|Year : 2007 | Volume
| Issue : 3 | Page : 110
Making a Difference: An Interview with Hilliard Jason
|Date of Web Publication||28-Jan-2013|
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|How to cite this article:|
Guilbert JJ. Making a Difference: An Interview with Hilliard Jason. Educ Health 2007;20:110
Hilliard Jason, MD, EdD, was Editor of Education for Health (1998-2001). In recognition of his past and continuing contributions to The Network, he has been designated an honorary life member of the organization. In the 1950s Jason was involved in the first known faculty development effort in medicine. Later he was responsible for the two largest studies ever done of the teaching-learning process in medicine. In the past half century, first as a medical student and then as a medical educator, Jason has been at the forefront of transforming medical education. This is a summary of an extended, multiple-part interview that I conducted via email over a period of several months in 2007.
Jean-Jacques Guilbert, M.D., Ph.D.
How did you get involved in medicine?
I was born in Montréal, Canada. During my high school and college years I spent my summers working in a camp for disadvantaged children, many of whom were rescued, orphaned holocaust survivors. I discovered some comfort in working with troubled kids and decided I wanted to be a psychiatrist. Applying to medical school was the necessary first step.
Where did you go to medical school?
I did my premedical studies at McGill University. I applied to McGill's medical school but knew that in those days the school accepted less than 6% Jewish students. One of my professors advised me to apply to the University of Buffalo, which never had a minority-group quota. I was accepted, and McGill turned me down. So I went to Buffalo, which proved to be one of the best things that have happened in my career.
Did your experience as a student cause you to want to change medical curricula?
I had believed the school's promise that they were devoted to preparing humane, caring, scientifically-well-grounded physicians. Instead, I found requirements of mindless memorization of trivia. Most courses weren't close to what I had imagined a good education would provide. I began reading some education and medical-education literature, and became a voice of discontent among my annoyingly docile classmates. One of my teachers was sympathetic and referred me to George Miller, a young faculty member who was seeking funds for "The Project in Medical Education," which would become the first known example of faculty development in medical education.
Tell us about the impact this had on your own development.
Miller got the funding. He found four Buffalo faculty members who were willing to devote half of their time for a year to learning about teaching and learning, and four faculty from other medical schools in the U.S. and Canada who were to join the Buffalo group as participants in The Project. Then, one out-of-towner had to withdraw, leaving an opening. I had met with Miller several times and he decided that my perspectives as a current student might enrich their discussions. I indicated that I would be willing (actually, delighted) to attend my final year of medical school on a half-time basis so that I could be the eighth participant. The Commonwealth Fund generously bent their rules and I became their first pre-doctoral candidate to be granted a post-doctoral fellowship. This enabled me to afford delaying my medical school graduation for a year, while supporting a growing family.
How did you decide to study for a doctorate in education?
The teachers for The Project were drawn from other parts of the university. One was Nathaniel Cantor, Chairman of the Department of Anthropology and Sociology. His book, The Teaching-Learning Process , about the conditions needed for meaningful learning, had a profound effect on me. Stephen Abrahamson of the College of Education was another important contributor. Even before The Project began, I developed a deep admiration of both men.
I was finding medical school tedious and boring. Pursuing interests in depth was impossible. All our energies had to be spent following orders and ingesting details. I hungered for more intellectual stimulation and applied for admission to the EdD program as a way of having more time with Cantor, Abrahamson and others like them. The EdD, my medical studies, and the Project kept me rather busy, but I loved the broadened intellectual horizons.
How was such an unusual arrangement perceived?
George Miller invited some of the senior leaders in US medical education to visit The Project, to contribute ideas and to provide critiques. They were all intrigued with my decision to pursue an education doctorate, but wondered about its appropriateness. They said a doctorate in education would likely have no value as a credential toward a faculty appointment in a US medical school during my lifetime. We now know that this attitude changed far faster than they predicted in the late 1950s.
Miller and Abrahamson went on to become leaders in medical education internationally. Can you tell us something about them?
They were quite different people. George was a rather stiff and formal internist who gave up a promising career in nephrology research to devote himself full-time to medical education for about 25 years. After our Project, he created the Center for Medical Education at the University of Illinois (Jason, 1999). Steve was a professor of education who was loved by his students for his informative, interactive and entertaining classes. He became the Director of the Division of Medical Education at the University of Southern California. The centers that George and Steve created were among the few pioneering world centers for teaching and research in medical education (Miller, 1980).
What did you do when you completed your basic medical training?
