The Happy Organization Changing toxic cultures in medical schools Mohammed Abu Aish EDUC 830 Implementation of Educational Programs Peter Grimmett
Introduction: Working in a positive work environment, where every worker feels safe, welcomed, supported and important is the dream of every worker at any organization. Work conflicts and pressure can inversely affect enthusiasm, productivity and personal lives of the unfortunate workers in such an environment Even when it comes to leaders, it becomes hard for a new leader to work in an organization full of conflicts and negativity as the leader’s role with require more efforts to transform this tense atmosphere in order for his job to be smooth and productive.(Hess, 2008) Deal and Peterson (1999) explained how a toxic culture created within an organization becomes an obstacle to success, a vicious cycle is created when every member in this culture becomes negaholics and every attempt to change it is faced with negativism and loss of hope Medical schools and hospitals have been always at risk of toxicity due to the great deal of competition not only among students, but also among different faculty members and staff (McCauley &. Irwin , 2006) In the first part of this paper, I will describe a toxic culture that I have experienced, before coming to Canada. I will analyze this culture from my own perspective using some of the skills I learned in the EDUC 830 class (Grimmett, 2009) and adding to it my personal subjective input
In the second part of the paper, I will introduce a positive experience that I had in Canada when a group of physicians collaborated to establish a successful nonprofit organization In the final part of the paper, I will try to implement some of the lessons I learned from this course and from my experience in Canada in a proposal to transform the toxic culture in my University upon my return
Part one: A “toxic� medical school In Saudi Arabia, we have a system that allows universities to hire faculty members immediately after graduation from universities after satisfying special requirements (GPA of B+ and more, strong recommendations from university professors and passing a long interview). The fortunate graduate will have a scholarship to complete his/her Masters and PhD abroad for non medical graduates and residency and fellowship for medical graduates. Upon returning back to Saudi Arabia, the graduate will be appointed an assistant professor job right away I was one of the fortunate medical graduates who applied for a position at relatively new medical school in my home town, Makkah, after graduating with a cumulative grade of B+ from medical school/ I got the position of a clinical tutor awaiting acceptance in Canada to travel and complete my postgraduate training in the field of pediatrics I had to wait for 18 months before getting accepted at a pediatric training program in Vancouver, during this waiting period, I was working as a clinical tutor to help teach medical students and organize their exams. I was able throughout this period to attend
faculty meetings and observe the dynamics between different faculty members. I observed a great deal of toxicity in the work environment and in medical staff relationships. Every meeting was a power showoff and a competition to pass and reject different agendas. On many occasions, I felt that there was a great deal of resistance to any new idea for different reasons, sometimes because it is new and some people naturally resisted change but other times the resistance was related to personal conflicts between different faculty members . As a newbie, I had no voice in the meeting but I felt that this helped me observe the environment deeply and silently, I did analyze different problems and problem makers and started at that time to think about solutions
Examples of different forms and toxicity and subjective analysis of factors leading to toxicity in the institution: Example 1: On multiple occasions, I witnessed many faculty members, who trained in North America, negatively criticize their colleagues who trained elsewhere. This is usually in the form of doubting their accreditation and experience. This is always triggered by medical students arguing with the faculty member and telling him/her what he learned from other faculty members. There are many areas in Medicine when there is no answer, so, it is natural that the opinions can differ among different faculty members. Payback by the other faculty member is the natural next step when he/she hears what the student was told about his/her opinion, experience‌etc. A never ending war starts between different faculty members due to similar issues and can be easily observed during faculty meetings
Example 2: Different schools of thought always clash in medical schools; the different visions of student-centered versus teacher-centered methods of instruction always collide. Young enthusiastic faculty members who belief in democratizing the educational process are always opposed by older members who believe in educational dictatorship especially in medical schools to assure that only tough students pass. This collision always favors the status quo and prevents reaching a conclusion on faculty meetings especially when this conflict of opinion becomes a personal conflicts and the phenomenon of “educational stubbornness” controls the environment. In 18 months, I saw no new idea passed even that many brilliant ideas are “discussed” or thought so.
