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J Gen Intern Med. Oct 2007; 22(10): 1422–1428.
Published online Jul 10, 2007. doi:  10.1007/s11606-007-0274-5
PMCID: PMC2305848

Authentic Community as an Educational Strategy for Advancing Professionalism: A National Evaluation of the Healer’s Art Course

Abstract

Background

Efforts to promote medical professionalism often focus on cognitive and technical competencies, rather than professional identity, commitment, and values. The Healer’s Art elective is designed to create a genuine community of inquiry into these foundational elements of professionalism.

Objective

Evaluations were obtained to characterize course impact and to understand students’ conceptions of professionalism.

Design

Qualitative analysis of narrative course evaluation responses.

Participants

Healer’s Art students from U.S. and Canadian medical schools.

Approach

Analysis of common themes identified in response to questions about course learning, insights, and utility.

Results

In 2003–2004, 25 schools offered the course. Evaluations were obtained from 467 of 582 students (80.2%) from 22 schools participating in the study. From a question about what students learned about the practice of medicine from the Healer’s Art, the most common themes were “definition of professionalism in medicine” and “legitimizing humanism in medicine.” The most common themes produced by a question about the most valuable insights gained in the course were “relationship between physicians and patients” and “creating authentic community.” The most common themes in response to a question about course utility were “creating authentic community” and “filling a curricular gap.”

Conclusions

In legitimizing humanistic elements of professionalism and creating a safe community, the Healer’s Art enabled students to uncover the underlying values and meaning of their work—an opportunity not typically present in required curricula. Attempts to teach professionalism should address issues of emotional safety and authentic community as prerequisites to learning and professional affiliation.

KEY WORDS: professionalism, community, doctor–patient relationship, humanism

BACKGROUND

Beyond the acquisition of knowledge and skills, professional identity formation is also a central goal in medical education.1 Although professionalism includes technical, intellectual, and cognitive competencies, it also encompasses relational and existential issues of humanism and values.2,3 Commitment to humanism is an enduring ideal of mainstream Western medicine. Medical humanism posits that physicians must consider patients as multidimensional people and attend to such complex issues as meaning, emotions, and trust in the therapeutic relationship. Calls to promote professionalism among medical students4,5 assume particular urgency in light of data showing progressive cynicism, ethical erosion, and decline in empathy as students progress through training.612

Individual and societal trust in physicians is earned by the profession’s insistence on accurate diagnostic and therapeutic knowledge and also by respect for patients as people, service commitment, and empathic responses to suffering.3,5 These concepts fit within the model of relationship-centered care.13,14 Teaching the humanistic elements of professionalism is challenging in the setting of conflicting role modeling and hidden curricular messages that may support behavior contrary to that advocated in the formal curriculum.15,16

Social learning theory suggests that learning is a social act that involves progressive participation in a community of practice.17 Education in meaning and values requires techniques different from those used to develop intellectual and technical competencies.18 Reflective and small-group strategies have been recommended for engaging students in these elements of professional development.19,20 It remains unclear how best to employ these strategies to teach professional values, and few approaches have proven feasible or are widely used nationally.2125

The Healer’s Art, an elective course in professionalism, was founded on the concept that a community of shared values and mutual safety can enable students to discover and strengthen their affiliation with the core values underlying scientific medicine and the profession itself. The Healer’s Art was developed by Rachel Naomi Remen, M.D., at the Institute for the Study of Health and Illness (ISHI) at Commonweal. The course was first offered in 1992 at the University of California, San Francisco26,27 and, since 1999, has disseminated nationally and internationally.

The course is designed to support medical students and faculty in embracing and preserving the humanistic values of health care. It consists of five 3-hour modules, each including both large- and small-group work centered on students’ reflections on their own experiences and on sharing those stories in an environment of mutual acceptance. Faculty are equal participants in the small groups, which form a community of inquiry to safely explore the human dimensions of a physician’s work.

The Healer’s Art has been evaluated positively across schools nationally.26 In 2003–2004, we invited Healer’s Art students nationally to complete a course evaluation. We analyzed the evaluation’s narrative responses to understand students’ perspectives on professionalism, the meaning of medicine, and the usefulness of the Healer’s Art course.

METHOD

Study Design We performed a qualitative analysis of students’ narrative responses to open-ended questions on the national Healer’s Art course evaluation.

Study Sample and Setting All students who participated in the Healer’s Art in North America during the 2003–2004 academic year were invited to complete a standardized evaluation. Prior to data collection, we received formal exemption from Institutional Review Board review by the University of California, San Francisco’s Committee on Human Research.

