Patient Education and Counseling 98 (2015) 162–167

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Medical Education

Teaching professional and humanistic values: Suggestion for a

practical and theoretical model
William T. Branch *
Division of General Internal Medicine and Geriartics, Emory University School of Medicine, Atlanta, USA

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To suggest and describe a practical and theoretical underpinning for teaching professional
Received 13 May 2014 and humanistic values.
Received in revised form 6 October 2014 Methods: The author describes four learning methods that together comprise a model for teaching
Accepted 18 October 2014
professional and humanistic values. The author defends this model by citing evidence and relevant
literature as well as his extensive experience with numerous colleagues in successfully applying the
Keywords: model in large scale programs.
Communication skills
Results: The combination of teaching methods that comprise the model evolved over 30 years from the
Curriculum development
Faculty development
experience of several large collaborations with educators in teaching learners at all levels of medical
Professional development education. The four teaching methods are (1) experiential learning of skills, (2) critical reflection, (3) a
Humanistic values supportive group process, and (4) a sufficiently longitudinal curriculum. Together, these methods create
Professional identity formation a theoretical model with mutually reinforcing elements for enhancing commitment to core values and
optimizing professional identity formation.
Conclusions: This paper describes the combined model and the methods in detail and reviews evidence
favoring incorporation into curricula.
Practice implications: The combined model educationally enhances core values that underlie the
professional identity formation of physicians. The model is practical and generalizable, and should be
used by curriulum planners.
ß 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction 30 years at every level of medical education [17–23]. Our efforts

were always predicated on the belief that capacities for empathy,
Calls for humanism in medicine are not new [1], but official compassion, caring, respect, service, and other core professional
bodies now recommend strengthening humanistic values and values can be strengthened and developed through an educational
virtues as centerpieces of professionalism in medical education process. By trial and error, programs that I and my colleagues
(Table 1) [2–7]. Caregivers widely embrace these virtues and designed eventually combined four educational methods with
values [8]. Leading educators believe that internalization of the mutually reinforcing elements into a coherent educational model
core values and virtues is foundational for accepting the social (the combined model) that predictably enhances learners’
roles, corresponding behaviors and ways of being that lead to the commitments to humanistic values in medicine, and positively
formation of professional identity [9–15]. But, although various influences their professional attitudes and behaviors. We have now
recommendations for teaching professionalism have been sug- evaluated this model used in faculty development, with statisti-
gested, few studies have objectively evaluated the effectiveness of cally significant positive results in two multi-institutional studies
these recommendations [12,16]. A recently published systematic [20,23]. Although perhaps implicitly understood, no one has
review of the topic concluded that there is no consensus on how to previously explicitly described how this combination of learning
optimally teach professionalism [16]. In collaboration with methods enhances the learner’s professional and humanistic
numerous colleagues, I have addressed this issue for more than practices. Here, I hope to clearly explain the rationale for use of
the combined model. I will argue for its widespread adoption by
medical schools and medical teaching programs.
The combined methods of the model are: (1) experiential
* Correspondence to: Division of General Internal Medicine and Geriatrics, Emory
University School of Medicine, 49 Jesse Hill Jr. Drive, Suite 446, Atlanta, GA 30303,
learning of skills, (2) critical reflection on one’s experiences, (3) a
USA. Tel.: +1 404 778 1610; fax: +1 404 778 1601. supportive and validating small-group environment, and (4) a
E-mail address: [email protected] sufficiently longitudinal cohesive program to allow molding of the

http://dx.doi.org/10.1016/j.pec.2014.10.022
0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
 W.T. Branch / Patient Education and Counseling 98 (2015) 162–167 163

