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Beyond Snapshots: Studying Medical Training Through Time · Health Ethics Podcast

0:09
Speaker 1: Welcome to Health Ethics, a series of conversations with leading
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Speaker 1: experts about ethical considerations associated with health and healthcare, both
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Speaker 1: locally and globally. I am Brian Pilkington, Professor of Bioethics
0:21
Speaker 1: in the Department of Medical Sciences at the Hackensack Meridan
0:24
Speaker 1: School of Medicine. This series, like its predecessor, which focused
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Speaker 1: on the COVID nineteen pandemic, relies on the idea that
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Speaker 1: challenging ethical issues are best addressed by folks from diverse
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Speaker 1: backgrounds practically reasoning together, and complements the Health Ethics series
0:41
Speaker 1: with its panel of leading experts from medicine, nursing, politics, economics, philosophy,
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Speaker 1: and the law. Thank you and enjoy the episode.
0:58
Speaker 2: It is my great pleasure to speaking with Doreen Baumber.
1:01
Speaker 2: Doreen is Professor of Pediatrics at the Perman School of
1:04
Speaker 2: Medicine at U Penn, an Education scientist at the MEDID
1:08
Speaker 2: Research Collaboratory at the Children's Hospital of Philadelphia. Doctor Balmer
1:14
Speaker 2: began her career as a pediatric nutritionist, but found herself
1:17
Speaker 2: fascinated not by nutrition, but by how residents became doctors.
1:21
Speaker 3: She did her PhD in.
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Speaker 2: Public health and health education at Temple and a postdoc
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Speaker 2: at U. Penn launched her faculty career at Columbia's Columbia
1:29
Speaker 2: University's College of Physicians and Surgeons and returned to CHOPP
1:33
Speaker 2: in twenty fifteen. In her current role, she provides consultation
1:37
Speaker 2: and mentorship for qualitative research, leads educate educational programs offered
1:41
Speaker 2: by the collaboratory, and supports large scale program evaluations.
1:46
Speaker 3: Doctor Bomber's independent.
1:47
Speaker 2: Research agenda focuses on identity work and career construction and
1:51
Speaker 2: health professions education. She's pioneered a longitudinal qualitative approach, which
1:56
Speaker 2: we're going to talk about in the moment.
1:57
Speaker 3: We talk about her great.
1:58
Speaker 2: Book to research in which she follows individuals through time.
2:03
Speaker 2: She's the associate and Associate editor for the Journal of
2:06
Speaker 2: Graduate Medical Education and has published over one hundred peer
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Speaker 2: reviewed academic papers, and given our conversations, I know is
2:13
Speaker 2: most excited about her narrative nonfiction and nonfiction book derived
2:17
Speaker 2: from the longitunal research that we'll talk about, The Long
2:20
Speaker 2: Arc of Training, Six Stories of Aspiring Doctors, which came
2:24
Speaker 2: out this year from the University of Toronto Press.
2:27
Speaker 3: Doreen, thanks so much for joining me today.
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Speaker 4: Thank you for having me.
2:31
Speaker 3: So I just finished the book a couple of days ago.
2:34
Speaker 3: It's great.
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Speaker 2: It's a wonderful book, which you note in the text
2:37
Speaker 2: relies on a kind of research that's a rarity in
2:41
Speaker 2: medical education. So before we get into the meat of
2:43
Speaker 2: the book, because we have folks from all over who
2:45
Speaker 2: listen to the podcast, we have a lot of medical student,
2:49
Speaker 2: health professional students, all sorts of folks, can you say
2:51
Speaker 2: something about sort of what motivated you to write the
2:54
Speaker 2: book and a little bit about the kind of longitudinal
2:57
Speaker 2: research that you've done.
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Speaker 4: Sure. Well, I think what needs to be clear is
3:04
Speaker 4: that I did not set out to write a book.
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Speaker 4: This was started as a study, actually an ethnographic study.
3:12
Speaker 4: So ethnography is that close prolonged observation in a natural setting,
3:17
Speaker 4: and that's what I had done as a doctoral student
3:20
Speaker 4: as a post doc, and assumed I would be able
3:23
Speaker 4: to do that in a faculty position. For a variety
3:26
Speaker 4: of reasons, that crumbled and I couldn't do the observation piece.
3:33
Speaker 4: But I had started the interviews actually that at that
3:36
Speaker 4: time had twenty one medical students that were engaged in
3:41
Speaker 4: what we thought would be an ethnography against the observational
3:45
Speaker 4: arm sort of fell apart, but the interviews continued, and
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Speaker 4: I realized what I was hearing were students saying things like,
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Speaker 4: you're the only person who knows this, or you know,
4:01
Speaker 4: I've not told anyone this before, and so I got
4:05
Speaker 4: a sense that they were sharing something with me that
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Speaker 4: likely hadn't been captured in a research context. So then
4:15
Speaker 4: it came to the end of med school, and I
4:17
Speaker 4: thought the study would end after four years, but several
4:20
Speaker 4: of them didn't want to stop. They wanted to continue
4:23
Speaker 4: to talk, and so I realized, Okay, well let's let's continue.
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Speaker 4: And it was really only towards I would say, around
4:31
Speaker 4: year it's a twelve year study, probably around year eight
4:35
Speaker 4: or nine, when I was struggling to publish what we
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Speaker 4: typically publish in health professions education, a journal article. You know,
4:45
Speaker 4: maybe you're allowed five thousand words, but a very strict
4:50
Speaker 4: structure that I realized I couldn't. I couldn't no longer
4:56
Speaker 4: conform to those rules. And it was actually the participants
5:00
Speaker 4: in cells. It said you should write a book. So,
5:05
Speaker 4: going back to your original question of what motivated me
5:08
Speaker 4: to write the book, I would say would be the
5:10
Speaker 4: participants in cells.
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Speaker 2: You know that this is a rarity in medical education,
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Speaker 2: health professions education research to a couple of months, Can
5:19
Speaker 2: you describe that kind of that kind of research, and
5:21
Speaker 2: then we'll sort of move forward with the details.
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Speaker 4: Of the book. Sure, So this is a longitudinal qualitative
5:28
Speaker 4: research that's very much grounded in the relationships. So they
5:35
Speaker 4: depending on what you want to study your relation, your
5:39
Speaker 4: study will have a time frame, a length, and it
5:42
Speaker 4: will have a tempo meaning how frequently do you speak?
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Speaker 4: For me, the ultimately realized I was studying career construction,
5:51
Speaker 4: which is not something that happens overnight, right, So it
5:54
Speaker 4: requires a length of time, and the tempo is about
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Speaker 4: every six months to a year. So that's sort of
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Speaker 4: some of the details of the study in terms of
6:05
Speaker 4: its timing. What makes for me, what makes longitudinal qualitative
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Speaker 4: research what it is is the notion of what I
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Speaker 4: call recursive interviewing. So rather than me asking certainly not
6:21
Speaker 4: new questions every time, the conversations are as much about
6:27
Speaker 4: me prompting things they said previously, so the participants are
6:32
Speaker 4: really hearing their former cells and responding to their former cells.
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Speaker 2: That I thought was one of the super interesting features
6:40
Speaker 2: of the book because I've read some qualitative research before.
6:45
Speaker 2: I mean, I you can, I really like, I really
6:48
Speaker 2: like what you wrote. But reading sort of later on
6:51
Speaker 2: in some of the reflections, how some of the ben
6:55
Speaker 2: students now practicing physicians thought about like, oh, I must
6:59
Speaker 2: have thought about this in this way, and the sort
7:01
Speaker 2: of metacognitive maybe like that I thought was terrifically interesting.
7:05
Speaker 2: But we could talk for hours about the book. I mean,
7:07
Speaker 2: to tell the stories properly would take that time. So
7:10
Speaker 2: I'm just going to tell listeners to go buy the book,
7:12
Speaker 2: read it, and then we can always have you back
7:13
Speaker 2: sometime we can sort of debrief fix. Each chapter brings
7:17
Speaker 2: out a particular theme, and so through the narratives of
7:19
Speaker 2: the sixth Aspiring Doctors, you highlight some different themes. You
7:23
Speaker 2: touch on socialization, on agency, on balance, which I really
7:27
Speaker 2: appreciated the use of that language as opposed to burnout,
7:30
Speaker 2: on emotion, on comfort. Without getting too detailed in the themes,
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Speaker 2: are there particular virtues or vices or general character traits
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Speaker 2: that you picked up on in thinking through and writing
7:42
Speaker 2: these narratives which might be beneficial for future or current
7:45
Speaker 2: physicians to reflect on. So sort of if you can,
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Speaker 2: and I think this is utterly unfair question. Distill sort
7:52
Speaker 2: of the big themes of the book into some helpful
7:54
Speaker 2: things for medical students and physicians.
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Speaker 4: Yeah, no, that's a great question. I hadn't really entertained
8:01
Speaker 4: that one before, but if I had to, it was
8:04
Speaker 4: sort of noodling on it. And the two virtues I
8:10
Speaker 4: would say that came to mind were one is like
8:14
Speaker 4: the idea of fidelity in terms of staying true to
8:19
Speaker 4: what you value. It was clear that each of the
8:22
Speaker 4: six now practicing physicians in the book valued different things.
8:29
Speaker 4: They found meaning in life in different things, but that
8:34
Speaker 4: sort of that commitment to those values that were what
8:38
Speaker 4: they shared. Their individual values were different, but within the
8:42
Speaker 4: individual they were pretty consistent. And thus that sort of
8:46
Speaker 4: explains really the topics of the chapters, and that each
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Speaker 4: chapter focuses one person. So, for example, the chapter about balance.
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Speaker 4: In that chapter, Nikki very much came about how do
9:01
Speaker 4: I be a wife and a mother and a pediatrician
9:04
Speaker 4: at the same time, So her tendency and her the
9:09
Speaker 4: sort of virtue I guess you would say, was coming
9:12
Speaker 4: back to that consistently. But balance wasn't what other people
9:17
Speaker 4: cared about. That was sort of unique to them. So
9:20
Speaker 4: it's the idea of commitment, but also I really want
9:24
Speaker 4: to put a plug in for self empathy and self awareness,
9:29
Speaker 4: if I may sort of conflate those two a little bit.
9:33
Speaker 4: Training is hard, right, It is tough. It is in
9:37
Speaker 4: some ways supposed to be tough and individual and trainees,
9:41
Speaker 4: I would say, need moments to sort of check in
9:44
Speaker 4: with themselves, to recognize the hard work that they're doing,
9:50
Speaker 4: and to sort of give themselves a little bit of
9:52
Speaker 4: grace and then move on. And I think this is
9:57
Speaker 4: where the notion of longitudinal qualitative research and their relationship grounding.
10:04
Speaker 4: It was not my intention, but you provide a space,
10:08
Speaker 4: a safe space where trainees can share things with you,
10:15
Speaker 4: sort of this somewhat of anomaly. I'm not a I
10:18
Speaker 4: wasn't their faculty member, I wasn't their evaluator, I wasn't
10:22
Speaker 4: from their institution, but we had developed a relationship through time.
10:27
Speaker 4: So a space where I think just being able to
10:30
Speaker 4: reflect on their former cells and to you know, they
10:34
Speaker 4: were very kind to their former cells. They would never
10:38
Speaker 4: they never said things like oh I was such a
10:41
Speaker 4: jerk or I was so stupid. They would look back
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Speaker 4: and think, man, I didn't know what I didn't know.
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Speaker 4: So that the two virtues I would say would be
10:52
Speaker 4: first sort of a fidelity commitment to values and then
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Speaker 4: second that notion of self empathy.
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Speaker 2: Both are great, and that the point about the kind
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Speaker 2: of reflection that they might have been able to engage
11:08
Speaker 2: in which others may not have have they not had
11:10
Speaker 2: those launch dudent conversations with you, is that I mean,
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Speaker 2: there's yeah, there's so much interesting and so.
11:16
Speaker 3: Much to unpack you.
