ADVISING AS TEACHING
Norma E. Wagoner, Ph. D., Dean of Students University of Chicago Pritzker School of Medicine
Text of presentation at the University of Illinois College of Medicine at the Academy for Excellence in Teaching on April 18, 2001

Why is that that you should consider yourself a teacher in your role as an advisor; why should your interactions with your students be viewed as a form of teaching? This is the challenge that Dean Hammett has asked me to take on in my discussion with you today.

The literature states that advising is an extension of teaching outside the classroom and, as such, is the key element in student retention, satisfaction and progress to degree. Let's look at the role of the teacher and for a minute think about the most salient aspects of the job. I believe that a teacher's interest and encouragement plays a crucial role in motivating students to reach beyond self-imposed limits.

Participating in the give and take of a learning experience under the guidance of a knowledgeable teacher is central to helping students understand an educational and career path that often appears littered with potholes and imminent danger. A sage advisor can help smooth that terrain a bit by pointing out guideposts along the way. Whether you teach your students using skills you acquired in professional development seminars, or through self-education, experience and honed judgment, this knowledge has undoubtedly proven highly beneficial. However, what students will most remember is your attitude toward them and toward the issues they bring to the table for discussion. In my experience of 30 years teaching and advising, I fully believe that what each student typically seeks in his or her interactions with an advisor is the opportunity for personal discovery. In a meandering conversation, full of intriguing tangents and autobiographical asides, the pitfalls of going nowhere during an advisory session certainly exist. However, if you always keep in mind that you and each student hold a common educational goal and that with sustained interaction, the goal can and will be reached. This is the heart of any teaching experience. Through this one-on-one interaction, you offer students the best opportunity to more fully explore their gifts, as well as guidance toward overcoming weaknesses that might hamper them. Teaching through your advisory capacity in this way induces students to demand more of themselves, leads them to new ways of solving problems, and awakens unsuspected talents.

I recently came across a statement that speaks volumes to me in my capacity as a teacher. "Teaching is like dropping ideas into the letter box of the human subconscious. You know when they are posted, but you never know when they will be received or in what form." Offering sound advice based upon personal educational goals and values can be a powerful force for students as they traverse through medical school. I believe that the job of advising is one of the singular most important functions that we perform in our medical centers in terms of producing competent, caring and productive physicians.

I am sure you have all had the experience of making what seemed to you a remarkably simple suggestion to a student during an advising session, then later you found out that this statement had a profound effect on the student. A thoughtful exchange of ideas and possibilities may serve as a seed to your student in generating new ideas, opening new avenues of exploration, gaining insights into his or her value system, garnering courage to dare or to change. If you have an opportunity to speak with graduates who have gained a few years experience in practice, ask them who or what they remember most from their tenure in medical school. I can bet that it won't be how great such and such a class was, but that it will be a person or persons who cared about them, helped them grow and change to become who they are today.

In preparation for this presentation, I came across a quote in a book entitled Universal Higher Education, and I thought to myself, this same statement could just as easily apply to our teaching goals for medical students. "The critical component of education attempts to expose students to multiple and conflicting perspectives on themselves and their society in order to test and challenge their previously unexamined assumptions. It strives to create conditions, that stimulate students intellectual, moral, and emotional growth so that they may ground their skills in a more mature, humane framework of values. Critical education deliberately tries to stimulate the student to re-formulate his goals, his cognitive map of the world, the way he thinks, and his view of his role in society." This statement resonates with my belief in that it serves to challenge each of us, whether faculty member or student, to move from an easier route of complacency to one of action.

Taking action provides its own set of basic challenges. The world of academic medicine for today s basic scientists and physicians has taken unprecedented leaps in terms of complexity and individual demands. And those of you who have worked with young medical students over a period of years also realize that today s student population has changed tremendously. For nearly two decades, we have been enrolling an ever-increasing number of students from diverse cultural, ethnic and educational backgrounds, and from a wider range of ages and a gender distribution more representative of society. You have also probably noticed a vast difference in students societal values and beliefs. From my vantage point, counseling students 20 years ago was much easier than it is today. Should this fact dissuade faculty from putting forth their utmost effort to offer wise counsel and advice? I hope not.

