How do you change a culture?

I meditated on my balcony this morning at roughly 9500 feet above sea level. I love moments where I can quiet my mind and feel connected to the present. The sun was just starting to illuminate two twin peaks in front of me and the rest of the mountains still cradled the valley below in dusky shadow. Not opening my eyes to take in the view was a struggle to say the least, but I reminded myself I needed tune myself for the day to come.

The rest of my first day at Telluride was more of a whirlwind compared to those quiet ten minutes, but now nestled back in my room, I am starting to comb through my thoughts. So many insightful ideas were posited that I cannot possibly touch on them all, but below is one quote that resonated with me. It is connected to the bigger picture of medical culture and the need to mold it.

“We are even afraid of appearing like we don’t know what’s going on during lecture!” –Telluride Participant

In coming to Telluride one of the things I have thought about is the extent to which learning and work environment culture shape our behaviors. As budding doctors we are told that we are the “best of the best” the “smartest of the bunch.” Our professors tell us how impressive we are and how amazed they are by our intelligence and work ethic. In clinics we will be “pimped” our knowledge and those who answer correctly will impress their peers. From the start of our medical careers we are subconsciously trained to think that confidently knowing the answer is key. Yes to be sure, knowing medical knowledge is key, but my mind goes to how this sets the stage for future interactions the medical student will have on the wards and how this is intimately tied to patient safety. The chain of command. Authority. Not wanting to dissent to superiors. This theme is not isolated to medicine. It caused a lot of unnecessary deaths in aviation due to botched communication and medicine is still playing catch up in effecting change in this area.

Most of us will not encounter the surgeon in the case we learned about today, who was so belligerent and threatening to the surgical resident when nurses reported a missing lap sponge that the resident was frozen in fear. Many communication and medical errors are made seemingly innocuously by the best healthcare professionals.

The quote above ties into the idea that as physicians we are not trained to regard error as acceptable. (Like the surgeon above who refused to listen to nurses). This becomes ever more complex when you factor in the hierarchy that exists in medical education, which adds the layer of questioning authority. This in turn seeps its way into how providers communicate among one another.

For me, this comes full circle to question in the title of this post: How do you change a culture? To say that medicine has not recognized the significance of preventing errors and effected tremendous change over the past decade would be false. Just at UVA, pioneering programs like Be Safe and Enhanced Recovery After Surgery  (ERAS) not only guide practice but set a positive example for healthcare professionals. But the fact remains that a unified perspective towards medical error is still lacking. You can have the brightest people come up with the best protocols and these protocols will work, but there is something stronger than that: culture.

I love this concept because it applies to every industry because where there’s a group of people, there’s culture. Whether or not we like to admit it, if we are around a group of people long enough, we will start to behave like them. If you send the message to a group of people that making mistakes is a weakness, don’t you think they will strive to hide them? Conversely, when you instill in a group of people the feeling that their opinion is important, don’t you think this will prompt people to share ideas and effect change?  But how to do this?

One way that corporations have effected culture change is through storytelling. People remember stories because of the emotional connections. Instead of telling new employees about how the company made a soon to be bride work on her wedding day, why not make changes to how employees are treated and start to tell stories that tout your better treatment of your employees? Stories relay culture and culture dictates behavior.

This is not a single solution for addressing medical error and does require top down assistance, since people follow by example. Leaders in our hospitals and health systems need to tell stories. As medical students we need our professors to tell stories that show that communication and a willingness to assume that a medical error could happen at any critical juncture is a proactive, not weak attitude. We believe this, we need you to show us that you believe this too so that we can feel confident that our ideas will be appreciated not derided.

A study done in the 70s found that the easiest way to get a child to eat a certain vegetable (let’s say peas) that he or she didn’t like was to sit them down at a table with children who loved that vegetable. Culture change in a meal. This next generation of healthcare professionals has an abundance of ideas on how to standardize patient safety. We are working from the ground up. But we also need our leaders to show us all how to eat peas.

(Examples on corporate culture change and eating study from Harvard Business Review: