A Professionalism Curricular Model to Promote Transformative Learning Among Residents

The Accreditation Council for Graduate Medical Education identifies professionalism as a core competency for trainees.¹  Yet, a lack of consensus exists regarding effective approaches for teaching professionalism in residency. Professionalism initiatives are often deficit based, focusing on lapses, rather than best practices.^2,3  Further, self-reflection and contextualized instruction (ie, specific settings with related behaviors and internal dilemmas) are important in understanding the complexity of professionalism.^4–6  An occasional lecture or single workshop may not prompt changes in perspective or provide opportunities to reflect on experiences that are key for professional identity formation.⁷ 

Situated learning theory emphasizes placing learning activities in real-world settings, within communities of practice, to help learners create meaning. Communities of practice refer to the environments where individuals function.⁸  Residents function in clinical settings, their specialty or residency program, and professional circles within the larger medical community. The responsibilities, roles, and learning potential of each resident vary depending on context and community membership. Each community has its own culture and hidden curriculum,⁹  which can challenge a learner's sense of professional identity.

Transformative learning theory¹⁰  posits learning is triggered by a disorienting dilemma that brings about a change in perspective through discourse and critical reflection. Professionalism training in residency presents a unique opportunity to foster transformative learning because of the pervasiveness of disorienting situations that may challenge professionalism.

Using the frameworks of transformative learning and situated learning theory⁸  we developed a technology-enhanced professionalism curricular model—Recognize, Appreciate, Practice, Reflect (RAPR). RAPR aimed to build a learning community and promote residents' self-reflection and self-awareness.^11–13  In this article, we offer a description of the model, its elements, and related assumptions. We examined the acceptability and practicality of our model in relation to teaching professionalism in a graduate medical education setting. For acceptability, we explored the perceptions of residents and faculty regarding the RAPR model. For practicality, we evaluated whether residents can perform curricular activities to support transformative learning.

We purposefully selected 52 of 168 internal medicine residents (postgraduate years 1–3 [PGY-1 to PGY-3]) at a large Midwestern academic medical center to participate in a 10-hour, 4-week professionalism curriculum. Residents were selected based on their availability during the planned implementation period of January and March 2015 (Mondays, 7 am). The program director notified the 52 eligible residents of their assignment to the RAPR curriculum and asked them to attend the sessions as part of their standard academic obligations. Residents were expected to attend; however, they were not penalized for schedule conflicts. Our implementation procedures are outlined in the online supplemental material.

A committee of educators and clinicians designed and implemented the RAPR professionalism curricular model. A detailed description of the 4 units Recognize, Appreciate, Practice, Reflect is provided as online supplemental information. Each week of the curriculum was dedicated to a unit: (1) Recognize (increased awareness of professional exemplars); (2) Appreciate (fostered a professionalism knowledge base); (3) Practice (targeted application); and (4) Reflect (prompted reflection about insights and implications).

The implementation of RAPR was technology facilitated through annotated videos, key articles, and relevant materials. Technology also enhanced faculty's ability to provide feedback through tools and immediate access to residents' reflections, comments, and concerns. We developed a web portal (http://www.cmfoshee.com/ccf-community) and organized content around RAPR using collaborative technologies (wiki, blogs, social media)¹⁴  to support the curriculum and the transformative learning tenets.

The Cleveland Clinic's Institutional Review Board designated the protocol for this curriculum as exempt.

To explore the acceptability and practicality of the model, we tracked attendance and completion of online activities in relation to required tasks. Upon conclusion of each 4-week curricular block, we administered a 15-item Educational Experience Questionnaire (EEQ) to assess outcomes for each curricular activity (eg, “Reflecting helped me clarify my understanding about professionalism”), provided as online supplemental material. We conducted 2 focus groups with a total of 10 volunteer residents to determine whether focus group participants voiced different reactions than those evidenced in the written reflections or questionnaire responses, and to improve the experience of the second cohort based on input from the first. After completing both 4-week blocks, we conducted faculty interviews (with 6 of 10 faculty who taught the curriculum) to elicit their perspectives on the curricular model and the practicality of the approach.

To evaluate the extent to which RAPR supports transformative learning of professionalism, we collected written reflections from the 4 required tasks: definitions, collaborative vision, critical reflections, and lessons learned. Adopting a constructivist paradigm,¹⁵  1 author (C.M.F.) conducted a thematic analysis¹⁶  and tagged comments related to the transformative theory perspective (self-awareness/changed perspectives, views, or attitudes), followed by repeated examination to infer prevalent patterns. Another author (S.B.B.) independently reviewed this analysis. Both authors explored the data to reach consensus on overarching themes. A similar approach was used to code focus groups and faculty interviews. These data served to support/refute patterns and themes inferred from the analysis of residents' written reflections.

Because our approach aimed to increase and encourage self-awareness, reflection, perspective taking, and positivity, we anticipated that empathy and resilience would be relevant by-products of the curriculum.¹⁷  We administered the Jefferson Scale of Physician Empathy¹⁸  and the Resilience Scale¹⁹  on 3 different occasions: the start of the curriculum (T1), midway (T2, after first 4-week block), and upon completion of both blocks (T3). We conducted a repeated-measures analysis of variance, with empathy and resilience as dependent variables and time as the independent variable. Residents received their individual scores along with their cohort's average score as tools for self-reflection.

