigation possible. As we were designing Mapping the Landscape, Journeying Together (MTL), the central initiative of the Arnold P. Gold Foundation (hereafter Gold Foundation) Research Institute,1 the mapping exercise I imagined was admittedly crude, a bit like the 1,000-piece puzzles that I loved assembling as a child. Each puzzle piece would represent one of the many small studies that formed the body of humanism research, and by funding rigorous reviews of the literature on humanism in health care, we would, section by section, reveal the multifaceted construct of humanism as defined by educators and researchers working in the field. We could then support new studies to fill in the empty spaces, effectively creating a road map for a research agenda. We would compile existing knowledge on humanistic values and attitudes (the Gold Foundation’s list is captured in the I.E., CARES mnemonic: integrity, excellence, collaboration & compassion, altruism, respect & resilience, empathy, and service). We would mine evidence for the best ways to bring these values and attitudes to life in the developing health care professional. We would find the most effective curricular and assessment methods, elucidate uses of the arts and humanities to cultivate humanism, deepen our understanding of the impact of role modeling and mentorship, and catalogue culture change initiatives. We would discover linkages between humanistic practices and the quadruple aim of health care.2 Moreover, we would find the straight edges of the puzzle, the places where humanism faces its traditional opponent of scientific reductionism, as well as the newer challenges that come with technology and managed health care. We would clarify boundaries between humanism and other constructs: What is the relationship between humanism and the health humanities? How do humanism and professionalism overlap and differ? What is the connection between humanism and patient-centered care? How does humanism relate to burnout and wellness for health professionals?
We imagined that our map would help the Gold Foundation chart a course to develop effective programming to further its mission of cultivating humanism in clinical and learning environments. The evidence base we would discover and depict would help leverage essential resources—curricular space, face-to-face time with patients and families, and the support of institutions and accrediting bodies—all in the service of advancing compassionate, collaborative, and scientifically excellent care. We knew the importance of keeping our work driven by curiosity, core values, and a commitment to rigorous methods; we were intentionally wary about the potential to lapse into “justification research.”
Embarking and Navigating
In 2013, our first MTL call for literature review proposals brought in over 80 proposal submissions from teams across the United States and Canada on topics ranging from teaching and assessing clinician–patient communication, to caring for underserved populations, to using the arts and humanities to cultivate compassion and support well-being. We selected 26 proposals; each was awarded a $5,000 grant, with the only required end product being a publication-ready manuscript and a presentation at an MTL symposium within a year and a half of the initial award.
It was at the first MTL symposium that I had what one of my mentors calls a “duh-ha” moment, an insight so obvious it feels almost dumb. As each team discussed their work, I realized we were not filling in a map of static territory. Rather, each team’s review of the existing literature framed new questions and opened new controversies. As our collective knowledge expanded, the boundaries between the known and the unknown morphed in complex and unpredictable ways. We were in sociocultural territory; meaning could not be drawn from a box like pieces of a jigsaw puzzle. Our synthetic reviews and subsequent conversations actively shaped meaning, and we realized the power of the cartographer to shape and create understanding of the territory, calling attention to distinctive features and contours of the landscape. We became explorers discovering the territory we were mapping. We came to realize we were not only adding to a complex body of knowledge but also actively cultivating a robust community of practice.3 New areas of the map emerged, and we saw how our topics fit into relational domains: intrapersonal, interpersonal, systemic, and social.4 We have started to clarify important conceptual distinctions, such as that between humanism and the health humanities. Although these terms are often conflated in health professions education, we are beginning to understand the ways in which text and images from the humanities serve as reflective triggers to cultivate humanistic values and attitudes, and how the study of the humanities helps to foster critical thinking skills and provide learners with frameworks to understand the broader historical, structural, and cultural patterns that influence health care interactions.5,6 Not surprisingly, we found that the traditional research methods of biomedicine were not always suited to our pursuits, and so we began honing and sharing effective tools.7
Although the MTL initiative has excelled by traditional academic standards (the first cohort has thus far achieved a 69% publication rate), our community felt strongly that our work should extend beyond the ivory tower. We wished to use knowledge in the service of real, on-the-ground impact, so we launched a phase 2 grant program for literature review teams, in which they could be awarded a $15,000 discovery or advocacy grant. Discovery grants allow teams to design studies to fill a gap in the literature, while advocacy grants allow teams to use literature review findings to make or advocate for change (Figure 1).
The MTL model has evolved over time to include an annual call for proposals for literature reviews, discovery and advocacy grants, an MTL symposium each May, and a gathering of the MTL community at the Association of American Medical Colleges (AAMC) Annual Meeting each November. Since MTL’s inception, we have funded 70 literature reviews and 17 discovery and advocacy projects. Collectively, MTL teams are made up of over 350 individuals from over 75 U.S. and Canadian institutions, who are now beginning to recombine to forge new collaborations with one another.
