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Executive Leadership in Academic Medicine® Message from the Director - November 2013

Diane Magrane, Director of Executive Leadership Programs

Diane Magrane
Director of Executive Leadership Programs

Sometimes the Answer to a Challenge Arrives in Camouflage...

I am quite fond of the works of the artist Bev Doolittle. She captures the spirit of nature and Native American life in beautiful watercolors, and each work holds the surprise of camouflaging one scene within another. My favorite is called "Calling the Buffalo." How often have we been in the position of this Native American, calling others to our efforts only to discover that what we seek is right in front of us, or as in this painting, languishing at our feet just waiting to be discovered? Such is the nature of some of our most perplexing problems.

When you own a problem deeply, and the solution is not readily apparent, it can gnaw at you relentlessly. Sometimes, the best thing you can do is to walk away from it and then find a way to approach it with a different perspective. Works in Progress (WIP) consultations construct a way for colleagues to offer a gentle calling out of the assumptions that are in the way of seeing our problems in new ways. When you "listen in" to peers who hold your problem for a short time, discussing your challenge without taking on full ownership, what you may hear is "Hey, look over here! I'm your real challenge and you haven't been paying attention to me!"

Calling the Buffalo, ©Bev Doolittle

Calling the Buffalo, ©Bev Doolittle, www.greenwichworkshop.com/doolittle

Last January, during the ELUM professional development program, we worked with an approach that brings new perspective to vexing challenges by giving them over to colleagues to discuss while the "owner" of the problem sits within earshot. This column describes that approach and hopefully will entice many of you to join Latha Chandran for a Works in Progress session at the meeting this coming January.

Latha Chandran, MD, MPH

"Years ago, I was exposed to the Step Back Consultation process at the Harvard Macy Program and found it extremely helpful to have a 'fresh set of eyes' look at my problem. Because group performance almost always exceeds individual performance and because our groups in particular have highly experienced, seasoned, caring and creative intelligent women, the new angles of thought that come out of such consultations are often eye openers for those of us 'stuck in a rut' with the problem. I have used this technique in various forms for faculty and resident retreats and most participants find it quite beneficial in finding ways to resolve the challenge presented."

Latha Chandran, MD, MPH (ELAM class of '06)
Vice Dean for Undergraduate Medical Education
Professor of Pediatrics
Stony Brook School of Medicine

This process of group consultation is grounded in our everyday experience of learning from our colleagues. It recognizes that:

  • Our innovative problem solving can get "stuck" in our own perceptions of the source and boundaries of our challenges.
  • Other perspectives are possible, informed by peer's experiences of prior challenges and outcomes.
  • A trusted group, grounded in relationship-building and reciprocity, can tend well to each other's challenges.

We all are familiar with how dilemmas are sorted out through conversation with others in the course of designing and interpreting research, in clinical care management, and both classroom and informal teaching. It is through dialogue that humans reach understanding, insight, and make sense of "messy" challenges. This process of Works in Progress consultation is adapted from similar approaches developed by Keith McCandless (a Liberating Structure for community problem solving, Wise Crowds Consultations) and Elizabeth Armstrong (Step-Back Technique for developing educational projects) of the Harvard-Macy Institute.

How the Consultation Works

Each member of a Works in Progress consultation team has an opportunity to listen to peer discussion of an organizational or professional challenge of her choosing. The method also is useful for thinking about how to move scholarly work ahead, and "next steps" of organizational changes. Although it can be difficult to listen to those "who do not understand completely" discuss how they would manage the situation, it is precisely because they have not become mired in the same situation that they can uncover new ideas!

A few Group Agreements enhance the process of learning to use the approach and achieve the most benefit from the consultations.

  • What is said in the circle remains in the circle.
    The narratives must be held in utmost confidence, with the same respect that ELUMs have come to hold the narratives of their Learning Community circles.
  • Open your mind to curiosity and close it to judgment.
    Consultant members should offer perspective with the best interests of the narrator who owns the challenge; the narrator must be able to receive information that might seem, at face value, irrelevant or counter-intuitive. Those new angles are the gift!
  • Listen with attention; speak with intention.
    The narrator's primary role is to listen, but this also applies to consultant members so that they can build upon each other's ideas.
  • Respect the structure of the consultation.
    This is a time-tested technique. Following the discipline of the methods opens the group to creativity of thought about the challenges they hold.
  • Trust the wisdom of the circle.
    These are often challenges that can ONLY come from experience and shared exploration. If the solutions were more obvious, there would be no need to bring them to the circle of consultation!
  • Organize the circle for efficiency.
    For each narration, the person to the right of the narrator serves as the recorder and the person to the left serves as the time keeper, so every member of the circle gets their time to discuss their challenge and gain from the wisdom of the group.

Roles are shared and rotated as each member of the group has an opportunity to offer her challenge for consultation.

