Working Interdependently: How Individuals Constitute Effective Systems.

A system's ability to function-its "systemness"-depends upon the mindsets and behaviors of its people, but what exactly is it that individuals do to constitute effective systems? Systemness requires three kinds of ongoing conversations devoted to (1) developing and maintaining a shared purpose or goal, (2) developing and maintaining a systems perspective-understanding how all the various parts fit together in service of the shared purpose and integrating many unique, diverse perspectives to gain a more complete understanding of the situation at hand-and (3) managing the myriad interdependencies of all the people involved in the work. These conversations are needed across all levels of scale, from one patient's care plan to the implementation of strategy for a whole organization. The three conversations of systemness will only be effective to the extent that people are willing to express their unique perspectives and to be responsive to and influenced by what they hear from others. The skills of personal reflection, self-differentiation, attunement, and multiple perspective-taking are particularly important. Understanding the conversations and individual skills on which systemness depends offers new directions for health professions education and quality improvement, and may be relevant to societal challenges beyond healthcare.

Intervening to enhance collaboration in translational research: A relational coordination approach.

INTRODUCTION: A core challenge of a multidisciplinary and multi-organizational translational research enterprise such as a Clinical and Translational Research Award (CTSA) is coordinating and integrating the work of individuals, workgroups, and organizations accustomed to working independently and autonomously. Tufts Clinical and Translational Science Institute (CTSI) undertook and studied a multifacted intervention to address this challenge and to create a culture of systems thinking, process awareness, responsive to others' needs, and shared decision-making. INTERVENTION: The intervention, based on relational coordination, included 1) relational interventions, in three staff retreats and a diagnostic survey to provide feedback on the current quality of relational coordination, and 2) structural interventions, in the launching of five new cross-functional teams with regular meeting structures. METHODS: A mixed-methods evaluation yielded quantitative data via two types of team surveys and qualitative data via interviews and meeting observations. RESULTS: The findings suggest that interventions to improve relational coordination are feasible for CTSAs, including good fidelity to the model and staff/physician engagement. Survey and interview data suggest model improvements in coordination and alignment. Further research about their optimal design is warranted.

The impact of a program in mindful communication on primary care physicians.

PURPOSE: In addition to structural transformations, deeper changes are needed to enhance physicians' sense of meaning and satisfaction with their work and their ability to respond creatively to a dynamically changing practice environment. The purpose of this research was to understand what aspects of a successful continuing education program in mindful communication contributed to physicians' well-being and the care they provide. METHOD: In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians who had recently completed a 52-hour mindful communication program demonstrated to reduce psychological distress and burnout while improving empathy. Interviews with a random sample of 20 of the 46 physicians in the Rochester, New York, area who attended at least four of eight weekly sessions and four of eight monthly sessions were audio-recorded, transcribed, and analyzed qualitatively. The authors identified salient themes from the interviews. RESULTS: Participants reported three main themes: (1) sharing personal experiences from medical practice with colleagues reduced professional isolation, (2) mindfulness skills improved the participants' ability to be attentive and listen deeply to patients' concerns, respond to patients more effectively, and develop adaptive reserve, and (3) developing greater self-awareness was positive and transformative, yet participants struggled to give themselves permission to attend to their own personal growth. CONCLUSIONS: Interventions to improve the quality of primary care practice and practitioner well-being should promote a sense of community, specific mindfulness skills, and permission and time devoted to personal growth.

Organizations as machines, organizations as conversations: two core metaphors and their consequences.

One factor contributing to the limited success of organizational change initiatives is the use of an outmoded conceptual model: the organization as machine. This metaphor leads to the creation of detailed blueprints for desired changes; invites unrealistic expectations of control; and creates anxiety, blame and defensiveness when events inevitably do not proceed according to plan, thus hindering the work. An alternative conceptualization--the organization as conversation--portrays an organization not as a reified object upon which we can act but as self-organizing patterns of thinking (organizational identity and knowledge) and relating (organizational culture) that exist in the medium of human interaction in which we participate. Principles of complexity dynamics (self-organization) have important implications for organizational change practices. (1) Organizational change requires mindful participation--reflecting on and talking about what we are doing together here and now, what patterns of thinking and interacting we are enacting, and what new behaviors might interrupt old patterns or give rise to new ones. (2) Diversity and responsiveness favor the emergence of novel patterns. Skilled facilitation can enhance these characteristics when novelty is desirable; checklists and protocols can diminish these characteristics when consistency and reliability are needed. (3) We cannot know in advance the outcomes of our actions so we need to hold plans lightly, value "not knowing" and practice emergent design. The organization-as-conversation perspective also has important implications for T3 translational research, redefining its purpose, suggesting new methodologies, and requiring new approaches for evaluating proposed and completed projects.

Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.

