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Culture of Academic Medicine

Recently, the culture of academicmedicine has become the subject ofrich dialogue. At its best, this cultureexemplifies commitment, achievement,collaboration, innovation, awe, andconnection.1We academic physiciansconsider ourselves to be high-achieving,focused, and scholarly.2Nonetheless,despite these favorable attributes,academic medicine demonstrates a highincidence of faculty dissatisfaction,3,4

student moral distress,5

and theperception of mistreatment amongtrainees.6In these accounts, we

describe ourselves as perfectionistic,hierarchical, intensely individualistic,and competitive.2,3,7This unforgivingculture contributes to high rates ofburnout, depression, and suicide amongphysicians.8,9

Throughout medical school and graduatemedical education, physicians in trainingnot only acquire the knowledge and skillsrequired for the practice of medicinebut also learn the culture of academicmedicine. Researchers and educatorshave turned to aspects of medicaleducation, such as professionalism,10thehidden curriculum,11studentteacherrelationships,7and relationship-centered care,12seeking strategies toimprove our culture from the earlieststages of training. As a result, we haveimplemented educational interventionssuch as core competencies that emphasizeprofessionalism, and interpersonaland communication skills. We haveimproved working conditions with

resident duty hours limitations. Beyondtraining, physician wellness programsimprove the satisfaction of practicingphysicians by helping them achieve morebalanced lives,13and disruptive physicianprograms work to eliminate threateningand unprofessional behaviors.14,15Manyacademic health centers have createdopportunities for reflective practicessuch as mindfulness, reflective writing,

yoga, or meaning-in-medicine discussiongroups that have been shown todecrease burnout and enhance learning

experiences.16,17Despite these variousinnovations, many still consider theculture of academic medicine to beproblematic.3,18

We propose that culture change isso challenging in part because of anevolutionary construct known as thenegativity bias19,20that is reinforcedserially in medical education. Here, weexamine the concept of negativity biasin the context of academic medicine andexplore the potential role of practicesrooted in positive psychology as powerfultools to counteract the negativity bias andaid in achieving desired culture change.

The Negativity Bias

The negativity bias has been exhaustivelyexplored in the field of psychology. Itdescribes the idea that humans are moreattentive to and are more influenced bythe negative aspects of their environmentthan by the positive. Presumably, there

has been an evolutionary benefit frombecoming instinctively wary, and overtime the negativity bias has come toaffect us across a broad spectrum ofthe human experience.19,20Baumeisterand colleagues19detail the science thatdemonstrates how negative events,emotions, and interpersonal interactionsgreatly influence us. Researchers haveshown that the learning, memories, andinformation processing that result fromnegative experiences dominate over thoserelated to positive experiences.19,20

Abstract

Despite ongoing efforts to improve

working conditions, address well-being of faculty and students, and

promote professionalism, many still

feel the culture of academic medicine

is problematic. Depression and burnout

persist among physicians and trainees.The authors propose that culture change

is so challenging in part because of an

evolutionary construct known as the

negativity bias that is reinforced serially

in medical education. The negativity biasdrives people to attend to and be more

greatly affected by the negative aspects

of experience. Some common teaching

methods such as simulations, pimping,and instruction in clinical reasoning

inadvertently reinforce the negativity

bias and thereby enhance physicians

focus on the negative. Here, the authors

examine the concept of negativity bias

in the context of academic medicine,arguing that culture is affected by

serially emphasizing the inherent bias to

recognize and remember the negative.They explore the potential role of

practices rooted in positive psychologyas powerful tools to counteract the

negativity bias and aid in achieving

desired culture change.

Dr. Haizlipis associate professor, Department ofPediatrics, University of Virginia, Charlottesville,Virginia.

Dr. Mayis associate professor of research,Department of Medicine, University of Virginia,Charlottesville, Virginia.

Dr. Schorlingis professor of medicine and publichealth sciences, University of Virginia, Charlottesville,Virginia.

Ms. Williamsis assistant director, Center forAppreciative Practice, University of Virginia,Charlottesville, Virginia.

Dr. Plews-Oganis associate professor, Departmentof Medicine, and director, Center for AppreciativePractice, University of Virginia, Charlottesville,Virginia.

Correspondence should be addressed to Dr. Haizlip,University of Virginia Department of Pediatrics,PO Box 800386, Charlottesville, VA 22908-0386;telephone: (434) 982-1707; fax: (434) 982-3843;e-mail:[email protected].

Acad Med. 2012;87:12051209.

