key: cord-0945701-kulswvz4 authors: Mennin, Stewart title: Ten Global Challenges in Medical Education: Wicked Issues and Options for Action date: 2021-09-20 journal: Med Sci Educ DOI: 10.1007/s40670-021-01404-w sha: e397d3133cf3e1b5d03a9b133ac162b2faeda17a doc_id: 945701 cord_uid: kulswvz4 Medical education and the health professions are facing multiple global challenges that are context specific yet are patterned across contexts. These challenges have been described as wicked issues that defy known solutions and are viewed differently by different people. Three simple approaches, inquiry, pattern recognition, and Adaptive Action, are presented as a way forward to tame wicked issues and take informed action. Today, more than ever, knowledge of medical education is necessary but not sufficient. Medical educators and medical education face many challenges, most of which are not isolated events. Instead, they are dynamical complex patterns that are in constant motion, shifting and evolving due to their sensitivity to small contextual changes in the local environmental in which they exist. These patterns span the breadth and depth of faculty development, curriculum change, teaching, assessment, program evaluation, scholarship, research, and leadership. While they have always been intrinsic to medical education, they have been exacerbated by the Covid-19 pandemic. Ten global challenges that are context specific, at the same time, occur across contexts. They are briefly described and collectively characterized as wicked issues [1] . Three options for action to tame wicked issues are discussed. The implementation of various pedagogies is inextricably linked to human relationships. Table 1 lists ten examples of challenges that confront educators and students in their daily practices. academic life, and any challenge to its space, time, and legitimacy generates tension. 4. Collaboration is difficult because it runs contrary to how health professionals are trained and how practice is remunerated. The currency of health professionals is independent practice and in research training is about being an independent investigator. Assessment of learners is based on individual performance and on the extent to which learners are capable of functioning independently. Promotion is based on individual achievement. Traditional concepts of leadership remain largely rooted in hierarchical hero-based models [2, 3] . Small-group learning has become a dominant format in medical education, yet assessment is still largely based on individual performance. Finally, competency-based and outcomes-based medical education emphasizes individual performance [4, 5] . 5. There is too much to do, not enough time, and not enough resources. This is a chronic problem that will not go away. It is true for patient care, research, teaching, and administration. 6. Bias of all kinds continues to be a challenge in professional and social circumstances. Examples include gender, age, race, status, experience, specialty, religion, and geography, to name a few. Men continue to dominate leadership roles in academic life. Race is an issue everywhere in the world. There is bias based on expertise and specialty. For example, surgery and internal medicine often have higher value and voice in most hospitals and academies. 7. Fulfilling multiple demanding professional and personal roles is another continuous challenge. When I am a teacher, I am not being a researcher. When I am a clinician, I am not doing administration. When I am doing one job, I am not doing the other, and when I am doing all of them, I am not with my family. For postgraduate trainees, there is a tension between service and the provision of education among post-graduate trainees. 8. Integration in the curriculum among silos of disciplines and departments, specialties, and interprofessional and multidisciplinary work is a common seemingly intractable challenges in medical education. The traditional approach to integration of adding more courses to the curriculum leading to an overwhelming learning task for students and more work for teachers is not a viable solution. 9. Conflict between individuals and groups is a constant challenge in health professions institutions and health care. It is not uncommon in a problem-based curriculum that in some small groups, facilitators refuse to stop lecturing even when students complain that their learning is not student-centered. 