INTRIAGE - Associates for Healthcare Improvement


Improving Medical Education

Medical educators and health care practitioners assume problems create “chaos” which must be managed by the imposition of decontextualized, authoritarian, control structures.  These structures suppress uncertainty and awareness of the complexity from which uncertainty arises, aiming instead for agency that is individualistic, authoritarian, reactive, projects “certainty”, and is assumed to be unfettered by constraints of context.

Medical education can repair the gaps in health care practice by designing constructivist pedagogy aligned with complexity theory.  Such education approaches result in professional agency which is collaborative, heedful of contextual constraints, and builds an envisaged framework of the activity system which improves outcomes through anticipation of demands on the system rather than through reactive responses.  Desirable outcomes are achieved by appraisal of complex situations using dialogue, narrative, experimental logic, and mindfulness.  Clarity, not closure, provides the basis for taking action.  Engagement in practical action includes design thinking which is human centered, and takes a constructive rather than an authoritarian role in designing solutions. These characteristics increase the design capacities of end-users.  This form of agency enables health care providers and patients to jointly create desirable paths through the labyrinth of complex health problems.

- Gilbert Jones MD, MSc teaches health care quality improvement through collaborative teamworking in the Saint Louis University School of Nursing, Saint Louis, MO, USA.  He is Honorary Tutor in Medical Education, School of Postgraduate Medical and Dental Education, Cardiff University, Cardiff, Wales, UK.


 There has been a significant amount of research performed on the process of medical socialization, its effects on medical students and practitioners, and the barriers the resulting social character presents to thinking across systems and acting collaboratively.  There seems to be much less research on alternate ways of interacting with people and information by physicians.  Klemola and Norros (1997) investigated what they labeled “habits-of-action” by anaesthetists (anesthesiologists).  Practitioners interacting with the dominant habit of action, called “reactive”, manifest little recognition of uncertainty of practice, fail to contextualize information, relate to patients in an authoritarian fashion, and react to adverse events after they occur.  In contrast, a minority of anaesthetists displayed an “interpretive” habit of action.  Physicians with this habit of action recognize uncertainty in their practices, contextualize information, engage in “conversations” with their patients.

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