On this episode of the Academic Medicine Podcast, Sam Clarke, MD, MAS, and Jon Ilgen, MD, PhD, join host Toni Gallo to discuss the importance of teaching adaptive expertise to prepare learners for the types of complex cases they will encounter in clinical practice. This conversation also covers what adaptive expertise is, how simulation can be used to foster this skill in learners, and the complementary relationship between performance-oriented cases and adaptive cases in health professions education.

This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.

A transcript is below.

Read the article discussed in this episode: Clarke SO, Ilgen JS, Regehr G. Fostering adaptive expertise through simulation [published online ahead of print April 21, 2023]. Acad Med. DOI: 10.1097/ACM.0000000000005257.

Transcript

Toni Gallo:
Welcome to the Academic Medicine Podcast. I’m Toni Gallo. I’m joined by Drs. Sam Clarke and Jon Ilgen, who are the authors of a paper entitled “Fostering Adaptive Expertise Through Simulation.” And that’s available now to read for free on academicmedicine.org. In their paper, Sam and Jon and their third coauthor, Dr. Glenn Regehr, suggest a different approach to simulation that really aims to build adaptive expertise in learners. And this model gives learners opportunities to practice and receive feedback on the types of complex problems that they’re likely to encounter during clinical care. We’re going to be talking about adaptive expertise and what it is, how it might guide the development of simulation cases. And then we’re going to get into is this work part of a larger shift in medical education toward using what Sam and Jon call ill-defined problems to teach clinical decision-making? So I want to start with introductions. Sam, would you like to tell our listeners who you are?

Sam Clarke:
Sure. I’m Sam Clarke. I am an associate professor of emergency medicine at UC Davis Medical Center in Sacramento, California. I am an education researcher and, in my day job, I help lead our department’s medical education and simulation fellowship. I am the director of education research in my department.

Toni Gallo:
Thanks. Jon?

Jon Ilgen:
Hi everybody. Jon Ilgen. I’m a professor of emergency medicine at the University of Washington. Also wear several hats. I’m our vice chair for faculty development and education and also director of medical education research fellowship. I guess I sort of consider myself an education researcher, although I always have an imposter syndrome around that title. So do the best I can.

Toni Gallo:
I think you both are going to impress our listeners today, so I wouldn’t worry about that. I want to start with just what is adaptive expertise. And our listeners might not know that term yet, so give us some background. What is it? How might it be different than a performance-oriented model that we’re used to seeing right now?

Sam Clarke:
Sure. Yeah. So adaptive expertise is a framework that has been around for a while. It describes a flexible approach to problem solving that is thought to be integral to expert practice and is distinct from but complimentary to routine expertise. And you can think of routine expertise as just the knowledge, the skills, the procedures that describe any particular practice. An adaptive expert is someone who has mastery of those routine elements of practice but also can recognize when a routine approach to a problem is unlikely to work or facets of a problem are so unique that there really isn’t a routine approach that can be employed and is able to balance efficient practice with innovation when necessary, whether it’s modifying an approach or even creating new knowledge to address a unique problem to affect the desired result.

Toni Gallo:
Why did you decide that now this was something that we should be talking about? What prompted you to write this paper?

Sam Clarke:
So adaptive expertise is very much in the conversation in health professions education broadly. I think other things to recognize about it, although there’s this common belief that adaptive expertise is just the natural outgrowth of experience, that probably isn’t true. There’s this feeling that it is an independent set of skills that need to be fostered from early on in one’s training. And I would say the education community broadly, we’re trying to wrap our heads around how that might work. For myself, I do a lot of simulation-based teaching and simulation-based teaching has long adhered to more of a performance orientation, creating simulated experiences that are really meant to elicit responses that are replicable, that are observable, that are measurable with a goal of improving performance towards a prespecified ideal. Simulation’s origins are really around teaching practitioners to perform procedures safely. That same model which has leaned heavily on things like mastery learning to help people perfect that type of practice has been adopted, I would say, in other types of simulation. I’m an emergency physician, we do a lot of fullscale simulation involving mannequins and recreating scenarios one might encounter in clinical practice that are high stakes or that we don’t encounter frequently. And we’ve historically done that with an eye towards optimizing individual or team-based performance. And I think all of that has worked well. But when you start to really dive into the sort of problems that we frequently encounter in our practice, and Jon can certainly speak to this too, often there isn’t just one single right answer or one approach that would work best. Often we’re engaged in something that’s more akin to making sense of what is going on, navigating uncertainty, and I think that’s the sort of experience that calls upon the skills of adaptive expertise and that simulation might need to change its practice to better support.

