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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. Basho Spoke to his Student Kikakou:. We should not abuse God’s creature, You must reverse your haiku. Not,

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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


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.


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


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


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.


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


How do you find your food in all this darkness?

Fish: What do you mean “darkness”?

Olfactory pit

Surface fish

Eyeless cave fish


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


Seeing Ourselves through ‘Fresh Eyes’: Student Journals at Indiana University School of Medicine

Professionalism

Competency

(UME)

Students’

Prof. Journal

Narratives


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.


*

‘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


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


Admission ApplicantsIUSM 1997-2006


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


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.


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