The Road to Professionalism: Reflective Learning and Reflective Practice WILLIAM T. BRANCH, JR., MD, FAACH, MACP Director, General Internal Medicine Emory University School of Medicine, Atlanta, GA ICCH – MIAMI ‘09

WILLIAM T. BRANCH, JR., MD, FAACH, MACP

Director, General Internal Medicine

Emory University School of Medicine, Atlanta, GA

. If I was Going to Die If I was going to die, And I just had a couple of weeks, Or months, Or whatever, I would just have to, You know, Prepare. You know, Because we all going, You know, All my loved ones, You know, I just don't want mine to be suffering. Branch WT, Jr, Torke, AM. If I Was Going to Die. J Gen Inter Med. 2006; 21: 96-98

TEACHING PROFESSIONAL VALUES “In theory, this cannot be done in practice…”

THE PATIENT-DOCTOR COURSE Harvard Medical School, 1985 - Present Small-groups meet weekly, years 1 and 3 8 students, 2 – 3 faculty per group Total 240 students and over 100 faculty Semi-structured, problem-based learning Faculty development component Branch WT Jr, Pels RJ, Calkins D, Forrow L, Harper G, Mandell F, Maynard E, Peterson L, Arky RA. A new educational approach for supporting the professional development of third year medical student. JGIM 1995; 10:691-694 Branch WT Jr, , Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. . Teaching medicine as a human experience: A patient-doctor relationship course for faculty and first-year medical students. Annals of Intern Med. 1991;114(6):482-9.

Small-groups meet weekly, years 1 and 3

8 students, 2 – 3 faculty per group

Total 240 students and over 100 faculty

Semi-structured, problem-based learning

Faculty development component

Branch WT Jr, Pels RJ, Calkins D, Forrow L, Harper G, Mandell F, Maynard E, Peterson L, Arky RA. A new educational approach for supporting the professional development of third year medical student. JGIM 1995; 10:691-694

Branch WT Jr, , Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. . Teaching medicine as a human experience: A patient-doctor relationship course for faculty and first-year medical students. Annals of Intern Med. 1991;114(6):482-9.

CURRICULUM OF PATIENT-DOCTOR COURSE Harvard Medical School, 1985 - Present Year 1 (Examples) Listening to patients’ stories Patient-interviewing skills Reflection on interviews - building a relationship - biopsychosocial model - alcohol and substance abuse - sexual history-taking - difficult relationships Year 3 (Examples) Communication issues - giving bad news Medical mistakes Difficult relationships Health policy Ethical issues for students - informed consent - DNR decisions- Critical incident narratives Branch WT Jr, Pels RJ, Calkins D, Forrow L, Harper G, Mandell F, Maynard E, Peterson L, Arky RA. A new educational approach for supporting the professional development of third year medical student. JGIM 1995; 10:691-694 Branch WT Jr, , Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. . Teaching medicine as a human experience: A patient-doctor relationship course for faculty and first-year medical students. Annals of Intern Med. 1991;114(6):482-9.

Year 1

(Examples)

Listening to patients’ stories

Patient-interviewing skills

Reflection on interviews

- building a relationship

- biopsychosocial model

- alcohol and substance abuse

- sexual history-taking

- difficult relationships

Year 3

(Examples)

Communication issues

- giving bad news

Medical mistakes

Difficult relationships

Health policy

Ethical issues for students

- informed consent

- DNR decisions-

Critical incident narratives

LEARNING THEORY OF PATIENT-DOCTOR COURSE Experiential learning of communication skills Skills “open the door” to reflective learning Topics related to the communication issues Topics address issues students encounter Narrative writing Critical reflection Transformative learning Branch WT Jr, Pels RJ, Calkins D, Forrow L, Harper G, Mandell F, Maynard E, Peterson L, Arky RA. A new educational approach for supporting the professional development of third year medical student. JGIM 1995; 10:691-694 Branch WT Jr, , Arky RA, Woo B, Stoeckle JD, Levy DB, Taylor WC. . Teaching medicine as a human experience: A patient-doctor relationship course for faculty and first-year medical students. Annals of Intern Med. 1991;114(6):482-9.

