Transformative Learning in Graduate Medical Education: A Scoping Review

At its core, residency represents a time of potential transformation in the life of a practicing physician. Transformative learning (TL) is an educational theory originally credited to Mezirow¹  that is about “dramatic, fundamental change in the way we see ourselves and the world in which we live.”^2(p166) In adult education, TL has traditionally been conceptualized as a learning theory that describes what happens in the course of living one's life. This is supported by examples that typically comprise the “disorienting dilemma” or spark for the TL process, such as the death of a friend or family member or termination of a job.³  However, some have argued that an educator, through pedagogical design or execution, has the ability to foster TL in a process similar to that which occurs naturally in the world.⁴  Since the outcome of TL is the development of a more open and inclusive worldview,²  fostering TL with this goal may be extremely relevant to the educator, including those in the health professions. This concept of TL as a pedagogy in the health professions has recently been recognized.⁵ 

TL may be particularly relevant for residency education, a critical time for professional identity formation.⁶  Within graduate medical education (GME), harnessing TL has been proposed within the competencies of practice-based learning and improvement (PBLI) and systems-based practice (SBP) and has been offered as a framework for quality improvement (QI) curricular design.⁷  Through critical reflection on a disorienting dilemma, learners may improve their own clinical practice (PBLI). Through the social change perspective of TL,^3,8  learners may recognize injustices in the health care system and intervene (SBP/QI). However, in contrast to traditional pedagogies, the worldview shift integral to TL theory may lead to more lasting individual or systems change.

The first major review of TL in health professions education⁵  excluded GME, and thus an equivalent scoping review is needed to view the TL landscape in GME in order to enrich understanding of this approach to learning and identify literature gaps for further work. Our research questions included: “What are the current venues in GME where TL occurs?” and “Where and how is TL utilized as a pedagogy in GME?”

In January 2020, with the assistance of a medical research librarian and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist,⁹  we performed a systematic search of 7 databases (MEDLINE, ERIC, Scopus, Cochrane Library, PsychInfo, Embase, and CINAHL) to identify the published literature on TL interventions and experiences in GME. Key search terms were harvested by the first author (B.V.) and research librarian (A.K.). Through an iterative process of multiple consecutive searches, a final search strategy was established (provided as online supplementary data). To identify additional studies, we hand-searched the reference lists of the articles included in our full-text review, as well as the Journal of Graduate Medical Education for additional articles that met our inclusion criteria.

Articles were included if they met criteria for both GME and TL. GME was defined as post-receipt of the terminal degree but before unsupervised clinical practice. To meet criteria for TL, articles either had to explicitly use the terms “transformative learning” or “transformational learning,” or they had to contain the following 4 essential components of TL theory identified by the authors as the key minimal standards defining TL: (1) disorienting dilemma, (2) critical reflection, (3) discourse, and (4) action.^2,10  We had no publication date or language restrictions. Given our broad research question and the anticipated paucity of empirical literature on TL within GME, we chose to perform a scoping review^11,12  without article type restrictions.

Abstracts and manuscripts were screened by 2 authors, and disagreements were arbitrated by a third author. The article review process proceeded as per Figure 1 for a final set of 28 citations to be analyzed in our scoping review.

We abstracted and charted data using a priori codes based on themes identified in a previous literature review of TL in undergraduate medical education,⁵  as well as themes that were identified during a proof-of-concept literature review on the topic.¹³  Additional a priori codes included GME venue, Accreditation Council for Graduate Medical Education (ACGME) core competencies,¹⁴  and TL components. Through inductive coding, additional unforeseen codes and subcategories relevant to TL within GME were included. Results were reviewed with all co-authors until there was consensus on themes to be included in our final analysis.

In the sections that follow, we will first provide an overview of our search results, including a description of the articles and their content as it relates to the 4 components of TL. Next, we have combined our thematic analysis with our discussion section in order to provide recommendations for practice that go beyond what is specifically addressed in our included articles. Finally, we review main gaps in the literature, limitations of our review, and provide some conclusions.

Twenty-eight citations met inclusion criteria and were published between 2000 and 2018. Twenty (71%) described empirical research^15–33  or were formal literature reviews.³⁴  Two articles (7%) used entirely quantitative methodology,^15,27  10 (36%) used qualitative methodology,^{16–18,20,22,23,26,28,29,34}  and 8 (29%) utilized mixed methods.^{19,21,24,25,30–33}  The remaining articles were either first person accounts of experiences or curricula^35–37  or were entirely conceptual.^7,38–41  Nineteen articles (69%) explicitly mentioned “transformative learning” or “transformational learning.”^{7,16–19,21–23,26,27,29,31,33,34,36,38–41}  In the case of empirical work and first person accounts, the educational venues were in the United States,^{15–21,23–25,27,30,32,33,36,37}  Kenya,^29,35  the Netherlands,²⁶  Norway,²⁸  Mexico,³¹  or described international health electives across multiple countries.²²  The majority of articles described traditional GME (ie, internship, residency, fellowship), with the primary care fields (internal medicine, family medicine, pediatrics, general practice, or unspecified primary care) being most represented (Table 1). Only 2 articles referenced surgical GME.^26,35  Additional GME populations included international medical graduates from medical and other health professions,³⁴  clinical pastoral education programs,^15,40  and pasantes (Mexican social service physicians between medical school and residency).³¹  We also stratified articles according to the 3 perspectives of TL (Table 1).^3,8  The cognitive perspective describes the traditional theory, beginning with the disorienting dilemma, followed by critical reflection and rational discourse, and leading to action. The beyond rational component involves recognizing insights and epiphanies and may involve doing so through spirituality, art, dreams, or other non-traditional means. The social change perspective more closely aligns with the cognitive approach but sees societal transformation through challenging oppression and social justice as the outcome, rather than through individual transformation.

