Article Text
PDF
Abstract
We report upon the design, content and feedback from an interactive, experiential series of Workshops in Healing for senior medical students. Fifty-six final year medical students enrolled in 2×3 h workshops designed around the core themes of ‘physician know thyself’ (Workshop 1) and ‘confronting suffering’ (Workshop 2). Of the 56 students who initially enrolled, 48 students completed both workshops and provided a written open-ended reflection of their learning experience. The study, undertaken over a consecutive 5-year period (2008–2012), employed an emergent, qualitative design using thematic analysis of the reflective comments. We found that the design and content of both workshops promoted transformative learning for these final year medical students. Students identified the following benefits: (1) the opportunity to reaffirm their commitment to their chosen career path; (2) the value of listening to other students share their stories; (3) the importance of the timing of the workshops to occur after exams; (4) the use of various mediums such as art, poetry, music and contemporary/classic literature to present concepts of suffering and healing; and (5) the creation of a safe and confidential space. Students reported that these innovative workshops gave them a renewed sense of drive and enthusiasm for their chosen career. They highlighted the importance of addressing an aspect of medicine (healing) not covered in the traditional medical curriculum. Workshops in Healing helped them to rediscover a deeper meaning to medicine and their roles as future healthcare professionals.
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/
Statistics from Altmetric.com
Introduction
Over the past few years, there has been a resurgent interest within medical education and practice in reclaiming the role of healing within the medical mandate.1–5 The scientific discoveries that underpin modern medical practice, dating from the mid-19th century, have been nothing less than startling; however, over many centuries, scientists, philosophers, artists, physicians, writers and historians have also regarded the practice of medicine as both an ‘art and a science’. Indeed, the extent to which the practice of medicine remains both an art and a science is a matter of continuing debate.6 ,7 In this context, several authors have recently drawn attention to, and defined the role of, the so-called ‘physician-healer’ as a healthcare professional who uses his/her cognitive skills and abilities to treat disease, while simultaneously using himself/herself as a therapeutic instrument to relieve suffering and to promote healing.1–5 ,8 Therefore, as suggested by Puchalski, “Medicine is being challenged to broaden its focus beyond cure to healing”.9
In this context, ‘healing’ is generally recognised as a relational process that leads to ‘wholeness’,2 or in Cassell's words, “a restoration of well-being so that persons are able to carry out their aims and purposes in life”.10 Whichever interpretation is adopted, ‘healing’ is an activity that relates to the whole person and therefore extends well beyond ‘cure’ or the ‘eradication of disease’.
In response to this perceived reorientation concerning the goals of modern medicine, an emerging number of medical schools have recognised the importance of teaching courses in communication skills, medical ethics, professionalism, self-care, mindfulness, spirituality and reflective practice. However, there have been only a few documented attempts to collate these related concepts into what may best be described as ‘courses in healing’ for medical students.4 ,11 ,12 In some medical training institutions, the importance of enabling medical students access to courses in the humanities has been stressed.13 ,14 The first, The Healer's Art,15 was developed at the University of California, San Francisco, in 1991, and is a 15 h elective course (5×3 h modules) for first-year and second-year medical students offered annually in over 60 medical schools in the USA as well as in several International Medical Schools. More than 1200 students complete the course annually. The Healer's Art course is focused on the inner life of physicians and students, and facilitates students’ understanding that who they are as a person is central to the outcome of their work as physicians.16
The second curriculum in healing was developed by the Faculty of Medicine, McGill University, as the ‘Physician as Healer’ and is embedded in the context of a programme that revolves around ‘Physicianship’.11 ,12 The ‘Physician as Healer’ course is organised around a set of six modules, and each module addresses a key learning concept related to healing in medicine. Individual medical students are assigned to a small student group and to a faculty mentor (‘Osler Fellow’) for the duration of their medical school experience. The main part of the course is taught during the third year, but a number of introductory whole-class interactive sessions take place in the first year and in the fourth year, prior to graduation. The McGill course has broader dimensions than the Healer's Art course and is delivered at different stages throughout the 4-year medical course.
Kligler et al17 have outlined a set of core competencies required to develop a medical school curriculum that incorporates aspects of healing within the much broader paradigm of ‘integrative medicine’.
