Language Matters

In response to a recent curricular change, students at the University of North Carolina School of Medicine wrote that “the administration had not involved students sufficiently in a curricular decision.” Speaking to my colleagues across the country, I have learned such concerns are also common at other schools.

In my new position of Senior Associate Dean of Medical Student Education, this statement troubled me. It troubled me not because the students were wrong. They were right. In hindsight, we should have involved the students earlier and in a more meaningful way. What troubled me was the use of the term “the administration.” In this column I want to examine this word and how its use influences the training of future physicians. I have invited Danielle Jameison to help me reflect. She is a senior medical student whose insights have shaped my thinking.

The definition of the word “administration” is innocuous enough:

noun
: the process or activity of running a business, organization, etc // “the day-to-day administration of the company”
: the management of public affairs; government

Beat Steiner: Danielle, thanks for helping me think through this. What are your thoughts about this word and how it relates to the bigger concept of communication and trust between faculty and students?

Danielle Jameison: Thank you for inviting me into the conversation. Often, when students use the word “administration,” particularly as in the context above, it departs from its innocuous origins. In this setting, it is more akin to the following definition: “a group of persons who manages or supervises the execution, use, or conduct of.” From this connotation arises a few problematic, albeit insidious, consequences. One, the identity of this “group of persons” is absorbed and made into a nebulous other. The motivations and intentions of this “group of persons” lose individual, personal granularity, and soon all members of the so-called administration are subsumed under the collective impersonal institution’s perceived mission. Secondly, when understood in the bureaucratic sense, the word “administration” becomes inevitably, even if subconsciously, associated with larger-scale uses of the word (ie, political administration). In the current climate, the “administration” is characterized, at best, by controversy and questions of truth. Neither of these consequences, however unintended, contributes to a culture of trust and open communication between students and faculty.

Beat Steiner: When I hear the term “the administration” I never know who it refers to. We have about 60 staff and faculty working in the Office of Medical Education. Does it refer to all of us or just one of us? The lack of specificity often makes it more difficult to respond to the critique. And the term is generally used when an issue worthy of critique has surfaced. The administration is invoked when raising a concern such as the one at the beginning of this column. Rarely is it used in a praising way such as “we congratulate the administration on a job well done.” But most importantly it sets teachers apart from students. It widens the gap between students and teachers. It creates an atmosphere of mistrust.

Danielle Jameison: At UNC and nationally, an atmosphere of mistrust seems to be more palpable over the past few years. Perhaps it is related to the broader national climate. This impression is in part anecdotal based on conversations with my peers, but it can also be seen on AAMC graduation questionnaire response trends. Regardless of the cause, a sense of mistrust between students and their administrators impedes a healthy, safe learning environment. It breeds retreat rather than relationship, animosity rather than authenticity. This dynamic is suboptimal in any setting, but particularly in medicine, which has the goal of teaching and cultivating the virtues of care, service, and humanism in the profession of medicine. Certainly, restoring this environment to one where the care is practiced as much as it is preached is quite an undertaking, but perhaps one small step is a restoration in language.

Beat Steiner: The goal that drew me into medical education and that has sustained and inspired me is the opportunity to help train caring physicians. The adjective “caring” is critical. Training highly competent and skilled physicians is important, but we have failed when those physicians do not also care deeply. And caring happens at many levels. The most obvious form of caring is caring for patients. Considerable effort is made to teach students skills of empathy and caring during training. At a second level, we now recognize the importance of caring for ourselves. Self-care and wellness have risen to the national consciousness. Poor self-care is linked to burnout and poor patient outcomes. Medical training has begun to incorporate strategies on how to care for oneself. But often the least talked-about level of caring is caring for our colleagues. When we care for each other in authentic ways, our lives are enriched.

Danielle Jameison: Caring for each other may at first glance seem like a task of peers. That is, faculty-to-faculty care, and student-to-student care. To the extent that faculty caring for students and vice versa does not immediately cross our minds as what “caring for one another” means, we perhaps get a glimpse of the hierarchical dynamic that underpins these relationships and subverts efforts at creating community. In reimagining caring for one another as something everyone is able to participate in with everyone else, we might also begin to reimagine the nature of our relationships themselves. Not an institution with students and administration, but a community of colleagues.

Beat Steiner: I really like the idea of using the word “colleague” to refer to each other. While we are at different levels of training, the term connects us as a community of professionals working together to heal. Making this switch raises important broader questions. What does it mean to care for each other in this community? How do we nurture each other so that we can best create healing relationships with our patients? What role does language play in this? These are the questions we are trying to answer as we respond to the UNC students’ concern that they have not been involved sufficiently in curricular decisions and that more transparent communication is needed. These broader questions are relevant because if we can nurture a community of colleagues where trust is high, it is easier to assume “best intentions” and work through problems. When we are in safe spaces, we are better able to speak freely and find creative solutions together. Replacing the words “the administration” with “our colleagues,” and considering students as part of a community of colleagues may be a small step in the right direction. Using this new language may bring us closer together, narrow the space between us and them, create a more positive learning environment, and help train physicians who truly care. Because language matters.

Beat Steiner: Danielle. Thanks so much for taking the time to think through this will me. I hope these reflections are helpful to the readers of Family Medicine and this will prompt further discussions.