Summary: The first of a series of blogs on the subject by Stewart Mennin. A free live virtual webinar can be found on the AMEE YouTube - Description: amee-logo-small.png                                                           human-dynamics-logo-small.jpg

Tame your Wicked Issues in Medical Education

A six-part guest blog by Prof. Stewart Mennin, with accompanying live webinar, July 30, 2019, 14:00 UK time (UTC+1): (The link will not be live until the webinar opens, if prompted for a code provide this - 587-976-5838)

Part 1: What Has You Stuck? How to Get Unstuck with Adaptive Action

Some of your problems are simple. You have seen them and solved them before. You know the parts and how they are related. You can see the whole thing at the same time. You can work on it bit-by-bit. You know what a solution looks like, and everyone agrees on what the problem is. You control the process and the outcomes. Problems like these involve minimum uncertainty. Examples include: taking vital signs, one best answer multiple-choice questions and best practice.
Other problems are complicated. You may have seen the problem before, but it takes special expertise to understand the parts and how they fit together. You can break it up into parts, solve each one separately, and then put them all back together for the “big fix.” These problems are complicated, for example learning a basic screening history and physical examination.
Simple and complicated problems require time and expertise to solve, but, if you work at it long enough and know enough, you will be able to find an answer. The problem is that some problems are neither simple nor complicated. They are complex, and we call them Wicked Issues (more in future Blogs).
Wicked Issues pose unpredictable and intractable challenges for which there are no adequate solutions (Rittel and Webber, 1973). In Human Systems Dynamics (HSD), (, we call these “Wicked Issues” because you feel “stuck.” We can’t find a solution or a way to approach these challenges. They share three common characteristics across diverse disciplines and theories. They are:
  • Defined differently from different perspectives
  • Context dependent, but patterned across contexts
  • Impossible to solve completely
The solution depends on how the problem is framed.
We look at the same challenge, but frame it differently, according to our different fields of study. Lack of effective teaching.  If you see it as lack of skills, then the best approach is faculty development. If it is lack of collaboration and alignment of people, you look toward alignment for a solution.
Stakeholders have radically different worldviews and different frames for understanding the problem. Decision-making looks different through the eyes of patients, clinicians, learners, leaders, and administrators. When each one defines the problem differently, then it is easy to get stuck.
The constraints of the problem and the resources needed to solve it change over time. Small-group problem-based learning may have been the best approach in the 1980s.  However, today, lack of available facilitators favors team-based learning.
The problem is never solved definitively. Wicked Issues sometimes seem to be “solved,” only to emerge again in other parts of the system or in alternative forms of the same challenge. On the one hand, we are expected to solve problems that arise. On the other hand, Wicked Issues cannot be solved. Curriculum integration never ends as new pedagogical approaches and new information keep emerging.
Solutions to Wicked Issues are neither right nor wrong.  A Wicked Issue is not absolutely right or wrong. It is about finding whatever is the best fit for function in any given place or time. What works in one instance may not work in another. So, every situation demands its own, unique, creative response. That is why inquiry is such an important competency when you deal with uncertainty. Every medical school is unique. 
You know you have a Wicked Issue when your problem: 
► Challenges old assumptions
► Won’t stay solved for long
► Is too big to think of all at one time
► Has too many pieces to manage
► Involves massive interdependencies

Key to Unlocking Wicked Issues: Adaptive Action
It is easy to TALK about Wicked Issues but doing something to make a difference is another matter. Adaptive Action is a basic tool to help us make the decisions and take the action to break through and tame Wicked Issues. This tool helps you to help others to succeed.
Adaptive Action
is a disciplined method to take action in complex Wicked Issues. Although Wicked Issues cannot be solved, you can engage with them and take informed wise action to make a meaningful difference.
Three basic questions set the stage for seeing what is happening, for making meaning, even when you are sure you don’t know the answer; and for taking action, even if you can’t predict or control outcomes. Adaptive Action is an iterative cycle.
1. What? is the opportunity to collect data and describe what is happening around you. Describe what you see. Describe what you want. Describe how the current situation has emerged in the system.
2. So What? is the question that helps you make meaning of what you see, identifying the conditions that shape the world as you see it. You look for implications of the current state and options for action to change the
conditions and to release tension that is held in your Wicked Issue.
3. Now What? is your plan for action to shift the situation and bring about
change. As you choose and take one action, you continue to observe the
changes and to move into the next, “What?” as you move forward in the
repeating process of discovery and action.
These deceptively simple Adaptive Action questions (What, So What? Now What?) unfold into many other useful questions, depending on the circumstances and your role. The end of each Adaptive Action Cycle results in real action, which shifts the system. Then, you are ready to ask, “What changed?” as you begin your next Adaptive Action cycle.

While there is benefit to exploring and learning from the past, the greatest benefit comes from seeing what exists now, identifying what will generate greater fitness for the system, and taking action to move your Wicked Issue toward whatever will be most useful and fit for function.

In the coming weeks, I will share insights about applications of Adaptive Action and some of the tools that will help you tame your Wicked Issues. Stay tuned and let me know ([email protected]) if you have particular questions you’d like to be addressed.

Have a question or comment? Join the discussion on padlet.

References and further reading

Eoyang, G. H., & Holladay, R. (2013). Adaptive Action: Leveraging uncertainty in your organization. Stanford, California: Stanford University press.
Mennin, S., Eoyang, G., & Nations, M. (2016). Leadership in Medical Education:  The Future of the Health Professions Workforce. Circle Pines, MN: Human Systems Dynamics Institute.
Rittel, H. W. J., & Webber, M. M. (1973). Dilemmas in a general theory of planning. Policy Sciences, 4(2), 155-169.

About Stewart

MenninS-(1).jpgStewart Mennin, PhD is Principal of Mennin Consulting & Associates and a Consulting Associate, Human Systems Dynamics Institute; Adjunct Professor, Department of Medicine, Uniformed Services University of the Health Sciences; Bethesda; and Professor Emeritus of Cell Biology and Physiology and former Assistant Dean for Educational Development and Research at the University of New Mexico School of Medicine.
Professor Mennin has published widely, served as an invited international consultant, editor and teacher at more than 100 medical schools and health institutions worldwide. In 2017, he received the AMEE Lifetime Achievement Award in Medical Education.
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