AAMC Reporter: March 2006

Thomas S. Inui, Sc.M., M.D., Indiana University School of Medicine and the Regenstrief Institute for Health Care

Viewpoint: "Culture Change at Academic Medical Centers: A Pebble Drops..."

All of us lead our professional lives within academic medical centers, each with its own strong traditions, standard ways of doing things, shared language, and a context of community values/meanings/mission — in other words, organizational cultures. These cultures affect our work and what we can achieve in a myriad of ways. They also constitute a major component of the hidden (informal) curriculum that radically influences our students as they become physicians.

One of the great challenges for medical school leadership — educators, researchers, clinicians, and administrative managers — is to become explicitly aware and mindful of the pervasive influence of organizational culture and the many ways in which it manifests itself.

We live so immersed in these influences that they seem to us to be simply "the ways things are." Asking us what we think about our culture is like asking fish what they think about the water. "What is water?" ask the fish.

For three years, my colleagues and I have been engaged in a variety of activities at Indiana University School of Medicine (IUSM) intended to influence and shape our environment and the culture it expresses. We have been particularly focusing on what the students experience in our organizational environment as expressions of professional values, the foundations of our commitments in medicine.

In approaching such large-scale organizational change, we knew we could not design and "impose" a culture, nor could we "process" every member of the organization through an intervention to "change" their behavior. We abandoned these engineering metaphors and instead adopted a metaphor of ripples spreading in a pond to refer to changes in patterns of relating that would start locally and then spread. Recognizing IUSM as a good example of a complex, responsive system, we adopted a strategy of emergent design, knowing that we could design only a first step — the stone dropped in the water — and only after it was completed could we discern the next step, based on who became involved, what ideas they developed, and what they wanted to do (the "ripples").

Our first step, described in more detail in the Journal of General Internal Medicine (2004;19:501-504), was a set of 80 appreciative inquiry interviews conducted by a "discovery team" — a group of 12 student and faculty volunteers — who sought to elicit stories of work at IUSM at its best, the qualities of the people in these organizational narratives, and the circumstances that supported these qualities. The initial 80 stories were analyzed, and the stories and themes were presented to the community in a number of open forums, offered to the medical school community at large. As a positive and hopeful image of IUSM began to emerge, more volunteers stepped forward offering to bring relationship-centered interactions to their departments, committees, offices, or projects. This team now meets monthly for peer coaching and instruction on organizational change in support of dozens of projects the team members have initiated. 

The ripple effect has been striking, with the volunteer "internal change agents" now numbering greater than 160 persons. The following are a few examples of the cascading changes that have ensued:

• The admissions committee developed new criteria and new interviewing methods to select relationally oriented applicants.

• The dean includes data on the work environment in performance reviews for department chairs and conducts these reviews in a relationship-centered manner.

• A major school-wide initiative in mission-based budgeting and management was designed and implemented with the explicit intention of fostering partnership, engagement, and trust.

• Students published two books of student stories that were presented to incoming students at our White Coat Ceremony.

• A committed group of students designed an honor code that all new medical students, residents, and new faculty are required to sign.

• Widespread practices to "humanize" meetings of the standing committees of IUSM (e.g., checking in, noticing successes, and appreciative debriefings) are spreading. 

• The school's weekly newsletter, Scope, now includes a column titled "Mindfulness in Medicine" that focuses on seminal events and experiences of trainees and faculty.

• A 50-hour career development course for newly hired faculty is being offered for a third year that incorporates relationship-centered principles and emphasizes the importance of mentorship.

• A seasonal retreat series, entitled "The Courage to Lead" will be offered for the third year in a row and focuses on intense reflective and interpersonal aspects of leadership.

We seem to be tapping into a pre-existing yearning for community and the expression of professional values. The vast majority of cascading changes resulted from self-initiated efforts and not from a prior planning and strategic design. Appreciative interviews seem to initiate a "virtuous cycle."

By focusing attention on existing capacity, they build a sense of competence and confidence and foster a more positive self-image within the organization.  This creates a sense of hope, a belief that change may indeed be possible, releasing people from the constraint of low expectations and giving people the courage to try new behaviors.

As more people experience these changes, the belief in the possibility of change becomes stronger and more widespread, leading to further change, the virtuous cycle. The fish have seen the water and are schooling!

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