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Humanities - The Allenberry Residents' Retreat
For the past twelve years Department of Humanities at Pennsylvania State University College of Medicine has conducted an overnight retreat for an interdisciplinary group of residents to explore humanistic dimensions of medicine and of the residency experience itself. The retreat has three main goals: to create a setting in which residents can explore complex and personally challenging aspects of their professional development; to combine intellectual intensity with emotional openness and increased self-awareness; and to lay the foundation for follow-up activities at Penn State Milton S. Hershey Medical Center that build on the participants' experiences at the retreat. We invite two residents from each of the programs at the medical center (one each from the various surgical subspecialties). Usually they are residents who will assume chief resident positions the following year, so they will have major responsibilities for education and supervision of the other residents in their programs. Between 14 and 18 residents have attended each year. We also include four or five senior clinical faculty, who participate as discussion leaders, role models, and mentors. By arrangement with each program director, the residents' schedules have been cleared and rendered beeperless for the duration of the retreat, which runs from 9:00 A.M. Thursday to noon Friday.
The retreat takes place at a conference center located about 45 minutes from the medical center geographically, but much farther psychically. It is in a lovely rural setting with woods, meadows, and a rushing trout stream. We meet in May. Dress is casual and some sessions are held outside. Discussions are intense, but there is also time for quiet reflection by the stream, a run before dinner, and a good night's sleep. The size of the group, the setting, and the pace of the retreat permit an extraordinary rapport to develop. This in turn allows us to probe some of those issues that by their nature resist being plugged into the typical conference format. These include: 1. communicating bad news;
2. dealing with medical mistakes;
3. caring for dying patients;
4. the stress and distress of residency; and
5. the changing role and status of physicians in society.
It is not that these topics are never addressed in the ordinary medical center milieu. But it has been our experience that some of the more profound and personally challenging dimensions of these issues are much less likely to surface there. When we address them at the retreat, we ask one of the senior clinical faculty to begin each session by recounting how he or she has experienced the particular issue, both as a resident and as an attending physician. This approach encourages the residents to participate actively, since the attending has not only "broken the ice," but has also legitimated the residents' expression of their own uncertainties, concerns, or emotions. A few short and provocative readings, distributed in advance, provide further common ground.
Each session runs for an hour and a half, but the discussions often flow into the break periods and on into meals. Common themes--e.g., the experiences of uncertainty and vulnerability, the ubiquity of moral concerns in patient care, the importance of open communication, and the need for supportive peers and attendings--appear and reappear throughout the various sessions, leading to richer and subtler understandings as the retreat proceeds. We schedule the session on dying patients (predictably the most profound and emotionally intense) after breakfast on the second day. Somehow the accumulation of shared meals and spending the night prepares people to trust each other with a degree of emotional and intellectual honesty that seems to emerge only rarely in other academic or professional settings.
Based on our experience, there are five key ingredients to a successful residents' retreat.
Support from residency program directors
Program directors' support is crucial for many reasons, especially for their willingness to free residents' schedules and to encourage follow-up activities. We sparked interest in our program directors by conducting our first retreat for them; at it, we explored the importance of attending to humanistic dimensions of residency education, and worked through some of the issues that have subsequently formed the agenda for the residents' retreat. Since then the residents themselves have become the best messengers regarding the value of the retreat; their responses have solidified the program directors' support from year to year.
Participation of senior clinical faculty
Senior clinical faculty who are respected attending physicians, who care about the quality of residents' educational experiences, and who have strong interest in ethical and humanistic aspects of medicine play important mentoring roles at the retreat.
The right setting
A trout stream and woods are probably not essential for a successful retreat, but a sense of genuine removal from everyday medical center life certainly is. A hospital conference room won't do the trick.
Central responsibility
The Department of Humanities assumed responsibility for planning and conducting the residents' retreat, in part because of our interest in the issues, and in part because no one else had done so. We also benefit in our clinical teaching from the rapport engendered at the retreats between our faculty and the residents. But from the standpoint of a successful retreat it seems less important who assumes this responsibility than that someone actually does assume it. The roles of building interest and support, selecting topics, and putting together the details of the retreat could be carried out under the auspices of the associate dean for medical education, or perhaps of clinical affairs, as well as by our department.
