rheumatology residents’ weekend in · pdf fileuring the last weekend of january, ......

CRAJ 2007 • Volume 17, Number 14

During the last weekend of January, a “first” took

place in the Canadian rheumatology community.

Thanks to an educational grant provided to the

Canadian Council of Academic Rheumatologists

(CCAR) by Schering-Plough inc., the inaugural

National Rheumatology Residents’ Weekend was held

in Montreal. The planning and implementation com-

mittee included Dr. Ciaran Duffy (Pediatric rheumatol-

ogy, McGill University), Dr. Eric Rich (Adult rheumatol-

ogy, Université de Montréal), Dr. Nader Khalidi (Adult

rheumatology, McMaster University) and was chaired

by Dr. Heather McDonald-Blumer (Adult rheumatology,

University of Toronto).

The weekend brought together pediatric and adult

rheumatology residents from across the country along

with Program Directors and Arthritis Centre Directors

from the active rheumatology training centres across

the country. In total, there were 42 trainees, 14

Program Directors and 8 Arthritis Center Directors.

The weekend was designed to provide a forum where

everyone could get to know each other better but at the

same time learn some rheumatology. The content was

chosen from interest areas identified by the residents

within the framework of the CanMEDS competencies,

as outlined by the Royal College of Physicians and

Surgeons.

On Friday evening, everyone assembled for dinner.

Dr. Hani El-Gabalawy was our introductory speaker and

his address provided the residents with a glimpse into

the world of research. The key message appeared to be

“if at first you don't succeed, try, try again.” Dr. Janet

Pope provided perspective on the role of the Canadian

Rheumatology Association. Dr. Bookman, who was sup-

posed to address the residents on Friday evening, sat on

the tarmac in Toronto courtesy of Air Canada and

inclement weather.

On Saturday morning, Dr. Claire Bombardier (Chair

of CCAR) and Mr. John Fleming (CEO of The Arthritis

Society) offered words of welcome and provided some

perspective on how these national organizations inter-

face with Canadian rheumatologists. The remainder of

the morning was dedicated to improving our under-

standing of lupus. Dr. Tamara Grodzicky blew people

away with her “Pathogenesis of SLE” lecture which was

then followed by Dr. Joyce Rauch eloquently discussing

the “Laboratory Aspects of Antiphospholipid

Syndrome” (APS). Rounding out the clinical side, Dr.

Carl Laskin reviewed the “Clinical Aspects of APS” in his

usual mix of wit and wisdom and Dr. Earl Silverman pro-

vided insights into the world of “Neonatal Lupus,” mak-

ing it relevant for both pediatric- and adult-rheumatol-

ogy listeners. All of the lectures were erudite and won-

derfully relevant. Collectively, they provided a balance

between basic and clinical science. As Canadian

rheumatologists, it was wonderful to see the expertise

of our own colleagues showcased so beautifully.

After a quick lunch break, Saturday afternoon had

two main presentations—one on communication and

the other on practice management. Our guest presen-

ter, Myra Plotnick, captivated the entire group with her

multimedia presentation on “Risk Communication”—

the art and science of communicating effectively in sit-

uations that are of high concern or sensitive in nature.

By the end of her session, many of us were certainly

able to identify the mistakes that we make in our day-

to-day communication with patients (and will hopeful-

ly improve upon these in the future.) Dr. Gary Morris,

from Calgary, rounded out the afternoon with a step-

Rheumatology Residents’ Weekendin Montreal

By Heather McDonald-Blumer, MD, FRCPC

TOPICAL MEDICAL ISSUES

CRAJ 2007 • Volume 17, Number 1 5

by-step review of the most critical issues to consider

when setting up a rheumatology practice. Although

aimed primarily at the residents, Dr. Morris had some

wonderful pointers for everyone in the audience and

his laminated card with key diagnostic codes is sitting

on my desk and has been a useful teaching tool ever

since.

In addition to the very content-based sessions on

Saturday, Dr. Arthur Bookman (who finally made it to

Montréal late Friday night) and Dr. Ronald Laxer pro-

vided a wonderful review of how adult (AB) and pedi-

atric (RL) rheumatology have developed in Canada and

how Canadians have made such amazing contributions

to these disciplines over time.

The National Rheumatology Residents Weekend con-

tinued on Sunday morning with a national objective

structured clinical examination (OSCE). Dr. Eric Rich

had prepared a multi-station OSCE for the adult resi-

dents and Dr. Ciaran Duffy had done similarly for the

pediatric trainees. Although heading off en masse to

several of the Montréal hospitals for the OSCE felt a bit

like heading to summer camp, the residents all com-

mented on the stressfulness of the situation but felt

that the OSCE served them well by showing what they

did and didn't know. On this note, the first-ever

National Rheumatology Residents Weekend concluded.