Rather, we must impress upon our students that in order to achieve the greatest gain, they should enter the advisory relationship with a questioning attitude, a desire to learn, and the courage to understand their own values and goals. And that if they have this dedication, we will be in a position to give them our best guidance toward overcoming obstacles and setting goals for their professional lives. I would encourage you at the end of any advising session to ask your student, "Now that we have had this conversation, what do you see as your job until we meet again?" The engaged student stands to benefit by learning new modes of thinking and new ways of solving problems that extend beyond the advisory sessions.

I am sure you have all heard it said that teaching is an art and not a science, yet every artist needs a grounding in technique before setting to work, and no artist or teacher in the world can afford to lose an opportunity to improve her skills. In the advising roles that you have been asked to assume, I would like to spend the remainder of the time talking briefly about those that are delineated in the 2001 Faculty Advisor Handbook. I'll touch upon some of the skills needed and the subtleties that can impede your transmission of these skills to students.

Professional Role Modeling
The first category, professional role modeling, offers the following description: "Clinical and basic science faculty provide students a glimpse into their profession, and can offer both inspiration and clarification about the choice of a professional life in a discipline."

On the surface, this sounds straightforward and simple. Of course most advisors would like to be viewed as good professional role models, and each of us would hope at times to inspire our students. Providing "a glimpse into their profession," however, may prove daunting. Understanding the role of the physician in today's changing field of medicine is a Herculean task, let alone attempting to speculate upon the future of medicine. The transformation that is occurring in medicine has in many respects, shaped the medical schools curriculum. For the student, there is more of everything to learn, a much expanded range of possibilities for career options in both science and medicine, and the role that medical informatics is and will play in the future has only begun to be foretold. You may think that to succeed in informing your students about changes in medicine and science, you not only need huge amounts of information, but a crystal ball. Yes, you do need to keep abreast of changes, but even more importantly, you must maintain a positive outlook regarding these changes. I can assure you that most students focus on the attitude that an advisor or teacher conveys toward change. And right after that, they will be listening for the degree of optimism with which you express your thoughts about their futures. From this perspective, you can encourage students to explore opportunities on all of the various levels these changes create to utilize their MD degrees in finding the right career niche.

In truth, there is nothing more crucial to the renewal of the profession of medicine than the effectiveness and capacity, the quality and vitality of the human beings flowing into the system. These young people will venture forth and replace current physicians. They will create the future. Given that reality, the task that falls to us as advisors and teachers cannot be overstated. We can aid our students by removing as many impediments as possible to their professional development, and we can assist each one of them to grow to full stature, instilled with the inherent value of the profession.

If you asked a medical student, What do you look for in a role model? what do you suppose she would say? Although the response may differ depending on the age, gender and background of the individual, I have found that most students will name the same character traits: honesty, respect, caring, compassion, sensitivity and the ability to listen. An important subtlety in the question of what constitutes a good role model lies in the societal values that students identify as important. What do I mean by this?

In the early 80 s considerable research was done that indicated a shift in our societal value system in the United States, and how this shift would shape our society in this new millennium. After two hundred years, the Christian work ethic, delayed gratification and unremitting toil model began to move aside to be replaced by greater emphasis on expanding personal choices of lifestyle by greater tolerance and less emphasis on sacrifice for its own sake. In other words, the self-denial ethic that once ruled American life was being replaced by an ethic that encompassed self-gratification first and foremost. While this new value system has introduced its challenges in teaching and advising, students feel that it provides them a world of possibilities. The downside of this is that with this panoply of options, it makes it much more difficult to choose, because the perception is that landing on one option now forecloses other choices. Part of the complicated nature of all this is that students have set the goal of achieving well in their careers, while at the same time having quality relationships with family and friends. This noble goal of having it all is admirable, but observing students trying to make this work is part of challenge that comes to us as teachers and advisors.

Now those of us who grew up under the Christian work ethic may be quick to criticize this generation s value system. However, I think we have to admit that in many respects it is healthier to be less constrained by choices and to have time for family and friends. But the idea that they can have it all has and is creating enormous conflicts for students. Many come to medical school with a certain mind-set that they can balance a career and personal life without the kind of sacrifice made by the previous generation. In my experience, students suffer serious ambiguity today as they search for that perfect specialty that will allow them to do it all. We are only now coming into a time when the effects of these changes in values are being expressed at the residency level. We have almost no data from the residency side to ascertain how programs are coping with the values that students bring and its impact on choices they are making. What we hear from program directors is that our graduates appear much more stressed, and that they have had to find ways to alter programs to help residents cope. Is this bad? I don t think so. Is it a big change? I think we would all have to echo a resounding yes. So what should our role as teachers and advisors be as students seek to make this all work? While telling them what you did in your life and how you have found balance may help, then again it may not.

