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Creating a Culture of Inquiry in Family Medicine

Peter J. Lawson, MA, MPH, MBA; Samantha Smith, MA; Mary Jane Mason, MPH; Stephen J. Zyzanski, PhD; Kurt C. Stange, MD, PhD; James J. Werner, PhD, MSSA; Susan A. Flocke, PhD

Background and Objectives: Strengthening the contribution of reflective practice and new knowledge generation to the learning relationships forged during graduate and undergraduate medical training offers a possibility to create a climate more conducive to the recruitment and retention of family physicians. The Culture of Inquiry (CI) fellowship, an immersive, experientially based training program, combines didactic instruction, workshops, and mentoring to develop the capacity of family medicine’s teachers to imagine, implement, and disseminate clinically relevant research and stimulate collaborations with those whom they train. This article outlines the CI fellowship program, summarizes its outcomes, and offers insights about programmatic features contributing to its success.

Methods: The Department of Family Medicine and Community Health at Case Western Reserve University selected CI fellows from interested local family physicians who train residents and medical students. Over 10 months, with 10% effort expected from fellows, the CI fellowship exposed each fellow to the entire research process and provided technical and logistical support for the design and completion of two research projects. Quantitative and qualitative program evaluation were used to assess outcomes.

Results: Scholarly productivity of fellows exceeded expectations. Collaborations with students and residents produced a ripple effect that amplified the fellowship’s impact by strengthening those relationships crucial to the creation of a culture of inquiry among family medicine’s teachers, learners, and practitioners.

Conclusions: The CI fellowship represents a highly replicable program to connect committed and interested clinicians to research mentors with the goal of increasing scholarship and creating a growing culture of inquiry in family medicine.

(Fam Med 2014;46(7):515-21.)

Recommendations of the Future of Family Medicine project and others1-5 suggest cultivating a culture of inquiry within a community of physician-teachers as a vital first step toward building a research culture in family medicine. Additionally, strengthening the contribution of reflective practice and new knowledge generation to the learning relationships forged during graduate and undergraduate medical training offers a possibility to create a climate more conducive to the recruitment and retention of family physicians.6,7 Therefore, we initiated an innovative and pragmatic fellowship program for family physicians who train residents or precept medical students in community practices. The purpose of this paper is to describe our approach, report on the program’s successes, highlight programmatic features that contributed to that success, and share the challenges and opportunities for others wishing to implement a culture of inquiry fellowship.

 

Methods

 
 

Overview

In 2008, the Department of Family Medicine and Community Health (DFM-CH) at Case Western Reserve University (CWRU) launched the Culture of Inquiry (CI) fellowship program to (1) address national calls to increase family medicine’s capacity to expand the clinically relevant knowledge base that underpins its practice,1,8,9 and (2) influence factors in the local clinical-learning environment that might contribute to the well-documented decline of medical student interest in family medicine.6,7,10 Offered as a part-time research fellowship from 2008 to 2011, the CI fellowship is an intensive, experientially based research training program developed to foster a culture of inquiry among residency faculty and community clinicians who precept medical students. An HRSA Title VII grant funded a team of four academic faculty members (totaling 0.25 full-time equivalent [FTE] positions) to serve as the program’s Inquiry Leadership Team (ILT) and three staff researchers (1.75 FTE) for organizational and research support. The CI fellowship was predicated on the central principle that, in order to be effective teachers and role models, clinical mentors should be equipped with the skills necessary to model inquiry-based practice patterns, wherein clinical observations are actively converted into opportunities to explore and expand the evidence base of family medicine.

