Year : 2019 | Volume
: 7 | Issue : 1 | Page : 92--95
Reimagining medical education: Part two – Practicing in an age of uncertainty and change
Elizabeth M Wooster1, Jerry M Maniate2,
1 Leadership, Adult and Higher Education, OISE/University of Toronto; St Joseph's Health Centre, Toronto, Ontario, Canada
2 Vice President of Education, The Ottawa Hospital; Department of Medicine; Department of Medical Education in Innovation, University of Ottawa, Ottawa, Ontario, Canada
Ms. Elizabeth M Wooster
Research Associate, Unity Health Toronto, OISE/University of Toronto, Ontario
The practice of healthcare professionals is influenced by multiple circles and globally, these circles are drastically changing. These circles include national demographics, local needs, social accountability, public opinions/knowledge, pedagogy surrounding the training continuum, knowledge expansion (both in terms of the amount of knowledge itself and how readily the public can access it with technology – computer in a pocket aka smartphone/tablet) and social media forces. Currently, there are many forces at play within these circles; resulting in physician practice environments that are in a constant state of flux. In their previous article, Wooster and Maniate discussed these forces in detail. This article will expand on the influence of these forces on practicing physicians and the impact of uncertainty. The article will then address micro, meso, and macro level initiatives that can be taken to help physicians to manage uncertainty as well as providing support for trainees and practicing physicians alike. The article will conclude with a call for the development of a culture that is conducive to supporting physicians to deal with uncertainty and change that is inevitable.
|How to cite this article:|
Wooster EM, Maniate JM. Reimagining medical education: Part two – Practicing in an age of uncertainty and change.Arch Med Health Sci 2019;7:92-95
|How to cite this URL:|
Wooster EM, Maniate JM. Reimagining medical education: Part two – Practicing in an age of uncertainty and change. Arch Med Health Sci [serial online] 2019 [cited 2020 Jan 17 ];7:92-95
Available from: http://www.amhsjournal.org/text.asp?2019/7/1/92/260014
Uncertainty and change and our interactions with them are constants in our daily lives. This is applicable to not only the personal aspects of our lives but also for those aspects within medicine. From the preparation for, to the study and practice of it, uncertainty and change are inherent forces at work within medicine. We recognize that uncertainty and change are prevalent from the simplest patient-physician interaction to the most complex health system reorganization. However, when the concepts of uncertainty and change are discussed about medicine, the public, and the practitioners are often uneasy.
While the terms uncertainty and change are regularly used in conversations about the healthcare and medical education systems, to discuss their interactions and influences we must first have a shared understanding of their meanings. Uncertainty is defined as “the fact or condition of being uncertain” with uncertain being defined as “not certainly known or knowing.” In addition, change is defined as “the act or instance of making or becoming different.” Throughout this paper, we will discuss the evolving forces that currently exist throughout the medical education continuum at different levels and how these forces impact physicians. Boucher, Van Melle, Oandasan, and Touchie describe these levels as follows: “macro (created by and affecting large, national or transnational issues and players); meso (affecting local health systems or teams), or micro (affecting the individual clinician)” (2017, p. 385). This paper will then examine the micro, meso, and macro level forces and the initiatives that can be undertaken at each level to assist manage uncertainty and change for both physicians and the public alike. Finally, the article will explore ideas that will need to be considered to facilitate the optimal practice and study of medicine in the realities of the 21st century world and beyond.
Uncertainty, Change, and Medicine Are Intertwined
William Osler once described medicine as “the science of uncertainty and the art of probability (Osler in Kim and Lee). This is probably one of the more eloquent descriptions of the relationship between uncertainty and medicine. The role of uncertainty in medicine is inherent as it permeates all levels of medicine; from that of the medical trainee to the expert professor of medicine. While there is often trepidation about the uncertainty that permeates medicine, uncertainty is not necessarily a bad thing, for it often brings hope in difficult circumstances for an unanticipated positive response to treatment at the individual level rather than following the population statistics of treatment response.
Uncertainty is influenced by a variety of forces, including probability, ambiguity, and complexity. It is important to understand the difference between these terms and the various roles they play in preparation for, the study and practice of medicine as they are often used interchangeably. Probability means the “likelihood of something happening” while ambiguity refers to “an expression able to be interpreted in two or more ways” In addition, complexity is defined as “being complicated and made up of parts.” For the remainder of this article, these terms will be used according to the definitions stated above.