Toni Gallo:
So do you think this is something that maybe wasn’t explicitly taught before, but clinicians sort of had to learn this skill anyway and now maybe you’re saying we want to make sure that this is a skill that you walk away from medical school with?

Sam Clarke:
Yeah. I would say in practice, I informally think of adaptive expertise as thinking on your feet well, and you know it when you see it. There are clinicians that are really able to pivot, modify their practice as needed. And I think a lot of us learn that through modeling and perhaps some people are just a little bit better primed to do it, whether from prior experience and things that may or may not be medical or they may just have a little bit more of a reflective stance in their own practice that makes them open to innovation when they need it. But for the most part, no, it isn’t something that we have been taught explicitly about very much. I think it is entering the conversation now more, but again, we’ve relied on models that really aren’t meant to support that, at least in the simulation environment, that aren’t really attuned to adaptive thinking or innovation per se but rather something that I would say is more akin to puzzle solving, trying to put the pieces together in the way that makes the most sense to move efficiently and to, you might say, ace the test. And I think again, that’s really, really useful in scenarios for which there is an expected course of management, perhaps like algorithmic care as in managing a cardiac arrest where it really comes down to situational awareness, how you manage a team, clear communication, and so forth. But again, although problems like that do present themselves in clinical medicine, more often we’re facing challenges that are ill-defined. We have problems that are truly, truly complex and for which perhaps the biggest piece is trying to make sense of the nature of the problem itself. And I think this is an area where simulation can be employed, but again, it’s a little bit different, especially in terms of the way we design scenarios, the way we conduct debriefing and the way we’ve traditionally done it.

Toni Gallo:
There was a line in your paper that I wanted to ask you to expand on a little bit, and it’s that “problems that initially hinder performance might actually facilitate learning.” And I wonder if you could just talk a little bit about what you mean there and what that might look like.

Sam Clarke:
So there is this concept of productive failure or productive struggle. Essentially the idea that just engaging with a really thorny problem or one for which a ready solution isn’t just immediately available, it’s actually a very healthy thing for a learner, although it can be unsatisfying in the moment, may initially even lead to confusion or frustration, that it’s that very process of engaging with a truly challenging problem and one for which the next steps aren’t clearly evident that helps us grow. And I would say that is the sort of thing that most closely resembles the clinical reasoning process as we experience it in clinical medicine. And again, it’s something that I think sim can support. I think by virtue of some of our traditions of trying to frame up scenarios around clearly specified learning objectives on the one end and critical actions or the expected course of management on the other, we’ve kind of created a rather narrow path that we expect learners to navigate through and it doesn’t really capture the idiosyncrasies of the way people solve problems or even conceptualize their problems. It really doesn’t accommodate when people go outside of what we expect them to do. Although in truth, that’s probably where a lot of the fruit lies is just in better understanding the thought process that guide those actions. So again, what we’re advocating for is to engage with those sorts of thorny problems, whether it’s irreducible uncertainty or true dilemmas for which there isn’t an obvious, better course of action, one versus another that lead to a slower but probably a deeper growth.

Jon Ilgen:
I’ll just chime in to say that I think that a lot of the things we’re talking about here are around framing clinical problems as ones that are solvable and are solution oriented is very much the tradition we’ve had in preclinical learning. When students learn archetypes of particular illnesses, they’ll be given cases that have hallmark features of those things and then each case has a solution, you get a diagnosis or a clear management approach that comes from that case being solved. And then they leave their preclinical experiences and go to the wards and realize that many of these problems that they’re facing don’t have clear solutions or that there are members of their team that disagree about how to interpret the most pertinent findings or even which findings are the ones they should be paying attention to. So I think at least students really feel this shift between problems that are solution oriented versus these, what we’ve been calling, ill-defined problems, which was originally a term that was adopted by Kitchener actually back in the ’80s. So really this idea of conflicting assumptions, conflicting evidence, conflicting opinions, really leading to possibly different solutions. And I think what’s really interesting that Sam has advanced here is this idea that simulation has a really powerful way to actually simulate that experience that you can try working through a problem one way, have some things that don’t go as well or go better and then just do it again. And I think that the benefit of simulation in that regard is this idea of really working to define and redefine problems iteratively, really working to think about, well, how would you think about this differently or how would you manage this differently? And I think if we think about simulation as an avenue to do that, it enables a really nice microcosm of what actually happens on the wards, in the operating room, et cetera, as experts try to make sense of these problems that aren’t clean, they’re messy and thorny and ambiguous, and they’re doing their best in that context to take care of that patient even though the solution isn’t immediately clear.