Approach

Drawing on the published literature describing successful models of student, resident, and clinician training,11–17 the CI fellowship is a project-based, collaborative learning experience. To answer recent calls for increased scholarly activity and the generation of new knowledge in family medicine,8-18 the CI fellowship focuses on exposing concrete methods to harness the richness of clinical observations to stimulate rigorous inquiry. Reflective practice3 is used to raise fellows’ sensitivity to possible research topics and to foster a sense of clinical curiosity as a source of researchable questions. By broadly defining research to include quality improvement,19 grounding the fellowship curriculum in clinically applied questions, and providing fellows with multiple opportunities to share research findings, the CI fellowship integrates features associated with scholarly productive residency programs.20 Finally, the CI fellowship seeks opportunities to translate fellows’ growing competence as researchers into the everyday practices of teaching and learning that could enrich future interactions with students and trainees.

Recruitment

Prior to the start of each program year, preceptors of CWRU’s School of Medicine students and affiliated residency faculty were invited to apply for the fellowship via email. The ILT personally contacted directors of the three family medicine residency programs to encourage applications from clinical faculty. Candidates applied by submitting: (1) a description of how the CI fellowship could enhance their teaching, (2) a description of a project or topic of interest, and (3) their curriculum vitae. The ILT reviewed applications, conducted interviews with all applicants, and secured a commitment from each applicant to dedicate 4 hours per week if selected for the CI fellowship. Based on post-interview deliberations, the ILT selected three or four fellows each year.

Curriculum

The 25-session curriculum leads fellows through a complete overview of the circle of inquiry (see Figure 1) from identifying and developing research questions, completing detailed literature reviews, selecting study designs, assessing resources, analyzing project feasibility, obtaining IRB approval, managing data collection and storage, undertaking quantitative and qualitative analyses, and finally writing results and disseminating findings (see Table 1). During each 3-hour training session, didactic information is front-loaded into the early portion with subsequent application activities following, mirroring the curriculum as a whole. A typical session begins with a brief (5–10 minute) faculty-led discussion of reflective practice drawing on fellows’ journal entries of clinical observations from the previous week, followed by 1–2 hours of discussion-based teaching, and concluding with skill-building workshops. This format leads fellows to immediately apply concepts, with the support of faculty and staff, and creates expectations to achieve tangible results each session. While individual sessions couple instruction and application, the program as a whole promotes engagement and experiential learning by immersing each fellow in the experience of participating in two complete projects: (1) a rapidly completed group project exemplifying the entire research process, followed by (2) the design and completion of a project of personal interest.

Figure1
Table1

The Two Project Model

Group Project. Prior to the first session, the ILT prepares at least one plausible project idea to provide to fellows as an example of a feasible group project topic. At the first session, CI fellows, proctored by faculty, are immediately challenged to collaborate on the formulation of a research question, typically related to the proposed topic, that the group will pursue during the opening months of the fellowship. The process of honing a research question is illustrated as fellows prepare a research abstract, outlining the proposed study’s question, method, anticipated results, and relevance. By the end of the first 3-hour session, a complete abstract for the group project, to be submitted as a proposal for presentation at a state-level research conference held 3 months later, is drafted. Abstract submission of the work in progress the following week establishes an aggressive timeline for the group to complete this first project.

Supported by project faculty, fellows learn by doing, contributing to each step of the research process. For example, during the sessions that follow, fellows operationalize the concepts explored by the research question, draft survey questions, and deliberate to develop an appropriate data collection protocol. Between weekly sessions, program staff expedite time-intensive tasks on behalf of fellows (eg, IRB submission, data entry). The CI fellowship is designed to be completed with only 10% effort from fellows, so program staff take considerable responsibility for executing the protocol developed by fellows during the course of the group project. The goal of the group project is to rapidly expose the fellows to the full research process, from study design to dissemination, which, in turn, lays the framework for a second, individual project that each fellow will undertake for the remainder of the fellowship. Fellows continually contribute to all phases of the group project and present the final results at the state conference, which also socializes fellows to the regional community of family medicine researchers.

