Assessing the cultural character of an academic department of family medicine

Corresponding author: Pablo J. Calzada, DO, MPH, Department of Humanities, Health and Society, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, Miami FL 33199.

E-mail address: pcalzada@fiu.edu.

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Attaining the goal of improving the quality of medical care for the public logically begins with providing high- quality medical education to today’s medical students, our future physicians. Medical educators confront numerous challenges as they strive for excellence in the education and training of the physicians of tomorrow.1 These challenges are multifaceted, containing elements of institutional, eco- nomical, and social factors, thus mandating faculty to find effective and novel ways of developing strong organiza- tional and leadership skills. To help faculty members over- come these challenges, they need to come together as a team. It appears, though, that at times they lack the skills or knowledge necessary to engage in teamwork, including striving toward a shared vision and mission. This paper will examine an attempt to help achieve these goals by assessing the cultural ambiance and providing feedback to the faculty within a Department of Family Medicine on the nature or character of its organizational culture.

‌In this study, an instrument designed to measure organi- zational culture was used to assess the cultural characteris- tics of a family medicine department to provide both lead- ership and faculty members’ critical information needed to facilitate the changes for the achievement of a more effec- tive and efficiently functioning academic department.‌

‌Background

Defining culture

Several definitions of culture have been offered in the literature. Hofstede2 stated: “Culture is the collective pro- gramming of the human mind that distinguishes the mem- bers of one human group from those of another.” Culture in this sense is a system of collectively held values.” As quoted by Brown,3 Edgar Schein defined culture as “ . . . the deeper level of basic assumptions and beliefs that are shared by members of an organization that operate unconsciously and define in a basic ‘taken for granted’ fashion an organiza- tion’s view of its self and its environment.”

For this study, culture may be viewed as the “group personality” resulting from people’s interactions over time. Culture takes on a persona—a “life of its own”—in that it guides behavior and generates agreements surrounding con- frontations. Leaders must recognize the characteristics of their organizational culture before embarking on the com- plex task of leading change. To interact successfully and promote changes within a defined group, leaders must iden- tify these elements of culture and understand the dynamics they exert within a culture.

‌To further understand culture, we need to depart from the notion that culture is determined collectivity via an intrinsic need to communicate at different levels. It should be un- derstood that communication can have mere superficial meaning or entail a deeper connotation where words, ac- tions, and expectations become part of a specific meaning for the group such as rituals for meetings, greetings, repri- mands, and other group processes. Symbols are created playing a role to remind the group of their culture, helping them to distinguish their group from others. Specific behav- ioral rules evolve that serve to propagate and explain the shared meanings within the group.

Culture in medicine

Identifying the cultural characteristics of an organization is an essential component of the preparation for the change process. Academic departments are known to resist change and Family Medicine is not exempt from this resistance.4,5

A study published in 2004 identified positive organiza- tional culture characteristics within a community health center medical practice environment.6 These characteristics were indicated to be substantially cultivated by specific values, attitudes, behaviors, and relationships among em- ployees in the environment. The categories of culture in the practice environments studied included: (1) Community mission and values, (2) leadership and organizational dy- namics, (3) workplace relationships, and (4) physical space. The culture in the practices studied proved essential for the promotion of employees’ spirit, the quality of patient care, and enhancement of the overall process of clinical care.

Change in organizations

Other research has explored the tensions resulting from cultural change implemented by organizational leaders. A 1991 report identified successful strategies used by depart- ments of family medicine.7 This study also identified the methods and skills considered to be important by the leaders of these departments. The authors of this study discussed the problematic issue of change relating to cultural conflict between the worlds of clinical care and organizational lead- ership. A case study was provided of organizational cultural change, facilitated through a physician leadership develop- ment program. Common themes among the successful de- partments of family medicine studied were: (1) Recruiting and mentoring the best faculty, (2) building a reputation for clinical excellence of faculty and residents, (3) becoming part of institution-wide curriculum activities, (4) establish- ing a scholarly presence, and (5) developing networks of support. The authors concluded that their locally developed physician leadership program can be extremely effective at both improving physicians’ leadership skills and increasing understanding of the strategic goals and direction of the organization.