Modest financial support
Our major expenses are for food, lodging, and use of meeting rooms at the conference center. These total approximately $2,200 per year. (The humanities and clinical faculty members contribute their time.) Half of the funding is provided by the Drs. Kienle Center for Humanistic Medicine, a multidisciplinary center at Penn State Milton S. Hershey Medical Center whose mission is to support education and research that will render medical care more humane and attentive to the patient as a person. The individual residency programs provide the other half by paying a prorated amount for each resident they send. For the past several years this has come to approximately $75 per resident. The programs provide additional in-kind support by arranging backup coverage while their residents are at the retreat.
Summary
The residents' retreat brings the process of medical humanities teaching into closer alignment with some of its most important purposes. The retreat format offers an opportunity to pursue profound and challenging aspects of residency education in more depth than is possible in the usual in-hospital teaching settings. The setting and pace of the retreat foster an attitude of reflection and heightened self-awareness for the residents; expose them to the values, insights, and feelings of their peers and faculty mentors; and lay a foundation for follow-up activities at the medical center that can involve more residents than can be accommodated at the retreat itself.
References
1. Barnard, D., and Clouser, K. D. Teaching Medical Ethics in its Contexts: Penn State College of Medicine. Acad. Med. 64 (1989):743-746.
2. McElhinney, T. K., ed. Human Values Teaching Programs for Health Professionals. Ardmore, Pennsylvania: Whitmore, 1981.
3. Lane, L. W., and Miles, S. H., eds. Special Issue: Teaching Medical Ethics. Acad. Med. 64 (1989):699-764.
4. Strong, C., and Connelly, J. E Clinical Teaching Activities in Ethics and Humanities for Residents and Medical Students. McLean, Virginia: Society for Health and Human Values, 1989.
5. Forrow, L., Arnold, R. M., and Parker, L. S. Preventive Ethics: Expanding the Horizons of Clinical Ethics. J. Clin. Ethics 4 (1993):287- 294.
6. Schön, D. A. The Reflective Practitioner: How Professionals Think in Action. New York: Basic Books, 1983.
Our yearly surveys reveal that we are quite successful in accomplishing our first two goals. The residents have found the retreats to be extremely valuable both professionally and personally. In addition to the pace, setting, and selection of topics, residents commonly single out three other features of the retreat for special commendation: the involvement of senior clinical faculty; the multidisciplinary nature of the retreat, which gives residents a chance to learn how their colleagues in other departments think and feel about issues that they face in common; and the opportunity to slow down enough to think and feel at all, to rediscover aspects of their own individuality and inner experience.
This last point is quite significant, because it highlights the way in which the retreat format succeeds in bringing educational process into alignment with educational purpose. As noted above, an important goal of medical humanities teaching is to foster attitudes of introspection and reflexivity, to contribute to the formation of what has been called the reflective practitioner.6 In both method and content, the medical humanities strive to give action-oriented professionals an opportunity to stand back and view their activities--and the values and assumptions underlying those activities--in a richer and broader context. Unfortunately, this goal is frequently undermined in residency education when we squeeze our reflective purposes into settings and formats that, because of their hectic pace and immediate problem-oriented focus, make it nearly impossible to do any reflecting.
By its nature, the retreat goes against the grain of everyday medical center activity. This is a retreat's primary virtue, but it also means that the number of residents who can be accommodated directly is limited. To spread the retreat's impact, we invite residents who are about to assume major teaching and supervisory responsibilities in their programs, and we devote time at the retreat to the subject of follow-up activities. This has led to several positive outcomes:
The rapport and mutual interest kindled during the retreat have helped us work more effectively with chief residents to schedule conferences, seminars, and grand rounds presentations on medical humanities topics throughout the medical center. Though these in-hospital formats suffer from the defects noted above, they are valuable for many topics and purposes, especially related to clinical ethics, and the retreats have been helpful in establishing these activities more widely.
As the retreats bring into clear focus the value of interdepartmental communication among the residents, and the need to bolster the residents' sense of community, they have given added impetus to plans for a residents' common room and lounge, something that has been lacking at the medical center up to now.
Some retreat participants have been motivated to work within their departments to design similar retreats for their own programs, using our retreat as a model. This is a development that our department would like to encourage, since it would broaden significantly the impact of our efforts without stretching us beyond our own resources.
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