Teaching and Learning in Medicine

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Transformative Leadership Training in Medical

Education: A Topology

Dafna Meitar, Daniel Marom, Penelope Lusk & Adina Kalet

To cite this article: Dafna Meitar, Daniel Marom, Penelope Lusk & Adina Kalet (2024)
Transformative Leadership Training in Medical Education: A Topology, Teaching and Learning in
Medicine, 36:1, 99-106, DOI: 10.1080/10401334.2023.2215755

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Teaching and Learning in Medicine
2024, VOL. 36, NO. 1, 99–106
https://doi.org/10.1080/10401334.2023.2215755

SERIES: Philosophy in Medical Education

Action Editor: Mario Veen, PhD, Erasmus Medical Centre Rotterdam

Transformative Leadership Training in Medical Education: A Topology

Dafna Meitara,b, Daniel Maromb,c , Penelope Luskd and Adina Kaletb
a
Mandel School for Educational Leadership, Mandel Foundation, Jerusalem, Israel; bKern Institute for the Transformation of Medical
Education, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; cFaculty of Medicine, Technion Israel Institute of Technology,
Haifa, Israel; dGraduate School of Education, University of Pennsylvania, Philadelphia, Pennsylvania, USA

ABSTRACT ARTICLE HISTORY

Issue: Efforts to improve medical education often focus on optimizing technical aspects of Received 26 September 2022
teaching and learning. However, without considering the connection between the Revised 9 February 2023
pedagogical-curricular and the foundational philosophically-defined educational aims of medicine Accepted 24 April 2023
and medical education, critical system reform is unlikely. The transformation of medical education
requires leaders uniquely prepared to view medicine and medical education critically as it is KEYWORDS
and as it ought to be, and who have the capacity to lead changes aimed at overcoming the Medical education; philosophy;
evaluation; leadership training
identified gaps. This paper proposes a five-level topology to guide leaders to develop this
capacity. Evidence: Without reference to a shared understanding of a larger, more profound
philosophical vision of the ideal physician and of the educational process of “becoming” that
physician, efforts to change medical education are likely to be incremental and insufficient
rather than transformative. Such efforts may lead to frequent pedagogical-curricular reforms,
shifting evaluation models, and paradigmatic conflicts in medical education systems across
contexts. This paper describes a leadership program meant to develop transformational
educational leaders. The leadership program is built on and teaches the five-level topology we
describe here. The five levels are 1) Philosophy 2) Philosophy of Education 3) Theory of Practice
4) Implementation and 5) Evaluation. Implications: The leadership development program
exemplifies how the topology can be implemented as a framework to foster transformation in
medical education. The topology is a metaphor exemplified by the Mobius Strip, a continuous
and never-broken object, which reflects the ways in which the five levels are inherently
connected and reflect on each other. Medical education leadership requires deeper engagement
with paradigmatic thought to transform the field for the future.

Introduction problem at hand,” and the reflection on the “what

Medical education leaders are responsible for ensuring
future physicians cultivate a robust medical profes-
sional identity as well as master the cutting-edge
knowledge, new competencies, and technological inno-
vations emerging within the field of medicine. Despite
these transformational aims, educational leaders com-
monly focus primarily on the pragmatic level, prior-
itizing immediate needs and functioning within a
fixed paradigm. This phenomenon can be attributed
in part to the fact that many medical educators are
clinicians accustomed to decision-making in acute
circumstances. But a rational-technical problem-solving
approach attends only to proximate issues, or to
superficially address issues, and may ignore the under-
lying assumptions that impact the definition of “the
for” and “why” questions underlying initiatives and
interventions. A common example of this phenome-
non is when educators spend a great deal of time
struggling to fit new instructional methods into exist-
ing curricular structures rather than considering the
desirability of those structures in the first place. Such
practices limit the potential of medical education to
broadly address societal health care needs.
We argue, as have others, that medical educators seeking
to effectively create change in their profession must study
and develop philosophies and theories of medicine and
medical education and be guided by them in devising
organizational, curricular, and pedagogical initiatives and
interventions.1,2 This process of medical education leader
development must include critical investigation of the phil-
osophical and paradigmatic ideas that guide the current

