Academic Medicine Issue:Volume 84(1), January 2009, pp 117-125
A Good Clinician and a Caring Person: Longitudinal Faculty Development and the
Enhancement of the Human Dimensions of Care
DOI: 10.1097/ACM.0b013e3181900f8aISSN: 1040-2446Accession: 00001888200901000-00032Full
Author(s):
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
Abstract
Purpose: To successfully design and implement longitudinal faculty development
programs at five medical schools, and to determine whether faculty participants
were perceived to be more effective humanistic teachers.
: Promising teachers were chosen from volunteers to participate in groups at
each of the medical schools. Between September 2004 and September 2006, the
facilitators jointly designed and implemented a curriculum for enhancing
humanistic teaching using previously defined learning goals that combined
experiential learning of skills with reflective exploration of values.
Twenty-nine participants who completed 18 months of faculty development at the
five medical schools were compared with 47 controls drawn from the same schools
in the final six months of the two-year project. For comparison, the authors
developed a 10-item questionnaire, the Humanistic Teaching Practices Effectiveness
Questionnaire (HTPE), to be filled out by medical students and residents taught
by participants or control faculty. Items were designed to measure previously
identified themes and domains of humanism. Control faculty were similar to
participants by gender, specialty, and years of experience.
: Thirty-four (75%) of the original 45 enrollees completed the programs at the
five schools. Faculty participants outperformed their peer controls on all 10
items of the HTPE questionnaire. Results were statistically significant (P
: A longitudinal faculty development process that combines experiential learning
of skills and reflective exploration of values in the setting of a supportive
group process was successfully accomplished and had a positive impact on
participants' humanistic teaching.
---------------------------------------------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.
Method
Intervention
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
Evaluation design
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.
Measures
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.
Analysis
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.
Results
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.
----------------------------------------------
Table 1 Characteristics of Faculty Who Completed a Faculty Development
Program at Each of Five Medical Schools, September 2004 to March 2006
---------------------------------------------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.
----------------------------------------------
Table 2 The Humanistic Teaching Practices Effectiveness (HTPE) Questionnaire,
with Data for Participants and Controls for Each Question, Five Medical Schools,
March 2006 to September 2006
---------------------------------------------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 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[horizontal ellipsis]. 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 [horizontal ellipsis]
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) [horizontal ellipsis] each student
[horizontal ellipsis] 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[horizontal
ellipsis]. The range, depth, and intensity of the stories [horizontal ellipsis]
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.
Discussion
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.
Conclusions
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.
Acknowledgments
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.
Disclaimer
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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Appendix Summary of the Required Curricular Components for the First Six
Months of Faculty Development Programs at Five Medical Schools, September 2004
to March 2005
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Appendix (Continued)
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