Workshops in Healing were created in the context of medical curricular change at the University of NSW (UNSW) over the past few years. Since 2008, the ‘new’ medical curriculum at UNSW has incorporated a greater emphasis on lifelong learning, professionalism and the need for students to become reflective practitioners. Given the resurgent interest in the subject of healing within the contemporary medical mandate, we thought it important to introduce the subject of healing into an undergraduate medical curriculum that did not yet cover this topic. We also felt it important to identify additional steps within the undergraduate medical curriculum to support medical student reflective and experiential learning activities, given that these activities may result in better overall patient care and may provide useful self-care activities for senior medical students and young doctors.
We also hypothesised how the universal problem of suffering might be dealt with by young doctors as future medical practitioners. We recognised that the course at McGill University is integrated throughout the entire medical curriculum, and to contemplate its introduction at UNSW would have required an extensive and ‘further’ significant curricular re-evaluation. The Healer's Art course could have been implemented, but as stated, the Healer's Art course deals largely with the role of the physician in relation to patient and self-care. Although some elements of the Healer's Art course have been incorporated into Workshop 1 (‘physician know thyself’), we wanted to extend the subject material of these workshops to incorporate some of the more practical and fundamental issues of understanding suffering to provide young healthcare professionals with an insight, and the skills, into how suffering might be confronted. This aspect of teaching is not covered explicitly in the Healer's Art course.
The aims of this report are twofold. First, to outline the design and content of these interactive, educational workshops that aim to encompass the essential elements of the theory and practice of healing. Second, to analyse written feedback from participants using qualitative research methodology to assess the relevance of healing to final year medical students and to their future practice of medicine.
Conduct of the healing workshops
Workshops in Healing are an annual, elective, experiential series of workshops provided to senior medical students in the pre-intern stage of their undergraduate curriculum at UNSW, Sydney, Australia. Given the availability of only one workshop facilitator (JHK), an empirical decision was made to offer the workshops to those students who might benefit most. It was our belief that senior medical students who were about to embark upon internship within the month would benefit most. The assumption made was that the workshops may enable final year medical students to offer better, ‘holistic care’ to their patients and also to derive better self-care strategies to assist them coping with the ‘often stressful’ daily life of internship. The workshops are held in November of each year, and they are advertised to senior students 3 months earlier. Students are accepted on a ‘first come, first served’ basis. Eight to twelve students per year participate over 6 h, in two sessions, several days apart. Reading material dealing with the workshop content is provided to students in the week prior to the first workshop. Each workshop addresses a core theme and contains subthemes.
Box 1 provides a thematic overview of the workshops.
Thematic overview of workshops in healing
Workshop 1 (3 h)
Theme 1: The definition and nature of healing (vs curing)
Theme 2: ‘Physician know thyself’
-
Understanding your motivation to choose medicine as a career
-
Understanding your sense of personhood
-
Understanding ‘roles’ in medicine (after Remen et al15)
-
Therapeutic use of self, and self-care
Workshop 2 (3 h)
Theme 1: Personhood and being ill
Theme 2: The nature of suffering
-
The experience of suffering
-
The expression of suffering
Theme 3: The importance of personal connectedness
-
Empathic listening and presence
Theme 4: Meaning-making and spirituality
Theme 5: The physician-healer concept
The themes and subthemes of the workshops are intended to reflect, extend and integrate prior seminal work by leaders in the field, including Remen et al,15 Boudreau et al,11 and Mount et al.18 Simultaneously, the workshops incorporate many features of transformative (adult) education, as espoused by Mezirow,19 and Boyd and Myers.20 Healing is seen as an evolving clinical skill, and the workshops are therefore regarded as ‘introductory’ exercises.