CONTACT Adina Kalet akalet@mcw.edu Stephen and Shelagh Roell Endowed Chair, Robert D. and Patricia E. Kern Institute for the Transformation
of Medical Education, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
© 2023 Taylor & Francis Group, LLC
100 D. MEITAR ET AL.
practice of medicine and of medical education in context,
as well as exposure to alternative paradigms and how these
translate into medical education policy and practice. On
a personal level, this undertaking requires intellectual flex-
ibility,3 the ability to move back and forth between the
world of ideas and the practical. It is our experience that
it is possible to hone a leader’s capacity to do this by
providing a supportive pedagogical framework.
We refer to such a framework—five distinct levels
on a continuum that dialectically links philosophical
ideas with educational practice—as a metaphoric
“topology.” A topology is a mathematical concept
describing a structure which maintains itself despite
constantly morphing, twisting, or stretching. A topol-
ogy describes and defines the relationships and inter-
actions between the elements of the structure. The
Mobius Strip is a classic topology. It is a single-sided
non-orientable surface that is continuously twisting
and never broken. We have employed the topology
proposed below as a method for questioning assump-
tions, engaging in rigorous dialogue, and building
transformative leadership in practice.
Conceptualizing the five-level continuum as a topology
allows us to extend the metaphor to how leaders in
medical education—as individuals and in groups—must
be trained to continuously move between the levels,
learning to detect and interrogate the philosophical
assumptions guiding the reigning paradigms of medicine
and medical education and develop more robust alter-
natives. These efforts, like all leadership efforts, should
be understood as professionally, nationally, regionally, or
institutionally specific, depending on the scope, and sub-
ject to the context of the given community or culture.
To this end, we describe the levels of the topology, share
a historical example of its application and then report
on an experimental medical educator leadership program
guided by the principles of the topology and developed
originally at the Mandel School for Educational
Leadership.4
The topology of medical education
transformation
The conceptual and methodological framework is drawn
directly from the work of Seymour Fox, Daniel Marom,
and Israel Scheffler, scholars in educational philosophy
and practitioners in the training of educational leaders.5
A first iteration of the framework was applied to cur-
riculum and pedagogy in the training of general edu-
cational leaders who were tasked with planning,
implementation, and evaluation of educational practice
in messy real-world conditions.6,7 Marom extended this
application to educational leaders in other professions
of human improvement.8,9 The five levels were then
tailored for use in the health professions education by
the authors (Marom, Meitar) as follows:
Level 1, philosophy, is the level at which philo-
sophical ideas are most abstract. At this level one poses
responses to philosophical questions relating to all
areas of human existence, knowledge, and activity. In
the context of medicine, these include questions around
health, society, and what it means to be a professional.
Questions such as: What is human health? Who deter-
mines how health is defined, attained, undermined,
and restored? Who carries the responsibility for pro-
moting and maintaining health? What ought to be the
specific roles of society, experts, and individuals and
how should they collaborate to ensure health? What
is expertise? How should experts define their role in
the promotion of health? What is learning? How does
it transpire in the context of expertise?
The ideas offered in response to these questions pro-
vide the foundations of educational practice and power
dynamics whether we explicitly discuss them or not. In
medicine, for example, health might be defined in terms
of biological longevity or quality of life. As one moves
on the continuum with each of these definitions, it will
dictate a completely different set of ideas regarding the
portrait, practice, and education of physicians. For
instance, if health is defined as biological longevity, it
follows that the most important thing is to find bio-
logical solutions for prolonging life and the role of the
physician will be to find and administer new medica-
tions or better technologies. If a human being is defined
as a social being whose aim is to thrive and flourish
in achieving social status, this conception suggests a
different, more expansive role for the physician.
The example of physician-patient communication:
level 1
Attention to ensuring masterful physician-patient
communication, an issue highly relevant to modern
medical education, is a historical (and current) exam-
ple of how the topology provides a useful leadership
lens. Many medical schools continue to struggle with
how to conceptualize and justify curricular and assess-
ment attention and time to clinical communication
skills. At this level it would be important to gain, for
example, a fundamental understanding of the biopsy-
chosocial model of medicine, a highly influential gen-
eral theory of illness and healing and the role of
human communication in facilitating health proposed,
in 1977, by George Engel, an American internist and
medical education leader.10 Such a theory provides
foundational philosophical support and guidance.