Toni Gallo:
Could you give us an example of what a case like this might look like? What would a case where you’re really trying to teach adaptive expertise, what would be some of the components and maybe how would it look a little different than a performance-oriented case?

Sam Clarke:
Sure, yeah, I can describe a recent sim case that I ran with a group of our residents. So I had mentioned earlier that speaking broadly, a traditional simulation case, it’s framed by learning objectives. There’s usually a known and knowable diagnosis that’s the throughline of the scenario. And there are supporting stimuli in terms of history, exam findings, lab data, imaging results and so forth that will allow the learner to navigate an expected course of action and arrive at the correct answer or the optimal management of the case. And then afterwards, there is usually a post event debriefing, which is a conversation which is usually a really powerful part of the experience, in which there’s the chance to reflect on the decisions that were made, the things that happened, reflect on practice collaboratively. There is often a chance to compare one’s performance to a prespecified ideal in the form of critical actions. And there’s a chance to clarify understanding about underlying pathophysiology or the content of the simulation and consolidate some of that learning to carry forward for the next time you encounter whatever it is. And all of that works quite well, but it can be constraining in certain ways. And to describe perhaps simulation intended to elicit adaptive thinking, I recently ran a case and like all good sim cases this is actually drawn from real life. I sit on my department’s QI committee and this was one that came up just because it was a very thorny case and one in which a room of 15 or so faculty were actively debating for several minutes what they would’ve done in this situation. I thought, okay, this is perfect because here there’s a real difference of opinions amongst a group of people that are very experienced at this. And so I would say starting with that in mind, the case was intended to present an authentic dilemma, one for which there isn’t an easy way out, and I’ll give the basics of it. There was a patient who had fallen down a flight of stairs and face planted, had some facial trauma, was brought to the hospital by ambulance, and the EMS crew says “This person fell down some stairs, knocked themselves out. When we found them, they were sitting upright and saying that they thought their neck was broken. They also happened to be a little bit intoxicated and said that they had used methamphetamine earlier, so they were quite anxious.” The EMS crew brought them to the hospital in a cervical collar but sitting bolt upright. And they said, “Every time we ask the patient to lay flat, they said they can’t because they think that their neck is broken.” Something about it makes them so apprehensive that they’re totally unwilling to lay flat. And so patient presents to the emergency department sitting upright, awake, talking and quite anxious. And in the routine approach to assessing a trauma patient, one of the first things we would do is try to ask the patient to lay flat so that we can get a complete physical exam but also so that we can facilitate other things that we’ll need, like having them go to the CT scanner. And in this particular case, the patient is unwilling to lay flat and the learners are asked, how are you going to solve this problem? You have it in mind that perhaps this patient has a cervical spine injury. Every part of you wants to get some sort of imaging study that will confirm what you suspect, but the patient is just unable to help you do it. And paths of management emerge from there. Most people will try giving the patient a little bit of pain medication, perhaps a little bit of a mild sedative just with the hope that if they’re a little bit more relaxed, their pain is a bit more tolerable, that they might be able to position the patient in a way that would facilitate imaging. Others talked about more radical ideas like maybe we need to intubate the patient or deeply sedate them in order to facilitate this imaging study. But each attempt to do these things is thwarted by the patient who just says, “I can’t do this, I can’t do this.” So from there, learners are asked to explore what are some other options. And some might think of having the x-ray technician come to the bedside, try to shoot a lateral film of the neck just to see, it may not be perfect, it won’t be a complete C-spine series, but perhaps it would reveal the injury. And if it doesn’t and you’re still stuck, that’s when things really got interesting, I would say. And just reflecting