organizational culture and the education of medical students thomas s. inui, scm, md indiana...
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Organizational Culture and the Education of Medical Students
Thomas S. Inui, ScM, MDIndiana University School of Medicine
University of Tokyo IRCME Invited Visiting Professor 2000
We should not abuse God’s creature,You must reverse your haiku.
Not,a dragonfly;remove its wings – pepper tree.
Buta pepper tree;add wings to it – dragonfly.
The world depends on which way this unfolds.
Basho Spoke to his Student Kikakou:
Educating for Professionalism in Medicine: Two Camps
DutyAccountability
Rules
ExperienceReflection
Values
MeasureFeedbackGrowth
Formal Curriculum(the classroom)
Informal Curriculum (the organizational environment)
DutyAccountability
Rules
ExperienceReflection
Values
MeasureFeedbackGrowth
Formal Curriculum(the classroom)
Informal Curriculum (the organizational environment)
Evidence fromresearch
Educating for Professionalism (and many other subjects) in Medicine: Two Camps
Evidence from experience, especially aboutculture
The beliefs, customs, traditions, ceremonies, standards, stories, institutions, and achievements of a particular nation, people, or group that, taken together, constitute a foundation for shared identity and meaning.
Culture in a small sense is transient, referred to as ‘popular’; culture in a deeper sense is enduring and shapes our lives, sometimes in ways that are difficult to recognize.
Culture: A Working Definition
Major features of the general culture of schools of medicine
• Belief in power of rational mind and ‘data’
• Belief in the power of science = biomedicine
• Commitment to the stance of positivistic science
• Focus on disease, pathogenesis, lesion, cure
• Emphasis on the individual, autonomy
• Belief in achieving excellence through competition and
and hierarchy - intellectual Darwinism
Cultures can be invisible to those living within them
Why do cave fish lose their eyes? Espinasa, Luis and Monika. Natural History (6) 2005: 114; 44-49
Eyeless cave fish Surface fish
Olfactory pit
How do you find your food in all this darkness? Fish: What do you mean “darkness”?
Conversations and Stories - A Shortcut to “Reading” Culture
We can recognize the culture of an organization by listening to the conversations and stories among the people who inhabit them.
The Irony and Paradox of History and Institutions
• What is most real and enduring about human institutions is not the bricks and mortar, the financial resources, or even the mission, but the conversations among the people who populate organizations and the stories these conversations transmit – from person to person and time to time.
These conversations resonate with one another, honor the past, uncover contemporary organizational currents, anticipate the future, and may serve as a guide to strategic action.
IUSM circa 2002: Sources of Distress
• The usual (budget, space) plus• Intensely bureaucratic culture• Anomie• Student/faculty/administrative rifts • Good USMLE scores, well above national
average, but student dissatisfaction with educational experience and declining applications
IUSM: The Relationship-Centered Care Initiative
• An outrageous objective – improve the culture of IUSM in order to enhance the ‘informal curriculum’
• The initial action – form a ‘Discovery Team’ and use methods of appreciative inquiry
• Uncover the organizational stories of IUSM at its best and communicate this back to the organization
Appreciative Inquiry – What is it?
Organizational development method that involves interviewing and storytelling to draw out the best of an organizational collective’s past experience. A process designed to: Facilitate the discovery of factors that give life
to an organization Change the nature of conversations in an
organization Stimulate the evolution of a collective’s ‘future
vision’
IUSM: The Relationship-Centered Care Initiative
• Stories from eighty interviews by the Discovery Team, after analysis and synthesis of themes, expressed as a ‘credo’:– The wonderment of medicine – the profound nature of
our work– The belief in people’s capacity, all people, given
freedom and support to pursue growth– The importance of connectedness – student/teacher,
clinician/patient, teams– The importance of passion – for learning, teaching,
new knowledge, innovation
IUSM: The Relationship-Centered Care Initiative
• Disseminating the stories from the eighty interviews by the Discovery Team triggered a self-directed and self-energizing process.
• Cascading engagement, none of it planned, e.g.– Student appreciative inquiry interviews– Admissions and other key committees– Executive coaching for executives– Faculty development for other leadership as change
agents
Contributions and Impact of The Relationship-Centered Care Initiative
• Introduction of new meeting formats and practices
• Cumulative engagement by a large number of individuals, especially leadership
Method Description
Checking in As a meeting starts, participants are offered an opportunity to reflect on how they’re doing at the moment or what has been going on for them outside of the meeting that might be diverting their attention.
Negotiation ofagendas
Participants help formulate and prioritize topics for the agenda at the start of a meeting.
Pairedinterviews
Participants divide into pairs to discuss an issue and then report each other’s views back to the larger group.
Appreciativedebriefing
At the end of a meeting, participants identify a moment during the meeting that was particularly useful and engaging for them
Students’ Prof. Journal
Narratives
ProfessionalismCompetency
(UME)
Seeing Ourselves through ‘Fresh Eyes’: Student Journals at Indiana University School of Medicine
Students’ Prof. Journal
Narratives
ProfessionalismCompetency
(UME)MS3
IntersessionIM Clerkship
Prof. NarrativeDialogues
HousestaffOrientation &
Retreats
HospitalStaff Physician
Meetings
Other IUSMCourses/ clerkships
Using similarnarratives
DepartmentalGrand Rounds
Faculty Development
National Prof. MeetingWorkshops &
Plenaries
Delese WearBook Chapter*
Impact of Student Journals at Indiana University School of Medicine
*Inui et al. in Wear D, Aultman JM. Professionalism in Medicine: Critical Perspectives. Springer (New York) 2006 165-184.
O.F.
O.F.
O.F.
D.T.R.
N.L. 3D R.A. C.E.
S.P.
M.R.
H.F. RRC H.F.
SET
SRL
FR
LC
CTL
CTL
CTL
CTL
CC
IO
SA
NSP
AS
PS
TLAC
AP JA SP
6 mo12 mo18 mo
‘Ripples in the IUSM Pond**
*
*
AAMC Graduate Questionnaire Trend Data, 2002-2006
AAMC Graduation Questionnaire DataIUSM, 2002-2006
Students Overall Satisfaction with the Quality of Their Medical Education - AAMC-GQ
60
65
70
75
80
85
90
95
100
2002 2003 2004 2005 2006
Year
% o
f S
tud
ents
Str
on
gly
Ag
reei
ng
o
r A
gre
ein
g
iu
national
Admission ApplicantsIUSM 1997-2006
-20%
-10%
0%
10%
20%
30%
40%
1997 1999 2001 2003 2005
Year of matriculation
Annual percent change in applications
IUSM total
IUSM non-resident
Natl total
DutyAccountability
Rules
ExperienceReflection
Values
MeasureFeedbackGrowth
Formal Curriculum(the classroom)
Informal Curriculum (the organizational environment)
Evidence fromresearch
Evidence from experience, especially aboutculture
Educating for Professionalism (and many other subjects) in Medicine: Two Camps
*
We should not abuse God’s creature,You must reverse your kaiku.
Not,a dragonfly;remove its wings – pepper tree.
Buta pepper tree;add wings to it – dragonfly.
The world depends on which way this unfolds.
Basho Spoke to his Student Kikakou: