Book Review: One World School House: Education Reimagined by Salman Khan

Salman Khan, former hedge fund manager, is a darling of the TED talks circuit and a bit of an education reform celebrity.  His story begins with his younger cousin, who was struggling with math in spite of overall strong academic performance.  What started as a long-distance internet based family tutoring session, has grown into a cottage industry of YouTube based lessons—technologically simple, relatively short and digestible—which can be viewed, reviewed and mastered at the learner’s own pace (Incidentally, if interested you can brush up on your immunology or cardiac electrophysiology).  His book, One World School House: Education Reimagined, is part history lesson, part pedagogical treatise.  Although it has nothing directly to do with medical education, it is useful to read this entertaining and accessible work through the lens of a medical educator.

Khan’s fundamental contention is that the current educational system is based on the 18^th century Prussian model of public education—innovative in its day.  The system was developed to meet the labor needs of an increasingly industrial society, and “to create loyal and tractable citizens”.  The system was not intended to foster independent thinking, learning or creativity.   The theme of the book, and his work overall, can probably be summarized in his words:

The old classroom model simply does not fit our changing needs.  It’s a fundamentally passive way of learning, while the world requires more active processing of information.

Basic tenets of Khan’s world view include:

• Basic concepts must be fully understood and mastered before moving on to other more advanced concepts (think competency based, rather than time based education).

• Teachers can convey information, assist and inspire learners. However, we ultimately educate ourselves.

• Associative learning is critical. Per Khan, it makes no sense to put courses into discreet boxes—to divide learning into periods and courses with discreet beginnings and endings. As humans, we truly learn by associating information systematically with knowledge that is already deeply rooted in our memory. “…no subject is ever finished. No concept is sealed off from other concepts. Knowledge is continuous; ideas flow.”

• There is incredible inertia in existing educational systems. It is difficult to escape customs established for decades or centuries, even when it is clear the customs do not serve us well.

• The knowledge explosion and subsequent rapid pace of change requires a change in pedagogy. We can no longer approach education as a process of filling heads with knowledge, so learners can coast off that knowledge for thirty or forty years. If you have children in school today, more likely than not the job they will be doing has not been invented yet. It is critical that we teach people how to teach themselves, rather than perseverating on what they learn.

• There is value to mixed aged classrooms. When there are learners at various degrees of progress it promotes an atmosphere where everyone can learn at their own pace. In addition, it provides opportunity for learners to to be leaders—the more advanced can help those still trying to master concepts.

• Testing has a limited (but important) role. Tests can measure quantity of information learned, at least when the test was taken. Tests are less able to measure “quality of minds [or]…character”.

• The current day university plays an important credentialing role—because you have completed this degree, you therefore have these skills. If competency and proficiency could be reliably measured, the credentialing role of education could be decoupled from the educational role.

This work is a rapid read, and worth the time.  It is not an academic treatise, and does not purport to be.  At times Khan’s enthusiasm for his subject, and his apparent success, leaves the reader feeling like his approach is an educational panacea (which he takes great pains to deny).  But his concepts resonate at an intuitive level.  He raises important fundamental questions about the nature of education in the information age.  His encouragement to move forward without waiting twenty years for a randomized trial is an important message in an era of reform.

With regard to medical education, although the work does not explicitly discuss the training of physicians or healthcare providers, it does align with some of today’s pressing concerns.  How do we provide high quality education at an affordable cost to our citizens, and to the world?  In an environment where information is increasing perishable, how do we turn a commitment to “life-long learning” from hollow platitude to a fundamental educational principle?  As medical knowledge is increasingly integrated, how do we evolve from a silo approach to knowledge acquisition, to one in which our new bit of genomics learning is associated with what we have already learned in cardiology, immunology and population health?  If you think these questions are important, Mr. Khan’s book is worth an investment in your time.

Incentives, Culture and Engagement

For a moment, imagine any group of people faced with great change, disruption or transformation -- a corporation, university, health system, department, family. Now here is a rhetorical question. You have a choice of joining one of two groups. In one, team members are aligned around a common mission and purpose; a diverse group of great brains are all working together in an environment of trust and collaboration to address fundamental and existential questions. In the second, the environment is best described as "every man for himself."  The members of this team are equally bright, equally talented, but not aligned behind any common mission.  To which team would you want to belong?

The answer is obvious, but begs the additional question: how do you create an engaged, aligned organization? Part of this effort often involves alignment of incentives. But how effective are incentives in driving a culture of engagement? There is significant evidence to support the answer -- not very.

The Daniel Pink YouTube posting The Surprising Truth About What Motivates Us is worth a six minute investment in time to begin to understand the nature of incentives. The contention of the piece is two fold. First, economic incentives may be effective in increasing the production of highly repetitive tasks, although the effect may be perishable and require ongoing escalation of the incentive to maintain the desired effect. Second, incentives directed at highly complex cognitive tasks have the paradoxical effect of decreasing the desired behavior.

Given the entertaining format of the Pink piece (stop motion white board cartooning), it is tempting to dismiss this as pop psychology. However, there is ample evidence to back up the conclusion.

The origin of this area of behavioral psychology has its roots back in the 1960s. Hertzberg published a study recently reprinted as a classic article in The Harvard Business Review, One More Time: How Do You Motivate Employees?.  Based on qualitative research from a variety of blue collar and professional groups, a common and persistent theme emerged. Groups were asked to identify factors in the workplace that, when present, drove extreme satisfaction and engagement; conversely, they also ranked factors that drove disengagement. Hertzberg's parlance, hygiene factors (e.g. compensation, company policies, relations with coworkers, etc.), when absent, or when present in the negative, where liable to create dissatisfaction and disengagement. However, when present in the positive, these factors do not drive extreme engagement. Pay someone poorly, they are likely to be dissatisfied. Pay them extraordinarily well, you are unlikely to buy their satisfaction or engagement.

Hertzberg went on to describe intrinsic motivators -- items like achievement, recognition and doing meaningful and important work. The results were exactly the opposite. Intrinsic factors, when absent, do not drive extreme dissatisfaction. However, when present in the positive they do drive rabid organizational fans. Similar observations have been made with groups of physicians. ¹

 

Intuitively this makes sense. Imagine a highly competent, experienced and motivated school teacher standing in front of a room full of students, and committed to bringing out the best in each of them. The teacher feels a responsibility to develop and challenge the best and the brightest, to help them reach their potential.  The teacher also feels a responsibility to lift up those who are lagging behind.  At the end of the day, satisfaction comes from making a positive impact on as many students as possible, and satisfaction emanates from a sense of professionalism. The teacher is motivated to constantly explore new and innovative methods of reaching the students, and these efforts are celebrated and rewarded.

Now let us introduce a hypothetical incentive. A bonus will be paid based on the number of students passing a standardized end-of-year examination, compared to a statistical peer group comparison. Let us further assume the unobtainable -- that this metric is perfect. That is, it is risk adjusted based on the characteristics of the class. Socioeconomic factors, school resources, strength of the family unit, local crime rates, etc. are all controlled. The incentive will be applied on a level playing field.

What is the likely impact? We may very well see increase in pass rates; but at what cost to our star teacher? To earn the incentive, the teacher could well ignore the gifted in the class --they are assured of passing. Similarly, the less academically successful could be written off -- they will not pass even with Herculean effort. The incentive is designed to bring more marginal students up to a common baseline, which by its nature is probably below typical expectations for the average student. The teacher will be celebrated by the organization and recognized by peers for generating better numbers; not for innovative techniques. Perhaps the teacher will deliberately change the approach in the classroom to maximize performance; that is, teaching to the test. Perhaps the teacher is so firmly rooted in a sense of professionalism that the commitment to all students will not be abandoned, even though the organization does not seem to value the effort. In either case, the teacher viewed to be more successful in the new incentive system, but less satisfied, and less engaged.