Swick recommends embracing change and molding ac- ademic medicine to intertwine with the business orientation of health care.8 To achieve this synthesis, Swick suggests that an open dialogue should be established between aca- demia, government, the health care industry, and the public. The dialogue must emphasize: (1) managing change rather than resisting it by focusing on the positive aspects of change, while reaffirming fundamental professional values of medicine and medical education; (2) making it clear to all stakeholders the need to balance all of the various roles required of them; and (3) fostering professionalism by in- creasing medical schools’ emphasis on faculty development by ensuring that schools keep an appropriate balance be- tween the science and the art of medicine, and by faculty who model appropriate professional values for their stu- dents. These three factors point to the need of developing new ways to better evaluate and, when needed, intervene in the organizational culture of medical settings. Based on these recommendations, this study applied a model of or- ganizational culture as described by Goffee and Jones.9

‌The Goffee and Jones Cultural Model

In this approach, Goffee and Jones9 have reduced culture to two dimensions—sociability and solidarity. They define solidarity as the degree to which people share tasks and mutual interests and think similarly. In solidarity, logic is the main driving force behind decisions made by individu- als. Esteem and mutual concern for others are the main forces motivating their performance in sociability. The main driving forces in decision-making processes are emotion and social concerns.

High sociability is considered “people-based,” whereas low sociability places a greater emphasis on the focus of accomplishing tasks.

They note that there are negative and positive forms of each element. Positive solidarity results in a job done effi- ciently and effectively. Negative solidarity, which does not value other people, can produce high levels of internal conflict or excessive/inappropriate self-interest. Positive so- ciability is a condition where people help one another to be successful. Negative sociability is characterized by the cov- ering up of other people’s errors, and it tolerates poor performance in the name of friendship or “saving face.”

These factors are graphically described by the Goffee and Jones Double-S Model (Fig. 1). It is a two-by-two matrix identifying four distinct cultures that are dependent on levels of solidarity and sociability.‌

Communal culture

‌The communal culture is characterized by both high sociability and solidarity, leading to open spaces, highly visible corporate symbols, a focus on face-to-face commu- nications, and situations in which persuasion is often used. People who value both high levels of sociability and soli- darity typically identify with company values.‌

Networked culture

The networked culture is one identified by high socia- bility and low solidarity. Physical spaces are open, includ- ing social areas with wall decorations such as photos that are typically separated into marked spaces to identify individual territories, especially in negative forms. Members prefer to engage each other at informal meetings and make great use of e-mail and telephone communications. Partic- ular attention to communicating the “right” way is empha- sized. Socializing occurs during work hours as people iden- tify with one another.

Mercenary culture

In the mercenary culture type, there is low sociability and high solidarity, leading to functional work spaces that are designed to do the job and little more. Displays of awards and recognitions are rare, yet the concept of winning is valued. Talk is short and focused, argument is confronta- tional, and long hours are spent working.

Fragmented culture

The fragmented culture has low sociability and low sol- idarity in which people have private offices or work from home. There is little interpersonal talk or communication, and when it occurs, it is focused on specific topics. Most communications are directed to people outside of the orga- nization. Members prize individualism and freedom.

Methodology

The purpose of this current study was to assess the organi- zational culture of a medical school Department of Family Medicine using a survey (Appendix) developed by Goffee and Jones.10 Furthermore, this study explored the applica- bility and usefulness in analyzing the cultural dynamics of an academic department. This study obtained approval from the university’s institutional review board for human subject use within the context of faculty development.

To assess the cultural characteristics of individuals within organizational groups, Goffee and Jones developed a 14-item survey (Appendix) based on their Double S Model. The instrument was distributed to all faculty members at a departmental meeting and the completed surveys were col- lected a week later.

Subjects

The subjects included clinical faculty (physicians) and nonclinical faculty (medical educators and behavioralists) and resident physicians from two different hospital-based family medicine residency programs.

Data analysis

A total of 51 individuals completed the instrument. This comprised of 9 clinical faculty, 12 nonclinical fac- ulty, and 30 resident physicians from two different pro- grams (Residency A: n = 18, Residency B: n = 12). The individual answers to each of the 14 survey questions determines the level of endorsement for each of the two cultural dimensions. This endorsement is further identi- fied as belonging to one of the four cultural characteris- tics previously described. For each question, the respon- dent answers by selecting one of three choices: low, medium or high. Values are: 1 = low, 2 = medium, and 3 = high. Questions 1 to 7 measure the concept of sociability; its score is the sum of the value for each of the choices answered. The same process is repeated for questions 8 through 14, which measure the concept of solidarity.

Each respondent’s score for solidarity and sociability is plotted on a two-by-two grid shown in Fig. 1. To examine group culture, all respondent scores are plotted on a single grid. With our group, scores were calculated from the 51 subjects and illustrated on the following grids.

‌The values that plotted equally between the cultural quadrants were considered to represent traits of two or more cultures and therefore were counted as belonging to two or more cultures.

