Reflective Practice and Leadership in Medicine and Medical Education Example Facilitative Responses: Facilitating Component 4: Plan for Strategic Action

In our experience participants – and sometimes faculty – often suggest and accept plans for action without any explicit evidence or rationale, or without consideration of the potential positive and negative consequences. Thus, faculty must carefully facilitate a discussion of plans that includes a rationale and a link back to the original hypothesis/diagnosis.

The following case illustrates how to facilitate planning for strategic action in an academics environment. In our seminar we conceptualize every type of challenge that fellows encounter as an analogy for what they will likely encounter in their future career. This includes a critique of their training program because all of the participants will most likely be involved in training other physicians.

The context – The challenging case at one seminar concerned the system for conducting evaluations in the fellowship program.

The framed question had two parts:

  1. What would be a better way to conduct evaluations to more accurately reflect the developing competencies of fellows over the course of the first (clinically focused) year, and do we get feedback in a time frame that is meaningful?
  2. How do you effect change in an academic setting from a position of little or no authority?

Working hypothesis:

The systematic reflection led to a working hypothesis that the participants were waiting for the faculty to: 1) “grant” them authority as the first year progressed, or 2) make the desired changes in the fellowship evaluation system.

Strategic plan of action:

This hypothesis in turn suggested that the participants might be more successful if they developed a systematic plan and rationale for change and presented it to the relevant faculty (e.g., program director and education committee). The faculty asked participants what they might consider doing if this hypothesis were accurate. They rapidly exchanged information about relevant organizational roles, infrastructure (e.g., program director, education committee), and procedures that would be involved in this type of institutional change. The participants collectively decided that they would test this hypothesis and plan by trying to effect the desired change in the program.


Over the course of approximately four months the participants formulated a complete proposal for an overhaul of the fellowship evaluation system. Using their strategic plan of action, they presented the proposal to appropriate decision-makers and through representatives (e.g., the chief fellow and two additional participants representing the first- and second-year groups). The proposal included the idea of a mid-month face-to-face discussion between the fellow and attending physician based on a set of dimensions developed by the participants. The discussion included the opportunity for attending physicians to specify individual learning targets for fellows and for fellows to give attending physicians feedback on their performance as clinical educators.