SUPPORTING THE PROFESSIONAL DEVELOPMENT OF FACULTY TEACHERS.

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.

Healthcare at the Crossroads: The Need to Shape an Organizational Culture of Humanistic Teaching and Practice.

BACKGROUND: Changes in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction. OBJECTIVE: To identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians. DESIGN: From January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations. PARTICIPANTS: Sixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors. APPROACH: Participants' responses were analyzed using the constant comparative method. KEY RESULTS: Motivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures. CONCLUSIONS: While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus.

The highly influential teacher: recognising our unsung heroes.

OBJECTIVES: This study was designed to investigate the roles, characteristics and contributions to the educational process of highly influential teachers described retrospectively by faculty members who were former medical students and trainees. METHODS: The authors collected 20 appreciative inquiry narratives from a convenience sample of 22 faculty members (91% collection rate) at three medical schools that had volunteered to participate in a year-long programme of faculty development in humanism in medicine. The faculty members wrote narratives in response to the prompt: 'Write about your most influential teacher.' The four authors performed qualitative analysis of the 20 narratives using the constant comparison method to identify the characteristics of influential teachers. RESULTS: Particular relational features with their learners explain the profound influences of these teachers on the professional development of their learners. All influential teachers shared qualities of excellence in teaching and nearly all were described as caring, generous and selfless in their relationships with learners. CONCLUSIONS: Highly influential teachers have no official roles, yet appear to profoundly influence the professional development of many learners at various stages of the educational process.

Faculty development to enhance humanistic teaching and role modeling: a collaborative study at eight institutions.

BACKGROUND: There is increased emphasis on practicing humanism in medicine but explicit methods for faculty development in humanism are rare. OBJECTIVE: We sought to demonstrate improved faculty teaching and role modeling of humanistic and professional values by participants in a multi-institutional faculty development program as rated by their learners in clinical settings compared to contemporaneous controls. DESIGN: Blinded learners in clinical settings rated their clinical teachers, either participants or controls, on the previously validated 10-item Humanistic Teaching Practices Effectiveness (HTPE) questionnaire. PARTICIPANTS: Groups of 7-9 participants at 8 academic medical centers completed an 18-month faculty development program. Participating faculty were chosen by program facilitators at each institution on the basis of being promising teachers, willing to participate in the longitudinal faculty development program. INTERVENTION: Our 18-month curriculum combined experiential learning of teaching skills with critical reflection using appreciative inquiry narratives about their experiences as teachers and other reflective discussions. MAIN MEASURES: The main outcome was the aggregate score of the ten items on the questionnaire at all institutions. KEY RESULTS: The aggregate score favored participants over controls (P = 0.019) independently of gender, experience on faculty, specialty area, and/or overall teaching skills. CONCLUSIONS: Longitudinal, intensive faculty development that employs experiential learning and critical reflection likely enhances humanistic teaching and role modeling. Almost all participants completed the program. Results are generalizable to other schools.

Treating the whole patient: passing time-honoured skills for building doctor-patient relationships on to generations of doctors.

OBJECTIVES: This paper aims to honour the Hippocratic Oath in modern practice by providing reflections on the development of ways for doctors to know the whole person that have accrued over the five decades to the present. METHODS: I present a perspective piece, which includes personal reflections and cites relevant literature. RESULTS: Powerful role models sustained the concept of knowing the whole patient in an era of scientific medicine. Beginning in the 1980s, skills allowing ordinary doctors to know the whole patient were made transparent to learners in courses and medical school curricula. As we approach the 2020s, increasing numbers of doctors have mastered these skills and are teaching them. CONCLUSIONS: A modern way of practice is emerging; this emphasises the human side of medicine and its rewards, despite barriers such as those imposed by time limitations.

Through the looking glass: how reflective learning influences the development of young faculty members.

BACKGROUND: Faculty development is needed that will influence clinical teachers to better enable them to transmit humanistic values to their learners and colleagues. PURPOSE: We sought to understand the processes whereby reflective learning influenced professional growth in a convenience sample of young faculty members. METHODS: We analyzed appreciative inquiry narratives written over 4 years using the constant comparative method to identify major underlying themes and develop hypotheses concerning how reflective learning influenced participants in the faculty development program. Six of the participants and the facilitator were participant observers in the qualitative analysis. RESULTS: Group support, validation, and cohesion led to adoption of common values that informed the professional development of the participants over 4 years of the study. Common values influenced the group members as they progressed in their careers. CONCLUSIONS: Faculty development programs that focus on humanism and reflective learning can facilitate the growth of young faculty members by influencing their values and attitudes at crucial phases of their careers.