Overall, this first-ever National Rheumatology

Residents Weekend was a wonderful event. It had a great

“feel” to it. It is my opinion that it helped foster a

greater sense of community amongst all of the partici-

pants and at the same time, provided some valuable aca-

demic content.

On a personal note, I extend my most sincere thanks to

the members of the planning committee—Dr. Khalidi,

Dr. Duffy and Dr. Rich for their wonderful contributions

and there unending support. Additionally, I must again

recognize the generosity of Schering Plough inc. for the

educational grant which made this possible. My deepest

gratitude goes to Dr. Douglas Smith, the past chair

CCAR and Dr. Claire Bombardier, the current chair for

allowing me the opportunity to be involved in this proj-

ect and for their wise counsel over the past 10 months.

Finally, thanks to all of the participants—you made it all

worthwhile.

Heather McDonald-Blumer, MD, FRCPC

Chair, Working Group

National Rheumatology Residents’ Weekend

Overall, this first-ever National

Rheumatology Residents Weekend was

a wonderful event. It had a great “feel”

to it. It is my opinion that it helped

foster a greater sense of community

amongst all of the participants and at

the same time, provided some valuable

academic content.


“I think my favorite part about Rheumatology is that youdon’t always have the right answer right in front of you. Youreally have to work to figure it out.”— Sabrina Fallavollita

“I wonder sometimes what kind of life a researcher has, thequality of life he or she has and the years of study someonehas to have to become a principle investigator...For me if Iwas going to be a researcher I would want to be a good oneand I am not ready to spend more years studying and

training and publishing... In the next few years, if everything goes well, I will be working incommunity practice, in a hospital, in a position that will allow me to have a family.”—Judith Trudeau

“I think a Rheumatology job bank would be very useful... I think knowing what positions are available along with the details isvery important: knowing whether its in an access centre, being frank about salary, how yourtime is divided, how much time would be devoted to researchand teaching. You would need to know all that information toknow if that job would be a good fit.”—Linda Hiraki

“Most rheumatologists I’ve encountered are very well-balanced.Alot of them are young women and I think its still an effort to bea woman and an academic, a researcher and a wife and amother. But I have alot of good role models that areRheumatologists who have been able to balance all of that.”—Bindee Kuriya

‘I came from Germany to complete my RheumatologyFellowship and do research in Canada.”—Heinrike Schmeling

“I didn’t choose Rheumatology as a specialty for one specificreason. There were multiple reasons. I have alot of familymembers in Rheumatology... growing up I spent alot of time with Rheumatologists”

— Jonathan Stein

“I would like to stay centralin Montreal or Quebec towork. When I wascompleting my generalrotation in InternalMedicine I did work in rural


We asked Residents about their own career choices within Rheumatology...

areas which I liked but I would stay in Montreal or Quebecwith my husband.”—Judith Trudeau

“I think it’s different for Pediatric Rheumatologists. If youwant Pediatrics to be the focus of your specialty you can’t gorural because you need to find enough children with yourdiseases. I think if you want to solely do PediatricRheumatology you can’t have a private practice for the samereason, you have to be in an access centre. Really I think ifyou are trying to be a Pediatric Rheumatologist you have to gain access to your patients.The question of how much time we divide between teaching or clincial work or researchwork, that’s the part we have flexibility with.”—Linda Hiraki

“I think there are alot of opportunities in Canada forRheumatologists. I don’t think we will ever beout of work, there’s always new trials anddevelopment... ideally in the next few years Iwould like to plan a practice so that I could workwithin a community and help alot of patientswho may not be able to reach an academic centrebut at the same time I would love to teach.”—Bindee Kuriya

“I’m from Ottawa and there’s a real focus on research for sure and not enough emphasis oncommunity work, its just not a priority in the Toronto Program. We don’t have mandatorycommunity experience... I’m definitely leaning towards community work now and in the next few years I hope to work incommunity practice in the greater Toronto area. After that I’m not sure...”—Angela Montgomery



