By Anne Bennett Swingle | Illustrations Keith Weller
Knowing how to inspire a group of students is hard enough for a practiced professor. For a physician, it can be downright baffling.
anaging conflict is the topic on the table today—not a bad skill to have at your fingertips these days. Still, the nine men and women gathered in this classroom at Hopkins’ Bayview Medical Center aren’t law enforcers or high-powered business types, but doctors.
This is the Johns Hopkins Faculty Development Program, and these beginning physicians and fellows have signed up to spend one morning a week for nine months in a course on clinical teaching skills. By studying human dynamics and practicing pedagogical techniques, they hope to unravel the secrets of successful instruction and use what they’ve learned to inspire students.
“We know that good educators need two things,” says Program Director L. Randol (Randy) Barker, “to know how to develop and implement a curriculum and good interpersonal teaching skills. But by and large, physicians haven’t had much formal training in either—maybe a couple of short seminars, that sort of thing. And invariably, if they’re connected with an academic medical center, they have to teach, whether it’s supervising students or residents who are learning to care for patients, or giving lectures or designing a curriculum (see box page 30). We’re here to help them get the basic competencies they need."
Among M.D.s, this program has acquired something of a reputation as the place to learn the basics of good teaching. Junior faculty from Hopkins and all over Baltimore now sign on for classes, and some even travel in weekly from D.C. hospitals and as far away as the University of Pennsylvania in Philadelphia.
Today’s session begins with a lesson in managing conflict in a doctor-patient encounter. Stephanie Boykin, an instructor in the Department of Family Medicine at the University of Maryland, is having difficulty dealing with a hypertensive, diabetic woman who refuses to take her medication. “I backed off,” she says, “and just had her keep a blood pressure journal, but I felt I didn’t do the best for this patient.”
It’s the kind of situation junior faculty wrestle with every day and, with proper guidance, can learn from. “Let’s act it out,” says facilitator Karan Cole. Effortlessly, and with the air of seasoned thespians, Boykin, playing the patient, and Munisha Mehra, a pediatrician at D. C. Children’s, playing Boykin, the doctor, segue into a role play:
Doctor: So, did you take your medications this week?
Patient: No. I am keeping the blood pressure journal you suggested, though.
Doctor: (solicitously) I know you’ve taken the first steps, but that isn’t enough to help you keep healthy. Let’s try another course of medicine.
Patient: (annoyed) Even if we repeat it, it won’t change anything. Anyway, I’m not sick enough to start taking the medicine.
Doctor: It sounds as though you have some concerns about medicines?
Boykin breaks away. “That line reaches me,” she says to Mehra. “It gives me a way in. Now I can point out that taking medicine doesn’t mean she’s a failure, I can ask about past experiences. Before, we were working on two levels, both of us wanting to prove a point. Now, we can collaborate.”
'70s-style Consciousness Raising
A couple of jargony-sounding, theoretical approaches drive classes in the Faculty Development Program: “self-directed” learning, in which participants identify the skills they want to acquire, as they’ve just done with this skit, and “learner-centered” teaching in which instructors re-spond to what participants say they need to learn.
Learning in groups is key, Barker says, and the same seven-to-nine people work together for the duration. Classes begin with “personal awareness sessions.” Anything that happened at work or at home is fair game for discussion. It’s a throwback to seventies-style consciousness raising and encounter groups, but Barker insists that the technique holds up, enabling physicians to feel less isolated from colleagues in their professional roles and helping them become better observers and listeners.
As group members get to know each other they become more and more comfortable about breaking into discussions. On this day, for instance, a topic on one young woman’s mind is the fact that the problems that crop up in teaching at an academic medical center are of a different magnitude from those in any other teaching realm.
“Where else,” she asks, “do educators have to ensure the health of a patient at the same time they’re serving the needs of a student?”
The Barker Tradition
The Faculty Development Program was launched in 1987 by five Bayview colleagues: Barker and David Kern of the Division of General Internal Medicine, and behavioral scientists Karan Cole, Donna Howard and Penelope Williamson. They offered a course on teaching skills and another on curriculum development. Over the years, it has turned into a genuine labor of love, and everyone in the original group except Howard remains involved today, more than 250 participants later.
Today, elements of the program have migrated to places like Dallas-based Baylor Health Care System. And in 1995, Barker spent a year on a Fulbright in Spain and put practitioners at the Institute des Estudies du Salud in Barcelona through the course.
Randy Barker (M.D.-1966) is part of a family that is practically synonymous with Hopkins’ Department of Medicine. His older brother, Lewellys (M.D.-1959), trained on the Osler house staff and is now a researcher connected with the School of Public Health. His twin, William (M.D.-1966), teaches geriatrics at the University of Rochester. Barker’s late father Halsey was an internist who graduated from the School of Medicine in 1932, and his grandfather Lewellys Barker succeeded William Osler as chief of medicine in 1905.
Barker joined Bayview (then City Hospitals) in 1970 and since then has helped build the Division of General Internal Medicine into a leader in medical education. Residents sign on there for a popular one-month rotation on communication skills, and the division is home base for internal medicine fellows specializing in medical education. Kern’s 1998 six-step guide, Curriculum Development for Medical Education, evolved out of the Faculty Development Program.
Five Ways to Slice an Orange
On this Wednesday morning, the group is continuing to deliberate about approaches to use in resolving disagreements. Once they’ve mastered the tacks they can take to settle a problem, they’ll be able to teach the skills to others to use in conflicts with patients.
At issue today is an orange. Facilitators Karan Cole and Nick Fiebach demonstrate that there are many ways—five to be exact—to slice an orange. It’s a matter of differences, you see. You can walk away from it (avoidance), fight over it (competition), or split it in two (compromise). You can be gracious and let the other person have it (accommodation), or you can look for a solution that satisfies both parties’ interests, eat the fruit and surrender the skin (collaboration). The key is to master all these techniques and realize that each has value in different situations. “It’s a way to approach managing conflict and build skills in negotiation,” explains Fiebach.
Besides these ongoing personal-style enhancement sessions, the course on teaching skills spends two full months in sessions on feedback, working in groups, precepting in clinical settings and giving presentations.
Participants in one precepting skills session watch two short videos showing residents making case presentations—one is a tad disorganized, the other a bit overconfident. Then they discuss which of the tactics used by the presenters proved most successful.
But the greatest value of this program, Barker maintains, is that it continues for nine months. Unlike the typical one- or two-day seminars on teaching offered at other institutions or courses on skills- enhancement, the course takes a deep look at the qualities that make for good teaching. It turns junior faculty on to teaching.
Some, like Erik Fromme, who’s on a two-year fellowship at Hopkins in medical education, plan to set up similar programs at other academic health centers when they move on. Fromme has just completed both the teaching skills and curriculum development courses and has now designed a curriculum on end-of- life care for residents. Next year, he’ll learn to be a facilitator in the program. “When I think of my own professional development,” he says, “this program is probably the most significant thing I’ve ever participated in.”
In an upcoming paper, the Faculty Development Program’s organizers de-scribe how they’ve used tools like participant evaluations and skill measurement to document the course’s success. The increasing numbers of applicants each year from outside Hopkins provide another testament.
Still, nothing, Barker says, feels quite so gratifying as the occasional encounter with former course participants. “When you run into someone and they say, ‘You know that program was a real pivotal year in my life. My teaching has really changed since then.’ That’s when you see that words like ‘learner-centered’ aren’t just jargon.”