Even though the interaction of uncertainty, change, and medicine have been noted for many years, the formal study of the interaction of these fields did not began until the early 1990s. Part of the rationale for the commencement of the investigation of these forces in medicine at this time is that the early 1990s is often when the knowledge explosion was formally acknowledged to exist. The concept of the knowledge explosion was initially studied in the mid-1960s, but it was not until the late 1980s and early 1990s, with the expansion of the personal computer and development of the Internet, that it truly occurred. Looking back, in the early 1900s, human knowledge doubled every century. By the 1950s, it was doubling every 25 years. By 2013, clinical knowledge was doubling every 18 months and the average human knowledge was doubling every 13 months. It is estimated that knowledge will soon be doubling every 12 h. At the present, the size of the Internet is estimated to be 14,929,285 petabytes, where 1 petabyte equals 1000 terabytes. This vast amount of knowledge and the rate at which it is increasing means that no one person can know all of the information that is currently available or exists. This is additionally true in medical specialities where this rapid growth in knowledge and the need to apply it fuels the drive to have even narrower scopes of clinical practice. This rapidly expanding knowledge base has increased the degree of uncertainty and the amount of change related to medicine and healthcare in general. In addition to knowledge and the Internet, there are other forces at play as well which are further discussed in greater detail in our previous article.
Preparing for Uncertainty and Change in Medicine
As the medical education continuum moves from a time-based system to a competency-based system, there will be a fundamental shift in how we envision medical education. In contrast to the current rigidity in structure and definitions noted for each level of practice, there will be greater fluidity and dynamism with knowledge acquisition and skill formation and perhaps attitudinal evolution.
For instance, an individual may be an expert in one clinical area but a novice in another. The fact that they are a novice in one area should not detract from their expertise in the initial area. For example, as we look at skills acquisition, there is generally an accepted progression that is noted in the individual from “unskilled” to “novice” to “intermediate” to “advanced” and finally to that of “expert.” The transitions cannot be clearly defined with regard to time spent not only in each phase but also incorporates the consistent demonstration of competence.
The planned shift in training structure from time-based to competency-based necessitates the re-envisioning of our training paradigms from a step-wise format to one that is the spiral format. In addition, by shifting our thinking from the dichotomous model of trainee and practicing physicians to one that is visualized as the novice-expert paradigm, we allow for the fact that learning is truly a lifelong endeavor and one that should not and cannot end once a physician has entered into professional practice.
In general, when uncertainty and change are discussed; they are viewed as forces that will negatively impact the status quo. This is because, we as humans, but especially within the context of health care, are generally risk adverse. The more risk adverse an individual naturally is, the more they will be resistant to change and uncertainty. While the instinct of being resistant to change and uncertainty cannot be changed; practices can be learned to modify an individual's instinctive reaction to these forces. The modifications are what must be instilled into physicians if they are to be prepared for the realities of clinical practice in the 21st century and beyond.
In his book, Smarter, Faster, Better, Charles Duhigg discusses productivity as a “process of learning with less stress and struggle.” Duhigg further discusses the concept of making “better” choices and taking control of the decision-making process. These are concepts when they are applied to medicine would allow us to provide concrete skills for handling decision-making process while recognizing that we are within a culture of uncertainty and change. The first concept that needs to be accepted is that it is unlikely that the result will ever be fully known. Given the earlier discussion about the amount of knowledge that currently exists and the rate at which this knowledge is increasing, this confirmed uncertainty is something that will continue to be prevalent in our daily lives.
Change in Practice
It is important for us as a profession and at the system level to recognize what is necessary to support the development of the individual who is ready to face uncertainty and change. Diagnostic uncertainty is only one type of uncertainty that physicians face. It is defined as, “subjective perception of an inability to provide an accurate explanation of the patient's health problem.” It is the one that is discussed the most in the literature, but there still remains a lack of consensus on how to train and prepare for it. Most literature discusses the stress associated with it and the impact of the stress on trainees. Guenter et al. remind us that Fox in 1957 noted that “our uncertainty might be the result of limitations or ambiguities in the medical knowledge base, or our own incomplete mastery of that knowledge base.” They go on to remind us that “much of our anxiety in our early careers stems from not knowing the difference.” While this may alleviate over time as the individual gain clinical expertise, this anxiety may flare up from time to time in the face of changes in clinical practice and management, for example with new knowledge, skills, equipment, or procedures.
Given the knowledge explosion, there needs to be a shift from knowledge memorization to understanding how and where to access the most up-to-date information to assist in clinical care and practice management decision-making. The realities of modern clinical care mean just-in-time access to such information that requires the individual to have a strong foundation of understanding medical principles and concepts that are broadly applicable, and on which other content is built on. Thus, the just-in-time information serves as a refresher or reminder of known knowledge or perhaps presents updated or expanded information that will inform the individual to adapt and apply this knowledge in a specific case.