Example 3: Every 2 years, the dean and head of departments change, this change comes from the university head office and it is not clear to me on what basis the new names are chosen, but the point here is that I was lucky to experience 2 diverse leadership styles, one was in the first year after my appointment and the other was after one year(was the 2nd year for the administration that hired me already so they got replaced by another administration). Unfortunately, the change of administration made things even worse as the leader changed from a dictator to a very passive person, I did not feel that productivity got better or conflicts started to resolve, all what changed was people raising their voices on meetings and conflicts becoming more obvious rather than concealed, but, at the end of the day, no real difference. Pay back was very obvious; people who used to
be under extreme oppression are changing to dictators now. Absence from meetings and inflammatory emails are face by a weak leadership that wanted to finish the “term” and leave. Passive staff who wanted no problems kept doing their teaching assignments without getting involved in discussions or even attending faculty members meetings What I found very interesting was that everyone thought he/she is right and others are against him/her. Being a newbie who listens only, I had friends from all parties and everyone complained to me and opened their hearts to my ears. Most of the factors that I thought important in creating and feeding this toxic culture were personality related and especially due to 3 factors 1. Attitude and respect issues 2. Conflicts of beliefs, vision 3. Problems with authority
Personality issues: Deal and Petterson (1999) described different “negative players” in a toxic school culture. I used similar methods to analyze people I observed in my Medical school. This analysis led me to have a 3rd group whom I called “passive” as I thought they are separate from being categorized negative. I believe “negative” person in an educational culture, is the one who has different values and beliefs from the organization (Daly, 2008), the passive personalities in my institution did not, and neither did they have similar visions and values of any administration
Positive Groups:
The Achievers Many physicians are used to be high achievers, they like to be good at everything they do, some of them are perfectionists. This is a group that will work hard for the organization if they belief in its vision, the toxic culture in my schools suppressed many of them due to the absence of recognition and promotion. The constructivists People who critique constructively, because they like the organization and want the best for the organization. They need to be listened to, many of these voices were not given a chance due to the presence of the loud dominant voices of the negaholics in the meetings. Passive groups: The Workaholics This group always busy working, but never initiate anything new, they had nothing to say at the meetings, they liked orders and regulations and never asked a question The Dependent This is a group that always needed assistance and invitation to participate any discussion or act, they never take the lead but they have something to say once supported and given a chance, again, with weak leaders or dictators, they never have the right amount of support or invitation to share Negative groups The nonbeliever
Simply people who do not share the same vision as others, we had many of those in our medical school The arrogant, Prima Donnas People who have problems with authority, they dominated the discussion and prevented others from sharing their ideas. Their voice was always loud and inhibiting to others. With bad leadership, they were the main cause of absence from staff meetings The Jealous (enemy of success They chase mistakes, spread negativity through bad stories, gossips and support other negative groups prevent change and success
Part 2: The SSSBC Model I am going to describe here a model of success that was created and managed by physicians sharing the same vision. I will argue that similar model can be incorporated in my medical school upon my return I came to Canada in 2001 after being accepted to complete my postgraduate training in Vancouver. I was one of many students sent by the Saudi government to complete their studies abroad. The number of students studying abroad reached 40000 last year To help Saudi students and their families settle in their new destinations, the Saudi government established what every Saudi student knows as “the Saudi clubs� which simply means renting a location that the students and their families meet together at the end of the week, meet and support new comers and organize parties for students leaving back to Saudi Arabia
The Saudi clubs around the worlds were directly supervised by the Saudi embassies and the Ministry of Higher education, every year, new administration is elected to run the place and to be the direct contact between the Saudi students in that city and the Saudi embassy In Canada, the Saudi clubs suffered from a major problem, it was almost always run by physicians. This is because most of the Saudi students who came to Canada in the 90s were physicians sent to complete their residency or fellowship. After the year 2000, the Saudi government started sending more undergraduate and graduate students to Canada. Surprisingly, the demographics inside the Saudi clubs weekly meetings were the same, mostly physicians, no undergraduate or graduate students attended. Many of those students expressed that they felt uncomfortable coming to these “apparently high class” meetings where everyone in the meeting only knows how to talk medicine and think medicine, they expressed, though, their happiness to have the Saudi clubs in their cities as a back up for emergencies in case they needed to discuss a problem or communicate with the Saudi embassy So in summary, the students looked at the club as a bureaucracy in which their voices are not heard and not important and that was the main reason why they lost enthusiasm and belief in them as successful organizations Many new leaders of the Saudi clubs expressed their concern about how things are going and tried, individually, to solve the problem without major success due to different reasons: First, the existing “elite” group resisted change as they were happy with
