Recruiting with care and rigor

As in many clinical departments, residents are key instructors and role models for each other and for medical students. The program director and other educational leaders identified the need to change the residency interview procedures to better evaluate the “goodness of fit” between the candidates and our core values. We implemented behavioral interviewing (BI), a method developed by industrial psychologists to elicit individuals’ prior behavior to better predict future performance. Despite studies in the 1980s showing BI to be more predictive than traditional interviews,⁸ BI was only introduced in OBGYN residency program selection very recently.^9,10

A key step in developing behavioral interviewing questions was to identify the key attributes the department was seeking in residents. The faculty members, charged with developing the next generation of OBGYN specialists, sought to recruit residents who shared their core values as a professional practice community and who would also help realize the department’s vision.

As each resident continued his or her personal journey of professional formation, we appreciated that they were also making a critically important impact on the informal curriculum and formation of the medical students. We created a series of questions to elicit each candidate’s experiences with stress management, peer respect, altruism, self-reflection, commitment to teaching and learning, enthusiasm, resiliency, leadership, tolerance of interpersonal differences, pursuit of excellence, and values supporting ethical decision-making. The questions were bundled together into five interview stations, each staffed by the same one or two faculty interviewers for all interview sessions, with additional stations for interviews with the program director and chief residents. Following each session, the faculty and resident interviewers discussed each candidate’s answers to the questions, which were scored and carried weight equal to or greater than the candidate’s academic record in the final ranking decisions. Since implementing behavioral interviewing in 2009, we have noticed qualitative differences in the humanism, self-reflection, resilience, and orientation to teaching and learning demonstrated by the residents.

For faculty, the departmental executive committee, which consisted of departmental division directors and mission-based vice chairs, reflected on the recruitment procedures and identified areas for improvement. Humanism and a relational approach to leadership were sought in all faculty candidates, but the procedures were insufficient for selection of faculty leaders. We subsequently introduced a formal appraisal of leadership characteristics and skills for all finalists for faculty leadership positions. This evaluation was outsourced to a company that conducts a two- to three-hour interview with the candidate, provides a summary and debriefing to the chair, and prepares a confidential summary for the new faculty leader and a personal development plan building on strengths to enhance performance. This formal appraisal process helped identify leadership challenges in finalists that the interview and vetting process had not identified and that could have led to discord among the faculty had the individual been recruited. Allowing time to fully vet candidates helped identify those who could help move initiatives forward and collectively build the department we all envisioned.

Aligning faculty recognition

To further engage faculty and help them reconnect with their individual passions and goals, a program of “mission grants” was implemented (and named after a beloved former faculty member who embodied humanism and compassion). The grant program was funded using the chair’s start-up funds to cover up to twenty percent of faculty time to pursue an academic project that served the department’s vision and values. The several grants awarded annually focused primarily on curriculum development. The criteria for annual teaching recognition was also revised. The 4.0 Award had been given to faculty and residents with sufficient student contact who exceeded a threshold of overall teaching effectiveness scores (i.e., between a 4.0 and 5.0 for eight out of nine rotations), given by the medical students on end-of-clerkship evaluations. To further align the award with the department’s high expectation for professional behavior, a criterion requiring an equally high score on a measure evaluating professionalism and humanism was created. The newly defined 4.0 Award was added to the criteria listed in a departmental academic incentive program, which distributes a small bonus payment annually to faculty who exceed a threshold of expected performance in education, research, or service.

Leadership development: recruiting a catalyst

Pivotal to implementing improvements in the educational environment was the recruitment of a Vice Chair for Education, to support the educational programs in administrative ways and in the further development of our culture of humanism. In 2009, after the initial retreats had been conducted and the vision and values statement was created, we sought a leader for this role who would bring both experience and formal training in education and be credible to clinically oriented faculty and learners. The typical phenotype for this kind of role would be an obstetrician–gynecologist with a master’s degree in education or a nonphysician with a doctoral degree in education. We were fortunate to recruit a vice chair (MJD) with a uniquely fitting set of experiences and expertise: a master’s degree in education focused on curriculum development, a Ph.D. in health communication, and many years of experience practicing as an occupational therapist and hospital administrator in mental health. The vice chair’s unique combination of formal training and clinical capabilities made him a highly effective catalyst for accelerating the development of humanism in the department. His ability to translate principles of communication and education to the real world of clinical teaching and learning further supported the formation of professional identity for students, residents, and faculty members.

