Improving the quality of work has been the subject of scholarly research for decades. Thinking on this subject was stimulated by Howard Gardner, Mihalyi Csikszentmihalyi, and William Damon, Good Work: When Excellence and Ethics Meet. The authors believe that "good work" can refer to at least two things. First, there is the quality of our experience at work and the contributions our work makes to our overall quality of life. Second, there is the quality of the product or service we offer. The two concepts are closely related,because if we take pride in our work we are more likely to enjoy it, and if we enjoy what we do we are more likely to do it well.
Gardner and colleagues criticize recent studies of work experience because they employ reductive or atomistic methods, confining themselves to breaking down complex work performances into elementary components. Examples in healthcare have included total quality management and continuous quality improvement. Viewing medical education from such perspectives, the final product might be students' scores on standardized tests, such as the United States Medical Licensing Examination. By analyzing the complex steps involved in producing a student's examination scores, we might develop strategies to reduce educational costs and improve student performance. These are laudable goals, and the quality movement has achieved important successes that have contributed to our educational programs.
Yet to really understand the quality of our work, we need to ask some additional questions. Why do medical educators do the work we do? What do we want from our work? What could be done to help us get the most from our work experience? Most of us feel better about our work as errors and inefficiency are reduced, but very few of us assess what we do strictly in terms of error rates and productivity. How do medical educators, and for that matter, learners in medicine, think about the quality of our educational experiences?
Gardner and colleagues encourage us to ask three fundamental questions. First, what is the impact of our work on the wider world? We need to see the work we do as contributing to life beyond our jobs and our organizations. If we do not believe that the world would suffer were we or our organization simply to disappear, then the probability that we will experience dissatisfaction and burnout is heightened. No matter how quickly or efficiently we do what we do, we need to feel that our work makes the world a better place.
Some might question this point of view, believing that Gardner and colleagues have set the bar too high. Is it not enough that we manage to perform our duties competently and provide for ourselves and our families, without enriching the wider world? In fact, however, people who excel at work frequently describe their work in such terms. They are not merely "punching a clock,"when they set off for work in the morning. Instead, through the work they do, they are giving expression to the very best that is in them.
As medical educators, we need to ensure that our colleagues and learners enjoy opportunities to see the difference our work makes in the lives of others, and ultimately, in the lives of the patients we serve. Systematic efforts to assess educational quality can be helpful, because they encourage us to think about how our work can be more efficient or effective in an immediate sense, such as its impact on student test scores. Yet we need to keep a bigger picture in view, as well. Test scores are not the ultimate measure of our effectiveness, and we need to foster a culture where we can share our larger aspirations for work, where we frequently share with one another what a job well done has meant to us and others. An educational program that insulates us from the larger meaning of our work is asking for trouble.
A second vital question is this: How do we know when we are doing a good job? If the only indicators of work performance are throughput and test scores, then we are courting disaffection. Suppose, for example, that educators were evaluated strictly on their number of contact hours with students, or the scores of their students on standardized examinations. Does merely spending more hours with students necessarily translate into improved learning outcomes? Do standardized tests capture the larger vision of what it means to excel as a clinician, a researcher, and a teacher?
We need to expand our conception of good work to encompass not only narrow senses of quantity but also relevance, engagement, and our sense that we are performing at our best. Having someone with a stopwatch looking over our shoulder all day may in fact prove counterproductive, if it does not reflect the broader meaning of good work in the minds of those of us who are doing it. When we feel proud of the work we are doing, we find it more fulfilling. Thus we need to look for ways to help our colleagues and our learners perform at their best. Those of us doing the work frequently understand our work and the factors that contribute to its quality better than anyone else. Getting us actively involved in defining, assessing, and enhancing quality not only improves performance, but also proves rewarding in its own right, because we feel more of a sense of ownership in the work we do.
