Newsletters Words of EnCOURAGEment #6 Fostering Relationship-Centered Care
Fostering Relationship-Centered Care
by Courage & Renewal Facilitator Chris Love, MH, MSOD 
“As we become more obsessed with succeeding, or at least surviving, … we lose touch with our souls and disappear into our roles.”
Regardless of the quality of its formal academic curriculum, a medical school with a learning environment lacking in compassion and respect and rewarding individual competitiveness forces physicians-in-training into survival mode. In such an atmosphere, students may disconnect from soul and become immersed in role beyond recovery. The long-term consequence can be a tragic loss of doctors’ ability to relate to patients, to hear deeply their cares and concerns, and ultimately, to nurture their healing.
In the late 1990’s, the Indiana University School of Medicine (IUSM) learned from student responses to the Association of American Medical Colleges Graduate Questionnaire (GQ) that despite years of effort to enhance its academic curriculum, its learning environment generated feelings of alienation and disrespect among students.
The IUSM Relationship Centered Care Initiative (RCCI) began in earnest in 2003 with a goal of nurturing a more “caring, respectful and collaborative culture throughout IUSM, enhancing the informal curriculum so it would more consistently embody and reinforce professional values.” The initiative chose to focus on relationships between patients and physicians, among interdisciplinary care teams and between the health care system and the community. Relationship with self was recognized and identified as a foundation for all other relational work.
Three theoretical principles guided the project. The first was that of emergent design, recognizing that the full course of the three-year initiative could not be planned at the outset but would best be allowed to emerge in steps along the way “through collaboration between project leaders and members of the organization.”
The second guiding principle was recognizing and sharing success, an approach that incorporated Appreciative Inquiry (AI) methodology. AI motivates organizations to initiate positive change by focusing on their “root causes of success,” rather than belaboring what they are doing wrong. Sharing stories of success, a key practice in this approach, was repeatedly undertaken in the initiative with every participant group.
The third guiding theoretical principle was a complex responsive process of relating, which recognizes that “large-scale patterns of interaction can be changed by changing local, small scale behaviors.” Planners knew that the desired culture changes could not be brought about by top-down mandates but would instead be more likely to happen by calling individuals’ attention to their ways of relating in the moment in various connections and how they might change to more positive patterns of relating.
From the outset, both qualitative and quantitative methods were used to evaluate the project. On the qualitative side, two project leaders kept journals, and an independent observer interviewed participants, reporting not to IUSM but to the Fetzer Institute’s board of directors. Minutes from project meetings and consultants’ field notes were reviewed and discovery team participant descriptions of “changes in patterns of relating” were collected. Quantitative measures included tracking student responses to relevant items on the GQ. Numbers and positions of initiatives and participants were recorded and applications to IUSM tracked after “RCCI-inspired” changes were made to the process. Both were considered indicators of project success.
Early in the initiative, a Discovery Team of volunteers made up of ten faculty, a student and a resident was recruited to conduct appreciative interviews about positives within IUSM. Overarching themes that emerged -- the wonderment of medicine, the importance of connectedness and passion for one’s work -- were shared at a public “Open Forum.” The gathering highlighted stories of strengths and successful relationships.
After the forum, the size of the Discovery Team doubled to 24 volunteers. The team “evolved into a learning community for internal change agents, meeting monthly for coaching and support.” In response to requests for more training, participants were invited to participate in a year-long “Courage to Lead” program made up of four one and a half-day sessions. The sessions were facilitated by Courage & Renewal Facilitators Penny Williamson, Debra Litzelman, and Rich Frankel, as well as external consultant Tony Suchman, MD, MA. More than 50 people have participated in three cycles of the program to date.
Developing this group of change agents is not the only evidence of the impact of RCCI. As a result of the initiative, the admissions committee has redesigned the admissions process, putting new emphasis on recruiting students with “a strong relational orientation.” The Dean and Executive Associate Deans requested monthly meetings with Penny Williamson and the other external project consultant, Anthony L. Suchman, MD, MA, to develop more relationship-centered approaches to executive actions.
The external consultants have also shared RCCI goals and outcomes with other medical school leaders and more than 30 groups within the school. Some meetings resulted in new policies and procedures aimed at improving relational aspects of group work. Many groups within the school now share success stories regularly, and new meeting formats, policies and procedures are in place to make meetings, hiring student leadership and other activities more relational and collaborative.
A final and perhaps most interesting impact of RCCI at IUSM have been student-initiated appreciative interviews with their peers. Student editors have compiled these interviews, focusing on “high-point experiences of professionalism,” into three successive booklets of student narratives presented to three classes of entering students since 2004. Two samples of narratives from the 2004 edition of Taking Root and Growing: Becoming a Physician at the Indiana University School of Medicine, speak volumes about the positives for students that have emerged as IUSM fosters a medical school culture based on relationship-centered care:
Our class of 16 became very close ... we worked together to get through our first two years. Often, fellow classmates would make and distribute handouts to everyone in the class that would summarize the information in an easily learnable format. We were here to learn medicine, not to compete with one another. Life at a center facility with this kind of action makes us cohesive. We genuinely care about each other as people instead of caring only about each other’s grades. **
An ortho resident invited me to take call with him for a night. This one-on-one experience learning from a resident was great. I felt I learned more by having hands-on experience with someone who was willing to teach. He never made me feel uncomfortable for asking questions or being curious.**
** Vani Sabesan, MD, Jill Pavlicek, Maggie McClelland, Derik Geist, and Jacob Pong, Editors, Taking Root and Growing: Becoming a Physician at Indiana School of Medicine, Dean’s Office for Medical Education and Curricular Affairs, IUSM, Indianapolis, 2004.
* This article is based on and all quotations within it, unless otherwise cited, are drawn from “Enhancing the Informal Curriculum of a Medical School: A Case Study in Organizational Culture Change,” published in Journal of General Internal Medicine, Volume 23, Number 6/ June 2008, by Ann H. Cottingham, MAR, Anthony L. Suchman, MD, MA, Debra K. Litzelman, MA, MD, Richard M. Frankel, PhD, David L. Mossbarger, MBA, Penelope R. Williamson, ScD, DeWitt C. Baldwin, Jr., MD. and Thomas S. Inui, ScM, MD..