11:17
Speaker 2: So, one of the topics that comes up a bunch
11:20
Speaker 2: of research ethics over the past however many years is
11:23
Speaker 2: the importance of giving back. And you noted this early
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Speaker 2: and I haven't really thought about in terms of as
11:28
Speaker 2: much in terms of qualitative launch qualitative research. But so
11:32
Speaker 2: do you think you gave back to the larger community
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Speaker 2: that you started with? Do you think you gave back
11:38
Speaker 2: to the six folks who made the long path of you?
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Speaker 3: I mean, I think that answer is clearly ask you
11:42
Speaker 3: whence comes up in the book.
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Speaker 2: But and how should qualitative metted researchers think about giving back?
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Speaker 3: Like is this something anything I'm giving back? And then
11:52
Speaker 3: I'll push a little more on it.
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Speaker 4: Yeah, Yeah, Well, I think as you noted that the
11:57
Speaker 4: participants would routinely tell me that they were getting something
12:01
Speaker 4: from the interviews, not that I would ask, but you know,
12:06
Speaker 4: at the end they would say, yes, this is so good.
12:10
Speaker 4: I really appreciate the time to talk. You know, thank
12:13
Speaker 4: you for the talk therapy. That again, I did not
12:16
Speaker 4: intend it to be a therapeutic relationship, but I think
12:20
Speaker 4: just in life, people that we can connect with and
12:23
Speaker 4: feel safe with, there is something that feeds our soul
12:26
Speaker 4: in those kinds of conversations. So yes, giving back to
12:30
Speaker 4: the participants in terms of giving back to the larger
12:34
Speaker 4: community a couple of things. I think there are many
12:38
Speaker 4: of us who secretly want to write a book, and
12:42
Speaker 4: whether that's fiction nonfiction, because I should be clear the
12:45
Speaker 4: book is narrative nonfiction. I did not want to write
12:48
Speaker 4: an academic book. And I think there are a lot
12:51
Speaker 4: of people in my space like, oh, I've always wanted
12:53
Speaker 4: to write a book. So if I can be an
12:57
Speaker 4: example of that of how to write a book, or
12:59
Speaker 4: that somebody could write a book, take their research and
13:03
Speaker 4: think about who do I really want to read this?
13:05
Speaker 4: Do I want? Do I want to put it in
13:08
Speaker 4: an academic journal? And if you want to great, there's
13:11
Speaker 4: there's plenty of venues. But if you want to write
13:14
Speaker 4: for you know, students, pre med students, or what I'm
13:21
Speaker 4: hearing is the participants in different readers are saying, oh
13:24
Speaker 4: my gosh, my parents have to read this. If you
13:27
Speaker 4: want to write for them or the general public, then
13:30
Speaker 4: you have to be able to write in a way
13:32
Speaker 4: that is going to be appealing and understandable. So, again,
13:37
Speaker 4: giving back to the HPE community, if this is a
13:40
Speaker 4: bit of a push for a more open, more expansive
13:45
Speaker 4: way to think about dissemination of findings, then I'd like
13:48
Speaker 4: to think that, Yeah, that's that's a way that I've
13:51
Speaker 4: given given back to the to the community. And also
13:54
Speaker 4: I think a broader understanding of longitudinal qualitative in research
14:01
Speaker 4: that it's not just these serial interviews. It's really grounded
14:05
Speaker 4: in building that relationship. And I think I just reading
14:11
Speaker 4: a paper here called the relational interview comes out of
14:14
Speaker 4: actually a different field, but there's something about that relationship
14:20
Speaker 4: that relational epistemology and then the axiology of sort of
14:25
Speaker 4: ethics of care that all play into that that is
14:28
Speaker 4: that is different than some other types of research.
14:31
Speaker 3: Yeah, I mean very helpful, and the book is so accessible.
14:34
Speaker 2: I mean even early on when you you know, for
14:37
Speaker 2: people involved in medical education, they probably moved through the
14:39
Speaker 2: early sort of framing book was on the medical education
14:41
Speaker 2: more quickly to get.
14:42
Speaker 3: To the powerful narratives.
14:43
Speaker 2: But I mean, I know what you mean when you
14:46
Speaker 2: say that you wrote this kind of book and you
14:49
Speaker 2: could have put something in an academic term. I think
14:51
Speaker 2: this book is terribly academic. I mean I sat up
14:53
Speaker 2: late at night. I mean not you know, in sadder so,
14:58
Speaker 2: but like thinking about nick eas Line when she says
15:02
Speaker 2: and you'd reference this earlier about wanting to keep her
15:06
Speaker 2: morals and something intact, and you think, like, are the
15:10
Speaker 2: kind of person that she was?
15:12
Speaker 3: And I think, oh, geez, what what.
15:14
Speaker 2: Is it that students training and in the health professions
15:17
Speaker 2: are going through? How do we think about curriculums butting
15:20
Speaker 2: up against that we write professional There's so much here,
15:23
Speaker 2: There's so much here. So I think this is a
15:24
Speaker 2: properly academic book. But that you can do that. And
15:28
Speaker 2: also somebody wants to give it to their parents or
15:30
Speaker 2: their loved once. I mean, it's it's great, it's great,
15:33
Speaker 2: and I think the giving back is is clear, and
15:36
Speaker 2: I'm with you. I'm all for more of our colleagues
15:40
Speaker 2: writing books, because you can't say all the stuff you
15:42
Speaker 2: want to say in twelve hundred words. So let's get
15:46
Speaker 2: into some of the characters, some of the people in
15:48
Speaker 2: the in the book. And the book is framed through
15:52
Speaker 2: Blake's thoughts. Right that the opening opening chapter on transformation,
15:56
Speaker 2: which I loved, and on becoming the kind of person
15:59
Speaker 2: or professional who might say. At some point Blake says
16:03
Speaker 2: something about, you know, you don't stop being a doctor.
16:06
Speaker 2: And I thought this was super powerful and knew, of course,
16:10
Speaker 2: the stories of you know, is there a physician on
16:13
Speaker 2: the plane?