Workshop 1
The first workshop explores and elaborates the imperative ‘physician know thyself’ in order to assist the medical student to become more aware of, and develop, appropriate professional and personal skills and attitudes as a future agent of healing. The workshop commences with an overview by the facilitator regarding the objectives of the workshops. The facilitator emphasises the confidential, interactive and experiential nature of the sessions that are conducted in an ‘explorative’ fashion, rather than in a didactic, examinable context. Therefore, there are usually no ‘correct’ or ‘incorrect’ responses to issues posed, and students are given the right of not responding to issues should they feel ‘uncomfortable’. Following initial personal introductions, each student is asked to briefly explain why he/she has chosen to enrol in the workshops. ‘Healing’ is defined in a traditional sense as “a relational process involving movement towards an experience of integrity and wholeness, which may be facilitated by a caregiver's interventions, but is dependent on an innate potential within the patient”.2 However, the practical importance of healing as the restoration of well-being and daily functioning of persons, as a fundamental goal of medicine (after Cassell10), is also emphasised. For the vast majority of students, curiosity about healing is the reason provided; a proportion of students indicate that they have enrolled in order to develop their interpersonal skills and personal effectiveness with patients. The facilitator then provides a 20 min overview of the various aspects of ‘healing’, in particular, emphasising the contrast between the ‘healing’ paradigm and the ‘curative’ paradigm upon which much of the medical curriculum has been focused. ‘Healing’ is outlined as a process related to the whole person, rather than ‘curing’, which is traditionally seen as referring to the ‘eradication of physical disease’. ‘Healing’ is therefore seen as a part of the traditional medical mandate, summarised often as ‘to cure disease, and to heal the sick’.
Issues are then explored that require personal reflection by students in relation to their motivation to choose medicine as a career. Why did you choose medicine as a career? Has anything changed over the past 6 years of the curriculum to influence your initial decision? What has been your ‘best’ and ‘worse’ experiences as a medical student? How do you feel now that your examinations are finished? How do you feel about your looming internship? What do you think you will need to become an effective doctor? How do you see your roles as a doctor in the future?
Students are then asked to reflect on their personal experiences of illness, caring and being cared for, and what emotions these experiences have aroused in them. What was it like to be ill? What helped and what hindered recovery? What has been the influence of your parents and siblings in terms of caring and being cared for? What do you consider to be your personal ‘strong points’? What do you see as your shortcomings? Have there been times of ‘wounding’? As a result of their past experiences, is there a sense that you can make a difference to the lives of others? Appropriate examples are discussed.
Finally, the issue of self-care is introduced, and each student is asked to reflect on his/her self-care strategies, including self-compassion. Communication skills training is raised as an important ‘at work’ self-care strategy, and students reflect on their experiences in communicating with patients, particularly those patients where difficult conversations have taken place. Then follows an experiential exercise and a discussion regarding the use of effective communication skills (presence, silence, touch, empathic listening) as healing gestures in the context of ‘difficult’ clinical conversations. Students are then introduced to the concept of mindfulness and the potential value of mindfulness practice in various clinical and personal scenarios. A short mindfulness meditation concludes the first workshop. As recognised by Novack et al,8 “healing involves physicians using themselves as diagnostic and therapeutic instruments”, and “through a process of personal growth and the development of self awareness physicians may be able to reclaim their full potential as healers”. Throughout the workshop, reflective and contemplative activities are facilitated by the use of artwork, evocative images, sculptures (eg, figure 1), music and literature readings. Images such as figure 1 evoke issues (see online supplementary appendix) that may be relevant to clinical encounters, witnessed or experienced, by a number of learners when they become interns.
A statue depicting connectedness despite both figures being broken.
Figure 1 provides an example of a sculpture that demonstrates connectedness, even though both figures are ‘broken’ or ‘wounded’ in different ways.
Workshop 2
The second workshop explores the theme ‘confronting suffering’ and builds on the theme and subthemes discussed in the first workshop. The second workshop is held a few days after the first workshop and aims to highlight the nature of suffering and the healthcare professional's role in working with a suffering patient to assist the patient in moving from a state of woundedness and brokenness (‘suffering’) towards an increased sense of wholeness, integrity and restoration of function so that personal achievements are accomplished. Principles discussed in the first workshop are used to achieve these aims.
The second workshop currently commences with the DVD A Story About Care (www.virtualhospice.ca), followed by a 45 min discussion of the major themes that are highlighted in the DVD. Among the issues discussed include the multidimensional nature of personhood, depersonalisation by the healthcare system, the role of empathic listening, human presence, the use of silence and touch and the role of meaning-making in treating suffering, and moving from woundedness towards healing. Also discussed is the personal validation achieved by the healthcare professional in achieving empathic connection with patients.
