SUPPORTING THE PROFESSIONAL DEVELOPMENT OF FACULTY TEACHERS

Abstract

I and my colleagues designed and implemented a longitudinal faculty development program to improve humanistic teaching and role modeling at 30 medical schools involving more than 1,000 faculty members and 50 local facilitators. Evaluation demonstrated that participating faculty members who completed our program were superior humanistic teachers compared to controls as rated by their learners on a validated questionnaire. Participants were also sufficiently engaged to attend 80% or more of the curricular sessions with few dropouts, indicating the feasibility and generalizability of the program. Preliminary analysis of participants' personal narratives at the beginning compared to the end of our program suggested advancement in professional identity formation. I provide examples of the narratives and discuss future studies addressing this topic.

INTRODUCTION

Can we teach compassion to faculty teachers? With six colleagues, I asked this question 19 years ago in a project, which has expanded to involve more than 1,000 faculty participants at 30 medical schools (1). The project tested whether a faculty development program designed to our best specifications would produce sustained improvement in faculty humanistic teaching and role modeling. We define medical humanism as the personal commitment to relate to patients compassionately, respectfully, honestly, and equitably, while providing excellent care always in the best interests of the patient and family (2).

We based our program on several premises: first, that physicians continue to grow in professional development throughout adult life; and second, that the professional growth of young faculty members is prone to a rapid catch-up because their humanistic attributes were previously inhibited in residency training by unsavory aspects of the “hidden” curriculum. We measured success of our program based on two studies using a prospective cohort design with matched controls in which blinded learners rated our participants on a validated scale to be more humanistic (3-5). We measured feasibility and learner engagement by documenting a low dropout rate (in the range of 5% to 10%) over the year of the program and high attendance at the twice-monthly sessions (approximately 80%), even though our faculty participants were extremely busy with their teaching and clinical duties (1). We think these latter parameters show a sense of need and strong desire among young faculty members for the humanistic experience.

DESIGN OF THE PROGRAM

Aiming for a sustained impact, we designed the program to be longitudinal. A small group of 8 to 12 participants at each school met with an experienced local facilitator (almost all schools have faculty members experienced in small-group facilitation) to follow a semistructured curriculum every 2 weeks for 1 year (1). Local facilitators were coached by experienced faculty on monthly conference calls. The curriculum created synergies by alternating reflective with experiential learning. The supportive small-group process promoted and reinforced humanistic attitudes and values (6). Our original curriculum focused on teaching and role-modeling skills derived from a series of workshops that our group presented at national meetings. Reflective learning was largely based on writing, reading aloud, and reflecting on personal narratives within the group. Experiential learning of humanistic skills included sessions using role plays for how to conduct bedside teaching, deliver difficult feedback, prime learners for role modeling, and practice caring attitudes. Additional topics were added by the leaders of new faculty cohorts who enrolled in the program. Additional topics included mindfulness and mindful practice, wellbeing and resilience, boundary issues and boundary violations in physician-patient relationships, and interprofessional education (1).

THE FORMATION OF PROFESSIONAL IDENTITY

Robert Kegan described stages of professional identity, of which stages 3, 4, and 5 apply to young medical faculty members (7). In general, a professional around the age of a junior faculty member would be expected to enter stage 4, wherein he/she internalizes and lives by the values of the profession. Within this person's community of practice, he/she should be a leader who can solve problems. Our concern was that adverse experiences in residency training might cause some residents, who later joined the faculty, to have remained in stage 3, wherein the professional follows the values of others, is a team-player, and seeks to fit in with peers and emulate role models. We believe these are the relevant stages for faculty development in our study, although at a higher level of stage 5, professionals evolve tolerance and understanding for the values of others (including other professions) and an ability to foresee potential problems and lead by creating solutions. Based on their personal narratives, we believe that some of our young faculty members approached entering stage 5 (stage 4.5). Kegan thinks that reaching stage 5 is unusual (only 2% to 3%) and generally occurs in persons in their mid-40s or beyond (8).

A major difficulty in studying identity formation in high-stage professionals is lack of a standard for measurement. Kegan has used an intensive 3-hour interview (8), which is obviously impractical for a large faculty development program. Although we have plans for approaching this problem more rigorously, at present we based the hypothesis that our participants entered or exceeded Kegan stage 4 on our interpretation of their personal narratives as they progressed through our program. These narratives describe participants' interactions with patients and others, reflecting who they are as physicians.

Richard Frankel and I described “formation narratives,” a class of narrative in which the writer, a physician in this case, performs a highly humanistic beneficial act in relation to a patient or other person, which also benefits the physician by promoting his or her growth as a moral agent and high level professional (9). This type of narrative was unusual at the beginning of our course but accounted for 25% of narratives collected at the end of the course (9). These narratives indicate willingness and ability to act on internalized professional values. We believe acting on one's values is an important indicator of high-level development. For example, Kohlberg considered individuals who lived by rather than simply espousing moral values to have reached the highest stage of moral development (10).