CONTEXT: Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce. OBJECTIVE: To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. DESIGN, SETTING, AND PARTICIPANTS: Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). MAIN OUTCOME MEASURES: Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. RESULTS: Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [Delta], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Delta = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; Delta = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; Delta = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Delta = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Delta = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; Delta = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; Delta = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Delta = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). CONCLUSIONS: Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.

Enhancing the informal curriculum of a medical school: a case study in organizational culture change.

BACKGROUND: Calls for organizational culture change are audible in many health care discourses today, including those focused on medical education, patient safety, service quality, and translational research. In spite of many efforts, traditional "top-down" approaches to changing culture and relational patterns in organizations often disappoint. OBJECTIVE: In an effort to better align our informal curriculum with our formal competency-based curriculum, Indiana University School of Medicine (IUSM) initiated a school-wide culture change project using an alternative, participatory approach that built on the interests, strengths, and values of IUSM individuals and microsystems. APPROACH: Employing a strategy of "emergent design," we began by gathering and presenting stories of IUSM's culture at its best to foster mindfulness of positive relational patterns already present in the IUSM environment. We then tracked and supported new initiatives stimulated by dissemination of the stories. RESULTS: The vision of a new IUSM culture combined with the initial narrative intervention have prompted significant unanticipated shifts in ordinary activities and behavior, including a redesigned admissions process, new relational practices at faculty meetings, student-initiated publications, and modifications of major administrative projects such as department chair performance reviews and mission-based management. Students' satisfaction with their educational experience rose sharply from historical patterns, and reflective narratives describe significant changes in the work and learning environment. CONCLUSIONS: This case study of emergent change in a medical school's informal curriculum illustrates the efficacy of novel approaches to organizational development. Large-scale change can be promoted with an emergent, non-prescriptive strategy, an appreciative perspective, and focused and sustained attention to everyday relational patterns.

Physician reactions to quantitative individual performance reports.

The purpose of this study was to learn how primary care physicians experienced the introduction and evolution of an individual physician pay-for-performance program. Thirty primary care physicians participated in audiotaped focus groups 13 and 26 months after beginning the program. Transcribed audiotapes were used to group comments into themes. Ten thematic groups were identified. Practitioners reviewed their profiles but found it difficult to use them to change behaviors. They were concerned about the data accuracy, the influence of specialists and patients on their "scores," and, less, the validity of quality measures. They described ways the program changed their practices and consideration of cost, quality, and satisfaction. There were important concerns about the influence of pay-for-performance programs on professionalism. Primary care physicians were skeptical of this pay-for-performance program. On the other hand, physicians described positive influences on making improvements in quality, satisfaction, and practice efficiency.

Control and relation: two foundational values and their consequences.

This paper explores and contrasts personal philosophies based on two different core values, control and relation, with respect to expectations, social relationships, habits of perception and interpretation, and ways of feeling grounded in the world. The paradigm of control is widespread in medicine and certain other health professions, but because it fosters unrealistic expectations, evokes fear and shame, and inhibits effective partnerships, it can actually compromise health outcomes. The paradigm of relation calls attention to interpersonal process and fosters receptivity and adaptability, thus enhancing partnership. A mature clinical approach combines these two perspectives, respecting both the benefits and limitations of reductionistic science and making room for self-organization and emergence.

A new theoretical foundation for relationship-centered care. Complex responsive processes of relating.

Relationship-centered care (RCC) is a clinical philosophy that stresses partnership, careful attention to relational process, shared decision-making, and self-awareness. A new complexity-inspired theory of human interaction called complex responsive processes of relating (CRPR) offers strong theoretical confirmation for the principles and practices of RCC, and thus may be of interest to communications researchers and reflective practitioners. It points out the nonlinear nature of human interaction and accounts for the emergence of self-organizing patterns of meaning (e.g., themes or ideas) and patterns of relating (e.g., power relations). CRPR offers fresh new perspectives on the mind, self, communication, and organizations. For observers of interaction, it focuses attention on the nature of moment-to-moment relational process, the value of difference and diversity, and the importance of authentic and responsive participation, thus closely corresponding to and providing theoretical support for RCC.

The biopsychosocial model 25 years later: principles, practice, and scientific inquiry.

The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient's subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessary contribution to the scientific clinical method, while suggesting 3 clarifications: (1) the relationship between mental and physical aspects of health is complex--subjective experience depends on but is not reducible to laws of physiology; (2) models of circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a more participatory clinician-patient relationship is in keeping with current Western cultural tendencies, but may not be universally accepted. We propose a biopsychosocial-oriented clinical practice whose pillars include (1) self-awareness; (2) active cultivation of trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming therapeutic relationships; (6) using informed intuition; and (7) communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. In conclusion, the value of the biopsychosocial model has not been in the discovery of new scientific laws, as the term "new paradigm" would suggest, but rather in guiding parsimonious application of medical knowledge to the needs of each patient.

Toward an informal curriculum that teaches professionalism. Transforming the social environment of a medical school.

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.