Education as Culture: The Amazing and Awesome Case Conference

“The point of my work is to show that culture and education aren't simply hobbies or minor influences.”¹

–Pierre Bourdieu

The readers of this journal clearly understand that education is not a minor influence; however, the intersection and importance of culture woven through that education may be less front of mind. Yet, the decisions that we make as educators are bidirectional in that they are both shaped by culture and go on to shape culture in crucial ways. This reality is perhaps most obvious in departmental conferences that serve as agents of cultural compression—moments when the values and beliefs of a group bear down on participants with particular intensity.^2,3 Considering these ubiquitous educational activities through a cultural lens will allow educators to move beyond didactic outcomes and to design activities that purposefully shape culture. We feel strongly that cultural objectives should be considered explicitly in the design and implementation of educational activities since culture is not a “minor influence.”¹

In this article we offer perspectives on how we reframed morbidity and mortality (M&M) rounds through the anthropologic lens of ritual, then reimagined it with the expressed objective of shaping safety culture. In sharing our perspectives, we hope to convince readers to take a culture-building approach to the design, implementation, and analysis of conferences that have historically been viewed through an educational lens.

M&M Conference Conceived as a Ritual

Rituals are a feature of all societies. They are practices carried out by a group that involve a prescribed set of events, occur at predictable times, and are laden with symbolic meaning. Some anthropologists suggest that rituals reflect the values and beliefs of a specific culture and are designed to maintain and stabilize social order.^4,5 Others feel that rituals are integral to prospectively shaping culture.⁶ They likely are a dynamic balance between creation and preservation of our communities.

Medicine is rich with rituals; perhaps most familiar is M&M rounds. For over a century, the M&M conference has been a cornerstone ceremony of medical education and clinical practice, focusing on system failures to investigate, understand, and improve patient care as well as to provide teaching for learners in multiples stages of training.⁷ Unfortunately, the conference is sometimes perceived to focus on negative personal traits and to function around a culture of shame and punishment,⁸ both of which can perpetuate a problematic organizational culture. Perhaps even more troubling, it might entrench a cultural mindset based on the weak notion of avoiding errors by reacting to their occurrences (Safety-I thinking) compared to the more constructive and proactive approach of learning around success and productive behaviors (Safety-II thinking).⁹

Designing a Ritual

With the intent of shaping safety culture and inspired by an article in an emergency medicine journal, 3 authors (E.P., E.B., C.M.) developed a new case-review system: The Amazing and Awesome (A&A) Conference.^10,11 This new ritual is based on the theoretical framework of positive deviance as an engine for analysis and change.¹²

Positive deviance is a social change approach based on the identification of individuals, teams, and behaviors (known as positive deviants) that perform exceptionally well within a system.¹² The concept springs from “the observation that in most settings a few at-risk individuals follow uncommon, beneficial practices and consequently experience better outcomes than their neighbors who share similar risks.”¹² Implementation researchers have observed these phenomena in hospitals with unusually fast door-to-balloon times for patients requiring emergent angiography or birth units with uncommonly low complication rates.^13,14 Positive deviance can be used as a teamwork change tool based on the notion that behaviors associated with extraordinary outcomes can be mimicked by all members of the community, leading to system improvement (ie, Safety-II thinking). Interventions to create system change based on positive deviance are founded by identifying those positive deviants, recognizing extraordinary traits, replicating their behaviors, and fostering widespread adoption in the group.¹⁵ The A&A framework focuses on identifying and understanding success, then constructs a ritual making explicit a cultural ethos aiming to disseminate and replicate those behaviors, emphasizing values of excellence, positivity, kindness, safety, and trust. The intent of this ritual is to manifest and strongly signal positive beliefs and values, and in so doing, may lead to a community-based experience of learning while supporting a positive attitude, communal sense of duty, and pride.

Implementing a New Ritual

After conception, rituals are then adopted and practiced by groups. The A&A was first implemented by an anthropologist and an emergency medicine resident, with the sponsorship of a faculty member at a tertiary care emergency department in Canada, with support from the department head and quality improvement lead. We shared this model online,¹¹ which led to adoption by 3 other academic institutions in the United States, Australia, and Chile. Each organization's event was different but deeply rooted in the foundations described above and designed to make explicit the positive values and beliefs consistent with the local culture. One of the global versions was focused on emergency medicine, one on pediatrics, and one in multidisciplinary acute care. This new ritual was simple to incorporate into preexisting educational curricula and schedules with minimal or no additional work. Anecdotally, the authors worked to introduce this new format in a culture that was heavily invested in the traditional M&M model, which is why its implementation served as complement instead of a complete substitute for M&M conferences. The Table describes in detail the different approaches and focus each organization took to adapt the concept and attendance at the events.

Table Implementation of A&A Conference at 4 Different International Institutions

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Over the 1- and 2-year periods that A&A was implemented at these sites, the resources necessary for success seem to be similar to the M&M model. The process, which draws on familiar practices from M&M, is divided into 3 components: (1) identification, (2) analysis, and (3) presentation of specific cases. Each iteration adopted the format of an expositive conference, with a presenter in front of an audience having a greater or lesser degree of interaction. The 4 organizing groups successfully piloted the A&A model and found resource use (faculty and time) similar to M&M conferences. Evaluation was limited to basic Kirkpatrick Level 1¹⁶ outcomes which were ostensibly positive.

Evaluating a Ritual

The reconceptualization of educational events as cultural rituals makes evaluation more nuanced, with traditional educational instruments becoming less relevant.^4,5,17 Our objective is to create sustained cultural and social change.¹² This type of change rarely happens overnight, or even in a few months; it takes years or decades and is often imperceptible to those embedded in the group itself. We are optimistic that the continuous focus on Safety-II thinking and positive deviant behaviors during a moment of cultural compression will beneficially shape our practice and the way that we see our department, our colleagues, our culture, and ourselves. Our next steps include employing approaches from fields outside of medicine and education, such as anthropology and organizational psychology, to understand the cultural and social significance of A&A and other such conferences and educational events.³

Perspective

Insight and reflection, not only around this conference, but around all the rituals we participate in as educators may allow us to deliberately shepherd our communities from where we are to where we hope to be. A&A is a new ritual, easily instituted within current organizational structures, that holds the potential to shape safety culture. It provides a model for the design of an educational event with explicit cultural objectives. We encourage you to join us in considering education as a form of cultural transmission. A simple first step could be engaging in the exciting process of learning from the amazing and awesome work happening in your department every day.