Eva’s Excerpt July 2020

Instability. This is what most, if not all of us, are feeling right now. COVID, financial challenges, furloughs, layoffs, re-openings and closings, unclear school schedules for our kids, unclear changes to our work environment and to our educational practices, and so much more. The ground under our feet is shaking, swaying and sometimes crumbling. I wish I could say that I could deliver a promise of how things will be in the fall, let alone next week, but I can’t. We are living in a world of uncertainty like never before and it is not only unsettling, it’s exhausting. It makes it hard to plan and that can feel paralyzing. But, make decisions, we must.

So, how does one make decisions and lead in a time of so much uncertainty? A colleague forwarded me an article about the Cynefin Framework, which I have found particularly helpful over the last few months. In essence, it describes four contexts for decision-making: 1) Simple- when we are dealing with “known knowns” and best practices are clear. This is how we do the things we know how to do and do well. 2) Complicated- the realm of “known unknowns”. This is where we rely on experts and expertise to help our decision-making (this is where we live most of the time in academic medicine). 3) Complex- this is the realm of “unknown unknowns”. In complex contexts things are emerging as potential best practices, but it is still very murky and there is little to no evidence to guide us- this is where we have spent most of the last few months and where we are now, I think.  4) Chaotic- things are completely out of control and you just need to do something.  This was where we were early in the pandemic.

In complex contexts, the right answer is not clear. In this situation we make decisions based on something many of us are used to- experiments. Some of these experiments will fail, but we try, sense, respond, pivot. It requires guiding principles rather than hard and fast rules. And it requires a distributed leadership framework rather than a command and control structure. This allows for innovation and it also allows us to identify emerging best practices. But, it’s scary.

For us educationally, as we think about our students and residents, our educational programs, our faculty and staff, we need to focus on three guiding principles:

  • Maximize safety for our students, residents, faculty and staff: This involves continually monitoring the local and national COVID environment and following up to date public health best practices. Our team is continually monitoring what is happening not just in our hospitals and clinics, but in our city, county, state, nation and world. It is this principle that is keeping us from resuming in person lectures for our MD students and residents at this time. Having 100 people in a room for an hour or more, even when wearing masks, just isn’t justified when that information can be shared via zoom just as effectively.
  • Ensure educational objectives can be met: As a school, we have course, clerkship and graduation objectives and competencies. It is our responsibility to ensure that our learners meet those objectives and competencies, even if it means changing how they are taught. This principle allowed our clerkship directors and simulation team to generate innovative online clinical education followed by hands on experiences in the clerkships for our completing third year students.
  • Ensure the environment can manage the task: This one is a little tough to wrap our heads around at times, but this is the principle that underlies our decision to limit visitors to the clinical space, including visiting subIs, pre-med learners, and even our own pre-clinical students. In the current clinical environment, it is challenging to maximize social distancing while rounding and completing the daily work of patient care. Having people in the environment who don’t need to be there impacts that environment in a way that makes it unsafe for those who do need to be there.

As I am sure is apparent, these three principles interact in complex ways. This again, makes it hard to create hard and fast rules. Instead, we must use our judgment as we think about bringing our learners, faculty and staff back. Each situation requires us to ask ourselves: Is it safe or as safe as it can be? What can I do to maximize safety? Is this activity necessary to ensure I meet required objectives? Are there alternatives? How will it impact or interact with other decisions that are occurring in the environment? Can the environment handle it from a resource perspective? These decisions are tough and often they are best made by a team, rather than an individual. This is how our educational leadership team has been functioning these last few months. And it is how we created the Learner Reentry Guidance. This document is a living document which will be modified as the environment changes.

While we all want things to be stable, to move back to the complicated environment we know and love, it seems unlikely that this will be the case for the next year. Instead, we plan for the unknown. We make the best decisions we can. We work together, we rely on each other, and we stay grounded in core principles so we never lose sight of what is important. Together we will get through these challenging times and learn to develop new and creative ways for the future.