Wisdom in medicine.

The pathway to wisdom is a crooked one. Doctors have many opportunities to become wiser, and may do so in different ways and to different degrees. We suggest several means to facilitate their passage. There remains an additional key step. Seeking wisdom should become embedded in the culture of medicine. This may follow from the types of activities discussed above. We believe that wisdom is underrecognized as a life goal for medical practitioners and teachers. It is the pinnacle that every doctor should strive to achieve.

Views of institutional leaders on maintaining humanism in today's practice.

OBJECTIVE: To explore leadership perspectives on how to maintain high quality efficient care that is also person-centered and humanistic. METHODS: The authors interviewed and collected narrative transcripts from a convenience sample of 32 institutional healthcare leaders at seven U.S. medical schools. The institutional leaders were asked to identify factors that either promoted or inhibited humanistic practice. A subset of authors used the constant comparative method to perform qualitative analysis of the interview transcripts. They reached thematic saturation by consensus on the major themes and illustrative examples after six conference calls. RESULTS: Institutional healthcare leaders supported vision statements, policies, organized educational and faculty development programs, role modeling including their own, and recognition of informal acts of kindness to promote and maintain humanistic patient-care. These measures were described individually rather than as components of a coordinated plan. Few healthcare leaders mentioned plans for organizational or systems changes to promote humanistic clinician-patient relationships. CONCLUSIONS: Institutional leaders assisted clinicians in dealing with stressful practices in beneficial ways but fell short of envisaging systems approaches that improve practice organization to encourage humanistic care. PRACTICE IMPLICATIONS: To preserve humanistic care requires system changes as well as programs to enhance skills and foster humanistic values and attitudes.

An intervention to overcome clinical inertia and improve diabetes mellitus control in a primary care setting: Improving Primary Care of African Americans with Diabetes (IPCAAD) 8.

BACKGROUND: Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control. METHODS: In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations). RESULTS: At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups (P<.001). After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback alone and feedback plus reminders groups was sustained: 52% did anything, and 30% did enough (P<.001 for both vs the reminders alone and control groups). Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c (P<.001 for both). CONCLUSIONS: Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings.

Reflection-Based Learning for Professional Ethical Formation.

One way practitioners learn ethics is by reflecting on experience. They may reflect in the moment (reflection-in-action) or afterwards (reflection-on-action). We illustrate how a teaching clinician may transform relationships with patients and teach person-centered care through reflective learning. We discuss reflective learning pedagogies and present two case examples of our preferred method, guided group reflection using narratives. This method fosters moral development alongside professional identity formation in students and advanced learners. Our method for reflective learning addresses and enables processing of the most pressing ethical issues that learners encounter in practice.

How physicians draw satisfaction and overcome barriers in their practices: "It sustains me".

OBJECTIVE: Major reorganizations of medical practice today challenge physicians' ability to deliver compassionate care. We sought to understand how physicians who completed an intensive faculty development program in medical humanism sustain their humanistic practices. METHODS: Program completers from 8 U.S. medical schools wrote reflections in answer to two open-ended questions addressing their personal motivations and the barriers that impeded their humanistic practice and teaching. Reflections were qualitatively analyzed using the constant comparative method. RESULTS: Sixty-eight physicians (74% response rate) submitted reflections. Motivating factors included: 1) identification with humanistic values; 2) providing care that they or their family would want; 3) connecting to patients; 4) passing on values through role modelling; 5) being in the moment. Inhibiting factors included: 1) time, 2) stress, 3) culture, and 4) episodic burnout. CONCLUSIONS: Determination to live by one's values, embedded within a strong professional identity, allowed study participants to alleviate, but not resolve, the barriers. Collaborative action to address organizational impediments was endorsed but found to be lacking. PRACTICE IMPLICATIONS: Fostering fully mature professional development among physicians will require new skills and opportunities that reinforce time-honored values while simultaneously partnering with others to nurture, sustain and improve patient care by addressing system issues.

A Multi-Institutional Longitudinal Faculty Development Program in Humanism Supports the Professional Development of Faculty Teachers.