Student Advocacy
Moving on to student advocacy, the opening sentence under this role responsibility from your advisor handbook states, "Faculty serve as the first line of defense in assisting students to navigate the College of Medicine curriculum." This translates into a tall order and a challenging goal for the serious minded advisor.

In my estimation, we cannot afford to simply provide passive allegiance to students. Young people entering our medical schools now do so at a time when the values underpinning their professional development have become rather hazy and less clearly articulated. As medical educators, we fully realize that the medical school environment serves in many ways as an incubator of professionalism, but rarely do we examine it. Fred Hafferty made this statement in his article in 1998 entitled, "Beyond Curriculum Reform: Confronting Medicine s Hidden Curriculum." As you get feedback from students about their experiences in medical school, I am certain that you hear their own struggles in trying to determine what it means to become a professional. Sprinkled among their comments you likely heard them relate particular examples of less than professional behavior that they witnessed or were subjected to. Student mistreatment has become a topic of much discussion in medical schools, along with ethical issues that arise in both pre-clerkship and clerkship years. Appropriate advocacy on the part of a trusting faculty member relevant to personal development can be tremendously beneficial to a student during this time of transition.

The core value system emphasizing service and quality care for patients as a central focus in discussions by our academic leaders has been sorely challenged during the 1990 s as health care reform has unfolded. Many would claim that a significant distortion of the original mission of the teaching hospital has occurred, not that there is less emphasis on the importance of service and quality care for the patients, but the time for faculty in emphasizing these important elements has been eroded. Attend any clinical chairmen s meeting and you will most certainly witness an intense concentration on the business aspects of the medical school and its role as a profit center, almost to the exclusion of other issues. As far as discussions about the education of medical students in the hospitals, you would be unlikely to hear a great deal.

In society, when people are torn loose from the context of community and shared values and the framework appears to disintegrate, individuals often experience it as a loss of meaning and a sense of powerlessness sets in. I would also contend that an inward focus develops and the focus on self-interest prevails. While we all value individuality, self-reliance, self-discipline and self-help, it becomes all the more critical that faculty rise above the chaos in our academic medical centers and lend clarity to their voices. It is you who will likely understand what is happening and why a student might be confused and exhibiting a sense of not belonging in this profession. It is you who can help the student maintain some degree of altruism. Students entered their medical school with great expectations of their faculty and advisors, and they need your help in finding others who believe in them and who want to see them achieve the highest level of professionalism.

For you as faculty, student advocacy does not come without a price. At times, it can be extremely difficult to ferret out a student s real issues among the many questions and concerns they relate to you. After 30 years as a faculty member, and 28 of those as a dean, I have found that my greatest reward has been in coming to know students in the truest sense. This is what really matters to them and to me. As educators, most of us understand that helping students realize their full potential is and must always be central to the student-advisor relationship.

Personal Counseling
Your workbook further states: "Faculty are critical in identifying student needs and providing the feedback and support necessary for academic success." This essential component in the role of an advisor can be the most trying directive in attempting to execute it well. For all medical students, success in the academic realm overshadows all other developmental aspects of professionalism. Without evidence of competence, the student has the potential to be dismissed. Figuring out how students learn and providing the appropriate help to overcome difficulties serves as a primary focus in these interactions. If a student relates to you that she has difficulties with standardized examinations, how can you best help her to overcome this significant obstacle? Another even more problematic situation involves a student who describes himself as a "slow reader," because English is his second language. Aware that this does not qualify as a learning disability, he asks you for help in dealing with this problem. What would you do? Then there s the student who tells you that she prefers to do her academic work alone, and doesn t need to be part of a study group -- yet she's failing? How do you convince this student that learning from and with others will prove to be a critical skill in the profession she has chosen?

