Ten years, for a change: Reflections on a decade at the Harvard Macy Institute

Established in 1994 with a $1.5 million grant from the Josiah Macy Jr. Foundation and an additional $2 million in 1997, the Harvard Macy Institute aims to create and foster a community of scholars who work to promote innovative change in medical education and advance leadership in health care delivery. The Institute is a collaborative effort of the faculties of Harvard Medical School, the Harvard Graduate School of Education, and the Harvard Business School. Since 2001, the Institute has been affiliated with Harvard Medical International. Over the ten-year history of the Harvard Macy Institute, 1,023 scholars representing 271 institutions from 43 countries have attended the Institute’s annual professional development programs.

In this edition of HMI World, Elizabeth G. Armstrong, PhD, the director of the Harvard Macy Institute, talks about helping physicians become better educators and leaders, and finds a personal reward or two in ten years of building a community of practice.

HMI WORLD: As the Harvard Macy Institute finishes its tenth year, how do you think that the mission of the Institute has changed from the way you first perceived it to what it is now? Have there been any surprising developments?

ARMSTRONG: The Harvard Macy Institute was started with a double-pronged set of goals: first, to bring about change in individual participants, and second, to create institutional change. We knew that in order to change institutions, we had to change people first, and this was the genesis of the idea of requiring scholars to come to the programs with an institutional project.

We’ve stayed true to these goals, but the powerful response from individuals and organizations that have now created the community is beyond anything I could have imagined.

From the beginning, I wanted the participants to feel like they were members of a network, but I never envisioned that the community was going to be such a motivator for them. When people talk about the Harvard Macy Institute now, they often say they have been transformed individually, and that they have a supportive network around them now. In some ways, we have allowed the community to own the Institute by inviting the scholars to teach and design with us, and through the way we ask for feedback. When you can involve the participants to such a great extent, you are rewarded in ways that you could never imagine.

I’ve also been pleased by the number of “frequent flyers.” By that, I mean that several organizations, such as Mayo Medical School and Cornell, have seen the Harvard Macy Institute as a critical faculty development program. This is a real demonstration of institutional impact, and shows confidence in us on the part of deans of medical education who are supporting faculty who come to the courses.

Finally, perhaps the most pleasant surprise of the past year occurred at the close of the 2004 Program for Physician-Educators. This year’s group announced that they are starting a scholarship fund to enable faculty from institutions with limited professional development resources to attend the Harvard Macy Institute’s programs. I can’t imagine a more glowing endorsement than that.

HMI WORLD: In the health care community, we are constantly hearing and reading that “Health care is always changing.” That mantra is, of course, one of the driving forces behind programs like those offered by the Harvard Macy Institute. How do you keep the content of the annual programs fresh so that they are aligned with the challenges facing health care leaders and medical educators?

ARMSTRONG: I believe that for programs like these to be successful, you have to have a personal commitment that the programs must constantly change. These courses have been driven by a mindset that there must be constant improvement—that there must be a better way to do it.

In the past five years, the scholars who have returned have played a large part in driving change in the programs. Inviting scholars to come teach has resulted in an infusion of ideas from a wide range of organizations. They tell us what their institutions need, and what their challenges are, and also, they let us know what they could have used more focus on when they first attended the course.

We also have a commitment each year to incorporate one or two experimental sessions. For example, we have introduced action groups, journal clubs, poster sessions, and the use of technology such as the simulator. This year, we invited faculty from several schools that had new curricula to come and share what they have learned.

The real key, above all, to maintaining the programs’ vitality and relevance is to be a listener. An educator who listens will hear where the new excitement is and what the needs are.

HMI WORLD: Going forward, how will the focus of the Institute shift, if at all? What areas or challenges will receive more attention?

ARMSTRONG: One of the main shifts in focus that I see going forward reflects what is happening in hospitals today. Health care providers are trying to figure out how to better develop patient care teams and work together. To address this, we have expanded our programs to include allied health professionals.

Another area we will continue to stress is the use of technology. We want to explore how we can utilize distance learning, simulation exercises, and our website to address both new ways of teaching and learning and continue to nurture our community.

A third area of focus that we are particularly interested in is creating and supporting a continuum in medical education, from undergraduate to graduate medical education and continuing medical education. When the programs were first conceived, they were largely directed at undergraduate medical education, but in the past five or six years, we have worked very hard to expand that focus to graduate medical education and continuing medical education, and will be directing more energy towards CME.

