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, experience…etc. 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

Refrences: Daly,Tom(2008)'Schoolcultureandvalues‐relatedchange:towardsacritically

pragmaticconceptualisation',IrishEducationalStudies,27:1,5—27Deal,T.,&Peterson,K.D.(1999).Shapingschoolculture:Theheartofleadership.San

Francisco:Jossey‐Bass.

DuFour,R,.&Eaker,R.(1998).ProfessionalLearningCommunitiesatWork:BestPracticesforEnhancingStudentAchievement.IN:NationalEducationalServices

Dufour,R.,&Eaker,R.(2006).Learningbydoing:Ahandbookforprofessionallearningcommunitiesatwork.Bloomington,IN:SolutionTree.

Engels, N, Hotton, G, Devos, G, Bouckenooghe, D and Aelterman, A (2008).

Principals in schools with a positive school culture',Educational Studies, 34:3,159 — 174

Grimmett,P.(2009).EDUC830.ImplementationofEducationalPrograms.ClassDiscussionandProjects.Surrey,BC.SimonFraserUniversity

Habegger,Shelly.(2000)ThePrincipal'sRoleinSuccessfulSchools.CreatingaPositiveSchoolCulture.Principal.Principal,88no1;42‐46

Hess,Robert.(2008).Followtheteacher.Makingadifferenceforschoolimprovement.Maryland,Rowman&LittlefieldEducation

McCauley,K&.Irwin,R(2006)ChangingtheWorkEnvironmentinICUstoAchievePatient‐FocusedCareChest;130;1571‐1578

SaudiStudentsSocietyofBritishColumbiawebsite,www.saudihouse.org