What's art got to do with it?-Transfer of learning in museum-based health professions education.

Museum-based education for health professionals is a rich and expanding field in which educators engage health professions learners in arts-based activities intentionally designed to support transfer of learning from a museum to a clinical context. Museum-based education for health professionals promotes several key learning outcomes including: mastery of core skills such as observation, interpretation, and communication; cultivating personal insight; fostering appreciation for multiple perspectives; opening avenues to explore social advocacy; and promoting wellness. Following a museum-based activity, translational facilitators guide learners through a debriefing process which supports the discovery of real-world connections to clinical teaching, learning, and care delivery. Translational debriefing involves practices such as attending to psychological safety, using reflective listening and open-ended questions, practicing cultural humility, maintaining neutrality, and modeling curiosity. These translational opportunities can also help participants who are themselves health professions educators gain insights into their own teaching practices and provide new tools to incorporate, including bedside teaching strategies and innovative ways to facilitate small group learning.

Exploring the intersection of psychiatry, art, and medical education through photographic portraits.

This paper describes a technique using photographic portraits in medical education to encourage close observation, cultivate empathic curiosity, explore learners' values and beliefs, and to reveal and reflect on fundamental biases. This new and evolving educational method uses the lens of psychotherapy to explore learners' experience of the portrait in a similar way we would discuss a case in psychodynamic supervision. Through close looking and small group engagement, the facilitator creates a space for deeper reflection and collaborative exploration of the therapeutic relationship, with emphasis on countertransference and the role of prior expectations. The exercise strengthens dialectical thinking through perspective-taking, challenging implicit assumptions and fostering cultural humility. Radiologists are taught to look in every corner of the X-ray and to observe each shadow, all while evaluating the entire image. Portraits can be examined in the same way, looking for subtle clues to the personality and history of the subject. Information from other sources confirms, or sometimes profoundly changes, our evaluation. In this example, we use a historical photographic portrait to demonstrate ways of engaging medical learners as they discover common psychotherapeutic approaches. The method has the potential to enhance therapeutic encounters, improve analytical skills and reduce bias.

The Harvard Macy Institute Art Museum-based Health Professions Education Fellowship: Transformational faculty development through the arts.

Museum-based education for health professionals can lead to a variety of important learning outcomes within the domain of skills development, personal insight, perspective-taking and social advocacy. The Harvard Macy Institute's Art Museum-based Health Professions Education Fellowship was designed to develop faculty expertise in art museum-based practices, encourage scholarship, and cultivate a cohesive and supportive community of educators. The Fellowship was piloted from January to May 2019 with twelve interprofessional Fellows. Two in-person experiential sessions were held at Boston-area museums with intervening virtual learning. Fellows were introduced to a variety of approaches used in art museum-based education and developed a project for implementation at their home institution. A qualitative formative evaluation assessed immediate and 6-month post-Fellowship outcomes. Outcomes are reported in four categories: (1) Fellows' personal and professional development; (2) Institutional projects and curriculum development; (3) Community of practice and scholarly advancement of the field; and (4) Development of Fellowship model. A follow-up survey was performed four years after the conclusion of the pilot year, documenting Fellows' significant accomplishments in museum-based education, reflections on the Fellowship and thoughts on the future of the field.

Third Things as Inspiration and Artifact: A Multi-Stakeholder Qualitative Approach to Understand Patient and Family Emotions after Harmful Events.

Patient and family emotional harm after medical errors may be profound. At an Agency for Healthcare Research and Quality (AHRQ) conference to establish a research agenda on this topic, the authors used visual images as a gateway to personal reflections among diverse stakeholders. Themes identified included chaos and turmoil, profound isolation, organizational denial, moral injury and betrayal, negative effects on families and communities, importance of relational skills, and healing effects of human connection. The exercise invited storytelling, enabled psychological safety, and fostered further collaborative discussion. The authors discuss implications for quality/safety, educational innovation, and qualitative research.

CEO-CLER Innovation Grants Program: Empowering Residents as Clinical Learning Environment Change Agents.