BackgroundAccording to the ACR-REF, “arthritis, rheumatic and mus-

culoskeletal diseases…strike one in every three American

adults…and will continue to increase as our population

ages.”1 Disturbingly, as the need for rheumatologists to

care for these patients is projected to escalate, “by 2015

the number of rheumatology retirees is expected to sur-

pass the number entering the field.” Of further concern,

between the years 1996 and 2003, only 1 resident from

among the University of Minnesota (UMN) Internal

Medicine residents pursued Rheumatology, having been

accepted to the University of Washington Fellowship

Program in 1996. In contrast, in the same six year period,

other subspecialties (Infectious Diseases—7 residents,

Cardiology—22 residents) were more successful in

recruiting from the local resident pool.2 The introduction

of upgrades, highly rated by house-staff, to the UMN

Rheumatology Elective after the year 2000, such as

space for conferences and study, a personal face-to-face

orientation to the Elective, a CD-ROM of tutorials and

learning exercises, a MSK exam workshop using “patients”

from the UMN Standardized Patient Program, and an

Injection workshop using limb models equipped with

indicator lights or replenishable knee “effusion,” did not

seem to increase resident interest in Rheumatology as a

sub-specialty. This Programs’ education outcome data such

as improvement in learner post-Elective confidence levels in

procedure skills, MSK exam skills and Multiple Choice test

scores over Pre-Elective baseline measures even indicated

that educational goals were being achieved. But is the UMN

Program truly successful if local house-staff choose other

areas over Rheumatology as their sub-specialty?

The Importance of CultureReading the book “Diagnosing and Changing

Organization Culture Based on the Competing Values

Framework”3 by Drs. Kim Cameron (Professor of Higher

Education; Organizational Behavior and Human

Is Educational CultureLinked to ResidentSub-specialty Choice?By Anne Minenko, MD, FRCPC, CCD

Dr. Minenko graduated from the University of Manitoba Medical School in

1987. She completed both her Internal Medicine residency and fellowship in

Rheumatology also at the University of Manitoba, in 1991 and 1993,

respectively. In 2000, she moved from Winnipeg, Manitoba where for seven

years she practiced rheumatology in the community, to join the University of

Minnesota, and establish herself as the Division of Rheumatic and

Autoimmune Diseases’ Education Leader. In 2003, she was awarded a 3

year Clinician Scholar Educator (CSE) Award by the American College of

Rheumatology–Research and Education Foundation (ACR-REF) to study

whether educational culture might be linked to resident sub-specialty choice.

The following article is a brief summary of the Project and findings to date.

She acknowledges Dr. Kim Cameron, Professor of Higher Education;

Organizational Behavior and Human Resource Management, School of

Business, University of Michigan, for granting permission to use the

Organizational Culture Assessment Instrument©. She also acknowledges the ACR-REF, for bestowing this award upon her and in

funding the Project, for their recognition of the importance of culture to organizational success. Even after relocating from Winnipeg

to the tropics of Minnesota, she and her husband continue to enjoy winter sports.



Resource Management) and Robert Quinn, both presently

of the School of Business at the University of Michigan, was

enlightening. The authors reassure that the UMN

Rheumatology Program is not alone in its failure to imple-

ment organizational improvements, quoting a 75% failure

rate. They explain that without considering culture, imple-

mentation of new procedures, better processes, and curric-

ular revisions, are simply superficial and short term as an

organization’s values are allowed to remain the same. To

rephrase, if one wishes to implement enduring organiza-

tional improvements, then culture change is needed.

Diagnosing Culture using the OCAI©But determining what the culture is presents as a challenge

because “culture” is not synonymous with “climate” or “eth-

nicity”, as culture is occult, recognized by symbols, slogans

and leadership behaviors. So, Dr. Cameron developed and

validated the Organizational Culture Assessment

Instrument© (OCAI©) in his research of culture of over

300 institutions of higher education.4 The OCAI© is a reli-

able,5 quantitative instrument used to diagnose culture

type and to measure culture strength. It takes 5 minutes to

complete only 6 questions, each question corresponding to

one of six key attributes of organizational culture:

Dominant characteristics, Criteria for success,

Organizational glue, Strategic emphases, Employee man-

agement, and Leadership style. Respondents divide 100

points among 4 alternatives labeled A–D, each alternative

corresponding to a culture type. (See Figure 1, Question

#1. Dominant Characteristics) More points are to be

assigned to the alternative that most closely currently

resembles the organization level that is the target of change

(i.e., the Rheumatology Program). The exercise is repeated

under the PREFERRED column, imagining the organiza-

tion as highly successful (i.e., Rheumatology as the sub-spe-

cialty of choice of UMN residents). The numeric answers to

the OCAI© are then plotted on a type of radar graph, the

Competing Values Framework, which arranges four core val-

ues into competing diagonal quadrants: Clan values com-

pete with Market values, Adhocracy with Hierarchy. (See

Figures 2 and 3 Student and Faculty Responses to Question

#1 addressing the attribute of Dominant characteristics)

to view the quadrant arrangement.