on this actual experience, and I’ll just share 2 vignettes that I think are illustrative. One is that a group of residents was trying the approach a little bit more medication, a little bit more sedation, let’s see if we can just get the patient to get the problem to fit the way we want it to, have the patient lay flat. And at one point, one of the residents said, “I just have this terrible feeling about this.” I paused and said is that because this is a simulation and you feel like I’ve laid some sort of trap for you? And she said, actually, no. I feel like in real life if the patient was telling me this, if there was something about them that was really telling them that their neck is broken and that they can’t do what I’m asking them to do, I should really listen to that. And I thought, this is great. This is one of those moments of a metacognitive awareness and what I like to refer to as one’s spidey sense, that the path that I’m moving down isn’t the right one. I don’t know definitively what it is with the patient, but I have the strong suspicion and, in this case, the patient shares that suspicion and I should respect that, I shouldn’t persist. So I would say that’s one example of the thought process that this problem and scenario is meant to elicit that we think kind signals some of that adaptive thinking. Another was people started to really get creative about how might we solve this problem. One group started to talk about the CT scanner itself. The CT scanner, when a patient gets a CT scan, they lay on a table, a gantry that moves them into the CT scanner. The scanner and detector rotate around the patient and create a 3D image. And understanding that about the technology, they started to reason, well, it doesn’t really matter the orientation of the patient in the scanner, they just need to fit inside the scanner. And that happens to be true. And so if the patient is not able to lay on their back, but if we could somehow safely get them onto their side, we might still be able to acquire the images that we need and do so more safely or if they could even be semi recumbent and again, just able to fit inside the scanner. And so here I’d say the things to highlight are just thinking about mechanisms, the how and why of how things work is one of the things that underlies adaptive expertise and that problem solving. Reasoning by analogy, knowing how things work in a certain situation allows you to apply them to a novel situation. And stitched throughout this all, and I say I’ll just call out 2 other shifts. One, there isn’t one right answer to this problem. It’s really meant to be an authentic dilemma and one for which there isn’t an easy right answer, or if you only just knew this one thing, then it would all work out fine. Two, it’s a fairly short case. It was intentionally designed so that as the conversation evolved, if people wanted to go back and try something a different way, they could. This wasn’t just a one and done and then we’ll have a conversation. And then three, and this was probably the biggest shift from a more traditional simulation case in which we let people do their thing. The learner is allowed to navigate the scenario to the best of their ability, and then we lean really heavily on this post event debrief to unpack it all. What were you thinking? What were you feeling? What did you do? What could you have done? Which really asks a lot of the learner and the teacher and just the time that you have to capture it all. Instead, in this type of simulation, the debrief is more of a rolling dialogue. It’s stitched throughout the scenario and led both by the learner and in this case me, the instructor, asking questions, pausing to tell stories when it’s appropriate, trying to make just all of our thoughts visible to each other with the hope that the decision making that is going on becomes more evident in real time, rather than looking back on “Well, I think what I was thinking when I did this…” Instead, at the moment of decision, the learner has the opportunity to just describe what’s in their head and why they might choose one course of action over another. And unlike traditional simulation where the instructor is out of the room in a sense, they’re standing back almost Wizard of Oz like, here I really feel intentionally that the instructor needs to be participating in the scenario that … One, there isn’t one right answer so the person leading the simulation doesn’t hold all the answers. They’re more of just an experienced voice. And two, just recognizing that this is intended to be an exchange of ideas. And so rather than just being silent and offering an opinion at the end, it can be much more of a dance and multiple voices in the room.