First published online July 25, 2012doi: 10.1097/ACM.0b013e3182628f03

Perspective:The Negativity Bias, MedicalEducation, and the Culture of AcademicMedicine: Why Culture Change Is HardJulie Haizlip, MD, Natalie May, PhD, John Schorling, MD, Anne Williams, MA,and Margaret Plews-Ogan, MD, MS
mailto:[email protected]:[email protected]


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The profound effect of negativeexperiences and the dominance ofmemories and learning resulting fromthem are clearly illustrated in oureveryday experience in medicine andin our education process. For example,a physician who has previously misseda particular diagnosis may choose topursue further imaging and lab work

on a patient despite evidence-basedguidelines suggesting a low risk of thatdisease. Physicians who develop thisonce bitten, twice shy approach after anegative patient experience have difficultydisavowing it no matter how strong theevidence to the contrary.21The pain,anger, devastation, or feeling of havingfailed a patient can endure indefinitely.22

Remarkably, even the anticipation of anegative interaction can change onesbehavior.23Every day, people inherently

and instinctively watch for what isdangerous, react based on previousexperiences, and anticipate or plan for theworst that might happen. The negativitybias unconsciously permeates allreactions and relationships. It is thereforenot surprising that the negativity biasalso affects the processes important ineducation: how people learn, how peopleprocess information, and what peopleremember.

Learning is the acquisition of knowledge

or skill that manifests in behavioral orcognitive change. Positive reinforcement(reward) and negative repercussion(punishment) are two accepted strategiesthat can motivate a learner. Researchershave evaluated the efficacy of rewardversus punishment with varyingexperimental constructs and acrossdevelopmental stages.20,24,25Vaish andcolleagues20concisely summarize thesedata:

Learning research indicates apowerful negativity bias at a very

basic psychological level: Negativereinforcement, as opposed to comparablepositive reinforcement, leads to fasterlearning that is more resistant toextinction in both human adults and inanimals.

Information processing is the mechanismby which newly obtained informationis manipulated, coded, and combinedwith previous experience, allowing it tobe used in thinking, problem solving,and performance of tasks. Informationprocessing is a critical step in determining

the meaning of new data and thecommitment of that knowledge tolong-term memory.19The negativity biasis manifest in information processingin that negative experiences have beenshown to command a greater quantityof thought than positive ones.26,27Thissuggests that people have a greater driveto understand the factors and meaning

of negative events. In medicine, this isillustrated by the tremendous energydevoted to understanding medical errorsand bad outcomes.

Negativity bias is present in the resultsof studies on memory as well. Severalresearchers have demonstrated that,compared with positive memories, bothchildren and adults have greater recallof unpleasant memories, more vividdescriptions of undesirable behaviors,and consistent recollection of the content

of negative memories over time.2830Interestingly, the affective intensityof the memory is determined by itscontent. Negative memories of self aredownplayed, whereas negative memoriesof others are not.31,32These data suggestthat we place great value on the detail ofnegative experiences but that a protectiveinstinct minimizes our own contributionswhile maintaining an awareness of theperceived negative behaviors of others.

The negativity bias is a powerful force

that humans have developed to protectthemselves from threat. It affects howwe act in the moment. It shapes whatwe learn, understand, and retain frompast experiences. It can influenceour relationships with others. Mostimportant, our negativity bias is soinstinctual, most of us are not even awarethat it exists.

Reinforcement of Negativity inMedical Education

Medical education reinforces thenegativity bias in many ways. Someare explicit, some are subtle, and someare likely unconscious to both theteacher and learner. In his book HowDoctors Think, Groopman33articulatesthat physicians are trained always toentertain the worst-case scenario first toavoid missing an important diagnosis.Medical students, for example, learnearly in their education always to ruleout the myocardial infarction beforeattributing chest pain to heartburn or a

musculoskeletal source. Although thisalgorithm is necessary and designedwith noble intent, it clearly reinforcesan inherent bias toward the negative.Lane34describes how this fatalisticthinking permeates her life: Upon closerobservation everything that seemedbenign was not. It captured one aspectof a physicians point of view: in all

places, the potential for pathogens andpathology is real.

Simulations are particularly effectivelearning tools and are therefore beingincreasingly incorporated into medicaleducation.35,36Young and colleagues36assert that it is imperative to create alearning environment of deliberatepractice, one in which the tension andemotion would be similar to that whichwould be present in a real-life scenario.In mock codes and trauma simulations,

the high-stakes nature of the simulatedpatients situation can cause situationalanxiety in even the most experiencedproviders. For students and trainees, theaffective component of being involvedin experiential learning creates a moreintense learning environment thansimply writing an essay or respondingto a multiple-choice question. Manyinstructors recognize this dynamic andtry to mitigate the tension associated withsimulations in their introductions anddebriefing sessions. Nonetheless, for some

students simply performing in front ofan audience of peers and instructors canprovoke anxiety. Although the purposeof simulation is certainly not to producelearner discomfort, we must entertainthe possibility that the efficacy of thisteaching method is due at least in part toa learners uneasiness.

