Reflection, Narrative, and Professionalism

This week, the University of Toronto Faculty of Medicine had a major event which brought together many people from all parts of our education world, and beyond, to attend a day and a half devoted to "Building a Culture of Professionalism". It was organized by a group of senior leaders responsible for Ethics and Professionalism, experienced faculty developers, and leading researchers from our institution who focus on Professionalism in medical education and medical practice.

To describe the experience as "mind-blowing" is to put it mildly. As a medical faculty, we generally describe ourselves like many others - with a strong research background (after all, Toronto is where both insulin and heparin were discovered, and we're still not over it), and where the clinical environment is dominated by the processes of care, which we pride ourselves on delivering in an efficient and effective manner. Yes, we deliver education, and we feel we deliver it well, very much a product of our hard work, ingenious mechanisms, and mobilized resources. And from this workforce of dedicated, very hard-working and hard-pressed individuals, about 75 came to attend a workshop where we listened to stories.

What? Well, this was an immersion into narrative, for which the overt agenda was to talk about professionalism. However, at the end, I believe the real agenda was a bit different - to get us to listen, appreciate, support, and collaborate, without necessarily "teaching" us anything. All of our activities were based around hearing or telling stories, mostly from each other, but also from our facilitators. This is what made it mindblowing, because we habitual busyworkers possibly walked away not sure of what had been produced in this time together. Where was the blueprint for changing the faculty's approach to professionalism?

We spent this time in the company of Dr. Tom Inui, and Dr. Rich Frankel, from Indiana University, who are both renowned for many things, but in this context spent time telling stories of how IU's school of medicine had a culture problem, extending from the undergraduate students all the way through faculty to the dean, and back. People just weren't happy to be working or studying there, despite many markers of success in the different parts of the institution. They began a process, without knowing what would happen, of getting faculty and others to tell stories of success. While this may seem like an odd way to open up a discussion aimed at helping problem areas, it has a name, Appreciative Inquiry, and a literature from Organizational Development which backs up its utility. From their account, this process took hold very quickly, and soon they had hundreds of faculty engaged in finding out all the "good stuff" that was going on, hearing about it, and spreading the news. This in turn led to faculty and others learning to share stories about other things going on, like personal illness, times of crisis, and things that they observed which they had feelings about. This brought a new culture of reflection, narration, and openness to the faculty, and by their account, the place has been transformed into one that attracts people instead of driving them away.

All well and good, but what did this do for us? Tom and Rich had a very sneaky parallel process going on. When we talked about a poem that was on the screen, many people contributed to a 45 minute open discussion, where widely divergent views were expressed, about what the poem was about, whether it was any good, or whether its message was valid. The tone of the discussion was pretty collegial, yet it was clear that people had strong views. All of them were health professionals who could have spent the time wishing they were taking care of other work. And when we were told to discuss "stepping stones" in our development, we all found a personal story to share, and did so to each other's full attention. So now I know something about a senior pediatrician, a departmental leader in faculty development, and an orthopedic surgeon that I never would otherwise have known. But what I really learned was what it felt like to open myself to colleagues, and to be open to them, on a personal level that we don't usually get to.

So what - can't we do this at a cocktail party? Yes, except that we don't have them, maybe because we might confuse them with a disease. (Or maybe I've just never been invited...) And we don't really get to hear our colleagues showing their deep and authentic selves, even if we did have a cocktail party (not that I don't want to be invited next time). Yet for people who do such important work, and commit so much of themselves to it, isn't it amazing how good it feels to learn about each other's successes, and what lies beneath the professional, competent exterior?

So we spent time over this day and a half learning bits and pieces about each other, but what we took away was the process. Telling and listening; "participating in a narrative" - if you like, an extended narrative about all the faculty. One could call this experiential learning, except that the experiences weren't brought back explicitly for reflection or discussion. It is up to each of us to take something important from this. My personal learning point is how transformative it can be to participate in this, and I want to do more.

I found that this was not, in the end, a session about professionalism per se. It was an immersion in narrative, or rather our narratives, and showed us implicitly how easily we could step out of our usual roles and relationships and do this. And by doing this, we open up the possibility of discussing professional behaviour, celebrating what is done well, and creating a new narrative for what we want to change. This day and a half was a spent in a process, and that process is where the learning occurred. The next part of the process will be to keep this going. Have we each been sufficiently transformed?

Thanks to Minneapolis - Had a great meeting at SGIM 2010!

This was my 9th meeting of the Society of General Internal Medicine, which is the national academic organization for General Internal Medicine in the US, and this meeting is the largest meeting for this medical specialty in the world.

Here are the American cities I've been to because of SGIM, all of them for the first time. This is one way to make sure I get to know many sides of our neighbour to the South.

1999 - San Francisco
2001 - San Diego
2002 - Atlanta
2004 - Chicago
2005 - New Orleans
2007 - Los Angeles
2008 - Pittsburgh
2009 - Miami
2010 - Minneapolis

SGIM has always had a significant Canadian membership, and most meetings have had a strong Canadian contingent, from both the Toronto area and the Western provinces. in fact, there have been 2 meetings held at Canadian sites (Vancouver, 2003 and Toronto, 2006), but I didn't make it to either of them. The first was during the SARS epidemic, and it was all hands on deck in Toronto, so I couldn't travel (nor could I risk taking the virus to the convergence of American General Medicine accidentally). And of course, when it was held in my own city, I could never make the time to go.

This is a pity, because I have consistently found these meetings to be excellent opportunities to learn about the American medical system, with all the frustrations that my colleagues express, as well as all the dedicated, imaginative, and passion-driven work that they do to deliver excellent primary care under the circumstances of their own system. It would have been great to be able to do this when my SGIM friends were on "my" side of the border!

On that note, it was exciting to be present at the first meeting since President Obama's health care reform bill was signed into law. There was a mood of optimism about the future, and Dr. Elliott Fisher gave a great plenary address, urging all present to see the challenges ahead as the "glass half full". This replaced the frustration and resignation that I have observed at previous meetings. Could it be that in my practice lifetime, the United States' health care system will actually serve all its citizens, in a just, equitable and comprehensive way? If they ever get the whole country's citizenry looked after the way the VA takes care of their vets, the Canadian system will have a lot to envy.

This year's meeting fulfilled my usual expectation of having great interactions with exceptional people, learning a great deal, and leaving with my head bursting with ideas. For the first time I took on leadership responsibilities for the meeting, as Chair for the Web-based Innovations in Medical Education category of submissions, and delivered 2 types of educational activities: One being a precourse, and the other being part of the annual Update in Medical Education. These deserve separate blog entries of their own.

And, I met some great new contacts who will be very helpful to me in the coming year, when I am responsible for the nascent Portfolio program of the undergraduate medical program at the University of Toronto. These new contacts, with whom I have significant overlap in interests (given that we kept running into each other at the same workshops!) were people that I automatically connected with on both a personal and professional level. I am VERY excited about the possibilities that these interactions will bring.

And the city of Minneapolis was a very pleasant surprise. So I'm making a blog entry for it as well.

Next year's meeting will be in Phoenix, Arizona, and I will again be on the Program committee. I'm looking forward to continuing to build my career in close association with SGIM!