Intervention All respondents participated in the nationally standardized Healer’s Art course. Students were required to attend a minimum of four of the five sessions (80%). Healer’s Art course directors are trained at a 5-day residential program, followed by ongoing technical support and consultation. This one-time director training program costs $2,000 per participant, although the majority of participants are supported by start-up scholarships from ISHI in addition to funding from their school. Course directors recruit and train their own small group faculty facilitators.

Instrument The anonymous course evaluation, which was developed over the preceding 11 years, requested age, gender, and year in medical school, and included Likert, yes/no, and written narrative response questions, which were: (1) What did you learn about the practice of medicine from the Healer’s Art class? (2) What was the most valuable personal/professional insight you gained? (3) If you think the Healer’s Art is useful for medical students, will you tell us why? Answers ranged from a sentence to a paragraph.

Procedures Completed evaluations were forwarded to the research team. Narrative responses were transcribed and assigned confidential numbers for purposes of analysis. Coded cases were entered into The Ethnograph©, a narrative data software program.

Analysis Frequencies and descriptive statistics were calculated for the demographic data using SPSS© software. We used a team-based qualitative analytic approach with three experienced researchers identifying themes and coding the narrative responses.28,29 In this method, team members individually read the narratives and together developed thematic codes. Sections of text could be assigned multiple codes. Two researchers (MWR and RNR) also served as faculty in the Healer’s Art. The third researcher (JW) had no knowledge of the course prior to data analysis.Beginning with 50 randomly selected evaluations, three researchers developed the coding protocol, adding and refining codes as they appeared in each subsequent evaluation, until achieving thematic saturation. The remaining evaluations were divided among the team members. Each coded a third of the evaluations and handed half of his or her coded evaluations to each of the other coders for verification. Thus, all evaluations were read by at least two team members. Coders achieved immediate concordance on 88% of evaluations. Disagreements were resolved through discussion. Descriptions of the two most commonly occurring themes for each of the three narrative questions are presented here.

RESULTS

Response Rate and Study Population

During the study year, 25 medical schools offered the course to 680 students (Table 1). Participation in the Healer’s Art elective ranged from 0.8 to 36.7% of first- and second-year class totals, averaging 13.9% among first-year and 8.6% among second-year students across the 25 schools. Twenty-two schools are included in this analysis, as two schools completed the course prior to development of the national evaluation form and one provided only summary quantitative data.

Table 1
All Medical Schools Offering the Healer’s Art in 2003–2004 (N = 25), with Total Number of Healer’s Art Enrollees and Medical School Class Sizes

Participating schools were geographically diverse (Table 2). Among the 582 participating students at the 22 schools, 486 students returned the evaluation form (83.7%) and 467 (80.2%) had complete responses to at least one of the three qualitative questions. Demographic information was provided by 423 (87%) students who returned the evaluation. Slightly more than half of the students were female (55.3%), with a majority of first-year students (57.9%). All but two respondents rated the course as useful, and students agreed strongly with the statement “The Healer’s Art experience is not available elsewhere in your medical school curriculum.”

Table 2
Healer’s Art Course Study Population, Participating Medical School Geographic Region, and Healer’s Art Utility (student N = 423, school N = 22)

Narrative Responses

Thematic saturation was achieved early in the first 50 evaluations reviewed. Among 18 themes uncovered in the analysis, five ranked in the top one or two most common themes in response to the three narrative evaluation questions (Tables 3 and and44).

Table 3
Frequencies of the Two Most Commonly Appearing Themes for Each Narrative Response Evaluation Question
Table 4
The Five Common Themes, Definitions, and Exemplars

1. What Did You Learn About the Practice of Medicine From the Healer’s Art Class?

Students most commonly wrote about their concept of professionalism and assigned humanism a central and legitimate role in medicine.

Definition of Professionalism in Medicine The Healer’s Art encouraged a deep exploration of the nature of the medical profession, healing, the doctor–patient relationship, and professional identity. Students recognized that medicine includes both intellectual and emotional involvement, as well as both curing and healing. Comments included: “You don’t have to have a hard heart to practice medicine,” “It doesn’t have to be so cold, you can be professional and loving,” and “If we only attempt to cure the illness, we’ve greatly failed our patients.”Self-reflection and self-awareness were seen as key professional skills. “To be a good physician, I must continue to look inward, to explore the meaning of life and of experiences. Looking inward allows me to know me better, which will increase my usefulness to others.” “Good doctoring requires consistent awareness.”Support for self-reflection reminded many students of why they initially entered medicine and led them to a deeper understanding of and recommitment to their personal motivations and values. “The Healer’s Art is a growth experience. It is a defining experience. It helped me recognize what medicine and healing mean to me. I think med students can stray away from the reasons they want to be physicians while in med school, and this course helps to re-center us.”Many felt drawn to integrate their personal humanity with their professional identity. “I learned that you can still be yourself as a physician. You don’t have to compromise your beliefs and feelings for a career in medicine.”Students described integration as protective against the dehumanizing aspects of medical training and practice: “I don’t have to work so hard to box-off the medical aspects of my life to control the damage to soul, spirit, or family. Instead, I can integrate these into my medicine and try to regain wholeness.”Many students came to see their work in spiritual terms. “The Healer’s Art allows students to experience medicine not as a skill to acquire (and compete for) but as an invitation to a purposeful, spiritual life.” Some recognized that for them, “Medicine is a calling” guided by “the ultimate simplicity of our mission: to love, to serve.”

Legitimizing Humanism in Medicine Students reported that the Healer’s Art validated their emotions and humanism. One student described learning “that feelings are as critical to true healing as understanding the science of medicine.” Another explained, “The healing aspect of medicine does not come from the treatments we prescribe, it comes from the caring we give.” Another wrote, “I have so much more to offer than knowing the correct answers to questions.” Students felt validated in forming relationships of empathy, compassion, and kindness. “It is ok for me to treat my patients with kindness.”Many reported a greater valuing of their vulnerability, individualism, and integrity and felt that the course allowed them an unusual measure of safety and freedom. “I learned that at my lowest points and times of great need, I was actually building resources/strengths that will serve me well as a physician. Previously I closeted that side of myself in medical school because I felt I had to maintain an image of unwavering ability and confidence.”For one, the course was “a great opportunity to be human. I stopped feeling human when I started med school.”In validating humanism as a professional quality, the course actively fostered humanistic values and allowed their open expression. “It forced me to put away the books and take time for me, others, and my soul.” “In no other forum are these ideas discussed and given a tone of importance in our current and future professional lives. This is the only setting in which many aspects of humanity in medicine are prioritized. Otherwise, I would always (almost always) have my head down.”

2. What Was the Most Valuable Personal/Professional Insight You Gained?

Students reported that the two most valuable insights gained concerned relationship—their relationship to patients and their relationship to each other and other members of the profession.

Relationship Between Physicians and Patients A central insight was the idea that medicine is about relationships. “The fundamental basis of medicine is a relationship between people.” Such relationship requires physicians to be in touch with their own lives and able to enter reciprocal relationships. “What we bring to our patients is ourselves – our histories, insights, hope and focus – this is what our patients bring to us as well.”Students recognized listening as creating the connection central to the doctor–patient relationship. “I learned to truly listen to people when we share a conversation, and not just to elicit/evaluate information, but to connect with them emotionally, as other human beings.” Students described learning about the importance of listening through the experience of listening to each other and being listened to in class. Many credited understanding themselves through self awareness as a source of greater empathy “Awareness of self is critical, that as people we are better suited to empathize and give compassion than as doctors (in the stereotyped sense).”Ultimately, students described the doctor–patient relationship as a relationship between equals, identifying fundamentally with the humanity of their patients even as they recognized the special responsibility of their professional role. “First and foremost we are people helping people. Only then are we doctors helping patients.” Resisting the pull to feel separate or superior because of their training, students continually returned to a sense of parity and connection. “We are people just like our patients. My medical education makes me no different from the people I care for.”

Creating Authentic Community Students also commented on their relationships with each other and with the larger community of physicians. They defined the professional community in terms of values as well as expertise. “I learned that there is a committed movement of physicians who have retained/regained some of the idealism that so many med students start in with.” “I am joining a community of professionals that are not only intellectually brilliant but also deeply caring and committed to true service.” Students contrasted the Healer’s Art community with other curricular experiences in that it offered an experience of genuine safety and mutual respect. “It is truly unlike any other class or small group experience in medical school. It is the first time I’ve felt respected on equal grounds with doctors and those further along in their medical career.”As a result of the Healer’s Art course, students felt less isolated. “I learned that I am not alone in my thoughts and opinions.” Students reported an increased sense of affiliation with peers, faculty, and the medical community in general. One student simply wrote, “I belong here.” Greater affiliation was experienced not only with the professional community but also with patients and the human community as well. “Everyone has powerful stories, colleagues are human, patients are human, and everyone has/had pain in their life.”