 

Individual Project. With the group project still in progress, fellows formulate clinical research questions for individual projects, deploying skills in literature review under faculty direction and mentorship. Questions relevant to their clinical practice are developed within the context of the feasibility constraints imposed by the fellowship’s duration. After the completion of the group project, attention is focused on formal protocol and instrument development. Tailored project management, data collection, and dissemination support continues for the duration of the fellowship. Although the CI fellowship group meets less frequently over the 7 months dedicated to individual project completion, weekly sessions are still reserved, and much of that time is allocated to one-on-one mentoring or intensive project assistance. The fellowship year concludes with a public presentation of each fellow’s work and a reception, and the fellowship staff and faculty continue to work with fellows to write up potentially publishable findings from projects.

 

Evaluation. The success of the CI Fellowship was evaluated using a pragmatic mix of quantitative and qualitative methods. Tracking of outputs produced by individual fellows (projects completed, presentations, grant applications, manuscripts produced for publication, number of student learners engaged, etc) during their time with the fellowship and in the 12 months following the end of the program were used to evaluate the primary objectives of the fellowship: namely to develop the capacity of family medicine’s teachers to imagine, implement, and disseminate clinically relevant research and stimulate collaborations with those whom they train. Additionally, throughout the fellowship, semi-structured interviews with fellows and the ILT faculty were conducted by program staff. These data were analyzed for common themes and unique insights on key elements affecting the program’s effectiveness. The CI fellowship program and its evaluation did not meet the definition of research involving human subjects as defined by the Social Behavioral Science Institutional Review Board (IRB) of Case Western Reserve University and, therefore, were granted exemption from review by the IRB.

 

Results

 
 

Participants

In three cohorts, a total of six clinical faculty and five community physicians participated in the 10-month fellowship program. Each was awarded a stipend to protect 4 hours per week of time to attend the training sessions and complete project tasks.

Research Implementation and Dissemination

The number and quality of CI projects exceeded expectations. All together, the 11 CI fellows, all of whom entered the fellowship as novice researchers, have produced 19 research projects using various methods including card studies, cross-sectional survey studies, chart reviews, qualitative interviewing, and mixed method approaches. To date these studies have generated 40 scholarly presentations (four of which won awards) and four funded institutional-level pilot grants for follow-up studies. Eleven manuscripts have been written (four have been accepted for publication,21-24 one is under peer review, and six more are being prepared for submission (Table 2).

Table2

Fellows have explored diverse topics relevant to their everyday clinical practice such as the effect of insurance formulary changes, adolescent Latina sexual health, implementing the patient-centered medical home, breast-feeding medicine and lactation consultation, patients’ and physicians’ ideas of quality and electronic medical records, the effect of free clinic treatment on patients’ health care insecurity, community interest in a school-based health clinic, diabetes management, shoulder dysfunction tests, and family physicians’ community involvement.

Mentorship and Collaboration

Under the guidance of the CI fellows, 30 learners (residents, medical, and master of public health students) have collaborated on projects. While the roles taken by learners varied, with some assisting in data collection and others working as co-investigators, all of these inquiry-focused, learning relationships were programmatically significant as early representations of an emerging culture of inquiry developing within local practice and training sites. The value of the CI curriculum is perhaps best illustrated by its successful adaptation for use with local residents, a project undertaken by one CI fellowship alumnus. In these ways, the CI fellowship has produced an intended ripple effect that has the potential to reach learners at various levels for years to come.

 

Discussion

 
 

After three cohorts, we consider the CI fellowship to be a successful realization of the overall initiative’s ambitious goals; however, the developmental trajectory of the program was not a linear journey from inception to success. Along the way, we faced particular challenges that required us to reflect and engage in thoughtful analysis reconciling the program’s goals with current resources and adaptively redesign the program’s structure. In the section that follows, we describe a few key episodes across the program’s lifespan where we faced and overcame barriers in order to highlight our processes of problem identification and illustrate the thinking processes, responses, and lessons that could benefit others attempting to implement a similar program in the future.

