Imagine a group of physicians sitting in a circle having open and honest conversations about what makes them feel alive—organized by an accrediting organization. For the past decade, this has happened at the Fetzer Institute's retreat center in Kalamazoo, Michigan, which has hosted the annual Accreditation Council for Graduate Medical Education's (ACGME's) Courage to Teach Physicians Formation Retreat.
The History
What is the history of this retreat? In 2001, when the ACGME had seen a significant percentage of its program directors resign each year, Dr David C. Leach, chief executive officer (CEO) of the ACGME, read Parker J. Palmer's book, The Courage to Teach.1 He was impressed with the teacher renewal program discussed in the book and with the philosophy of living divided no more and connecting the role with the soul—so that one does what is right not for one's own benefit but for the rightness of it. The Courage to Teach was written for primary and secondary school educators who had become dispirited by disconnecting from the core principles of teaching. Dr Leach believed that “good learning for good patient care” was a core principle in graduate medical education, and he wanted to explore it further.
He inaugurated the ACGME's Parker J. Palmer Courage to Teach Awards Program for program directors and, subsequently, the Parker J. Palmer Courage to Lead Awards Program for designated institutional officials. He and Dr Paul B. Batalden, past director of health care improvement leadership development at the Center for the Evaluative Clinical Sciences of the Dartmouth Medical School, enrolled in Dr Palmer's year-long facilitator program to learn his Courage concepts and ultimately introduce them to the awards' recipients. The aim was 4-fold: (1) honor and celebrate physicians and leaders in graduate medical education; (2) renew these individuals' spirits to allow them to reclaim their teaching roles; (3) create a safe place for reflective practice and contemplation for medical educators; and (4) disseminate these concepts by having awardees start similar movements in their own institutions to revitalize teaching in graduate medical education. This was the beginning of a magical retreat and physician formation movement.
The vision was to lead the retreat for 10 years, and then to reassess. Ten physicians would participate each year, and over the 10-year period this would produce 100 physicians to disseminate the concepts and ideas of teacher formation in graduate medical education. Dr Leach reached out to the Fetzer Institute to help defray costs, and it welcomed the ACGME to Seasons, its meeting facility where a “magical” venue and retreat experience took shape.
Content and Concepts
One of the concepts introduced in the retreat was the use of poems to stimulate reflection and contemplation. The poems of Thomas Merton, Rumi, Mary Oliver, William Stafford, and Vaclav Havel were among those read often. Participants also analyzed The Woodcarver by Chuang Tzu, and asked such questions as: What was the motivation behind the work? What are the tools that carry the work forward? What is the other to which the work relates? What are the outcomes of the work? They then applied the concepts analyzed to both their work as doctors and to their personal lives.
Drs Leach and Batalden also adapted the use of “clearness committees,” an approach developed by the Quakers in the 1660s. Dr Palmer says that behind the clearness committee is a simple but crucial conviction: each of us has an inner teacher—a voice of truth—that offers the guidance and power we need to deal with our problems. The function of the clearness committee is not to give advice or “fix” people, but to help remove the interference to allow individuals to discover their own wisdom from the inside out. Dr Leach noted that not “fixing” someone was hard for doctors because that is what they are trained to do. In the environment of the retreat and the clearness committee, doctors were asking doctors open questions. The goal was not to answer, advise, or fix, but to stir something inside each doctor's very being. The aim was for the whole person to show up, not just the façade of the doctor. Some participants found the clearness committee life changing.
The poem The Way It Is by William Stafford was used as a thought-provoking tool to reflect on the retreat experience. Using crayons, colored pencils, and paint, the doctors drew a “lifeline” about what they had learned from their own stories and what can be learned. Finally, each participant also wrote him or herself a letter reflecting on this experience. The letters were mailed to participants 1 month after the retreat.
Participant Reactions
In November 2009, participants were surveyed about what they viewed as the retreat's major strength. The responses revealed that some participants truly had experienced the magic:
Enforced time away from my crazy-busy work life.
The setting really allowed “retreat.” Openness and trust among attendees.
A chance for close interpersonal communication of like minds.
Time away from usual routine, exercises to reflect.
Fresh view of our roles, meeting other people.
Thoughtful reflection on teaching and sensitivity.
The ACGME celebrated its 10th year of the Parker J. Palmer Courage to Teach Award, given to outstanding program directors, at the March 2011 Annual Educational Conference. In May 2011, the Physician Formation Retreat celebrated its 10th anniversary as well. To date, 102 physicians have received the Courage to Teach Award and 15 physicians and 2 PhD holders have received the Courage to Lead Award. Of those, 69 (58%) have attended the ACGME's Courage to Teach Physician Formation Retreat.
In March 2011, Dr Palmer, staff members from the Center for Courage and Renewal, and I interviewed some retreat participants asking whether they had carried the work forward, fulfilling a goal of Drs Leach and Batalden. The interviews revealed that the retreat had enhanced participant's skills as educators and also broadened their understanding of connecting the role with the soul.
As an educator, I've been able to feel more confident in connecting emotional context to teaching—pathos, humor, anxiety, etc.
From a professional standpoint, [the retreat has] been amazing. I've cut back on PowerPoint usage! I do retreats for new residents modeled on the Courage retreats. I use poetry and other third things, break into small groups, spend the entire day and evening in retreat format.
[Participating in the retreat] changed a number of things I've done in undergrad and medical education. It's helped me to sharpen my sense of future direction and influence a career change. Helped me become more aware of what I'm good at and how to integrate talents like writing, music, and other outside interests with my work, and balance career and family better.
It also created a community of colleagues, with shared values and a heightened sense of the importance of education:
The retreat formed a community of people that I stay in touch with—relationships that are very important to me.
We also discovered that concepts from the retreat had found their way into the day-to-day work of the participants and that dissemination of these concepts continues. As some participants noted:
After the retreat, I built reflection into orientation by asking the interns to write a letter. You could hear a pin drop. They were so wired, and underlying all of this is a huge emotional transformation, and this is a good time to capture how they feel. At mid year, I give the letters back and they break into small groups, share their letters, and write goals for themselves. At the end of the year, we return the letters and they talk with each other about their internship year; often, there are a lot of tears. It is an enabling place for them to reflect, share, and realize.
I have been interested in the issue of fatigue, stress, and burnout in medicine; working in retreat with David and Paul on these issues gave me the inspiration to create a weekly group at the medical center, called “Relaxing, Rejuvenating, and Rejoicing in Residency.” We have been doing RR&R for two years, and it is open to anyone in the medical community including residents, CEOs, lawyers, and staff.
I use the same retreat model for the faculty for a year-long course called “Patient-Doctor III” during first clerkship year, based on reflective practice, looking at one's values/ideals/biases. It helps students become mindful practitioners and focuses on medical professionalism, as well as dealing with pain, suffering, and death; dealing with difficult patients and dysfunctional teams; dealing with medial error and importance of apology; delivering bad news; ethical decision making under uncertainty. Students write three reflection papers on personally transformative experiences, and the course has largely been influenced by my experience with Parker Palmer and his writings, the retreat, and with the Courage to Teach Program.
Imagine that.
References
Author notes
Marsha Miller, MA, is Associate Vice President, Office of Resident Services, and Director, ACGME Awards, at Accreditation Council for Graduate Medical Education.
