Portal de Periódicos da CAPES

Creating Health Professions Trainee‐Heroes Through Transformative Learning

2024; Wiley; Linguagem: Inglês

10.1111/medu.15589

1365-2923

James H. Wykowski, Benjamin Vipler,

Ethics in medical practice

When trainees join a health profession, they begin a journey of personal and professional development. This path shares many characteristics with the storytelling archetype of 'The Hero's Journey', where a protagonist sets off on a quest, faces challenges along the way and returns transformed by their experience. From the Odyssey, to Wonder Woman, to Star Wars, the Hero's Journey is central to our cultural understanding of how we conceptualize the process of growth and development [1]. In health professions education, our trainee-heroes encounter different challenges than their mythological counterparts, from ethical conundrums, to devastating patient outcomes, experiences that challenge trainees' perspectives abound in health professions education [2, 3]. Three articles in this issue of Medical Education highlight the experience of trainees grappling with watershed moments in their education. In each article, the authors apply Transformative Learning Theory—an educational analogue to the Hero's Journey—to understand if and how trainees make meaning of these challenging experiences [4]. While they describe some instances of transformation, they also highlight the barriers to Transformative Learning present in the learning environment, cases where the outcome is anything but a more open, inclusive worldview integral to Transformative Learning Theory. These articles highlight what we believe to be the antithesis to transformative learning—the Hidden Curriculum [5]. From ethical conundrums, to devastating patient outcomes, experiences that challenge trainees' perspectives abound in health professions education. If Transformative Learning represents sublimation in response to a difficult experience, the Hidden Curriculum is an opposite, negative response. Described as the 'understandings, customs, rituals, and taken-for-granted aspects of what goes on in the life-space we call medical education', the Hidden Curriculum is entrenched in all aspects of medical education [5]. There are a breadth of experiences in medical education that can be a fork in the road between Transformative Learning and the Hidden Curriculum [6]. These three articles describe a wide range of contexts, from senior medical students caring for dying patients, to medical residents remediating their own lapses in professionalism, to senior cardiology trainees navigating a new competency-based medical education system [7-9]. Unfortunately, in each context, Transformative Learning was rare. Instead, students were left to struggle with disorienting dilemmas in isolation or without the support necessary to engage in reflection and discourse. For example, in the case of Competency-Based Medical Education, required activities intended to serve as opportunities for reflection on skill development instead became administrative burdens that inhibited meaningful reflection. If Transformative Learning represents sublimation in response to a difficult experience, the Hidden Curriculum is an opposite, negative response. The preponderance of work aimed at limiting the Hidden Curriculum has focused primarily on fostering learners' humanism, critical reflection skills and professional identity [10]. However, these are often very individual efforts on the part of the learner. Here, we would like to continue to highlight the role of the medical educator in the dichotomy between Transformative Learning and the Hidden Curriculum as an outcome. Two key barriers to trainees' critical reflection are their own lack of familiarity with critical reflection and a clinical environment that fails to provide opportunities for reflection. And while reflection is necessary, it is not sufficient for Transformative Learning. Since the theorization of Transformative Learning by Mezirow, the process of discourse, or dialogue between an educator or coach and the individual transforming, has been a key step towards moving from disorientation to action [11]. Discourse comes in many forms, but one key component is discourse with trusted mentors. Any Hero's Journey is doomed to fail without a guide/person of wisdom. Odysseus needs Athena. Luke Skywalker needs Obi-Wan Kenobi. And our trainees need faculty capable of not just supervising them but helping them make meaning of the challenges inherent in the clinical learning environment. Successfully facilitating transformative learning across health professions education will require better understanding and reckoning with the cultural and institutional factors that inhibit discourse in the clinical learning environment. Two key barriers to trainees' critical reflection are their own lack of familiarity with critical reflection. Faculty are paramount to facilitating this change. How can we retrain faculty to be the guides our 'heroes' need? The mismatch between student and faculty-directed innovations to untangle the hidden curriculum highlights the challenges in creating faculty behaviour change. We offer a few practical solutions. First, facilitating reflection and discourse should be highlighted as topics for continuing education for all faculty who work with trainees, regardless of whether they identify as clinician educators. Second, training programmes should employ longitudinal coaching programmes, where trained individuals with a background in facilitating discourse can fill in gaps created by faculty less comfortable with these topics. But perhaps the most important is for faculty to recognize and model their own Transformative Learning. Many faculty members trained in an educational environment that did not emphasize clinical reflection or discourse as critical skills. Like many participants in these studies, they were left without a guide to support their own transformative learning when confronted with disorienting dilemmas. To change this culture for the next generation of physicians, faculty must recontextualize their own pivotal learning experiences in training and beyond. Doing so will require faculty to embrace a growth mindset and a willingness to acknowledge the harm perpetuated by a learning environment that eschews vulnerability in favour of stoicism. To change this culture for the next generation of physicians, faculty must recontextualize their own pivotal learning experiences in training and beyond. The papers in this issue of Medical Education also highlight the stakes of our ongoing failure to facilitate transformative learning. When death is treated as a taboo topic inappropriate for further discussion, patients are left feeling abandoned at the end of their life. When professionalism remediation is viewed as a cause for fear rather than an opportunity for growth, trainees' future patients suffer. And when a novel educational intervention is defined by administrative burden rather than a lens for trainee growth, it seeks to undermine the value of the work itself. Disorienting dilemmas are inevitable in healthcare. Transformative Learning is not. Sound medical knowledge and renowned teaching skills are no longer sufficient for the clinician educator. We need educators to challenge their learners' previously held worldviews, debrief after critical incidents and help move the needle away from cynicism and towards inclusivity; that is the transformation we need. James H. Wykowski: Conceptualization; writing–original draft. Benjamin S. Vipler: Conceptualization; supervision.