Summary: The third in Stewart Mennin's Wicked Issues series of blogs, this time on the subject of The Anatomy of Wicked Problems. Watch AMEE Social Media and mailings for the next webinar. Description:

The Anatomy of a Wicked Problem:  Part Three of a Six-Part Series

Stewart Mennin, PhD

Making improvements in people’s lives requires dealing with complex issues such as governance, poverty, violence, gender, and empowerment, but the bulk of resources are devoted to specific diseases, technical intervention, and measurement (Sridhar, 2019)
Improving people’s lives is a wicked problem. 

Some words about language.

The terms Wicked problems, wicked issues and sticky issues each refer to similar complex challenges, like improving people’s lives. The literature contains all of these terms in reference to complex and wicked problems (Rittel and Webber 1973; Eoyang and Holliday, 2013; Cleland, 2018: Mennin, 2019a; 2019b).  To promote clarity and consistency in our discourse going forward, it is proposed that authors adopt the following terminology and language:

Wicked problem: - any situation that causes difficulties for which there are no obvious, available and  known solutions. Any problem that is extreme, intractable, massively entangled, and complex.  For example, changing the curriculum of a medical school or institution with the goal of improving people’s lives. (Ottawa Charter for Health 1986; Sridhar, 2019)
Sticky/Wicked issue: – a subset of a wicked problem upon which we are focused currently and with which we are engaged.  For example establishing assessment of learning during a community family medicine clerkship.
 

Introduction

Change is a constant.  Everything we do involves change, and most of the changes are wicked problems.  Some examples include: we expect medical students, post-graduates and practitioners to learn and change with and from their experiences; researchers change knowledge as they probe, question, experiment and learn;  families and individuals learn as they seek to optimize their health; and health systems are wicked problems as people work to keep the system relevant to social needs. 

This blog looks at how we can perceive and understand the nature of wicked problems that involve change in our own day-to-day work lives. What might the anatomy of a wicked problem such as resistance to school-wide curriculum change look like?  Is there a general pattern irrespective of different contexts?  How might such a view be helpful?

Anatomy is the study of structure and function.  The structure and function of a problem look different depending on whether they are simple, predictably replicable and have a finite beginning and end or if they are complex, unpredictable and have no clear beginning and end.  If your problem is simple, you can dissect and reduced it to its component parts to understand it and then reassembled the parts to make the whole again.  Knowing the anatomy of a simple problem one can predict the function and knowing the function one can predict the anatomy.  The structure-function relationship is linear and obeys Newtonian laws of cause and effect. 

On the other hand, a problem is wicked when you can’t identify, predict or control all the parts involved (Table 1).  You can’t know when and how they will interact and reductionistic logic and linear cause and effect thinking is not useful.  A problem is wicked if it has no clear beginning and end, like chronic illness, poverty and violence. Wicked problems appear as dynamical patterns sensitive to changes in internal and external conditions.  A small change in conditions can lead to a large effect and large change can have little or no effect (nonlinear change).   For the pattern of a wicked problem to change, the system in which it exists has to become unstable and be far from equilibrium.
Table 1.  Characteristics of Wicked Problems1

Tame Problems (Simple Problems) Wicked Problems (Complex Problems)
Replicable, predictable.  Single best definition Adaptive, unpredictable. Defined differently from different perspectives
Best practice. Known, clear answers and solutions work best, evidence and expertise useful Presumptive answers and solutions. Impossible to solve completely. Context dependent, yet patterned across contexts
Clear boundaries Ambiguous, flexible boundaries
Explicit beginning and ending No clear starting point and no clear end
Specific rules, standards and measurements The rules keep changing
Cause and effect are directly proportional (linear) Cause and effect are nonlinear, self-organization
  Questions work best when there are no clear answers or solutions, expertise of limited use
The whole is equal to the sum of its parts The whole is different from and greater than the sum of its parts
Old assumptions maintain their usefulness Old assumptions are challenged
Simple Intractable, massively entangled, complex
1 From multiple sources: Rittel and Webber,(1973); Conklin, Basadur, VanPatter (2007, a; 2007b); Eoyang and Holladay, (2013); Mennin (2019a; 2019b)

Anatomy of Resistance to Change Among Members of the Faculty

Resistance a handful of members of a single department in the faculty of medicine to the introduction of new teaching and assessment methods is a commonly encountered issue that is subset of a larger wicked problem of institution-wide change in pedagogy.  By definition (see above) it is a sticky issue.  Figure 1. illustrates who and what might be involved: students, patients, teachers, departments, clinics and administrator, and more.  Teachers identify with the rules and values of their discipline.  Patients and students are diverse, as are ambulatory clinics and tertiary care hospitals, research institutes, and schools.  There are differences and similarities of governance at municipal, regional and national levels; each with their own rules, resources, expectations and workers.  The players (agents) in this sticky issue interact in ways and at times that are too numerous to measure or consider in detail (dotted lines between agents in Figure 1). Some teachers support the curriculum change, others refuse.  Some students and patients prosper in the new small-group style of interaction and communication.  Some students prefer to learn in lectures.  Some powerful clinical departments declare they don’t have time for the new changes. Clinicians in the local community clinic benefit from access to students and post-graduates.  And so it goes. Tensions ebb and flow.  Over time they can increase to the breaking point or remain as they are.  These are characteristics of both wicked problems and sticky issues.