The remainder of the workshop is taken up discussing the personal impact of illness, the nature of suffering (diagnosis, experience, expression) and the work of Mount et al18 in emphasising the importance of personal connectedness and spirituality. An experiential exercise dealing with a time of suffering in the lives of the attendees is used to discuss how students experienced suffering and what resources were helpful in addressing the life event described. The two workshops are concluded with a discussion of the physician-healer concept that ties together the important themes from both workshops. The second workshop is concluded with a visual (photographic) embellishment of the song ‘Memory’ (from the 1981 Andrew Lloyd Webber musical ‘Cats’).
Evaluation of workshops
Participating students provided a written open-ended reflection of the workshops within a week of the final workshop. Of the 56 students who were initially enrolled, 3 students attended one workshop only, and 5 additional students did not provide written feedback despite repeated requests. Students were specifically asked, “Please provide a written reflection of your overall experience(s) of your participation in Workshops in Healing”. No details of individual students were requested. Ethical approval for this study was sought from the UNSW Human Research Ethics Committee (HREC), which decided that the study was exempt from ethical review (personal communication, Prof M Grimm, Chairperson, UNSW HREC), given that students’ reflections were written on plain paper and their identity was unknown.
Data analysis
The study employed a qualitative design that takes general procedural direction from grounded theory research.21 In grounded theory, confidence in the theoretical scheme is high when saturation is achieved, ideas are well-developed and there is both repetition and variation in the data patterns.21 Data saturation was deemed to have occurred when the themes recurred, and no new information emerged from the subsequent written reflections.22 ,23 Patton considers that a sample size of 40 is sufficient to achieve data saturation.23 The hand-written reflections from students were forwarded to JHK, and each reflection was read several times by EAL and JHK, and together they developed thematic codes. This type of open coding involved repeated reading of the sections of the students’ reflections and a line-by-line analysis of these data. Sections of text in each reflection could be assigned multiple codes. A coding protocol was developed with codes added and refined as they appeared in each reflection until thematic saturation was achieved. Disagreements were resolved through discussion. This style of thematic analysis is based on the constant comparison method.22
Results
Analysis of student feedback regarding the value of Workshops in Healing resulted in the identification of five major themes: (1) the opportunity to reaffirm their commitment to their chosen career path; (2) the value of listening to other students share their stories; (3) the importance of the timing of the workshops to occur after final exams; (4) the use of various mediums such as art and music to present concepts of suffering and healing; and (5) the creation of a safe and confidential space.
The opportunity to reaffirm their commitment to their chosen career path
Many students found the workshops to be a unique experience, unlike any other that they had experienced over the prior 6 years of the medical curriculum.
With the course I shifted my focus in medicine from science to human beings. I feel worthwhile of being a doctor who alleviates suffering rather than treating the disease. The change may seem tiny, but it will be able to sustain me through.
Students frequently commented that their participation had reminded them why they chose to study medicine in the first place.
I think attending the healing workshop was a very worthwhile experience in which I am reminded of the purpose to do medicine. I think it is a good class in which the humanity of medicine is reintroduced. It has made me more sensitive towards the needs of patients again.
Several students indicated that their enthusiasm for clinical medicine had already begun to wane prior to the workshops, and for most, the workshop experience was one that they highly recommended should continue for future students, and even for senior doctors.
… an even more unprecedented subject was that surrounding our own personal wellbeing as doctors in the future. I mean, sure we have heard of all the long working hours; night calls, stress etc at being a doctor, but I realise that we have never really been encouraged to explore those feelings and concerns in-depth, until now. I felt that such a topic would really help equip phase 3 students better for their upcoming intern year.
A number of students drew attention to their observation that many doctors in the health system appeared cynical and ‘burnt out’, and that the workshops may assist them in the future to avoid similar negative consequences of being a doctor.
It was really encouraging to be able to hear your thoughts and the other student's experiences. I was actually becoming quite cynical about clinical practice and losing a lot of motivation about becoming a doctor.