As an illustration, a young doctor responded to a patient's fear of death by kneeling and holding her hand while explaining that the condition was almost certainly curable, and thus taught by example the importance of compassion in medical practice to her medical student (9, 11). Another physician overcame her inhibitions and medical protocol to wheel a dying elderly lady onto the balcony outside the ward so that the patient could realize her wish “to feel sunlight on her face for one last time” (9). A pediatrician who had herself been sick as a child later devoted her career to “working with children whose medical and developmental issues made it hard for people to recognize their humanity” (12).

In one transformative event, a physician somewhat insouciantly sought to understand an indigent patient's difficult experience by herself having an HIV test at an anonymous clinic (13). Surprised by the depth of anxiety she herself experienced while awaiting results of her test, this physician (on learning that her own HIV test was negative) unexpectedly filled, first with gratitude for the life she lived, and then, with an essentially universal compassion for patients —those in the waiting room where she stood, as well as all patients she had previously cared for. Members of the faculty development group to whom she read this story learned by vicariously experiencing first her disorienting experience, then her empathic emotions (14). Her story, similar to others others in my examples, memorialized an important event, uncovered previously unsuspected inner resources, and benefited others. I believe this transformative event produced a permanent and salutary change that helped this physician become a force for good at her medical school.

Our stories show that many faculty members who completed our program had the capacity to create seminal events that benefited patients, perhaps had life-long beneficial influences on the professional trajectories of learners and others, and contributed to the professional growth of the faculty member. The stories fall short of proving an advance in professional identity formation. The nature of human character and moral development and related development of human culture(s) are complex subjects, fascinating to study. To scratch the surface of questions to be studied, we do not know if our subjects are always, most of the time, or only some of the time highly humanistic physicians, or if they maintain their high-level humanism under stress? Yet, they demonstrated evolving humane capacities that could be further strengthened and expanded. These observations beg the question: does the internalization of values with development of related skills and strengthening of motivations likened to moral courage constitute an evolving character trait? Simply learned behavior? Or some combination thereof?

CONCLUDING COMMENTS

Learner surveys and qualitative analyses of their personal narratives provided evidence that faculty members who completed our program changed by, among other things, behaving more compassionately (1-3). Faculty engagement was high (1). Anecdotally, I have also been told many times by faculty participants as I visited their schools that the program was highly meaningful to them and their careers. We designed our program for maximal sustained impact by making it longitudinal and using educational principles of reflective and experiential learning within the context of a supportive learning community (6). Our goal was to facilitate humanistic professional development by uncovering inner capacities for core professional values, such as compassion, respect, and integrity, by awakening sensitivity to human dimensions of care, and by providing the motivation and skills needed to transmit one's values into action.

I think that our program and its educational principles can be a template for faculty development at many schools, not only for strengthening medicine's humanistic traditions, but also adapted to interprofessional education (in which we are now engaged), faculty leadership development, medical student education, and graduate medical education. I suggest replacing sporadic, interesting, but nonsustained faculty educational activities with comprehensive longitudinal faculty development programs based on these principles.

We envisage accomplishing further goals with our program. We would like to carry out a definitive large prospective controlled trial of our program's impact using our validated humanistic teaching and practice questionnaire to obtain learner ratings. We would like to study advancement in professional identity formation over time using a series of targeted qualitative studies of both participating and control faculty members. We foresee expanding the focus of our program to specifically assist those faculty members who are charged with developing medical student and graduate education. But for now, we view our most important accomplishment to be contributing to the humanistic professional development and the teaching impact of the more than 1,000 faculty members who have completed our program to date.

DISCUSSION

Konstam, Boston: That was a terrific presentation and obviously very important and needed work. I wonder if you could speak to the importance of leadership. It's occurred to me for some time that in the medical profession in general, in our medical schools, and in our house staff training there really is very little, if any, special emphasis on leading — on developing leadership skills and understanding what leadership really is. My thinking is that — and I'm sure you've thought very much about this — that everything you're talking about along the way really moves faster if folks know how to lead and have some training in that. I wonder if you could speak to that?

Branch, Atlanta: Well, of course, a short answer is that we hope that folks who participate in our program will become leaders. At Emory, I will tell you, I trained a group about 15 years ago, at the very beginning of this, and they are now the leaders of our educational and practice programs. I am absolutely convinced that they are terrific compassionate leaders of a type that would never have risen without having participated in this kind of a program. But having said that, I also say that we are now turning our attention to the social component — the practice community component of professional identity formation. Because we've begun to do some studies of what's going on in practice, and we are uncovering a tremendous amount of stress among the faculty. We've also actually got a paper under review in which we interviewed major leaders at these universities, and we found some interesting things. But I would just summarize by saying we need to focus on this, and we need to focus on the professional formation part of leadership. The ability to move up to stage five is what I think is going to be the goal that will be necessary in order for medicine to solve the problem, the huge challenges that it faces at this point.