It is not difficult to imagine analogous dynamics in healthcare or medical education. We can develop incentives to drive specific, measurable clinical outcomes. We can measure success of educational efforts based on certification exam scores. But we need to pause and reflect what could be lost in the process.

The quote "Culture eats strategy for breakfast" has been attributed to management guru Peter Drucker. I would amend this: A culture of professionalism eats incentives for breakfast. There is certainly an important role for metric driven organizational goals. However, there is pernicious danger in placing blind faith our ability to create culture through perfect alignment of incentives. 

¹ Cassel CK, Jain, SH. Assessing individual physician performance: does measurement suppress motivation? JAMA. 307(24):2595-6, 2012 Jun 27.

Change Management: Is the Juice Worth the Squeeze?

Change in the US healthcare system is likely coming on a scale not experienced for generations. (see Feb 12, 2013  and Feb 15, 2013)   It is useful to pause and reflect upon the responsibilities leaders in our field have to help anticipate and manage the process of change.  In particular, under what circumstances does a leader deliberately take a group of people – physician practice, clinic, hospital, delivery system, teaching program – through a deliberate and orchestrated change management process?  One critical question: Is the juice worth the squeeze?

There are a number of theoretical academic management models of change management.¹    One model was developed and popularized by William Bridges who publishes widely in this area, both in traditional print media and on-line.  The following figure is adapted from Bridges’ work:

Bridges’ schema of change management has distinct Kübler-Rossian overtones (see “Curve A” above).  In this model, organizations go through a mourning process for the old world order, before the new can be embraced.  During the “Endings” period people are encouraged to let go of the old ways – often ways that met with success in the past .  The “Transition Zone” is a zone of discomfort.  Some people may leave the organization; others will marshal their creativity to find ways to succeed in the new era.   In “New Beginnings” some will display new behaviors, developed to meet the demands of the new playbook, and ultimately become role models for others.

The impact of the change is felt in “Curve B”.  During the process, the overall level of anxiety increases, peaks and ultimately returns to baseline as the change becomes the new normal.  Directly related to the waxing and waning of group anxiety, organizational performance will actually decrease, before rebounding – this is the critical point – to a level of performance higher than where it started ("Curve  C").  The organization must endure the expected rise in anxiety (the squeeze) in order to enjoy the ongoing benefit of enhanced performance (the juice).

We have plenty of examples of looming changes in healthcare and education – shift from volume to value payments, curricular innovations, group physician visits, team based care, competency-based rather than time-based education to name only a few.  Here are a few questions to ask prior to embarking on a deliberate change process.  If none of these conditions exist, you may want to pause and reflect carefully before launching a major change initiative:

• Does my organization have a commitment to a particular strategy, and are current behaviors incompatible with this strategy?  (e.g., we think the our future success depends on innovations in training providers to thrive in a new delivery system – department chairs are focused on building research programs).

• Is the organizational behavior that needs to change damaging the organization? (e.g. inattention to known regulatory requirements).

• Is the anticipated improvement in performance significant?  If you presented to results of the process to an objective observer, would they be impressed or lulled to sleep?

• Is the anticipated improvement, once obtained, sustainable, or just a one-time event (e.g. a single year improvement in productivity)?

• Is the organization sufficiently stable to weather the transition?  Is it already engaged in too many disruptions and transitions?

In an unstable environment, leaders have responsibility to instill as much discipline around change as possible.  To paraphrase the Serenity Prayer:

"God grant me the serenity 
to accept the things we do not need to change; 
 courage to change the things we must;  
and wisdom to know the difference."

¹    McDeavitt JT, Wade KE, Smith RE, Worsowicz G. "Understanding Change Management" Am J Phys Med Rehabil. 4(2) pp 141-43, 2012.

Academics and Care Delivery: A Necessary Symbiosis in an Era of Reform

(Note: I originally wrote the following content in April 2012 for the Wing of Zock, the blog run by the Association of American Medical Colleges).

At the 2011 AAMC Annual Meeting in Denver, I participated in a panel called “Organizing for Success during Reform,” which showcased a variety of care and research initiatives designed to align academics with the goals of health care reform at AMCs throughout the country. In some way, I think this may be the wrong question. Rather than asking how to align academics with health care reform, we need to start with a stronger alignment with health care.

