Educational Strategy

A transatlantic jet airliner entered a large storm system where it was buffeted about by strong winds. During the most intense turbulence, the passengers were startled to hear an explosion in the cockpit. Minutes later, the co-pilot's voice was heard over the intercom:

Ladies and gentlemen, we have sustained damage to our equipment as a result of the storm. I have good news and bad news. The bad news is that our plane's navigational system is ruined and we do not know in what direction we are traveling. The good news is that we are experience strong tailwinds, and we are making record time.

Sadly, this story rings true for many educational leaders, who find ourselves tossed about in a sea of turbulent change in medical education. Some of us have been working so hard just to keep our program's head above water that we have little energy left to think about where the currents are carrying us. Treading water is simply no way to navigate: you get nowhere, you soon grow exhausted, and you end up drowning anyway. As educational leaders, we cannot afford to neglect two crucial questions: where we want to go, and how we are going to get there.

The future of medical education hinges on the quality of our leaders' strategic planning. We need to cultivate a strategic outlook, a type of outlook not always found in the framework of medical science or clinical medicine. This means critically examining our own assumptions and biases. It means not only asking, "What is?" but also, "What if?" We need to develop and sustain an ongoing dynamic interchange between medicine and the broader world, expanding educators' and learners' notions of relevance to encompass information that is not only accurate but thought provoking.

The benefits of a strategic approach in medical education are manifold. It enables us to develop a well-grounded identity, and fosters consistency in decision making and the identification of clearly specified goals. It encourages us to study the present situation in light of our aspirations for the future, helping us to determine where innovation is most vital. It requires us to communicate, both among ourselves and with colleagues in other organizations. It makes our programs and institutions more coherent and cohesive wholes. Finally, it may improve financial performance, by fostering greater coordination between goals and resources. Often the strategic plan itself is less important than the process of sharing perspectives and developing new ideas.

What are the elements of a strategic plan? Moving from top to bottom, they include mission, vision, strategy, goals, and actions. The mission of an organization is its reason for being. One of the most damning criticisms we could level at any educational program is that it lacks a mission. Without a mission, an organization does not know what it is ultimately trying to do. It is like an airliner whose pilot keeps it airborne, but is not proceeding toward any particular destination.

Nearly as bad as lacking a mission entirely is failing to ensure that all the members of the organization know the mission. If we do not know how our jobs fit into the overall purpose of the organization, then our ability to contribute to its achievement is severely compromised. If we do not know the mission, see it clearly, and pursue it enthusiastically, then we are unlikely to excel in our work. We need to believe that the world would be a poorer place without our work.

Vision is the organization's mental picture of what it is trying to become in the future. The mission provides a frame of reference for the vision, but mission alone is not enough,because it does not specify how the organization's purposes are going to be achieved. If the mission tells why we need to erect a new building, the vision describes what the building will actually look like, based on the purpose it is being built to serve. The vision gives members of the organization a sense of what they are supposed to be moving toward, and thereby creates a sense of progress. It is important periodically to check the vision against the mission, to ensure that the organization's future faithfully reflects its reason for being. For example, do we educate our medical students with the intention that they pass all the standardized tests, or are we attempting to train first-rate physicians?

Strategy is the plan for achieving the vision. It is not enough to know what our educational programs are attempting to become. We must also understand how they are going to do so. There are many possible routes by which to reach a particular destination, and strategy considers such factors as effectiveness and efficiency in choosing among them. Effectiveness is the probability that we will reach the destination. Efficiency is the amount of resources we expend in doing so. The fact that efficiency appears only at the level of strategy, subordinate to mission and vision, highlights the secondary nature of its role in strategic planning. We must first determine why the medical school exists; then we can determine what resources it needs to accomplish its mission. Efficiency calculations can help determine what route to take, but they cannot specify what should be the destination.

Goals are specific targets for achieving the organization's vision. If strategy is the route the organization chooses to reach its destination, then goals are like the steps that must be taken along the way to get there, such as specific legs of the journey and stops for rest and refueling. A common strategy for formulating goals is to step back from time to time and construct top-five lists of key targets that must be reached if the organization is to realize its vision. Generally, such goals should be outlined at least annually, and more often in environments that invite rapid change. Of course, goals must not be written in stone, and should be subject to change as circumstances demand. In the absence of clearly defined goals, however, even the most visionary strategic plan will produce little in the way of results, because no one sees what to do now to move the organization along.

Actions are specific tasks that must be accomplished to achieve goals. For example, while driving along the leg of a particular journey, it is necessary to turn the steering wheel, sometimes to the right and other times to the left, in order to avoid crashing. In organizations, such tasks must be assigned to particular individuals, have clearly defined time frames, and specify both authority and accountability for their completion. By planning actions appropriately, it is possible to build short-term successes into longer-term strategic plans, thereby fostering morale and momentum throughout a lengthy strategic course.

Permeating all levels of the strategic plan are the organization's ethical principles. Ethical principles are our moral compass, our sense of what kind of an organization we are and what we will and will not do in pursuit of our objectives. Ethical principles powerfully affect the organization's performance because they define our basic way of doing business. How are our targets formulated, how do we reward ourselves, how do we handle disagreements, and so on? Do we allow faculty members to publicly berate medical students or residents? What are learners supposed to do if they encounter a situation that makes them ethically uncomfortable? Who are our role models, and what do they exemplify? Such principles set a tone throughout the organization, and making sure the best principles are in place is one of the most important missions of educational leaders.

