Successful organizations strive to understand and harness institutional culture in the pursuit of their mandates [1, 2]. In this issue, Bourgeois and colleagues observe that it is a time of great transformation in the field of medicine [3]. These authors suggest that the curricular changes required by nascent competency-based medical education (CBME) frameworks [4−6] create an opportunity to facilitate the development of an organizational culture of academic scholarship in postgraduate medical training programmes [3].

The role of organizational structure and culture

Bourgeois and colleagues astutely acknowledge the substantive role that institutional culture plays in optimizing academic productivity [3]. Harnessing the urgency for change created during transition to CBME, however, is but one element in a complex series of change management techniques required to improve the scholarly output of postgraduate medical education programmes [1, 7, 8].

There is substantial non-medical literature on organizational culture; much of this theory is found within the leadership and management canons [2, 7−9]. Authorities within these domains suggest that innovative research and scholarship requires a culture that values these pursuits [2, 9]. Importantly, institutions that are successful in producing exceptional academic scholarship align the culture of their organizations with these goals [7, 9].

For more than a decade, medicine has characterized the academic physician and striven to understand the factors that create a rich academic environment and its converse, an environment that discourages academic pursuit [10]. In 2002, Souba wrote about the factors that contribute to an unpleasant workplace environment for academic physicians. These included heavy workloads with poor compensation, lack of appreciation and recognition, limited time for research and teaching, and failures of collegiality and teamwork. Souba also suggested a solution: engaging physicians in patient care, research, and education through personal and organizational leadership. In other words, creating an institutional culture that supports and facilitates academic engagement concrete commitment to cultural change. Bourgeois and colleagues [3] rightly point out that, despite Souba’s paper [10] being a decade old, physician and resident engagement in scholarly pursuit remains inadequate.

The shift towards CBME provides an opportunity for change within the academic medical training system, but CBME’s potential for improving scholarship among trainees will be foiled if the challenges posed by longstanding institutional culture are not addressed.

The challenge of culture

An organization’s culture may include many barriers to change [7]. These barriers are often difficult to identify, and many institutions fail to address them appropriately. The result is a failure of well-intentioned change initiatives [1]. As CBME is implemented, educators will not identify and overcome these barriers without an intimate understanding of their institutional culture and how it drives behaviour. The following case illustrates a fictional example of a department struggling to meet its scholarly potential.

The four frames model by Bolman and Deal

Bolman and Deal published a popular approach to assessing organizations using a ‘Four Frames’ conceptual model based in management, leadership, and organizational theory literature [7]. This model helps define the current state of an institution and identify changes required to transform its culture into the desired state.

The ‘Four Frames’, along with some guiding questions for assessing their status, are detailed in Table 1. The structural frame refers to the organizational design of the institution, and outlines how work is divided and coordinated. The human resources frame addresses the interactions between people within the organization and how well the intrinsic needs of the individuals are met. The political frame explores relationships and power dynamics within the organization and how the organization interacts with external bodies. Finally, the symbolic frame concerns the symbols, stories, beliefs, values, and practices of the people within the organization. Each of the frames affects the development and evolution of organizational culture, but the symbolic frame includes its most tangible features [7].

Table 1 Guiding questions for the assessment of scholarship organized using Bolman and Deal’s Four Frame model [7]
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Bolman and Deal’s ‘Four Frames’ framework, and the questions outlined above, can facilitate the examination of a department’s barriers to enhancing scholarly output. Table 2 contains the case analysis for the illustrative case we presented earlier in the paper.

Table 2 A sample of the analysis of the case in Box 1 conducted using Bolman and Deal’s Four Frame model [7]
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‘Culture eats strategy for lunch’

This quote, attributed to management guru Peter Drucker, succinctly encompasses the challenges faced by those who try to change the status quo. As outlined by Bourgeois [3], the implementation of CBME will require substantial change in how we educate and assess medical learners and create opportunities for encouraging a culture of scholarship. While these changes may provide an important opportunity for insightful leaders to shift the scholarly culture of their organizations, broad change initiatives are challenging. A detailed organizational analysis based on established principles from the leadership literature such as Bolman and Deal’s [7] Four Frame Model can provide valuable early insights into potential problems and sources of resistance.