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This paper describes a collaborative curriculum project integrating 4 leadership programs at three academic levels. What emerged from this effort was a theoretical model understood as a boundary object that allows our diverse perspectives a space within which we can communicate, collaborate, and learn from each other.

BackgroundRecurrent operational problems in teaching clinics may be caused by the different medical preferences of patients, residents, faculty, and administrators. These preference differences can be identified by cultural consensus analysis (CCA), a standard anthropologic tool.ObjectiveThis study tests the exportability of a unique CCA tool to identify site-specific operational problems at 5 different VA teaching clinics.DesignWe used the CCA tool at 5 teaching clinics to identify group preference differences between the above groups. We averaged the CCA results for all 5 sites. We compared each site with the averages in order to isolate each site's most anomalous responses. Major operational problems were independently identified by workgroups at each site. Cultural consensus analysis performance was then evaluated by comparison with workgroup results.ParticipantsTwenty patients, 10 residents, 10 faculty, members, and 10 administrators at each site completed the CCA. Workgroups included at minimum: a patient, resident, faculty member, nurse, and receptionist or clinic administrator.ApproachCultural consensus analysis was performed at each site. Problems were identified by multidisciplinary workgroups, prioritized by anonymous multivoting, and confirmed by limited field observations and interviews. Cultural consensus analysis results were compared with workgroup results.ResultsThe CCA detected systematic, group-specific preference differences at each site. These were moderately to strongly associated with the problems independently identified by the workgroups. The CCA proved to be a useful tool for exploring the problems in depth and for detecting previously unrecognized problems.ConclusionsThis CCA worked in multiple VA sites. It may be adapted to work in other settings or to better detect other clinic problems.

Some problems in clinic function recur because of unexpected value differences between patients, faculty, and residents. Cultural consensus analysis (CCA) is a method used by anthropologists to identify groups with shared values. After conducting an ethnographic study and using focus groups, we developed and validated a CCA tool for use in clinics. Using this instrument, we identified distinct groups with 6 important value differences between those groups. An analysis of these value differences suggested specific and pragmatic interventions to improve clinic functioning. The instrument has also performed well in preliminary tests at another clinic.

Teaching clinic managers struggle to convert performance data into meaningful behavioral change in their trainees, and quality improvement measures in medicine have had modest results. This may be due to several factors including clinical performance being based more on team function than individual action, models of best practice that are over-simplified for real patients with multiple chronic diseases, and local features that influence behavior but are not aligned with core values. Many are looking for a new conceptual structure to guide them. In this paper we briefly review several theories of action from the social and complexity sciences, and synthesize these into a coherent "ecological perspective". This perspective focuses on stabilizing features and narrative, which select for behaviors in clinic much like organisms are selected for in an ecosystem. We have found this perspective to be a useful guide for design, measurement, and joint learning in the teaching clinic.

Recurrent problems in medical teaching clinic are common and difficult to address because of complex interpersonal dynamics. To minimize this difficulty, we developed a conceptual model that simplifies problems and identifies the root cause of tension between groups in clinic. We used recursive analysis and modeling of the data from a larger multi-site, multi-method study of problems in teaching clinic. The first dataset from this study consisted of problem lists generated and prioritized by knowledgeable insiders from each site. The second dataset was a cultural consensus analysis independently performed at each site. The final model was checked for face validity and construct validity (using model predictions versus prior data and convergent/discriminant analysis). The study was performed in five Veterans Affairs teaching clinics in the U.S. Our final model, the Perception of Care Map, is a pentagram with five critical perspectives of the clinic visit. These five perspectives are "structured care, educational care, relationship-based care, algorithmic care" and "efficient care." Each group emphasizes one or more of these perspectives, and group locations on the conceptual map explain the observed tensions between groups. Validity of the model is high. The Perception of Care Map may be a useful adjunct for understanding and addressing recurrent problems in teaching clinic.