BACKGROUND: Many efforts over the past decade have focused on developing quality improvement and safety curricula for residents. Sponsoring institutions have encountered challenges aligning resident projects with institutional quality and safety priorities, engaging faculty mentors, and securing support for resident initiatives from executive leadership. OBJECTIVE: We developed a small grants program to support resident-led change projects intended to improve the clinical learning environment. We assessed program acceptability to residents and faculty, impact of program structure in supporting successful change projects, and program feasibility and financial sustainability. METHODS: Program acceptability was assessed through a review of resident participation. Three aspects of resident change project success were considered: (1) accomplishment of stated aims; (2) institutional change beyond the end of grant funding; and (3) academic publication or presentation. The impact of program structure on project success was assessed through a review of submitted end-of-year narrative reports. RESULTS: The Award Selection Committee has given 41 awards to 44 residents over 4 years, engaging 21% (44 of 213) of residents. Seventy-one percent of projects (29 of 41) produced changes that continued beyond the grant year, and 46% (19 of 41) produced an academic publication or presentation. At the end of the grant period that funded the program's initial 3 years, the chief executive officer elected to continue program funding. CONCLUSIONS: A small grants program supporting resident-led change projects intended to improve the clinical learning environment is acceptable to residents and faculty, feasible to administer, and sustainable with support from institutional senior leaders.

A Multi-Stakeholder Consensus-Driven Research Agenda for Better Understanding and Supporting the Emotional Impact of Harmful Events on Patients and Families.

BACKGROUND: The nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. METHODS: A one-day conference of diverse stakeholder groups to establish a consensus-driven research agenda focused on (1) priorities for research on the short-term and long-term emotional impact of harmful events on patients and families, (2) barriers and enablers to conducting such research, and (3) actionable steps toward better supporting harmed patients and families now. RESULTS: Stakeholders discussed patient and family experiences after serious harmful events, including profound isolation, psychological distress, damaging aspects of medical culture, health care aversion, and negative effects on communities. Stakeholder groups reached consensus, defining four research priorities: (1) Establish conceptual framework and patient-centered taxonomy of harm and healing; (2) Describe epidemiology of emotional harm; (3) Determine how to make emotional harm and long-term impacts visible to health care organizations and society at large; and (4) Develop and implement best practices for emotional support of patients and families. The group also created a strategy for overcoming research barriers and actionable "Do Now" approaches to improve the patient and family experience while research is ongoing. CONCLUSION: Emotional and other long-term impacts of harmful events can have profound consequences for patients and families. Stakeholders designed a path forward to inform approaches that better support harmed patients and families, with both immediately actionable and longer-term research strategies.

Do Gold Humanism Honor Society Inductees Differ From Their Peers in Empathy, Patient-Centeredness, Tolerance of Ambiguity, Coping Style, and Perception of the Learning Environment?

Construct: Induction into the Gold Humanism Honor Society (GHHS) during medical school is recognized as an indicator of humanistic orientation and behavior. Various attitudes and interpersonal orientations including empathy and patient-centeredness have been posited to translate into behaviors constituting humanistic care. BACKGROUND: To our knowledge there has never been a longitudinal, multi-institutional empirical study of the attitudinal and interpersonal orientations correlated with GHHS membership status. APPROACH: We used the American Medical Association Learning Environment Study (LES) data set to explore attitudinal correlates associated with students whose behaviors are recognized by their peers as being exceptionally humanistic. Specifically, we examined whether empathy, patient-centeredness, tolerance of ambiguity, coping style, and perceptions of the learning environment are associated with GHHS membership status. We further considered to what extent GHHS members arrive in medical school with these attitudinal correlates and to what extent they change and evolve differentially among GHHS members compared to their non-GHHS peers. Between 2011 and 2015, 585 students from 13 North American medical schools with GHHS chapters participated in the LES, a longitudinal cohort study using a battery of validated psychometric measures including the Jefferson Scale of Empathy, Patient-Practitioner Orientation Scale and Tolerance of Ambiguity Questionnaire. In the final survey administration, students self-identified as GHHS inductees or not (non-GHHS). T tests, effect sizes, and longitudinal generalized mixed-effects models examined the differences between GHHS and non-GHHS students. RESULTS: Students inducted into GHHS scored significantly higher on average over 4 years than non-GHHS inductees on clinical empathy, patient-centered beliefs, and tolerance of ambiguity. GHHS students reported higher levels of empathy and patient-centeredness at medical school matriculation. This difference persists in the 4th year of medical school and when controlling for time, race, gender, and school. CONCLUSIONS: GHHS inductees enter medical school with different attitudes and beliefs than their non-GHHS classmates. Although humanistic attitudes and beliefs vary over time during students' 4 years, the gap between the two groups remains constant. Medical schools may want to consider selecting for specific humanistic traits during admissions as well as fostering the development of humanism through curricular interventions.