LEARNING THEORY OF PATIENT-DOCTOR COURSE

Experiential learning of communication skills

Skills “open the door” to reflective learning

Topics related to the communication issues

Topics address issues students encounter

Narrative writing

Critical reflection

Transformative learning

Critical Incident Report Three Years on the Faculty I laid my pen down carefully, placed both palms down on the desk, and made eye contact with my patient. Without wasting time, I directly broached the subject of HIV risk and testing. I felt a smile creeping across my face as I triumphantly completed the consent form. It was as if I’d sold her a new car Manning, KD. A person of status. JAMA. 2009; 300:483-84

Critical Incident Report

Three Years on the Faculty

I laid my pen down carefully, placed both palms down on the desk, and made eye contact with my patient. Without wasting time, I directly broached the subject of HIV risk and testing.

I felt a smile creeping across my face as I triumphantly completed the consent form. It was as if I’d sold her a new car

Critical Incident Report Three Years on the Faculty - cont’d - That day, I resolved to take my first ever voluntary HIV test at a local community AIDS outreach center. Manning, KD. A person of status. JAMA. 2009; 300:483-84

Critical Incident Report

Three Years on the Faculty

- cont’d -

That day, I resolved to take my first ever voluntary HIV test at a local community AIDS outreach center.

Critical Incident Report Three Years on the Facul ty - cont’d - As I took my seat in the waiting area. My palms became sweaty as I gripped the laminated fuchsia card tightly in my hand. I looked around at the other people in the room and somehow felt we were kindred spirits. What were their thoughts, their risks, their fears? The simple truth was that I was afraid. Manning, KD. A person of status. JAMA. 2009; 300:483-84

Critical Incident Report

Three Years on the Facul ty

- cont’d -

As I took my seat in the waiting area. My palms became sweaty as I gripped the laminated fuchsia card tightly in my hand. I looked around at the other people in the room and somehow felt we were kindred spirits. What were their thoughts, their risks, their fears? The simple truth was that I was afraid.

Critical Incident Report Three Years on the Faculty - cont’d - Finally, the counselor prepared to give me my first "real" HIV test result. The ear-pounding returned full throttle as I braced myself for information that could change life as I knew it forever. Manning, KD. A person of status. JAMA. 2009; 300:483-84

Critical Incident Report

Three Years on the Faculty

- cont’d -

Finally, the counselor prepared to give me my first "real" HIV test result. The ear-pounding returned full throttle as I braced myself for information that could change life as I knew it forever.

Critical Incident Report Three Years on the Faculty cont’d – I pushed open the glass door, stopped with closed eyes, and felt the warm sun on my face. Without warning, I began to cry. It surprised me. Tear after tear fell as I thought of every single HIV-positive patient I’d ever encountered. Manning, KD. A person of status. JAMA. 2009; 300:483-84

Critical Incident Report

Three Years on the Faculty

cont’d –

I pushed open the glass door, stopped with closed eyes, and felt the warm sun on my face. Without warning, I began to cry. It surprised me. Tear after tear fell as I thought of every single HIV-positive patient I’d ever encountered.

TRANSFORMATIVE LEARNING Transformative learning is the expansion of consciousness through the transformation of basic worldview and specific capacities of the self. Individuals change their frames of reference by critically reflecting on their assumptions and beliefs and consciously making and implementing plans that bring about new ways of defining their worlds. It is also a profound experience that can be described as emotional or spiritual transformations as well Boyd RD, Gordon MJ. Transformative education. Int. J. of Lifetime Educ.1988; 7: 261-284 Mezirow J. Transformative dimensions of adult learning. San Fran: Jossey-Bass 1991

TRANSFORMATIVE LEARNING

Transformative learning is the expansion of consciousness through the transformation of basic worldview and specific capacities of the self.

Individuals change their frames of reference by critically reflecting on their assumptions and beliefs and consciously making and implementing plans that bring about new ways of defining their worlds.

