Leaving Our Silos

By Daniel Ehrmann, fourth-year medical student, University of Michigan Medical School

I have fond memories of the beginning of medical school. The first weeks were a whirlwind. As we adjusted to this new way of life, we developed an early camaraderie. It seems like so long ago when we used to all go to a barbecue after class. Literally, almost all 170 people attended. Looking back on those days, I think what united us all was a common interest in one another (combined with a common goal to survive the next four years).

Then, as my training continued, something odd happened. We started to split into factions. We put up our own silos—self-contained towers only big enough for our like-minded colleagues. The lecture-goers hung out with the lecture-goers. The home podcasters hung out with the home podcasters. The people who were more interested in bench research found collaborators with shared interests, as did those who were more interested in community advocacy, or health disparities, or medical education.

But that, in itself, was not the problem. Surely, it’s unrealistic to remain friends with every single person in your medical school class. What was more troublesome to me was that we all began to lose our connection with one another. Not only did we build our own silos, but we stopped caring as much about the others. We identified those who were like us, who were likely to share the same goals and interests, and frankly ignored most of the rest.

Then we entered our clinical years of medical school. Many of us were disillusioned because we found more silos than even before. I can’t count how many times I heard statements like “Who cares what the emergency room doctors say, we’re the surgeons” or “Why don’t the nurses just do their job and let us be doctors.” We were inculcated with the belief that when you do your psychiatry rotation, you are to think like a psychiatrist and when you do your internal medicine rotation, you are to think like an internist and so on.

It’s ok and even healthy to think like your mentors when you’re trying to learn more about their specialty. This is especially true when patients have problems that require a specialty-specific knowledge base and approach. But what happens when there’s a problem that’s bigger than any one specialty or way of thinking? I’m thinking about the kind of situation that I wrote about in my commentary. I bet most of us stay in the silos that we’ve been building since the first year of medical school. We’ve been too busy critiquing others’ silos from inside ours to sit down and have a meaningful conversation about a problem where our interests and goals are likely to be shared.

The ideas broached by Dr. George and colleagues in their article in November issue of Academic Medicine are essentially ways to prevent trainees from erecting our silos in the first place. It will be vital to expose trainees to the system-wide issues (e.g. care coordination) that are likely to affect all of us as aspiring physicians, nurses, and public health professionals, no matter what specialty we choose to pursue.

I’m imaging one of many changes in medical education that can be made to address this problem. Instead of reserving quality improvement electives for the fourth year of medical school, long after many of our silos have been erected, why not try something else? First- and second-year medical, nursing, and public health students can join a quality improvement “track” early in their graduate training. As part of this track, students voluntarily meet in small, fifteen-person groups tasked with defining a relevant quality improvement project (e.g. care coordination). Through concurrent formalized leadership and communication training by interdisciplinary graduate school faculty, students will learn how to gather data to quantify the problem, work with consultants in the hospital and medical school (e.g. residents, attending physicians, hospital and medical school administration, etc.), and implement pilot projects. Distinction can be given upon graduation, and the additional benefits of joining such a track (e.g. networking, problem-solving skills, etc.) will make it very attractive to future employers. Not to mention, quality may actually improve.

This is just one idea. I challenge you to think about other solutions to the problem of care coordination, where we all have a shared interest in pursuing a common goal. It is only in this context where we can lay the foundation for an anti-silo culture that can last the rest of our careers.

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  1. Kemi Tomobi
    October 3, 2013 at 6:08 AM

    I think this is common for medical school.  Some say it is like high school all over again.  Everyone is actually interested in meeting and learning from everyone in the beginning.  Everyone comes out to the same classwide events, people can laugh about shared experiences, and learn from one another.  However, with time, it becomes natural for people to naturally “prefer” and get along with people who are more like them.  These “cliques” may be fine, as long as it does not hinder the educational process or workplace environment for anyone. 

