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Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
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Appendix A

Evolution of a Decision Tree

On September 30, 2021, Robert Cain, president and chief executive officer of the American Association of Colleges of Osteopathic Medicine, presented a decision tree for a panel to comment upon (Figure A-1).1 The panel included Alison Whelan, chief medical education officer, Association of American Medical Colleges; Julie Kornfeld, vice provost for academic programs, Columbia University; and Kecia Kelly, senior vice president and chief nursing officer, Legacy Health. He asked the three panelists to think about how a decision tree might have helped them in their decision making at the beginning of the pandemic. Cain described the steps in this tree. It begins with asking whether students should be considered part of the health care workforce, then it drills down into whether students should be part of the health care workforce during a crisis. Consideration of the risks and benefits of students continuing in current roles, being removed from clinical settings, or augmenting the workforce, is encouraged.

Patel reflected on the first node of the decision tree and how it might extend into stakeholder considerations. Figure A-1 asks only whether or not a learner should be removed from the experiential learning environment. Patel suggested a more fundamental question probing whether versus how: whether or not to keep learners in the clinical learning environment versus

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1 This decision tree and its subsequent iterations were drafted by Robert Cain and are based on the discussions of individual workshop participants during the workshop sessions. The questions raised are those of the individual participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine, and the figure should not be construed as reflecting any group consensus.

Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Image
FIGURE A-1 Decision tree, first draft.
SOURCE: Cain presentation, September 30, 2021.
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×

how to keep learners in the clinical learning environment (Figure A-2). Making this decision in the first node leads to other decisions that lead to a variety of stakeholder considerations. Through a series of questions listed in the orange and blue boxes, Patel suggested leaders and educators would think through the effect their decision would have on different stakeholder groups. For example, if the blue path of how is selected, decision makers might ask themselves if learners get to decide if a clinical learning environment is too dangerous for them. Similarly, will patients’ and families’ opinions be considered? These are just some of the issues that would need to be thought through based on the selected path, she said.

After describing what this decision tree would potentially look like, Cain asked the panelists for feedback on his presentation. Kornfeld offered an initial observation saying it is important to keep in mind that learners are not full-fledged members of the health care workforce. She noted how during the pandemic, first- and second-year medical students were treated quite differently than third- and fourth-year students. The first- and second-year students were generally removed from the clinical setting because their lack of clinical experience did not warrant their risk of exposure. Whelan agreed that a learner’s contribution to the health care workforce is highly dependent on how far along they are in their training and the skills and competencies they have developed. For some learners—such as fourth-year medical students—their meaningful contributions in a health care setting may be worth the risks. However, she also believed that while individual students are not part of the workforce, the student body as a whole is critical for the future workforce.

Illustrating Whelan’s point, an individual student can leave for summer break with no effect on the health care system, but if the education and training of an entire class of students is delayed, this will create a workforce shortage down the line. For this reason, Whelan said, it is essential to ensure the student body in all the health professions continues to learn and progress, even during times of crisis. To answer the question of whether to put a learner in a specific clinical setting, she noted, it is necessary to assess the risk-to-benefit ratio for that particular learner and setting. For example, “We would never put a student in with an Ebola patient,” because the risks are too high and the benefits do not outweigh the risks.

One observation by Whelan about this decision tree was an absence of student volunteerism. Many health professions’ students volunteer in the community, which is normally not an issue. However, during the pandemic, there was pressure on students to either volunteer or get paid to do care work outside of their core curriculum. For both students and schools, she said, it is important to balance the risks and benefits of doing such work; for example, a student could get infected, which could interrupt his or her educational progression. The Association of American Medical Colleges’

Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Image
FIGURE A-2 Considerations for leadership, student input.
NOTE: CLE = Clinical Learning Environment.
SOURCE: Cain presentation, September 30, 2021.
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×

(AAMC’s) perspective is the priority needs to be the students completing their training so they can join the workforce. Patel added how the pandemic had widespread economic impacts, and some students may have turned to paid care work to mitigate economic hardships; it is important to consider how rules about paid work may have a disproportionate effect on some students.

There were so many unknowns in the early days of the pandemic, said Kelly, which resulted in a lot of reactionary and knee-jerk decisions about learners in the clinical setting. As Legacy experienced with its nurse residents, the result of this has been that some health professions graduates missed out on building important skills and competencies. Moving forward, it is important to “figure out how to operate in a crisis without just completely shelling out our students.” Health professions students are our future workforce, she said, and it doesn’t benefit us when we cut off or cut short their training.

