Summary: The second of a series of blogs on the subject by Stewart Mennin. A free live virtual webinar will be given on Zoom, September 23rd, 2019. Watch the AMEE website, his Linkedin and facebook pages, and AMEE social media for the URL Description: Stewart Mennin, PhD
Resistance to change in methods of teaching and assessment in an existing curriculum is the most commonly encountered Wicked Issue in medical education.  Other examples include developing the capacity for self-directed and collaborative learning among students; achieving sustainable quality teaching in busy time-constrained clinical situations (Eoyang and Mennin, in preparation); and promoting equity of access in the selection of medical students (Cleland, Patterson, Hanson, 2018).
 
Even the best-informed medical educators struggle with Wicked (complex) Issues for which there are no adequate, known and replicable solutions available. These issues pose unpredictable and intractable challenges to educators, administrators and practitioners alike (Rittel and Webber, 1973).  Wicked Issues share three common characteristics across diverse institutions, disciplines and theories (Mennin, 2019; Eoyang and Mennin, in preparation).  They are:
  1. Defined differently from different perspectives (students, teachers, administrators, patients, other stakeholders);
  2. Context dependent, yet patterned across contexts (no two situations are identical, each program, educational institution and health system is unique);
  3. Impossible to solve completely (they keep coming back).
It is a costly error to treat Wicked Issues as if they are simple problems.  The purpose of this blog is to illuminate key characteristics of and strategies for dealing successfully with Wicked Issues different than simple and complicated problems (Glouberman and Zimerman, 2002). 

Simple and Complicated Problems have:
► Clear boundaries.  For example, there is only one best answer for a multiple-choice question; specific items on a check lists of an OSCE station; basic and clinical science disciplines and subspecialties are separate and distinct.  Committees have one chair, and medical schools have one dean or director.

► Explicit beginning and ending.  Medical education proceeds in a stepwise fashion with a clear beginning and well-defined end. Measuring vital signs, inserting intravenous lines, various surgical procedures, annual budgets, and publishing manuscripts all start and stop in predictable defined ways.

► Specific rules, standards and measurements exist for demonstrating performance competencies, outcome measures, institutional accreditation, and medical licensing. Some competencies, such as empathy, social accountability, trust and ethical behavior, are not simple, because standards and measures are not clear or consistent.

► Defined hierarchies.  Authority and responsibility in a clinical team are top down: From attending physician to medical student. Miller’s assessment triangle is a good example of hierarchies in pedagogy because it defines authenticity as top down: Does, Shows How, Knows How and Knows (Miller, G.E., 1990).

Each of the above problems and situations has measurable and replicable outcomes that can be predicted and controlled. 

Success requires:

► Setting clear goals, objectives, competencies, and defined outcomes

► Monitoring performance – formative and summative assessment and evaluation

► Providing incentives – a passing grade, progressing to the next level of education; institutional accreditation; licensing to practice

► Define regulations and best practices.  Outcome-based medical education.

► Build protocols and checklists – Direct observation, OSCEs, Mini-CEX, entrustable professional activities and milestones, curriculum evaluation

► Expect reliability and accountability.  Replication and reproducibility are essential for quality control in medical education and practice.
 
In marked contrast, Wicked Issues are not problems that can be reduced to their component parts, solved and reconstituted.  They do not follow a linear cause and effect logic and the whole (Wicked Issue) is greater than and different from the sum of its parts.
 
Wicked Issues have:
► Ambiguous and/or flexible boundaries.  For example, the progress of chronic illness such as diabetes, depression, individual learning.

► No clear starting point and no clear end.  Examples include community health, trust among team members, ethical issues, professional behavior, social accountability, etc. Each of these began long before it presents and will continue long after a project or initiative is complete.  
► The rules keep changing.  New leadership, interdisciplinary and interprofessional collaboration, etc.

► There are many ways to assess learners.  Clinical assessment depends on who is on service during a rotation and what patients are present.

► Allies become opponents (or opponents become allies) unexpectedly.  One person may support one change and resist another. You cannot know ahead of time how each person will respond or what concerns they will voice.


Success with Wicked Issues involves three things
► Engage in inquiry. When there are no answers, questions are the only option

► Look for and identify patterns of change over time and across place. For example, recognize patterns of improvement and change in learners and groups

► Use Adaptive Action to experiment until you find what works.
 
 
 
 
Adaptive Action: Succeed in Dealing with Wicked Issues
Adaptive Action (Eoyang and Holladay, 2013) is a disciplined method for informed action in Wicked Issues.  While Wicked Issues cannot be solved, you can engage with them and take wise action to make a meaningful difference.

Adaptive-Action.png

Adaptive Action: A simple, iterative, three-question
method for making decisions and taking action in
wicked (complex) situations.

Three basic questions set the stage for seeing what is happening, for making meaning, even when you are sure you don’t know; and for taking action, even if you can’t predict or control outcomes. Adaptive Action is an iterative cycle with three questions:
 
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, identify the conditions that shape the situation as you see it. Look for implications of the current state and options for action to change the conditions and release the 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.
were developed through the institution.

Success dealing with Wicked Issues using Adaptive Action provides informed action that is optimal for the situation at a given time and place and:
► Reflects what is currently known about the situation
► Works across scales—individuals, teams, organization, community
► Moves the system toward its ultimate goal, even when that goal is ambiguous or changing
► Empowers those who can and should act to shift the pattern

Finally, you cannot know ahead of time if the action you take is the best of all possible choices. A choice that seems to fit may or may not be perfect. Future information may lead to a different conclusion. Change that emerges from Adaptive Action may not match your expectations or the expectation of others. However, it is enough to move you and
your Wicked Issue forward toward your goals.
 
If you are accustomed to being in charge, if you expect yourself always to pick the right answer, if you think you can and should always know what is best, then you will not be satisfied with the measure of success for Wicked Issues. When answers can be known, when success can be measured, then know it and measure it. However, when you are working in emergent authentic situations, where uncertainty is the only certainty, then turn your eyes to a different standard, and find what the best fit for the situation is. Find what is excellent enough to move you, your students, your team, and your patients forward.
 
References
Cleland, J. A., Patterson, F., & Hanson, M. D. (2018). Thinking of selection and widening access as complex and wicked problems. Medical Education. doi:10.1111/medu.13670
Eoyang, G. H., & Holladay, R. (2013). Adaptive Action: Leveraging uncertainty in your organization. Stanford, California: Stanford University press.
Eoyang, G.H., Mennin, S. (in preparation).  Wicked problems in health professions education: Adaptive Action in Action.
Glouberman, S., & Zimmerman, B. (2002). Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? (Vol. 8): Commission on the Future of Health Care in Canada.
Mennin, S. (2019, July 30). Tame your Wicked Issues in Medical Education: Part 1: What Has You Stuck? How to Get Unstuck with Adaptive Action. Blog Retrieved from https://www.mededworld.org/Reflections-All/Reflection-Items/July-2019/Tame-your-Wicked-Issues-in-Medical-Education-Part.aspx
Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic Medicine, 65(7), S63-S67.
Rittel, H. W. J., & Webber, M. M. (1973). Dilemmas in a general theory of planning. Policy Sciences, 4(2), 155-169.
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