Rewriting the hidden curriculum: Keeping empathy alive

Medical educators say Indiana University School of Medicine is changing the academic climate at the institution and could be creating more sensitive physicians.

By Myrle Croasdale — Posted April 24, 2006

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Southern Illinois University School of Medicine's dean, J. Kevin Dorsey, MD, PhD, remembers teaching freshmen medical students -- they seemed so idealistic, altruistic and "fresh as the driven snow."

"Then I'd go back to my practice with physicians who'd been working for 25 years, and say, 'Whoa, what happened?' " Dr. Dorsey recalls. "We come in with a full bucket of empathy, then we go through the process of acculturation, the rigors of training, and our bucket gets holes in it. When you're ready to become a doctor ... There's not much empathy left."

Dr. Dorsey is one of several medical school leaders looking for ways to keep medical students' empathy alive. And he, like a number of other deans, is looking to Indiana University School of Medicine for guidance.

Medical educators say Indiana has hit on a model of organizational change that is successfully revising its hidden curriculum from one that chews up idealistic students and spits out cynical doctors to one that produces physicians who care. The effort is being led by a cadre of IUSM faculty with the help of outside consultants, the support of the school's dean and a $2 million, three-year grant from the Fetzer Institute in Kalamazoo, Mich.

Tom Inui, MD, president and CEO of Regenstrief Institute at IUSM, is leading the effort.

"Why should we be doing this?" Dr. Inui asks. "We're accountable to have teaching done in humane environments, and it turns out that the operating room where the surgeon is swearing and throwing instruments is not a safe place for patients."

The team at IUSM is basing its efforts on a model called relationship-centered care. The idea is that it's not just physicians' relationships with patients that matter. Respecting and listening to colleagues, residents, students, support staff and even the community at large also are key.

IUSM leaders began introducing these ideas to interested faculty and students in January 2003. Among other things, they held monthly meetings with top administrators and open forums for students and staff. They sponsored leadership retreats and produced newsletters.

An estimated 1,000 people have attended at least one meeting out of a school with 1,100 students, 1,200 faculty, 1,000 residents and thousands of affiliated university and hospital employees.

Anecdotally, the values learned, such as turning confrontations into discussions or pausing to consider the effect of one's actions, are being put into practice.

For example, a third-year medical student on his surgical rotation was in the operating room when the resident refused to start a surgical procedure because the attending wasn't there and the resident had never performed the procedure. The attending arrived late and proceeded to scream at the resident for not starting on time, according to Richard Frankel, PhD, a medical sociologist at IUSM and one of the leaders in the relationship-centered care initiative.

Then, when the surgeon calmed down, he apologized. He told the resident he had done the right thing. The surgeon admitted he was running late and had hoped the resident would have put him back on schedule

"What a wonderful role model," Dr. Frankel says. "The senior surgeon had the insight to apologize." Such stories have Dr. Frankel convinced they are onto something. "I've been at this for 30 years, and this is the most extraordinary transformation I've seen," he says.

Small steps

Such changes were desperately needed, according to Indiana's leaders.

In 2003, IUSM graduates' overall satisfaction with their medical education pushed the school below the national average on the Assn. of American Medical Colleges' survey of U.S. medical school seniors.

The numbers were the reality check that prompted IUSM's dean, D. Craig Brater, MD, to recruit Drs. Inui and Frankel. They joined Debra Litzelman, MD, associate dean for medical education at IUSM, and outside consultants Tony Suchman, MD, and Penny Williamson, ScD, to change the climate at the academic medical center.

Six months after the relationship-centered care initiative began, scores rose profoundly. In 2004 and 2005, overall satisfaction of IUSM's graduating seniors was above the national average.

To spur changes that turned those numbers around, Drs. Inui, Frankel and Litzelman gathered 10 other faculty members who shared their desire to make IUSM a place where doctors stopped behaving like ill-mannered gods and started treating others with respect.

Discovery team group members interviewed colleagues about times they had been at their best at the institution and what allowed that to occur.

This process, called appreciative interviews, intentionally focuses on what works instead of what's broken, Dr. Williamson said. By building on what's going right, the broken things get fixed without focusing on problems and trying to place blame.

"Appreciative inquiry sounds touchy-feely, but it's not," Dr. Williamson said. "It started 20 years ago in the business community and spread because the results are so amazing."

After interviewing 80 clinical and research faculty members, students, residents and administrative staff, the IUSM team distilled key themes of what helped people be their best:

  • An environment that supports the notion that everyone can learn and where there is support for individuals to grow professionally.
  • A workplace where individuals feel connected; for example, a connection between patients and doctors, or students and teachers, or the radiology department and the oncology department.
  • An environment in which there is passion for patient care, learning, teaching, creating new knowledge and trying new things.
  • A workplace that promotes the wonderment of medicine and the profound nature of medical work.

These findings were shared in a number of settings, from small meetings with top medical school administrators to open forums where guests conducted appreciative interviews among themselves and discussed ways to put relationship-centered care into practice.