One of the major challenges we will have to address in the near future is the globalization of medical education standards. The differences in how nations prepare physicians are going to be blur, and the migration of physicians will force more standardization of practices, assessment, and so forth. Leaders in academic medicine are going to come to Harvard Macy Institute grappling with this, and we need to be ready to respond.

HMI WORLD: What do you think makes the programs of the Institute unique from other professional development courses?

ARMSTRONG: First of all, the goal of the Institute was not going to be to provide people with a skill set that said “how to.” We reversed the paradigm and asked people to really consider what they currently do, articulate why they do it that way, imagine new ways of doing it, and then invent those new ways. We never offered up recipes. Instead, we challenged people to think about the rationale behind their educational practices.

Second, these programs were never envisioned as “one shot deals.” Often faculty development programs are a wonderful experience, but then when they are over, you’re done. From the beginning at the Harvard Macy Institute, we have told the participants, “Welcome to this family” or “Welcome to this community.” Everything we did was focused on making sure that people felt like they were part of an ongoing process, rather than a static presentation of skills.

Finally, the programs have been about more than educating an individual. We believe that we are changing institutions as well, and that goes back to our original goals.

HMI WORLD: Both programs rely on a multidisciplinary faculty drawn from different schools, different disciplines, and a wide variety of real world experiences. How does the Harvard Macy Institute faculty and its collaborations serve as a model for the kind of “work across disciplines” that the programs encourage in their participants?

ARMSTRONG: The interdisciplinary conversations and dialogues actually contribute to the new solutions or new models that people invent, because they are thinking with people they don’t typically interact with. For instance, bringing the business world into our courses was a major breakthrough. I never envisioned that would be as important as it has turned out to be, but so many participants have felt this to be a breath of fresh air that brought a relevant perspective to what they were trying to accomplish.

In terms of how the programs are organized and taught, we have tried to model how we hope people view education and each other, and how professionals with a diversity of roles and experience can work together.

HMI WORLD: The Harvard Macy Institute programs call on the faculty to engage in different kinds of teaching, including lecturing and leading small-group activities. What do you look for in a potential member of the Macy faculty?

ARMSTRONG: First of all, as I said before, being a good listener is crucial to keeping these programs vibrant and relevant, and so we look for that characteristic in our faculty members. Also, these programs rely on faculty whose model of teaching is not telling—we need educators who are invested in an experiential learning model. Otherwise this would be a course with PowerPoint slides from morning to night, and for the challenges facing the scholars, that approach simply doesn’t work. Finally, we’re looking for coaches and mentors, people who are interested in helping individuals collect data, invent models, and then experiment with those new models.

HMI WORLD: A significant number of Harvard Macy Institute alumni have returned to serve as faculty members. What does that mean to you?

ARMSTRONG: The powerful contribution of the scholars who return, at their own expense, to teach has been a gift that has continually brought new ideas to the program and allowed us to create the kinds of small-group activities that keep the programs intimate and community-focused. The energy and enthusiasm of our alumni community has been another of the really wonderful surprises—something that I think we had hoped would develop from the beginning, but never envisioned becoming such an integral part of the Institute.

HMI WORLD: As the director of the Institute, and as a leader of many workshops offered by HMI that utilize the Macy teaching modules, what do you get out of teaching in the Macy programs?

ARMSTRONG: I think the fact that these people come together and feel recognized for their work in education, and the vigor with which they explore and create new ideas, is energizing for me. The way we teach is the way we learn. Every time I run a teaching session, I learn a new way to approach a problem or get a new idea that keeps me going.

It’s also gratifying to me to have the opportunity to work with the faculty and scholars who make these programs so invigorating, including the faculty across Harvard University. The diversity of their experiences, their willingness to share their ideas and explore the ideas of others, and the energy they bring to each session are the catalysts for real change, and I hope that they benefit from these programs as much as I do.

Clayton Christensen, at the end of the June leadership program, typically tells the participants, “Teaching by the case method is really a racket, because I’ve learned more from you people than I know I could have taught.” That’s what it’s all about for me as well, in addition to knowing that in some small way, we’ve had an impact internationally on medical education, so that young people can receive a better medical education, and that this will translate into achieving the ultimate goal of better patient care. Our hope is that if there are better models of who a teacher is, then perhaps there will be better models of who a doctor is, because a doctor is a teacher.