The disconnect between reality and expectation: doctors are made, not born

Not long after the new vice chair (MJD) was hired, a chief resident came to his office with a litany of legitimate professionalism concerns regarding medical student performance on the obstetrics and gynecology clerkship. It was the second clinical rotation of the third year, and the extensive list encompassed everything from inappropriate attire to the lack of preparation before a surgical case. As a newly graduated, nonphysician educator, the vice chair was shocked, and in an attempt to gain a deeper understanding of the issue, he asked a seemingly rhetorical question, “Has anyone explicitly told the students what is expected of them?” The equally shocked and perplexed resident responded, “They should just know what is expected of them. This is a surgical rotation.”

This encounter was nothing short of a revelation for the vice chair. It illustrated a fundamental flaw: not preparing learners with a clear understanding of the professional behavior expected in the clinical learning and practice milieu as well as the role of the medical student–doctor on practice teams that include more advanced learners (residents) and attending physicians. It also highlighted the lack of focused resident and faculty development in recognizing and promoting the role that clinical preceptors and teams play in the development of these professional behaviors and identities. It is just as much a faculty’s role and responsibility to understand the reality that “doctors are made, not born” in relationship to the behavioral aspect of medicine as it is to teach students to create a differential diagnosis.¹¹ However, addressing professional expectations and promoting professional identity was clearly a more unfamiliar task than providing biomedical training, and therefore not in line with resident and faculty expectations of themselves as clinical preceptors. Ironically, at times the developing learner was faulted for not being fully formed at the onset of his or her training.

What then became the key task was to identify which philosophical and pragmatic issues lay at the heart of the matter for both the learners and the preceptors, in order to develop and implement a process of change. Cognizant that reality is co-constructed,¹² the vice chair set out to understand and address this issue from the learner and preceptor perspectives, in order to create a cohesive intervention that recognized the role that each member of the learning dyad played in professional identity formation. The ultimate goal was to change the culture of the department and the experience for both learners and clinical preceptors, so as to support professionalism and professional identity formation, as well as foster the department’s vision and values related to education for all stakeholders.

What resulted was an intervention that encompassed a series of educational practice changes, theoretical lectures, and training in giving and receiving feedback, which has narrowed the chasm between preceptors’ and learners’ expectations and understanding of clinical medical education, professional expectations, and professional identity formation. The program, which is based upon the subsequent topic areas covered in this chapter, has been used to train residents and faculty and is part of a school-wide student orientation before the start of all third-year clerkships. An OBGYN-focused version is presented at the clerkship-specific orientation. The program has greatly reduced the incidence of unprofessional behaviors and expectancy violations, making it nearly a nonissue in the OBGYN clerkship.

The change in learner identity: from the classroom to the clinic

One of the initial questions we asked ourselves as educators was, “What changes are fundamental from the pre-clinical years in medical school to the clinical years?” After all, students should be prepared for the rigors of clinical training, especially given what they have had to accomplish, and in some cases overcome, in the pre-clinical years of medical school. However, what became apparent is that there were several fundamental shifts in learning processes, foci, and assessment that proved students were ill-prepared despite their previous experiences.

First and foremost is the learning environment itself. The standard classroom setting, where most students received the vast majority of their education, creates a teacher-centered approach based on the behaviorist tradition.^13,14 The instructor is solely responsible for the structure and content of the learning and outcomes, and the focus is the learners’ needs, understanding, control, and schedule.¹⁵ In sharp contrast, during the clinical years, a completely different educational paradigm is introduced: a patient-centered approach based on constructivism, without much prior preparation or training, at a time when the stakes are very high for the learner.