Another common teaching strategy thatreinforces the negativity bias is pimping.This technique has likely evolved fromthe Socratic Method, in which,

[r]ather than giving information, ateacher instead asks students a series ofquestions. The students either come tothe desired knowledge by answering thequestions or become more deeply awareof their own limits.37

Whereas the Socratic Method can bea positive experience through whicha teacher leads a learner to the correctanswer, Louie and colleagues38describepimping as follows: the attending willquery students in turn about medicalfacts. Students who fail to provide


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the answer sought are shamedintoreading more that evening (emphasisadded). Simply put, pimping is teachingby intimidation.7Here, the negativerelational aspect is a powerful motivatortoward the acquisition of knowledge.

In her award-winning Humanism inMedicine essay, Miller39captures how fear

is an integral component of the culture ofacademic medicine.

As medical students, whether preclinicalor on the wards, we live in fear, afraid tomake a mistake, to forget a fact, to appearstupid in front of peers or superiors, oreven to cause harm to patients throughour ignorance. [I]t does not end withgraduation; the rigid hierarchy of medicaltraining means that the underlying fearpersists, albeit at a more subtle level, asthe physician-in-training advances up theranks.

This statement suggests that thereinforcement of many of the educationalbiases toward the negative persist intograduate medical education as well.

The Culture of Academic Medicine

Presumably, the culture of academicmedicine has evolved to its currentstate because many aspects of thenegativity bias enhance our culture.It is appropriate to critically appraisefactors contributing to medical errors

or unanticipated patient outcomes sothat we may practice more safely. Acutelyremembering the teaching points from amock code can improve performance ina real one. Healthy skepticism has led torevolutionary changes and advancementsin our field. Yet, there may be unintendedconsequences to this pervasive focus onthe negative.

By inadvertently serially reinforcing ourinherent negativity bias, we may notsimply be teaching young physiciansnecessary critical thinking skills and

clinical judgment. We may also beheightening their natural tendency tolook for threats in myriad situations.If this is true, it is not surprising thatphysicians can become pessimistic andproblem-focused, creating a dominantculture that seeks and expects the worst.

Given that the negativity bias is basic andfundamental to us all, it is no wonder thatthe culture of medicine is extraordinarilydifficult to change. Academic medicine,however, is changing for the better. We

are increasingly aware of the potentiallasting effects of events and interactionsboth in the academic realm and with ourpatients.7,40Initiatives to improve workconditions, promote professionalism, andaddress physician wellness send a strongmessage that positive experiences and rolemodels are important.41,42Our inherentbias toward the negative, however,

encourages us to continue to find faults,dangers, and pitfalls. As a result, weunderestimate the improvements andsharpen our focus on the next problem.For this reason, if we hope to fully realizeculture change in academic medicine, wemust begin to educate ourselves and ourlearners to intentionally acknowledge andemphasize the positive.

Positive Psychology

Researchers in the field of positive

psychology assert that day-to-dayemotional experiences affect thevery course of peoples lives. Bydeliberately noticing positive emotionand experiences, individuals have theopportunity to fundamentally changehow they perceive their environment,how they think, and how they act. Ina placebo-controlled trial, Seligmanand colleagues43established that simplykeeping a daily what went well journalcan markedly lower the incidence ofdepression at three and six months.

In comparison with negative emotionsthat narrow peoples ideas about possibleactions, Fredrickson and colleagues44,45demonstrated that positive emotionsbroaden peoples ideas about possibleactions. Losada and Heaphys46work withmanagement teams confirms this. Losadaand Heaphy observed the character ofconversation in the team meetings ofhigh-, medium-, and low-performingteams (as determined by profitability,customer satisfaction, and 360-degreeevaluation). High-performing teams

were significantly more likely to speakpositively to one another (5.6:1 positive:negative remarks) than were low-performing teams. Members of high-performing teams explored each othersremarks and ideas with questions ratherthan simply advocating their own pointsof view. Additionally, high-performingteams considered the effects of theiractions on others as well as themselves.Losada and Heaphy46concluded thatthe positive interactions among theteam enhanced their functioning

and ultimately contributed to theorganizations success.

