Indiana University School of Medicine (IUSM), like all medical schools, has struggled to overcome the hidden curriculum that can undermine our best efforts to promote professional behavior among trainees.1–3 There was no specific incident that inspired us to consciously integrate professionalism into the culture at IUSM or propelled us down this road of culture change; rather, a gestalt that I would describe as a persistent “noise level” was too high. For example, our students performed well, but the Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) results showed they did not enjoy their experience compared with national data. The AAMC GQ survey also showed that our students felt they were exposed to a more adverse climate than their peers from other schools, and that our students did not bring these issues forward. When we discussed this with them, they indicated that they did not feel safe in doing so and that they believed it was unlikely we would ever take any action. We also noticed that the traditional spoof acted out by the students each year had recently become coarse and, in some instances, outright inappropriate in its attempts at humor. Lastly, I personally had become increasingly distressed at how medicine had become more of a business than a calling and at the concomitant—and appropriate—decline in esteem of our profession in the eyes of the public.
As a consequence, beginning in 2000, the IUSM executive associate deans (EADs) and I had a series of discussions in which we wrestled with the challenge of seriously addressing these issues at our school, realizing that we were talking about an effort to do nothing less than change the culture of a large organization. The easy alternative would have been to conclude that the issues that troubled us were a reflection of the times, an affliction of medicine as a whole rather than being particular to IUSM, and a mountain too high to climb in an organization as large, complex, and resource constrained as ours.
This issue caused me many sleepless nights. On the one hand, I had a strong conviction to do something that would rectify what I believed was a true threat to our profession, but on the other hand, the challenges were daunting. Ultimately, I became convinced that institutions must role model the very behavior we say we expect of our faculty, staff, and trainees. As such, we would be abrogating our responsibility if we failed to pursue culture change at IUSM. We jumped with both feet into what became a seesaw of mixed emotions. Sometimes we were suffused with excitement over a conviction that we were doing the right thing; then, we would be consumed with trepidation that a cultural overhaul would unleash unknown consequences.
Core Values and Guiding Principles
Once we decided to commence this journey of culture change, we had to decide what our first step would be. This step had to show unambiguously that culture change was the highest priority of the school. I felt strongly that we needed to formally declare our values as an institution. This values statement would then serve as our guidepost—something to which we could always refer when times got tough or when we needed recentering. In 2000, I created the first draft of what became our IUSM Core Values and Guiding Principles statement. I do not point this out to claim credit but rather to emphasize that, in my opinion, a dean’s personal involvement in such tasks underscores their importance to the institution as a whole.
The EADs offered their input about this draft, and then we sought comments and suggestions from all 25 department chairs; the entire faculty (approximately 1,300); around 950 residents, fellows, and postdoctoral trainees; and about 1,500 students. Comments were collated and incorporated through several iterations of the values statement until we had a final document that was formally approved in November 2001 by all bodies representing the school leadership, faculty, residents, and students. The document makes clear that to achieve IUSM’s mission and vision, we must have an environment grounded in professionalism. Our core values of excellence, respect, integrity, diversity, and cooperation provide the framework for this culture of professionalism. The guiding principles spell out IUSM’s expectations for such an environment. Our statement concludes with a reaffirmation that all members of the IUSM community are committed to fostering and embodying professionalism as engendered by adherence to the core values and guiding principles we collectively established (http://medicine.iu.edu/body.cfm?id=979&oTopID=979).
Importantly, because these principles are IUSM policy formally approved by the faculty, enforcement of them becomes a mandate of the faculty as opposed to a personal action by the dean and other leaders.
These principles also allow us to make our cultural expectations clear to recruits. As I interview faculty candidates, we discuss the usual expectations of productivity, but we also discuss the core values and guiding principles of our culture and the kind of faculty who “fit” at IUSM. In fact, I frequently state that an individual should not consider a position at our school unless he or she is prepared to embrace our values and role model them. When I first started doing this, I was worried that candidates would react negatively to such a philosophic discussion at a time when they were thinking about laboratory space, start-up funds, etc. I have been enormously gratified that these conversations have resulted in an overwhelming response of enthusiasm. I interpret from this response that academic medicine faculty are hungry for change and that they yearn for a culture that allows their own efforts to have more meaning. This simple act of discussing our expectations of professionalism during faculty interviews has served as an effective recruiting tool.
