Removing Barriers to Change in Medical Education Using the REDUCE Framework

Dear Editor,

Employees of organizations are accustomed to doing routine works, so they do not tolerate change. That is why change is hard and maybe even harder to manage change. The subject of change even becomes more difficult when it is brought to the domain of education. Change management, as the overarching approach is taken in an organization to move from the current to a future desirable state using a coordinated and structured approach in collaboration with stakeholders (1), is complex and impossible without emulation of approved models. One of the most famous and common models of change management was presented a quarter of a century ago by John Kotter in his book "Leading Change" (2). Although this model is widely used in change management in higher education and medical education (3, 4), I intend to introduce a new model in this letter.

Jonah Berger, a marketing professor at the Wharton School at the University of Pennsylvania, in his recent book, "The Catalyst: How to Change Anyone's Mind" (5), tried to write about changing minds, inciting action, and how catalysts (managers or leaders of change) can transform organizations by understanding the science of change and how they can be better at changing anything. In his book, Berger acknowledged that although new things and ideas are often always better than old ones, every change from old to new is a costly affair and has upsides and downsides. He considered the root of any resistance to change in two behavioral characteristics of people: the status quo bias and loss aversion. The first behavior is rooted in the fact that whenever people think about changing, they compare new things to their current state, and the second one refers to this psychological fact that always losses loom larger than gains and to overcome this perception, the advantages of new gain have to be at least twice as good as the disadvantages of losing old ones. Berger believes without starting with the barriers themselves, it is going to be really hard to figure out how to create change. So in the rest of the book, he outlines five ways to overcome obstacles to change and organized them into an acronym as reduce Reactance, ease Endowment, shrink Distance, alleviate Uncertainty and find Corroborating Evidence. Taken together, that spells the word REDUCE, which is exactly what great catalysts do to reduce roadblocks in the path of change.

In explaining each component of the REDUCE framework, Jonah Berger cited different real-world scenarios and drawn on specific metaphors. The first part of the framework (Reactance) refers to the reaction that people typically show to change. In fact, people have an innate anti-persuasion system. The second part of the framework (Endowment) refers to people's attachment to what they have. They do not easily get rid of what they are attached to. In fact, ownership increases the value of beliefs and ideas, and the longer people own or do something, the more they value it. The third component of the framework (Distance) refers to the fact that perspectives that are too far away fall in the region of rejection and get discounted. If information is in people's zone of acceptance, they're willing to listen. The fourth component of the framework (Uncertainty) is the reality behind any change. In fact, when people do not know whether something new will be better than what they're doing already, they tend to hit the pause button. The fifth component of the framework (Corroborating evidence) refers to the fact that providing as much evidence as possible about the benefits of change can pave the way for people to accept change. In other words, some things just need more proof, more evidence to overcome the translation problem and drive change.

To reduce reactants, it is necessary to encourage people to persuade themselves. In this case, people feel like they have more control over the decision they are making. Now they have more freedom and autonomy and can participate in the decision-making process. By giving them the trade-offs, they get an opportunity to choose. Furthermore, people should be given more time to ask questions. Questions do a couple of things. First, it shifts the listener's role, and more importantly, increases by-in. Finally, there is always a disparity between what people might recommend to someone else versus what they are actually doing themselves. When their attitudes and behaviors conflict, they tend to get uncomfortable. To reduce this cognitive dissonance, people take steps to bring things back in line.

To ease the endowment effect, it is necessary to help people realize the costs of doing nothing. Surfacing the costs of an action help people realize that sticking with the status quo isn't as costless as it seems. So the catalysts need to highlight how much people are losing by doing nothing. In addition, they have to encourage people to set aside the old and instead think about which new thing is worth pursuing. Also, there is no escape unless framing new things as old.

To shrink the distance, there is no choice but to overcome the confirmation bias, a tendency to look for and process information in a way that confirms what everyone already thinks. Introducing more rigorous evidence about the benefits of the change sometimes makes people more likely to believe the truth, but other times and often, it just reaffirms falsehoods. In fact, due to the confirmation bias, people change their minds in the opposite direction. Jonah Berger introduces some main strategies to mitigate distance, such as "taking big change, breaking it down into smaller, more manageable chunks or stepping stones", "asking for less before asking for more," and finally, "starting with the place of agreement and pivoting from there".

To alleviate uncertainty, it is necessary to lower the upfront cost, reducing the money, time, effort, and energy required to experience whether something is good or not. Also, the catalysts may even need to drive discovery, bringing the trial to people who might not know that they are interested in what they have to offer. By easing uncertainty, anyone can drive change.

To find corroborating evidence, it is necessary to provide people with multiple opinions from discrete sources. Using the opinions of certain types of others from independent groups is going to increase the impact. Concentrating on them over time will make sure that people hear from enough others to change.

At the end of his book, Berger includes a checklist of what needs to be done to mitigate common barriers and roadblocks in the path of change. Due to the simplicity of the text, the novelty of the model, and having a proper checklist, I recommend using this model in leading and managing change in medical education.