Lisa Laskow Lahey

Questioning the 'big assumptions'. Part II: recognizing organizational contradictions that impede institutional change

Background Well‐designed medical curriculum reforms can fall short of their primary objectives during implementation when unanticipated or unaddressed organizational resistance surfaces. This typically occurs if the agents for change ignore faculty concerns during the planning stage or when the provision of essential institutional safeguards to support new behaviors are neglected. Disappointing outcomes in curriculum reforms then result in the perpetuation of or reversion to the Status quo despite the loftiest of goals.

Questioning the "big assumptions". Part I: addressing personal contradictions that impede professional development.

Background The ultimate success of recent medical curriculum reforms is, in large part, dependent upon the facultys ability to adopt and sustain new attitudes and behaviors. However, like many New Years resolutions, sincere intent to change may be short lived and followed by a discouraging return to old behaviors. Failure to sustain the initial resolve to change can be misinterpreted as a lack of commitment to ones original goals and eventually lead to greater effort expended in rationalizing the status quo rather than changing it.

From Subject to Object: A Constructive-Developmental Approach to Reflective Practice

In the first part of this chapter, Kegan and Lahey offer constructive-developmental theory as a framework to understand the goals (increasing or transforming a person’s way of knowing) and processes of reflection (moving what is subject to object). They explain the three successively encompassing ways of knowing in adulthood, showing how each has a different subject–object relationship, with each being able to look at (take as object) what the prior way of knowing could only look through . In the second part of the chapter, the authors integrate practice and theory: they explain how to support development from one way of knowing to another, by describing and illustrating a novel reflection approach they call the immunity-to-change process. They show how overturning an immunity results in a person’s new way of knowing, where the person is able to “take as object” that which he was before subject-to. As a consequence, the person is capable of accomplishing his more complex self-improvement goals.

Immunity-to-Change: Are Hidden Motives Underlying Patient Nonadherence to Chronic Disease Medications?

Abstract:New approaches to understanding patient nonadherence to chronic disease medications are urgently needed. To explore whether patient hidden motives and their underlying assumptions contribute to nonadherence, we examined an innovative application to health care of a transformative learning process successfully used in work settings, immunity-to-change. Eligible participants taking at least 2 chronic disease medications, filling prescriptions at U.S. chain drugstores, wanting to continue to take medications and reporting adherence problems underwent a psychological interview focused on their medication-taking behavior as part of a market survey. Participants (n = 46) were interviewed as a construction sample to create a preliminary set of motive clusters. To test the completeness of the cluster categories, 17 additional eligible persons were interviewed. An established psychological interviewing method was used to identify hidden motives and unrecognized assumptions underlying nonadherent behavior. Hidden motives (n = 167) for nonadherence were identified and categorized into 6 clusters based on their commonality (n, %): (1) to avoid interference with other priorities (40, 24%), (2) to avoid losing control (35, 21%), (3) to avoid a negative identity (28, 17%), (4) to be ones own doctor (28, 16%), (5) to keep an arms length relationship to ones medications or to the medical establishment (27, 16%) and (6) to avoid unpleasantness (10, 6%). Within each cluster, a set of previously unrecognized assumptions inhibiting adherence was identified. In conclusion, hidden motives, and their underlying assumptions, contributing to chronic disease medication nonadherence were identified using a transformative learning process. Research is needed to test this approach in larger general population samples.