16:14
Speaker 3: Is there a doc in the house?
16:15
Speaker 4: Right?
16:15
Speaker 2: He mentioned this on the plane, and we actually I've
16:19
Speaker 2: talked about this with medical students and this is not
16:21
Speaker 2: long of jenneral research at all, but anecdotally over the
16:24
Speaker 2: last eight or so years. And I'll ask because we
16:26
Speaker 2: make him read a little Aristotle, and Aristotle at one
16:29
Speaker 2: point in the Nicomachy and Ethics uses physicians as an
16:34
Speaker 2: analogy for the kind of life. I leave philosophy story
16:38
Speaker 2: later on, but basically says, oh, look, it's like being
16:41
Speaker 2: a doc.
16:41
Speaker 4: Right.
16:41
Speaker 3: You do medicine a lot, you don't do it all
16:44
Speaker 3: the time.
16:45
Speaker 2: And so I'll ask like and eight years ago. If
16:47
Speaker 2: I say, hey, are you always a doc? Or how
16:49
Speaker 2: much time are you a physician? A lot of hands
16:52
Speaker 2: go up and a lot of claims the numbers are
16:54
Speaker 2: really high. The hands have started dropping the folks who think.
16:58
Speaker 2: And so I thought, Blake is a very very long
17:01
Speaker 2: winded question. So I thought Blake was terrifically interesting. And
17:05
Speaker 2: so I'm curious how you think about a response like
17:09
Speaker 2: Blake's I'm a physician all the time, this is and
17:13
Speaker 2: what you've seen in current health professions trainees, current medical students.
17:18
Speaker 2: Do you think that those sorts of thoughts, the transformation
17:22
Speaker 2: into this kind of professional being still exists.
17:26
Speaker 4: That's a great question. So Blake offered this, you don't
17:31
Speaker 4: stop being a physician when he was starting his internship year.
17:37
Speaker 4: And the question that I had asked him was, Blake
17:42
Speaker 4: is interesting because he chose a career that sort of
17:45
Speaker 4: surprised me, and I was sort of curious about that
17:49
Speaker 4: particular career choice, and so I asked him sort of
17:53
Speaker 4: point blank, like what do you think people should know
17:57
Speaker 4: about becoming a doctor and these kinds of decisions you
18:00
Speaker 4: have to make, And he said, you know, people think
18:02
Speaker 4: it's just a job, but it's not just a job
18:04
Speaker 4: that you know, you said, you sort of start to
18:08
Speaker 4: see yourself differently. And he said he's wasn't being like,
18:12
Speaker 4: this isn't about like me, egotistic me, but it was
18:15
Speaker 4: like people that go into medicine, the way you come
18:18
Speaker 4: out is not the way that you started. And so
18:21
Speaker 4: he was saying, you know, when he started medicine, he
18:24
Speaker 4: was thinking it would be a it would be a job.
18:28
Speaker 4: But hey, you realized, you know what, Hey, I didn't
18:30
Speaker 4: you know, maybe I didn't even sign up for this.
18:33
Speaker 4: There is there a doctor on the plane. But it
18:36
Speaker 4: changed his thinking about who he was as a doctor,
18:40
Speaker 4: and at least as an intern. Now we all know
18:43
Speaker 4: that internship year it can be really grueling. So maybe
18:46
Speaker 4: this was just his perspective then. But and it would
18:50
Speaker 4: be interesting to reconnect and ask him that same question
18:52
Speaker 4: because he's actually chosen a career that allows him to
18:56
Speaker 4: travel quite a bit and move around, and so I'm
18:58
Speaker 4: not quite sure whether he's sees himself as you don't
19:02
Speaker 4: stop being a doctor. That would be something to sort
19:05
Speaker 4: of in my next book. I'll follow up, but I
19:07
Speaker 4: don't I appreciate your question about your comment about medical
19:11
Speaker 4: students today, and you know, the fewer hands that go up.
19:14
Speaker 4: I really, I really don't. I don't know. I am
19:18
Speaker 4: in my position currently at Children's Hospital of Philadelphia. I
19:22
Speaker 4: work mostly with residents and fellows and practicing clinicians, so
19:25
Speaker 4: I don't have my finger on the pulse of medical
19:28
Speaker 4: students as much as much as you might. But there's
19:32
Speaker 4: certainly certainly changes the.
19:34
Speaker 3: Folks that you work with.
19:36
Speaker 2: Would you do you think they would resonate with Blake's thought,
19:40
Speaker 2: or at least the blak of the time of the book,
19:42
Speaker 2: that there are always physicians, or they're always health professionals
19:45
Speaker 2: of their particular profession, or have you noticed any trends
19:50
Speaker 2: either positively towards a better work life balance or maybe
19:54
Speaker 2: negatively away from away from sort of a constant focus
19:58
Speaker 2: on patient care or something like that.
20:00
Speaker 4: I think they would say, as a doctor, as who
20:03
Speaker 4: they are part of their identity, that that's who they
20:05
Speaker 4: are all the time. But I think that sort of
20:08
Speaker 4: being able to distinguish between who I am at my
20:12
Speaker 4: core and what I do in my day to day
20:14
Speaker 4: every day. I don't have to be at the hospital
20:16
Speaker 4: all the time. I don't have to be taking care
20:18
Speaker 4: of patients all the time. I don't have to feel
20:20
Speaker 4: like I need to be at all meetings and be
20:22
Speaker 4: there all things for all people. But from the sense
20:25
Speaker 4: of a sense of self, I think that they would
20:28
Speaker 4: probably say, you don't stop being a doctor.