Planting seeds

Making sure people feel valued at an institution as large and geographically spread out as IUSM's nine campuses and eight affiliated hospitals is not simple. But pockets of change have emerged.

On an institutional level, this has included restructuring admissions to attract like-minded students and reshaping the budget process. Instead of the traditional secret negotiations between each department chair and the dean during the budget process, the dean now shares financial information with everyone. The goal is for department chairs to collaborate to make sure the money will be used to support the school's mission, instead of individual department goals.

Equally important is the change that's taking place on an individual level.

Tara Dodd, MD, an internal medicine intern, might not be familiar with the term "relationship-centered care," but she's learned the principles from her attending, Dr. Litzelman.

This winter, Dr. Dodd had a noncompliant patient with complications from weight reduction surgery. She and others at the hospital had done what they could for the patient and felt it was time for him to move a nursing facility. He refused to go.

"The intern felt she had done all she could do, but she was mindful enough to slow down, acknowledge that she was exhausted, then she went back and talked to the patient again," Dr. Litzelman said.

The reflection was part of the relationship-centered care process, Dr. Litzelman said. By not pushing ahead out of frustration and trying to convince the patient to leave against his will, Dr. Dodd was able to see her patient as a person and treat him with respect. As a result, Dr. Dodd's next conversation with the patient disclosed that his wife was bipolar, and he felt she was too fragile emotionally to be left alone. He didn't want to be moved to an extended care facility where she might not have access to transportation to see him. Armed with this information, the staff had a problem it could solve, instead of one that seemed at an impasse.

"Everyone has a reason for what they do," Dr. Dodd says. "I've found I'm more successful if I spend the time to tease out why."

It's these kinds of stories that have medical educators outside of Indiana intrigued.

Paul Haidet, MD, MPH, a general internist at Michael E. DeBakey VA Medical Center and an assistant professor of medicine at Baylor College of Medicine in Houston, has written about the hidden curriculum and is hoping to mirror Indiana's successes in Texas.

"If you go to Indiana, sure, you'll see your share of pimping [teaching through intimidation] going on, but you'll also find people who are really embracing relationship-centered care," Dr. Haidet says. "The good things you'll find there, you won't find anywhere."

Dr. Haidet recommends Baylor, of course, when students ask for medical school advice, but his next recommendation is IUSM. He said: "If you could go to a medical school where your teachers were happy to be there, where doctors are happy taking care of patients on the wards, where would you go?"

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Changes for the better

Three years isn't much time to create culture change, especially at a large school like Indiana University School of Medicine. But it has made both small and large changes in that time, including:

Guiding new students: Starting in 2004, students collected stories from classmates of positive experiences at IUSM and published them in a book to give incoming students during the white coat ceremony.

Constructive criticism: The academic standards committee reviews student course evaluations and works with faculty members to evaluate what they could do better rather than sending out form letters telling them they received a poor course evaluation.

Recognizing accomplishments: A resident writes a quarterly newsletter on the relationship-centered care initiative to share stories and news about the project.

Listening:Many committee meetings start with a time for individuals to share what's going on with them personally before dealing with the meeting agenda.

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Producing competent physicians

Indiana University School of Medicine created a competency-based curriculum in 1999. Its graduates must show they are capable of:

  • 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
  • Professionalism and role recognition

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Illinois takes lesson from Indiana

Indiana University School of Medicine is beginning to share what it's learned about creating a culture where faculty, students and patients feel valued.

Representatives from 26 schools applied for eight positions to attend a conference in Indianapolis last fall to learn how IUSM has leveraged appreciative inquiry and relationship-centered care to change individual behavior at the school.

Southern Illinois University School of Medicine in Springfield's Dean J. Kevin Dorsey, MD, PhD, was among those who attended. He took information home and met with residents to find out what they thought worked and didn't work in the SIUSM community.

Dr. Dorsey then asked residents to rate the school's departments from least respectful of individuals to most respectful. Family medicine, internal medicine and pediatrics scored extremely high. The surgical department did not fare as well.

"Surgery is an exceeding professional department, ... but they performed very badly on this survey," Dr. Dorsey said. "You can look professional and act professional, but when it comes to crunch time, how are you perceived as treating patients?"

He took the results and went to each of the chairs and said, "This is how you did. What are you going to do about it?" Those who did poorly were initially defensive, but they took it back to their faculty, who are starting to take it seriously, Dr. Dorsey said.

"One heart surgeon said, 'It is what it is. We stunk up the place on the survey. Some of us are behaving like idiots with the residents in the OR,' " Dr. Dorsey said.

In May he will distribute the survey again to see if things have improved. "What [I'm hoping] I've done is raise the issue of respect."

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External links

Indiana University School of Medicine's relationship-centered care initiative (link)

Pew-Fetzer Task Force report "Health Professions Education and Relationship-Centered Care," in .pdf (link)

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