Criteria for Admission
Just as we have tried to prospectively enrich our faculty by hiring individuals who share our values, we have embarked on a similar effort to enrich our student body. In 2003–2004, our EAD for educational affairs (Stephen Leapman, MD) and our director of admissions at that time (Lynda Means, MD) determined with our admissions committee the qualitative attributes that we sought in our students. The committee then created a list of questions to be used in interviewing that would best explore for these attributes among applicants.
To ensure that our interviewers were sufficiently skilled and consistent in probing for these agreed-on characteristics, we created an objective structured clinical examination-like exercise in which actors were trained as students. Interviewers were videotaped, critiqued, and taught how effectively to detect the desired qualitative traits in an applicant during the course of his or her interview. Though I am sure a number of our admissions committee members may have prospectively viewed this exercise with trepidation or outright scorn, we exercised the autocratic method and forged ahead. However, the interviewers quickly became engaged, and they continue to cite this activity as an example of how progressive we are in selecting our class. We have continued to reinforce the training interviewers received by interspersing actors posing as students into the regular interviewing process. The results of the interview are a major component of the decision whether to admit. Has this initiative succeeded in promoting in our student body the professionalism and culture we seek? Of course, there is no way to know this definitively, but it is clear that the interview plays a more important role in the admissions process than it did in the past. Because of our emphasis on applicant interviews, we have rejected students with stellar academic credentials who “failed” to meet the qualitative attributes we value.
Explicitly Incorporating Professionalism into the Curriculum
In addition to the prominence of professionalism in our competency-based curriculum (described recently in this journal4), we, like others, have an annual white coat ceremony that includes a lecture by a prominent faculty member that addresses professionalism in some capacity. We have also introduced a formal vertical mentoring program in which the mentoring team comprises two faculty members and at least one student from each year. Professionalism is a frequent topic of discussion of these mentoring teams. In 2005, we also established a chapter of the Gold Humanism Honor Society to recognize students nominated by their peers and faculty each year for demonstrating exemplary humanism in patient care. At graduation, where the theme of my address is always professionalism, these students who are part of the Gold Humanism Honor Society are accorded the same level of recognition as their Alpha Omega Alpha Honor Society colleagues.
We also revamped and reenergized our Teacher Learner Advocacy Committee (TLAC). This committee is the body to which a member of the IUSM community can report unprofessional behavior. The TLAC now has a rapid response team. Anonymity of individuals reporting unprofessional behavior is protected as much as possible so students and others can feel safe bringing issues to the committee. Everyone at IUSM has learned that actions will be taken to prevent unprofessional behavior and that retribution will not be tolerated. For example, a recent event reported to the TLAC resulted in our taking learners away from a senior faculty member, an action that firmly stated that hosting students on a rotation is a privilege, not an entitlement.
Relationship-Centered Care Initiative
Our Relationship-Centered Care Initiative (RCCI) is described in a recent publication in this journal4; here, I will focus on my personal impressions of the initiative. I am a convert to RCCI, which uses appreciative inquiry, a process that asks individuals to reflect on good stories and events that illustrate what is best about medicine. When initially briefed on RCCI, my first reflex was that this was too “warm and fuzzy” and that people would trivialize it no matter how well intentioned the program. Despite these misgivings, I participated in all the initial components of this program, as did the EADs, again demonstrating the priority we as the leadership placed on culture change.
To my surprise, we experienced an outpouring of truly remarkable stories that created a groundswell of pride and inspiration among participants. This response told me that there was a hunger for sharing what is right, good, and fulfilling about our profession and a frustration with the persistent negativity that envelops most academic medical centers as a result of the myriad pressures we collectively and individually encounter every day. The following story from an emergency medicine faculty member is a good example:
After stabilizing the GI bleeder and asthmatic, I have a moment to glance at my pager; seven o’clock. Four hours have passed and I haven’t glanced at the time. In the middle of the battle I realize how lucky I am. Through the alarming monitors, the squeaky gurneys, the overhead paging, the shuffling of shoes, a sense of satisfaction grows inside me. I am so fortunate to have the opportunity to spend my life with such interesting patients, from all walks of life, in their most feeble times, sharing their secrets. The challenge of making the diagnosis, treating the patient and their families, convincing consultants, addressing nursing needs, makes every day more interesting than the past. I can go home with my chin up. Despite thinking over difficult decisions, rest comes easy, as I know I gave all I could, that I have a chance to make a difference. In the cloudy whirlwind of patients, I realize the clarity of my profession.
