Making decisions "in the dark": Learning through uncertainty in clinical practice during Covid-19

Urvashi Vaid; Henriette Lundgren; Karen E Watkins; Deborah Ziring; Grace A Alcid; Victoria J Marsick; Dimitrios Papanagnou

doi:10.1002/aet2.10909

Making decisions "in the dark": Learning through uncertainty in clinical practice during Covid-19

AEM Educ Train. 2023 Oct 2;7(5):e10909. doi: 10.1002/aet2.10909. eCollection 2023 Oct.

Authors

Urvashi Vaid¹, Henriette Lundgren², Karen E Watkins³, Deborah Ziring⁴, Grace A Alcid⁵, Victoria J Marsick⁶, Dimitrios Papanagnou⁷

Affiliations

¹ Division of Pulmonary and Critical Care Medicine Sidney Kimmel Medical College at Thomas Jefferson University Philadelphia Pennsylvania USA.
² Human Resource Development, Department of Organization and Leadership Teachers College at Columbia University New York New York USA.
³ Department of Lifelong Education, Administration, and Policy University of Georgia Athens Georgia USA.
⁴ Department of Medicine Sidney Kimmel Medical College at Thomas Jefferson University Philadelphia Pennsylvania USA.
⁵ Adult Learning and Leadership Program, Department of Organization and Leadership Teachers College at Columbia University New York New York USA.
⁶ Department of Organization and Leadership Teachers College at Columbia University New York New York USA.
⁷ Department of Emergency Medicine Sidney Kimmel Medical College at Thomas Jefferson University Philadelphia Pennsylvania USA.

Abstract

Purpose: The purpose of this study was to explore how decision making and informal and incidental learning (IIL) emerged in the clinical learning environment (CLE) during the height of the Covid-19 pandemic. The authors' specific interest was to better understand the IIL that took place among frontline physicians who had to navigate a CLE replete with uncertainty and complexity with the future goal of creating experiences for medical students that would simulate IIL and use uncertainty as a catalyst for learning.

Method: Using a modified constructivist, grounded theory approach, we describe physicians' IIL while working during times of heightened uncertainty. Using the critical incident technique, we conducted 45-min virtual interviews with seven emergency department (ED) and five intensive care unit (ICU) physicians, who worked during the height of the pandemic. The authors transcribed and restoried each interview before applying inductive, comparative analysis to identify patterns, assertions, and organizing themes.

Results: Findings showed that the burden of decision making for physicians was influenced by the physical, emotional, relational, and situational context of the CLE. The themes that emerged for decision making and IIL were interdependent. Prominent among the patterns for decision making were ways to simplify the problem by applying prior knowledge, using pattern recognition, and cross-checking with team members. Patterns for IIL emerged through trial and error, which included thoughtful experimentation, consulting alternative sources of information, accumulating knowledge, and "poking at the periphery" of clinical practice.

Conclusions: Complexity and uncertainty are rife in clinical practice and this study made visible decision-making patterns and IIL approaches that can be built into formal curricula. Making implicit uncertainty explicit by recognizing it, naming it, and practicing navigating it may better prepare learners for the uncertainty posed by the clinical practice environment.

Keywords: Covid‐19; clinical learning environment; decision‐making; informal and incidental learning; uncertainty.