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Courage in Medical Education: Cultivating Stories for Change

Sklar, David P. MD; Hafferty, Frederic W. PhD

doi: 10.1097/ACM.0000000000002906
From the Editor

Editor-in-chief, Academic Medicine

Professor of medical education, Mayo Clinic

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

As I was contemplating possibilities for my final 2 editorials for Academic Medicine, I had a conversation with Fred Hafferty—one of the journal’s editorial board members and an outstanding journal reviewer—about how to make the most of these last opportunities to speak to the journal’s readers as editor-in-chief. He offered to help me think about this and began by working with me to examine all the editorials I had written. Our initial conclusion was that after 7 years, I had pretty much covered the landscape of medical education.

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Tough Problems

We also noted, and disconcertingly so, how little progress had been made on so many of the topics. Some of the problems described in the editorials seem beyond our community’s control, like the federal health policy changes that have altered provisions of the Affordable Care Act over the past 3 years. Those changes have given mixed signals about how much direction and support the government intends to give the health care system, which in turn makes it harder to predict what medical education could do to prepare our graduates for the changes coming down the road. Will the government play an active role in creating innovative alternative models to fee-for-service, or will it be more passive and allow the marketplace to determine the configuration of integrated systems of physicians, hospitals, and insurance companies? Moses et al1 describe how difficult it will be for integrated health systems to be successful in an environment that has conflicting financial incentives for population management, chronic care, and acute care.

There are, however, other problems that are clearly ours to solve, such as the selection and preparation of a diverse and interprofessional health workforce that will meet the needs of our population, a topic that I discussed in 3 editorials.2–4 We continue to struggle with what is fair and effective in aligning our trainees with the communities they will serve.

We also struggle with medical errors associated with poorly designed and managed health systems and inadequate education and supervision of residents and students. We tout the artificial intelligence capabilities of big data systems that should be able to improve our diagnostic capabilities, and we praise the improvements in hospital processes and simulation technology. And yet, in spite of these advances, medical error as a cause of death has probably not been substantially reduced since it was addressed in an Institute of Medicine report in 1999.5–7 While systems changes may be difficult for medical educators to make, teaching the diagnostic process in a way that trains students to avoid diagnostic error is a central responsibility of medical education.8

Similarly obdurate has been the scourge of resident and student abuse, which is part of the larger topic of wellness—an aspiration that seeks to prevent the tragedies of depression, suicide, divorce, and resident and student stresses related to pregnancies and support of families. We found 4 of my editorials9–12 that addressed various aspects of these problems over the past 5 years, and while there have been national and international meetings to discuss these topics, progress over that time has been sporadic at best. We believe that our local and national academic organizations could have done more.

In this issue of Academic Medicine, several more articles13–16 add to the growing literature about 1 vulnerable group: those residents and students who wish to combine a family with medical training. Some of these authors13,14 emphasize the need for stronger and more consistent family leave policies. And Worthington et al15 call for standardized family leave policies, urging the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties to

work collaboratively and lead the way in updating residency training guidelines to create a standard policy for a minimum paid parental leave period . . . to allow residents to take at least 8 weeks of leave without having to extend training for an additional year or becoming ineligible to sit for board certification exams.

Similarly, Webb et al16 note that despite years of discussion and dialogue, parental leave policies for undergraduate and graduate medical students “lack standardization, and are currently ill defined and inadequate.” The authors suggest implementing more parent-friendly curricular innovations, adopting standardized parental leave options, and having more flexible approaches to medical school graduation requirements and to eligibility for specialty board examinations.

While there is plenty of blame to go around for our lack of progress in all of these and several more areas, blaming gets us nowhere. Instead, we need to explore how we in academic medicine might find the incentives and motivations to do better and take the necessary bold steps into the future. But even when such incentives and motivations exist, we find that there are 2 factors that prevent us from acting: fear and complacency. Fear prevents us from admitting the truth about important problems like abuse, errors, or discrimination because acknowledging these truths might force us to take costly or uncomfortable actions—actions that themselves may have unknown or uncertain effects on ourselves or on our institutions. Complacency is intellectual laziness and acceptance of the status quo because it is easier for us than the alternatives. As Souba and Souba17 explain:

At its essence, reform or institutional change is about people; it is imagined by people, led by people, wrought by people, and can be thwarted by people. Because most of us are risk averse, we tend to resist adopting new ways of being, thinking, and acting.

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Need for a Different Mindset

Change, however, requires a different mindset, one that focuses on the needs of others and that embodies a vision—bolstered by courage—to move beyond fear and complacency and go where we need to go.

Are there ways to help people to overcome the fear and complacency that cause us to resist change? Are there ways to instill a different, more courageous mindset? Franco et al18 have studied heroism, altruism, and courage and suggested several different types of heroic acts that occur in military, civilian, public, and private spaces. They note that while there are some extraordinary people who perform heroic acts, most of those who do so are ordinary people thrust into situations that compel them to do extraordinary things. They suggest that societies can increase the potential of heroic behaviors when situations call for them by fostering a heroic imagination, which is

a mindset or a collection of attitudes about helping others in need, beginning with caring for others in a compassionate way, but also moving toward a willingness to sacrifice or take risks on behalf of others or in defense of a moral cause. . . . Every person has the potential to act heroically.