I find stories like this inspiring. In my interactions with students, residents, and faculty, I frequently read one or more of these stories, which delivers several messages. First, leadership thinks it is important to recognize and reflect on these humanistic moments. Second, acknowledging these moments humanizes us all. Third, it emphasizes that dialogue and caring about one another are valued. Lastly, it communicates what is good about medicine.
I hope to remind deans in particular of the power of personal stories. At IUSM we now continually collect stories, and they are widely circulated. I and many others read these avidly; they give me personal strength in dealing with the issues of the day, and they help me set priorities.
I also commonly cite stories when describing IUSM to lay audiences. The response is invariably positive, as they correctly interpret our culture change as an overdue effort to right the ship of medicine.
If we are serious about valuing professionalism and the culture that we seek, we must reward it. Thus, we developed a compensation policy for the school that was formally approved, details of which vary by department. Specifically, the policy states that we value and will reward team work, professionalism, mentoring, leadership, qualitative measures of teaching, and the quality of faculty interactions with patients, referring physicians, and one another. Establishing a reward system has required us to develop ways to capture information about quality, including routine measurement of quality of teaching, regular use of patient and physician satisfaction surveys, 360-degree surveys, self-assessment instruments, etc.
By measuring the qualitative attributes of faculty performance, we indicate its value in the culture of IUSM, and, in turn, such measures allow us to reward those who exhibit quality in their everyday actions. Interestingly, our students have been strong advocates of this process. They believe that if they are to be measured and held accountable to the qualitative measures of a competency-based curriculum, faculty should be subject to the same expectations. If we are going to be appropriate role models, mustn’t we demand of ourselves behavior worthy of emulating?
The overlap of all the initiatives we have undertaken (not all of which are discussed here) is obvious, as is the thread of professionalism development that runs through them. Are there more things we should be doing? Undoubtedly, there are. We hope we are vigilant enough to recognize and implement them. Do we have any tangible evidence that all this makes any difference? Because we cannot do a controlled trial of the outcomes of our efforts, we have to depend on anecdotes. Several metrics suggest we are moving in the right direction. IUSM’s applicant pool has increased substantially more than the applicant pool nationally. When we query applicants as to why they are interested in IUSM, they tell us that they hear about and see on our Web site the programs discussed here, and they are impressed. We appoint students to all our major committees, and the number of interested applicants for these assignments has grown to the point that the students had to develop a formal interviewing process to pare the list to a manageable number. Our residency programs have seen improved “fill” rates. Faculty, though stressed by outside forces, such as National Institutes of Health funding, ever-changing clinical reimbursement challenges, and myriad other distractions out of our control, tell us, through a recent vitality survey, that we as a school are heading in the right direction.
From a personal perspective, the most consistently gratifying component of my responsibilities and day-to-day tasks has been our concentrated efforts toward culture change and professionalism. We have ambitious goals in research and in clinical care, but I have publicly stated that if we exceed those goals but fall short in our efforts in professionalism, we will have earned a very hollow victory. Many of the stories we have collected are in a file on my computer. I often open that file and read a few stories. Doing so always relaxes me, and in some cases I am overcome with emotion at what represents the very best in medicine. Let me share another of many examples:
While doing VA staffing, I had a patient who had cancer and eventually lost both kidneys, got on dialysis, and had a stroke. An Indiana farmer, he had been an extremely independent man who was now very dependent because he couldn’t speak his thoughts readily and he couldn’t drive a vehicle. He was miserable. Then he had a heart attack and was placed in the ICU. Once out, he said he never wanted to return to the ICU again and didn’t want any more therapy. I had a junior student, Chris, in his first rotation, who was very close to this patient.
While I was out of town one weekend, the patient died. Chris took it hard. He had worked with the patient and his family, mainly his daughter, to help them understand their options, both medical and nonmedical. When I came back I called the daughter, thinking she might be upset that I was gone when her father died, but she was fine. A very religious woman, she told me that her family had wondered a long time why God had allowed her dad to suffer so much and for so long, but now she knew why. She said her dad went through all that and died to make Chris a better doctor.
This story affects me profoundly. I dwell on it because it captures for me the enormous responsibility we as deans have to our patients, as leaders of our schools of medicine, and therein as guardians of our profession. How can we not pursue establishing the type of culture at each of our institutions that best fulfills these responsibilities? At IUSM, we have conducted the experiment and the results have been rewarding at all levels. By sharing our experience, I hope to reinforce in others not only that culture change can be done, but that, as we’ve known all along, it should be done.