Insight #1: Address Time and Resource Constraints

Roughly 3 months into the first fellowship year, we realized that fellows were losing the momentum necessary to first complete a group project and subsequently complete individual projects within the 10-month fellowship year. Fellows were making slower than expected progress on the group project, since the topic had been selected as a compromise among competing research interests and therefore did not inspire as much early enthusiasm and commitment to fellowship activities. Further, carving out, protecting, and coordinating times for fellowship meetings was difficult for all participants: fellows were busy full-time clinicians (with only 10% time protected by fellowship funds), and fellowship faculty were only supported for 5%–10% effort to coordinate the program, deliver instructional content, and mentor fellows. In year one, a single staff member (100% FTE) was assigned to the project. In subsequent years, two additional project staff brought the total to 175% FTE in order to “keep the needle on the record” by overcoming coordination and communication barriers. These staff brought additional skills in biostatistics, data management, qualitative research, and project management, which offered fellows additional opportunities to work with experienced researchers, while the ILT could focus effort on the content and delivery of curricular material, as well as one-on-one mentoring of fellows. Annual salary costs for the project, including fellows’ salary support, were approximately $164,000 US.

Insight #2: Program Evaluation to Aid Ongoing Redesign and Improve Relevance

At the completion of the first year, a small-scale program evaluation used interviews with all outgoing fellows and ILT faculty to generate areas for improvement. A half-day retreat to review recommendations from the evaluation generated two of the program’s most successful features: (1) a redesigned CI curriculum, which tightly integrated the group and individual projects into a reinforcing sequence of instruction and application and (2) a high-energy, 3-hour, first session led by a veteran clinician-researcher (KS) outlining the entire research process “soup to nuts” (see Figure 1), facilitating the selection of the group’s research question from a set of faculty-developed choices, creating an abstract for a regional research conference presentation, and inspiring the group’s commitment to an aggressive timeline for the project’s completion (and fellowship as a whole). By integrating the group and individual projects (see Table 1) and facilitating a rapid start to the group project selection, we were able to overcome one of the barriers—the requirement of a completed group project prior to initiating individual projects—which limited the success of our first cohort of fellows.

At the mid-point of the second fellowship year, an evaluation was conducted wherein fellows provided feedback about those areas where they felt they needed more instruction or learning opportunities. The content of the remainder of the fellowship year was then adapted to fill those needs. Fellows also indicated a desire for more one-on-one time with faculty to develop their research projects and to consider possibilities for sustaining their research after the fellowship; therefore the number of structured group sessions was reduced to allow fellows more time for individual meetings with the ILT and staff.

Insight #3: Synchronized Training, Not Teaching

Reflection on feedback from fellows also led to revisions in the CI curriculum guided by a renewed commitment to explicitly adopt a training model and eschew a less-effective, didactic, teaching model.25 Workshops were added or expanded to immediately ground fellows’ nascent skills in concrete practice. By synchronizing the content of sessions and workshops to the pace of the group and individual project sequence, fellows were positioned to apply knowledge and skills introduced in a given session directly to their own projects in the subsequent weeks. As fellows progressed through each step in the research process, individual and group needs were anticipated and scrutinized for additional learning opportunities, and the pace at which new session content was presented was flexibly adapted.

Insight #4: Create Transparent Platforms to Manage Tasks and Display Project Progress

As the second year began, we worked to increase the fellows’ use and familiarity with our interactive, web-based project management platform, Basecamp (37signals.com), in order to administer the CI fellowship program efficiently while also modeling effective project communication and coordination. Basecamp became the site where fellows were able to manage their individual projects through a shared file-management system, organize and manage tasks using to-do lists, and collaborate with the ILT, research staff, and other fellows using threaded discussions. Perhaps most importantly, Basecamp allowed fellows to monitor and display their progress as well as the progress of their peers, creating a group culture of achievement and accountability.