My core message was the desirability (if not outright necessity) of aligning our academic infrastructure with the core mission of the health system. The growth of Carolinas HealthCare System (CHS) over the past 30 years has been dramatic: from a single public hospital, to 33 hospitals in two states and over 9 million patient visits. This growth creates the potential for an incredible clinical laboratory. We have access to patients representing all aspects of diversity: ethnic, economic, urban/rural.

During the same period, our research and education programs have grown as well. It is our fundamental belief that the academic programs planted in the middle of a strong health care system create great opportunity to strengthen our education and research efforts. At the same time, the academic core should produce real value back to the system…specifically by enhancing our ability to deliver high-quality, efficient patient care to a broad geography. Regardless of the outcome of health care reform, we believe this is a model for the academic health system (as opposed to academic medical center) of the future.

A case in point: Several academic medical centers in North Carolina participated in a study on lung cancer funded by the American Cancer Society. The study showed that African-Americans who are diagnosed with lung cancer have a delay in definitive treatment from the time of diagnosis compared to Caucasians; one of many health care disparities documented in the literature. The identification of these disparities is good and important work. However, the academic health system of the future will have the vertical integration necessary not only to identify a care delivery problem, but to correct it.

So how can we actively work to build this linkage between organizational mission and academic capability? I outlined one small step in that direction: the formation of Carolinas HealthCare System Research Centers of Excellence (COE). We developed an internal RFP process to select and fund two COEs. Applications were based on the following criteria: Investigators had to represent more than one specialty. More important, there had to be evidence of geographic diversity. That is, the investigators were expected to produce a realistic plan to leverage the scope and scale of CHS to begin to work in our large clinical laboratory. Finally, as part of the outcome measures, successful applications were expected to have a measurable impact on one of the six Institute of Medicine Aims for Improvement.

To date, one center has been funded: the Carolinas Trauma Network Research Center of Excellence. This center builds on a substantial base of clinical and academic excellence. Its objectives are:

▪ To develop and maintain an efficient multidisciplinary infrastructure to support the conduct of trauma-related research across the continuum of care provided by CHS

▪ To facilitate collaboration across disciplines, facilities, and scientific methods to contribute to the evidence base in trauma care

▪ To identify and prioritize the most critical issues challenging delivery of care for trauma patients across all CHS facilities

▪ To contribute to the science of conducting trauma research on challenging patients in challenging environments

▪ To use Comparative Effectiveness Research strategies to identify the safest, most effective, and least costly treatments for injured patients

▪ To leverage the strengths of this COE and CHS to attract external funding to support trauma related basic and translational science, clinical research, and population-based/implementation research.

In a way, the funding of the COEs is an experiment in itself. Can we deliberately drive synergies between the care delivery system and academic excellence? As a large, mission-oriented organization, it is our responsibility to try.

The Next Cultural Transformation in Medicine, Part II

So if the first great cultural transformation in modern medicine was a collective mindset shift in the approach to quality and safety, what is the next transformation? It could be -- and I believe should be -- an analogous shift in thinking around issues of professionalism.

Concepts of professionalism have deep roots in medicine, from the time of Hammurabi and Hippocrates. John Gregory (1724-1773), a Scottish physician, philosopher and ethicist, believed intellectual and moral excellence in medicine demanded adherence to three fundamental principles.¹ First, the physician must accept the intellectual discipline of science, so that his practice is as free from bias as possible (in other words, evidence based medicine). Second, the physician's primary consideration must be the protection and promotion of the patient's health. Finally, all other forms of self-interest (economic benefit, status, lifestyle) must be secondary to the needs of the patient. Furthermore, he believed these core principles were supported by key virtues of integrity, self-sacrifice, self-effacement and compassion. Although written in 1770, I am not sure this definition can be greatly improved upon.