Table 1 I observed how reflective learning assisted the students in working

Core values and virtues of the physician.
through these struggles, especially when coupled with peer and
Arnold P Gold Project Professionalism, Physician Charter, faculty-support in the small-groups [27]. When also provided with
Foundation [6] ABIM [7] ABIM, ACP, EFIM [9] skills taught in the course to communicate with patients and deal
Integrity Honor and integrity Primacy of patient welfare with difficult dilemmas and clinical challenges, students seemed
Excellence Excellence Patient autonomy better enabled to function as caregivers without relinquishing
Compassion Altruism Social justice their empathy or values [26]. Recently published work shows that
Altruism Respect for others
the issues faced by our medical students in the late 1980s and early
Respect Accountability
Empathy Duty 1990s remain at the forefront of medical education today [27].
Service There were early adopters of courses similar to Harvard’s
Core values and virtues that underlie skills, attitudes, knowledge and behaviors Patient Doctor Course [28,29]. Other authors have emphasized the
comprising the human dimensions of care. From: Arnold P Gold Foundation [6]; importance of enhancing professional values in medical education
Project Professionalism, American Board of Internal Medicine (ABIM) [7]; Physician [5,9,12,30,31]. Authors subsequently recommended learning
Charter, American Board of Internal Medicine Foundation (ABIMF), American College methods thought best suited for assisting students with profes-
of Physicians (ACP) and European Federation of Internal Medicine (EFIM) [9].
sional identity formation. Rabow et al. believe faculty role
modeling and mentoring are central [12]. Others add feedback
whole. As illustrated in Fig. 1 and explained further on, the first and effective integration into communities of practice [13–15].
three methods of the model are mutually reinforcing, while the Stern and Papadakis also emphasize feedback, reflection, and role
fourth (longitudinal process) reinforces all. modeling [32]. Various institutions have developed programs in
narrative medicine, appreciative inquiry, mindful practice, guided
reflection, and integration of spirituality in medicine for teaching
2. Derivation of the combined methods model humanistic and professional practice [33–37]. Reflection has
received particular emphasis, and official bodies in medicine have
My understanding of the combined model shown in Fig. 1 called for its incorporation into all levels of professional education
emerged in the 1980s and 1990s from my experiences with the [4,9,10,38,39]. Although no inventory has been published, reflec-
required longitudinal, small-group-based patient–doctor courses tions by medical students are now included in the curricula of
implemented on a large scale at Harvard Medical School [17,18]. I many schools. As discussed below, many essential elements of the
observed students in the small-groups embrace reflective learning above recommendations were incorporated into the four reinfor-
and master communication skills. I observed them identify with cing educational methods included in Fig. 1 [17,18,20,23].
their carefully selected faculty facilitators as role models for
becoming doctors. Qualitative analyses of student-written narra-
tives provided insights into their many struggles with socialization 3. Components of the combined methods model
into medicine [24–26]. Students were frustrated when their
empathy for their patients often contrasted with perceived lack of 3.1. Experiential learning of skills
empathy by other caregivers on clinical services [24]. Students
sought to maintain their core values and moral principles when Skills are best acquired through deliberate practice. Looking
exposed to less-than-savory aspects of the hidden curriculum [25]. back, we can observe that many elements of deliberate practice

Fig. 1. The combined model for teaching professional and humanistic values. Arrows indicate reinforcing elements of the model.
164 W.T. Branch / Patient Education and Counseling 98 (2015) 162–167