Level 2, educational philosophy, serves as the
linchpin to educational practice, as broad philosoph-
ical questions are “translated” to the level at which
the high level aims and means of the educational
endeavor are determined. Here one’s philosophy guides
one’s normative conception of education by positing
the desired outcomes and processes of education. Who
is the educated person? What is the process of mat-
uration and learning that facilitates this becoming?
When looking specifically at medical education, the
community of medical professionals and other key
stakeholders might reformulate level one ideas into a
portrait of the educated physician. Who is this physi-
cian and what are his or her virtues and values? How
does such a physician contribute to the promotion of
health as defined at level one? With whom must she
collaborate to do so and how? What is the desired
relationship and mode of interaction of this physician
with patients? How will they arrive at diagnoses, prog-
noses and administer treatments? By which subject
matters and learning experiences might such a medical
learner come to embody this portrait? What is the
process by which their learning will be internalized
and grow? Who is the ideal medical educator to train
in this manner? How ought that educator be trained?
The example of physician-patient communication:
level 2
In 1980, Engel proposed the clinical application of the
biopsychosocial model which unified biomedical and
psychosocial perspectives in patient care and empha-
sized the centrality of the physician-patient relationship
as therapeutic.11 This model impacted how medical
educators conceptualized the educated physician, as one
who must have highly sophisticated communication
skills. Engel’s work launched transformational change
in the way medical education was enacted, including
ensuring that medical educators were biopsychosocial
clinical practitioners, leading to an emphasis on sys-
tematic teaching of the medical interview as a main-
stream, not extracurricular, activity.12,13
Level 3, is described by Fox and Scheffler as “theory
of practice.” Answers to “level two” questions must be
translated by the leader into practical realities of educa-
tional practice. Therefore, they must go beyond pro-
nouncements of the larger purposes and aims of the
educational endeavor—however inspiring, clear, or imple-
mentable they may be—toward providing principles that
guide the practice of education. At this level, philosoph-
ical ideas are translated into curriculum and pedagogy,
the education of educators, the design of settings con-
ducive to learning. It is critical to emphasize that these
Teaching and Learning in Medicine 101
foundations are not defined as independent
functional-instrumental domains, but rather as applica-
tions that coherently flow from the levels one and two
ideas and direct concrete educational practice in
real-world conditions.1 Fox suggested that the process of
translation at this level can be broken down into two
separate stages: a) guiding principles in ideal conditions;
b) consciously compromising those principles in consid-
eration of specific real-world conditions.
The example of physician-patient communication:
level 3
Engel’s biopsychosocial model of medicine was directly
translated into an approach to teaching medical inter-
viewing; a program for the training of faculty to edu-
cate physicians in this mode of interviewing; textbooks
which served as the subject matter for a course on the
interview; pedagogies by which medical learners could
engage in graded supervised rehearsals of such inter-
viewing; and settings appropriate for such rehearsal.
This work was initiated in the real-world conditions
of 1950s University of Rochester School of Medicine
and Dentistry and the six hospitals in that city.a
Level 4, implementation, is concerned primarily
with carrying out guiding principles formulated at
level three in real time and place as explicit enact-
ments of those principles not simply independent
technical practices. Level 4 reflects the everyday work
of curriculum planning and faculty training, interact-
ing with learners, speaking, lecturing, modeling, scaf-
folding, supervising, remediating, providing feedback,
reading out loud, giving homework, and more. In
each of these activities, the theory-of-practice that
guides the work should be visible and explicit.
The example of physician-patient communication:
level 4
An educational system must create the complex con-
ditions that ensure that an educator teaching the med-
ical interview is able to, for instance, distinguish
between open and closed-ended questions and employ