3. If You Think the Healer’s Art is Useful for Medical Students, Will You Tell Us Why?

Students again focused on the central theme of community and the unique opportunity the Healer’s Art provides in the setting of traditional medical curricula.

Creating an Authentic Community The professional community established during the Healer’s Art course was described by many students as unique and distinct from their experience of other small groups and classes. Students described these unique elements as greater interactional honesty, acceptance, respect, support, kindness, and love. “For me it helped break down the walls and barriers that we all put up when we interact with the world and I think in particular in medical school. I felt a connection with my peers, a realness, openness and honesty. It helped create intimacy and an understanding that we are all in this together—to help and support one another. I think it helped me to be a better person and will help me be a better physician.”The authentic community experienced by Healer’s Art students created an uncommon opportunity for in-depth exploration of thoughts and feelings. “I think that it provides a forum to address issues that we all think about but rarely talk about.” “At no other time are we rewarded for sharing our personal values, fears, experiences, beliefs, and qualities.”

Filling a Curricular Gap Nationwide, students identified a significant curricular gap in their professional training that the Healer’s Art helped fill. Students from all 22 schools observed that Healer’s Art topics were rarely part of their required curriculum, nor available for discussion and reflection elsewhere in medical school. “It provides a forum for medical students to explore areas of life and medicine that are not explored elsewhere in the curriculum.” “It addresses a side of medicine that currently has no place.”Students commonly felt that the topics discussed in the Healer’s Art should be offered elsewhere in the curriculum but usually are not. The Healer’s Art “provides a forum to explore ideas and emotions that should be present in the forefront of a doctor’s mind, in training and in practice, but too often get forgotten.” “The Healer’s Art required me to reconnect with the idea of humanness—its beauty and its fragility. The Healer’s Art allows time for reflection and recommitment to service. Much of this is often pushed aside as we master the technicalities of medicine.”Students noted that the course was unique, even compared with other classes using a small group format. Students reported the course enabled them to experience and to practice what was only advocated elsewhere in the curriculum. “Humanism is paid a lot of lip service. It’s nice to actually discuss it in concrete, personal examples and experience its power and importance, rather than simply to be told to employ it by an instructor.” In helping to fill a curricular gap, the Healer’s Art provided a measure of hope. “Parts of you that your medical school education has neglected can still grow.”

DISCUSSION

Based on evaluations from nearly 500 students from 22 medical schools across the country, the Healer’s Art course appears to successfully engage students in a discovery process that helps them identify defining values and qualities of professionalism. The themes that emerge from their narratives replicate many of the professional qualities called for in directives from professional organizations. Interactional safety, which is deliberately built into the course design, appears to be central to the reported outcomes. In legitimizing humanistic elements of professionalism and creating a mutually respectful, safe community, the course enables students to explore the underlying values, meaning, and intention of their work. Students reported that few, if any, such educational opportunities existed within their required curricula. Despite the many hours students spend together in school, most traditional curricula are unable to evoke the sort of safe, professional community that allows the professional values shared by the student group and faculty to be articulated and validated. In filling the curricular gap, the Healer’s Art encouraged students to engage personally with the concept of professionalism and find their place within it.

The Healer’s Art appears to help students commit (or recommit) personally to basic values that underlie the practice of medicine, including compassion, empathy, integrity, and service. Nationally feasible and widely adopted, the course appears to offer one answer to ubiquitous calls to promote foundational and humanistic elements of medical professionalism.30 Moreover, the Healer’s Art is an intentionally affirmative approach that focuses on supporting and promoting professional values and character, not simply avoiding deficiency or misconduct.

In addressing the three evaluation questions about learning, personal and professional insights, and course utility, “creating an authentic community” emerged as a common theme for two of the three questions. The fact that students’ responses to question 2 (insights gained from the course) and question 3 (course utility) overlapped supports the conclusion that the Healer’s Art offers a setting and perspective that is uncommon in the required curriculum. Although the two evaluation questions do ask about related concepts, the emergence of community as a central theme is especially notable given that the course offers no didactic teaching on the concept of community.

Many of the findings in our analysis mirror struggles commonly identified in medical student professional development. As students become physicians, they must reconcile a number of issues: what it means to them personally to be a physician and how this corresponds with professional standards and traditions, what is the place of healing and emotion amidst the promise of science and cure, and what are the implications of growing professional expertise on a trainee’s human relationship with patients. As students are enculturated into the profession of medicine, the statement “we are people just like our patients” is both a simplistic aphorism and a fundamental challenge for professional development. Undeniably, medical education does make students different, but what curricular experiences enable a student to hold fast to the empathic principle that “my medical education makes me no different from the people I care for”?