The value of listening to other students share their stories
Several students were surprised at how much they learnt about the personal aspects of other student colleagues, and themselves, as a result of attending Workshops in Healing.
My favourite part of the workshop was the sharing of stories in the second workshop. It made me realise how much I can learn from my friends and how much I admire them. I feel like this aspect only worked for us because we are friends and are able to share some quite personal experiences with each other.
Many students acknowledged that the current medical curriculum does not encourage the sharing of patient stories. The opportunity presented in the workshop to explore this aspect, along with the views of their colleagues, was empowering.
I think that your workshop was possibly one of the best and most useful experiences I have had in the entire time I have studied medicine. It is such a shame that we have so few opportunities to talk about the patient experiences and to take time to find out our own points of view on a very real part of the patient doctor interaction. It was very empowering.
Some students were able to take a retrospective longitudinal view of how they, and others, had changed personally over the 6-year course.
In two hours I learnt more from others’ experiences than I may have done from 6 years of medical school because we tend to form a perspective that interprets a situation in a particular way.
The importance of the timing of workshops to occur after completion of final exams
Many students remarked at how the Workshops in Healing had been held at an ideal time, once all final examinations had been passed, at the end of their period of studenthood. Students indicated that the relaxed, informal context of the workshops contrasted with a sterner and restricted environment associated with teaching of the formal medical content. Students appreciated the lack of pressure, the novelty of the subject material and the sense that they could ‘be themselves’ in relating to the learning material.
This course was wonderful. It was great to have the opportunity to be a part of this. Especially well-timed, eg after exams where we could feel we could ‘afford’ to spend time learning about something not examinable as such. It is rare that we get the opportunity to have time devoted to learning about healing.
The use of various mediums such as art and music to present concepts of suffering and healing
The vast majority of students commented favourably on the value of interpreting and discussing various sculptures, works of art, poetry and other literature, and music in developing idiosyncratic insights into personally relevant aspects of suffering and healing. Examples of the modalities employed are provided in the online supplementary appendix.
I particularly liked the use of different mediums (art works, references to history, scripture, as well as visual aids) to engage us on a number of levels and flush out the issues. These tools really helped me develop an emotion/personal connection and fuller understanding of the meaning of concepts such as suffering and healing.
Students commented on how individual items (often unexpectedly) carried specific meanings and provided a source for personal reflection.
Visual reinforcement with shattering a bowl and dropping an egg provided a powerful metaphor depicting how vulnerable and despairing patients may become when facing illness.
The creation of a safe and confidential space
Several students commented on how the creation of a safe and confidential time space contributed to their enjoyment of the workshops. Many commented on the uniqueness of the experience, an experience rarely available, or considered to be unimportant, in more junior years of the medical curriculum. These factors contributed positively to engendering a sense of camaraderie and a willingness to share thoughts, opinions and experiences that may have been considered to be ‘unprofessional’ in earlier years. A number of students saw their opportunity to engage with fellow students as a useful self-care exercise. Several students also commented on the important role of the facilitator (JHK) in creating an environment conducive to openness.
It was a very unique workshop in that I really felt that you were comfortable to be yourself and that allowed me to be myself. Your workshop allowed me to experience and show feeling which in other situations may be frowned upon. Thank you for allowing it to be a safe environment where tears were welcomed and not rejected.
