Number of Citations: 0

Submitted: 9 September 2023
Accepted: 29 January 2024
Published online: 2 July, TAPS 2024, 9(3), 55-57
https://doi.org/10.29060/TAPS.2024-9-3/PV3134

Sean B Maurice

Northern Medical Program, Division of Medical Sciences, University of Northern British Columbia, Prince George, Canada; Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, Canada

I. INTRODUCTION

Risk management is a skillset that is embedded within clinical practice. Clinicians use protective equipment to safeguard themselves from pathogens carried by patients, learn de-escalation techniques to manage violent patients, and learn to ask for help. Patients of course are also at risk, because they present with illness or injury that may get worse despite our best efforts, and because there’s always a chance of iatrogenic injury or disease. Healthcare providers dedicate themselves to healing injury and illness, and to not causing further harm. In contrast, risk management is rarely considered with regards to teaching and learning, as they are not commonly understood to involve risk. When a teaching or learning experience feels risky, but we don’t think it should, then we don’t talk about it, and this can create cognitive dissonance and discourage us from engaging in teaching and learning.

Health systems around the world need more healthcare providers, at a time when they are dealing with very significant burnout (Office of the Surgeon General, 2022). In the face of this burnout, we may not be inclined to innovate, but Eva (2022) encourages us to step up and embrace the opportunity to make change, as during challenging times, “… it is critical that every stakeholder in the medical profession strive for excellence by adapting to modern realities rather than clinging to the seemingly safe status quo.” If we need to train more healthcare providers at a challenging time, when not making change is potentially more dangerous than innovating, then we should consider the metaphor of adventure to inspire our innovations and help us think about risk management in teaching and learning.

II. RISKS IN OUTDOOR ADVENTURE

In self-propelled outdoor adventure (hiking, mountaineering, kayaking), risks are largely obvious, and consequences can be very serious, so talking about risk management is both natural and normalised. Participants engage in ‘calculated risk-taking,’ which involves identifying risks and managing them as well as possible to keep the risk at a level considered reasonable by all who partake. Prior to the adventure, risks are managed by ensuring that the team have the right skills, training, and equipment; and judgement is used in choosing the objective and monitoring conditions like the weather, or snow conditions. During the adventure, participants need to make decisions in response to changes that occur over time, including changes in the weather, or the group condition (fatigue, minor ailments like blisters); along with the unpredictable (weather that washes out a key bridge, a bear stole all your food). Additionally, in self-propelled outdoor adventures, the team are limited by the resources that they brought with them, so working as a team to overcome challenges with limited resources is inherent.

For those who choose to embark on self-propelled outdoor adventures as a leisure activity, the idea that fun can involve hard/tedious work and a degree of suffering, is not foreign. Some mountaineers proudly talk about “Type II fun,” with phrases like “It doesn’t have to be fun, to be fun” ­– an acknowledgement that a challenging adventure can be worthwhile even though it involves hard/tedious work, risk, and some discomfort. In fact, the reward is often greater because of the effort required (within reason). The motivation for these adventures is intrinsic, and the journey is as important as the destination.

Adventure leaders must ensure all members of the group are appropriately prepared for the challenge ahead and stay safe and engaged. This involves having the ability to teach the physical skills required, ensuring the group has appropriate equipment for the conditions, and making judgement calls as conditions change. In addition, adventure leaders need to care deeply for the wellness of participants, watching for non-verbal cues that a participant might be suffering physically or mentally, and use wisdom to decide when and how to intervene, to improve participant satisfaction, and reduce the chances of a problem escalating.

III. RISKS IN HEALTH PROFESSIONS EDUCATION

Risks in teaching and learning include the fear of public speaking (common, though rarely acknowledged), the risk of embarrassment (from getting something wrong in front of others), and the risk of losing control (if you hand over too much control to the learners and can’t reign them back in). In the clinical environment, there’s a risk of learner harm and loss of empathy if we don’t prepare and support them adequately during their training, there’s a risk of losing clinical faculty if we make unreasonable requests of them, and there’s a risk of compromised patient outcomes if we don’t consider impact on patients due to our innovations, or lack thereof.

IV. IMPLICATIONS OF AN ADVENTURE METAPHOR

A. Academic Teaching

For academic faculty, an adventure mindset might encourage learning about teaching practices and experimenting with new techniques with some risk that they might not be successful. It also encourages innovations in teaching and scholarship to meet important social needs, even if these don’t seem like the most fruitful or safe endeavours from the perspective of traditional tenure and promotion metrics. If the academy would acknowledge the importance of unconventional approaches to scholarship and teaching to meet social needs, then it would need to reconsider how it evaluates performance.

