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J Gen Intern Med. May 2004; 19(5 Pt 2): 501–504.
PMCID: PMC1492320

Toward an Informal Curriculum that Teaches Professionalism

Transforming the Social Environment of a Medical School
Anthony L Suchman, MD, MA,4,6 Penelope R Williamson, ScD,5,6 Debra K Litzelman, MD,2 Richard M Frankel, PhD,1,2,3 David L Mossbarger, MBA,1 and Thomas S Inui, ScM, MD1,2
1Received from the Regenstrief Institute for Health Care, Indianapolis, Ind
2The Indiana University School of Medicine, Indianapolis, Ind
3The Richard L. Roudebush VAMC, Indianapolis, Ind
4The University of Rochester School of Medicine and Dentistry, Rochester, NY
5The Johns Hopkins University School of Medicine, Baltimore, MD
6Relationship Centered Health Care, Rochester, NY
The Relationship-centered Care Initiative Discovery Team

Abstract

The social environment or “informal” curriculum of a medical school profoundly influences students’ values and professional identities. The Indiana University School of Medicine is seeking to foster a social environment that consistently embodies and reinforces the values of its formal competency-based curriculum. Using an appreciative narrative-based approach, we have been encouraging students, residents, and faculty to be more mindful of relationship dynamics throughout the school. As participants discover how much relational capacity already exists and how widespread is the desire for a more collaborative environment, their perceptions of the school seem to shift, evoking behavior change and hopeful expectations for the future.

Keywords: medical education, professionalism, curriculum, competencies, relationship-centered care

One of the most consequential and enduring aspects of learning to be a doctor is the formation of one's professional identity—the development of a set of personal beliefs, values, and role expectations that guide and inform virtually all subsequent behavior.1 Notwithstanding a variety of significant innovations in the formal curriculum of medical education (e.g., the white coat ceremony, small group reflection, and the articulation and assessment of specific professional competencies),24 we believe it is the social environment and the organizational structure of the medical school, the so-called “informal” and “hidden” curricula5, that have the greatest influence on identity formation. Students tend to internalize and perpetuate the patterns of behavior that surround them—the way they see people treating each other and the way they themselves are treated.1 In this report, we describe our initial experience with an institution-wide initiative to improve the social environment—and therefore the informal curriculum—of a large medical school.

Description

The Indiana University School of Medicine (IUSM), a large state school with approximately 1,100 students and 1,200 faculty, is the only medical school in Indiana. Basic sciences are taught at 9 centers around the state; clinical rotations take place primarily at 4 hospitals in Indianapolis including one public and one Veterans Health Administration hospital. Over the past 4 years, IUSM has fully implemented a new formal curriculum based on 9 competencies: effective communication; basic clinical skills; using science to guide diagnosis, management, therapeutics, and prevention; lifelong learning; self-awareness, self-care, and personal growth; the social and community contexts of health care; moral reasoning and ethical judgment; problem solving; and professionalism and role recognition. Each basic science and clinical course addresses both traditional and professionalism-related competencies.

In the present initiative, our intention is to develop an informal curriculum that consistently reinforces the values of the formal curriculum. We hope ultimately to promote mindfulness on the part of every faculty member, resident, and staff member about the values we exhibit and thereby teach in our everyday interactions. We also hope to foster a widespread practice of reflecting on and talking about interactions as they are taking place, for this is what best enables us to continually learn, adjust, repair mistakes (which are inevitable), and harness diversity. To help our students learn and change their behavior, we have committed ourselves to our own continuous learning and behavior change.

Changing patterns of interaction across an entire medical school defies linear planning and design; we do not believe that standardized prescriptive interventions, measurements, and benchmarking will work. Instead, we have adopted the nonlinear perspective of “making ripples in a pond,” envisioning our work as introducing constructive disturbances in existing patterns of interaction that other people might then adopt, modify, and propagate.6 We use an organizational change methodology known as appreciative inquiry, which focuses attention on existing capabilities and successful experiences as a foundation for creating more of what is desired.7

We began by assembling a discovery team (DT) comprised of 13 volunteers, ranging from medical students to senior faculty (some of whom helped create our competency curriculum), plus 2 external consultants (ALS and PRW). The team's task was to conduct interviews across IUSM to identify the best elements of the current informal curriculum. After interviewing each other and noticing the most frequently occurring themes in their own stories, the team members identified 3 areas of focus for the discovery interviews: meaningful experiences, exemplary collaboration, and being entrusted with important responsibilities. The team developed a semistructured 45-minute interview protocol that elicited stories on these 3 topics, and also explored what interviewees value most about IUSM, their vision for IUSM's future, and which individuals made exemplary contributions to IUSM's learning and work environment.

