Deepening and Expanding the Concept of Professionalism:
An Intensive Healer’s Art Retreat for 3rd and 4th Year Medical Students on Service Values, Relationships, Commitment and Meaning in Medicine

Michael Rabow, MD; Rachel Remen, MD
Fall 2003

BACKGROUND
Since 1991 Dr. Rachel Naomi Remen has offered "The Healer's Art at UCSF,” an immensely popular elective for 1st and 2nd year medical students. Over the last 12 years, an average of 44% of each first year class has participated in the Healer’s Art, which uses an innovative discovery model of experiential learning to explore themes of service, calling and commitment, relationships, identity, and meaning in medicine. UCSF students have consistently rated the quality of this course and its importance to them professionally and personally as outstanding.

In 2002 the course was featured in US News and World Report as an example of excellence in innovative medical education. This led to a surge of interest in the course among medical educators nationally. Medical schools across the country and in Canada now offer the Healer’s Art as an elective course. This national dissemination has meant that during the 2002-2003 academic year, 19 medical schools nationwide and in Canada implemented the course. Evaluations of the Healer’s Art from students and faculty at these schools have been as consistently outstanding as those from UCSF. In 2003-2004,
an additional 8 schools will be offering the course and another 20 have expressed interest. Although a great deal of information has been gathered about the value of the course to 1st and 2nd year students, the potential effects and benefits of this curriculum have not been explored for clinical students at the end of their medical school training. For the last dozen years, UCSF Healer’s Art students have frequently appealed to Dr. Remen to open her course to clinical students. Many faculty have reported hearing students in their clinical years longing for another “dose” of the Healer’s Art, seeking to recover the personal sense of service, meaning, and professional affiliation they experienced in the Healer’s Art. Recently, approximately 20% of students in the UCSF Class of 2004 responded to an informal email survey about potential Healer’s Art experiences during the clinical years. The survey revealed that most 4th year students would be interested in the opportunity to experience or reconnect with the Healer’s Art, with most respondents preferring a single intensive event, rather than a multi-session course.

Notably, medical student “professionalism” and “professional development” have recently become central concerns of institutional medicine in the United States, including directives from the Association of American Medical Colleges (AAMC), the National Board of Medical Examiners (NBME), the American College of Physicians (ACP), and the American Board of Internal Medicine (ABIM). The academic medical literature documents a long struggle to define medical professionalism and medical schools across the country must decide how to “teach” professionalism. While there are threads of professional development training throughout the 4 years of UCSF medical school, in the clinical years, professional development receives just 10.5 hours of dedicated, required curricular time, all of it during the 3rd year, as a small part of the 3-week Intersession curriculum. Generally, the bulk of this time is spent in unstructured processing groups where students reflect on the issues raised during 3 90-minute panel discussions on medical mistakes, career choice, and professional/personal balance. Foundations of Patient Care and the 1st year Healer’s Art course are the major sources educational experiences directly addressing the deeper, humanistic professional issues of meaning and sustained commitment in medicine, compassion, and service. In the 2003 AAMC Medical School Graduation Questionnaire, the percent of 4th year UCSF students reporting that role modeling adequately addressed “the compassionate treatment of patients” fell compared to the prior 2 years, dropping below the national average. Similar findings were found for the issue of role modeling “respect for the privacy and dignity of patients.”

GOALS
We propose to develop and implement an innovative elective experience for 3rd and 4th UCSF students. This course will be called The Healer’s Art Consolidation Retreat. Our goal will be to offer a 1-day off-site retreat experience to clinical medical students to help them consolidate their medical school professional development experiences and to set the groundwork for ongoing personal and professional reflection during residency training and beyond.

For Retreat participants who participated in the Healer’s Art course during their first year, the Healer’s Art Consolidation Retreat will reinforce and cement positive professional development begun during the 1st year and can reinforce positive growth and insight gained during medical school. This retreat will be a reminder of passions and promises that may have slipped below the intensity of clinical work and career decisions. We expect, as well, that a significant number of students who did not participate in the Healer’s Art as 1st or 2nd years will take advantage of this elective before they leave
UCSF medical school, and gain in the recognition that a community of their peers shares their concerns and passions.

Specific Retreat Objectives
By the end of the retreat, the students should be able to:
(1) Understand the connection between grief work and professional burnout.
(2) Recognize the power of their presence and listening to effect change.
(3) Experience the therapeutic use of self with colleagues.
(4) Build a new model of collegial community and relationship.
(5) Discuss issues of professional meaning with professional peers.
(6) Self-assess their own cynicism/idealism index.
(7) Define service and its meaning to them professionally and personally.
(8) Elucidate the model of patient-physician relationship that they believe is most therapeutic.
(9) Understand the shadow of medical culture and how it has influenced their own professional development and thinking.
(10) Appreciate the value of ongoing reflection both personally and
professionally.

