“…that is the type of family physician I’m becoming”: Learning as becoming

By: Frances Kilbertus, MD, MMedEd

F. Kilbertus is a family physician and associate professor, Department of Clinical Sciences, Northern Ontario School of Medicine, Mindemoya, Ontario, Canada.

What is memorable learning for our trainees? How is this aligned with the values of our institutions and the needs of our societies? Over many years as a clinician and teacher, I found that thinking of learning as the acquisition of knowledge, skill, and attitude, or as workplace participation did not adequately explain the complex and often profound experiences that occur during medical education and their consequences on the emerging professional identity of physicians. But how else could learning be conceptualized?

As a family physician, palliative care has always been a part of my clinical and educational practices. I observed myself, colleagues, and learners struggle with this practice domain and heard many reasons for this: questioning whether this is part of family medicine as palliative care has grown as a specialty practice, challenges with moving from acute disease–focused interventions to a palliative approach, managing strong or difficult emotions, and finding ways to include learners in intimate and moving patient and family events. I had discussions with colleagues who felt ill prepared for this practice let alone to teach or mentor learners about it. I also spoke with learners who felt they had inadequate preparation in palliative care during undergraduate or postgraduate years. Some learners felt unable to embrace this domain as part of their emerging independent practices for a variety of reasons: lack of confidence about the knowledge and skills, no experience of palliative care practice outside of the hospital, never attending a patient at home, or simply not considering this practice as how they perceived themselves as physicians as it challenged the notion of physicians as “healers.” I wondered whether this narrowing of trainees’ views of their future professional selves was something learned in a broader sense and beyond the limitations of learning as acquisition or participation.

Recounting memorable stories is a common way to make sense of life experience and physicians can be masters of regaling their colleagues with anecdotes in formal (e.g., case presentations, rounds) and informal (e.g., staff lounges, social events) ways. An important purpose of narrative is in recounting identity: the stories we tell ourselves and others of who we are.1 During conversations and in response to questions about palliative care, learners and colleagues often told me moving stories about participating in or observing death and dying from personal and professional perspectives. These events had often occurred many months or even years prior and were often so powerful as to shape personal or professional life choices. As my curiosity evolved into a research project, narrative methods seemed a perfect fit to explore the lived experiences of learning palliative care.

The results of my recent Academic Medicine study, as one might gather from the quotation used in the title of this post, changed the way I think about learning and opened my eyes to different ways of “being” a teacher. Neither learning as acquisition nor participation explained the depth and breadth of experience and the associated powerful emotions recounted by participants in their narratives of memorable palliative care learning. By reconceptualizing learning as a process of “becoming,” the interplay between individuals, workplaces, cultures, and professional identity is made evident and accessible for those who develop curricula and support learners.2 I believe that we ignore learning as the complex process of “becoming” at our peril—at best missing opportunities to align learning with desired outcomes and at worst traumatizing learners and perpetuating misalignment of declared institutional values and intentions with the lived experience of learning.

References

  1. Riessman CK. Narrative Methods for the Human Sciences. Thousand Oaks, CA: Sage Publications; 2008.
  2. Hager P, Hodkinson P. Becoming as an appropriate metaphor for understanding professional learning. In: Scanlon L, ed. “Becoming” a Professional: An Interdisciplinary Analysis of Professional Learning. Dordrecht, Netherlands: Springer; 2011:33–56.

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