Informal and Incidental Learning in Complex Clinical Environments: An Examination of Critical Incidents of Frontline Physicians During the COVID-19 Pandemic and Implications for Medical Education.

Abstract

Purpose: The uncertainty and complexity of everyday clinical practice was amplified by the COVID-19 pandemic and illuminated the gap in training that students receive to function in uncertain environments. To date, formal training to navigate uncertainty in practice is lacking. Educators require an understanding of informal and incidental learning (IIL) to prepare students for this uncertainty. Learning in the clinical environment, long described as informal, represents a process for learning that is implicit, unintended, opportunistic, and unstructured. The authors explore IIL as a guiding framework for developing a curriculum that prepares students to navigate uncertainty. Method: Using a constructivist grounded theory approach, we describe physicians’ IIL while working during times of heightened uncertainty. The critical incident technique was used to elicit narratives from 6 frontline emergency medicine and 6 critical care physicians who worked during the height of the pandemic (March–June 2020) and asked them to describe their learning in the clinical environment. Interviews were virtual, recorded, and transcribed. We re-storied narratives to build a cohesive, chronological story in the participants’ own words. We reviewed re-storied narratives as part of an inductive analysis, which allowed for the collection of patterns, assertions, and organizing themes. We examined what participants did in the face of uncertainty and how IIL manifests in their narratives. Results: Physicians were challenged by not being able to rely on evidence-based medicine. Physicians reported an increased reliance on the interprofessional team (specifically, nursing colleagues) to overcome fears of failure. They highlighted the importance of team consensus and agreement as they learned how to care for COVID-positive patients. Their learning was characterized by “pattern recognition” (i.e., known procedures of care), “intuition” (i.e., gut feeling), and reliance on past experiences (i.e., “new things are just new versions of old things”). In many instances, participants had to comfortably engage in “poking at the periphery” (i.e., trial and error) and “pivoting on the fly” (i.e., making do with the information and/or equipment available) to navigate their learning. Physicians relied on consensus building, previous knowledge and expertise, and abductive problem solving to navigate uncertainty in their clinical practice. Discussion: Physicians’ critical incidents provide rich data to clarify our understanding of what IIL looks like in the clinical context when working through uncertainty. Physicians relied on consensus building, previous knowledge and expertise, and abductive problem solving to navigate uncertainty in their clinical practice. Significance: Our findings may inform educational interventions that prepare medical students to navigate uncertainty in clinical practice. There are opportunities in medical education to cultivate skills in formal curriculum, to prime students for IIL, so they are better prepared to navigate situations of clinical uncertainty.