Sri Ramachandra Medical College & Research Institute has established itself as a focal point of progress in Indian medical education.

Academic leaders in India find their way to the negotiation table

This much is clear: one of the most significant challenges facing leaders in academic medicine has to do with striking a balance between, one, the need to equip students with an ever growing body of medical knowledge, and two, the demands of the modern day, patient-centered health care environment. With that idea firmly established, these same leaders are now turning to the real challenge: how to reach agreement on the way this can be achieved.

The Medical Council of India (MCI), responding to an increase in patient expectations and a global concern about professionalism among health care professionals, has prioritized improving the training of medical professionals in the area of professionalism. Doctor-patient communication, professional ethics, self-assessment, reflection, altruism, and honesty are but a few of the attributes needed by professionals prompting the MCI to reevaluate the place of professionalism in the medical curriculum. Well aware that quality is the key differentiator in the health care marketplace, local providers have also sharpened their focus on professionalism.

The issue served as the backdrop for a recent education program held in Chennai. For the second consecutive year, Sri Ramachandra Medical College & Research Institute (SRMCRI) welcomed academic leaders from other regional medical schools for an HMI-organized workshop on leading and managing change. The centerpiece of the program was an exercise designed to help these leaders develop their negotiation skills, with the teaching of professionalism as the subject for discussion.

Tom Aretz and Krishna Seshadri, MD, associate professor at SRMCRI and the liaison officer of the HMI-SRMCRI partnership.

“No one doubts the importance of professionalism in the education of medical students,” said Tom Aretz, MD, HMI vice president for medical education. “But the debate over the teaching of professionalism comes in light of the recent reduction in the basic science curriculum by six months. The introduction of a professionalism course may therefore place additional burdens on an already shortened curriculum and present a significant barrier to its implementation.”

The MCI is reviewing the different ways in which this topic could be integrated into the curriculum. Adding six months at the beginning of the curriculum for the study of professionalism would certainly drive home the importance of the topic, but some students may perceive that this is time spent “waiting” for the lessons in clinical knowledge, while basic science faculty may wish to regain some of their “time lost.” Others advocate introducing the topic only after the students have gained some clinical experience. A third idea calls for professionalism to be seamlessly integrated into all courses, either as a coordinated longitudinal course or an integral theme.

A recent survey of 116 medical schools by the American Association of Medical Colleges (AAMC) found that while about 90 percent of the schools offered some formal instruction related to professionalism, only 60 percent incorporated professionalism into multiple courses. Just over a quarter of the surveyed schools taught professionalism in a single course or sequence of courses, and only a third offered professional development programs on the topic. While many medical schools have made concerted efforts to introduce professionalism as a subject, it has also become increasingly clear that teaching it is not sufficient, but that observing and assessing it is of equal or greater importance. A recent study in California has shown that incidents of unprofessional behavior during medical school are strong predictors of unprofessional behavior in the lives of physicians later on.

Topic for debate offers opportunity to build skills
The three-day leadership program in Chennai included 32 deans and department chairs from medical schools in the region. The main event of the second day was a three-part negotiation exercise that asked the workshop participants to imagine themselves as stakeholders at the center of a real debate on the teaching of professionalism. The exercise had been developed previously for another group of academic leaders to address a highly contentious and controversial local issue. Aretz explains: “Given the complexity of the issues facing academic leaders today, the ability to set goals and negotiate agreements between groups with different agendas that do not compromise those goals is critical. When money and time come at a premium, as they do in the environment of academic medicine, there is the risk that different parts of the campus will become home to rival factions that argue their own case without gaining any ground for themselves or the institution as a whole. But through negotiation, the key stakeholder groups can arrive at a solution that is based on objectivity and common purpose rather than emotion.”

The issue of professionalism provided an excellent opportunity for these Indian leaders to test the waters of negotiation. “The main focus of the leadership program was to help build and explore new skills to become better leaders of change, and choosing a controversial or acute issue that really resonates with the participants makes this exercise doubly relevant,” said Aretz.

From left to right: Dr. Usha Vishwanath, associate professor of obstetrics and gynecology at SRMCRI; Connie Bowe; Elizabeth Armstrong; and Latha Ravichandran, Curriculum Committee Chair of SRMCRI.

The workshop participants were divided into three stakeholder groups: basic scientists, clinicians, and ethicists. Each group has its own perspective on the introduction of professionalism into the medical curriculum.The participants in each group were given scripted roles to play. In the first part of the negotiation exercise, the three groups discussed the issue amongst themselves. “The groups were tasked with determining what they wanted to get out of the negotiation and what they were willing to compromise. This helped them to reevaluate and refine their positions,” said Aretz.

Following the meeting of the groups, two representatives from each group convened for a “power lunch” attended by the negotiation chairperson, with a “social anthropologist” present as an observer. The chairs and the observers also had pre-defined tasks. The group representatives attempted to outline an agreement, develop a timeline, project the next steps in the process, and define metrics for evaluation.

The exercise concluded with reports from both the chairperson, who outlined what had been agreed upon and what the next steps would be, and the observer, who talked to the assembled group about which tactics worked during the activity, and which were not as successful.

According to Aretz, the exercise accomplished three goals. First, it forced the participants to take a position that they would not normally endorse and thereby gain a different perspective on the problem. Second, it encouraged these leaders to talk about a controversial and emotion-laden issue, and to do so in a safe environment. Finally, the wrap-up gave the participants the opportunity to closely examine the mechanics of negotiation, and begin to think about how to formulate and achieve their goals going forward.