Findings from the Harvard Medical School Cambridge Integrated Clerkship, a Year-Long Longitudinal Psychiatry Experience.

OBJECTIVE: The Harvard Medical School Cambridge Integrated Clerkship is a longitudinal integrated clerkship that has provided an alternative clinical model for medical education in psychiatry since its inception in 2004. This study was undertaken in an effort to better understand the student experience of the Cambridge Integrated Clerkship and how it may have impacted students' perceptions of and interest in psychiatry, as well as performance. METHODS: Qualitative surveys were sent via e-mail to the first 11 student cohorts who had completed the Cambridge Integrated Clerkship (from 2004 to 2014) and for whom we had e-mail addresses (N = 100), and the free-text responses were coded thematically. All available standardized scoring data and residency match data for Cambridge Integrated Clerkship graduates were obtained. RESULTS: From 2006 to 2014, 12 out of 73 Cambridge Integrated Clerkship students who entered the match chose a psychiatry residency (16.4%), four times more than students in traditional clerkships at Harvard Medical School (3.8% of 1355 students) or the national average (4.1% of 146,066 US applicants). Thirty of the 100 surveyed Cambridge Integrated Clerkship graduates (30%) responded to the qualitative survey with free-text remarks on a number of themes. CONCLUSIONS: Cambridge Integrated Clerkship students compared positively to their classmates in terms of standardized test performance. Their fourfold higher match rate into psychiatry compared to other students raises intriguing questions as to what role a longitudinal clerkship might have played in developing interest in psychiatry as a career.

In Pursuit of Educational Integrity: Professional Identity Formation in the Harvard Medical School Cambridge Integrated Clerkship.

Graduates of Harvard Medical School's Cambridge Integrated Clerkship (CIC) describe several core processes that may underlie professional identity formation (PIF): encouragement to integrate pre-professional and professional identities; support for learner autonomy in discovering meaningful roles and responsibilities; learning through caring relationships; and a curriculum and an institutional culture that make values explicit. The authors suggest that the benefits of educational integrity accrue when idealistic learners inhabit an educational model that aligns with their own core values, and when professional development occurs in the context of an institutional home that upholds these values. Medical educators should clarify and animate principles within curricula and learning environments explicitly in order to support the professional identity formation of their learners.

Mapping the Landscape, Journeying Together: The Gold Foundation's Model for Research-Based Advocacy in Humanism in Medicine.

Mapping the Landscape, Journeying Together (MTL) is an initiative of the Arnold P. Gold Foundation Research Institute. The MTL initiative awards teams with a grant to complete a rigorous review of the literature on a topic related to humanism in health care. Teams may then seek a discovery or advocacy grant to fill in gaps in knowledge or to make or advocate for change. In this Commentary, the author reveals the MTL journey through the metaphor of cartography. She describes the initial development of a road map, as well as the MTL community's experience of navigation, discovery, and exploration. MTL participants are not only incrementally adding to a complex body of knowledge but also actively cultivating a robust community of practice.

Do Medical Students' Narrative Representations of "The Good Doctor" Change Over Time? Comparing Humanism Essays From a National Contest in 1999 and 2013.

PURPOSE: To explore medical students' conceptions of "the good doctor" at two points in time separated by 14 years. METHOD: The authors conducted qualitative analysis of narrative-based essays. Following a constant comparative method, an emergent relational coding scheme was developed which the authors used to characterize 110 essays submitted to the Arnold P. Gold Foundation Humanism in Medicine Essay Contest in 1999 (n = 50) and 2013 (n = 60) in response to the prompt, "Who is the good doctor?" RESULTS: The authors identified five relational themes as guiding the day-to-day work and lives of physicians: doctor-patient, doctor-self, doctor-learner, doctor-colleague, and doctor-system/society/profession. The authors noted a highly similar distribution of primary and secondary relational themes for essays from 1999 and 2013. The majority of the essays emphasized the centrality of the doctor-patient relationship. Student essays focused little on teamwork, systems innovation, or technology use-all important developments in contemporary medicine. CONCLUSIONS: Medical students' narrative reflections are increasingly used as rich sources of information about the lived experience of medical education. The findings reported here suggest that medical students understand the "good doctor" as a relational being, with an enduring emphasis on the doctor-patient relationship. Medical education would benefit from including an emphasis on the relational aspects of medicine. Future research should focus on relational learning as a pedagogical approach that may support the formation of caring, effective physicians embedded in a complex array of relationships within clinical, community, and larger societal contexts.