Jon Ilgen:
I think what’s really neat about that story, Sam, is because these problems are wicked, are problems without clear solutions and you’re drawing from mechanisms, for example, to think about doing things the way that you haven’t done before but have reasonable chance of success. I think the other piece is that it really rises things like emotions to the surface there and perhaps won’t surprise you that I really heard in that reflection of “I’m feeling worried that something might happen.” That sounds like what experts say when they talk about uncertainty, actually. And a lot of the times, at least in some of the doctoral work that I did, when we asked clinicians to describe that sense of trying to make predictions about the future or having a sense that things weren’t going the way that they thought they were going to go, that was sort of the best they could do. “I was worried that something bad was going to happen. I wasn’t sure what that thing was, but something didn’t feel right here.” Someone described this sense of it was like someone following you down a dark alley or down a street. It’s like you can’t see them, but you have this sense that there’s someone behind you. And that the opposite is also true, that carrying forward with a sense of comfort may also be a bit harder for people to describe, but other than “Things just seem like they were going the direction I expected them to.” And it doesn’t necessarily have to have clear words or clear explanations, and they may still not even know what’s necessarily happening, but they have a reasonable idea that they’re on track. I think the other bit that I think is really interesting there is because these problems are so negotiated, there’s this sense of co-construction within a room, and I think you in that context have some degree of power and expertise and probably guidance that’s a little bit different. But you could also imagine a scenario where all of the people in the room have a similar degree of expertise, and I think it really expands this idea that we’ve had historically around self-regulation, which is how individuals manage themselves, their emotions, their cognition, et cetera, to these more expanded ideas of co-regulation where somebody has a bit more authority or socially shared regulation where you’re really looking to people around you to try to make sense of things together and using their reactions alongside yours to make sense of is this the best way forward that we can come up with. Recognizing again that there isn’t actually an answer, it’s just the best that you can do with what you’re given.

Toni Gallo:
You’ve both mentioned uncertainty and a couple of other skills that people can develop if you have one of these adaptive oriented cases. And I wonder if you can talk a little bit more about that, how it seems like part of it is not just learning the clinical decision-making, but also how do you deal with uncertainty, how do you communicate with your team, and all of the other pieces that go into, not just am I asking the patient the right questions. It seems like there’s a lot more that goes into some of these cases and then also those get discussed as part of the debrief that happens that you were talking about. So could you maybe talk a little bit about some of those other things that become a part of this?

Sam Clarke:
I might start first by talking a little bit more about the simulation context and how important I think wrestling with uncertainty is there and then we can talk a little bit more about clinical work and I would love to hear Jon’s thoughts about that. But I would say one of the things that has always irked me about simulation is that, as people get more familiar with it, they often get very good at solving puzzles and viewing any sim case as “I just need to as quickly as possible find the right answer.” And they’re often just primed to think in that way, help me, I’m going to put the puzzle pieces together. And sometimes very cleverly and understandably drawing on extraneous clues. I remember at this training up in Tahoe, we were getting ready to start a case and one of the physicians said to another, “This is a meningitis case, just so you know.” And I said, “Tell me more. Why did you say that?” He said, “Well, there’s an LP trainer sitting on the table over there.” And in this case, it wasn’t actually a case involving meningitis, but I thought this is so illustrative of what I often see, which is just taking stock of the room and thinking like, okay, I happen to know that the person leading this scenario is a toxicologist. I bet this will be a case involving a toxidrome and just primed to make some really big predictions and bold moves in a way that feel pretty inauthentic, whether right or wrong. Just feels much more like playing a game than wrestling with the deep uncertainty that sometimes we’re faced with in clinical medicine. And so I think by shifting the emphasis, again, for a certain type of training to uncertainty that is irreducible, that involves conflicting or incomplete information or genuine dilemmas for which there isn’t really a right answer, that that comes closer to the thought process that we engage in actual practice in which you’re constantly weighing one bit of information against another. The history suggests this and the physical exam backs that up, but we have this weird radiology read that says, consider so on and so forth, and which are you going to put more stock in? We actually get really comfortable doing that decision-making and navigating uncertainty with comfort. And this is something that Jon has written about. But a lot of SIM scenarios, I think in an effort again towards creating conditions that are replicable, eliciting behaviors that are observable and measurable, a lot of that just gets drained away, and instead you have something that looks more like a puzzle, sometimes an elaborate puzzle, but one for which there is one right answer. And I think in clinical practice, as I was saying, we’re often engaged in a practice of sense-making. What is it I’m actually looking at, how do these pieces speak to something that we think fits with what’s going on with the patient and acting in accordance with that? But also holding in mind multiple possibilities that we may need to manage in almost a parallel fashion knowing that we may not arrive at a single answer. So I think, again, by placing uncertainty front and center in some types of simulated experiences, we create the conditions that more accurately reflect the sort of mental work we’re doing in clinical practice.