It is also a profound experience that can be described as emotional or spiritual transformations as well

Faculty Development for Reflective Learning and Reflective Practice A longitudinal faculty development process to positively influence professional and personal growth in key faculty members Faculty development alternated experiential teaching skills with reflective exercises We hypothesized that the group process over time would enhance faculty commitment to humanism and professionalism Branch WT Jr , Frankel R , Gracey CF , Haidet PM , Weissmann PF , Cantey P , Mitchell GA , Inui TS . A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

A longitudinal faculty development process to positively influence professional and personal growth in key faculty members

Faculty development alternated experiential teaching skills with reflective exercises

We hypothesized that the group process over time would enhance faculty commitment to humanism and professionalism

METHODS Groups of 8-12 faculty participants from 5 medical schools 18 months of weekly or bi-monthly sessions Experienced facilitator with promising and/or influential teachers 6-months curriculum addressing key topics, following by 12 months of group-planned sessions Branch WT Jr , Frankel R , Gracey CF , et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25. Branch WT Jr , Frankel R , Gracey CF , Haidet PM , Weissmann PF , Cantey P , Mitchell GA , Inui TS . A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

Groups of 8-12 faculty participants from 5 medical schools

18 months of weekly or bi-monthly sessions

Experienced facilitator with promising and/or influential teachers

6-months curriculum addressing key topics, following by 12 months of group-planned sessions

Branch WT Jr , Frankel R , Gracey CF , Haidet PM , Weissmann PF , Cantey P , Mitchell GA , Inui TS . A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

Survey Questionnaire Evaluation A humanistic teacher-evaluation questionnaire Items based on “themes and domains” of humanistic teaching identified from narratives from early faculty development sessions Responses to each item recorded on a linear analog scale Branch WT Jr , Frankel R , Gracey CF , et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25. Branch WT Jr , Frankel R , Gracey CF , Haidet PM , Weissmann PF , Cantey P , Mitchell GA , Inui TS . A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

A humanistic teacher-evaluation questionnaire

Items based on “themes and domains” of humanistic teaching identified from narratives from early faculty development sessions

Responses to each item recorded on a linear analog scale

Results: Humanistic Teaching Evaluation Instrument Absolute Differences Subjects vs. Wilcoxon Qualities Controls p – Value Examples Branch WT Jr , Frankel R , Gracey CF , et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25. Branch WT Jr , Frankel R , Gracey CF , Haidet PM , Weissmann PF , Cantey P , Mitchell GA , Inui TS . A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25. Inspires me to grow personally and professionally 10% .0018 Actively uses teaching opportunities to illustrate humanistic care 15% <.0001 Stimulates reflection by the team on our approach to the patient 13% <.0001 Serves as outstanding role model for how to build strong relationships with learners as well as patients 13% .0004 Explicitly teaches communication and relationship-building skills 14% .0014

Reflective Process: Appreciative Inquiry Appreciative inquiry identifies and works from strengths and inspires those engaged in the process to emulate each other. It also enhances self awareness. We used appreciative inquiry as a faculty development tool.

Reflective Process:

Appreciative Inquiry

Appreciative inquiry identifies and works from strengths and inspires those engaged in the process to emulate each other. It also enhances self awareness. We used appreciative inquiry as a faculty development tool.

Appreciative Inquiry “ Upon my return from clinic, I learned of a reportedly seamless meeting with 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. Later the family told the ICU team that they did not know really what to expect and that they felt afraid. Branch WT Jr , Frankel R , Gracey CF , et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25. Branch WT Jr , Frankel R , Gracey CF , Haidet PM , Weissmann PF , Cantey P , Mitchell GA , Inui TS . A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

Appreciative Inquiry

“ Upon my return from clinic, I learned of a reportedly seamless meeting with 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. Later the family told the ICU team that they did not know really what to expect and that they felt afraid.

Appreciative Inquiry Less than five minutes before my next (teaching) session, I decided to do something completely different. I sat down and took a deep breath. I shared with them 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 will be playing the role of the patient’s loving daughter Branch WT Jr , Frankel R , Gracey CF , et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25. Branch WT Jr , Frankel R , Gracey CF , Haidet PM , Weissmann PF , Cantey P , Mitchell GA , Inui TS . A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med 2009; 84: 117-25.