Discussion
The results of our study add to a small, but significant, body of evidence that demonstrate that experiential courses in healing impact in a positive way on the personal and professional perspectives of medical students.11 ,12 ,15 Although many students enter medical school with a desire to make a positive impact on the health of patients, the medical curriculum may be found wanting in its ability to draw out and develop (‘educate’) the more humanistic characteristics that many medical students bring with them into medical school and that are regarded as essential to being future ‘physician-healers’. While the medical curriculum may prepare students well in the theoretic, factual and purely clinical aspects of medicine, one of the conclusions of our study is that medical educators involved in curricular design need to consider carefully the apparent benefits of including curricular activities that foster students’ humanistic qualities. Otherwise, it is likely that many students will continue to perceive that they are trained, and are expected to behave, like medical scientists.1 ,5 We observed how frequently senior students in our study had subjugated their initial altruism and enthusiasm regarding a career in medicine in favour of the necessity to embark on a study programme that many experienced as gruelling and depersonalising. Hence, many students valued the workshops in healing because the content and experience reminded them of their need to reclaim personal authenticity, rather than to conform totally to those depersonalising aspects of medical training, as outlined by Shapiro.24 ,25
The feedback analysis suggests that Workshop in Healing provides not only practical skills for students in catalysing the healing process but also those ‘disorientating dilemmas’ (vide infra) and ‘awakening’ experiences of Yalom26 that must be resolved to enable students to rediscover the meaning and purpose of their daily study and clinical routines. Many student reflections referred to ‘eye-opening’ experiences of new, or renewed, insight and greater awareness of their daily routines. Andre27 refers to the ‘moral blindness’ associated with medical training and suggests a number of initiatives to enable medical students to reclaim a moral vision of patients as persons. Novack et al8 suggest that the development of self-awareness, personal growth and well-being among medical students represents fundamental requirements in the development of ‘physician-healers’ who are able to embody holistic care for their patients.
Many of the experiences of our students may be regarded as transformational. The study of transformative learning in adult education emerged from the work of Mezirow who regards transformative learning as a process that is primarily ‘rationale, analytical, and cognitive’ in response to a ‘disorientating dilemma’ in the lives of those who are transformed.19 For Mezirow, transformation strives to achieve rationale insight; the purpose of critical reflectivity is to generate perspective transformation, the kind of self-understanding that yields a measure of mastery and control over self and world, rather than an expanded consciousness. In contrast, several related theories of transformative learning, particularly the work of Boyd and Myers, appear to be of equal, or even greater, relevance to the experience of the students who participate in Workshops in Healing.20 Boyd and Myers view transformative learning as an ‘intuitive, creative, emotional process’ and their theory of transformational education is based on analytical (Jungian) psychology of the conscious and unconscious self. For Boyd and Myers, transformation is a “fundamental change in one's personality involving the resolution of a personal dilemma and the expansion of consciousness resulting in greater personal integration”[20 Both types of transformational learning (cognitive and contemplative) appear to be embodied in the many reflective comments from our students.
It is therefore reassuring that many students reported that the workshops gave them a renewed sense of drive and enthusiasm for their chosen career. Students decide to study medicine for a variety of reasons; those students who elected to take part in these workshops were mostly self-selected to have a positive experience, given their reasons to study medicine reflected largely a desire to have a positive impact on the health of the sick. For many students, re-telling the stories about their interactions with patients proved often to be a powerful, emotionally charged time as the students related and reflected on how they were able to connect with patients, how they were inspired by patients, how they experienced a range of emotions and, finally, how privileged they had felt to be included in their patient's story. These are interactions with patients that many of these senior students may never have experienced previously during their training; some experiences may be regarded as epiphanic. A number of authors have found that the use of reflective writing and the ability to share one's stories within the confines of a confidential small group setting are the basis of reclaiming empathy in a medical curriculum that is often responsible for erosion of empathy and ‘hardening of the heart’.28 ,29 In this regard, the positive, enthusiastic responses from participating students are identical to feedback reported by students from the Healer's Art course.4
In the context of a ‘traditional’ 6-year undergraduate medical curriculum, our results indicate that it is both possible and practical to design an experiential workshop dealing with the fundamentals of ‘healing’ to young medical students. Feedback from students has been positive and suggests some simple, yet practical, initiatives that could be woven through existing teaching structures in order to maintain a healing thread. These initiatives include the perceived need by students for more personal and group reflective times, a better understanding and practice in narrative competence, and more emphasis on a ‘spiritual ’ history, rather than attempting to ‘know’ the patient by taking a traditional medical history. Puchalski and Larson30 have published on the need to incorporate a ‘spiritual’ history into medical training, and they have highlighted the increasing number of medical schools in the USA that now offer courses in spirituality. Our results also validate the initiatives of those institutions that place emphasis on exposing medical students to the humanities as a means of enriching their clinical experience and re-personalising the medical curriculum.13 ,14 Several students were able to rediscover a deeper meaning to their present and future work in medicine as a result of being able to reflect on specific pieces of artwork, statues, literature and poetry, music, the experience of mindful meditation and small group reflection.