10. Faculty development is a continuous challenge. Not everyone who needs it participates in workshops or capacity building activities. Commonly, such activities are voluntary and not a significant part of promotion decisions. Often, faculty development occurs as a single event without continuity over time. Rittel and Weber (1973) described a new class of problems called "wicked issues" that are impossible to solve. These ten challenges in medical education are wicked issues. They are defined differently by different people and do not follow assumptions of linear causality. They are context dependent yet exhibit patterns across contexts (Table 2) . For example, one such common wicked issue, collaboration in teaching and in clinical care, looks different to each person involved. The wicked issue of collaboration changes all the time. It is not an issue that ends because it is continuously sensitive to multiple conditions at the same time. Wicked issues, especially those involving human relationships, are too big and have too many parts to manage all at What to do when dealing with wicked issues? What is possible? Three approaches are suggested to tame wicked issues and make them more manageable: inquiry, patterns, and Adaptive Action. All organisms inquire about and continuously sample their environment. Medical education and the health care professions depend on effective inquiry. Four behaviors promote inquiry in human systems. 1. Turn judgment into curiosity. Curiosity leads to learning. Judgment in the present context does not refer to summative assessment in which a decision is made based on evidence and experience. Instead, judgment refers to negative bias, early closure of a discussion before all the available information is shared, and everyone has had a chance to participate. It refers to deciding how you feel about something before you have explored it. Curiosity creates an open environment for students who want to learn. Leadership without curiosity fails all concerned. 2. The second challenge of inquiry is to turn disagreement into shared exploration. Differences are essential for progress and growth. They create the energy of change. It is how science challenges the status quo. Finding a gap in the literature or an unexplained difference leads to the formation and exploration of new hypotheses. 3. Turning defensiveness into self-reflection is the third challenge in inquiry. Sometimes, disagreement becomes personal, and individual identity can become confused with a difference in perspective. Challenges in collaboration can lead to hurt feelings and defensiveness. 4. Turning assumptions into questions is the fourth challenge in inquiry. It is natural to make assumptions about how things work and for the reasons for human behavior. Finding and questioning our basic assumptions is the key to successful inquiry in medicine, science, and human relationships. Thus, managing wicked issues benefits from inquiry, and inquiry involves curiosity, shared exploration, self-reflection, and questioning assumptions. There are static, fixed patterns like crystals and machines, and there are ever changing patterns like human relationships, collaboration, and the social determinants of health. We are concerned herein with the latter. A useful way to define patterns is to understand them as many interacting interdependent parts in which similarities, differences, and connections have meaning across time and space [9] . Thus, wicked patterns are not stable; they do not stay in one position. The pattern of a health care team behavior changes and adapts itself with each clinical challenge [10, 11] . Collaboration changes from moment to moment as do doctor patient relationships [12] . Recognizing patterns of wicked issues is facilitated by asking five questions: Adaptive action is a way to take informed action in the face of the uncertainty of wicked issues. will we teach? After an action is taken, a new situation and a new pattern appears, and the Adaptive Action process begins again iteratively with a new What? Adaptive Action helps us to inquire about and perceive the pattern in a wicked issue. It leads to informed action based on understanding. When there are no satisfactory answers, when what has worked before is no longer working, then Adaptive Action is the best strategy to tame wicked issues and challenges in medical education. Today, knowing about medical education is necessary but not sufficient. There are multiple real and significant challenges along the way to successfully implementing medical education. Ten common challenges can be characterized as wicked issues that appear as patterns without solutions. However, they can be tamed and managed through inquiry, pattern recognition, and Adaptive Action. Seeing these challenges as wicked issues and pursuing inquiry, pattern recognition and Adaptive Action provides a viable practical path forward. Ethics approval and consent to participate Ethical approval was not necessary or relevant. The authors declare no competing interests. Dilemmas in a general theory of planning A treatise on efficacy: between Western and Chinese thinking An emerging complexity paradigm in leadership research Competency-based medical education: theory to practice Outcome-based education: a practical guide for medical teachers Rethinking wicked problems: unpacking paradigms bridging universes open (Part 2 of 2) Rethinking wicked problems: unpacking paradigms, bridging universes (part one of two) Wicked problems in health professions education: adaptive Action in Action. MedEdPublish Adaptive Action: leveraging uncertainty in your organization Using complexity to promote group learning in healthcare Self-organization and leadership emergence in emergency response teams Complexity in primary care: understanding its value