Reconciling technology and humanistic care: Lessons from the next generation of physicians.

PURPOSE: There is concern among physicians that the rising use of technology in medicine may have a negative impact on compassionate patient-centered care. This study explores medical student attitudes and ideas about technology in medicine in order to consider ways to achieve symbiosis between technology use and the delivery of humanistic, patient-centered care. METHODS: This qualitative study uses data from 138 essays written by medical students in the United States and Canada responding to the prompt "Using a real life experience, describe how technology played a role, either negatively or positively, in the delivery of humanistic patient care." Data were analyzed for themes about technology and the impact on humanistic patient care. RESULTS: Seven themes emerged from the medical students' essays: Patient Perspective; Life-Giving versus Life-Prolonging; Boundaries between Human and Technology; Distancing versus Presence; Adapting to Change; Tools to Enhance Care; and Definitions of Technology. CONCLUSION: Listening to medical students lends insight into ways to integrate technology into the healthcare environment, to ensure that physicians' ability to deliver compassionate care is enhanced, not hindered. Utilizing perceptions of the next generation of physicians, educational and developmental strategies are proposed to ensure the successful integration of technology with humanistic patient-centered care.

Into the future: patient-centredness endures in longitudinal integrated clerkship graduates.

OBJECTIVES: This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time. METHODS: The authors' earlier work compared the 27 graduates in the first three cohorts of students undertaking the CIC with a comparison group of 45 traditionally trained HMS students; CIC graduates emerged from their clerkship year with a higher degree of patient-centredness and felt more prepared to deal with numerous domains of patient care. Between April and July 2011, at 4-6 years post-clerkship, the authors asked these original study cohorts to complete an electronic survey which included measures used in the original study. The authors also reviewed data from the National Residency Match Program to compare career paths in the two groups. RESULTS: The response rate was 62% (42/68). The immediate post-clerkship finding that CIC students held more patient-centred attitudes was sustained over time (p < 0.035). Reflecting retrospectively on their clerkship experiences, CIC graduates continued to report that their clerkship year had better prepared them in a wide variety of domains. Graduates of the CIC attained awards and published papers at the same rates as peers, and were more likely to engage in health advocacy work. Both groups chose a wide range of residency programmes. Among those expressing a preference, no CIC graduates said they would choose a traditional clerkship, but 6 (27%) of the traditionally trained graduates said they would choose a longitudinal integrated clerkship. CONCLUSIONS: This paper indicates that benefits of longitudinal integrated clerkship training are sustained over time across multiple domains.

Psychiatry in the Harvard Medical School-Cambridge Integrated Clerkship: an innovative, year-long program.

OBJECTIVE: The authors present what is to their knowledge the first description of a model for longitudinal third-year medical student psychiatry education. METHOD: A longitudinal, integrated psychiatric curriculum was developed, implemented, and sustained within the Harvard Medical School-Cambridge Integrated Clerkship. Curriculum elements include longitudinal mentoring by attending physicians in an outpatient psychiatry clinic, exposure to the major psychotherapies, psychopharmacology training, acute psychiatry "immersion" experiences, and a variety of clinical and didactic teaching sessions. RESULTS: The longitudinal psychiatry curriculum has been sustained for 8 years to-date, providing effective learning as demonstrated by OSCE scores, NBME shelf exam scores, written work, and observed clinical work. The percentage of students in this clerkship choosing psychiatry as a residency specialty is significantly greater than those in traditional clerkships at Harvard Medical School and greater than the U.S. average. CONCLUSION: Longitudinal integrated clerkship experiences are effective and sustainable; they offer particular strengths and opportunities for psychiatry education, and may influence student choice of specialty.

Commentary: two kinds of intelligence.

This commentary is a celebration of the 10th anniversary of the Academic Medicine feature Teaching and Learning Moments. The authors reflect that the moments highlighted in these columns are everyday moments in every medical school, in every residency program, in every clinic, in every hospital. These moments become extraordinary and personally transformative only when we pay attention. The invitation to honor these moments and value our subjective experiences is an invitation to integrity, to unite "soul" and "role." Yet the power of these narratives is not truly unleashed until they are discussed in community. In conversation, these personal narratives or "stories of self" have the potential to find common cause with the stories of others and become "stories of us." Through conversation that is rooted in a particular time and place, these stories of self and stories of us are linked to a "story of now." And these public narratives have the power to catalyze movements for change.