Jon Ilgen:
I think that’s a great reflection on that. The other piece to me that I think is really useful to think about is that I think this had its broad relevance to every field in medicine and across health professions. Part of the things that I think are important to recognize is with 5 people in the same room, that experience of uncertainty is likely to be different for each of them based upon their own past experiences, based upon their knowledge of that environment and what resources are available, their knowledge of the patient or the problem, et cetera. And so I think this kind of construction of beginning with the stimulus that is intentionally ill-defined, really trying to mimic the realities of what a lot of us experience in practice, enables us to surface just the ways in which that experience manifests in each of us and actually unpack those things together about how one person may feel very comfortable, whereas another person is feeling intense discomfort with the same stimulus. And I think those of us who supervise trainees very frequently experienced this, where the trainee encounters a problem they’ve not seen before and it is very angst producing. And then the nurse in the room is like, “We got it, kid. We see this all the time. You don’t need to be worried about that.” Or when a generalist speaks to a specialist or a specialist speaks to a generalist, encountering a problem that’s just not within their realm of expertise. I think all of us have those kinds of reactions. So the benefit of creating those kinds of experiences is it makes real the work of being in that moment. And I think there’s this notion of tolerance that’s been advanced, a tolerance with uncertainty, which implies that it’s this almost like a personality characteristic that one can just sit in that space. And I think what we’re trying to argue here is that space is dynamic. That the space requires negotiation. That space requires being attentive to oneself, to others in the room, to the patient, to the system, to the environment. And that is the work of managing that experience. So the management of the uncertainty is things that we can really get into in simulation spaces with more intentionality to reflect the kinds of things that we’re actually managing in practice, as Sam mentioned, the things you pay attention to, the things that you let go, the ways in which you engage your colleagues and how they’re doing with that situation so that they surface things that you might’ve missed. And how’s the patient doing in this context and what are they thinking? I think there’s lots of different pieces of that puzzle to unpack there. But I think at least a lot of the uncertainty work that we did previously with emergency physicians, and I think very much echoed in the work of Carol-anne Moulton’s work in the operative setting, these ideas of trying to make sense of a situation are really these dueling tensions of what they refer to as forward planning, the ability to make predictions about the future, and then continuous monitoring of yourself, of your situation, of the patient, of others, et cetera. And that the cycle between those two helps you to get a sense of how am I doing here? Am I feeling comfortable enough that I can handle this on my own? And am I having enough discomfort that it’s time to ask another person for help or to garner more resources or to slow down or whatever it might be? And really helping people to feel those kinds of experiences authentically with someone there who can help unpack yes, that’s a real feeling, I want you to pay attention to that. That’s not the feeling I’m having, but that doesn’t actually matter. The fact that I’m feeling comfortable doesn’t help the person who’s feeling discomfort. They need some clues about how to manage that experience effectively. So I think that’s really what the work is here and that’s really exciting.

Sam Clarke:
Yeah, I really love all of that, Jon, and I agree, and I think the only thing I would add is that in the clinical environment, so much of that work, that negotiation, and the reconciliation cycle that you described may be invisible to the learner or we may not have the opportunity to unpack it in real time and thinking certainly of experiences in the resuscitation room where conversations may happen in shorthand or sometimes just with a glance and there’s a world of meaning within it, but we may not really have the chance to talk about it until well afterwards. And again, just leveraging some of the affordances of the simulation environment, which are really independent of technology, just the ability to stop and break the scenario for a moment and have a discussion about things like what you’re worried about or tying it back to something that you’ve seen or done in clinical practice and wondering, was that what you would do? Is that what I would do? Again, just the ability to again, make some of those thoughts visible, to be able to share them, on both sides, both the learner and the instructor or the person who is the more experienced voice in the room, I think is so powerful and really starts to engage this thought process that adaptive thinking is really founded in.

Toni Gallo:
So I have one more question to finish up our conversation, and that’s around the movement from using cases that have a right, definitive answer and the goal is to just get learners to that right answer to this how and why and what does the process look like and you have an ill-defined question and you really want to get them to understand how to work through what that scenario might be. And we talked about it a lot in terms of simulation, but is this something you see happening in other areas of medical education or how might it be used in other areas?