In his book Flourish, Seligman47demonstrates the translation of positivityinto desirable outcomes in an educationsetting. In a controlled interventionin a Philadelphia high school, half ofninth-grade students were assigned to

language arts classes that incorporatedpositive psychology and personal strengthidentification, whereas the others hadthe standard curriculum. He found that,when rated by blinded teachers, thestudents who received the interventionhad improved curiosity, creativity, love oflearning, and engagement in school.47

With this knowledge, consider bedsiderounds: How would the content of thoseconversations be coded? Is there moreinquiry or advocacy? Are comments

supportive or cynical? Is the focus onother or self? Although these conceptsare not as fully explored in academicmedicine as they are in other disciplines,two investigations suggest that deliberateinfusions of positivity can have adesirable effect on medical professionals.Isen and colleagues48studied theinfluence of positive affect on clinicalproblem solving in third-year medicalstudents. This study demonstrated thatstudents with an induced positive affectshowed greater efficiency and integrativeconsideration. They were also more likelyto go beyond the scope of the assignedtask and had improved organization.Similarly, Estrada and colleagues49studied44 internists as they reasoned througha simulated case study of a patient withchronic active hepatitis. They found thatthe internists who were in the inducedpositive affect group considered liverdisease earlier than those in the controlgroup did and were more likely toconsider additional pieces of informationbetween hypothesis generationand arriving at their final diagnosis

(demonstrating greater flexibility in theirdecision making).

Interestingly, the techniques used toinduce positive affect in the participantsin these studies were very simple. Themedical students were praised for theirperformance on a simple puzzle priorto starting the study case. The internistswere given a small bag of candy inappreciation for their participation.This suggests that positive interventionsneed not be grandiose to be effective.


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In fact, Fredrickson45found that excesspositivity (a ratio of 11:1) was perceivedas insincere and was therefore dismissed.From these data, one can conclude thatsimple, sincere positivity used commonly,but not excessively, could be the sparkfor culture change in academic medicine.Thanking a colleague for his or herconsult, complimenting a speakers grand

rounds, or listening to a student whohas had a difficult experience may havelasting effects that extend beyond theirintended meaning.

Changing the Culture

Guarnaccia and Rodriguez50assert thatto become a professional involves atleast two processes of acculturationoneto the dominant culture and the otherto that of the profession. Schools ofmedicine have created extraordinary

programs to integrate students andtrainees into the profession of medicine.Now we must turn our attention tothe dominant culture. Changing ourperspective is an uphill battle. Thepowerful evolutionary negativity biasis reinforced by some essential aspectsof medical education. It is crucial thatwe continue to teach critical decisionmaking and to entertain the possibilityof life-threatening disease first. Wemust continue to improve our careof patients through evaluation oferror and flawed judgment. But if wechoose, we can balance their effectsby making a conscious effort also tonotice the positive. Following the lead ofappreciative inquiry,51we can recognizesuccesses and seek to learn how they areachieved. We can inquire into how ourpractices affect others and elicit theirthoughts. We can explore how a masterclinician was able to arrive at a diagnosisand learn from his or her paradigm. Wecan ask our patients about the times theyhave been healthiest or have overcome anadverse event so that we may understand

their strengths and capitalize on thatinformation to contribute to theircontinued health.

Many of these changes are simple,but they do not come naturally. Beingintentional about taking time to changeour focus to include not only theworst-case scenario but also to envisionthe ideal will take effort. Nonetheless,the imperative for culture change isclear. Burnout, faculty dissatisfaction,and depression in medical schools are

visible all around us. Appreciating theaspects of medicine that give it meaningmay be the antidote to the culturalcontaminant of negativity. Initiativeslike Remens Healers Art course52andthe interprofessional Schwartz CenterRounds53create dialogues and positiverelationships that lend support, cultivateunderstanding, and reinforce the

importance of service. Business46andeducation47studies suggest that creatingan environment that incorporatespositivity and inquiry leads to superiorteamwork and personal success. Studiesin medical communities suggest thatthis philosophy might also improve ourclinical performance.48,49

Louie and colleagues38suggest that everytime a medical student or resident walksinto an inpatient service to start a newrotation, we have an opportunity to teach

from a sociocultural perspective. Wecan take advantage of this opportunityto truly change the culture of academicmedicine.

Acknowledgments:The authors thank Dr. J.Anderson Thomson for introducing them to thenegativity bias.

Funding/Support:The UVA Center for Apprecia-tive Practice is supported by internal fundingfrom the UVA Health System.

Other disclosures:Dr. Plews-Ogan and Dr. Mayreceive funding from Bristol Myers Squibb

for researching self-care of diabetes in AfricanAmerican women.

Ethical approval:Not applicable.

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Perspective the Negativity Bias, Medical.19