In previous blogs we discussed what being stuck in a wicked issue meant and how it was possible to get unstuck using the three questions of Adaptive Action. WHAT? See the current pattern and where it is stuck. SO WHAT? Know the capacity of the system to change. NOW WHAT? Take some specific action to move the system forward.   How and where this works in wicked issues is explored next and illustrated in Figures 1-3.



Figure 1[1].  Who and What are involved in a sticky issue?

What? The departments of family medicine and general pediatrics found it difficult to meet the new requirements to assess learners in their clinical rotations.  However, when they collaborated, they successfully produced an objective structured clinical exam (OSCE).  So what did that mean? Students and department members found it useful for their learning, teaching and assessment.  As separate departments there was increasing tension among faculty members.  When it reached a critical state they got together and created a new system-wide pattern/structure that enabled them to meet the demands for curriculum change that they faced.  The departments developed a new structure, the OSCE, that fit the necessary change.  Figure 2 shows the new emergent OSCE as ovals, however, it could be any sticky issue. 



Figure 2.  The increase in the tension of potential energy among the individual agents is released spontaneously and a new system-wide pattern emerges.  


 
Faculty members in other departments saw the new structure and began to experiment with similar changes in their teaching and assessment.  Thus, the new system-wide pattern in the departments of family medicine and pediatrics influences faculty members in those and other departments Figure 3. 
 

 
Figure 3.  New system-wide patterns influence future interactions among the agents and with the new system-wide pattern as well. 


 
The wicked problem of changing a medical school curriculum to be consistent with improving the lives of people will continue as long as the medical school exists.  However, sticky issues such as resistance of  teachers and students to new teaching and assessment methods can be addressed through adaptive action, pattern logic and inquiry, which are the subjects of the next three blogs (Eoyang and Holladay, 2013; Mennin 2019a; 2019b). The anatomy of the process by which new structure emerges from the release of tensions in complex systems is similar at every level whether is it a large wicked problem or a sticky issue embedded in a larger wicked problem.  Agents with similarities and differences interact and tensions rise and fall.  As they rise to a critical level, the anatomy is no longer fit to hold the rising tension, and the structure spontaneously reorganizes itself into a more complex and energetically fit state at a system-wide level, which in turn influences future interactions among the agents.

If you know the conditions that influence the agents in a wicked problem or sticky issue  you cannot predict how it will behave, but it is possible to manage and influence the strength, speed and direction of the self-organization change process.  The outcome is still unpredictable, yet recognizable.  If you know the anatomy of the newly emergent structure, you cannot work backwards to know the preceding conditions that led to the new structure.  How this works and what it means for medical education is the subject of the next blog, Part 4 in this 6-part series.  Stay tuned.

Please log into a free webinar about the anatomy of wicked problems and sticky issues DATE AND TIME AND URL HERE.  Be sure to view the recording of this webinar and other blogs by Stewart Mennin at https://www.mededworld.org/Reflections-All.aspx.
 
A more complete and individual guided journey through wicked problem in health professions education will be available as an 8-week online ESME course entitled ESSENTIAL SKILLS IN ACTION:  TAMING YOUR WICKED PROBLEMS IN MEDICAL EDUCATION.  Registration information is available here.

References

Cleland, J. A., Patterson, F., & Hanson, M. D. (2018). Thinking of selection and widening access as complex and wicked problems. Medical Education, 52(12), 1228-1239. doi:10.1111/medu.13670
Eoyang, G. H., & Holladay, R. (2013). Adaptive Action: Leveraging uncertainty in your organization. Stanford, California: Stanford University press.
Glouberman, S., & Zimmerman, B. (2002, 2002). Complicated and complex systems: what would successful reform of Medicare look like? Discussion paper No. 8.  Retrieved from https://www.alnap.org/system/files/content/resource/files/main/complicatedandcomplexsystems-zimmermanreport-medicare-reform.pdf
Kauffman, S. (1995). At home the in universe: the search for laws of self-organization and complexity. New York: Oxford University press.
Mennin, S. (2010). Self-organization, integration and curriculum in the complex world of medical education. Medical Education, 44, 20-30.
Mennin, S. (2019a). Tame your Wicked Issues in Medical Education: Part 1: What Has You Stuck? How to Get Unstuck with Adaptive Action.  Retrieved from https://www.mededworld.org/Reflections-All.aspx
Mennin, S. (2019b). Tame your Wicked Issues in Medical Education: Part 2: Wicked issues in medical education are not simple.  Retrieved from https://www.mededworld.org/Reflections-All.aspx
Ottawa Charter for Health Promotion (1986).   Retrieved from https://www.who.int/healthpromotion/conferences/previous/ottawa/en/
Prigogine, I., & Stengers, I. (1997). The end of certainty: time, chaos, and the new laws of nature. New York: The Free Press.
Rittel, H. W. J., & Webber, M. M. (1973). Dilemmas in a general theory of planning. Policy Sciences, 4(2), 155-169.
Sridhar, D. (2019). Holding a mirror up to global health. The Lancet, 394(September 28, 2019), 1136.


[1] Figures 1-3 are used with permission of the Human Systems Dynamics Institute.  Special thanks to Glenda Eoyang, Executive Founding Director and Royce Holladay, Director of Services.