instructional methods to ensure the learner under-
stands and internalizes why these techniques are
important and can ultimately demonstrate this skill
with finesse in live interviews.
Level 5, evaluation, is the level at which the degree
of success of the educational endeavor is determined
and areas for improvement are identified. Evaluation
includes establishing what indicators of success are
worth measuring, and guiding the interpretation of
102 D. MEITAR ET AL.
these indicators, forcing practitioners to challenge
underlying assumptions and re-assess the activity at,
and between, each of the five levels to identify flaws.
Without reference to the other levels, evaluation will
be unable to determine the degree of success and iden-
tify with precision the factors that contributed to it.
The example of physician-patient communication:
level 5
Shortcomings identified may require reevaluation at any
level of the topology for example: A student performing
below expectations in communication skills simulation
exercises may indicate a flaw in implementation such as
unclear subject matter, poor teaching or ineffective feed-
back given by actors participating in the simulations. The
student’s struggle may also be the result of a flaw in the
theory of practice (level 3), such as the choice of simu-
lation over live rehearsal with real patients to develop
communication skills. Alternatively, it may result from
the conception that becoming a doctor requires learning
communication skills at an early pre-clinical stage of
training, or that the ideal candidate for medical training
must possess the capacity to develop excellent commu-
nication skills—both level 2 (philosophy of education)
analyses. A further level 1 analysis could require ques-
tioning the assumption that health outcomes are influ-
enced by a physician’s communication skills. Of course,
one could also stick to a level 5 analysis and critique the
validity of the measurement methods to accurately eval-
uate a student’s communication ability. This evaluation
method reflects principles of “layered analysis” as a means
to interrogate the practices and outcomes of educational
endeavors.14 The biopsychosocial model and its clinical
and educational implications has been rigorously debated
for decades. Currently there are a robust set of activities
in American medical education including licensing and
accreditation requirements for medical school and resi-
dency training programs that can be traced to this lay-
ered analysis.15
The metaphor of the Mobius Strip (Figure 1) illus-
trates how each level on this continuum may act upon
the others, with leadership requiring the flexibility
and knowledge to transform the shapeshifting land-
scape of medical education.
A medical educational leadership program
based on the topology
A training program for medical educational leaders
was launched at the Mandel School for Educational
Leadership in Israel in 2018–2020, using this topology
as a central framework for both planning the program
Figure 1. The symbolic Mobius Strip, showing how the five
levels of the topology.
and as the core pedagogical lens for the program. The
motivation for developing this program was in part
due to a perceived need across all five Israeli medical
schools to modernize the curriculum and profession-
alize medical education. The need for transformational
medical education leadership was further highlighted
by the critiques of an International Review Committee
report in 2014.16 Participants in the resulting program
included 25 senior physicians and one medical educa-
tor—representing all five medical schools, various hos-
pitals, nominated and supported by their deans and
hospital administrators—in two consecutive cohorts,
each studying 30 full days over a 9 month period that
concluded with a 3 day retreat. The curriculum was
planned and facilitated by the two first authors of this
paper, who have expertise in medical education and
in education respectively (Meitar and Marom).
The portrait of a transformational medical educa-
tional leader (levels 1 and 2) was an outcome of con-
sultations among the trainers (DM, DM) with a broad
swath of representative medical education leaders,
including the deans of most Israeli medical schools.
The desired or ideal transformational medical educa-
tional leader in this context was conceptualized as a
person who develops her educational interventions
across the whole five-level continuum, is open to
simultaneously approaching medical education as it
currently exists and as it could ideally be, based on
an aspirational definition of health and medicine as
derived from learning diverse approaches such as