20:31
Speaker 2: Yeah, I mean, it's just terrifically interesting thinking about how
20:34
Speaker 2: folks are brought into a profession. So here's a big,
20:39
Speaker 2: probably another unfair question. I want to know what medical
20:43
Speaker 2: education can do better, and so what in particular meded
20:46
Speaker 2: research can do better? And a theme of the text,
20:49
Speaker 2: and again I'm not a qualitative researcher, but this made
20:53
Speaker 2: a lot of sense of the argument. A theme of
20:54
Speaker 2: the text is that snapshot research much of what seems
20:58
Speaker 2: to go on in medical education research you don't think
21:00
Speaker 2: is the best way to do things. And correct me
21:02
Speaker 2: if I've got the wrong interpretation. So is the worry
21:05
Speaker 2: that it's not great research? Is the worry that it's
21:09
Speaker 2: on ethical in some way? Is it that it's just
21:11
Speaker 2: not especially useful or is it just that that happens
21:14
Speaker 2: through the dominant kind But we're missing out on this
21:16
Speaker 2: sort of the longitudinal research that's extremely helpful and it's complementary.
21:21
Speaker 3: So can you clarify that, and then I'll over follow up.
21:23
Speaker 4: Absolutely, I think to the latter it's complementary. There are
21:30
Speaker 4: many times when we do snapshots or cross sectional research
21:34
Speaker 4: which are amazing and very appropriate methodology or sort of
21:39
Speaker 4: time frame. However, if you look at the body of
21:44
Speaker 4: literature that is in health professions, education, and you think
21:48
Speaker 4: you compare snapshots to longitudinal and I haven't done that research,
21:53
Speaker 4: but I can guarantee you there's not much longitudinal and
21:56
Speaker 4: right away the first thing out of the people's mouth
21:59
Speaker 4: it takes too long, too much time. I don't have
22:02
Speaker 4: the resources, and as a result, what I've been struck
22:07
Speaker 4: by is that it doesn't even enter our level of
22:10
Speaker 4: awareness or of possibility. I remember sitting around a table
22:15
Speaker 4: with some I won't name names, but some of the
22:18
Speaker 4: top notch people in our field, and they were talking
22:21
Speaker 4: about how understandings of programmatic assessment have shifted. So when
22:27
Speaker 4: it first sort of came on the scene, say ten
22:30
Speaker 4: years ago, it was understood this way, but now it's
22:33
Speaker 4: understood differently in some problematic ways, and so they were
22:39
Speaker 4: you know, right away, in my mind, I thought, oh
22:42
Speaker 4: my gosh, what a great longitudinal study like to follow
22:45
Speaker 4: people as they understand things differently through time. But that
22:49
Speaker 4: didn't even come up in conversation as a possible method
22:54
Speaker 4: or methodology. I would say, so, I think just more
22:58
Speaker 4: what we need is more more longitudinal qualitative work. We
23:02
Speaker 4: continue to need cross sexual work for sure, and you know,
23:05
Speaker 4: it really depends on the research question. But I would
23:09
Speaker 4: say that given a lot of a lot of research
23:12
Speaker 4: energy is put into things like professional identity formation or
23:18
Speaker 4: construction or career choices, how do people navigate that? How
23:22
Speaker 4: do people navigate well being? I mean, all of those
23:26
Speaker 4: kinds of phenomena that we're really interested in. Our complex processes.
23:33
Speaker 4: They're fluid, they change, and if we just do cross
23:37
Speaker 4: sectional work will continue to just get snapshots.
23:42
Speaker 5: There are things that you can only learn by following
23:45
Speaker 5: people through time, by walking with them through time and
23:49
Speaker 5: having them narrate their own story in real time as
23:54
Speaker 5: it's happening.
23:55
Speaker 2: So well put because the thinking about changes that folks
23:59
Speaker 2: go through, I mean, this seems to be with to
24:01
Speaker 2: figure it out.
24:02
Speaker 3: I know, we have.
24:03
Speaker 2: I get to teach a bunch of electives, which is
24:05
Speaker 2: super fun, and I mean I'm with students a lot
24:08
Speaker 2: of time for the month that they're in this optional elective.
24:11
Speaker 3: They're motivated, it's optional, and when I try.
24:13
Speaker 2: To evaluate their professionalism in terms of their growth, that's hard.
24:18
Speaker 2: And it's a month, and they spend a lot of
24:20
Speaker 2: time that month with me, but still that's hard. So
24:23
Speaker 2: I can I mean snapshots, it's just what you've laid
24:27
Speaker 2: out in the book.
24:27
Speaker 3: I see the power of that.
24:29
Speaker 2: I mean, it's and I'm sensitive to concerns about time
24:32
Speaker 2: and resources, and everybody wants more resources. But I think
24:35
Speaker 2: this adds value, which moves me quickly to.
24:37
Speaker 3: The follow up.
24:39
Speaker 2: I imagine another question that folks ask about longitudinal research
24:43
Speaker 2: is about generalization. And again I'm out of social scienceide
24:47
Speaker 2: so this may be badly posed. But you have that
24:50
Speaker 2: line from Frank about stories echoing other stories.
24:53
Speaker 3: I thought that was great. I love that line.
24:56
Speaker 2: And we chat with students about human beings a storytelling
24:59
Speaker 2: animal just as a way to try to get them
25:01
Speaker 2: to stop staring at charts in the future and all that,
25:03
Speaker 2: and we borrow and do a little bit of work
25:05
Speaker 2: from Alistair mcintion. But what I always wonder is about
25:08
Speaker 2: the diversity of experiences. Right, stories are powerful, but how
25:12
Speaker 2: do we understand the efficacy the impact of insights if
25:17
Speaker 2: they're not generalizable or intended to be generalizable, or is
25:21
Speaker 2: there another concept that sort of does the work of
25:23
Speaker 2: you know, because I read this and I think, wow,
25:26
Speaker 2: like what Nikki was thinking about, and I want to
25:28
Speaker 2: think about other medical students in that way, but I
25:30
Speaker 2: don't know, and so help me.
25:32
Speaker 3: Think about generalization generalized ability.