The DT members conducted 80 interviews between February and April 2003. They chose interviewees to maximize the diversity of voices: clinical and basic science departments; students, residents, fellows, and junior and senior faculty, administrative staff and organizational leaders; minorities; individuals who helped develop the competency curriculum and individuals who did not or were overtly skeptical. After each interview, the interviewer recorded in narrative form what (s)he judged to be the most compelling of the three stories from the interview, key themes from the other two stories, and responses to the other questions.

Once the interviews were completed, the DT reviewed the stories, identified key themes, and prepared a public presentation of their findings. This presentation—the Open Forum—was intended to enhance and extend the process of reflecting on the nature and educational impact of IUSM's social environment. Personal invitations were sent to all interviewees and to various organizational leaders. Subsequently, DT members have prepared a written version of the presentation for ad hoc distribution, and have given formal and informal presentations to various individual leaders and groups. The DT continues to meet monthly to share observations about changes in their own and others’ behavior and to help each other identify and act upon opportunities to foster change.

RESULTS

Interview Themes

Every interviewee was able to recount positive experiences; collectively, their stories involved all the principal activities of the medical school: clinical care, teaching, research, and administration. Table 1 summarizes the major themes with illustrative narratives.

Table 1
The Major Themes About IUSM at Its Best, with Illustrative Stories

What interviewees valued most about IUSM were “collegiality of kindred spirits,”“wide spectrum of people and clinical experience,”“collaborative, nonhierarchical academic community,”“encouragement for learning and personal growth,” and “commitment to caring for the people of Indiana and for the underserved.” The most frequently expressed desires for the future of IUSM were “relationship building between and among researchers, teachers, clinicians, students, and residents”; “more open space and unstructured time to allow spontaneous, informal conversation”; “a greater sense that everyone is pulling together to achieve common goals”; “more diversity in the faculty and student body”; and “interactive engagement of administration at all levels, helping with projects both large and small.”

No less striking than the content of the interviews (the stories and themes) were the interpersonal and emotional dynamics. Many interviewers reported that the interviews were uplifting and enjoyable, raising feelings of closeness, respect, joy, and hope for interviewee and interviewer alike.

Public Presentations

The uplifting nature of the individual interviews carried over into the Open Forum. Presenting the themes and stories from the interviews was like holding up a mirror to the IUSM community and reflecting back a very positive image, one that contrasted sharply with the organization's usual self-image in daily conversations that habitually focus on problems and deficiencies. These stories reminded the community of its own quality, its deep reservoirs of caring about patients, students, and colleagues, and its widely shared passion for service, learning, and discovery. One participant said, “Now that I see how good we really are, I have to ask myself why we tolerate it when people aren’t as good as this. I can’t just look on quietly anymore when people are disrespectful or hurtful. It's no longer okay to remain silent; this is too important.”

Observations of Subsequent Rippling

Table 2 illustrates the kinds of observations that DT members have reported since the Open Forum. These range from increased mindfulness about expressing praise to incorporating appreciative interviews into existing activities to an ongoing commitment by the executive deans to reflect on the relational aspects of their work.

Table 2
Examples of Changes that Discovery Team Members Have Observed in Themselves and Others Following the Public Presentations of the Discovery Interviews

DISCUSSION

This report describes our preliminary experience in a multiyear culture change project at a large medical school. Recognizing our inability to predict or control the outcome, we set forth with a method for eliciting and disseminating inspiring narratives about the informal curriculum (the social environment) at its best, with the hope that the relational patterns and values in these stories might be carried forward and amplified in ensuing interactions. Early indications suggest that this is starting to happen for the participants in the discovery interviews and Open Forum. The discovery process appears to be reengaging a sense of hope in these hundred or so participants—an enspiriting that, far from being wistful, is solidly grounded in actual capacities and successes, and inspires them to try out new behaviors. As they begin to see IUSM in a different light (as IUSM's organizational identity changes in their eyes), they begin to interact differently, which might then constitute further evidence of the new organizational identity and call forth even more of the new behaviors, thus creating the potential for a virtuous, self-reinforcing cycle.