how things were, they always said that the place is not spacious enough to accommodate all the young students anyway and that we should continue supporting them in emergencies without a real need to let them “invade” the place with their “immature” ideas and behaviors After September 11 2001, things started to get even worse as the Saudi embassies were told to stop the financial support to the Saudi clubs around the world to avoid any headache related to “where and who has the money?”. This was unfortunate to all Saudi students around the world as these clubs were helping them in many ways even without phyically attending them, but the Saudi government asked all students to go and establish their own local organizations supervised by the countries they live at, instead of being supervised by the Saudi embassies In Vancouver, a group of physicians got together and discussed the situation from all aspects, everyone had the same vision that the place is important to us and to our families as well as to all young students coming to Canada with weak language and communication skills. Everybody agreed that we should not give up and close the place. We were lucky that our location lease was still active for three more years before the support from the embassy cease. We started working together, planning together to establish the first Saudi students society in Canada, a nonprofit organization supervised by the Canadian government that replaces the Saudi club but still gives similar services. We registered the Society as a nonprofit organization and started working to get every single Saudi student in British Columbia on board. This was not easy, as the taboo was strong against physicians leaders being dictators and arrogant. The picture changed with time as new
students started to come and discover that the Myth is not really a fact, at least in Vancouver group of physicians We did a thorough evaluation of all the factors preventing others to engage in the community and started solving them one by one, other than the myth discussed above, three themes were found to be obstacles of young students’ engagement: Absence of fun programs, absence of professional development programs and transportation issues To solve these issues, we launched “the largest professional development program for Saudi scholarship students in Canada�. This program runs every Friday, nonstop for the last 4 years as massive workshops attended by 100-200 students. Computer skills, communication skills, leadership, ESL classes, poem competitions and game shows are just few examples of what is presented on these workshops We also launched a massive soccer program to attract young students to come and mix with the older guys, if there is one fun activity that gets Saudis together, soccer without competition ranks first. 50 students play together every week on the huge fields rented from the city of Richmond A major development was the introduction of mentoring services for young students to guide and support them during the TOEFL preparation and application to different universities, a service that attracted even more students to join us During the last 5 years, the administration of the Saudi Students Society of BC (SSSBC) expanded dramatically, everybody with promising potential or skill is invited to join the administration, now 20 members are on the board of directors of the organization. Collaboration was the key and democracy was the way to solve conflicts and controversial decisions
The SSSBC was the only Saudi club in the world that did not get affected by the decision to cut its support, in fact once the embassy stopped funding the SSSBC, the organization became independent and started collecting monthly membership fees. Instead of depending on the 3000 dollars that used to come from the Saudi embassy, the SSSBC income is now 8000 dollars per month coming from its 300 members. We moved from the small house that the embassy rented to a huge recreational facility that we rented ourselves. This is just the beginning as SSSBC reputation has reached beyond the BC borders to reach all Saudi students around the world through our website, YouTube channel broadcasting our professional workshops to the whole world and the extensive media coverage of our contributions and participation in major events in Canada Most of who started this dream, that seemed initially impossible, were enthusiastic physicians getting together and collaborating against all odds, I am the only one left of that group and I am quite happy that even when I go back to Saudi Arabia, the team of physicians, undergraduate and postgraduate students on the board of directors, the team we inspired, are going to run the organization smoothly and collaboratively, but the questions I have now, can I do this in my own institution back home?