The authors describe the first 11 academic years (2005-2006 through 2016-2017) of a longitudinal, small-group faculty development program for strengthening humanistic teaching and role modeling at 30 U.S. and Canadian medical schools that continues today. During the yearlong program, small groups of participating faculty met twice monthly with a local facilitator for exercises in humanistic teaching, role modeling, and related topics that combined narrative reflection with skills training using experiential learning techniques. The program focused on the professional development of its participants. Thirty schools participated; 993 faculty, including some residents, completed the program.In evaluations, participating faculty at 13 of the schools scored significantly more positively as rated by learners on all dimensions of medical humanism than did matched controls. Qualitative analyses from several cohorts suggest many participants had progressed to more advanced stages of professional identity formation after completing the program. Strong engagement and attendance by faculty participants as well as the multimodal evaluation suggest that the program may serve as a model for others. Recently, most schools adopting the program have offered the curriculum annually to two or more groups of faculty participants to create sufficient numbers of trained faculty to positively influence humanistic teaching at the institution.The authors discuss the program's learning theory, outline its curriculum, reflect on the program's accomplishments and plans for the future, and state how faculty trained in such programs could lead institutional initiatives and foster positive change in humanistic professional development at all levels of medical education.

The importance of spirituality in African-Americans' end-of-life experience.

A profound and moving spirituality provided emotional and psychological support for most terminally ill patients at Grady Memorial Hospital. The authors were able to trace the roots of these patients' spirituality to core beliefs described by African-American theologians. Truly bedrock beliefs often reflected in conversations with the patients at Grady included the providence of God and the divine plan for each person's life. Patients felt an intimate relationship to God, which they expressed through prayer. Importantly, almost all patients were willing to share their beliefs with the authors in long bedside interviews. This willingness to share indicates that physicians can learn about and validate such patients' spiritual sources of support.

Viewpoint: teaching respect for patients.

Respect is a core value of medical professionalism. Respect for patients often manifests itself as an attitude, of which the physician is only partially self-aware. To teach respect means bringing it fully into consciousness. Physicians then should strive to make respect an inner quality, beyond being a behavior. The author illustrates the depth of feeling involved in respecting another person by citing passages from Let Us Now Praise Famous Men, James Agee's classic book that describes Depression-era tenant farmers. However, major barriers inhibit teaching of respect in clinical settings. The author proposes that synergies can be achieved that overcome the barriers by combining the effective modeling of respect in bedside teaching with formal teaching exercises involving patients and deep critical reflection using narratives wherein learners describe their experiences in patient care.

Role modeling humanistic behavior: learning bedside manner from the experts.

PURPOSE: Humanistic care is regarded as important by patients and professional accrediting agencies, but little is known about how attitudes and behaviors in this domain are taught in clinical settings. To answer this question, the authors studied how excellent clinical teachers impart the behaviors and attitudes consistent with humanistic care to their learners. METHOD: Using an observational, qualitative methodology, the authors studied 12 clinical faculty identified by the medical residents enrolled from 2003 to 2004 as excellent teachers of humanistic care on the inpatient medical services at four medical universities in the United States (University of Minnesota Medical School, Emory University, University of Rochester School of Medicine, and Baylor College of Medicine). Observations were conducted by the authors using standardized field notes. After each encounter, the authors debriefed patients, learners (residents and medical students), and the teaching physicians in semistructured interviews. RESULTS: Clinical teachers taught primarily by role modeling. Although they were highly aware of their significance as role models, they did not typically address the human dimensions of care overtly. Despite the common themes of role modeling identified, each clinical teacher exhibited unique teaching strategies. These clinical teachers identified self-reflection as the primary method by which they developed and refined their teaching strategies. CONCLUSIONS: Role modeling is the primary method by which excellent clinical teachers try to teach medical residents humanistic aspects of medical care. Although clinical teachers develop unique teaching styles and strategies, common themes are shared and could be used for the future development of clinical faculty.

Is Rorty's neopragmatism the "real" foundation of medical ethics: a search for foundational principles.

Principlism, the predominate approach to bioethics, has no foundational principles. This absence of foundations reflects the general intellectual climate of postmodern relativism. Even America's foremost public philosopher, Richard Rorty, whose pragmatism might suggest a philosophy of commonsense, seems to be swimming in the postmodern swamp. Alternatively, principlism's architects, Beauchamp and Childress, suggest a constantly evolving reflective equilibrium with some basis in common morality as a workable framework for twenty-first century bioethics. The flaw in their approach is failure to conform to real doctors' and patients' experiences. Real doctors adopt a scientific paradigm that assumes an objective reality. Patients experience real suffering and seek effective cures, treatments, palliation and solace. The foundation of medical ethics should be that doctors altruistically respond to their patients' suffering using scientifically acceptable modalities. Compassion, caring, and respect for human dignity are needed as guides in addition to justice, beneficence, nonmaleficence and respect for autonomy.

An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7.

OBJECTIVE: Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS: A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS: Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001). CONCLUSIONS: Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.