have been applied to medical education since the 1980s [17,18,26], each topic [17,18,20,23]. Experiential learning of skills may be
although the theory of deliberate practice was more recently alternated with sessions addressing a related topic [17]. Reflection
elucidated [40,41]. In our early programs, learners were coached, on interactions with patients, learners or colleagues can occur
provided with feedback and asked to reflect on their learning during these follow-up sessions, or within the confines of a single
during and after interviews with real or standardized patients, role well-facilitated session using role play or other skills-learning
plays, and trigger tapes [17,18,20]. Learning was guided by a methods [17,18,20,23].
faculty facilitator, who acted as a coach [17]. Feedback came from Typical groups comprise about eight learners and a facilitator.
trusted peers in the group as well as the facilitator, so was Facilitators of these groups should effectively combine the roles of
generally received constructively and non-defensively by the teacher, skills coach, role model, advisor, and mentor to the group
learner [26]. Continual practice using these methods over several members. Facilitators generally receive faculty development
years of the course often achieved high levels of student training in leading the sessions and fulfilling these roles
performance [26]. [17,18,20,23]. Requirements of the groups include confidentiality,
Communication skills designed to build trust and relationships listening to others with respect, attendance and participation in
provide opportunities to understand the patient, her family, and the group [17,18,20,23]. Practices to be encouraged and monitored
her culture by listening closely to the patient’s life-story and by the facilitator include adequate preparation, willingness to
allowing expression of emotional and other difficult topics. provide and be open to honest feedback, adequate ‘‘air time’’ for all
Likewise, skills in teaching, role modeling, and holding difficult group members, and providing support, understanding, and
conversations with patients provide opportunities for participants validation for each other’s experiences. The facilitator can
in the groups to reflect-in-action, receive feedback, and thereby encourage optimal group dynamics by example, and by artful
enhance self-awareness [42–47]. Thus, experiential learning of and well-timed interventions. Medical learning groups should
skills provides insights that may deepen and expand understand- meet often enough to develop and maintain trusting dynamics –
ing of oneself and one’s experiences. Experiences extend as skills generally weekly or twice monthly [17,18,20,23].
are applied in situations involving ethics, palliative care, service to A key to good group dynamics is participants’ comfort level in
patients, care of the underserved, truth-telling, confidentiality, and reflecting deeply by disclosing challenging experiences and core
physician integrity. This enhanced understanding enriches subse- values and beliefs, and in giving and receiving honest feedback
quent reflective learning. [55]. They will do these things in a climate of understanding,
validation, and acceptance from other group members and the
3.2. Critical reflection facilitator. I have dubbed this positive group dynamic the ‘‘counter
to the hidden curriculum’’ – it is the informal curriculum that
Rest, Mezirow, Brookfield, Sprinthall, and Schon elucidated the develops in the group and strengthens participant commitment to
importance of critical reflection to learning [48–52]. Reflection compassion, empathy, and respect [57]. Thus, the group becomes a
promotes re-evaluation and integration of facts and reframing of learning community. By constantly modeling caring and respect,
experiences into one’s pre-existing knowledge, beliefs, values and the faculty facilitator becomes a powerful role model of humanistic
attitudes. Reflective discussions promote application, analysis, and teaching. As might be predicted from social learning theory, this
evaluation of previous learning, and promote the creative dynamic reinforces the commitment to core values and facilitates
reframing of concepts and events. Deep, critical reflection is an good professional identity formation. A critical mass resulting from
emotional as well as intellectual process and can transform these groups of faculty members, trainees, and/or students may
perspectives and deepen commitments [48–54]. positively influence the culture of an institution.
A supportive group environment where individuals are Learning groups may prove effective in many ways, such as
comfortable disclosing their core values and beliefs encourages problem-based and collaborative learning, even without achieving
new perspectives to emerge on experiences. Reflecting on these the deep mutual support and reflection on values optimally needed
perspectives can strengthen, reinforce, influence, and enhance a to influence capacities for empathy, compassion, and other core
person’s deeply held values [38,39,49]. Hence, moral commitment, values of humanism and professionalism. However, intentional
concern, and sensitivity can be reinforced and connected to planning by curriculum developers to incorporate combined
professional situations [25,48]. These explorations will shape methods as a longitudinal model for enhancing professionalism
professional and moral development and humanistic care is generally necessary to set the stage for the most highly-
[12,21,25]. functioning, reflective learning groups. Narrative-writing exercises
The combined model benefits by connecting experiential with group discussion and reflection have proved especially
learning to the reflective component. Reflecting on the implica- effective in our programs for establishing a reflective learning
tions, meaning, and importance of experiences like those listed climate, exploring values, enhancing self-awareness, and promot-
above allows their integration with the learner’s values, attitudes ing group cohesion [24,57–61].
and knowledge [12,21,25,48–54].
3.4. Longitudinal process
3.3. Group process
Sufficient time is needed to develop mutual support and trust in
Small learning groups enrich and expand knowledge while also the group as well as to master high level skills. Accurate feedback
focusing on the skills-based and value-laden aspects of doctoring and coaching lead to the acquisition of advanced skills that open
[18,19,21,24]. Reflective learning and experiential learning carried the richness of patients’ worlds. Critical reflection done with others
out in the small-groups benefit from the group’s supportive in a supportive atmosphere strengthens participant core values
learning climate. Thus, the group process powerfully facilitates this [21]. I have observed that these processes are mutually reinforcing,
type of learning. Basic principles of group process apply to learning especially so when done over time. Our programs have maintained
groups and explain their facilitative nature [55,56]. These groups this group-learning by meeting weekly to twice monthly for 2 years
do not engage in therapy for the individuals, but instead focus on or longer with medical students [17,18], periodically for 3 years with
their professional development as physicians [17,18,20,23]. residents [22], and for 9–18 months with faculty development
Learning groups usually follow a semi-structured curriculum groups [20,23]. Whenever possible, we maintain the same group
with learning goals, prescribed exercises, and references given for members and facilitator(s) throughout the longitudinal process
 W.T. Branch / Patient Education and Counseling 98 (2015) 162–167 165

