First we should ask, “What would a system that was designed to interfere with—rather than promote—learning look like?”
* Faculty salary and promotions would be inversely related to time spent with trainees.
* The organizational culture would be characterized by rigidly defined hierarchies (e.g., physicians > nonphysicians, subspecialists > primary care physicians).
* Selection criteria for faculty and leaders would emphasize excellence achieved in their discipline (as demonstrated, for example, by scholarly publications) over communication and team skills assessed by peers and team members.
* Everyone would operate under chronic, intense time pressure.
Regrettably, these are the very characteristics of most academic health centers (AHCs).
Along with these barriers to learning, one great advantage for trainee and organizational learning is present in AHCs: an enormous diversity of intelligent and highly educated people, most of whom are extremely motivated to make a positive difference in the world.
Given the barriers, what is most essential to helping this diverse, talented pool of faculty and learners to develop their potentials? In the siloed hierarchy of high achievers that characterizes many AHCs, I recommend a system-wide emphasis on practices that enable both speaking up about core values and the effective bridging of differences. Currently, fear of speaking up and lack of candor in AHCs are taking a costly toll. The majority of medicine and surgery department chairs report multiple “elephants” (i.e., undiscussables) in academic medicine.1 When even senior leaders are withholding questions and information, poor decisions that affect the entire AHC are inevitable.
Since conflicts are natural in competitive settings, and since differences represent sources of innovation and opportunities for learning, individuals and groups need to be skilled at making the most of them, rather than avoiding or suppressing them. People tend to overestimate the extent to which others agree with them and to underestimate the importance of how they communicate.2 Converting tough issues into ones that people can openly discuss, therefore, depends on self-awareness and on relational communication skills, such as the following three core skills:
1. Instead of just advocating a point of view, try to stimulate a dialogue and to elicit others’ perspectives. Reveal your reasoning (“This is how I arrived at this idea and why I’m raising it …”). Test assumptions (“Perhaps we’re starting from different assumptions about the goal. Here are mine…. How do you see this?”). Focus on needs and interests (“What needs of yours does this solution not address?”). Ask for help in understanding your own thinking (“I may be missing something here…. Do you have any insights?”).
2. Ask open questions to learn about others’ assumptions and goals and then listen to their answers with curiosity, rather than automatically sorting their comments into agree/disagree. Ask yourself, for example, which goals a person’s ideas might advance.
3. Notice your own inner reactions, especially when you are reacting strongly. Before responding, ask yourself, “What hooked me?” or “What assumptions of mine are at the root of this anger/dismay/agitation?”
Effective communication is hardest when people feel devalued or if some aspect of their professional identity is at stake3; the tendency is to get defensive or to disengage, thus forfeiting the possibility of dialogue. Yet these emotionally charged circumstances are the very ones for which dialogue is most important. If administrators, faculty, staff, and trainees were all to get even a little better at just one of the above capacities, the level of confidence about broaching important, sensitive subjects would increase, as would organizational learning and the discovery of shared commitments. Further, observing the skilled handling of conflicts, junior members of the academy would learn by example.
Some of my recommendations for stimulating the improvement of these capacities are as follows:
* Create interdisciplinary opportunities to practice discussing values and conflicts, beginning with the most pervasive “undiscussables.”
* Incorporate both emphasis on and practice with these skills for students and residents throughout the curriculum, and for faculty and administrators in retreats and leadership development.4
* Require all committee chairs to complete training on the effective execution of the skills required in that role: that is, in maximizing the engagement of all members and in naming the tensions the group is experiencing as they arise and placing these in a larger context.
* Place more emphasis on modeling effective listening, dialogue, and information sharing during the evaluations of senior professionals and administrators since these leaders bear special responsibility for effective communication.
* Remind health care professionals that even though practice settings differ markedly across academic medicine, the well-tuned clinical skills of careful listening and expressing empathy transfer to all settings.
People cannot bridge the differences or solve the problems that they do not talk about. Greater skill in raising difficult subjects will translate into critical improvements in both individual and organizational learning, and these improvements, in turn, will help maximize the potential of all members of the academic medicine community.
1. Souba W, Way D, Lucey C, Sedmak D, Notestine M. Elephants in academic medicine. Acad Med. 2011;86:1492–1499
2. Goulston M Just Listen: Discover the Secret to Getting Through to Absolutely Anyone.. 2010 New York, NY American Management Association
3. Stone D, Patton B, Heen S Difficult Conversations: How to Discuss What Matters Most.. 1999 New York, NY Penguin
4. Suchman AL, Sluyter DJ, Williamson PR Leading Change in Healthcare: Transforming Organizations With Complexity, Positive Psychology and Relationship-Centered Care.. 2011 London, UK Radcliffe Pub. Ltd.