Engel’s biopsychosocial model of medicine among
other models (Level 1). They persistently seek to
improve the current realities in pursuit of this ideal
by articulating and translating it to both theoretical
guidelines (Level 3) and practical modes of educating
(level 4) and developing indicators to evaluate these
initiatives (Level 5). These initiatives apply not only
to frontline activities such as the planning of curric-
ular units and the training of faculty, but also to
persuading stakeholders in medical education to create
the conditions for change in accordance with this ideal.
In designing the program’s curriculum (Levels 3,4,5) the
trainers: a) formulated a set of aims for the program, the
achievement of which would cultivate medical educational
leaders with the qualities and characteristics defined in
the Level 2 portrait; b) developed curricular components
and educational experiences at Levels 3 and 4 designed
to achieve those aims; and c) defined program outcomes
at Level 5 that would signify success. Table 1 delineates
these elements, illustrating some of the ways the curric-
ulum was enacted and tailored to the local context. As
symbolized by the Mobius Strip, all program elements
were actively refined iteratively and continually.
Discussion
We have come to believe that the research-based bio-
medical paradigm adopted by medical systems has
dictated a functional-instrumental approach to medical
education at the expense of professional identity devel-
opment of doctors and career advancement for medical
educators. This system leaves little room for the intro-
duction of overarching paradigms of medicine and
medical education into the training of doctors and
medical educators. The topology is one approach to
make paradigmatic thinking central to leadership in a
way that is context-specific and built on the needs and
discourse among members of the relevant group.
In our program we investigate medical identity
formation at Level 2 as part of building a portrait of
the educated or ideal physician which of course is
grounded on earlier discussions defining health and
medicine (Level 1). The definition of professional
identity formation varies by theoretical perspective,
and most identity theorists refer generally to the “per-
son’s understanding of who he or she is, and that this
self-understanding underlies the person’s interpretation
of events, frames their motivation, and guides their
decisions and actions.”17,18(p3),19 The portrait that has
emerged from our work in the program so far is
comprehensive and integrated and does not assume
a duality between professional identity and the knowl-
edge and skills of the physician. In investigating the
Teaching and Learning in Medicine 103
nature of the ideal physician, we suggest further ques-
tions: Who is the educated community of medical
professionals? How can the role of the medical pro-
fession in society consciously preclude systemic exclu-
sion from the community?
There are many philosophical paradigms that shape
medicine and education. Therefore, there are predictable
and potentially productive tensions that impact medical
education communities of practice. We see these tensions
in our work with medical educators who often initially
bristle at our expectations that they question underlying
assumptions and consider philosophical paradigms before
jumping to the practical. Using the topology involves
moving back and forth between opposing ideas—poten-
tially paradigmatic opposition, or dialogic conflict between
participants who are engaging with the topological levels.
This is all “grist for the mill” in our discussion sessions.
Consequently, this approach allows for a very expansive
inclusivity of the voices and perspectives of the group
members. We have anecdotal reports that, the participants
in the leadership program have come to be able to facil-
itate such conversations at their home institutions. In this
way, we hope to expand the stakeholder groups (e.g.
inclusive of CEOs, policy makers, a range of community
members, trainees) included in articulating the guiding
vision for medical education at all levels of the topology.
This topology aims to subvert a form of leadership
which is top-down, or what Transformational Leadership
Theorists have termed “transactional,” to support an
approach to leadership which grows through involving
a range of voices, grappling with assumptions, and aiming
toward shared visions of what medicine should be in the
context of the society at hand.20–22 We have centered our
work on social theories of learning which emphasize
building communities of practice, bringing in theoretical
and empirical frameworks that highlight the individual
characteristics and capacities, such as emotional intelli-
gence and strategic thinking, when relevant. In our train-
ing model leadership is not perceived as being enacted
by a singular leader but is rather performed by the pro-
fessional community as a continuous reevaluation and
re-articulation of shared principles.
The topology provides a lexicon for dialogue among
physicians which provides freedom and space to
reflect on and address social issues. This dialogue is
not conflict free. However, the five-level topology pro-
vides a variety of lenses through which to help indi-
viduals in a group navigate differing values, identity
shifts, place in community, and the role of medicine.
This process, a very practical one, builds the skills
needed by transformational leaders.
There are limitations of this approach. Teaching
and implementing the topology among a group of
Table 1. The General Aims of the Program, the curricular components and educational experiences that address each of these aims, and the anticipated outcomes for participants.
Program General Aims (defined
at level 3):
• Cultivating the educational
professional identity and
practical capabilities of
transformational leaders in
medical education and
• Engaging participants in critical
appraisal of the dominant
paradigms and protocols of
medicine and medical education
through the study and
development of alternative ideal