Results

As shown in Grid #1, all faculty members tended to align mostly within the communal and fragmented quadrants. Clinical faculty (Grid #2) showed a much higher degree of Fragmented and Mercenary cultural characteristics com- pared with the nonclinical faculty (Grid #3). Nonclinical faculty plotted in a distribution along the Communal and Networked cultures, with a single respondent in the Merce- nary quadrant.

Residency A (Grid #4) plotted mostly in the Networked and Communal cultures quadrants, with three members in the Fragmented culture position and one member in the Mercenary culture position. Residency B (Grid #5) mostly plotted in the Communal culture quadrant, with one indi- vidual falling in the Networked culture quadrant and one individual in the Fragmented culture quadrant.

Discussion

The higher degree of fragmented and mercenary cultural characteristics of the clinical faculty compared with the nonclinical faculty was hypothesized to be related to the general disenchantment resulting from the sum of extrinsic and intrinsic factors. External factors of importance are the lack of control on decision making when caring for patients, the inability to provide prompt access to specialty care, fragmented continuity of care, perceived lack of prestige among other specialties, poor reimbursement, and overall feeling of belonging to a specialty whose viability is seri- ously threatened. Internal factors include cultural factors like uncertainty in the future role and identity as clinical teachers, lack of common values and bonding as a commu- nity of educators with common goals, and attitudinal and affective needs that remain unmet.

Most of the nonclinical faculty members are educators and behavioralists by training who specialize in adult med- ical education. Their responsibilities are framed into the design of educational tools and strategies for curricular improvement and in the evaluation of competencies in both medical students and residents, which may account for their majority plotting in the Communal and Networked culture quadrants.

The Goffee and Jones Cultural Model identifies cul- tural attributes that contribute to the effectiveness of a team as proportional to the degree of Solidarity and Sociability characterized by the team. Solidarity cultural attributes will determine the reliability of the team. Med- ical care and medical education are strongly based in team efforts. Traits characterized by low sociability and solidarity will be detrimental to both patient care and the development of well-rounded competencies in learners. Sociability is an essential attribute of the human condi- tion, and its presence in any community of employees will only enhance feelings of security, attitudes toward the support of higher performance levels, and overall happiness. Given that, it is likely that Departments with Communal cultures are best suited to perform at a higher level of productivity and dynamics, thus driving them closer to excellence. According to Goffee and Jones,9 the presence of Networked and Mercenary individuals yields a balanced distribution on the overall cultural traits, given that these two cultural types offer positive values: Networked individuals are rich in sociability but deficient in solidarity traits and are therefore more emotional sup- porters than collaborators, whereas Mercenary individu- als are high in solidarity and less in sociability and are therefore the opposite of Networked individuals. Frag- mented individuals are at a higher risk of not contributing at all to the dynamics and productivity of the department because they lack both solidarity and sociability. Frag- mented cultural traits isolate and disengage individuals from a team.

The evaluation of organizational culture traits gained in this study was used in defining and implementing change within this academic department. The following guidelines will be considered in the planning and implementation of departmental change:

• Department’s culture should be encouraged within the Communal (positive solidarity and positive sociability) frame of culture.

• Culture should be continuously assessed, analyzed, and communicated to all members.

• A continuum of processes should be developed that en- courage the culture’s positive solidarity and sociability traits.

• Cultural values identified as deviations from the pro- moted ones should be redirected before they become a permanent feature of the culture.

Conclusions

Departments of family medicine in academic centers must continue to ensure the future scope and quality of family practice patient care and general medical education, the ongoing evolution of family medicine as a scholarly disci- pline, and a continued flow of qualified medical school graduates into family practice residency programs and even- tually into practice.

Change is rapidly becoming an integral component of health care improvement. To implement change effectively, it is necessary to provide clear vision, leadership, and ade- quate time to develop followers. Consistent integration of changes in practice to promote positive outcomes is known as an essential continuum for successful and dynamic health care. Change must be, at all times, parallel to quality im- provement interventions.2 The development of primary care depends on high-quality leaders who are able to draw on a range of different management skills and styles. Change leaders are most likely to be effective if they appreciate the merits and drawbacks of their different styles and are will-ing to work in partnership.1

Implications

Academic physicians can be helped to develop leadership skills to face and embrace transformational change. Studies have supported and encourage the use of leadership devel- opment programs that includes the components of careful curriculum design, program monitoring, and opportunities to apply new skills in practice. This organizational transfor- mational change effort can be successfully achieved with faculty development programs oriented to professional growth and organizational leadership.3