Insight #5: Encourage a Culture of Inquiry

Perhaps the most difficult challenge during the CI fellowship was the creation of multiple layers of learning relationships wherein fellows, residents, and medical students would collaborate and reproduce the program’s core principles of reflective practice and inquiry-based learning throughout the medical training ecosystem. Our original proposal called for us to connect fellows with medical students, whom they would mentor in the techniques of reflective practice and systematic inquiry; however, by the second year of the program we recognized both that expecting fellows to take on a mentoring role during the fellowship was overly ambitious and that synchronizing medical student availability and interest with the pace and productivity of the CI fellowship curriculum was nearly impossible. While we are confident that CI fellowship alumni are now well-equipped to offer engaging, inquiry-rich, learning experiences during clerkships, the CI fellowship program was unable to produce these relationships directly. Instead, we found that we could encourage learners from a variety of disciplines (most notably students from CWRU’s Master of Public Health program) to work with fellows on their individual research projects to expedite project tasks and enrich their own educational experience. It is worth noting that both during and after completing their fellowship year, a number of residency faculty participants partnered with their residents to complete existing projects or launch entirely new lines of inquiry. We consider this ripple effect to be one of the most powerful contributions of the CI fellowship program to the growing culture of inquiry among family medicine clinicians and teachers.

Further, the fellowship alumni are now prepared to act as co-investigators on new grants, provide new research ideas well grounded in clinical practice, produce new publications that add to the department’s productivity, participate meaningfully in practice-based research networks and bring research methods into the clinical training setting. Mentoring faculty, whose work with fellows represented a significant investment of time and energy, also now benefit from the addition of new, well-prepared collaborators and potential co-investigators ready to contribute to existing or new lines of inquiry or serve as clinical consultants on research projects.

Finally, we believe the CI program has nurtured a number of characteristics in our department that Bland and others26,27 suggest as predictors of research productivity. Specifically, the CI fellowship supported positive individual development through the socialization, training, and practical experience gained by fellows and also fostered institutional characteristics conducive to the productivity of the organization, including the provision of resources, the availability of mentors, and a group culture that encourages inquiry as integrated activity in everyday clinical practice.26 With the expiration of our grant-funded program, the future of the CI fellowship will likely depend upon the leadership characteristics identified by Bland et al, most notably, the ability of leaders—ideally both program faculty and alumni fellows— to raise funds to sustain a productive research environment.26

 

Conclusions and Future Directions

 
 

Potential future directions for the CI program include a repackaging of the curriculum into a user-paced, web-based format to maximize its potential reach. Implementation of the program with medical students as primary participants is also currently being considered to foster students’ nascent skills in reflective practice while identifying those students with a potential aptitude for research and providing additional exposure to research and mentorship opportunities within the discipline of family medicine. However, any future incarnation of the fellowship program will face an uncertain climate of scarce resources, particularly in light of declining federal support through Title VII of the Public Health Service Act. Thus, future activities that build upon previous investments made in the CI fellowship will likely require a continuing and potentially increased commitment from institutional leaders for support.

The CI fellowship represents one approach to promote and integrate new knowledge generation into clinical practice and instruction. We believe the program is highly replicable at other primary care training sites where some resources can be found to connect committed and interested clinicians to research mentors with the goal of increasing scholarship and creating a growing culture of inquiry in family medicine.

Corresponding Author: Address correspondence to Dr Flocke, Case Western Reserve University, Department of Family Medicine and Community Health, Research Division, 11000 Cedar Avenue, Suite 402, Cleveland, OH 44106. 216-368-3887. Fax: 216-368-4348. susan.flocke@case.edu.

Acknowledgments: This work was supported by HRSA grant # 1D54 HP05444-03 (Dr Kikano, PI). Dr Stange’s time was supported, in part, by a Clinical Research Professorship from the American Cancer Society.

An earlier version of this paper was reported at the Family Medicine Education Consortium (FMEC) Annual Meeting, Danvers, MA, October 2011.

The authors wish to thank all of the fellows who contributed to the success of the Culture of Inquiry program and all of the teachers and learners who continue its work today.

 

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From the Department of Family Medicine and Community Health (all) and Department of Epidemiology and Biostatistics (Dr Stange, Dr Flocke), Case Western Reserve University; and Case Comprehensive Cancer Center, Cleveland, OH (Drs Flocke, Zyzanski, Stange, and Werner).

 


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