Cain said that avoiding knee-jerk decisions was part of the motivation for creating a decision tree. Rather than immediately removing learners during a crisis, such a decision tree can be used to help leaders make meaningful decisions about where learners can play a role and how to keep them safe. Whelan agreed, noting the pandemic was the first time where the risks and benefits of having learners in the clinical setting had to consider population health, not just individual patient care. A decision tree can help academic leaders take a step back and look at their goals and values, and help them see how they can continue to move toward their goals. For instance, if one goal is to ensure continuity of the health professions workforce, keeping learners progressing in their education and training is critical. This perspective can also be useful in discussions with other academic and health care leaders; for example, the workforce argument was helpful in getting hospitals to allow students back into the clinical setting.

Kornfeld added another consideration: decisions and their implications may differ depending on geographic region or student population, and that a decision tree can help take these considerations into account. An illustration of this, Kornfeld suggested, is what motivates some learners to participate in paid care work during school. The drivers toward paid work may be different for students from low-income backgrounds, which should be taken into consideration when evaluating the risks and benefits of allowing such work. Whelan agreed that decision making must take into account local conditions, noting that some schools did not remove medical students from the clinical setting, depending on availability of personal protective equipment (PPE) or local transmission rates. That said, the AAMC guidelines were helpful for the vast majority, and many leaders who questioned the need to remove students from clinical settings later agreed that it was the right call at the time.

Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×

DECISION TREE—SECOND DRAFT

Cain presented an updated decision tree in the October 27, 2021, workshop session in which participants heard from educational leaders who did not remove learners from in-person, experiential learning during the COVID-19 pandemic. It is impossible to know, said Cain, when the next crisis will strike or what it will be. What we do know, however, it that there will be another crisis. COVID-19 caught the health professions community off guard, so it is critical to take this time to consider how decisions were made, how they affected stakeholders, and how to make informed and rational decisions during the next crisis. As part of this work, Cain presented a second decision tree, which was evolved from the first version based on discussions with workshop participants (Figure A-3).

Image
FIGURE A-3 Decision tree, second draft.
SOURCE: Cain presentation, October 27, 2021.
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×

The first step is to understand and define the crisis, Cain stated. If a situation is immediately life threatening, removing trainees from the danger zone may be the most reasonable course of action. If the crisis is not immediately life threatening, decision makers can begin to think about how a decision will affect various stakeholders, including learners, educators, providers, and patients. In the decision-making step of a framework, stakeholder considerations would be weighed in a collaborative environment to decide upon next steps. Cain added that reevaluation of the decision is important, particularly as circumstances change or evidence emerges. Depending on how risks and benefits change, a different or modified path could be taken.

Cain again asked the panel of speakers to comment on whether a decision tree like this would have been helpful while making decisions in the early days of the pandemic. The panel included Laura A. Taylor, program director and chair, Uniformed Services University of the Health Sciences Graduate School of Nursing; Heather Johnson, chair and director, Family Nurse Practitioner and Women’s Health Nurse Practitioner programs, Uniformed Services University of the Health Sciences Graduate School of Nursing; and Jessica S. Thomas, Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College.

Johnson replied that making decisions was enormously difficult, and everybody at every level of leadership was worried if they were doing the right thing: “Are we doing the right thing if we keep students in clinical? Are we doing the wrong thing if we pull them out?” There was a “little bit of paralysis” because there were so many unknowns about the extent of the pandemic, how long it would last, and what the risks were. Johnson said there was generally a lack of student input into these decisions. Students were concerned they would not get the rigorous education and preparation they wanted.

Thomas agreed and noted the trainees at Houston Methodist Hospital largely did not want to be remote and they were “very insistent” the hospital come up with something other than sending them home. The initial thinking, said Thomas, was the situation was life threatening, therefore learners should be removed (as the decision tree also suggests). A tool like this decision tree would have helped to start the conversation and give a framework for what to consider, said Thomas, instead of just “winging it … and hoping that we were making the right decisions.”

Cain asked the three speakers how their parent organizations played into the decision-making process. Thomas replied saying Houston Methodist Hospital stepped in and made some decisions, such as how many people can be in a room, but that it also permitted programs to make decisions for themselves about how to move forward. Some programs were entirely offsite or moved trainees into different areas with different roles. Once programs

Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×

developed a plan, the institution was on board. Thomas then added, “nobody really knew what the Accreditation Council for Graduate Medical Education was going to do,” and it took some time to hear whether there would be flexibility in terms of graduation requirements. She said it “was a bit of the Wild West.” Johnson agreed, saying there “was a lot of waiting for other people’s decisions,” and sometimes she had to simply make the call herself.