The following two examples of MTL projects highlight the evolution from an initial literature review to a discovery and/or advocacy project:
West and colleagues’8 literature review, “Interventions to Prevent and Reduce Physician Burnout: A Systematic Review and Meta-analysis,” was published in the Lancet in 2016. The team subsequently received a discovery grant for a qualitative study on institutional approaches toward work–home interference. A year later, they received an advocacy grant to develop and disseminate a charter on physician well-being in partnership with the Collaborative for Healing and Renewal in Medicine (CHARM).
Martimianakis and colleagues’9 literature review, “Humanism, the Hidden Curriculum, and Educational Reform: A Scoping Review and Thematic Analysis,” was published in Academic Medicine in 2015 and was recognized with the Outstanding Research Paper Award for the 2015 AAMC Research in Medical Education papers. Follow-up projects led by the original team members include one on humanism in the premedical realm, another on pre-health-professions training in empathy and affect recognition, a third that explores the premedical realm through a graphic novel, and a fourth (supported collaboratively with the American Board of Internal Medicine Foundation) that seeks to deepen our understanding of the quality of research on professionalism in medicine.
Our grant recipients report that the MTL funding, although modest, provides an impetus for their institutions to prioritize humanism-focused projects, and the follow-up grant mechanisms allow projects to evolve through emergent design. Teams have indicated that they particularly value the annual symposium as a forum to disseminate findings, receive feedback on works in progress, build skills, and forge new collaborations. They appreciate the innovative, interactive design of this forum, which draws on theories of adult learning and exercises both sides of the brain with modalities such as step-back consultations, storytelling, Insight Dialogue, World Café, and reflective conversations using visual images.
Several teams have been able to leverage larger-scale support using the preliminary results from their MTL projects. For example, one team’s work on best practices for patient-centered electronic medical record (EMR) use10 is now being championed by Epic, the EMR company with the largest share of the U.S. market. Another team garnered funding from their home institution to launch a speaking-up curriculum based on their initial MTL projects on conflict and negotiation in health care.11
Into the Future
As with any journey of exploration, we carry forward discoveries that came before. All too often, literature reviews are a perfunctory afterthought when a researcher is preparing their work for publication. By rooting each team’s work in a rigorous review of the literature, we weave continuity and a respect for lineage into the MTL design. We continue to find inspiration in the literature review project initiative of the Society of Directors of Research in Medical Education12 and the community-building success of the Harvard Macy Institute.13
Certain stars help us chart our course into the future. We value interprofessional and intergenerational teamwork, try to walk the talk of humanism in our relationships with one another, and hold ourselves to standards of academic excellence. We are always interested in including like-minded partner organizations on our journey. Future aims for the MTL initiative include developing and publishing standards for humanism scholarship and increasing the dollar amount available for our phase 2 grants.
Like early cartographers, who perfected the art and science of mapmaking, we believe our efforts to more accurately map the landscape of humanism in medicine will help lead us to a world of better, safer, and more humane care.
The author thanks Maren Batalden, Richard Frankel, Brandy King, Richard Levin, and Arthur Rubenstein for reviewing the draft of this article.
2. Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med. 2014;12:573576.
3. Cruess RL, Cruess SR, Steinert Y. Medicine as a community of practice: Implications for medical education [published online ahead of print July 25, 2017]. Acad Med. doi: 10.1097/ACM.0000000000001826.
4. Gaufberg E, Hodges B. Humanism, compassion and the call to caring. Med Educ. 2016;50:264266.
5. Dennhardt S, Apramian T, Lingard L, Torabi N, Arntfield S. Rethinking research in the medical humanities: A scoping review and narrative synthesis of quantitative outcome studies. Med Educ. 2016;50:285299.
6. Haidet P, Jarecke J, Adams NE, et al. A guiding framework to maximise the power of the arts in medical education: A systematic review and metasynthesis. Med Educ. 2016;50:320331.
8. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet. 2016;388:22722281.
9. Martimianakis MA, Michalec B, Lam J, Cartmill C, Taylor JS, Hafferty FW. Humanism, the hidden curriculum, and educational reform: A scoping review and thematic analysis. Acad Med. 2015;90(11 suppl):S5S13.
10. Alkureishi MA, Lee WW, Lyons M, et al. Impact of electronic medical record use on the patient–doctor relationship and communication: A systematic review. J Gen Intern Med. 2016;31:548560.
11. Kim S, Bochatay N, Relyea-Chew A, et al. Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review. J Interprof Care. 2017;31:282290.