Sam Clarke:
I think I’ll have to lean on Jon a little bit for this one. I do think that these concepts are very broadly applicable. In fact, earlier this morning I was meeting with my physical therapist, and we were having a conversation about adaptive expertise and relating it to his own practice. And I think really any professional work certainly benefits from acknowledging the role of this thinking. I want to make clear, too that what has been gained already through a more performance orientation in simulation-based teaching is really huge. There’s a mountain of evidence to suggest the ways in which it works. I think what we’re suggesting here is that there’s another face to the mountain that hasn’t been explored as well. And I think that that’s true in simulation-based education, but it’s true elsewhere, really specifically addressing learners, their self-regulated learning, their forward planning, their metacognitive abilities, their self-monitoring, and also their reflective ability in addition to just their openness to flexibility and problem solving would pay dividends not only in the clinical environment but even in the classroom environment and helping people create both a durable and a flexible body of knowledge as they move forward through their training years and beyond. And I think that’s how I feel a lot of this ties into preparation for future learning, that we’re helping people recognize that what they know now is going to change and that, as it changes, it may also affect the way they look back on the things that they were taught originally, and there’s an enormous amount of strength in that process. So in short I’ll say yes, there are lessons here that are broadly applicable throughout health professions education and I would say just professional training.

Jon Ilgen:
Yeah, I like the analogy of having 2 sides of the mountain. I would say that the idea of well-defined or more routine problems or problems that have clearer solutions around either a diagnosis or management are important as a complementary approach here. And I think learners need scaffolding. You can’t teach them about cardiovascular disease and say this case could be anything. That’s not a very predictive way to learn about disease either. So I think that there needs to be a balance between learning those building blocks and acknowledging that sometimes those building blocks are going to be insufficient and/or, as people start seeing in more and more cases, that the building blocks for each of us are idiosyncratic and importantly informed by our past experiences. So I think in some ways trying to strike that balance between having some foundational knowledge that gives you a degree of sort of ground beneath your feet with also the acknowledgement that the work of medicine is quite messy. I think one thing that I reflected upon a lot as an attending is the ways in which we define success is largely based on who defines it. And so Glenn Regehr has often referred to this idea of the myth of expert convergence, namely that 2 experts seeing the same poorly defined problem would approach it, define it, treat it the same way, when in fact that is not often the case at all. And in fact, many of us experience that in practice all the time where a consultant will see a problem very differently than we have, or 2 different people seeing the same patient in succession define it very differently as a hospitalist changes over service to another hospitalist, for example. And so I think a lot about myself as the gold standard for the people that I’m training probably isn’t the right message just because I think that I’m making sense of this person’s shortness of breath as heart failure doesn’t mean that a very reasonable person couldn’t think something else, and that there may be some degree of 2 diagnoses at play, for example. So I think to me, this idea of really giving people agency and that idea of refining and redefining and being really attentive and paying attention to how cases are evolving is a really important part of helping people to work effectively in authentic clinical environments, even when the answers aren’t clear. And I think redefining what failure in that context, for example, looks like. It’s not agreeing with me. That sometimes a very reasonable person who is much more novice may have a different understanding of a problem and that’s a valid understanding that I certainly need to pay attention to, and we can work together to sort of negotiate our way forward. So I think it is easier as within a system of education to say that we define what the answers are, but I think it’s a disservice to our learners when they reach the places where we’re actually training from and realize that ultimately they’re going to be having to make these negotiations and these decisions on their own eventually. And really helping them to lean into those experiences where there isn’t a clear answer, there isn’t a clear management approach, and you feel your way forward in ways that you’re trying to leverage the things around you to keep the person safe or to get the best possible outcome you can get, even when the answer may not be clear.

Sam Clarke:
There’s a lot more that needs to be explored here. Our back and forth prior to this interview we talked about the role of assessment and how you have a sense that the things we’re looking for are actually happening, and I think that’s the next frontier for this. So there are a lot of really important questions that are still out there but to return to this idea of a different face of the mountain, there’s a lot of exciting territory here to be explored.

Toni Gallo:
Well, I want to thank you both for being here today. I really appreciate it. I think this was a great conversation, and I want to encourage our listeners to look for Sam and Jon’s paper, which is out in Academic Medicine now. So thanks everyone.

Sam Clarke:
Thank you, Toni.

Toni Gallo:
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