Change in medical education is hard. Arguably, major, persistent, and widespread changes have been few in number since the Flexner report of 1910. What is it that makes organizations and education hard to change? Although many factors may be at play, one important factor is resistance to change. From where does the all-too-familiar resistance originate? The answer to this question is us, people, individually and collectively. All of us at one time or another resist change. We are at times innovators, early adopters, and laggards². Whether as a leader or follower, we are all empowered and at the same time imprisoned by a psychology of inertia¹ and an organizational culture that often supports the status quo. All leaders need to realize that this resistance is not an enemy to be vanquished or a delay to be endured but a natural and important part of the change process, the leader’s friend. This Cell will lay the intellectual and attitudinal direction and foundation for your efforts to successfully change and improve medical education.

Learning Objectives (what you can reasonably expect to learn in the next 15 minutes):

1. List two psychological and two cultural forces for inertia (resistance against change)
2. Explain how resistance to change (both cultural and psychological) is natural, understandable and, yes, even helpful.

To what extent are you now able to meet the objectives above? Please record your self-assessment. (0 is Not at all and 5 is Completely)

To get started, please take a few moments to recall a recent change effort in which you were involved either as the innovator or the one needing to change. What were your first impressions and, yes, feelings, about the change process? 

Now proceed to the rest of this CORAL Cell.

New ideas represent a personal and corporate threat to old, familiar, and comfortable ways of being at work. Ideas and innovations that do not pose a threat are by definition not that new, at least not to those who embrace them, advocate for them, and attempt to implement them.

Usually, those who promote these new ideas have thought about them, tried them out, made some observations, perhaps written up their results, and then invited the rest of us to give them a whirl. Over months and maybe years those with the new ideas have come to terms with the implications of the change, become competent in new ways of thinking and doing, made sense of the innovation, and started to move forward.³ That is not the case for many others.

Change can be a distressing and often evokes emotional responses. These responses, whether anger, confusion, feelings of incompetence and uncertainty, and/or conflict often lead to what we label as resistance to change⁴. When change comes knocking we realize, often subconsciously, that we are about to face loss, awkwardness, incompetence, uncertainty, confusion, and conflict⁵. 

Psychologically, people faced with changes in the medical school may feel their job security slipping, their sense of place evaporating, and their self-esteem shrinking. When someone says, “you should try this _______ “ (insert: flipped classroom or jigsaw or small group discussions or even competence by design) what they may hear is “what you have been doing for the past 15 years, and all the time you spent perfecting your lectures, was a waste of time!” These are some of the psychological forces of inertia.¹  That is, those forces that influence a person to resist change. Under those perceptions of reality it is quite reasonable for people to grieve, to cling to the past, and to resist⁴.

However, sometimes people notice that the innovation isn’t that good and either needs modifications or rejection. Promoters of new ideas often succumb to confirmation or other biases and don’t see the weaknesses that others may notice. This type of resistance can be a positive force in change, as it often causes promoters to pause and think, and refine their change proposal for the better.  Who is do you think is in the right and who is in the wrong in this clip art to the right? Both of them, maybe?

We have titled this Cell “Resistance to Change: Friend, not Foe” for two reasons. First, people who resist may see flaws that those who are promoting the change do not or will not see. The resistance is truly camouflaged support to make the innovation better. Second, from an interpersonal perspective, promoters of change don’t want to consider their friends and colleagues who resist change as enemies to be vanquished but rather as people who are experiencing some degree of loss with the adoption and implementation of the new ideas. As Burke argues on p.108, we are “not simply and naturally resistant to change” … but that people resist the imposition of change and fear the loss that change brings.⁴

We’ll explore the leader’s role a little further into this Cell. Now let’s explore cultural inertia and the status quo.

Organizational culture is a set of shared assumptions and related behaviours that allow members to know how to act and what to do in certain situations. These are passed on to new organizational members affecting the way people and groups think and feel and interact with each other (Ravasi & Schultz, 2006).⁵

Cultural forces of resistance have more to do with shared or collective norms and values: “we do it this way” or “we found that it works better this way”. Sometimes those forces show up as articulated collective beliefs: “PBL is the way to go!” or “Active learning just dumbs down the course”.

Take, for example, negotiating the proportion of time (and implicitly the priority) that various courses, competencies, or blocks will have in the curriculum. The allocation of time and weight given to non-medical expert skills and knowledge (patient advocacy, inter-professional practice and collaboration, leadership among others⁶ in the medical school curriculum) compared to the biomedical sciences partly represents the cultural values and assumptions about what is important in medicine. Even though strategy documents such as The Future of Medical Education in Canada⁷ or the CanMEDs⁶ may officially espouse different values, it is the deeply held and shared cultural assumptions and values that play a large role in shaping behaviour, day after day. Clearly, as Giga Information Group put it: "(organizational) culture eats strategy for breakfast!" ⁸.   