In the clinical years, the patient is the focus of not only the preceptor but also the learner, who is no longer the central focus in the learning paradigm and must assume ownership and control over his or her own education.^13,14 Education happens through and as a result of providing excellent patient care and integrating knowledge with practice. For many learners, this transition is challenging. If the proper foundation is not created prior to the start of the clinical experience, and if the preceptors are less conscious of the paradigm change, they are less likely to facilitate the shift in learner and professional identity. This is moving the learner from “student head,” whose hallmark is often a focus on a singular issue, process, or outcome, to “doctor head,” which requires higher order, system-level thinking.¹⁶ For example, if a student will be preparing for a case in the operating room for the following day and asks his or her preceptor if the only needed preparation is to read about the procedure, the preceptor could say, “That’s student head. What else would a doctor want to know about prior to a surgery besides the basic steps of the procedure?” Hopefully, the student will identify independently, or with prompting, the need to be familiar with the patient’s history, diagnosis, co-morbidities, and basic anatomy.

Second, the student is unable to develop for any sustained period of time a singular sense of learner or professional expectation, behavior, and identity because the clinical experiences in the various medical specialties can be short lived (e.g., two to five weeks in traditional block clerkships). Even for those clinical experiences that are integrated, there can be great variations in the experiences and roles students are asked to assume. In each specialty and setting, what the student is exposed to via the specialty or departmental culture, and the resulting hidden curriculum, can vary greatly.¹⁶ The key to success in both types of clinical education is not merely a question of form, but that learners have the opportunities to actively engage in patient care in an environment that is structured, fosters interaction, and invites participation in cultural practices.¹⁷ This is because medicine is not monolithic, and each specialty, department, and institution has its own culture and worldview. Therefore, the clinical experience is not unlike visiting a foreign country: students are told they are merely visiting “OBGYN world” or “Pediatrics world” and “Hospital X or Y.” One should expect to encounter differences in language, customs, cultural norms, and identity expectations, but both the visitor and the “natives” will need to navigate these differences with mutual respect, reflection, and understanding in order to promote mutual growth. However, for someone who is in the process of transformation, there is not one sense of emerging, consistent identity or set of behaviors and expectations that can solidify over time. Instead, there is the continuous destabilization or reinventing of the self in each specialty, and the driving motivation is often survival based (i.e., to pass the clerkship), which is “student head” instead of the focus being on learning medicine and integrating a sense of professional behaviors, role, and identity.

Third, the assessment of performance during the clinical years is based far more on subjective assessment of skills and group-level behaviors (i.e., working in teams with the introduction of a new hierarchy and coordinating with other professions) than in the pre-clinical years, when assessment relies more heavily on individual objective performance, such as exams. Although there are still exams in the clinical years (e.g., National Board of Medical Examiners Subject Exams), the increased importance placed on communication and group process whereby constructive feedback can be given in real time and publicly adds to the difficulty in transitioning between learning milieus. In addition, learners are being asked to accept their lack of mastery over the skills and information in each clinical setting, at a time when the stakes regarding graded performance can be at its highest. This often breeds resistance to learning and feedback, which is then manifested as an external attribution instead of humility, acceptance, and taking responsibility for one’s professional growth. In turn, this external attribution can breed resistance on the part of preceptors to give constructive feedback, especially for non-biomedical issues.

Attribution theory: interpreting behavior and attributing causality

Attribution theory¹⁸ posits that when an individual must assign a reason or rationale for his or her own negative behavior (e.g., being late to work), the individual is inclined to find an external attribution (e.g., there was an accident on the highway) versus an internal attribution (e.g., I’m lazy) as the cause of the situation. In contrast, when an individual needs to assign a reason or rationale for someone else’s negative behavior (e.g., being late to work), the individual is inclined to find an internal attribution (e.g., the other person is lazy) versus an external attribution (e.g., there was an accident on the highway) as the cause of the situation. When this feedback “attribution dance” unfolds between a preceptor (e.g., you were late to work and missed morning report) and learner (e.g., there was an accident on the highway), it can be interpreted that the learner is being (1) defensive, (2) not accepting responsibility for his or her actions, and (3) unwilling to learn. This perception of not taking responsibility for one’s own action as a professional in training can be seen as such an affront to professional identity that it can result in two common responses, which can have a negative impact on the mentor-mentee relationship.