25:34
Speaker 4: Yes. So there's a quote that I heard from Chris
25:37
Speaker 4: to Tippett, who's a facilitator, interviewer, journalist who does a
25:44
Speaker 4: podcast called on Being, and it has always struck me,
25:47
Speaker 4: and she says, the more particular you get with your story,
25:52
Speaker 4: the more universally it can be received. So the more
25:57
Speaker 4: particular you get with your story, the more universal can
26:00
Speaker 4: be received. And I think if I could share from
26:04
Speaker 4: my own experience growing up, I never read fiction because
26:08
Speaker 4: I didn't think it was real. I didn't like cartoons
26:11
Speaker 4: as a kid. I only wanted to see and to
26:15
Speaker 4: know and to read and consume what was real. Fast
26:18
Speaker 4: forward to a good decade and I moved to New
26:21
Speaker 4: York City for my first faculty appointment. I didn't know
26:26
Speaker 4: a soul in New York, but at the time I
26:30
Speaker 4: was working with doctor Rita Sharon, who as you might know,
26:33
Speaker 4: does a lot with a major force in narrative medicine,
26:39
Speaker 4: and as part of some of the work that I
26:41
Speaker 4: was doing on one of her grants, she would meet
26:43
Speaker 4: with her team members and they would discuss literary fiction,
26:48
Speaker 4: John Bander, The Sea and all these kinds of great books.
26:52
Speaker 4: And so I started reading a book, a fiction book
26:55
Speaker 4: sort of prompted by Rita, and the protagonist was had
27:00
Speaker 4: moved to Paris, didn't know a soul, felt so alone,
27:04
Speaker 4: and that's exactly how I was feeling in New York
27:07
Speaker 4: City as a new person who knew no one. And
27:10
Speaker 4: it just just struck me like, Yeah, this is obviously
27:13
Speaker 4: not a true story. It's fiction, but I can tell
27:17
Speaker 4: you this is really resonating with me because the was
27:21
Speaker 4: the novel true. No were the feelings we were feeling true. Absolutely,
27:28
Speaker 4: So I think less in terms of generalization and more like,
27:35
Speaker 4: what is the what is the core whether you call
27:38
Speaker 4: it a virtue or a feeling or the tension that
27:44
Speaker 4: I think is universal and that's really the power of stories,
27:48
Speaker 4: right for each of us to tell our story, and
27:53
Speaker 4: that's really what connects us, not so much all the
27:56
Speaker 4: details of the story, but that the humanness and the
27:59
Speaker 4: human feeling and emotions.
28:01
Speaker 2: That's great, and that's really helpful because it wasn't even
28:04
Speaker 2: sort of the technolgical terminology ge of generalizations, right, it's
28:09
Speaker 2: the how do we identify particular features of stories and
28:13
Speaker 2: then think about them as it shapes our experiences and
28:16
Speaker 2: interactions with others? And I like the Tipot line that
28:19
Speaker 2: the more particular you are, the more universally it can
28:23
Speaker 2: be applied.
28:23
Speaker 3: That's good. That's good.
28:24
Speaker 2: Okay, So stepping back a little bit and thinking about
28:28
Speaker 2: the book as a whole, would it be fair or
28:31
Speaker 2: just just inst in your action? This is the book
28:34
Speaker 2: a set of I mean well written, just phenomenal case
28:38
Speaker 2: studies into the hidden curriculum of medical education or health
28:42
Speaker 2: professions education across the continuum. And I asked that because
28:45
Speaker 2: I had in the back of my head sort of
28:47
Speaker 2: different features that might not be part of the you know,
28:51
Speaker 2: expressed curriculum.
28:52
Speaker 3: And it was probably.
28:53
Speaker 2: Prompted because the blurb on the inside cover is half
28:56
Speaker 2: ready right, So I was thinking about Haffernie and Franks,
28:58
Speaker 2: any thoughts about the hidden curriculum relative to the stories
29:02
Speaker 2: that were told in the book.
29:03
Speaker 4: I know, doctor Hafferty and He's been an amazing supporter
29:10
Speaker 4: of my work, and he knows that I sort of
29:12
Speaker 4: have a problem with the hidden curriculum, particularly the term,
29:16
Speaker 4: because it doesn't easily accommodate things that we learn about kindness,
29:23
Speaker 4: that respect, empathy, and so I guess you could you could,
29:29
Speaker 4: you could look at it from a hidden curriculum lins.
29:32
Speaker 4: But the other thing where that also is a limitation
29:36
Speaker 4: or is that these were while over the course of
29:40
Speaker 4: twelve years, and they were.
29:42
Speaker 5: All in med school for four years or some for
29:44
Speaker 5: five years if they did a.
29:46
Speaker 4: Dual degree, and then residency range from three years to
29:50
Speaker 4: five years, and some did a fellowship and some didn't.
29:53
Speaker 4: But there was a fair part of just life. People
29:56
Speaker 4: are living life, and I think in medical education, particularly
30:03
Speaker 4: if you're in the medical school space, there can be
30:07
Speaker 4: some like everything's about the hidden curriculum because there's this
30:11
Speaker 4: more formal and informal those lines really seem to blur.
30:17
Speaker 4: And is it just socialization, I don't know, but I
30:21
Speaker 4: think as they moved into residencies, they moved into fellowship
30:25
Speaker 4: and into clinical practice, the notion of a hidden curriculum
30:28
Speaker 4: just isn't big enough to hold all of that. That's
30:31
Speaker 4: my critique.
30:33
Speaker 3: This is good and as tough fun.
30:37
Speaker 5: For you.
30:37
Speaker 2: I'll have to write a paper in response to a
30:39
Speaker 2: podcast or we'll get them on.
30:42
Speaker 3: So just to flesh this out a.
30:44
Speaker 2: Little bit, is there something like that which is much
30:49
Speaker 2: more expansive or is the concept or send me to
30:54
Speaker 2: the paper you've written on this and but or is
30:57
Speaker 2: the concept just a bad one?
30:58
Speaker 3: I mean, the life examples powerful.
31:01
Speaker 2: A lot of the changes in my in how I
31:04
Speaker 2: interact with the world might be due to features outside
31:07
Speaker 2: of the formal education, but they're not hidden curriculums stuff.
31:10
Speaker 4: Yeah.
31:11
Speaker 2: Right, I had this life experience, I had that interaction,
31:14
Speaker 2: and now I think about things this way. So is
31:15
Speaker 2: it just something bigger? Or is like the approach just
31:18
Speaker 2: not a great approach.