paradigms.
• Launching medical education
initiatives based on alternative
paradigms within medical schools,
hospitals and community clinics in Educational experiences
partnership with institutional
leaders and
• Establishing a group of leaders
that will champion medical
education as an institutional
priority and lay the groundwork
for additional initiatives.
• Building a professional community Curricular Components
of medical educational leaders who • Integrative processing: aimed at connecting the various curricular components and ongoing fieldwork in- between
support one another and collectively
strengthen the voice of the medical
profession in its exchanges with
Israel’s medical systems.
• Undertaking program evaluation Curricular Components
and research on the training
innovations that enable
curricular and pedagogical
improvements and provide
evidence to stakeholders to
support institutionalization of
the program.
104
Anticipated Practical Outcomes (refined at
level 5 reflecting iteration through levels 1, 2, 3
Curricular Components/ Educational experiences (defined iteratively at level 3 and 4) and 4)
Curricular Components • Dedication to making professional development
Education studies: separate from medicine and medical education, provides an infrastructure for engaging in in medical education a priority at the
educational leadership within a medical context institutional and national level.
Medical education, real and ideal: provides a basis for critical appraisal of existing realities and the paradigm on
D. MEITAR ET AL.
which they are based and devising alternative paradigms for field initiatives aimed at change and improvement
Educational experiences
Learning how to see, plan, implement and evaluate educational practice on the continuum of the five levels through study,
observation, deliberation and exercises (based on texts from Fox et al., 2003; Marom, 2021; Schwab et al., 1978).5,9,23
Structured introductions to educational philosophy, educational planning and evaluation methodology, education of
educators, pedagogy and curriculum, professional education - (e.g., Buber’s conception of character education; Dewey’s
conception of growth; various visions of Jewish and Israeli education, curriculum and pedagogy as in Marom et al., 2018;
clinical pastoral education as in Compton, 2007; use of cognitive theory of professional development as in Kegan, 1982;
Lewin et al., 2019; Japanese Lesson Study as in Lewis, 2000).24–30
Reading and analyzing texts that inform the current and possible alternative paradigms of medicine and medical
education paradigms (i.e.: Flexner report, Carnegie 2010 report).31,32 Evaluation of different approaches to medicine
including Platonic and Maimonidean ideals, research-driven system-based biomedicine, somatically informed
biopsychosocial medicine, Illych’s notions of culturally based medicine.11,33–35
Field research (i.e. analyzing one own’s medical school’s mission statement and how it is reflected in its admission
criteria, curriculum, and evaluation); Observation (e.g., visiting and interviewing participants at a site where a educational
debriefing system is implemented); participant-observation and evaluation of medical educational events and conferences.
Workshops (remediation, reflective writing, feedback)
Meeting with international transformational education leaders in various areas of medical education (i.e. research,
comprehensive curriculum development, professionalism).
Curricular Components • Continued learning and networking among
• Humanities and leadership studies: this includes the study of philosophy, literature, poetry, Israeli culture, and graduates - independently or in partnership
context as well as inspiring and informative encounters with educational leaders in various professions. with others, to support ongoing development,
growth, and impact on the field of
• Meetings with accomplished transformative educational and social leaders from diverse social and professional backgrounds transformative educational leadership;
(i.e.: an Ultra-Orthodox woman who created a training program for educational and social leaders in her community; a Successful and inspiring institutional initiatives
young lawyer who at the time helped create the conditions for a law which improved protection for sex workers to be that advance institutional commitment to and
passed in the Israeli parliament). practice of medical education.
• Learning experiences led by inspiring teachers, intellectuals, and artists in the humanities (poets, writers, historians,
philosophers).
• Networking among graduates, stakeholders, and
others at various levels, including consultations,
sessions with a larger internalized transformative educational leadership orientation and capacity and the establishment partnerships, continuing education, and recruiting
of an ensuing community of learning and practice others to the professional community of leaders
Educational experiences and practitioners in medical education.
• Reflective exercises (i.e. journal and narrative essay writing, and peer feedback)
• Learning about the educational value of group discussion through participating in a facilitated peer group experience.
• Initiatives- seminar based on participants’ first efforts to develop field initiatives in medical education at their home institutions.
• Integrative processing group discussion at the beginning and at the end of every learning day.
• An ability to convince stakeholders to advance
• Continuous recruitment of support, interaction and learning with stakeholders in participants’ home institutions. the status of medical education and continue
Educational experiences their own learning about the field at the national
• Group exercise in convening and implementing a learning event on medical education for stakeholders from home and international levels.
institutions. • Formative and summative feedback on the
experiment that contributes to improvements in
curriculum and pedagogy and provides an evidence
base for its impact as a program serving all Israeli
medicine.