The preceptor could invest scarce and limited time and energy in a struggle to make the learner take ownership of the learner’s actions or could take the easier and more common approach, which is to just stop investing the effort to give the learner feedback. One of the telltale signs of the latter response is, when a learner asks a preceptor, “How am I doing?” and receives monosyllabic responses such as, “Fine.” In such circumstances, it is not until the end-of-clerkship summative evaluation that the learner receives the preceptor’s actual subjective assessment of the learner’s skill-based and professionalism performance. Fortunately, it is easy to rectify this communicative misstep. Clinical preceptors and learners had to be trained to recognize this communication process, understand it, and be provided with a tool for both giving feedback and receiving it.

However, before embarking upon that process, a list of past patterns of learner behaviors consistent with the clerkship and the department’s culture that the residents deemed violations of professional identity for the specialty was compiled, in order to make the learners explicitly aware of them. This then became the initial round of behaviors that we focused on in the educational intervention (described in Table 18.1). We then set forth to develop a two-pronged approach to change the learning environment, which required us to address both the structural impediments to learning and communication skills training.

Creating a climate for formative feedback

To promote humanism in medicine, we have to be willing to promote humanism in medical education. Unless an educational atmosphere is created that explicitly recognizes and rewards the behaviors being promoted, we cannot in good conscience expect there to be change on the part of the learners.¹¹ If we begin with the educational axiom that education is an expected process of growth and change through exposure, trial and error, and feedback, then we accept the natural learning curve and expect progression from adequacy to mastery. Any expectation of a learner to be more “fully formed” than they are is unrealistic and bound to breed resistance to instruction, feedback and, most importantly, self-reflection, behaviors deemed integral to the formation of the professional role and identity of those entering a life in medicine.

Explicitly establishing this educational axiom with students as a departmental mantra has helped to foster a relationship with learners that has allowed them to more readily acknowledge their actions, take responsibility for them, and mutually construct a plan for improvement. Importantly, there are no “scarlet letters” for behaviors that are identified, accepted, and corrected. Corrected behaviors do not get documented on evaluations because they are considered “water under the bridge,” provided that the behavior or infraction does not breach a legal or ethical boundary, which could require a greater response. The rationale is that in terms of the natural progression of skill building and professional formation, no health professional has “clean hands.” All health professionals have, without malice or intention, erred in the pursuit of professional identity formation, skill acquisition, and mastery, and at times under less than ideal circumstances. The goal of medical education has become increasingly focused on quality and performance improvement processes, which promote increased self-reflection and questioning: do you recognize it, do you take responsibility for it, and have you demonstrated progress toward correcting it?¹⁹ But, to facilitate that process in medical education, the learning environment must be purposefully and consciously shaped and molded to address students’ worries about documentation and grade implications, so that growth in skills, as well as professional identity, is fostered.

For example, in the department, no performance concern can be documented on the summative final evaluation (which is reflected in the student’s Medical Student Performance Evaluation or Dean’s letter) that was not documented on the formative mid-rotation evaluation, because it is assumed the learner was not given the feedback or the opportunity to improve before the final summative evaluation. However, this was not meant to place the sole expectation on the preceptor to provide constructive feedback and documentation. Instead, the institution developed a mid-rotation process that required the student to complete a narrative self-assessment of strengths and areas for improvement on each of the dimensions that the preceptor would evaluate, both at the formative mid-rotation and the end-of-clerkship summative evaluation (e.g., data acquisition, problem solving, communication, and professionalism). Then, at mid-rotation, the learner and the preceptor exchange evaluations in order to assess for any discrepancies in perception, discuss areas of strengths and concerns, and construct any plan for remediation, thereby creating a shared accountability for learning and outcomes. The department then took this process one step further by requiring each student to have a fifteen-minute, face-to-face meeting (in person or by videoconferencing) with the clerkship director or his or her designee, to review the learner-preceptor evaluations and discuss the learning environment, evaluate goals, and identify if any modifications or enhancements were required to assist with goal attainment. This model has proved effective, but only after a philosophical and communicative foundation was created.