Appreciative Inquiry

Less than five minutes before my next (teaching) session, I decided to do something completely different. I sat down and took a deep breath. I shared with them 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 will be playing the role of the patient’s loving daughter

FOSTERING THE DEVELOPMENT OF YOUNG FACULTY MEMBERS: THE PROMISING YEARS Appreciative Inquiries, Five Years of Faculty Development Assoc Prof: It was unpopular but I had to discipline a medical student for unprofessional conduct. Asst Prof: I gained confidence from a mentor in my ability to lead my residency program. Now residents come to me for advice and encouragement. Assoc Prof: Was proven correct in her clinical judgment even when the resident disagreed; resident later admitted he had learned an important lesson from her . Asst Prof: Successfully supported medical students having personal difficulties interfering with their studies. Asst Prof: Recognized when he needed to intervene to support a resident in his role as associate program director. Asst Prof: Experiences success as a role model of an empathic teacher and physician. Higgins S, Bernstein L, Manning K, Schneider J, Kho A, Brownfield E, Branch, W T Jr. Fostering the Development of Young Faculty Members: The Promising Years. Submitted for publication 2009

Appreciative Inquiries, Five Years of Faculty Development

Assoc Prof: It was unpopular but I had to discipline a medical student for unprofessional conduct.

Asst Prof: I gained confidence from a mentor in my ability to lead my residency program. Now residents come to me for advice and encouragement.

Assoc Prof: Was proven correct in her clinical judgment even when the resident disagreed; resident later admitted he had learned an important lesson from her .

Asst Prof: Successfully supported medical students having personal difficulties interfering with their studies.

Asst Prof: Recognized when he needed to intervene to support a resident in his role as associate program director.

Asst Prof: Experiences success as a role model of an empathic teacher and physician.

RANDOMIZED TRIALS SHOWING THAT EDUCATIONAL INTERVENTIONS IMPROVE COMMUNICATION SKILLS AND INFLUENCE VALUES AND ATTITUDES Smith RC. Lyles JS, Mettler JA, et al. A strategy for improving patient satisfaction by intensive training of residents in psychosocial medicine: a controlled randomized study. Acad.Med.1995;70:729-32. - Patients “more satisfied” with care by trained residents (P = .02) Smith RC. Lyles JS, Mettler JA, et al. The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann.Inter Med. 1998;128:118-26. - Trained residents had superior interviewing skills with patients (P< .05) Moore GT, Block SD, Briggs-StyleC, Mitchell R. The influence of the new pathway curriculum of Harvard medical students. Acad Med.1994;69:983-9. - Students in new pathway demonstrated better relationship skills and humanistic attitudes (P< .05) Alon PA. Margalit, MD, PhD, Shimon M. Glick, MD, Jochanan Benbassat, MD, Ayala Cohen, PhD. Effect of a Biopsychosocial Approach on Patient Satisfaction and Patterns of Care . JGIM. 2004; 19: 485-491. - Improved patient satisfaction after physicians received reflective/active learning compared to controls (received lectures) (P< .05)

RANDOMIZED TRIALS SHOWING THAT EDUCATIONAL INTERVENTIONS IMPROVE

COMMUNICATION SKILLS AND INFLUENCE VALUES AND ATTITUDES

Smith RC. Lyles JS, Mettler JA, et al. A strategy for improving patient satisfaction by intensive training of residents in psychosocial medicine: a controlled randomized study. Acad.Med.1995;70:729-32.

- Patients “more satisfied” with care by trained residents (P = .02)

Smith RC. Lyles JS, Mettler JA, et al. The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann.Inter Med. 1998;128:118-26.

- Trained residents had superior interviewing skills with patients (P< .05)

Moore GT, Block SD, Briggs-StyleC, Mitchell R. The influence of the new pathway curriculum of Harvard medical students. Acad Med.1994;69:983-9.

- Students in new pathway demonstrated better relationship skills and humanistic attitudes (P< .05)

Alon PA. Margalit, MD, PhD, Shimon M. Glick, MD, Jochanan Benbassat, MD, Ayala Cohen, PhD. Effect of a Biopsychosocial Approach on Patient Satisfaction and Patterns of Care . JGIM. 2004; 19: 485-491.

- Improved patient satisfaction after physicians received reflective/active learning compared to controls (received lectures) (P< .05)