#thefutureofmeded: Mental models for the clinician educator

Dan Dworkis (@TheEmergMind) and Felix Ankel (@felixankel)

You are a new postgraduate dean hired to provide leadership for the clinical learning environment.  The organizational structure is based on a hierarchical model of strong departmental chairs, long standing traditions, and favorable accreditation visits.  In your first six months, you do the obligatory internal and external environmental scans and conclude that many clinician-educators have achieved personal mastery in bedside teaching, assessment, and presentation skills.

At the same time, you also sense an unease. Residency directors talk about ever increasing compliance requirements to maintain accreditation. They feel challenged because communication, finance, IT, and planning paradigms have changed from supportive infrastructures into proscriptive superstructures. Many residency directors enthusiastically started their positions hoping to create value in the system by developing and implementing a generative vision of innovative medical education.  They now feel constrained by a check-the-box culture of maintaining compliance.  This distress has affected clinician-educators and residents. 

You hope to set a tone for the future and hope to give educational leaders the tools to excel within a system. How do you start? What language do you use? What resources do you share?

Systems-thinking

Systems can be thought of as simple (using a recipe to bake a loaf of bread), complicated (launching a rocket ship), or complex (raising a child).  The distinction between complicated and complex systems is particularly important: in complicated systems, the value of the whole is the sum of the parts, while in complex systems the value expands to involve not only the parts but the connections between them. A common challenge for #meded leaders is relying on tools to manage complicated systems when dealing with complex systems such as #meded. Peter Senge is a systems scientist who wrote the fifth discipline,  where he describes the five elements of a learning organization:  Personal mastery, mental models, shared vision, team learning, and systems thinking. [Reference 1] In this blog, we will discuss using mental models to advance systems work.

Mental Models

Mental models are the conceptual frameworks that we use to explain how parts of reality work. Anytime you extrapolate information from previous experiences to guide upcoming choices, identify patterns and guidelines for how things “should” function, or balance multiple priorities to improving decision making, you are using mental models to experience and act in the world. Some mental models are simple but powerful ideas, like the concept of a lever or a force multiplier. Others are more involved and complicated like the Frank-Starling curve.

Like all theoretical constructs, mental models are imperfect but useful representations of reality. Each model has its own strengths and weaknesses and performs better at describing some parts of reality than others. Making mental models explicit allows you to access them directly, improve on and experiment with them, and use them more effectively across a variety of situations. Understanding the mental models your team is currently using–and the ones you want them to be using–will be key to improving morale and building the culture you hope to create. [References 2, 3, 4]

To explore deeper, let’s consider three key mental models and how they can apply to the team of clinician educators you are leading.

Wabi-Sabi

The Japanese concept of “wabi-sabi” encompasses the idea that natural things are inherently imperfect, impermanent, and incomplete. [Reference 5] Traditionally applied to the realm of art and design, wabi-sabi evokes the dynamic, natural world and the inherent cycle of growth, change, and decay. Its “opposite” would be a static and artificial situation, unchanging rules, and rigid structures. Working with the mental model of wabi-sabi helps you and your team move past an unproductive and illogical need for perfect answers or permanent, unchanging solutions in order to focus on what actually works. Instead of rigid, authoritarian systems of how your department should function, cultures and teams built with wabi-sabi in mind are flexible and adaptive, resilient to failures of individual components, and more likely to succeed under pressure. Change, growth, and experimentation are baked into their “cultural DNA.” A residency director with a wabi-sabi mind set may help influence a program’s focus from one of “pursuing perfection” to one on “pursuing improvement”. For example, residency conversations that previously included “if it isn’t broke, why fix it” could be shifted to “all things are inherently imperfect, how can we improve things “. An unintended benefit of a residency shift to a wabi-sabi mindset may be a greater appreciation of humility, vulnerability, and diversity of thought for the program.

Ask better questions

The “ask better questions” model helps orient your team to searching for and asking questions which drive you forward toward a common goal as opposed to siphoning energy and wasting resources. In or out of a crisis situation, your team’s ability to perform is tied closely to the strength and quality of questions they routinely ask. The best questions are present-focused and action-oriented. These questions are asked from within your sphere of influence and designed to address the most important decisions first. In the emergency department, for example, you might face a sudden loss of a critical resource like a CT scanner or the EMR. In this case, individuals often respond with poor quality questions, like “Who’s fault is this? How did this happen? How can they possibly expect us to work like this?” Higher quality questions focus on what you and your team could do right now with what you have to make this situation better, for example, “Ok, the computers are down, let’s come together and build a map of the patients currently in the department, who is the sickest that needs our attention first?” Then, when the immediate response phase is over, you could go back and try to figure out what happened. The recent shift to competency based medical education (CBME) has allowed us to ask better questions.  Rather than traditional time based, or number of procedures performed based proxies for readiness for independent practice, more programs are now discussing what assessments are needed before entrusting residents to independent practice.

Graduated pressure

The “graduated pressure” model empowers your team to experiment and try new ideas in low-stakes situations before rolling them out for full use. Applying graduated pressure is a key component of residents, since skills like intubating or placing a central line need to be practiced and mastered in friendly environments before being deployed in life-or-death situations. In the same way, graduated pressure can be used to test new ideas for validity in increasingly difficult scenarios before putting them into general practice. For example, when deciding to change the flow of patients through triage, you might test the idea during a handful of your historically lowest-volume days to work the kinks out before completely applying the new system. Likewise, when making significant changes in #meded programs (e.g., recruitment, assessment, curriculum, governance), consider piloting these changes in friendly low-stakes environments.

Final thoughts

1.  #meded is a complex adaptive system.  Use systems-thinking to grow and build value
2. Although personal mastery is foundational for #meded leaders, applying and sharing mental models facilitates system growth.
3. There are many forms of mental models (see here and here for two examples). We have described three mental models to get the juices flowing
4. Become facile with a few mental models for yourself and your team and try them out.  
5. If the mental models you identify that you currently use do not seem to work or become obsolete, try new ones and see if they fit.
6. The map is not the territory. Organizational artifacts and structures have limitations. Mental models can help with team learning.

Photo Credit: GoodFreePhotos

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