We also anticipated that this curricular experience would enhance professional interactions; therefore, we awarded Professionalism Quality Improvement certificates commensurate to their level of engagement.

A total of 52 residents met the inclusion criteria, and 49 (94%) participated. Prior to start of the curriculum, 3 residents dropped out due to scheduling conflicts. Those available in January (24) comprised the first cohort, and those available in March (25) comprised the second cohort. The majority of participating residents were male (33 of 49, 67%), younger than 30 years (43 of 49, 88%), and equally distributed among PGY-1 through PGY-3 (PGY-1, 17 [35%]; PGY-2, 16 [33%]; and PGY-3, 16 [33%]). There were no statistically significant differences between means across the factor of time (T1, T2, T3) for either empathy or resilience.

A majority of the residents who completed the EEQ (87%, 34 of 39) agreed they would participate in the program again (table). Focus group data and faculty interviews augmented the sense of acceptance by describing the experience as a “much-needed forum to discuss issues” not addressed elsewhere in residency curricula. The technology utilization/acceptance was not as anticipated: residents shared minimal reflections using social media, and focus group data confirmed that residents disliked using social media to share reflections. Nonetheless, a small majority agreed that the portal increased engagement. Technology enabled the online submissions of required tasks: definitions, critical reflections, and lessons learned.

We observed higher acceptance/compliance in the second cohort, which may be due to changes implemented, based on feedback from the first cohort focus group. Changes included extended orientation, weekly reminders, printed to-do lists distributed at each session, in-session time to work on “shared vision,” and electing a volunteer from each small group to submit the group's final vision.

Successful completion of required tasks (table) and awarding of 45 certificates (92%) confirmed the practicality of the curricular activities. Certificates were awarded at various levels to recognize resident's efforts toward improving professional interactions: attendance (8 of 49, 16%), participation (18 of 49, 37%), and achievement (19 of 49, 39%). While focus groups and faculty interviews highlighted that residents found it challenging to find the time to engage with the curriculum during busy rotations, faculty and residents agreed that the activities were worthwhile and manageable.

The thematic analysis of residents' reflections (82 reflections, 314 codes) suggested that the curriculum fostered professionalism transformations in 3 general domains: attitudinal, behavioral, and cognitive, with the EEQ responses echoing the themes in the analysis (table).

Attitudinal domain related to reflections about a change of view, attitude, or perspective. Consistent with the goal of the activities in Recognize—to enhance awareness—residents reported viewing professionalism in a more positive light.

Behavioral domain denoted explicit reflections about having modified, adopted, or stopped specific behaviors. Residents' comments supported the Appreciate aim of building a cognitive base with statements that alluded to increased empathy and deeper understanding.

Cognitive domain reflections comprised residents' interpretations about the meaning of professionalism. This domain exhibited features of Practice and Reflect with its focus on creating meaning and reflecting. Residents viewed the reflections, discussions, and process of defining professionalism as activities that helped them shape their thinking and behavior.

Our approach gained acceptance from residents and faculty, who reported they would participate in the program again. Residents expressed awareness and perspective shifts indicative of transformational learning. Although our intervention did not enhance residents' empathy or resilience, our study identified a facilitative role for technology in facilitating task completion, and potentially self-reflection.

The grounded theory data offer 1 strategy to engender self-reflection about professionalism that aligns with best practices in the literature.²  In contrast to the typical lectures or 1-time seminars, our 4-week approach placed emphasis on fostering self-awareness, developing strengths, exploring relationships between values and behavior, and creating meaningful experiences through critical discourse. RAPR presents educators with an intervention to deepen the teaching of professionalism with needed framework to address professionalism and its related ethical dilemmas.²⁰ 

The lack of impact of the curriculum on residents' empathy and resilience is inconsistent with the literature.^21–23  It is likely that sample size and poor completion rates across time contributed to the nonsignificant changes, as only a minority of residents completed all 3 assessments. It also is possible that the length of exposure to the curriculum was too brief, or the measures used were not sufficiently sensitive to detect changes.

Our expectation that residents would share professionalism-related thoughts/feelings using social media was not met. Residents rejected this public forum, likely because it does not provide the safe environment required for self-disclosure and candor related to professionalism. Also, the social media activity did not capture residents' reactions to content shared. For example, through focus groups, we learned that 1 video (TED: “Doctors Make Mistakes. Can We Talk About That?”) was so powerful that residents engaged in hallway conversations—yet, they remained silent on social media.

The assessment of this intervention has limitations, reducing the generalizability of our findings. Aspects include the reliance on self-reports and the modest sample size from a single specialty at 1 institution. Both faculty and learners viewed time as a major barrier to future replication.

Based on our experience, we recommend making the curriculum part of academic half-days; protecting faculty time; training chief residents to provide feedback; removing social media; utilizing existing tools (eg, Moodle or other learning management systems); including existing professionalism ratings; and considering using a transformational learning instrument.²⁴  To evaluate the impact of the curriculum on professional behavior, future implementations should consider delivering RAPR over 8 to 12 weeks in a face-to-face format enhanced by the online reflection activities.

Our findings support the use of RAPR as a promising model to cultivate self-reflection and deeper understanding about professionalism. We found RAPR to be an acceptable and practical approach to teaching professionalism in graduate medical education. The face-to-face sessions were the most successful aspect of the intervention. Providing protected time to explore professionalism in meaningful ways is key to a transformative learning approach.