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Response to the 2012 Question of the Year


A Model for Institutional Leadership and Culture Change

Slavin, Stuart J. MD, MEd; Schindler, Debra PhD; Chibnall, John T. PhD; Fendell, Ginny MSW; Shoss, Mindy PhD

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doi: 10.1097/ACM.0b013e31826c525a
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For those who work and learn in medical schools and teaching hospitals to develop their full potential, fundamental institutional culture change needs to occur. Far too many medical students, residents, faculty, and staff not only fail to reach their potential but also suffer unnecessarily from anxiety, burnout, and depression related to the unhealthy environment in which they work.1,2 Too often, programs that address these problems are directed primarily at treating distressed individuals and fail to look at the workplace environment as a significant source of distress. Systematic efforts, spearheaded by forward-thinking institutional leadership, are needed to create healthier workplace cultures and thereby prevent mental health problems.

PERMA (Positive emotions, Engagement, Relationships, Meaning, and Achievement) was developed as a conceptual model by Martin Seligman, PhD,3 as a guide to help individuals find paths to flourishing. Seligman believes that strength in each of PERMA’s areas can help individuals find lives of happiness, fulfillment, and meaning. PERMA has also been used to develop programs that help individuals develop new cognitive and emotional tools. We believe that the model can be taken even further and used as a framework for institutional leadership and culture change to help all medical students, residents, faculty, and staff reach their full potential. Following are examples of initiatives consistent with promotion of PERMA.

Positive emotions: (1) Reduce unnecessary stressors. For example, pass/fail grading in the first two years of medical school has been shown to reduce anxiety and stress while not leading to a drop in educational outcomes. Programs to reduce non-value-added work should be supported throughout the medical and educational enterprise. (2) Introduce programs to promote resilience and coping skills. Mindfulness-based stress-reduction programs have been shown to be effective in reducing distress. (3) Transparency in decision making that includes real and meaningful input from stakeholders should be utilized whenever possible; timely and complete explanations for changes in policies and procedures should be provided.

Engagement: (1) Create opportunities for all to engage fully in their work through reduction of nonvalued work, reduction of unneeded policies, and streamlining of administrative processes. (2) Promote reflection, particularly for students and residents. Encourage learners to truly engage their patients beyond symptoms and physical findings to learn about their experience of illness; cultural beliefs; financial, social, and psychological barriers to achieving good health; and emotional, cognitive, and spiritual assets.

Relationships: (1) Create programs to increase opportunities for meaningful and productive relationships: mentorship for students, residents, and junior faculty, small-group teaching sessions at all educational levels, and development of learning communities. (2) Promote interdivisional and interdepartmental activities.

Meaning: (1) Institute programs where health care workers have the opportunity to reflect on their work, such as Schwartz rounds and Healers Arts courses, to help revitalize the values and motivations for becoming a doctor in the first place as well as combat a culture of negativism and complaint. (2) Support medical humanities programs to help students and employees find greater meaning and richness in their work.

Achievement: (1) Promote a culture of innovation and advancement. Reduce barriers to individual initiative. Avoid micromanagement; delegate to and empower employees to work to their potential. (2) Align incentives with institutional mission and values. (3) Celebrate and reward successes in achieving institutional missions and goals. Recognize humanism and generosity of spirit.

Too often, institutions have implemented “wellness” programs to promote learner, faculty, and staff well-being in relative isolation without connection to other initiatives and a culture of care. These initiatives are likely to be met with skepticism and cynicism. They can be successful only if they are part of a culture of concern and investment in human capital that is broad-based and integrated. Individuals working in the health care environment can reach their potential only if the institutional leadership is invested in creating multifaceted programs and working conditions in which individuals can truly flourish.


1. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80:1613–1622
2. Chopra SS. Physician burnout. JAMA. 2004;291:633
3. Seligman ME. Flourish: A Visionary New Understanding of Happiness and Well-Being. 2011 New York, NY Free Press
© 2012 Association of American Medical Colleges