I still had my doctoral dissertation in education to complete, so I remained in Buffalo, pursuing a rotating internship at one of our teaching hospitals. Subsequently, I undertook a residency in psychiatry at the University of Rochester's Strong Memorial Hospital, one of the most educationally-focused residencies in the country. It was a one-hour drive from Buffalo, so I could attend the School of Education's doctoral seminars, complete my dissertation research, and meet with my dissertation advisors. [As far as I know, my dissertation research was, and remains, the largest, multi-institutional observational study of medical teaching ever done (Jason, 1962).]
I successfully defended my dissertation during my second residency year. I wasn't able to remain in Rochester for the final year of my residency because a US immigration officer, later certified as psychotic, inaccurately concluded that I had over-stayed the years of study allowed by the terms of my US visa. Despite the best efforts of our university's legal team I was forced to return to Canada, rather than conclude my residency in the US.
Fortunately, the folks at McGill were accommodating, enabling me to complete my residency at the Allan Memorial Institute and serve as consultant on medical education to the Dean's office, while also conducting another observational study of medical teaching (Jason, 1964).
What did you do after fulfilling the requirement that you return to Canada for two years?
The University of Rochester kindly invited me back, to create their first Office of Medical Education. Because of an even better invitation came along quickly, I remained in Rochester only two years. But those were important years. Working at a high-prestige, well-established medical school I learned several lessons. Perhaps the most important was that acquiring a good national or international reputation, which that school had, can be dangerous to a school's ongoing educational development. Being well-regarded by others can become an impediment to further innovation. Some people in admired medical schools worry that changes could jeopardise their school's reputation. Although Rochester had a decent share of people who weren't held back by their good reputation, there were enough who were that I became concerned that the desirability of continuous educational change would need to become more widely accepted among medical schools before the prestigious schools would embark on meaningful departures from their established patterns. So, I felt ready for a different kind of challenge and welcomed an invitation to help create a new medical school at Michigan State University.
What kind of programs did you develop when you created OMERAD at MSU?
We implemented an approach that made OMERAD (the Office of Medical Education Research and Development) a central component of the medical school. In addition to having several of our own core faculty members, we found at least one committed educator in most academic departments who served as our liaison to their home department.
Those early years at MSU were exhilarating. It was a time of reasonably well-funded support for the expansion of medical education programs throughout the U.S., and our campus had more than the usual share of forward-looking, energetic, inquisitive people. There was a genuine sense of adventure and excitement. The early faculty welcomed fresh ideas. We had virtually no difficulty securing acceptance for a new kind of course for first year medical students using simulated (standardized) patients and video recordings (Jason et al., 1971).
I understand you were not only interested in the area of communicating with patients. What were some of the other features of the new program at MSU?
I was still close enough to my own medical education to be deeply concerned that we try to avoid the conventional mistake of having the so-called basic sciences taught as separate courses, removed from any serious engagement with the clinical world. I felt we needed a better understanding of how expert clinicians think and solve problems to help us design appropriate instructional activities. I invited Lee Shulman, then an impressive young faculty member in the College of Education, to a joint position in OMERAD. We submitted a proposal to the National Institutes of Health for the "Medical Inquiry Project." After receiving our grant, Lee introduced me to his former classmate, Arthur Elstein, a psychologist in Boston. We convinced Arthur to begin a career in medical education with us.
The Medical Inquiry Project led to several articles (e.g., Elstein et al., 1971; Elstein, 1976) and culminated in a book on medical problem solving (Elstein et al., 1978). This work helped us prepare learners to begin thinking like clinicians as early as possible, with far less rote accumulation of information and more emphasis on seeing information as connected to managing clinical decisions. This led to our so-called "focal problem" approach, one of the precursors of problem-based learning (Ways, 1973).
You gathered very capable people around you. Who was on your team then?
In addition to Lee Shulman and Arthur Elstein, Norman Kagan, a counseling psychologist in the College of Education also joined our team. Norm had developed what he called "Interpersonal Process Recall," preparing school counselors by videotaping them while engaged in interactions with clients, then reviewing playbacks of those tapes. He and I subsequently developed the first course for medical students using video recordings and standardized patients.
My work in the community led to a friendship with John Krismer, the associate administrator of one of our community hospitals. He had secured a grant to implement one of the first computer-based information management systems for patient care in a hospital. This was in the 1960s, two decades before most people heard of personal computers. I wanted to exploit computers to make every patient encounter a potential learning experience for clinicians, providing immediate feedback on their data-gathering and management plans. John wanted to undertake a study of their project and asked my help in finding someone to conduct that study. I reviewed the doctoral candidates in education and found Ron Richards, who we invited to do that study, which became his doctoral dissertation. He then joined our OMERAD team.
In addition to these staff and others we were fortunate to recruit, our lives and work were hugely enriched by people who came to learn with us for extended periods of time as post-doctoral fellows. I'll mention only two who are well known to many members of The Network. The late Harmen Tiddens, founding Dean of Maastricht University's Faculty of Medicine, studied with us before shifting his career from being a pediatric nephrologist to being a medical educator and administrator. Vic Neufeld spent a year with us prior to settling in to his productive career as an educator at McMaster University.
How did you become interested in a community orientation, which led to the Upper Peninsula program with Ron Richards?
During our discussions about the nature of a medical school, we decided against a conventional university hospital, which we felt could damage our educational program. Most of our graduates, like most graduates of all medical schools, would spend most of their careers caring for ambulatory, not hospitalized, patients. In the U.S. less than 4% of medical graduates become full-time academics. Instead of having a university hospital, we cultivated close relationships with two community hospitals in our town, and subsequently with others in nearby communities. We also hoped to attract students from the more rural parts of the state, hoping such students would choose to practice in or near their home communities. This meant developing educational experiences in a rural region. The northerly, rural Upper Peninsula region was in need of more doctors and more accessible health care, so we selected it as our alternative site. Ron Richards became the first director of that initiative. Were there external forces or factors supporting or inhibiting change at MSU?
The main supporting factor derived from the "Land Grant" heritage in the U.S. It helped fund institutions of higher education by granting federally controlled land to the states. The first land-grant university (1862) was Michigan State University. Others include the Massachusetts Institute of Technology and the University of California at Berkeley.
During my first visit to MSU I became aware of that university's deeply felt commitment to its surrounding community. Discovering that Andy Hunt, our founding Dean, fully supported those premises raised my interest in moving to that university. The additional discovery of wonderful potential colleagues convinced me that our family needed to relocate again.
Not long after arriving I began learning how all institutions, even under the best of circumstances, need care and vigilance if they are to avoid the risk of slipping back from their innovative achievements (Jason, 2001).
What were some lessons you learned in building OMERAD?
I'll focus on just two.
First, it isn't enough to recruit good people if you want to get good outcomes. You also need to provide opportunities for cross-fertilization among members of the group. We used weekly meetings in which everyone took turns presenting their work, their vision, their successes and their challenges, in an atmosphere that focused on expecting high standards while being supportive and non-judgmental.
Second, is the process of recruiting faculty. Unless careful thought is given to the personal characteristics and values being sought, the founders' dreams can be quickly diminished or lost from the effects of newcomers who aren't supportive of the organization's mission. It isn't enough to count the number of published papers and grant awards received. The expectations and perspectives each candidate is likely to bring are also important. Otherwise people we hire as potential contributors to a program can turn out to be saboteurs of the organization's goals.
Have there been promising spin-offs from your work at MSU?
I hope so, although I don't know nearly enough to answer that question fully. I do know that we were the only ones in the middle 1960s using video recordings and standardized patients to teach communication skills to first year students, and that within less than a decade a majority of US medical schools were doing so (Kahn, 1979). I think our early work on the "diagnostic and problem-solving process" and on the "focal problem" approach, contributed both research and instructional ideas for others. Our colleagues at McMaster and at Maastricht fully deserve the credit they've received for carrying those initiatives far further, but I think we helped lay the foundation for the building that they and others have done.
What were your main projects after MSU?
When I left MSU in 1972 I intended to return after one year. I support the principle that the builders and leaders of organizations have an obligation to step aside before they've lost all their original enthusiasm and energy, and they should get out of their successor's way for some time. There is no single, optimal duration for leadership applicable to all situations. I felt that 6 years was about right for my time as Director of OMERAD. It coincided with the arrival of an invitation from the National Library of Medicine to spend a year there as a "Scholar in Residence." I left on sabbatical. To my surprise and delight, the staff at the NLM felt that my serving as an informal, in-house advisor on some of their programs (while spending most of my time catching up on reading, doing some writing, and studying sculpture with a local artist) was sufficiently helpful that they broke their own precedent, asking me to stay on for a second year. I felt like I had won a lottery.