A determination of culture type, culture strength, align-

ment among attributes and mismatch between current

and desired cultures can then be made. The higher the

point on the scale, the stronger the culture in that quad-

rant. A discrepancy in excess of 10 points between the

current and preferred plots identifies attributes in need

of culture change. Drs. Cameron and Quinn reference an

extensive list of their own and other’s scholarly work,

including studies of organizations in the health care

industry and institutions of higher education, in support

of the facts that organizations with strong cultures are

more effective than those with weaker ones, organizations

with culture congruency among attributes and between

current and preferred cultures are more effective than

those with incongruencies and, that culture type is the

most powerful predictor of an organization’s success.3

Of further concern, between the years

1996 and 2003, only 1 resident from

among the University of Minnesota

(UMN) Internal Medicine residents

pursued Rheumatology, having been

accepted to the University of Washington

Fellowship Program in 1996.

Figure 1.

Question #1: Dominant Characteristics Now Preferred

A The organization is a very personal place. It is like an extended family. People seem to share a lot of themselves.

B The organization is a very dynamic and entrepreneurial place. People are willing to stick their necks out and take risks.

C The organization is very results oriented. A major concern is with getting the job done. People are very competitive and achievement oriented.

D The organization is a very controlled and structured place. Formal procedures generally govern what people do.

Total 100 100


The CSE ProjectWith this new appreciation for culture, the following

hypothesis was formulated: in spite of upgrades to the

Rheumatology Program at UMN, local residents are disin-

terested in Rheumatology as a career sub-specialty because

the existing (undesired) culture is overly oriented towards

efficiency, structure and achievement of measurable

results. For Rheumatology to become the sub-specialty of

choice to UMN residents, culturally, the Program might

need to become more oriented towards personal develop-

ment, mentorship, and participation. This CSE Project

proposed to perform a “culture needs assessment” and to

determine the current and desired cultures of the

Rheumatology Program at the University of Minnesota.

Between March 2004 and June 2006, the OCAI© was

completed by 12 of 19 medical students at the end of

their 3 week UMN Rheumatology Elective, 6/18 Internal

Medicine residents at the end of their 4 week

Rheumatology rotation and 4/5 UMN Rheumatology

Clinical Faculty once in 2006. Of the 18 residents who

rotated through Rheumatology, 2/3 either didn’t com-

plete the OCAI© or their 4 week rotation was abbreviat-

ed by vacation or the need to involuntarily fill inpatient

service vacancies. One of the six residents who completed

the full 4 week rotation went on to pursue Rheumatology.

Results to date First the responses by house-staff and faculty to each of

the 6 attribute questions were reviewed. Figures 2 and 3,

respectively, represent the student and faculty responses

to e.g. Question #1 assessing the attribute of Dominant

characteristics. Each 4 point plot represents a single

respondent’s answers. Presently, for this attribute, students

perceive an orientation towards Hierarchy and secondari-

ly, Market, but they prefer Clan and secondarily, Adhocracy.

In contrast, for this attribute, Faculty presently see a strong

orientation towards Market, but they prefer a strong

Adhocracy and secondary Clan and Market balance.


...organizations with strong cultures are

more effective than those with weaker

ones, organizations with culture

congruency among attributes and

between current and preferred cultures

are more effective than those with

incongruencies and, that culture type is

the most powerful predictor of an

organization’s success.3

Figure 2 . Organizational Culture Attribute of Dominant Characteristics

Clan

Market

Hierarchy Adhocracy

Student responses (n = 12)

Hierarchy: emphasis on structure and efficiency

Adhocracy: emphasis on creativity and innovation

Clan: emphasis on mentorship and teamwork

Market: emphasis on competition and productivity


Next, the collective responses by house-staff and fac-

ulty to all 6 questions were superimposed to look for

alignment among the key culture attributes. Figures 4

and 5 represent the resident and faculty responses,

respectively. Each 4 point plot represents a single

attribute. According to the residents, presently there is

neither congruency among the attribute culture pro-

files, nor between the current and preferred responses.

