Elephants in academic medicine.

PURPOSE: To study the types, causes, and consequences of academic health center (AHC) "elephants," which the authors define as obvious problems that impair performance but which the community collectively does not discuss or confront.
METHOD: Between April and June 2010, the authors polled all the chairs of departments of medicine and of surgery at the then 127 U.S. medical-degree-granting medical schools, using a combination of Web and postal surveys.
RESULTS: Of the 254 chairs polled, 139 (55%) responded. Of 137 chairs, 95 (69%) reported that elephants in their organizations were common or widespread. The most common elephant reported was misalignment between goals and available resources. Chairs felt that the main reason faculty are silent is their perception that speaking up will be ignored and that the consequences of elephants include impaired organizational learning, flawed information resulting in poor decisions, and negative effects on morale. Chairs felt elephants were more problematic among deans and hospital leaders than in their own departments. Of 139 chairs, 87 (63%) said that elephants were discussed inappropriately, and of 137 chairs, 92 (67%) believed that creating a culture that dealt with elephants would be difficult. Chairs felt the best antidote for elephants was having senior leaders lead by example, yet 77 of 139 (55%) reported that the actions of top leaders fed, rather than dispelled, elephants.
CONCLUSIONS: AHC elephants are prevalent and detrimental to learning, organizational decision making, and morale, yet the academic medicine community, particularly its leadership, insufficiently confronts them.