PROCEDURES
Preparation Prior to Innovations Funding
During the 6 months prior to the beginning of Innovations funding in July, 2004, the investigators will begin to develop the course format, content, and evaluation. The investigators have secured private, outside funding to support this preparatory work. In addition to beginning work on refining an evaluation strategy, Drs. Rabow and Remen will be taking the opportunity prior to formal initiation of the Innovations funding cycle to accomplish the following:
(1) perform a needs assessment of 4th year students and the professionalism issues they find relevant but most unaddressed;
(2) survey the state of current curricular offerings in medical professionalism at UCSF using the directives from the AAMC and the NBME;
(3) make a detailed schedule for the format and content of the retreat itself;
(4) assemble and begin training 2 ISHI physicians to help facilitate small groups at the retreat.

It is expected that approximately 15 students from each of the 2 classes will participate in one retreat during the first year it is offered. However, Commonweal retreat facilities and the planned curriculum could accommodate the entire class at once if necessary. For more than a decade, the Healer’s Art elective has attracted more than 40% of the 1st year class. Over the next few years, we look forward to growth in popularity of the Retreat elective and seek, ultimately, to engage each UCSF medical student in some reflective experience around the humanistic elements of medical professionalism. We will seek integration with other elements of the curriculum attending to professionalism issues. Drs. Rabow and Remen are investigating the possibility of participating more directly in the Intersession professionalism curriculum. In addition, we look forward to publicizing the Consolidation Retreat during Intersessions, as well as via the medical student education web portal.

PLAN FOR MEASUREMENT AND DOCUMENTATION OF PROJECT
EFFICACY AND OUTCOME
We propose to rigorously document the student experience and evaluate the impact of the course on students' sense of cynicism, emotional intelligence, empathy, and physician values. We plan to examine whether experiential learning about service, relationship and meaning in medicine leads to improvement (or protection) of important medical student characteristics and behaviors. Through traditional pre/post-course evaluations, we will assess student satisfaction with the retreat and their suggestions for improving it. However, demonstrating the impact of this innovative project is vitally important and much of our time during the months prior to Innovations funding and prior to the implementation of the retreat will be dedicated to developing a research strategy to characterize the effect of this experience on a number of student outcomes.

One of the important research challenges is to distinguish the impact of the course from the bias generated by studying a self-selected group of students. To address this, we plan to control our survey with a random, double-sized sample of 3rd and 4th year students not participating in the retreat. Designing an effective recruitment strategy for control subjects will be a major activity during the preparatory and project periods. Students interested in the Retreat but unable to actually attend during the initial study year will be a particularly revealing control group (waitlist group). Throughout, we will seek to assess possible influences of prior exposure to Healer’s Art for both participants and controls. Ultimately, we will have 4 comparison groups: retreat participants who had or had not taken Healer’s Art as 1st or 2nd year students and control students who had and had not taken Healer’s Art previously.

Using this design, we can begin to examine research questions that remain vital areas of inquiry in medical education. As Spiro asked in his 1992 paper, “Can empathy betaught?” Also, given the known attrition of student compassion and well-being during the training years, “Does experiential learning about service, relationship and meaning in medicine lead to “immunization” against the attrition of centrally important characteristics and behaviors of physicianhood?”

PLAN FOR CONTINUATION OF PROJECT AT THE END OF FUNDING
CYCLE
The submitted budget for the Academy’s proposed funding cycle includes 1-year costs for faculty and administrative time devoted to curricular design and research evaluation. These development costs are not expected to recur. The Healer’s Art has been supported for 12 years by a gift to Dr. Remen and the Institute for the Study of Health and Illness (ISHI) from an anonymous supporter. This support is expected to be ongoing. Importantly, Drs. Remen and Rabow have received financial support from the Flow Fund to support the early development and follow-up evaluation of the proposed Healer’s Art
Retreat. This private donor has committed funds with the hope that the 1st year of the project’s design and implementation will be supported by the Academy of Medical Educators. These private funds are dedicated to help the investigators during the 6 months (January-June, 2004) prior to potential initiation of Academy support and following completion of Academy funding. Ultimately, we expect to incorporate the Healer’s Art Consolidation Retreat in an integrated program of medical student professional development at UCSF, including ongoing support from the School of Medicine and new grant funding from the National Institute for Complementary and Alternative Medicine via the R25 mechanism.

IMPACT
We believe this project is an important innovation that has implications both locally and nationally. This elective adds significantly and uniquely to the curricular offerings available to clinical students at UCSF. The Healer’s Art Consolidation Retreat will be an unique contribution to the ongoing national focus on the humanistic elements of professionalism and build on the extraordinary local experience with the Healer’s Art. The Healer’s Art Consolidation Retreat will be the first stage in a comprehensive, longterm plan to use the uniqueness, success and popularity of the Healer’s Art to understand and improve medical student commitment and professionalism at UCSF and nationally.

For more information, please contact:
Michael Rabow, MD
Rachel Remen, MD