Our study had a number of limitations. First, the students who participated were self-selected only in that they were the first students to see the workshops advertised and to respond. Although students indicated that they had enrolled, mostly because of ‘curiosity’, it is also equally likely that their attendance was based upon a more profound pre-existing desire to embrace a deeper understanding of their potential roles as doctors in the future. Second, students were requested to provide an ‘overall’ reflection of their experiences, rather than being asked about specific themes and subthemes of each workshop. In their reflections, many students did highlight aspects of each workshop that were particularly meaningful and evocative to them. We do not regard this as an important limitation to the study. Third, there was no longitudinal follow-up made to assess the effect on participant's behaviour when they became young doctors. Therefore, it remains unclear whether a total of 6 h of teaching about healing is sufficient to achieve the behavioural changes intended. Although a total of 6 h appears an extremely modest teaching time, the course content and the experiential nature of the workshops do allow for epiphanic experiences to take place, and for ‘awakening’ experiences to be integrated into students’ behaviour in future months and years. For Boyd and Myers, this type of learning is fundamental to transformative educational principles.20
Many students commented positively on the role of the facilitator in enhancing the value of the workshops. In the process of transformative education, the facilitator has several critical roles to play.31 First, the facilitator must create a safe, confidential and supportive environment that encourages the telling of personal reflections and stories, and participation in creative activities.31 ,32 Transparency and authenticity are two essential facilitator characteristics. The facilitator serves as a collaborator, a guide (rather than an expert) in assisting students to explore workshop content, and to gain insight and meaning from their reflections. He/she also needs to link the learning activities directly to students’ current experiences and to promote critical reflection.32 A final important role is to devise and integrate a range of experiential and creative learning activities in order to facilitate insight, dialogue and reflection, given that the nature of transformative learning will be influenced by students’ differing biographical histories and sociocultural influences.32 Given these important personal requirements of an effective facilitator in transformative (adult) education, it is apparent that a greater number of like-minded facilitators will be required in order to extend the reach of Workshops in Healing in the future to a majority of students in final year. Manualisation of the workshop design and content is likely to be an important step in progressing this initiative.
Despite the positive feedback, there is a possibility that these workshops may cause distress to some students when they begin their busy internships unless ongoing support (eg, mentorship) is provided. A few students commented that they felt ‘guilty’ and ‘ashamed’ as they realised how the workshops had reminded them how they had forsaken their original altruistic ideals when they first entered medicine. In order to improve the evaluation further, we will consider using selected quantitative assessment measures, for example, those of moral distress, in the future. It is our hope that a heightened awareness of their potential roles as ‘healers’, the successful application of transformative learning to practice and the use of self-compassion will have a validating effect, thereby counteracting potential feelings of guilt. It is in this context that ongoing support from senior colleagues would seem to be mandatory.
Conclusions
Within the context and structure of a traditional 6-year undergraduate medical curriculum, we have demonstrated that it is feasible to create an introductory series of interactive, experiential workshops that cover the essential elements of ‘healing’. Positive student feedback suggests a successful transformative learning experience. We believe that Workshops in Healing should be continued, and extended, in the future in order to provide better holistic care, both for people who are ill and for young doctors themselves.
Acknowledgments
The authors acknowledge ‘the Healer's Art Resource Guide’ created by the Institute for the Study of Health and Illness at Commonweal (ISHI) and its director, Rachael Naomi Remen MD. We have used as content some of Dr Remen's other published work; however, we wish to acknowledge that no module (in whole or part) from ‘The Healer's Art Resource Guide’ has been used in either of the two Workshops in Healing. This work was carried out in accordance with the Declaration of Helsinki; in particular, there was no potential harm to the students whose anonymity was guaranteed at all times.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online supplement
Footnotes
-
Contributors JHKauthored the majority of initial drafts of the paper. EAL authored sections of the paper dealing with methodology and analysis of student reflections, as well as making significant contributions to the ‘Results’ section and to parts of the section ‘Discussion’.
-
Competing interests None.
-
Ethics approval University of New South Wales, Human Research & Ethics Committee.
-
Provenance and peer review Not commissioned; externally peer reviewed.