Part 3: The difficult job back home: This part of the paper describes my proposal to transform the toxic culture I experienced. This proposal comes from my optimism after studying educational
leadership and after my positive experience with SSSBC. There is no guarantee that this proposal will work in the context described Over the past 7 years, and after my SSSBC experience, I became optimistic in the possibility of change. I was fortunate again to enroll in Professor Peter Grimmett EDUC 830 class at SFU to become even more optimistic I know that change does not only require enthusiasm but require training and experience in leadership; I also believe that change needs to come slowly as there will be always opposition to it and that is why the process needs patience, enthusiasm and persistence
Professional learning community and Collective Leadership The SSSBC model is a perfect example of a professional learning community (PLC). According to Dufour & Eaker (1998), PLCs share common characteristics: “Shared vision and values that lead to a collective commitment Solutions actively sought, openness to new ideas Working teams cooperate to achieve common goals Encouragement of experimentation as an opportunity to learn Questioning of the status quo, leading to an ongoing quest for improvement and professional learning Continuous improvement based on evaluation of outcomes rather than on the intentions expressed Reflection in order to study the operation and impacts of actions taken�
To transform the SSSBC model to the medical school, the leader of the organization should not control everything in the organization in the usual top down approach, a collective leadership model is best here. It is not easy for the new leader to create a collective leadership model, a model in which professionals with shared goals and visions collaborate to achieve a common goal (Dufour & Eaker (1998),. Many steps must be done to gain sense of the culture, gain trust of individuals and finally inspire visions and values among team members. It is important that every faculty member feels that he/she is important player in the organization and that his/her voice is heard. The top down approach cannot transform the culture of medical schools, leaders are supposed to lead from the center not from the top to establish a shared leadership, a model the SSSBC adopted and succeeded with (Dufour & Eaker, 1998) Changing a bureaucratic organization to a democratic one is not easy, but I claim that it is is still possible to introduce democracy even within the most rigid bureaucratic system
Initial phase: Gaining sense of the culture: As a new leader, it is important to gain sense of the existing culture by deeply analyze the culture, its characters, stories and myths. The best initial strategy for the new leader is to listen to everyone in the organization, ask about what went well and what didn’t go well with the previous administration
Other attempts to understand the culture by meeting the previous administration members to get their input of all the obstacles they faced Introductory meetings to get to know everyone individually and the group as a whole is helpful to set the scene for the new culture
Setting ground rules Setting ground rules at the beginning of these meetings is probably the most important step in this phase especially when the group sets these rules together rather than the leader forcing them on the group. As the leader is one of the group, he/she can share setting the ground rules he/she believes vital to him/her Examples of important ground rules that I see important to put up front to: 1.Respect to others opinions 2.Disagree with a point not a person 3.No interruption of others 4.Time limits for discussing a point 5.Voting is the way to solve complex controversial issues 6.Introduction of a new idea and/or the criticism of an idea should be supported by logic reasoning, evidence based explanation and alternative approach 7.No sudden agendas, all point to be discussed are supposed to be sent in advance to the leader to organize it and email it to the group before every meeting
Passing Agendas:
Everyone is encouraged to send his/her agenda to the leader in advance before meetings, the agenda is then organized based on urgency and priority and the final version is sent to the group before meetings During staff meetings, the agenda is introduced by the leader who then allows everyone who raised an issue to introduce his/her idea before opining the floor for discussion Having the ground rules clearly identified and set will allow this discussion to go in a smooth and productive way. If a point is not solved in the time allocated to discus it, voting can help solve the issue Sometimes, things are not that simple, a final conclusion cannot be reached for complicated issues or new ideas, the rule of the leader in such circumstances is to ask for an evidence based analysis of the situation to present for next meeting An example of such conflict is the introduction of a new curriculum, voting here cannot solve the issue of uncertainty that many members may still have if the issue is passed just because they were outnumbered in the voting process, here, the role of the good leader is to ask for an evidence based review of the theory, practicality and other centers experiences with such an issue. Dealing with the issue in this organized way can help encourage the passive personalities to step forward and support the new idea and prevent the negative ones from gossiping and moaning about being unheard and ignoared.