The word strategy is drawn from a Greek root that refers to leading an army, and a synonym for strategy in this sense would be generalship. In military parlance, strategy is distinguished from tactics. Generally speaking, tactics refers to decision making that takes place once the enemy has been engaged, whereas strategy refers to planning that takes place prior to engagement. During the Second World War, the United States and its allies engaged in strategic bombing of German industries such as petroleum refining and manufacturing, in an effort to undermine the German capacity to wage war. Most battles are decided before the first shot is ever fired.

The resources of every organization are limited, and one mission of strategic planning is to plan the allocation of those limited resources in a way that produces the maximum medium-term and long-term payoffs. Many of us spend too much time thinking tactically, taxing our ingenuity to solve problems as they arise in daily work. By dint of years of experience in the trenches, we become quite good at bandaging wounds, but too often we fail to step back and examine the system that repeatedly gives rise to the injuries in the first place. The strategic approach is to step back and think creatively about how to improve the system, be it a particular process or the whole organization. It means asking radical questions about why the system is composed and structured as it is, and whether it really ought to remain that way.

Physicians tend to be a fairly conservative group. Since our first days in medical school, we were reminded again and again of the Hippocratic maxim, "First do no harm." Eager to excel, we became adept at recalling what our teachers told us to learn, a pattern that often continues and intensifies during residency training. Creativity is not a priority. Ask most medical students or residents what we want to learn, and we will point to a textbook. The implicit message? Learn everything, and do not get caught not knowing something. Our curriculum is more conducive to conformity than creativity, despite the fact that the latter is greatly needed.

The future of medical education does not depend on cultivating leaders who are so careful they never make mistakes. Quite the opposite; the future of medical education, and ultimately that of the whole profession of medicine, depends on cultivating leaders with the courage to take risks, the judgment to know which risks are worth taking, and the ability to learn from mistakes. Show me a department chair or a dean who never makes mistakes, and I will show you an organization in desperate need of new leadership. If we adopt a defensive posture and attempt to insulate ourselves from change, we become mere stepping-stones for innovators who are eager to blaze new trails.

Among the greatest enemies of innovation are complacency and fear. Good enough is the enemy of better, and academic physicians who are satisfied with the status quo are unlikely to attempt to enhance performance. Every one of us has colleagues whose attitude toward the future is one of trepidation. Their perspective may be likened to that of Lord Salisbury, who argued that whatever happens will be for the worse, so it is best that as little happen as possible. They regard strategic planning warily. As long as such individuals regard the unknown as more threatening than the status quo, meaningful innovation will be impossible.

Leaders need imagination, the ability to foresee a future better than the present, or at least better than the current trajectory. And one key attribute of imaginative leaders is openness. Getting people to do what we want is less important than the ability to listen to what others have to contribute and put it to good use. In the knowledge economy,freedom and creativity become increasingly important, and they require an open exchange of ideas and perspectives. The totalitarian state, as embodied in the former Soviet bloc, illustrates the antithesis of a model of effective leadership, in which conformity underwritten by the threat of force was prized above all. In the future of medical schools, outstanding leaders will be defined not by how much power they wield but by how much they know, and how much they know will depend on how well they listen.

To be successful, we need to promote and encourage conversation. Most leaders are overburdened with information, but starved for genuine perspective. In what new and fruitful ways could we think about our organization and its mission? We need to become the number one connoisseurs and disseminators of new perspectives. We need to build cultures where everyone at every level is encouraged to learn and to share what they know. Effective strategic planning requires inclusiveness, taking advantage of as many perspectives as possible. Especially helpful are colleagues who help us to see problems and opportunities in new ways. The last thing we need is yes-men. Such people merely confirm our prejudices. Instead we need people who help us to reexamine our assumptions and biases.

An insulated leader is an ineffective leader. We need constant exposure to new ways of thinking, especially those from outside our field. The solutions to the most important problems rarely lie within the perspective of the people who first recognized them. We need to spend time reading and attending conferences outside our field. We might enroll in courses in other disciplines. The muscle of creativity is strengthened by such interdisciplinary experience. When it is not challenged, that muscle grows weak and flabby.

Creative leadership requires a questioning attitude. People who think they have everything figured out are the last ones to ask questions. Only through continuous inquiry can leaders ensure that organizational strategy is appropriately tuned to the true state of affairs. Every important decision involves uncertainty, but intelligent questioning can reduce that uncertainty to more manageable levels by providing a clearer conception of what the world really looks like.

Risk and reward are tightly correlated. As a consequence, we view uncertainty not as a handicap, leading to a paralysis of judgment, but as an opportunity for innovation, with substantial rewards for the organization. If there were no uncertainty, every program would thrive to the same extent as every other. Because uncertainty is always present, the best leaders are able to use superior understanding to full advantage. The organizations most likely to thrive are those whose vision extends beyond the box of conventional assumptions and who effectively integrate that vision into their strategic planning.

Socrates famously declared that the unexamined life is not worth living. Certainly the success of academic departments and medical schools that do not engage in frequent self-examination is likely to prove short-lived. Such self-examination requires above all a willingness to acknowledge and redress deficiencies. The inability of academic physicians to face up to our mistakes sentences our programs to years of underachievement, our potential for flourishing largely untapped. Everything we do needs to be scrutinized, to determine whether current performance is in line with potential achievement. Mistakes are not signs that we should give up but laboratories of success. We need to cultivate a culture where mistakes are not only tolerated but welcomed. If we are not making mistakes from time to time, we are not learning, and if we are not learning from small mistakes, bigger and more catastrophic failures become inevitable.

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