For example, they perceive Leadership style to be

strongly oriented towards Clan, but Organizational glue

towards Hierarchy. However, uniformly among the key

attributes, residents have a preference for a strong Clan

culture and secondary Adhocracy, with some variation

in strength, depending on the attribute. Like the resi-

dents, according to the collective faculty responses,

presently there is neither congruency among the attrib-

Figure 3 . Organization Culture Attribute of Dominant Characteristics

Clan

Market

Hierarchy Adhocracy

Faculty responses (n = 4)

Hierarchy: emphasis on structure and efficiency

Adhocracy: emphasis on creativity and innovation

Clan: emphasis on mentorship and teamwork

Market: emphasis on competition and productivity

Figure 4 . Determination of Alignment Among Attributes

Clan

Market

Hierarchy Adhocracy

OCAI© plot for residents (n = 6)


ute culture profiles, nor between the current and pre-

ferred responses. For example, Faculty perceive Dominant

characteristics to be strongly oriented towards Market,

Leadership style, Organizational glue towards Hierarchy, but

Employee management balanced between Clan and

Adhocracy. Once again, for Faculty, there is alignment

among attributes’ preferred culture profiles. However, unlike

house-staff, Faculty prefer a strong culture balanced among

Adhocracy, Clan and Market.

Figure 6 plots the calculated dominant culture types

from the responses of the one resident who chose

Rheumatology as a sub-specialty. Important to the deter-

mination of organizational effectiveness, there is a clear

match between the current and preferred culture profiles,

specifically a strong Clan, moderate secondary Hierarchy

and weaker Market, Adhocracy. Upon closer examination,

(plot not shown) and unique to this resident, the existing

and preferred profiles match exactly for 4 of the 6 attrib-

utes, the highest degree of attribute congruency of all the

respondents.

Development of a PlanTo date, house-staff and Rheumatology Faculty respons-

es to the “culture needs assessment” of this specific US

Program suggest that fellows are more likely to be

recruited from the local resident pool if the Program was

to develop a strong CLAN, and secondary ADHOCRACY

cultures for all 6 key attributes. Therefore, along with

programmatic improvements, the UMN Rheumatology

Faculty should give priority and focused attention to

developing their Clan and Adhocracy managerial com-

petencies. Examples of Clan quadrant skills include

clearly stating expectations for performance, turning

students into teachers, and ensuring learner tasks have

variety, identity, significance, autonomy and feedback.

Examples of Adhocracy quadrant skills include celebrat-

ing trial and error learning, showing off underdevel-

oped, experimental ideas, measuring improvement not


Figure 5 . Determination of Alignment Among Attributes

Clan

Market

Hierarchy Adhocracy

OCAI© plot for residents (n = 6)

For Rheumatology to become the

sub-specialty of choice to UMN

residents, culturally, the Program might

need to become more oriented towards

personal development, mentorship and

participation.


just goal accomplishment, posting of results so that

(even small) successes are visible, and frequently com-

municating the vision of the future aloud, in written

form and in their behaviors.

According to Cameron’s and Quinn’s book, in prepar-

ing for this educational culture reorientation, the UMN

Rheumatology Faculty “should hold a discussion regard-

ing the culture that should characterize the Program in

the future and reach a consensus.” At the present time,

Faculty are examining the expectation systems that are

driving their behaviors that are perceived to be of the

(undesirable) Market and Hierarchy and are looking for

ways to alter the incentives.3

According to the responses of the one resident who pur-

sued Rheumatology, it might be possible to identify UMN

specific house-staff, who will enter a Rheumatology

Fellowship by the matching of their currently perceived cul-

ture profiles of the UMN Rheumatology Program with pre-

ferred culture profile, congruency among the 6 key attrib-

utes, and/or by his/her preference towards Clan and sec-

ondarily Hierarchy. To determine if these identifiers and

pro-recruitment culture profiles are applicable to other sub-

specialty Programs or to other institutions, plans are also

underway to expand the distribution of the OCAI© among

UMN residents rotating through other sub-specialty

Electives and to other Rheumatology Programs in this city.

Figure 6 . Determination of Dominant Culture Type

Clan

Market

Hierarchy Adhocracy

OCAI© plot for resident AD

1. ACR Research and Education Foundation. Available at: www.rheumatology.org/ref/accessed November 2006.2. University of Minnesota Internal Medicine Residency Graduate Tracking Data.3. Cameron, Kim S. and Quinn, Robert E. Diagnosing and Changing Organization CultureBased on the Competing Values Framework. Reading, MA: Addison–Wesley PublishingCompany, Inc., 1999.

4. Cameron, Kim S., Freeman, Sarah J. Cultural congruence, strength, and type:Relationships to effectiveness. Research in Organizational Change and Development1991; 5:57-73.5. Yeung, Arthur, et al. Organizational culture and human resources practices: Anempirical assessment. Research in Organizational Change and Development 1991; 5:59-81.

rheumatology residents’ weekend in · pdf fileuring the last weekend of january, ......

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