There is nothing as practical as a good theory.
—Kurt Lewin1
The COVID-19 pandemic has changed individuals and health care institutions and is testing the graduate medical education (GME) community's collective adaptability and potential for growth under adversity and uncertainty.2,3 The effect on GME programs and sponsoring institutions (SIs) has been profound; many teaching hospitals shifted focus to primarily care for COVID-19-positive patients.3,4 This is not the first time SIs have confronted major crises; other examples include Hurricanes Katrina and Sandy and other natural and manmade disasters. In contrast with regional events, COVID-19 is affecting hospitals across the nation, and uncertainty surrounding the pandemic suggests that a return to the pre-COVID-19 state is unlikely in the near term. Across local, regional, and national crises, a pressing challenge for SIs and their leaders is how to address the concerns and needs of trainees and faculty whose world has been upended, and how to best to promote the well-being and professional growth of both groups.
Attempts have been made to adapt models of personal change and growth to the context of COVID-19.5 These models often focus on intentional change followed by restabilization.6 This may underestimate the disruption and uncertainly that characterize institutional crises resulting from external factors and the extent to which they require cognitive reframing.7 The focus on restabilization also may not appreciate that leaders need to “embrace the disequilibrium”8 present for some period during an extended crisis.
In this perspective, we present a pragmatic model for SIs' response to crises and disasters (Figure), with zones of crisis, adaptation, and growth. We draw on articles about adaptive leadership during a sustained crisis,8 and on theories for promoting a growth mindset for leaders, faculty, and trainees.9 This model is applicable to a range of crises SIs and their leaders might confront.
The Crisis Zone
I learned that courage was not the absence of fear, but the triumph over it.
—Nelson Mandela10
Prior to a crisis, SIs and the individuals within them function in an environment with reasonably predictable and familiar stresses and challenges. Disruptions are present but typically are not fundamental and are accepted as “known” attributes of the work.
In contrast, the “Crisis Zone” is characterized by disruption and uncertainty and the realization that established rules and business-as-usual thinking no longer hold. Fear and confusion prevail, with institutions and individuals experiencing a loss of control.
Behaviors and reactions in the Crisis Zone may be a response to individuals being pushed out of their comfort zones into a place where some degree of fear is prudent. Major external events often make institutional routines and contingency plans obsolete. Faculty and trainees may lose their sense of control, which may contribute to mistrust and undermine professional identity as individuals' focus turns inward.2 Trainees may experience internal conflicts between concerns about safety and their commitment to serve patients.11
For SIs, a critical response in the Crisis Zone is to continue their core mission and activities. For the COVID-19 pandemic, this meant caring for sizable numbers of critically ill, highly contagious patients and supporting trainees and faculty in their efforts. As mandated by the Accreditation Council for Graduate Medical Education for all disaster situations, SIs must ensure adequate resources, training, supervision, and adherence to work hour requirements, along with other efforts to protect the safety of learners.12 In the context of any crisis, particularly an extended one, there is no substitute for timely and effective communications, including regular updates, affirming current information, and noting there may be added changes as information becomes available.13
While institutional leaders expect faculty and trainees to progress to the “Adaptive Zone,” some may linger in the Crisis Zone. How GME leaders work with individuals “stuck” in crisis mode is important for the individuals and the larger community. Fear may manifest as residents communicate that they will not take care of COVID-19 patients or abandon their posts to ensure their families are safe during a hurricane, leaving leaders shocked and disappointed. References to moral responsibility may not resonate. Under these circumstances, the strategic response is to pause, take stock, and seek to understand. This requires acknowledging anger and concern when it is not possible to offer immediate solutions. Leaders' transparency about their own concerns could be helpful, while dismissive or critical responses may further entrench individuals' fears. Fear does not have to disappear for the individual or institution to move forward.
The Adaptive Zone
Disaster is virtue's opportunity.
—Seneca the Younger14
The “Adaptive Zone” entails a gradual embracing of the new reality. This may be a longer-term institutional disequilibrium as the optimized response to a lingering crisis.8 SI leaders should reinforce the message that the institution is prepared to take on the crisis and needs faculty and resident physician engagement. Programs and institutions should provide just-in-time training and adapt policies and rules of engagement that allow trainees to opt out of clinical situations when safety and supervision parameters are not met. This may include leaders showing their care for individuals at all levels of the organization,13 including policies that ensure trainees get equivalent access as their faculty to resources such as personal protective equipment or be excused from clinical care. Leaders must be open to uncomfortable questions and offer opportunities for courageous conversations that publicly discuss the rationale for differences in approaches.8 Lack of transparency, failure to deliver on promises, or discounting concerns may push individuals back into the cycle of fear and unproductive responses that characterizes the Crisis Zone.13
Leaders need to find opportunities for those sidelined by the crisis to become engaged. For the pandemic, this entailed assigning trainees to understaffed, non-COVID-19 areas, contact tracing, or remote emotional support for vulnerable populations.15 Communicating the value of these efforts and their connectedness to the institution's mission is critical.
A key element in coaching individuals in the Adaptive Zone is helping them understand that holding on to “the way things used to be” may be counterproductive in a changing environment. During extended crises, the pace of change in knowledge and guidelines requires ongoing adaptive leadership and encouraging others to prevent regression.
The Growth Zone
This knowledge that you might have to really reorganize and redefine yourself and build new skills is really important.
—Carol S. Dweck9
The “Growth Zone” is when institutional learning from the disaster begins to dominate. At the individual level, adopting a growth mindset is important to prepare leaders, faculty, and trainees for ongoing work and future crises. In residents receiving formative feedback, a growth mindset (contrasted with a fixed mindset) was associated with a focus on professional development, asking more questions, and looking for opportunities for growth.16 A growth mindset has been associated with positive effects on the brain's neural network.9 For institutional leaders, modeling a growth mindset9,17 includes modeling transparency and self-compassion and an empathic response to patients and team members. It also includes demonstrating gratitude, appreciating suggestions, and ensuring mistakes are viewed as improvement opportunities. In a longer-term crisis, SIs may move between the Adaptive and Growth Zones. This may require expanded leadership that draws on the SI's collective intelligence by placing responsibility for adaptive work at lower levels of the organization, leaving leaders free to address upcoming challenges.8
Conclusions
Disasters result in disruptive change for leaders, faculty, and trainees. In this context, it is helpful to have a framework that highlights effective strategies for working through and learning from crisis situations. We suggest a pragmatic model that may help promote leaders, faculty, and trainees to transition from crisis to adaptation to growth. We hope it offers guidance to GME leaders to promote adaptation and a growth mindset in the face of current and future crises.