Resilient #MedEd #Leaders: Reflective Practice and Learning Organizations (Part 4)

By Felix Ankel (@felixankel) and David Abelson

“Music is the space between the notes.” —Claude Debussy

You are a #meded leader charged with integrating health professions education within a health system. You are trying to guide the educational enterprise from a knowledge- and time-based system to a competency-based one. You attempt to create assessment tools and faculty development opportunities for preceptors who are increasingly burning out because of operational stressors. Local schools are increasing enrollment numbers and class size and wanting you to increase clinical capacity for rotations. How do you maintain direction? How do you systematically incorporate reflective practice to maximize your potential as a learning organization?

There is a debate about what elements of resilience are related to the capacity of the individual to handle stress, a.k.a. the gene code (see Daniel Cabrera’s excellent posts here and here), and what elements are related to the capacity of the system to handle stress, a.k.a. the zip code.

This is the fourth of four posts in the #meded leadership series that focus on developing resilient educational programs capable to handle system stress (the zip code). The four topics include:

  1. Identifying clear values
  2. Maximizing the density of connections
  3. Maximizing the ability to bend and adapt 
  4. Incorporating systematic reflective practice (discussed in this post)

Humans have a hard-wired desire to create trust, learning, and communication networks.  (Geek warning: This is because of oxytocin , mirror cells, and eusocial traits).  The quality of these networks is influenced by the relational competencies of the individuals in them. Peter Senge, a visionary on the topic, described a learning organization as a “group of people working together collectively to enhance their capacities to create results they really care about.[i]

Viewing the capabilities of a learning organization as relational allows the consideration of whether the four relational practices developed by Koloroutis and Trout—attuning, wondering, following, and holding—can be used to advance learning organizations (2012).

Understanding the four relational practices

The following describe Koloroutis’ and Trout’s relational practices for individuals:

  • Attuning is the practice of being open, aware, and present in the moment. It usually includes “tuning in” to an individual or situation. Attuning is the most foundational of all of the practices; without it, the other practices are simply not possible.
  • Wondering is the practice of discovery, grounded in curiosity and genuine interest in the other. Wondering prevents us from making assumptions, rushing to judgment, or disconnecting from people prematurely. We become more scientific when we wonder, as we resist reaching conclusions too quickly, we welcome and even seek new data, and we imagine possible explanations beyond the apparent ones.
  • Following is the practice of attending to the rhythm and flow of a person’s words as much as to their content. Following means focusing on what an individual is teaching us about what matters most to that person and allowing that information to guide our interactions with him or her. It requires consciously suspending our own agenda.
  • Holding is the practice of creating a safe haven for healing in which people feel accepted and held with dignity and respect. We hold someone when we do what we said we would do. We hold when we remember the things people tell us and, perhaps, act on them. We hold when we listen without defense or retort. (Koloroutis & Trout, 2012; Trout & Koloroutis, 2017)

 Applying relational practices to a learning organization

 As CEO of a large health care organization, David Abelson incorporated relational practices into health care delivery operations. His reflections, which follow, describes these relational practices through an operational lens, and shows how attuning, wondering, following, and holding can catalyze learning organizations. The discussion is adapted from the “Care Delivery Design” chapter of his book Advancing Relationship-Based Cultures (2017), co-edited with Koloroutis.

Attuning as an organizational practice entails regular pauses in the day-to-day urgency of work, taking the time to recognize our responsibility to design health care delivery to first do no harm, and then to do great good. David built these important pauses into leadership team meetings.

Each monthly management meeting began with a patient or family member attending the meeting and telling his or her story. These narratives gave the executive team a sense of reverence for the importance of their mission in caring for people, and the importance of continuously improving the design and implementation of care delivery. The stories also put some of the most practical ideas of what patients and their families want and need into the consciousness of those designing care.

Attuning means addressing with humility the unknowns, unknowables, and unintended consequences that accompany changes in a complex, interdependent system. Most design changes, no matter how well planned, result in unintended consequences. Humble attunement involves constantly asking how we know that a change is an improvement: What more do we need to learn? What more do we need to improve?

Wondering as an organizational practice entails asking questions about how the organization is doing and how it can do better. Following involves translating what we learn into actionable assessments using a variety of methodologies including focus groups, surveys, and standardized data collection of key processes. The practice of Appreciative Inquiry  inspires another sort of questioning, equally based in wondering and following. In appreciative inquiry, questions are aimed at uncovering what is working well within the organization and how to make more of it happen.

The practices of wondering and following need to be built into the rhythm of organizational processes. A SWOT analysis as part of strategic planning is a process of wondering about organizational Strengths, Weaknesses, Opportunities, and Threats. Selecting annual improvement projects begins with wondering about what we can learn by looking at any measurements of current performance. Leaders should have regular monthly, weekly, and daily dashboards gauging the organization’s progress along various metrics to make the practice of wondering practical and expected.

Holding, as an organizational practice, entails viewing all individuals involved with the organization—patients, families, employees, suppliers, referring physicians, community members, and more—as partners. It means holding individuals harmless when processes fail. At the same time, it means holding people accountable for personal ownership of results, improving imperfect processes, and leading within their zones of responsibility and authority.

All the partners in the organization hold by doing what they say they will do or what people expect them to do in order to produce the promised, wanted, or expected result. Leaders hold by cultivating a positive and psychologically safe environment in which people are able to flourish in their roles and experience pride in being part of a health care community that serves the noble cause of human caring.

A learning organization counts on the effectiveness of relationships. Even the processes and structures are created and refined by people working in relationship with each other. Thus, the quality of relationships is paramount to the success of any organization. The four relational practices provide a conceptual and practical framework for creating and advancing quality relationships at an individual, group, and system level.

Tips for incorporating systematic reflective practice:

When building resilient educational programs, consider the following:

  1. What is your discipline of systematic reflection?”Incorporate “space between the notes.
  2. How attuned are you with your educational operations? How can attunement help you unlearn? Invite a student or educator to share his or her story at the beginning of every senior educational meeting.
  3. Do you use wonder and following for strategic and annual planning? Integrate Appreciative Inquiry into planning.
  4. How do you hold the relationships within your program? How do you balance accountability and psychological safety? Be deliberate in building your trustlearning, and communication networks.
  5. How do you grow the four practices of attuning, wondering, following, and holding into your day-to-day leadership practice? Incorporate systematic reflective practice to maintain a resilient educational program.

Follow Dr. Abelson’s blog, Reflections on HealthCare, Leadership and Mindfulness, at


  1. Cooperrider D., Whitney D. (2005) Appreciative Inquiry: A Positive Revolution in Change. Berrett-Koehler.
  2. Koloroutis, M., & Trout, M. (2012). See me as a person: Creating therapeutic relationships with patients and their families. Minneapolis, MN: Creative Health Care Management.
  3. Senge P. (revised 2006). The Fifth Discipline: The Art and Practice of the Learning Organization. Doubleday.
  4. Trout, M., & Koloroutis, M. (2017). A Relationship-Based Way of Being. In Koloroutis, M., & Abelson, D. (Eds.), Advancing Relationship-Based Cultures. Minneapolis, MN: Creative Health Care Management.
  5. Wessel, S., Abelson, D., & Manthey, M. (2017). Care Delivery Design. In Koloroutis, M., & Abelson, D. (Eds.), Advancing Relationship-Based Cultures. Minneapolis, MN: Creative Health Care Management.

Image from Pixabay used under Creative Commons License CC0