Patel asked the speakers to reflect on what was missing from the decision tree. Johnson pointed to the comfort and wants of the students as being vitally important, and said, “We kind of underestimated” how much the students wanted to keep moving with their education and training. Patel commented that the student group expressed this same sentiment, and how some of them spoke of going into health care because they wanted to “run toward crises.”

When students were pulled out of the clinical environment and forced to take a backseat, they reported it “left a bad taste in their mouth” and affected their sense of professional identity, said Patel. Students also voiced a concern that decision makers should consider the effect that pulling students might have on patients and community members. For example, when learners are a highly diverse group serving a diverse community, she said, it may negatively affect that community to pull learners out and leave the community with a less diverse group of health professionals to connect with. Johnson, Taylor, and Thomas responded that while they did not consider this specific type of impact when making their decisions during COVID-19, they agreed that it was important to include the perspective of multiple stakeholders, including patients.

DECISION TREE—THIRD DRAFT

Cain described how his next iteration of the decision tree was shaped by discussions at the previous workshop sessions and expanded to include definitions of cultural safety (discussed on November 11, 2021) and external factors (discussed on November 22, 2021) (Figure A-4). Cain outlined the first set of decisions before shifting to his evolutionary thinking where input from all entities is weighed in a collaborative environment to decide upon the next steps. Cain added that reevaluation of the decision is an important part of a decision tree, because decisions are not necessarily stagnant. As decision paths are reevaluated and multistakeholder considerations are reflected upon, he said, a different or modified path can be taken based on what is required to mitigate risks and use assets to their greatest advantage.

Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Image
FIGURE A-4 Third draft of decision tree and external factors.
SOURCE: Cain presentation, November 11, 2021.
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×

DECISION TREE—FOURTH DRAFT

Building on previous presentations of decision trees by Cain, Jonathan Amiel, senior associate dean for innovation in health professions education at Columbia University, presented Patel’s and Cain’s final iteration to be used in the closing session of the workshop held on December 8, 2021. This workshop session aimed to explore the usefulness of decision trees in different health professions educational crisis situations. Amiel underscored that it is impossible to predict what the next crisis in health professions education will be:

It could be another pandemic, the disruption of the power grid from a natural disaster, or the lack of faculty because of stress and burnout of our health professional educators—we simply don’t know what is ahead. What we do know is there will be another crisis. It could be regional, local, or global; it could be acute or it could simmer. The pandemic caught us off guard. From an educational perspective, we believe we are recovering now, but (1) do we know how our decisions affected stakeholder groups like learners patients and community members? And (2) will we experience the same level of chaos the next time we’re confronted with a different unforeseen crisis?

Amiel then described this final decision tree (Figure A-5), which can and should continue to evolve beyond this session and the close of this workshop series.

Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Image
FIGURE A-5 Final draft of the decision tree and external factors.
SOURCE: Amiel presentation, December 8, 2021.
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Image
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 61
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 62
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 63
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 64
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 65
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
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Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
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Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
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Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 69
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 70
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 71
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
Page 72
Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
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Suggested Citation:"Appendix A: Evolution of a Decision Tree." National Academies of Sciences, Engineering, and Medicine. 2022. Exploring the Role of Health Professional Students and Trainees as Members of the Health Workforce During Crises: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26695.
×
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Next: Appendix B: Unanswered Questions for Further Exploration »
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The onset of COVID-19 pandemic and inundation of the U.S. health care system emphasized infrastructural and health professional education vulnerabilities. A planning committee of the National Academies of Sciences, Engineering, and Medicine Global Forum on Innovation in Health Professional Education conducted a series of public workshops in the fall of 2021 to explore whether students and trainees should be viewed as members of the health workforce, particular in times of emergency as was experienced during the COVID-19 public health crisis. The planning committee gathered educators, students, administrators, and health professionals to share ideas, experiences, and data to strategize expansion of learning opportunities for medical trainees and enhancement of medical preparedness to unforeseen crises without compromising the quality of patient care. The workshops explored issues such as identifying evidence on value-added roles for students to serve in the delivery of care and in a public health capacity, and balancing the role of learners as consumers (tuition payers) and not licensed providers versus members of the health workforce. This Proceedings highlights presentations and discussions from the workshop.

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