Some physicians would embrace these concepts as an almost sacred duty. Others might view them as a professional North Star: aspirational, unobtainable but an important directional beacon. Few (I would hope none) would reject them out of hand.

So as a profession, how do we work to raise the bar of professionalism today? It is my contention that current progress in this area is where our commitment to quality was 25 years ago. If we refer back to our two previous bell curves, we tend to root out the bad apples (eliminate the underperforming tail of he curve):




We typically do not effectively shift the curve -- for those with deficiencies in the "soft skills" (e.g. communication, working effectively in teams, interpersonal skills), we need to help remediate those with severe weaknesses; help the average improve, and at times, excel; and support the truly outstanding to set a new aspirational standard:

How do hospitals, physician practices, medical executive committees, professional societies, licensing boards and accrediting bodies deal with issues of professionalism today? By dealing with the outliers on the left side of the curve.

Our national medical culture allows some behaviors, and prohibits others. As a very broad generalization, you cannot use obscenity, at least routinely. However, you can be sarcastic and subtly belittle others. You cannot flip over an instrument tray in a display of frustration in the operating room. You can throw an occasional instrument. You cannot publicly berate another member of the care delivery team. You can react to a patient complaint by casting aspersions on other members of the team, undermining the effectiveness of the team ("I'm sorry your dressing did not get changed. We've had real trouble with nursing on this floor").

The profession needs a fundamental shift in thinking. It cannot just be about the bad apples. The physician with average communication skills needs to become a more effective team member. The brilliant clinician needs to improve his empathic skills. The physician who routinely displays exceptional integrity, self-sacrifice, self-effacement and compassion must be recognized, celebrated and acknowledged as a role model.

This transition will not occur by natural evolution or serendipity. It will only occur as the result of deliberate effort. Just like at the dawn of the quality revolution, without some required foundational components, the transformation will not occur. Here are seven conditions I believe are necessary:

Commitment.  Physician professional societies, specialty boards, health care systems must aspire to shift the culture. Progress has been made. The ACGME core competencies have clearly focused attention on some of medicine's softer skills. The Arnold P. Gold Foundation has established a national recognition system for physicians with exceptional humanistic qualities. Societies have developed to promote some of medicine's "softer" skills, such as the American Academy on Communication in Healthcare. 

However, at times these efforts still feel like fringe issues -- not a core focus of the House of Medicine.

Definition. What specifically are we trying to develop? Can professionalism be broken down into component skills-- e.g. communication, empathy, cultural competence?

Real Patient Engagement.  At the end of the day, patients and their families should be the beneficiaries of a renaissance of professionalism. We need to engage them deeply and broadly to understand what is important to real people. Which is more important? That their doctor took a ballpoint pen from a drug rep, or if he is effective in delivering unexpected and life altering news?

Measurement. Valid, reliable and practical assessment tools must continue to be developed, with meaningful benchmarks.

Pedagogy.  We need tested and effective educational methods to build skills and culture, rooted in sound adult learning principles. We may not have a clear vision today of what this entails, but we clearly know it is something more than giving an annual lecture on ethics.

Selection.  If a college student scores a 36 on the MCAT, and has a science GPA of 3.8, barring a random cataclysmic event, there is a 100% chance they will succeed in medical school. We deliberately select bright students, and help them to use their gifts to practice medicine. As hard as we might try, the high school drop out who never made it through introductory algebra cannot be adequately supported to be successful. Similarly, I will never be drafted to play for the NFL, and it would be comical to try. However, we currently accept a number of students into medical school-- hopefully few -- who are inherently poor communicators or are clearly lacking in natural empathic skills. We need better tools to select students with strong inherent traits that we can enhance and polish. As hard as we might try, we will almost never take an individual with a lifetime of poor communication skills, and turn him into a good communicator.

Resources.  This cultural transformation is difficult; perhaps impossible. It clearly will not occur unless organized medicine and the delivery system commits time, talent and treasure to support continuing and deliberate progress. 

I think it would be worth the investment.

¹Hendrikson, MA, Qual Manag Health Care. 17(1):9-18, 2008 Jan-Mar.