1. Integrating Finding Meaning in Medicine into FM residency education Martha C. Carlough, MD, MPH Robert Gwyther, MD, MBA Susan Slatkoff, MD UNC-Chapel Hill Department of Family Medicine

2. Objectives: Participants will be able to: Describe the core strengths of Finding Meaning in Medicine (FMM) and how these can be used in strengthening and sustaining a personal sense of vocational call for residents Understand ways in which using a FMM model can reinvigorate behavioral components of residency education and provide residents with opportunity for healthy self-expression, mutual encouragement, and generous listening to one another. Discuss ways of including FMM exercises and group meetings into resident education

3. Background The Institute for the Study of Health and Illness (ISHI) founded by Dr. Rachel Naomi Remen in 1992 Mission – “contribute to the healing the culture of health care through educational programs and formation of supportive communities” Offers tools, practices and resources to sustain service values, humanity and passion for physicians at all levels of training

4. Dr. Rachel Naomi Remen Pioneer in movement to rediscovering compassion and a heart for service in medical education and medical careers In 1991 designed THE HEALER'S ART course now taught annually in 70+ medical schools and 5 countries abroad Author of Kitchen Table Wisdom and My Grandfather’s Blessings (translated into 21 languages) Founder of The Institute for the Study of Health and Illness and Clinical Professor of Family Medicine and Community Health at UCSF

5. ISHI Programs Remembering the Heart of Medicine Website and Finding Meaning in Medicine Renewal in Residency (under development) The Healer’s Art Course for medical students Multidisciplinary CME, BRN and CEU workshops for clinicians and educators See: www.ishiprograms.org

6. Why this is so vital? Recognizing the inherent worth of telling and listening to personal stories in healing Counteracting the insidious “shadow side” of medicine which can repress parts of ourselves and result in a loss of personal wholeness Fostering authentic and non-competitive community among physicians Strengthening and renewing sense of calling and professionalism while learning potential tools for self- care

7. Why now, and why does it fit in Family Medicine? Rich history of attending to personal growth and reflection, but perhaps has been usurped by shifting focus, competing demands and limited curricular time and funding Commitment to forming whole physicians for the whole family Compliments with other models and components of behavioral medicine training

8. History of FMM and Healer’s Art at UNC Chapel Hill Heard “Reclaiming the Practice of Medicine” presentation at Pre-Doc meeting (2005)…stunned and immediately knew we needed this at UNC Two FM faculty and one internist trained at ISHI and started HART course for students and FMM course for faculty in 2006 Two additional FM faculty trained in FMM 2007

9. At UNC Chapel Hill: Healer’s Art course for MS1s annually in winter months since 2006 »20-30 students/year »“Bullet proof” FMM faculty group monthly »Average 6-8 attendance »Mostly academic physicians – mixture of FM, Peds, Internists, OB/GYN, psychiatrists, surgeons

10. Integrating FMM into Residency: Backdrop of “behavioral curriculum” in diverse components throughout training History of support groups for residents which waxed/waned in terms of focus, positive impact, attendance Need for renewal and including BEST components of Balint group functions, community building within residency, and a safe place for sharing and listening Began using some exercises from FMM with residents in 2008, and have moved to fully embracing this in 2011- 2012

11. Nuts and bolts: Committed to core and consistent physician faculty presence Adapted ISHI’s FMM resource guide materials and lessons learned from FMM workshop Began with introductory exercises 90 minute session with PGY2 and PGY3s together Introduced format and ground rules Brainstormed focus topics with residents

12. Potential Topics Resilience Miracles and Mystery Boundaries Breaking bad news Work/Life balance Altruism Integrity Justice Reward Joy Fear Service Forgiveness Control Compassion Confidentiality Relief

13. Ground Rules Agree that the goal of FMM is to establish a comfortable safe place to share Come with something relevant to topic of the day Listen generously, allow silence Respect confidentiality and boundaries Remember we are not together to give advice or come to an agreement When the conversation “drifts off” any of us can gently remind the group to bring it back

14. Survey of Resident Views on FMM POSITIVES: Fellowship, getting to know colleagues Safe forum for introspection and self discovery Learning from others’ experiences/wisdom Learning about coping strategies to deal with job stress

15. Survey of Resident Views on FMM DESIRES FOR CHANGE: Smaller groups (?via breakout time) More equal “floor time” for talkers and introverts More “interesting” topics Shorter session vs. second hour for discussion about “interesting” cases

16. Positive impacts Growing sense of community, continuity and ownership of FMM among the residents An opportunity to talk about issues (example of JUSTICE…) that there is not room for anywhere else in the workday and formal curriculum Fostering skills of self-care, listening generously, and authentic community

17. Challenges: Protecting the time and space needed for consistency FMM is a REQUIRED session for our PGY2 and PGY3s, and yet to be successful needs to be built on participation and willingness to be vulnerable Shorter life histories and limited patient experiences to draw from Trusting that all contributions have value and meaning and that generous listening is as key a contribution to the discussion as speaking

18. Mini FMM role play Setting – small conference room, two physician faculty and mixture of R2 and R3 residents Gathering and joining exercise Reviewing ground rules TOPIC – making mistakes Sharing and generous listening Selecting topic for next meeting, closing circle

19. Reflection and Discussion Ideas for how it “fits” into FM education? Anticipated obstacles/challenges for using this at own institution? Need for support, resources, training? WHAT ELSE?

20. “I beg you to be patient toward all that is unsolved in your heart And to try to love the questions themselves…. Like locked rooms and like books that are written in a very Foreign tongue. Do not seek the answers which cannot be given you Because you would not be able to live them And the point is to live everything. Live the questions now. Perhaps you will gradually, without noticing it, Live along some distant day Into the answers.” Rainier Maria Rilke Letters to a Young Poet

21. References and Resources: www.ishiprograms.org website - FMM and Healer’s Art resource guide and modules, Remembering the Heart of Medicine resources/weblinkwww.ishiprograms.org Churchill, L and D Schenck. Healing Skills for Medical Practice. Ann Intern Med 2008; 149. 720-724. Evans, K. Greater Good – The Science of a Meaningful Life. FMM on line journal. Fall/Winter 2006. Rabow, MW, Wrubel, J, Remen. NR. Authentic community as an educational strategy for advancing professionalism: a national evaluation of the Healer’s Art Course. J Gen Intern Med. 2007; 22(10): 1422-8. Remen, N. Humanistic Medicine: The Myth of Service. The New Physician. 1977 Remen, N. My Grandfather's Blessings, New York: Riverhead Books, 2000 Remen, N. Kitchen Table Wisdom: Stories That Heal, New York: Riverhead Books, 1996 Russvold, R and N Remen. Finding Meaning in Medicine: Reclaiming the Soul of Practice. San Fransisco Medicine. May 2002 Zwerling, M. The Gathering of Physicians. Sonoma Medicine. Spring 2003 Kirk, T. This is When it Happens. The Pharos. Autumn 2009