Organizational Culture and the Education of Medical Students

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Organizational Culture and the Education of
Medical Students

• Thomas S. Inui, ScM, MD
• Indiana University School of Medicine
• University of Tokyo IRCME Invited Visiting
  Professor 2000

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Basho Spoke to his Student Kikakou

• We should not abuse Gods creature,
• You must reverse your haiku.
• Not,
• a dragonfly
• remove its wings pepper tree.
• But
• a pepper tree
• add wings to it dragonfly.
• The world depends on which way this unfolds.

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Educating for Professionalism in Medicine Two
Camps
Informal Curriculum (the organizational
environment)
Formal Curriculum (the classroom)
Duty Accountability Rules
Experience Reflection Values
Measure Feedback Growth
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Educating for Professionalism (and many other
subjects) in Medicine Two Camps
Informal Curriculum (the organizational
environment)
Formal Curriculum (the classroom)
Duty Accountability Rules
Experience Reflection Values
Measure Feedback Growth
Evidence from experience, especially
about culture
Evidence from research
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Culture A Working Definition

• 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.

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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

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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
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(No Transcript)
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How do you find your food in all this darkness?
Fish What do you mean darkness?
Olfactory pit


Surface fish
Eyeless cave fish
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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.

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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.
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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

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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

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Appreciative Inquiry What is it?

• Organizational development method that involves
  interviewing and storytelling to draw out the
  best of an organizational collectives 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 collectives future
  vision

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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 peoples 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

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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

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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

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Seeing Ourselves through Fresh Eyes Student
Journals at Indiana University School of Medicine
Professionalism Competency (UME)
Students Prof. Journal Narratives
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Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Housestaff Orientation Retreats
Faculty Development
Departmental Grand Rounds
Hospital Staff Physician Meetings
Delese Wear Book Chapter
Other IUSM Courses/ clerkships Using
similar narratives
National Prof. Meeting Workshops Plenaries
Inui et al. in Wear D, Aultman JM.
Professionalism in Medicine Critical
Perspectives. Springer (New York) 2006 165-184.
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Ripples in the IUSM Pond

O.F.
N.L.
3D R.A.
CTL
C.E.
S.P.
CTL

D.T.R.
CTL
TLAC
FR
AS
CTL
LC
O.F.
PS
O.F.
NSP
SRL

SA
M.R.
IO
AP
JA
SET
SP
CC
H.F.
RRC
H.F.
6 mo
12 mo
18 mo
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AAMC Graduation Questionnaire Data IUSM,
2002-2006

• AAMC Graduate Questionnaire Trend Data, 2002-2006

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Admission ApplicantsIUSM 1997-2006
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Educating for Professionalism (and many other
subjects) in Medicine Two Camps
Informal Curriculum (the organizational
environment)
Formal Curriculum (the classroom)

Duty Accountability Rules
Experience Reflection Values
Measure Feedback Growth
Evidence from experience, especially
about culture
Evidence from research
24
Basho Spoke to his Student Kikakou

• We should not abuse Gods creature,
• You must reverse your kaiku.
• Not,
• a dragonfly
• remove its wings pepper tree.
• But
• a pepper tree
• add wings to it dragonfly.
• The world depends on which way this unfolds.