During that second year, Dr. L. Thompson Bowles announced his resignation as Director of the Division of Curriculum at the AAMC. I was invited to take his place. I conveyed my interest, with one fairly significant condition: that the AAMC leadership accept the premise that the dominant challenge in medical education was not the rearrangement of curricula, but the elevation of the competence of the faculty members who design and implement the curricula. They agreed, and converted their Division of Curriculum into the Division of Faculty Development. As far as I know, that was the first time the phrase "faculty development" was used in a medical education context. I felt it marked the beginning of a needed transformation in the thinking of some of our country's medical education leaders, towards accepting faculty development as a foundation requirement in medical education (Jason, 1978).
Our primary project at the AAMC was a major study of teaching in US medical schools, which was subsequently described and reported in a book I did with my wife, Jane Westberg, who has been my closest collaborator (Jason & Westberg, 1982). That study involved gathering data on instructional decision-making from the largest sample of teachers ever studied. We had a stratified, random sample of 2,700 faculty members, drawn from 28,393 faculty who were involved in medical student teaching at all 113 fully operational medical schools in the US.
Our other large activity during that time was offering workshops on various aspects of faculty development. Unfortunately, during the fourth year of these activities the AAMC was experiencing serious budgetary constraints and our division was disbanded.
The AAMC allowed me to move the remaining funding I had secured from outside foundations to a position I was offered at the University of Miami. We created the National Center for Faculty Development, where we remained for 12 years. The primary staff for the Center was just Jane and I, so we were a far more modest operation than our grandiose name implied. We did have significant help, however, from many collaborators, drawn intermittently, as needed, from medical schools around the U.S. We continued to offer workshops for faculty and produced a fairly large collection of resources for use in faculty development, including booklets, instructional videos and self-study documents. We also pursued a large, federally-funded, 5-year faculty development project involving the faculty and residents of all 9 family medicine residency programs in Florida. (Jason & Westberg, 1984).
In the late 1980s we concluded that there was no longer a requirement for a national effort to be promoting the idea that faculty development was needed in medical education. Almost all medical schools and professional medical societies were supporting some level of faculty development, as were many projects in a variety of institutions. In 1990 we terminated the National Center and relocated, joining the University of Colorado's Department of Family Medicine, which was in the forefront of fostering the much-needed expansion of high quality primary care in the U.S. In addition to conducting workshops for and consulting with educational programs nationally and internationally, Jane and I produced four books for the Springer Publishing Company's Series on Medical Education (Westberg & Jason, 1993, 1994, 1996, 2001).
How and when did you get involved with The Network?
Tamas Fülöp, former director at the WHO, and I had become friends, crossing paths in multiple ways, beginning in the early 1970s. In particular, he was a member of the external review committee that I chaired for the then new medical school being developed as the beginning of the new Maastricht University. We had many discussions about the importance of community-focused medical education and about his ideas for establishing The Network. I like to think that some of my ideas played a small role in the evolution of the concept and goals of The Network, but I didn't have much direct, personal involvement until about 10 years ago when I was invited to take over as Editor of The Network's journal, Education for Health, from its founding editor, Charles Engel. All along I've been a strong supporter and "cheerleader" for The Network and its mission. Beginning with my responsibilities for EfH, I've devoted a considerable amount of time and effort, doing my best to support The Network's activities in several ways, especially through the journal, contributions to the executive committee while I was serving as editor, and contributions at the annual meetings.
What were some of the challenges you faced as Editor of EfH?
During the years of establishing the journal, Charles Engel had been extraordinarily generous in carrying almost the full burden of running the journal himself. When I took over I set 7 primary goals for my tenure as editor: 1) Develop systems that would enable the journal to function smoothly regardless of who was editor, 2) Prepare staff at the Maastricht office who could take responsibility for managing the journal, 3) Create a Manuscript Information System, a computer-based system for keeping track of all submissions, of all reviewers, and of the progress of each submitted paper, 4) Build a group of peer reviewers who could provide thoughtful decisions and guidance to authors, 5) Establish a pattern of greater than customary support for authors, to help increase the number of publishable contributions from faculty members in developing countries, 6) Make the journal sufficiently attractive that experienced authors would regard EfH as an appropriate outlet for their work, and 7) Secure approval of the journal for becoming indexed in MEDLINE. Happily, all these goals were achieved.
What directions would you like to see The Network take in the next few years?
I'll begin by expressing my admiration for what has already been accomplished. I consider The Network a wonderful organization with members who are doing important, exciting work, with the support by an excellent, dedicated staff. I want to also give special recognition to Art Kaufman, who has come to the end of his six-year term as Secretary General. I think that he has brought an exceptional level of leadership and vision to the position. He will be a hard act to follow.
I think that the organization is facing several challenges at this time.