As has been suggested by social learning theory,17,18 our study provides some empiric evidence that understanding and affiliating with the core elements of professionalism may require the lived experience of sharing personal stories, experiences, and values within a safe community of inquiry. The Healer’s Art appears to create a “community of practice” as defined by Wenger.17 Students learn as they interact with one another; the community thus created becomes a living curriculum. The Healer’s Art community of practice appears to impact learning in all three of Wenger’s domains: internally (learning skills such as listening through participation in a community of learners); externally (connecting student experience to actual practice through participation in a broader community with faculty facilitators); and, potentially, lifetime learning (through developing habits of reflection, self awareness, and commitment to values).

Whereas some educators might be concerned that the personal involvement and shared vulnerability possible within the Healer’s Art exposes students to the potential risk of emotional distress, the organization and principles of the course are designed to support and honor students’ individual experiences and character.

Our study has some potential limitations. The generalizability of conclusions drawn from student evaluations of an elective course is inherently limited. Students evaluated here are self-selected, and this may bias the results towards fitting closely with the beliefs underlying the course. However, the Healer’s Art does have a widespread appeal to students and faculty and a consistently beneficial outcome reported across a wide variety of schools nationally.26 Although the course was developed and taught by Dr. Remen at one school, successful training of faculty and international dissemination of the course shows that it can be effectively replicated and taught by a wide variety of faculty across a wide spectrum of institutions.

No information is available about enrolled students who did not return evaluations. These students represented a small minority of enrolled students and, in our view, their inclusion would be unlikely to impact our findings. As our data are based on course evaluations, it is possible that students reported back what they believed their faculty wished to hear. This type of response bias is offset by the fact that the course uses a discovery model and allows students to uncover what is true for them. Whereas the course has well-defined educational objectives, didactic instruction is limited and students are encouraged to discern the meaning in their own experience. Additionally, common themes emerged across 22 different schools in varied settings and institutional cultures. The analysis may have missed or misinterpreted some themes because two of the raters were also course faculty. However, one of the raters (JW) who is an accomplished qualitative researcher with no preexisting exposure to the course came to the same conclusions as the faculty raters.

Finally, little is known about the potential of the Healer’s Art to change student attitudes, rather than support and develop existing ones. We argue that supporting positive professional commitments is an important end in itself. Whereas most students reported using things they had learned in the Healer’s Art in both their personal life and professional work,26 our study did not verify that behavior actually changed. As this was a cross-sectional evaluation, it is not known whether the Healer’s Art influenced students’ professional behavior and developmental maturity1 or “immunized” students from some of the negative influences of medical training.10,30 Future studies will examine the effect of exposure to the Healer’s Art on such longitudinal outcomes.

In 2006–2007, the Healer’s Art was offered in 53 medical schools in the United States and Canada as well as Slovenia and Israel. Whereas the course is an elective, a few schools plan to experiment with requiring the course for all students. Regardless of whether the Healer’s Art course can or should be adopted into the required curriculum, it will always remain true that self-discovery requires personal learning-readiness. There does appear to be a large community of medical students ready to explore and embrace the foundational values of medical professionalism and affiliate themselves with the lineage of our profession.

Acknowledgements

The success of the Healer’s Art depends on the commitment and energies of many, including the course directors and faculty at each participating school across the country. We are indebted to them for their help in carefully collecting the course evaluations. Jan Ellis, MA, former Associate Director of the Healer’s Art National Program, was instrumental in coordinating many elements of this research effort. Kim Gallelli, Ph.D., formerly of Commonweal, was helpful in preparing and reviewing the manuscript. We wish to thank Susan Folkman, Ph.D.; Patricia O’Sullivan, Ph.D.; and Dean David Irby, Ph.D., for their thoughtful reviews of the manuscript. Our deepest appreciation to Dean Joseph F. O’Donnell, M.D.; Dean Nancy Oriol, M.D.; and Dean Molly Osborne, M.D., Ph.D., for their leadership, support, and guidance throughout the dissemination and evaluation of the Healer’s Art. The Healer’s Art is a program of the ISHI at Commonweal, which has been generously supported by many foundations and individuals.

Financial Support The Healer’s Art course is supported by grants to ISHI at Commonweal from private donors and the George Family Fund, the MACH Foundation, the Barnard OSHER Foundation, and the Flow Fund.

Conflicts of Interest Two of the authors of this manuscript (MWR and RNR) also serve as faculty in the Healer’s Art course at one of the 22 medical schools included in the analysis. One author (RNR) originally developed the course and continues to direct its national dissemination.

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