Organizational Culture and the Education of Medical Students

1. 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

2. Basho Spoke to his Student Kikakou: We should not abuse God’s 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.

3. 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

4. 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

5. 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.

6. 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

7. 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

9. How do you find your food in all this darkness? Fish: What do you mean “darkness”? Olfactory pit Surface fish Eyeless cave fish

10. 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.

11. 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.

12. 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

13. 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

14. 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’

15. 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

16. 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

17. 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

18. Seeing Ourselves through ‘Fresh Eyes’: Student Journals at Indiana University School of Medicine Professionalism Competency (UME) Students’ Prof. Journal Narratives

19. 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.

20. * ‘Ripples in the IUSM Pond * O.F. N.L. CTL 3D R.A. C.E. S.P. CTL * TLAC CTL D.T.R. FR AS CTL LC O.F. PS NSP O.F. SRL * SA M.R. IO AP JA SP SET CC H.F. RRC H.F. 18 mo 12 mo 6 mo

21. Students Overall Satisfaction with the Quality of Their Medical Education - AAMC-GQ 100 95 90 85 iu or Agreeing 80 % of Students Strongly Agreeing national 75 70 65 60 2002 2003 2004 2005 2006 Year AAMC Graduation Questionnaire Data IUSM, 2002-2006 AAMC Graduate Questionnaire Trend Data, 2002-2006

22. Admission ApplicantsIUSM 1997-2006

23. 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 God’s 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.