current or future leaders requires expert facilitation,
a commitment to preparation, reading and reflective
writing, and time and practice. The topology it is not
a formula. It is a lens, or logic for evaluating, trans-
lating, questioning, and reconsidering given norms and
practices in medicine. In our experience, through the
one-year leadership program, participants are not yet
able to fully engage systematically and fluidly with the
five levels, but are able to understand and identify
that paradigmatic issues are at stake in every single
question that arises in leading medicine education. We
see this ability as the first step on a long journey.
Conclusion
The topology provides guidance for the development
of transformational medical educational leaders in that
it provides a framework and language for engaged
study, dialogue, and debate that prepares them to
enact systematic change. By forging a pathway between
philosophy and practice in the context of their train-
ing, it cultivates their capacity for paradigm-sensitive
training of others down the line.2
The Mobius Strip metaphor helps us understand how
the five levels are intrinsically intertwined, and to ignore
any one level does not mean it disappears, but rather that
its meaning is missed—which makes it harder to know
exactly what one is doing, and thus harder to do it well.
We are studying the impact of the development
program based on the topology. A more detailed
description of the curriculum and pedagogy and out-
comes is forthcoming. In this work we hope to under-
stand if and how the topology helps medical
educational leaders steward the medical profession,
representing its commitments and values in dialogue
with the systems that train and employ medical prac-
titioners and within a given society-at-large to
strengthen the medical profession’s social contract.
Note
a. For a study of Engel’s translations of his ideas of bio-
psychosocial medicine to the practice of educating
students in medical interviewing, see Marom D.
Insights on medical educational leadership from the
biography of the founder of biopsychosocial medicine,
George L. Engel (Manuscript).
Acknowledgements
For their engagement in early conversations that helped for-
mulate this manuscript we thank Fabrice Jotterand, PhD,
Rachell H. Ellaway, PhD and Lara Varpio, PhD. We thank all
Teaching and Learning in Medicine 105
the participants in the Mandel School for Educational
Leadership experimental program in Transformative Leadership
in Medical Education as well as the Mandel faculty, graduates
and fellows who contributed to the effort of transformation.
Disclosure statement
The authors have no conflicts of interest to report.
Funding
The author(s) reported there is no funding associated with
the work featured in this article.
ORCID
Daniel Marom http://orcid.org/0000-0001-5136-3811
Penelope Lusk http://orcid.org/0000-0001-6202-9376
Adina Kalet http://orcid.org/0000-0003-4855-0223
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