31:19
Speaker 4: Now, I think what we've done is looked at. And
31:22
Speaker 4: this was back when I was in the in a
31:26
Speaker 4: medical school space and actually even into residency. But we
31:29
Speaker 4: would look at Elliott Eisner's work, who talks about the
31:31
Speaker 4: implicit curriculum, the explicit curriculum in the null curriculum as
31:36
Speaker 4: a different way to understand implicit explicit and in what
31:40
Speaker 4: else goes on outside of the extra curriculum as trying
31:44
Speaker 4: to again to put words around this big the whole
31:48
Speaker 4: of not just centering the hidden curriculum, because again, I
31:53
Speaker 4: just I don't think it's quite enough to capture all
31:58
Speaker 4: of the life stuff that happens that really influence who
32:03
Speaker 4: we are as teachers, as healthcare professionals.
32:07
Speaker 2: Yeah, yeah, that's one sounds right. And I suspect, well,
32:11
Speaker 2: this isn't a we'll get fed on sometime. We'll find
32:14
Speaker 2: about this, because I think the intention was something smaller,
32:17
Speaker 2: but this makes sense in the life examples persuasive. So
32:20
Speaker 2: I you talk in the book at one point about
32:22
Speaker 2: longitudino storytelling as a way to get closer to truth,
32:26
Speaker 2: and I think we've talked a bunch around sort of
32:28
Speaker 2: sort of that idea relative to other kinds of research approaches,
32:31
Speaker 2: and what I thought about that idea a lot in
32:35
Speaker 2: connection to your discussion of paradoxes. And so you talk
32:39
Speaker 2: about paradox and something seems right there. So I was
32:41
Speaker 2: just hoping you cant unpack it and say a little more,
32:43
Speaker 2: and you talk about two things which can be held
32:45
Speaker 2: as true at the same time, and actually reminded me
32:48
Speaker 2: in some ways of the Frost poem that opens. I
32:51
Speaker 2: think the Eliza chapter and so you have these two
32:54
Speaker 2: paths in front of you. And so basically this is
32:56
Speaker 2: just an invitation to say more about paradoxes and how
33:00
Speaker 2: aspiring physicians might think about navigating those, because I think
33:05
Speaker 2: when I talk to physicians and I don't have the
33:10
Speaker 2: kinds of experiences of going through health professions educations of
33:13
Speaker 2: any stripe, I imagine when they show up to medical school. Anecdotally,
33:17
Speaker 2: given the folks I've talked to, if they read Frost,
33:20
Speaker 2: they think one path is the right one and one's
33:22
Speaker 2: the wrong one, and there's a better one. The view
33:24
Speaker 2: would not be these are just two different paths. And
33:28
Speaker 2: so I could tell us more about paradoxes because I
33:31
Speaker 2: thought that was helpful and important, but I don't totally
33:34
Speaker 2: have my mind around it.
33:35
Speaker 3: Yeah.
33:36
Speaker 4: Yeah, So when I think, as an educator, somebody who
33:40
Speaker 4: does a lot with in education sort of pedagogical paradox,
33:44
Speaker 4: I would point readers to the work of Parker Palmer
33:48
Speaker 4: and The Courage to Teach. He writes about pedagogical paradox
33:52
Speaker 4: and one I'll give an example because it relates back
33:55
Speaker 4: to something I said about, you know, universalicularity and universality,
34:01
Speaker 4: Like how do you do both of those, and he
34:03
Speaker 4: writes about how do you create space as an educator
34:08
Speaker 4: for the little stories of individuals and also for the
34:12
Speaker 4: big stories of the discipline? Right, so how do you
34:17
Speaker 4: do how do you do both? Because there has to
34:19
Speaker 4: be room, he says, there has to be room for
34:21
Speaker 4: soulful realities that grow in students' lives. And at the
34:25
Speaker 4: same time, you know, those big stories of the of
34:29
Speaker 4: the profession, like you know, dawning of the white coat
34:32
Speaker 4: and the professional and some of these traditions also help
34:36
Speaker 4: us to understand how our little stories fit with and
34:41
Speaker 4: make sense within the big stories, so that when you're
34:45
Speaker 4: when you ask about paradox again, the work of Parker
34:49
Speaker 4: Palmer has been useful when I think about in response
34:53
Speaker 4: to your question, what do you how do you tell trainees?
34:57
Speaker 4: You know which one's right? There you go, welcome to life.
35:01
Speaker 4: I think personally, my personal recommendation will be to practice
35:04
Speaker 4: yoga because you sort of learned to hold both. But
35:07
Speaker 4: also again, now here's sort of pulling on Rika and
35:11
Speaker 4: some of his poetry. Right, to be patient towards all
35:14
Speaker 4: that is unsolved in your heart and to love the
35:17
Speaker 4: contradictions themselves. And the point is, you know, to live everything,
35:22
Speaker 4: to live the contradictions, and to sort of be open
35:25
Speaker 4: to what one might offer and one might not. So
35:29
Speaker 4: no clear answer, Brian, No, this is I.
35:32
Speaker 2: Mean, it's just it's the leads I think further conversation.
35:35
Speaker 2: And so the reflection on poetry, on some of these
35:38
Speaker 2: bigger questions of meaning, on narrative fiction nonfiction brings me
35:41
Speaker 2: to my well penultimate question, which is should there be
35:45
Speaker 2: more humanities in health professions education? Should medical students study
35:50
Speaker 2: the humanities more? And I kept thinking, I've thought about
35:54
Speaker 2: this before, and I've got a view, so this is
35:56
Speaker 2: sort of a you.
35:58
Speaker 3: Know, I've stacked the deck or something.
35:59
Speaker 2: But I was reflecting on Allen and the discussion of
36:03
Speaker 2: stepping stones and how there's a sort of increasing complexity,
36:07
Speaker 2: increasing responsibility, increasing gravity, and you sort of and it's
36:12
Speaker 2: painted so well. And then I thought, well, it's not
36:14
Speaker 2: just health professions educators, or medical students or parents who.