Here, we talk about the formal elements of TL as they appeared in the articles (Table 2).

We identified multiple experiences that could be interpreted as disorienting dilemmas, mainly involving difficult clinical encounters. These scenarios could be real or simulated, and often revolved around death, trauma, medical errors, ethical issues, or communication challenges. Trainee recognition of resource limitations or poor patient outcomes when caring for the underserved also appeared to be a disorienting dilemma with transformative potential. Factors related to the learning climate were also interpreted as disorienting dilemmas, such as when trainees experienced pressure or humiliation from faculty members.

Our review provided insight into the content, processes/venues, and barriers to critical reflection. Disorienting dilemmas were most often the content of reflection. Regarding where and how reflection occurred, Balint groups, “verbatim sessions,” video debriefing, focus groups, and curriculum inquiry (through a process called duoethnography) were all cited as potential venues. The humanities as a means for reflection were also commonly referenced, notably journaling, drawing, storytelling, and meditation. Unfamiliarity with the concept of reflection did pose a barrier to the process, as did lack of reflective skill. Time constraints were also identified as a barrier with some programs providing protected academic time for trainee reflection.

Mentors or coaches were integral in helping provide trainees awareness of unrecognized behaviors and questioning their assumptions. Surgical residents (compared to general practice residents) valued dialogue with peers over that with experienced supervisors. In addition to faculty and peer mentors, others involved in transformative discourse included nurses, community organizers, and patients. When the reflection discussed in the section above was accomplished in group format (in particular, small groups), such reflection resembled rational discourse. Interestingly, in one case, the research interview itself resembled discourse.

The outcomes of TL among our citations included attitudinal or culture shifts, increased spirituality, gaining new perspective (often surrounding social justice), and recognition of limitations. Reaffirming or assuming a new professional identity was a frequent result of TL in GME. Repetition and practice in situations similar to those that led to TL were seen as a prerequisite for lasting behavioral change.

There were 3 major themes identified: TL and professionalism, TL and primary care, and TL by other names (Table 3). We combined our thematic analysis with our discussion section to provide recommendations and implications for practice that references literature outside of, but relevant to, our literature search results.

While our database search yielded a multinational body of literature, we chose to map the selected articles according to the ACGME core competencies (Table 1). While every core competency was represented to some degree (Figure 2), there was a preponderance of emphasis on TL as it pertained to professionalism. While some citations discussed professionalism curricula using TL as a pedagogy, the concept of TL as professional identity formation comprised a larger subtheme. The GME literature on TL appears to focus more on formation than transformation,¹⁶  in other words, developing a professional identity rather than changing it. While TL theory assumes prior life experience through which beliefs are developed, residents and fellows may still be in the formative phase of gaining such experiences. The Lancet report of the Global Commission on Education of Health Professionals for the 21st Century⁴²  also interprets formation and transformation differently, with formative learning encompassing socialization and professional identity formation, and TL producing leaders and enlightened change agents. Thus, greater attention should be paid to differentiating formation and transformation in the literature, as well as in the training environment, so that the desired outcome may be achieved.

Mentorship, role-modeling, and coaching appeared integral to both professional identity formation and TL of residents and fellows (referenced in 64% of our citations). Such mentors were faculty members, attending physicians, or near-peer mentors (senior residents).³¹  Mentors created content on which to reflect (eg, sharing personal stories, introducing or recognizing “entry points”^22,39) and facilitated critical reflection (eg, unpacking assumptions, bringing awareness to the subconscious). Cruess et al⁴³  argued that combined with the accrual of individual experience, mentorship and role-modeling are the most powerful influencers on socialization and professional identity formation. We assert that explicit recognition of TL by the mentor may move the learner more efficiently through such processes toward the goal of unsupervised practice as professionals.

The vast majority of articles describing TL in GME pertained to the primary care fields. Procedural skills training integral to surgical GME or other technical specialties may more closely align with informative learning, or learning with the goal of knowledge and skills expertise.⁴²  Culture and context may also limit recognition of TL in the surgical fields, with faculty supervising general practice residents receiving more training on giving feedback than surgical faculty.²⁶  One study on communication skills learning found that “surgical residents received little support and their supervisors' feedback was primarily focused on medical content and accurate diagnosis.”^26(p95) Perceived time constraints also appeared to be a factor influencing specialty-specific TL. Surgical residents' “daily workload left no time for experimentation with new approaches,”^26(p94) whereas general practice residents were afforded extra time for discourse with facility, which “prevented their reverting to old behavior due to stress or time constraints.”^26(p94)

As mentioned, the Lancet Commission⁴²  recognized TL as a pedagogy to teach leadership attributes. In their review of leadership curricula in GME, Sadowski et al⁴⁴  identified primary care specialties to be the most common venues for such curricula. If formal attention to fostering leadership is more common within primary care training, it is not surprising that similar training programs apply pedagogies theorized to achieve this intended outcome more effectively. This parallel between leadership development and TL theory warrants further study.