Narrator

The narrator briefly shares the "story" of one of her own vexing challenges. To do so requires a bit of preparation in order to present:

  • The context—environment, players involved, pertinent history—of the challenge
  • Her role in the situation and how she has approached it
  • The question being presented for discussion

It is best for the narrator to remember that the peers in the circle do not have a big picture understanding of your institution or your specific situation. So when the narrator is sharing the story, it is best to think of yourself as a teacher clarifying a concept to a student. Explain in clear terms the overall picture, the specific situation and the challenge you need to group's help with. To do this in five minutes certainly requires careful thinking and organizing what to say and how to say it.

After five to six minutes of telling the story of her challenge, the narrator takes questions for clarification only from the consultants for another few minutes. (No advice, or offering shared experiences, please! This time belongs to the narrator and all others are welcoming listeners.)

For the next eight to ten minutes, the narrator then "sits back" literally and figuratively, from the table, to listen to the consultation team take on her problem. It is helpful for her to sit with her back to the group with a notepad and pen in hand to jot down some of the discussions heard and the new thoughts that may arise during some "aha" moments when your mind is fully concentrated on one thing only–listening carefully.

Recorder

The recorder captures the essential elements of the presenting team's history, context, and challenge on the consultation record. Before the group consultation begins, the recorder should check with the narrator to be certain the challenge or problem question is clear. The recorder then documents the questions and recommendations of the consultation team. These notes are given to the narrator at the end of the consultation. These notes, along with the narrator's own captured thoughts, will serve as excellent written guides for resolving the discussed challenge in the future.

Timekeeper

The timekeeper keeps an eye on the clock, gives two-minute warnings and polite but firm signals if the narrator or consultants extend beyond the allotted time. The timekeeper keeps the playing field even for everyone to benefit from consultations in the time allotted for the group.

Facilitator

The facilitator monitors group process, encouraging contributions from everyone by guiding the balance of questions and suggestions among all members of the consultation team. The facilitator may directly ask questions or request team members to step back to take the role as listeners. She encourages brainstorming, discourages premature dismissal of ideas, and encourages members to explore and build upon new ideas.

Agree upon an agenda

The consultation process can be accomplished in as little as 15 minutes each or as long as 40. Below is an agenda for a 15-20 minute consultation.

  • Three minutes for the narrator to describe the history, context and challenge of his or her institutional team's dilemma
  • Two minutes for clarifying questions
  • Ten minute group consultation where members should take on the dilemma as if it were their own. They may not ask further questions of the narrator and, in fact, should act as though the narrator is not even in the room. In the last two to three minutes, the facilitator should call for recommendations, a summary of "best thoughts" from the consultation.

Close the consultation with reflections

The reflection goes in both directions: two minutes for the facilitator to verbally share the recommended actions and three minutes for the narrator to report on what she heard and how she will use the recommendations. This final round serves 1) to clarify the group consensus (sometimes the narrator hears something quite different during the conversation!), 2) to clarify and solidify what the narrator heard, while 3) giving the group feedback on the value of their discussion. This is not a time to continue the consultation or for either party to ask more questions. The only response appropriate after the reflections is "Thank you!"

After two or three consultations, take 10 minutes to debrief on the Teams in Consultation process. What is working well? What could the group improve? What specific actions would you like to try with the next set of consultations?

Pearls and Pitfalls of the Consultation Process—a Few Tips

  • Be as clear as possible as to the questions the narrator needs to address before beginning the consultation. While the consultation may reveal new questions or perspectives, it is disappointing to put one's challenge "on the line" and have the group fail to address the very real problem with which the narrator is struggling. On the other hand, sometimes the real challenge of the narrator is the lack of clarity of her question or position. In this case, the group may wish to explore what the REAL questions or dilemmas might be. Clarity can be a marvelous gift from a consultation.
  • The narrator should talk for absolutely no more than five minutes. (When your story is finished, STOP.) Armstrong warns us "the more the presenter talks, the more s/he will shape the discourse in the room to resemble the way she is already thinking. New ideas don't get in."
  • The narrator must not interrupt the consultation with additional information. It is very difficult to be a silent observer and listener when others who are less informed about the facts are discussing your circumstance. However, interrupting the consultation with more "facts" can be destructive to the creativity and utility of the process.
  • The consultation team members need to take on the project as though it were their own, no matter how confusing the question or how ill-equipped they feel to take on the dilemma. Trust that new, useful ideas will emerge from the group's collective wisdom in discussing the problem and potential approaches.

 

ELAM is a core program of the Institute for Women's Health and Leadership at Drexel University College of Medicine, Philadelphia, Pa. The Institute continues the legacy of advancing women in medicine that began in 1850 with the founding of the Female Medical College of Pennsylvania, the nation's first women's medical school and a predecessor of today's Drexel University College of Medicine.