36:17
Speaker 3: Should be reading this book Philosophers human Being.
36:19
Speaker 2: You seem like big human points and they're powerful themes
36:22
Speaker 2: in the book.
36:23
Speaker 3: It's not that I didn't think medical.
36:24
Speaker 2: Students are health professions, those weren't humans, But I mean,
36:27
Speaker 2: should I make my medical students read more philosophy. I mean,
36:31
Speaker 2: what's the should people be doing more humanity's work in
36:35
Speaker 2: health profession's education. Is that a fair conclusion or observation
36:40
Speaker 2: that might come out of reading the book.
36:41
Speaker 4: I don't know that I have had the answer to that.
36:45
Speaker 4: I worry about separating the humanities from patient care and saying, Okay,
36:51
Speaker 4: now we're going to do clinical work, and then when
36:53
Speaker 4: you're done your clinical work, then we'll go read it,
36:56
Speaker 4: you know, philosophy. I think I would look for and
37:00
Speaker 4: hope for more ways for the two to be woven
37:05
Speaker 4: into each other, and a story that I'll share. It's
37:09
Speaker 4: actually not in the book. This was Allan who said this,
37:13
Speaker 4: and I was at a at the time. They were
37:15
Speaker 4: medical students, very engaged in narrative medicine as part of
37:18
Speaker 4: their curriculum, and when he was a fourth year medical student,
37:23
Speaker 4: he said, you know, I remember, back in our pre
37:28
Speaker 4: clinical years, we had to take narrative medicine and we
37:32
Speaker 4: were supposed to take on different perspectives, be able to
37:36
Speaker 4: take on the perspective of a patient. But as I've
37:38
Speaker 4: been making my career decision, I think that really applies
37:43
Speaker 4: here because I have to be able to take on
37:46
Speaker 4: different perspectives and like what would it be like if
37:49
Speaker 4: I were a surgeon, what would it be like if
37:51
Speaker 4: I were an nephrologist, And so taking lessons that were
37:56
Speaker 4: very much humanities focused in a space and time for
38:00
Speaker 4: pre clinical students where a lot of the humanity stuff sits.
38:04
Speaker 4: I mean it's ripple effects years later, we're really important.
38:09
Speaker 4: So I think there's certainly some room for the humanity's teaching,
38:13
Speaker 4: But for us to think that it's always it's going
38:16
Speaker 4: to stay within its humanities box is problematic.
38:21
Speaker 2: That's great, and I think it just it highlights the
38:24
Speaker 2: power and again I'm biased, I've used this, but it
38:26
Speaker 2: highlights the power of interactions with sort of the humanistic
38:31
Speaker 2: side of things. And it might even be that the
38:34
Speaker 2: content of things that falls in under the humanities label
38:37
Speaker 2: is actually not only beneficial for patient care, it's actually
38:40
Speaker 2: beneficial in other features. And this brings us to a
38:43
Speaker 2: question I will not ask you right because it is
38:44
Speaker 2: the age old, like whether you embed something longitudinally and
38:48
Speaker 2: a health profession's a bit of education or discrete and
38:50
Speaker 2: how you do that. So I'm going to get you
38:52
Speaker 2: on this. For folks who enjoyed the conversation. Other than
38:55
Speaker 2: buying the book which everyone should buy, The Long Ark
38:58
Speaker 2: of Training Six Stories of Aspiring Doctors by Dorian Baumer.
39:01
Speaker 3: I loved it.
39:01
Speaker 2: It was great. Other than that, what's the next book?
39:04
Speaker 2: What's the next paper?
39:05
Speaker 4: Where?
39:06
Speaker 2: For folks who are interested, where can they hear you?
39:08
Speaker 2: Where can we point them if they want more?
39:10
Speaker 4: Thank you well. I will be presenting at the Double
39:15
Speaker 4: AMC for anybody who's in med at the Rhyme of
39:18
Speaker 4: Research and Medical Education Planning. I'm at pen and we'll
39:21
Speaker 4: be doing some work here at penn On the We
39:23
Speaker 4: have a focus for women's health and leadership, so we
39:26
Speaker 4: also run a put a plug in for Children's Hospital
39:29
Speaker 4: of Philadelphia. On the end of September, we have a
39:32
Speaker 4: Humanities Conference Health Humanities Conference. I'll be speaking there as well,
39:37
Speaker 4: So little blips of how to all be doing. But
39:41
Speaker 4: what perhaps more important than that, And this goes back
39:44
Speaker 4: to something you said about about giving back. I don't
39:47
Speaker 4: think there'll be another book. Perhaps I am not one
39:49
Speaker 4: hundred percent sure, but I don't think there'll be another book.
39:52
Speaker 4: But what we're what I'm trying to do more is to,
39:56
Speaker 4: as I said, encourage people to consider longitu work. I
40:00
Speaker 4: suspect it's not as many barriers as people think, but
40:05
Speaker 4: it does take a commitment to relationships. And if you're
40:09
Speaker 4: not able to or interested in committed relationships, then please
40:13
Speaker 4: don't try longitudinal qualitative research because otherwise you're just doing
40:18
Speaker 4: back to back snapshots. So I'm doing more work to
40:21
Speaker 4: really promote that and to promote wider options for dissemination
40:27
Speaker 4: in health professions education.
40:29
Speaker 2: That's excellent, and we'll make sure that we have the
40:31
Speaker 2: link to the book and some of the other places
40:33
Speaker 2: you'll be speaking in our show notes during Thank you
40:36
Speaker 2: so much for the time.
40:37
Speaker 4: Thank you, Brian, appreciate it.
40:38
Speaker 1: Series is a production of the Health Ethics Lab, and
40:41
Speaker 1: I am grateful to colleagues in the Department of Medical Sciences,
40:44
Speaker 1: the IHS Library, and the Hackensack Ready in the School
40:47
Speaker 1: of Medicine for making this collaboration possible. To learn more
40:50
Speaker 1: about our work or to engage with the series content,
40:53
Speaker 1: reach out to me Brian Pilkington at Brian dot Pilkington
40:57
Speaker 1: at HMH and org.