We believe that TL has a place in surgical residency. Thus, one area for future work is to better understand the TL potential in the procedural fields. In addition, faculty development for graduate medical educators in the surgical fields should be more explicit about educating for TL and contain skill-building sessions on feedback, guiding reflection, and leadership development.

Multiple articles described theories that seem to be surrogate terms for TL. Identity transformation, professional formation, professional identity, and formation were often used interchangeably with TL. Additionally, the transtheoretical (or stages of change) model³²  closely resembled TL, picking up at stage 2 of Mezirow's stepwise model, omitting the disorienting dilemma. In addition to theories we felt were synonymous with TL, we recognized multiple other interrelating educational theories or concepts, including experiential or situated learning, the informal or hidden curriculum, communities of practice, and self-directed learning.

Given the large proportion (approximately one-third) of articles demonstrating implicit TL, we suspect that TL may be happening without educators being aware of the theory behind it. We propose that a greater understanding of TL theory for graduate medical educators would have increased potential for achieving learning outcomes, especially across the more esoteric of clinical competencies. One framework used “critical reflection as the decision point,” guiding the trainee down a path from disorienting dilemma to either PBLI or SBP, improving their personal practice or the health care system, respectively.⁷  The medical educator's ability to recognize this decision point is essential to moving a learner from reflection, to critical reflection, to transformation.

We recognized multiple areas within GME where TL likely occurs but was not captured in our search. The main area where we failed to identify a significant body of literature about TL pertained to diversity, equity, and inclusion in the GME environment. Residents and fellows from races or cultures that are underrepresented in medicine (UiM) likely face disorienting dilemmas on a daily basis. Similar to the findings from a realist synthesis on international medical graduates transitioning to their new workplaces,³⁴  UiM trainees may experience disorienting dilemmas should they matriculate in training programs situated in vastly different cultures than where they grew up. Underrepresented health professions trainees may need to choose when to “be themselves”^45(p43) versus conform to the culture of their current learning environment (ie, code-switching), for fear of their racial identity being perceived as unprofessional.⁴⁵  Such dilemmas may pressure UiM learners to remain silent⁴⁵  or speak up as leaders for change.^45,46  After racial injustices and police brutality yet again came to the forefront in 2020, medical residents were often those who led hospitals to join protests.⁴⁶  These disorienting events leading to structural change align well with the social critique perspective of TL.^3,8 

The graduate medical educator can also experience TL as it pertains to the training of UiM residents and fellows and the care of ethnically diverse patients. Smith⁴⁷  provides a framework for utilizing reflection as a means for White individuals to develop an antiracist worldview. We believe this to be a perfect encapsulation of the 4 key elements of TL. Through this lens, non-UiM educators in the GME setting may move beyond allyship into action. While we all observe social injustices in society (TL element No. 1, disorienting dilemma), a recognition of TL theory may promote subsequent introspection surrounding White privilege (No. 2, critical reflection), and perhaps organizing venues for group dialogue on diversity (No. 3, discourse). Such a process may lead to GME faculty adopting more equitable recruiting practices, promoting curricula recognizing race as a social construct, and leading health systems innovations to promote equity in access to care (No. 4, action).

Our review had several important limitations. First, while we utilized at least 2 reviewers for article screening, only a single author performed data abstraction. While this potentially limited the reliability and consistency of our review, a truly objective review may not be possible, nor should it be.⁴⁸  The literature review has just as much potential to describe the properties of the reviewers, as does the literature reviewed. Nevertheless, we attempted to minimize bias by having all reviewers reach a consensus on themes. Next, while contextual factors of the learning environment are traditionally felt to be an essential component of TL theory, we included articles that referenced simulated experiences. However, we are not the first to recognize the TL potential of simulation.¹⁰  Finally, while we attempted to stratify other authors' works according to the components of TL, there is potential that we misinterpreted their intent. It is well documented that much literature on the practice of TL is not theoretically grounded.²  Thus, we believe our interpretation is an act of dialogue between the adult learning and medical education community as to what constitutes TL both in theory and in the practice of GME.

The available literature on TL in GME emphasizes its relationship to professionalism and the primary care fields. TL is occurring in other settings but goes by different names in the literature or may go unidentified altogether.

The authors would like to thank Dr. Britta Thompson, Associate Dean for Student Assessment and Program Evaluation, Penn State College of Medicine, and Dr. Libby Tisdell, Professor-in-Charge, Graduate Programs in Lifelong Learning and Adult Education, Penn State Harrisburg, for their insightful feedback on multiple stages of this scholarship.