Constituency. The Network has enjoyed the contributions and support of some of the most dedicated, selfless and imaginative people in the health professions. But, the participation of too many of our member institutions depends on the energy, enthusiasm and commitment of too few people. I worry that if just one or two people left some member institutions, the ongoing participation of that program might decline or disappear. The Network, I think, needs to find ways to cultivate a deeper and broader involvement of faculty members at participating schools, while also seeking the engagement of more institutions.
Focus. I think The Network has a vulnerability that is analogous to one faced by most schools of the health professions. Too few people in our professions have a sufficient understanding of the educational process, causing many leaders to not recognize the importance of instructional programs as key determiners of the character and quality of health care. Although there are other factors influencing health care, the weak link, too often, is the insufficient educational competence of the health professional faculty, deriving from the limitations of the educational programs that prepared them for their careers. The Network is vulnerable to the risk that new leadership won't understand these issues sufficiently and will diminish the ongoing contribution that The Network has made through its validation of the importance of educational innovation and through the models it has helped develop and disseminate. I worry that The Network, particularly at this time of pending transition in its most senior leadership, could be at risk of being steered away from its original, still highly relevant, goals.
Funding. The lack of a sufficiently large, dependable funding base creates an ongoing set of uncertainties and requires repeated scrambles to find additional funds, which dissipates too much time and energy that could be devoted toward more productive activities. The organization has remained dependent for too long on the generosity of Maastricht University. Although the university has provided extraordinary support, I don't think it is desirable for an international organization to be quite this dependent on any one source. I hope a broader base of stable support can be found soon.
I understand you are now involved in a new project.
I'm slowly but steadily building a series of essays that I will make available for review and critique by anyone, under the theme: "Rethinking Medical Education." I will place these essays on a web site. If those who visit that site encourage me to do so, I may accumulate some of those essays into a published book.
Thank you very much for sharing your thoughts with us.
You are most welcome. And thank you for what has been one of the most thorough, well prepared, and comprehensive interviews I've experienced.
Elstein, A. S., Kagan, N., Shulman, L. S., Jason, H., & Loupe, M. J. (1972). Methods and theory in the study of medical inquiry. Journal of Medical Education, 47(2), 85-92.
Elstein, A. S. (1976). Clinical judgment: psychological research and medical practice. Science, 194(4266), 696-700.
Elstein, A. S., Shulman, L. S., & Sprafka, S. A. (1978). Medical Problem Solving: An Analysis of Clinical Reasoning. Cambridge, MA: Harvard University Press.
Jason, H. (1962). A study of medical teaching practices. Journal of Medical Education, 37, 1258-1284.
Jason, H. (1964). A study of the teaching of medicine and surgery in a Canadian medical school. Canadian Medical Association Journal, 90, 813-819.
Jason, H., Kagan, N., Werner, A., Elstein, A. S., & Thomas, J. B. (1971). New approaches to teaching basic interview skills to medical students. American Journal of Psychiatry, 127(10), 1404-1407.
Jason, H. (1978). Is faculty development necessary? In fact, what is it? Journal of Medical Education, 53(5)(5), 442.
Jason, H. & Westberg, J. (1982). Teachers and teaching in US medical schools. Norwalk, Conn: Appleton-Century-Crofts.
Jason, H. & Westberg, J. (1984). Microcomputers in faculty development: the Florida FAC-NET Project. Journal of Family Practice, 19(1), 72-79.
Jason, H. (1999). In Memoriam: George E. Miller, MD. Education for Health, 12: 2, 145-147.
Jason, H. (2001). Reflections on change: educational and institutional implications of "regression toward the mean". Education for Health, 14(3)(3), 351-355.
Kahn, G. S., Cohen, B., & Jason, H. (1979). The teaching of interpersonal skills in US medical schools. Journal of Medical Education, 54(1), 29-35.
Miller, G.E. (1980). Educating Medical Teachers, Cambridge: Harvard University Press (A Commonwealth Fund Book).
Ways, Peter O. (1973). Focal Problem Teaching in Medical Education. Journal of Medical Education, 48(6), 565-571.
Westberg, J., Jason, H. (1993). Collaborative clinical education: The foundation of effective health care, New York: Springer Publishing Company.
Westberg, J., Jason, H. (1994). Teaching creatively with video: Fostering reflection, communication and other clinical skills, New York: Springer Publishing Company.
Westberg, J., Jason, H. (1996). Fostering learning in small groups: A practical guide, New York: Springer Publishing Company.
Westberg, J., Jason, H. (2001). Fostering reflection and providing feedback: Helping others learn from experience, New York: Springer Publishing Company.