Dealing with the complex dynamics of teaching hospitals

Abstract

Innovation and change in postgraduate medical education programs affects teaching hospital organizations, since medical education and clinical service are interrelated.Recent trends towards flexible, time-independent and individualized educational programs put pressure on this relationship. This pressure may lead to organizational uncertainty, unbalance and friction making it an important issue to analyze.The last decade was marked by a transition towards outcome-based postgraduate medical education. During this transition competency-based programs made their appearance. Although competency-based medical education has the potential to make medical education more efficient, the effects are still under debate. And while this debate continues, the field of medical education is already introducing next level innovations: flexible and individualized training programs. Major organizational change, like the transition to flexible education programs, can easily lead to friction and conflict in teaching hospital organizations.This article analyses the organizational impact of postgraduate medical education innovations, with a particular focus on flexible training and competency based medical education. The characteristics of teaching hospital organizations are compared with elements of innovation and complexity theory.With this comparison the article argues that teaching hospital organizations have complex characteristics and behave in a non-linear way. This perspective forms the basis for further discussion and analysis of this unexplored aspect of flexible and competency based education.

What is the state of complexity science in medical education research?

“…55 Other papers used language from one orientation but references from another, such as in a study on the dynamics of teaching hospitals, in which complexity science was invoked to describe the patterns and behaviours of the organisation as variables change. 50 In this case, an aggregate orientation was signalled, but the primary source cited represented a deterministic orientation. That such combining was never explicitly discussed in the papers begs the question of whether the respective authors appreciated the incompatibility of these references.…”

“…For instance, some papers combined citations from multiple orientations, such as secondary sources about chaos and entropy from the deterministic orientation, and secondary sources about social interactions from the aggregate orientation, in order to explore issues of remediation . Other papers used language from one orientation but references from another, such as in a study on the dynamics of teaching hospitals, in which complexity science was invoked to describe the patterns and behaviours of the organisation as variables change . In this case, an aggregate orientation was signalled, but the primary source cited represented a deterministic orientation.…”

“…Several papers 41,43,[49][50][51] in our dataset cited papers that summarised and adapted original concepts, such as the 2001 The BMJ series 24 and the 2011 Medical Education debate, 52,53 as support for their definitions of complexity. The fact that only a few papers used primary sources from before 2000 48,50,54 suggests insufficient engagement with primary sources. Secondly, citations were not always appropriate or accurate for the ways in which the authors were using complexity science.…”

Who owns responsibility? An administrator’s take on implementing time-variable medical training in teaching hospitals

“…In the case of PGME, the main actors are trainees and clinical teachers whose role is not only to provide clinical service, but also to be actively engaged in the process of learning or teaching and designing education, respectively. A change in such an organization can have non-linear, unintended and far-reaching effects (Plsek and Greenhalgh 2001;Mennin 2007;van Rossum et al 2016). Since PGME is workplace-based, it is fully embedded in teaching hospital organizations, meaning that education and clinical service are very much intertwined.…”

“…Indeed, there is strong evidence that TVMT can have external effects, such as a greater need for supervision time (Sonnadara et al 2014;Frank et al 2017) and difficulties to organize and schedule departments, which jeopardizes the continuity of clinical service delivery (Greenhalgh et al 2004(Greenhalgh et al , 2008(Greenhalgh et al , 2010van Rossum, et al 2016;Cleland et al 2018). These issues complicate the implementation of TVMT in daily practice.…”