B. Clinical Teaching

There’s a growing recognition that demonstrating vulnerability and empathy, can lead to more effective patient care and more effective clinical education, while also being more rewarding for preceptors. Many physicians have long since given up wearing a lab coat, and some are comfortable being on a first-name basis with medical trainees, as part of “an ethic of caring” which ensures learners feel safe and are better able to learn (Balmer et al., 2016). When teaching while providing clinical care, the clinician needs to think about how they are perceived by the patient, as well as by the trainee. It may be possible to balance the need to maintain credibility, while being vulnerable and modelling the clinical reasoning process for both student and patient, by exhibiting “Intellectual Candour” (Molloy & Bearman, 2019). Showing vulnerability and empathy might seem like a loss of formality, and this might feel risky, yet if this is a calculated risk, with opportunities for gain in the form of a more meaningful teaching experience and more impactful learning for students, then this might be a worthwhile adventure to embark on.

C. Underserved Populations

Some of the most medically underserved people in Canada (and globally), are rural and Indigenous peoples. If we are trying to train more healthcare providers to meet the needs of equity deserving groups, we need to consider how we are currently discouraging this. If cultural safety is not always experienced by Indigenous peoples (especially on their own, colonized lands), we need to keep cultural safety at the top of our list of priorities and we need to invest in it. If we currently provide a largely specialist curriculum which discourages rural generalist practice, we need to look at how we can make the curriculum more of a generalist curriculum. If we acknowledge that family practice has become less appealing as many family physicians now work in clinics with more limited scope, and less longitudinal relationships with patients (albeit more reasonable hours), then we should consider how to better support learners to consider full scope family practice.

In discussions about the characteristics of rural family physicians who provide full scope care, people often talk about ‘rational risk takers,’ as physicians who are more willing to accept risk, because they work in locations where timely access to specialist and subspecialist care is often not available, and working near or beyond the limit of their training is the alternate to seeing some patients not receive care at all. This is a form of calculated risk-taking and has recently been described as “Clinical Courage” (Konkin et al., 2020). If clinical courage is necessary for care providers serving our most underserved populations, then we need to encourage it, to reduce the healthcare provider maldistribution. This means ensuring that characteristics of clinical courage are embedded: when admitting students to our programs, in both our pre-clinical and clinical curricula, and in our assessments, for all learners.

V. CONCLUSION

Teaching and learning in the health professions should be fun, though a serious sort of fun. Our learners are now much more diverse than in the past, and they are advocating for needed changes in the healthcare system, while our clinicians are struggling. If we must innovate to sustain and improve what we do, then an adventure metaphor will encourage and inform how we approach this.

Health professions programs should ensure that working as a team, managing risks, and overcoming challenges with limited resources, are embedded within our curricula. We should also focus on intrinsic motivations of learners and faculty, and emphasise the importance of the journey, alongside the destination. Our systems need to ensure that clinical faculty have the capacity to care about the wellbeing of learners, alongside providing patient care. Embracing the metaphor of adventure should help invigorate our teaching and learning, and counteract burnout, while we work towards needed change in our health systems.

Notes on Contributors

The author conceived and wrote this manuscript.

Acknowledgement

The idea for this manuscript came from the author’s teaching philosophy and teaching dossier prepared for the Society for Teaching and Learning in Higher Education, 3M National Teaching Fellowship (2022 recipient). The idea has been shared at the Centre for Health Education Scholarship (CHES) Day of Scholarship (October 2022), the International Congress on Academic Medicine (ICAM, April 2023), and the Asia Pacific Medical Education Conference (APMEC, May 2023) and the idea has been improved and clarified through the critical feedback of peers at these meetings.

Funding

No funding was required for this study.

Declaration of Interest

The author has no conflict of interest, including financial, institutional, or other relationship that might lead to bias.

References

Balmer, D. F., Hirsh, D. A., Monie, D., Weil, H., & Richards, B. F. (2016). Caring to care: Applying Noddings’ philosophy to medical education. Academic Medicine, 91(12), 1618-1621. https://doi.org/10.1097/ACM.0000000000001207

Eva, K. W. (2022). An open letter to all stakeholders involved in medicine and medical education in Canada. Canadian Medical Education Journal, 13(4), 1-2. https://doi.org/10.36834/cmej.75549

Konkin, J., Grave, L., Cockburn, E., Couper, I., Stewart, R. A., Campbell, D., & Walters, L. (2020). Exploration of rural physicians’ lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): An international phenomenological study. BMJ Open, 10, Article e037705. http://dx.doi.org/10.1136/bmjopen-2020-037 705

Molloy, E., & Bearman, M. (2019). Embracing the tension between vulnerability and credibility: ‘Intellectual candour’ in health professions education. Medical Education, 53(1), 32-41. https://doi.org/10.1111/medu.13649

Office of the Surgeon General (OSG). (2022). Addressing health worker burnout: The U.S. Surgeon General’s advisory on building a thriving health workforce. US Department of Health and Human Services. https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf

*Sean B Maurice
3333 University Way,
Prince George, BC,
Canada, V2N 4Z9
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Email: sean.maurice@unbc.ca