Having observed the transformational potential of these initial conversations, our next step in the project is to engage many more participants. DT members are looking at existing forums (e.g., grand rounds), committees (e.g., admissions and promotions committees), student organizations, school-wide events, and other opportunities to encourage more people to notice and talk with each other about the way they are interacting, and to raise more generally throughout the medical school the hope and belief that the desired culture of collaboration, connectedness, passion, and wonder can truly be realized. We are also exploring two other high-leverage opportunities: the selection and orientation of new community members (students, residents, faculty, and leaders) and leadership development (programs for student leaders, new R2s and chief residents, unit chiefs, department chairs, and deans). As the project continues, we will undertake a systematic evaluation, looking for changes in students’ responses to the quantitative and qualitative components of the annual American Association of Medical Colleges Graduation Questionnaire as evidence that the informal curriculum is changing.

Two theories of organizational change inform this project. Appreciative Inquiry (AI) builds on the social constructionist insight that “reality” (how people perceive their environment) is created in conversation, and depends heavily on how attention is focused.8 Typical management conversations in organizations (like most clinical conversations) focus attention on what is wrong and how to fix it. This creates a general perception of deficiency and sets in motion a self-fulfilling dynamic of emotions (fear and shame), behaviors (defensiveness and counter-attack), and expectations (hopelessness). AI transforms that dynamic by calling attention to what is right, what is working, and how to have more of it. Expectations and behavior thus organize around a core perception of capability and hopefulness rather than deficit. AI also activates a dynamic of community building with its extensive use of storytelling.

The other theory is Complex Responsive Process (CRP), the first complexity theory developed specifically for the social sciences (other complexity models—notably Complex Adaptive Systems—come from the natural sciences or cybernetics and are applied to organizations only by analogy).6 CRP, too, focuses on conversation, describing how patterns of meaning (e.g., an organization's identity) and patterns of relating (e.g., the way people talk with each other or the breadth of participation in decision making) arise, propagate, and evolve spontaneously in the ongoing flow of human interaction. Although these patterns cannot be planned or controlled, they are susceptible to influence, albeit unpredictably. Small changes in behavior or new ideas can sometimes spread quickly and widely, transforming organizational patterns of thinking and interacting. The theory of CRP encourages organizational change agents to focus their attention not on elaborate idealized designs but rather on what is actually happening—to participate in and foster reflection on the here-and-now interactional processes of the organization, to notice what patterns are propagating and how, and to explore opportunities to act differently, thus introducing the possibility of new and potentially more desirable patterns. The theory also legitimizes not knowing and paradox, thus weaning leaders from unrealistic and anxiety-provoking expectations of control.

In summary, the recognition that the workplace and educational culture of a medical school constitutes an informal yet potent element of the curriculum has led us to undertake an organizational change project based on appreciative storytelling and reflection on action. For the hundred or so people who have participated to date, we see evidence that IUSM's organizational identity is shifting in a way that raises hope and expectations and prompts new behaviors that are consistent with the values of the formal competency-based curriculum. Our hope is that the enthusiasm and the myriad small successes unleashed thus far will grow to become a person-to-person cascade of change across the organization.

Acknowledgments

The authors wish to acknowledge the 80 interviewees who contributed their time and stories to this project and the JGIM reviewers and editors for helping us improve the clarity of the presentation.

Supported by a grant from the Fetzer Institute, Kalamazoo, MI.

Members of the Relationship-centered Care Initiative Discovery Team: Mary Alice Bell, MS, Stephen Bogdewic, PhD, Nancy Butler, MD, Ann Cottingham, MA, Margaret Gaffney, MD, Tolly Goldberg, MD, Gregory Gramelspacher, MD, Kurt Kroenke, MD, Gary Mitchell, MD, David L. Mossbarger, MBA, Bill Walsh, MD, Joann Warrick, MD, Kathleen Zoppi, PhD.

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Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine
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