[17,18,20,23]. The optimal duration for the combined model to satisfaction after communication skills training [69–75]. A
enhance commitment to core values and professional identity systematic review concluded that training to enhance communi-
formation in a sustained way is not precisely known and warrants cation skills was effective [77]. The elements most strongly
further study. Experience suggests that students should begin this associated with effectiveness, small-group discussion and receiv-
process on entry to medical school and continue in the third and ing structured feedback, are in the combined model [77]. Also
fourth years [15,17,18], when they are exposed to the hidden consistent with the combined model, the review concluded that
curriculum [62]. relationship-building as well as data-gathering skills could be
taught [77]. In support of the longitudinal nature of the model,
4. Evidence and experience supporting the combined methods another author recommended early training followed by rein-
model forcement later in medical education [15]. Another systematic
review concluded that empathy as measured by various scales
Evidence supports each of the methods described above as well could be educationally enhanced in medical students [76]. The
as the combination of methods. We performed two studies testing most effective method for enhancing empathy, consistent with the
the effectiveness of the combined methods model in faculty combined model, employed role play for communication skills
development [20,23]. Our results in the two prospective cohort training [76]. Reflection on narratives also enhanced empathy [76].
studies provided statistically significant evidence that the model A systematic review and an extensive overview of literature
is educationally effective [20,23]. Our studies employed a regarding teaching professionalism and self-awareness identified
validated questionnaire designed to measure humanistic practice some factors that promote professionalism [16,78]. Learning
and teaching [63]. The questionnaire was filled out by learners methods thought to be effective include role modeling and
taught by our participants compared to those taught by matched mentoring by faculty teachers and reflective learning [16]. One
controls at a total of 13 medical schools [20,23]. The studies set of authors concluded that increased involvement of students
demonstrate that the longitudinal model works in practice and is with inspiring, supportive teachers who are actively engaged and
generalizable, because the busy faculty members who partici- communicating with their learners had the strongest influence
pated in our programs had high attendance and completion rates [78].
[20,23]. The model for faculty development has now been or is In summary, multi-institutional evaluations suggest that the
currently employed at over thirty medical schools in the United combined model as a whole is effective and generalizable [20,23].
States and Canada. Qualitative analysis of participant narratives Both quantitative and qualitative studies and consensus strongly
at one school in our program revealed intensive engagement by support individual elements (experiential learning of communi-
faculty in the process and provided an understanding of how cation skills, small-group learning, reflective learning, faculty role
narrative methods provoked deep reflection by group members modeling, and faculty engagement with students) of the combined
[21]. model [69–78]. The model also finds support in experiential,
A randomized trial of the pilot phase of the Harvard New reflective and social learning theories.
Pathway tested the longitudinal, small-group components of the
model. After 2 years, students enrolled in the small-group
learning process demonstrated significantly superior communi- 5. Integration and use in the curriculum
cation skills and higher levels of interest in psychosocial topics
[64]. After 10 years, residual effects regarding interest in How should the combined model be incorporated into the
psychosocial topics persisted [65]. A prospective cohort study overall curriculum? Based on evidence and expert recommenda-
with matched controls of a ten-month faculty development tions supporting the model and each of its elements [13–
program employing most elements of the combined model also 16,20,21,23–26,34–36,69–78], I argue that longitudinal inclusion
suggested psychosocial interest persisting over time on parts of of the combined methods of the model in curricula produces
its questionnaire [66,67]. sustained high-level skills, encourages reflective practice, and
The section above describing the four components of the model enhances professional development that may counter the hidden
provides reasons to support my contention that experiential curriculum. I do not specify the number and sequencing of the
learning enriches reflection, and vice versa, and that both are skills-training, narrative reflection, and other types of sessions.
reinforced by a supportive group process given adequate time to This would depend on the local milieu and educational goals with
develop (Fig. 1). the provisos that curriculum designers should aim to produce high
I believe that our programs by their long durations enhanced levels of communication skills, and that reflective learning sessions
sustainability and prevented backsliding [17,18,20,23]. These should recur periodically, at times alternating with related skills-
assertions are consistent with qualitative analyses describing training. The combined model can form the backbone of a
powerful, potentially transformative, experiences by learners curriculum in humanism and professionalism that is augmented
participating in programs using the combined model [21,24–26]. by additional initiatives, such as White Coat ceremonies, human-
Qualitative analyses and participant evaluations of The Healer’s Art ism awards and societies, intensive electives, enhanced role
Course support the combination of group process, reflection, and modeling in clinical settings, international electives, volunteer
experiential learning by similarly describing inspiring and healing work, orientation sessions, and humanistic policies and procedures
experiences [36]. Analyses of training in mindful practice and of [32].
the large-scale programs aimed at cultural change and faculty Our extended process allows for the inclusion of related topics
development, respectively, at Indiana and McGill Universities are in the behavioral and social sciences [2,79]. Topics like health-
also consistent with the above findings [34,35,68]. This qualitative related behavioral change, cultural competency, health care
work suggests that combinations of the methods in the model have disparities, patients’ rights, social supports, medical ethics,
powerful, important positive impacts on professional development palliative care, risky sexual behavior, and patient safety can be
in medical students and other participants. integrated at appropriate times into the longitudinal curriculum
Studies of teaching communication skills provide the strongest [80–82]. These topics are likely to be received positively by medical
evidence supporting a component of the model [69–77]. Small students engaged in a powerfully learner-centered, reflective
randomized trials show improved communication skills, some- group process [83]. Mastery of the topics may also benefit from
times sustained for 6 months. Some studies show better patient active learning, such as role plays or trigger tapes, in the groups.
166 W.T. Branch / Patient Education and Counseling 98 (2015) 162–167

6. Summary [16] Birden H, Glass N, Wilson I, Harrison M, Usherwoood T, Nass D. Teaching

professionalism in medical education: a best evidence medical education
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educational practices to establish a learning climate that educational approach for supporting the professional development of third
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