This can be explained through a couple of examples. Example #1: adapting one's clinical practice to incorporate new evidence-based guidelines; example #2:inserting a central intravenous line or performing a thoracentesis with point-of-care ultrasound support; and example #3: Creating patient education materials that appropriately incorporate concepts of readability and accessibility.
Creating a System That Supports Physicians Through Change and Uncertainty
Recognizing the reality of uncertainty and change on our healthcare system and medical education, there is a need to consider what supports are needed regardless of the formal level of training that the individual is at, that is undergraduate medical education, postgraduate medical education or continuing professional development. There is the holistic level transition that an individual makes not only from novice to expert but also at specific subsets within an individual's experience, for example as they learn a new skill while maintaining their past expertise.
In light of the fluctuating or fluid transitions that occur between novice to expert, another issue that must be explored is how to identify individuals before fluctuating competency can result in issues of compromised patient care. Also related, is the necessity to appreciate what are the factors – personal, professional, social, etc., – that may be at play to result in fluctuating competency. For example, we know that sleep deprivation, something commonly impacting healthcare practitioners due to work hours and shift work, can compromise a highly functional and competent individual.
In reflecting on current practices in the healthcare system and medical education, most of the strategies and initiatives that are implemented are focused on preparing the individual– the micro level. While this is important, there are factors beyond the individual's control and influence that can prevent or prepare them for success.
When we consider the development of an individual, there are similarities with the extensive resources and efforts that are undertaken to create a long-lasting physical structure such as a building. Before one can begin, there is a need to understand the factors that will facilitate and hinder the building process. There must be thoughtful development plan, one that has contingencies for change and uncertainty in the process, but there must be sufficient time to consolidate and solidify before proceeding to further development.
For individuals, as they go through this thoughtful development process. There is a need to create a mentality and reality of support, one that has an established superstructure that will hold and support physicians as they transition. The structures must be able to identify and foster the foundational elements that are critical to the success of the individual as they progress through their career.
It is important to recognize that individual's do not function as isolated agents within the health care and medical education systems. The reality is that they must engage organizations/systems (the macro level) and groups/departments (the meso level) to provide the care they do for patients and populations. Thus there is a need to examine their structures, policies, and processes to identify barriers and facilitators for individuals (and perhaps teams) to deal with uncertainty and change.
In doing so, perhaps there needs to be a culture of inquiry and curiosity that permeates the organization, one that embraces the reality of uncertainty and change, which seeks to quickly gather available knowledge, to analyze, and adapt that knowledge into the context experienced by physicians and other clinicians. Importantly, this culture needs to flatten hierarchy to permit voices to be heard and encourage speaking up to provide safe, high-quality patient care. Whether those voices are peer-physicians, or near-peer healthcare practitioners or even those of patients, families, and caregivers, they all provide an invaluable perspective.
Thus, healthcare organizations need to establish and develop their educational mandate to support clinical care delivery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Kim K, Lee YM. Understanding uncertainty in medicine: Concepts and implications in medical education. Korean J Med Educ 2018;30:181-8.|
|2||Boucher A, Frank JR, Van Melle E, Oandasan I, Touchie C. Competency Based Medical Education – A White Paper. Ottawa: The Association of Faculties of Medicine of Canada; 2017.|
|3||Greenstein L. Assessing 21st Century Skills: A Guide to Evaluating Mastery and Authentic Learning Paperback. Thousand Oaks, CA: Corwin; 2012.|
|4||Available from: https://www.live-counter.com/how-big-is-the-internet/. [Last accessed on 2019 Apr 08, 20:50 h EST].|
|5||Hodges BD. A tea-steeping or i-doc model for medical education? Acad Med 2010;85:S34-44.|
|6||Duhigg C. Smarter Faster Better: The Transformative Power of Real Productivity, Toronto: Double Day, Randon House; 2017.|
|7||Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: A systematic review. J Gen Intern Med 2018;33:103-15.|
|8||Simpkin AL, Khan A, West DC, Garcia BM, Sectish TC, Spector ND, et al. Stress from uncertainty and resilience among depressed and burned out residents: A cross-sectional study. Acad Pediatr 2018;18:698-704.|
|9||Fox R. Training for uncertainty. In: Merton RK, Reader G, Kendall PL, editors. The Student Physician. Cambridge, MA: Harvard University Press; 1957.|
|10||Guenter D, Fowler N, Lee L. Clinical uncertainty: Helping our learners. Can Fam Physician 2011;57:120-5.|