Maintenance of stability phase: The initial phase of listening and studying the context will give the new leader the chance to analyze the different personalities mentioned in the first part of this paper. With
good leadership, one can use the positive and passive people to his/her favor, and even change some of the negative ones to be at least passive ones. Leaders should do deep analysis of any situation and not go for simple shallow explanations for negativity or passivity of others. a person who is positive in one place might be passive in another, so it is wrong to generalize assumptions, for example, a person may be passive at work that he sees as routine job but very positive doing another job in the organization. The words positive or negative do not imply bad and evil but indicate enthusiasm and belief in the leadership and organizations’ visions and values, So, the question should not be”what is it they cannot see?” But rather “How can we make them see?” If the initial stage is passed smoothly, most of the leader’s challenge is dealing with different personalities and to keep recruiting new members to the team of collective leadership, time and persistence accompanied by role modeling and enthusiasm will slowly change the culture to a positive one. The aim of this phase is to keep positive personalities enthusiastic and productive, recruit the passive personalities to join the positive ones, hold the negative personalities under control or changing them to passive ones or even positive with time
Dealing with different personalities: The achievers: The achievers do not like to be busy just for the sake of work itself like the workaholics but rather for the sake of achievement (internal or external) and success. The leader should recognize their needs and recognize their efforts publicly for major
achievements and implicitly for ongoing day to day work, even a thank you word or email is highly appreciated by the achievers. With good recognition and support, the achievers will always be engaged and enthusiastic. The leader should be careful not to make others who achieve less than the achievers feel bad or hopeless as everyone who tries deserve encouragement as well. For this reason, recognition needs to be implicit, sometimes and others times it must be public and explicit. The constructivists: The constructivists like their voice heard. A good leaders is who seeks advice and accept it to nourish the values and beliefs of the organization. It Is so easy for an enthusiastic impulsive leaders to rush to decisions without consultation, an act that is only needed for critical times when the values of the organization are at stake. Consulting others will let them feel they are important and that their voices are heard, even, sometimes, when the leader already knows the answer. The believers: If the leader is fortunate, he/she will have many believers of his/her vision when he/she starts the difficult job, if not he/she has to create them. The believers are effective team members, they are the backbone of the collective leadership model. They should have freedom and authority (sometimes implicit) to act, experience and evaluate the results. This freedom and authority, though, should not contradict with the ground roles that was set earlier as this will be viewed by others as double standards.
The workaholics: Even that I classifieds the workaholics as passive, some are not truly passive. Some of them are silent achievers whose needs are not met or cannot be communicated, so, they keep working without enthusiasm. For those, the ongoing relationship with the leader will reveal their needs, demands and hunger for recognition. They may suddenly change to become achievers once they find the right amount of empowerment, recognition and support The dependents: The dependents need scaffolding, support, mentoring, and invitation. I find this group hard to change but if their roles are classifieds, organized and structured for them, they can become reasonably productive Arrogant, Prima donnas: Setting ground roles is the best way to control them. Once the standards are set, they cannot usually jump over them, and if they do, it is not going to be only the leader who deals with them but the whole organization. I realize here that this group is a very powerful group and their voice is strong and I am not claiming that I will be able to control them easily, but at least I have a plan of action to control them that can be always evaluated with collaboration with the believers in my team. The non believers: Many of the non believers are good people who just happened to disagree with the leader’s vision. They may change when the leader respect their voice and ask them to explain their concerns, their concerns must be carefully studied and presented to the
whole group using evidence based approaches and other centers’ experiences. They should be asked to defend their positions and provide alternative plans and solutions This way even if they are outnumbered in the democratic process of final decision making, they will feel respected and appreciated The Jealous, enemies of success: The most difficult group to deal with, this group produces gossips, rumors and searches for mistakes. Leaders should be aware of their existence without confusing them with the non believers. This distinction is important as the nonbelievers need to be treated with respect versus the jealous who needs to be controlled. The best strategy here is not to ignore their concerns and behaviors but rather discuss it with the whole group to get them exposed and controlled
Limitations: This proposal to change a toxic culture in medical school by adopting the collective leadership model of SSSBC is an optimistic view of my personal future career. I clearly realize that the SSSBC model and the medical school model represent two different contexts, Leadership is so complex and context specific (Engels et al, 2008). In SSSBC the collective leadership model worked because, from the beginning, the team shared the same values and visions and thus, were enthusiastic and devoted to their ultimate goal. In the medical school challenge, the leader may find him/herself surrounded by negativity from all directions. That is why the initial steps of gaining trust and slowly changing the culture may take more time, but, once achieved, the organization will rapidly advance towards excellence
Time will be the judge here, I am going to read this paper in 10 years from now and hopefully write about my medical school model in a way similar to what I wrote about the SSSBC model,‌ hopefully
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