Press19 reinforces the idea that social connections and support from like-minded resisters shape both how moral courage is generated and why certain people engage in risky forms of dissent.

There are 2 manifestations of courage that are important to consider. The first occurs at the individual level, often as a spontaneous reaction to a situation that violates a deeply held belief or moral principle. For example, I am walking along a street and witness 2 individuals fighting. One is bleeding, and I am confronted with a decision requiring individual courage. Will I intervene and put myself at risk, or will I look the other way and keep on walking?

Comparable scenarios frequently occur, to different degrees, in health care as one finds out about patients whose care is delayed or neglected because of inadequate staffing or administrative errors. Will I get involved? If I am in a position of power, the risk may be minimal. But what if I am a medical student or nurse? Here, the risk may be far more significant. Dwyer and Faber-Langendoen20 describe an exercise in which students were required to speak up when they noticed problematic situations in their third-year clerkships in which patient care could be improved or when they observed unprofessional behaviors. After the exercise, the authors reported that speaking up had often improved care and that most students felt that the exercise would encourage them to speak up in the future. However, 12 students of 111 experienced negative reactions from speaking up, including 1 student who received negative comments on an evaluation. The authors believed that a combination of supportive institutional culture and development of habits of speaking up should be encouraged. We believe this approach is consistent with creating a heroic imagination.

The second type of courage is organizational. While organizations can be thought of as representing the net actions of the individuals within them, organizations also create value structures and priorities that protect the organizations’ interests. Like financial performance metrics, sometimes short-term results can place longer-term interests in the shadows.

Resident abuse and the need for better family leave and for improvements in learning environments to reduce burnout are examples of problems linked to an institution’s longer-term interests. All health professions organizations would declare support for eliminating these and other problems but might hesitate when the substantial consequences of making the necessary changes became clear. The question of organizational courage would occur as multiple stakeholders consider the risks of supporting an initiative that was consistent with overall organizational values but could anger critical partners. Organizational courage would be manifest if such actions were taken by the organization in spite of significant risks.

Under such circumstances, it requires courage from leadership to support such an action even if it might threaten other organizational interests. Although organizations that behave heroically are not always recognized due to the lack of transparency of organizational decision making, the importance of such courageous action is critical. Creating a community of heroic imagination that supports the development of heroic habits in leaders and stakeholders similar to those that Dwyer and Faber-Langendoen describe for medical students could be reinforced by our membership organizations, journals, and other communications networks.

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Cultivating Stories for Change

While heroic imagination may facilitate courageous decision making, there also is a need to develop a vision for the future that can motivate others. Such a vision, in turn, needs to become part of an organization’s culture. While there seem to be no shortage of targeted solutions for many of the problems outlined, we remain stymied. Could that be because a vision for change has not been translated into a story that can be widely understood and shared? Souba and Souba17 noted:

Changing people’s entrenched beliefs and behaviors, which have helped them be successful for decades, almost always requires a story about the future that engages and captivates them. That future, which is only a possibility today, must be appealing enough to draw people out of their comfort zones and accord them the necessary courage to take on the status quo.

So what are some stories that might create a cohesive and exciting vision for the future, stories that could inspire heroic imagination for us and our organizations in academic medicine? Below we have listed a few of several possible stories, stated as questions, that we believe could inspire us and our institutions and thereby give us the courage to take risks to turn them into reality.

  • What if admission to medical school was open to all who could do the work and, even more important, had a demonstrated commitment to service, with standardized tests used only to identify those applicants who lacked the minimal capabilities to succeed?
  • What if our medical education systems were built around the attributes of quality—safe, timely, effective, efficient, equitable, and patient- and learner-centered—with longitudinal relationships between faculty and students and with data resources more oriented to patient safety and error-free care rather than documentation for billing?
  • What if residency programs allocated resident time based on potential for learning, supported combining a career and a family, and (as in some European countries) had adequate staff support to limit work time to no more than 50 hours per week?
  • What if everyone who worked in a hospital or medical school, from the president or dean to the custodian or parking attendant, had to spend at least some dedicated time each week in clinical care areas with patients and families to hear their stories, which would increase their understanding of their institution’s fundamental purpose and vision and help them build a heroic mindset to inspire solutions to the problems they encounter?

Leaders need to lead, and to lead with a courage grounded in heroic imagination. Conversely, defense of the status quo is not heroic. It is strategic. Each of us needs the courage to move from ideas to action as we help each other to cultivate and circulate stories that can inspire a heroic imagination that helps us all to seize the moment when we could make a difference for the better. Each of the stories that we have presented is eminently achievable. It is for all of us to add the next line and the next line and the next line of medicine’s continuing story as a noble and courageous profession.

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