    I was very, very fortunate to have had a great anatomy group, I therefore try to always reach out to make others have a decent anatomy experience as well.  Not many others were as fortunate. 

    Certainly, you start to have more in common with your neighbors, people with shared religious beliefs, shared philosophies on relationships, and more.  As a result, cliques can form.  It can be fine, because anyone should be able to choose friendships, but when it comes to group work in the academic or work setting, such cliques can be isolating for those who are struggling and may not have the means (or is not willing) to share.

    But all this is nothing, and I mean nothing – compared to what the clinical years can do to a medical trainee. Empathy drops dramatically in the third year of medical school, and this empathy tank drops even more in graduate medical education training (residency).  Therefore, the ability and desire to maintain such a connection to coworkers and comrades and peers should be pursued to the fullest.  The “Humanism in Medicine” movement must grow strong.

    I like the idea of interdisciplinary education, as it is one of the valuable changes that should be made to medical (and all of health professions) education.  Such an approach will improve communication between different groups.  Patients, especially those with complex chronic conditions like sickle cell disease, stand to benefit the most from multidisciplinary care.  From a conference I recently attended, I learned that one of the fears of promoting interdisciplinary education and practice is that each individual professional group may lose out on what makes them unique, for the sake of blending in with this new “image” of health professions that one may not recognize.  Each profession fears losing its professional identity. Perhaps doctors fear losing the sacred domain of diagnosing and establishing a treatment plan; perhaps nurses fear that as the health professionals who spend the most time with the patients, that they would lose that special privilege, and that no one would care about spending as much time with the patient anymore.  Who knows?

    One way to combat these feelings and fears is education and early exposure, to introduce healthcare professions earlier on. High school is a great start. There, students can get an overview and better understanding of what all the professions are and how they work together, while doing a special health professions exposure internship.  There students will learn that there is more to healthcare than just the doctor and the nurse. Likely, there are several hospitals willing to take on such a program if it does not already exist.  In health professions schools, people can get a great practice in interdisciplinary topics during Grand Rounds or other department wide gatherings where all the different health professions of a given specialty gather together.  Finally, another option is to pursue a track, or specialized area of study to better understand health professions education.  In such a pursuit, allies will be health professionals from various fields.  What better place to collaborate and determine the future of multidisciplinary care than in understanding and refining the education of health professionals, alongside other healthcare professionals in various fields?


    • Daniel Ehrmann
      October 7, 2013 at 10:58 PM


      Thanks so much for your comment. I was struck by your statement “… one of the fears of promoting interdisciplinary education and practice is that each individual professional group may lose out on what makes them unique, for the sake of blending in with this new “image” of health professions that one may not recognize. Each profession fears losing its professional identity.”

      I agree that this sentiment is common. But I also think that medical educators need to do a better job conveying the message that maintaining a unique professional identity and working effectively with different disciplines toward a shared goal are not mutually exclusive. Perhaps the approach should not be to develop a new image of the multidisciplinary health care professional at all. Rather, its the ability to work with and understand others’ points of view that should be stressed.

      This idea of losing your professional identify is also interesting because, in my experience, simply “exposing” professional students to others’ fields can even be counterproductive and cause people to retreat even further into their “silos.” Instead, I think there needs to be a project that REQUIRES individuals to work with others of different fields to accomplish a shared goal. In the process, one learns to appreciate others fields’ relative strengths and weaknesses while improving their communication and leadership skills. Most importantly, their own identify need not be in jeopardy at all.

  2. Sally Smith
    October 3, 2013 at 5:04 PM

    I found Daniel Ehrmann’s post to be a fascinating and well-written first person account of the way that silos begin forming in medicine during clinical training. It provided a window into a formative period in the development of physicians. While cultural and social identity formation is a necessary step in any professionalization process, it is clear from his post that this also presents a challenge for the way the practice of medicine and delivery of care is transforming toward the use of interprofessional teams and enhanced care coordination. I look forward to hearing more ideas from this insightful young mind as he advances in his career.

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