A third vital question is this: How do we become good at our work? If we adopt as our definition of work improvement minimizing the number of errors we commit each day, then we may begin to regard ourselves, our colleagues, and our learners as parts in a machine. This is a reliable way to discourage the best among us, because those who excel regard themselves not as interchangeable parts but as unique and committed professionals on whose distinctive contributions the whole organization depends. We should strive to create a culture in which we invest in ourselves, by encouraging ongoing education, enabling us to emulate the people we admire, and serving as role models to others.
If a group of medical educators feels that we are losing autonomy, the ability to control the structure and quality of our work, then our sense of commitment is likely to suffer. Likewise, if we feel we are being manipulated into increasing throughput at the expense of quality, some of us will begin seeking opportunities elsewhere. What seems like a good way to increase productivity in the short run, such as replacing live instruction with computer-based tutorials, may in the long run come back to haunt us, by compromising the many educational rewards that arise from contact with learners.
Where should medical educators who wish to improve the quality of our work focus our attention? Gardner and colleagues recommend focusing on what they call the three Ms: mission, models, and mirror. The mission of our educational program is the answer to this question. What are we trying to accomplish, and how does it serve others? If we do not know the answer to this question, we cannot perform at our best. When invited to discuss our mission, many of us feel both grateful and reinvigorated, because it helps us see more clearly what we are really doing. Deep down inside, we want to make a difference.
Even the most senior among us may lose sight of our mission from time to time. In general, this is most likely to occur in situations where we are overworked, in which substantial changes are taking place in the work environment, or in which we feel we have little or no authority in defining, assessing, and improving the quality of our work. In an educational program that is losing people, an attitude of survivalism may quickly prevail, and we may begin to see the program as a sinking ship from which we should take as much as we can before it goes under. We may start making decisions based on our own short-term financial or career interests, rather than the long-term mission of the organization. We may lose interest in longer-term efforts to improve the quality of work life, build future infrastructure, or enhance patient care.
To get our educational programs on track, we need to focus our attention on the program's mission and the role each person plays in achieving it. The best leaders are good at aligning the personal goals of workers and the larger mission of the organization. If there is a large discrepancy between the two, the worker, the program, or both are likely to suffer.
The second M is models. We need to interact with other people we deem worthy of emulation. Principles and techniques are important, but until we see them put into practice by real people, they remain too abstract for many of us. Role models are absolutely vital to every educational program, both for educators and for learners. We need to put a human face on the ideals we intend to pursue.
In an educational program that is declining, an effective leader needs to find admirable people and draw attention to their outlooks and habits. The goal is to get us focused on our shared vision of excellence, not to pick us or our program apart based on pet peeves and vested interests. Regular meetings are vital, because they allow us to discuss and reexamine our personal visions of what a great educational program should be doing.
Perhaps people from other programs that have surmounted the kinds of challenges we are facing could be invited to participate, sharing their experiences and recommendations. What were the key factors in improving their work? How did role models help people focus on the longer-term missions of the program? What pitfalls would they warn us against? It is good to discuss theories of work quality with educational consultants, but there is no substitute for face-to-face conversation with peers who have confronted similar problems and opportunities.
The third M is mirror. It is vital that we pause from time to time to step back and examine the direction in which we are traveling. What kind of people and program are we becoming? When we look in the mirror, we need to ask ourselves, "Are we proud of what we see? Would we be willing to hold ourselves up as a model of how this work ought to be done?" Many educational programs end up looking quite different from what we intended simply because we rarely take the time to look at ourselves in the mirror.
Winston Churchill called attention to the important difference between making a living and making a life. He said that we make a living by what we get, but we make a life by what we give. Making a living is important, even necessary, but we need access to far more than an investment portfolio to take the measure of a person.
In reflecting on our work lives, we need to address these questions. What do the many hours we spend each week at work contribute to our larger sense of what we want to do with our lives? How do they enrich the lives of others? What can we do to make work more enriching for everyone involved? If we really care about the work we do, not because it provides a paycheck but because it enables us to make a big difference in the lives of others, we will enjoy strong intrinsic motivation to do it well.
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