Unfortunately, sometimes even the most well-meaning leaders may become impatient with the pace of change. They may also need to implement unpopular changes (for example, extensive program cuts).  This makes change much more difficult for everyone.  When leaders try to force changes, inevitably some followers will resist. Followers may only incorporate the change superficially or truly sabotage the change whether knowingly or otherwise.

Real change needs to go beyond just changes to policies, procedures, organizational charts, and new course names. Real change must penetrate cultural beliefs and assumptions, to assimilate or displace the old.⁹ The new way then becomes the way of doing things, and ultimately represents a change in norms and values, through which the organization has renewed itself.

Is there hope for change, a way forward; can the psychological and cultural inertia to change be overcome? Yes, but we must go carefully, read the signs, and not ignore or, worse, disparage human nature. Being unrealistic, trying to go too far too fast is truly and predictably counterproductive¹⁰. We must marry reach with realism¹⁰. Leaders need to find that balance between too fast and too slow and a direction that avoids both fierce resistance and suffocating stagnation. Learning about specific leader behaviours that support change, such as those espoused by Bland et al. (2000)¹¹ we will leave for other Cells. The main point of this Cell is to convince you that resistance is not the enemy nor are those who resist change our foes. Change can be and ought to be managed from a humanistic perspective.

Please complete the following very short self-assessment on the objectives of this CORAL cell.

To what extent are you NOW able to meet the following objectives? (0 is not at all and 5 is completely)

To what extent WERE you able the day before beginning this CORAL Cell to meet the following objectives? (0 is not at all and 5 is completely)

Thank you for completing this CORAL Cell.

We are interested in improving this and other cells and would like to use your answers (anonymously of course) along with the following descriptive questions as part of our evaluation data.

Provide feedback on module

Thanks again, and come back soon!

The CORAL Cell Team

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References:

¹ D’Eon M. The challenges of educational change: cultural and psychological inertia. CMEJ;4(2):e1-e3.

² Rogers, EM. Diffusion of innovations. Toronto, Canada: Collier-MacMillan; 1962.

³ Marris, P. Loss and change. New York: Anchor Press/Doubleday; 1975:166.

⁴ Burke R, Friedman L. Essentials of management and leadership in public health. Jones & Bartlett Learning; 2011 Jan 28.

Ravasi, D.; Schultz, M. (2006). "Responding to organizational identity threats: Exploring the role of organizational culture". Academy of Management Journal. 49 (3): 433–458.

⁶ Frank, JR. (Ed.). The CanMEDS 2005 physician competency framework: better standards, better physicians, better care. Royal College of Physicians and Surgeons of Canada; 2005.

⁷ Busing, N. The future of medical education in Canada (FMEC): a collective vision for MD education. The Association of Faculties of Medicine of Canada (AFMC); 2009.

⁸ Goldsmith J. Keynote address, Academy for Health Services Research Annual Meeting, Los Angeles, 26 June 2000, as reported in Teasdale, S. Culture eats strategy for breakfast! J Info Prim Care; 2000:195-196.

⁹ Shein, EH. Organizational culture and leadership. San Francisco, CA: Jossey-Bass; 2010.

¹⁰ Evans, R. The human side of change: reform, resistance, and the real-life problems of innovation. San Francisco, CA: Jossey-Bass; 1996.

¹¹ Bland CJ, Starnaman S, Wersal L, Moorhead-Rosenberg L, Zonia S, Henry R. Curricular change in medical schools: how to succeed. Academic Medicine. 2000 Jun 1;75(6):575-94.

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Further reading:

Fullan, MG. The new meaning of educational change. 2^nd ed. New York, NY: Teachers College Press; 1991:31.

Moore, B., & Rose, J. (2000), Recovered paper trading, ready for the Web? PIMA’s North American Papermaker: The Official Publication of the Paper Industry Management Association, 82 (9), p. 26 -28.

Schwandt, D.R., & Marquardt, M.J. (2000). Organizational Learning. From World-Class Theories to Global Best Practices. Boca Raton, Florida: CRC Press.

Credits:

Authors: Marcel D’Eon, University of Saskatchewan; Joanne Hamilton, University of Manitoba
Series Editor: Marcel D’Eon
Reviewer/consultant: Irene Ma, University of Calgary

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