Academic medicine faces unprecedented challenges, es- pecially the impact of the changing and more business- oriented health care system on medical education. There is an inherent clash of values between business and medicine: among key business values are profit and competition, whereas among the traditional values of the medical pro- fession are service, advocacy, and altruism. Business inter- ests have already gained a central place in medicine, so the challenge has become how to use the positive elements of the entrepreneurial spirit to enhance professional values and advance academic medicine’s central enterprise. In 1998, Swick concluded that although change inevitably brings challenge and a sense of loss, it also brings the opportunity to help reshape medical education to meet the needs of society.8

To be truly effective, academic family physicians must possess skills as both educators and as leaders. Effective curriculums result in educational programs that are likely to be successful, achieve established goals, and meet expectations of the learners. Establishing effective lead- ership results in individuals who feel valued for their opinions, empowered to act independently, and account- able for setting and achieving personal goals. The aca- demic environment provides an excellent framework for the development of approaches and strategies to task change and to lead in a rapidly changing, challenging health care environment. Family physicians training stu- dents and residents have the great responsibility of per- fecting and using educational and leadership skills to positively contribute to the organizational effectiveness of their departments.

In today’s health care environment, a number of organizational, economic, and social factors are presenting new challenges to primary care medicine. How those changes are addressed relates proportionally to the degree of positive solidarity and sociability found in the culture of the specific department. A culture characterized by negative solidarity and sociability traits will eventually become a culture of fragmentation.

In large part, the future of primary care departments resides in the strength and knowledge of their faculty. En- couraging faculty interactions conducive to a higher degree of functionality is of paramount importance. Leaders of change should constantly assess the status of their organi- zation’s culture and develop ideas and strategies to enrich their departmental culture, perhaps through the quest to enhance solidarity and sociability.

Organizational and leadership development occur in the context of both academic and clinical teaching domains. In this case, the use of faculty development programs could serve as an effective vehicle to provide the backbone for faculty professional development, which in the long term could provide faculty with the framework to interact suc- cessfully at a higher level of performance. The reshaping of a department’s culture can only take place when problems and deficits are seen as opportunities, and when faculty members, including leaders, can accept those deficiencies and embrace renewal.

Once faculty members have introspectively analyzed their department’s culture, and once the tools to think stra- tegically are in place, the organization values will start moving toward the direction of positive solidarity and so- ciability. The culture can then emerge to a stronger position, ready to face the challenges of change.

Overall, the result suggests that how cultural changes are addressed could be directly proportional to the degree of positive solidarity and sociability found in the culture of the specific department. A culture characterized by negative solidarity and sociability traits will eventually become a culture of fragmentation.

‌Appendix‌‌

WHAT IS YOUR ORGANIZATION’S CULTURE?

Goffee and Jones (1996)10

Please answer these questions based on your perception of your organization. Check the box that best reflects your view.

1. People here try to make friends and to keep their relationships strong.

2. People here get along very well.

3. People in our group often socialize outside the office.

4. People here really like one another.

5. When people leave our group, we stay in touch.

6. People here do favors for others because they like one another.

7. People here often confide in one another about personal matters.

8. Our group (organization, division, unit, team) understands and shares the same business objectives.

9. Work gets done effectively and productively.

10. Our group takes strong action to address poor performance.

11. Our collective will to win is high.

12. ‌When opportunities for competitive advantage arise, we move quickly to capitalize on them.

13. We share the same strategic goals.

14. We know who the competition is.

SCORING: Low = 1 Medium = 2 High = 3

LOW MEDIUM HIGH

References

1. Association of American Medical Colleges: Learn, Serve, Lead: The Mission, Vision, and Strategic Priorities of the AAMC. Washington, DC: Association of American Medical Colleges, 2007

2. Hofstede G: Culture’s Consequences: Comparing Values, Behaviors, Institutions, and Organizations Across Nations, 2nd ed. Beverly Hills, CA: Sage Publications, 2001

3. Brown A: Organizational Culture. London: Pitman, 1995

4. Magill MK, Rainelle AP, Haas L, et al: Cultures in conflict: a chal- lenge to faculty of academic health centers. Acad Med 73:871-875, 1998

5. Bloom SW: The medical school as a social organization: the sources of resistance to change. Med Ed 23:228-241, 1989

6. Craigie FC Jr, Hobbs RF 3rd: Exploring the organizational culture of exemplary community health center practices. Fam Med 36:733-738, 2004

7. Taylor RB, Colwill JM, Puffer JC, et al: Success strategies for depart- ments of family medicine. J Am Board Fam Pract 4:247236, 1991

8. Swick HM: Academic medicine must deal with the clash of business and professional values. Acad Med 73:751-755, 1998

9. Goffee R, Jones G: The character of the corporation. Harper Business, 1998

10. Goffee R, Jones G: What holds the modern company together? Har- vard Business Review. Nov-Dec:135-148, 1996