When a student acknowledges that he has an academic problem and needs to take some kind of action, it becomes imperative for an advisor to listen and to detract the student from believing the worst about his situation, which is what most students tend to do. As an advisor, you must first provide an environment conducive to a meaningful exchange, and then serve as a confidant. If, in your capacity as an advisor, you have full awareness of your own instructional and interpersonal strengths, you will be able to easily determine whether you can help a student directly or whether triaging the student to another source might be necessary. In either case, you have provided evidence to the student of your caring and commitment. A key factor in your commitment to students is accessibility making yourself time available to deal with student problems as they arise, rather than attempting to fit them into a rigid schedule. Teaching professionalism and broadening the students knowledge as to methods of coping and instilling strategies for dealing with stress will give them a solid basis for problem solving. Other critical components in personal counseling involve demonstrating responsiveness to the degree of a student's understanding of an issue, fostering responsibility, treating each student impartially, respecting divergent views and enhancing self-esteem.

Career Guidance
The handbook states that "all faculty can assist students in the process of self-assessment and clarification of personal goals which are essential to good career planning." Twenty years ago, this aspect of advising provoked little anxiety among either students or faculty. Students selection of a specialty flowed logically out of their curriculum sequence. Because the residency selection process was not as high powered and high-pressured as it is today, the student stress level was markedly lower. Then a series of events occurred: the balance of positions and candidates began to shift, students choices of specialties started to change, fill rates of residency programs on match day approached 99%, leaving few or no choices for those students who failed to engage in the process correctly. Consequently, career advising shifted from being centered in the third year, to beginning in earnest with entrance into medical school. Many medical educators feel that much of the residency selection process is out of control, that politics play too large a part, and that Dean s Letters need a major overhaul in order to increase their usefulness.

Coupled with changes at the residency level, students have migrated to the so-called "lifestyle" specialties in droves in the last few years. Many of these specialties, such as dermatology, have only one or two positions in each of the programs, thus forcing students to apply to some 30-50 programs. If a student goes on 20 interviews, this may seem like a lot. Considering that this is probably fewer than 40 positions nationwide that the student is vying for, it represents a major gamble to achieving this career path. If this is your student and his academic record raises questions as to whether he is strong enough to qualify for one of these highly competitive specialties (i.e. if his USMLE Step I score falls below 210), you might ask, "So, what would you like to choose as a back-up specialty?" If the second or third choices are other so-called lifestyle options, such as radiology or radiation oncology, you know you re in trouble with counseling this student, since these are now among the most competitive specialty choices today. Of course many of these specialties require a transitional year, which is becoming very competitive as well. Indicating to the student that he should list a transitional at the end of his primary list of the advanced specialties and apply again during the PGY 1 year is not really a viable option for becoming the specialist that he hopes to be. For the first time this year, I experienced students being turned away for interviews from transitional programs because their board scores were not high enough. So if you are counseling a good, solid student, there is a likelihood that you could be advising this student to apply to 60 or more programs, with the hope of interviews in 25 or so of the advanced and transitional year programs combined. It is not difficult to fast-forward to the expenditures by the student in the thousands of dollars bracket, and one can only hope that the final outcome is what is desired.

The time investment for the residency selection process not only complicates the medical education of the student, but the advisor system as well. During the interview frenzy from November to February, you had hopes that your student might spend time self-reflecting and analyzing his strengths and weaknesses in order to better understand his values and beliefs, develop affirmation for commitment to his specialty choice through this self-knowledge and to leave the school well informed about his greatest personal strengths. You had also hoped to invest more time in talking about what might constitute a balanced life and to help him develop a realistic perspective on what might lie ahead. You feel very challenged in doing the best job given the circumstances that have evolved over time. Are there any ready solutions on the horizon? I haven't seen them, but creative efforts will need to be expended in finding ways to relate to your students.

Being an advisor is serious business. To do it well takes time time to keep abreast of changes in the medical field, to attend workshops or other educational venues, and to gain knowledge and skills through every possible means. Most importantly, it takes time to learn to know every student you teach. And remember, attitude is everything; maintaining optimism and perceiving career possibilities for every student in a field that he or she wishes to consider may prove your greatest challenge. As I have said before, successfully guiding, motivating and shaping young professionals requires a strong desire to make a difference in the young lives of medical students.

That's it then, that's all it takes: dedication, time, and optimism and you will attain great success as a teacher and advisor. I wish you the very best.