Teaching medical students organisational behaviour Marjorie Rosenthal1 and David Berg2 1
Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut, USA 2 Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA INTRODUCTION
s doctors increasingly embrace health care leadership roles, we believe that they need an understanding of and mastery over complex health care systems. Third-year medical students are thrust into complex health care systems as soon as they start their
clerkships, yet most leadership training programmes target mid-career doctors. Through our teaching, we, an organisational psychologist and a paediatrician, recognised this gap and created a class called Leadership Rounds (LR). We used case-based learning and emphasised three organisational behaviour concepts, all important for
leadership: (1) group culture; (2) intergroup relations; and (3) scapegoating.
RATIONALE We believe medical students need to understand organisational events in other than strictly personal or interpersonal terms, and instead need to see
Medical students need to understand organisational events in other than strictly personal or interpersonal terms
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Doctors, when they experience workplace difficulty, often ‘diagnose’ the problem as caused by themselves or by other individuals
organisational behaviour as both the root of difficulty and the source of solutions in health care settings.1,2 Doctors, when they experience workplace difficulty, often ‘diagnose’ the problem as caused by themselves or by other individuals.3 This limited ‘differential diagnosis’ restricts their potential actions to those that ‘cure’ or cope with other individuals. Learning to consider organisational explanations, or expand their ‘differential diagnosis’, we believe allows doctors to seek solutions that do not depend on changing individuals, but in changing the systems in which individuals work. Additionally, third-year medical students spend time navigating hierarchy and power differences for the purposes of learning. We believe LR could help students understand the effects of individual and group behaviour in order to increase their ability to manage these forces in the service of their learning.
PLAN The instructional setting for LR was longitudinal and voluntary. Five third-year medical students volunteered for the approximately 20–hour class. In each class one student presented a situation on the wards that he or she found disturbing, confusing, curious or interesting. The two faculty facilitators stimulated reflection on experiences and helped students generalise experiences by identifying recurring phenomena and introducing organisational concepts. The field of organisational behaviour includes the perspective that organisations are not only systems of interacting individuals, but also systems of interacting groups.4 This perspective led us to emphasise three core concepts: (1) group culture
– the development of norms in organisational groups and the roles created and assigned to individuals in those groups;2 (2) intergroup relations – the influence of relationships between groups or their representatives on organisational events;5 and (3) scapegoating – the tendency for problematic issues or tensions in a system to be located in one subgroup or one individual.2 Below is an example of a case presentation and discussion in which all three concepts were highlighted.
CASE: 18–YEAR-OLD FEMALE WITH SICKLE-CELL DISEASE AND PAIN CRISES The student reported that the patient rated her pain as 10/10, but that the residents were treating the patient’s pain scores and not thinking about the patient ‘as a person’. The student told her medical team that in the 5–year period when the patient was receiving
psychotherapy there were no admissions for pain. The student reported that she received derision for her observation regarding psychotherapy. The student did not mention the patient’s African American race during the presentation. The LR group discussed their observation that although psychiatric issues should be considered in diagnosing and treating patients, in practice, psychiatric services were considered second-tier services by the medical team. The LR group reflected that the group culture of medical and surgical teams is to explore psychiatric issues largely as a last resort. The LR group noted that as a profession we no longer routinely start a patient’s description with a statement of race, but what if race seems pertinent? The medical team had been composed of only white individuals and the patient was African American.
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The LR group (white and Asian) acknowledged that as sickle-cell disease is perceived as exclusively experienced by people of African descent, attitudes and behaviours surrounding the disease are nested within attitudes and behaviours regarding race. We discussed that given historical discrimination, when a student feels her all-white team is not treating the AfricanAmerican patient ‘as a person’, race and intergroup relations are important. Thus, for this case, the LR group decided that naming the patient’s race was important information. At first this experience seems to be about a student’s frustration with individual residents on her team, and her perception that she is being scapegoated (where the tension in her team from not solving the patient’s pain feels like it is aimed at her). On reflection, we discussed that her frustration may stem from the group culture (norms within medicine about the role of psychiatric treatment) and the lack of recognition of the possible influence of intergroup relations (between a white health care team and an African American patient). The LR group began to consider that the levers
of change in this situation might be at the level of relationships within and between groups. Our evaluation of LR to date includes both written and face-to-face feedback from the participants, all of whom rate the class highly useful in managing their clerkships and residencies. As we are aware that participation in LR involved a select group of students who volunteered for the class, further evaluation should assess the use and value of, as well as comfort level with, organisational behaviour concepts among LR participants and non-participants 1–2 years after the class is completed.
version (not discussed here) the paediatrician facilitated the LR by herself, with consultation from the organisational psychologist, during clinical clerkships. We believe either model is useful for students, and that a clinical teacher with supervision from an expert could facilitate LR. Finally, LR may be a feasible manner in which trainees can gain the skills and knowledge necessary for a greater understanding, mastery and ultimately improvement of the health care system in which they work. REFERENCES 1.
Berg DN. Developing clinical field skills: An apprenticeship model. In: Cooper CL, Alderfer C, ed. Advances in Experiential Social Processes. New York: Wiley; 1980; pp. 143–163.
Wells L. The group-as-a-whole perspective and its theoretical roots. In: Colman AD, Geller MH, ed. Group Relations Reader 2. Washington, D.C.: A.K. Rice Institute; 1985; pp. 109–126.
Stoller JK. Developing physicianleaders: a call to action. J Gen Intern Med 2009;24:876–878.
Miller EJ, Rice AK. Systems of Organization. Tavistock Publications: London, 1967.
Berg DN. Senior executive teams: Not what you think. Consulting Psychology Journal: Practice and Research 2005;57:107–117.
CONCLUSIONS We believe organisational theory can be applied to systems of health care and taught to medical trainees in order to give them a greater understanding of health care systems. In this version of LR, we had one faculty member who was well skilled in organisational behaviour (the organisational psychologist) and one (a paediatrician) who had taken a year-long class, similar to LR, and continued to be supervised by the organisational psychologist throughout LR. In another
A clinical teacher with supervision from an expert could facilitate learning rounds
Corresponding author’s contact details: Marjorie Rosenthal, Yale University School of Medicine, Department of Pediatrics and Robert Wood Johnson Clinical Scholars Program, IE–61 SHM, PO Box 208088, New Haven, Connecticut 06520–8088, USA. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Not required. doi: 10.1111/tct.12267
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