Qualitative analysis of a large ethnographic database from observations of a resident teaching clinic revealed three important findings. The first finding was that breakdown, a situation where an "actor" (such as a person or the group) is not achieving expected effectiveness, was the most important category because of its frequency and explanatory power. The next finding was that exposure to breakdown was a necessary ingredient for reflective learning. The final finding was that effective response to breakdown (with concomitant reflective learning) requires six factors to be present: the patient is engaged directly;responsibility is matched to authority; tools are matched to tasks; information resources are matched to need; values are matched between co-participants; and expectations are matched with capacity. These findings have implications for planning, improvements and further studies in ambulatory teaching clinics.

s Issues of communication and the possibilities for the transformation of perspectives through an experimental dialogue resulting in a mutual, open, receptive, and non-judgmental consideration of the other are addressed in this paper from transdisciplinary theoretical and conceptual standpoints. The warrant for cultivating this type of communicative ability is based on arguments resulting from the assumption of widespread confusion and conflict in intrapersonal, interpersonal, intergroup, and ecological relations across the globe. I argue that there are two distinct classes of 'reasons' for this proposed practice of dialogue. First is recognition of the need for human individuals to engage in a regular and systematic 'social maintenance' of embodied consciousness to forestall the continuous colonization of the past/future on the living present that embodied consciousness entails. Second is the teaching of a skill to creatively and respectfully engage with others in a mutual transformation of perspectives. This paper addresses the general problem of perspectives and reflexivity at the root of the communication phenomenon and by extension - to its scale and to its pathologies in individuals and collectives. It is argued that suspension of judgment, assumption, and habit (broadly) helps interlocutors to recognize the possibility of holding one's history in a tensional abeyance and to focus on the living present independent of habitualized and reified identities and the embodied manner in which we unconsciously carry ourselves as social or 'universalized selves' in social situations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Recurrent operational problems in teaching clinics may be caused by the different medical preferences of patients, residents, faculty, and administrators. These preference differences can be identified by cultural consensus analysis (CCA), a standard anthropologic tool. OBJECTIVE: This study tests the exportability of a unique CCA tool to identify site-specific operational problems at 5 different VA teaching clinics. DESIGN: We used the CCA tool at 5 teaching clinics to identify group preference differences between the above groups. We averaged the CCA results for all 5 sites. We compared each site with the averages in order to isolate each site's most anomalous responses. Major operational problems were independently identified by workgroups at each site. Cultural consensus analysis performance was then evaluated by comparison with workgroup results. PARTICIPANTS: Twenty patients, 10 residents, 10 faculty, members, and 10 administrators at each site completed the CCA. Workgroups included at minimum: a patient, resident, faculty member, nurse, and receptionist or clinic administrator. APPROACH: Cultural consensus analysis was performed at each site. Problems were identified by multidisciplinary workgroups, prioritized by anonymous multivoting, and confirmed by limited field observations and interviews. Cultural consensus analysis results were compared with workgroup results. RESULTS: The CCA detected systematic, group-specific preference differences at each site. These were moderately to strongly associated with the problems independently identified by the workgroups. The CCA proved to be a useful tool for exploring the problems in depth and for detecting previously unrecognized problems. CONCLUSIONS: This CCA worked in multiple VA sites. It may be adapted to work in other settings or to better detect other clinic problems. [ABSTRACT FROM AUTHOR]

Some problems in clinic function recur because of unexpected value differences between patients, faculty, and residents. Cultural consensus analysis (CCA) is a method used by anthropologists to identify groups with shared values. After conducting an ethnographic study and using focus groups, we developed and validated a CCA tool for use in clinics. Using this instrument, we identified distinct groups with 6 important value differences between those groups. An analysis of these value differences suggested specific and pragmatic interventions to improve clinic functioning. The instrument has also performed well in preliminary tests at another clinic. [ABSTRACT FROM AUTHOR]