SGIM Forum

President’s Column

Navigating an Environment of Unknown Unknowns

In looking back, it is apparent that what we thought was a complex environment has only become more so. There are certainly more unknown unknowns now than ever. VUCA feels like an understatement some days. Many of us have felt that we have spent all of our waking (and at times sleeping) hours solving unsolvable problems.

In 2018, I gave a presentation at the ACLGIM Hess Institute entitled “Leadership in Complexity: Succeeding in the Setting of Unknown Unknowns.” I talked about the current environment as being consistent with VUCA.1,2

  • Volatility: The speed of change; the more volatile the world is, the more and faster things change
  • Uncertainty: The extent to which we can confidently predict the future; the more uncertain the world is, the harder the future is to predict
  • Complexity: The number of factors that we need to take into account, their variety and the relationships between them; under high complexity, it is impossible to fully analyze the environment and come to rational conclusions
  • Ambiguity: Lack of clarity about how to interpret something; when information is incomplete, contradicting, or too inaccurate to draw clear conclusions

I emphasized the complexity of the academic environment, describing complexity as the domain of the unknown unknowns. In this domain, considered the domain of emergence, cause and effect cannot be known in advance. Experimentation and monitoring and diversity of perspective are often necessary to solve problems. I shared Dooley’s tips for being successful in the setting of complexity:

  1. Create a shared purpose (explain the “why”)
  2. Cultivate inquiry, learning, experimentation, and divergent thinking (build many relational connections and networks)
  3. Enhance external and internal interconnections (sense-making)
  4. Instill rapid feedback loops for self-reference and self-control (learning)
  5. Cultivate diversity, specialization, differentiation, and integration (work through ambiguity and paradox)
  6. Create shared values and principles of action (leverage values and behaviors as the “how”)
  7. Make explicit a few but essential structural and behavioral boundaries (simple rules to maximize emergence)3, 4

As general internists, we are well-prepared to lead change in complex organizations. The accompanying table provides examples of ways in which general internists are well suited to address common issues encountered in academic medical centers. Our role as leaders in this complex environment is helping others make sense of what is going on around them.

In looking back, it is apparent that what we thought was a complex environment has only become more so. There are certainly more unknown unknowns now than ever. VUCA feels like an understatement some days. Many of us have felt that we have spent all of our waking (and at times sleeping) hours solving unsolvable problems. Consciously or unconsciously, we have had to invoke approaches to leading, and navigating, in a complex environment.I have seen remarkable leadership at all levels—the students whose expected clinical training has been disrupted innovating ways to meet key organizational and patient needs; the trainees, staff, and providers identifying ways to provide compassionate care guided by the rapidly evolving evidence; the researchers applying their research skills to addressing key issues related to care delivery and the care experience, and the educators creating ways to assure that the need of students and trainees from all levels are being addressed.

None of us have done this before. We are all learning together. We have become not a learning health system, but instead a learning health care community. We now find ourselves at the intersection of both continuing to address the emerging needs of caring for those who become ill with COVID-19 while considering the longer term implications. At our institution, as with many others, we are considering what we continue, what we never go back to, and how the care we deliver, the research we conduct and the education we provide will be changed going forward. So much has changed, and the future remains uncertain. It is truly a VUCA environment.

There are plenty of opportunities for general internists, and SGIM, to demonstrate leadership in this environment. If anything, the COVID-19 pandemic has further elevated the priority topics for SGIM and its members, such as social determinants of health, health disparities, improving healthcare delivery, provider well-being, leadership development, innovations in education, advocacy, and research. It certainly has highlighted the needs of older adults and the gaps in the social and medical support systems for this vulnerable population. This moment in time reminds me of when I was interviewing for my current role as Chief Medical Officer. A member of the search committee asked me, “How do we know that you won‘t just use this as a platform to advance your palliative care agenda?” Before I could answer, another search committee member responded, “That‘s exactly what she should do.” Our communities, patients, families, healthcare organizations, and academic medical centers need us. We, as a general internal medicine community and professional organization, remain strong. We thrive in complexity. Now is the time to step up, in whatever capacity, and provide the voice, expertise and compassion to address the needs that have become only more urgent.

In this time of uncertainly some constancy is welcome. I am thus delighted to share with you that Eric B. Bass, MD, MPH, FACP, has agreed to a five-year renewal of his contract as SGIM Chief Executive Officer. To quote Immediate Past President Karen DeSalvo, MD, in her message to Eric when he returned his signed contract, “The Council is so thrilled to have you at the helm of SGIM in regular times. I can’t tell you how appreciative we are in this time of crisis. Your steady hand, love of the organization and people, and thoughtful/innovative approaches to weathering this storm are recognized and appreciated by all.”

Even as we are working on launching the virtual version of the 2020 Annual Meeting, we are looking ahead to planning for 2021. We recognize that annual meeting planning remains a uncertain venture at this point, especially as we have all been learning to function and interact in a more virtual environment and as we face the economic realities of the impact of the COVID-19 pandemic. SGIM is acutely aware of the importance of assuring that the Annual Meeting is of relevance and seen as value to its members in our rapidly changing world. I am thus pleased to announce that Rita Lee, MD, and Yael Schenker, MD, MAS, FAAHPM, will serve as the 2021 SGIM Annual Meeting Chair and Co-chair. Rita is an associate professor of general internal medicine at the University of Colorado School of Medicine. She has a passion for medical education, leadership development, and advocacy. Her advocacy work has been primarily around LGBT health equity. She serves as an at-large member of the SGIM Council and is core faculty for the ACLGIM LEAD program. During her free time, Rita is an avid gardener and enjoys hiking, skiing, kayaking, and rock climbing with her wife and two boys. Yael is associate professor of medicine in the Division of General Internal Medicine and director of the Palliative Research Center at the University of Pittsburgh. She is a palliative medicine physician with a primary care background and a proud member of SGIM since 2007. As a health services researcher, she is passionate about improving the quality of serious illness care and mentoring a diverse new generation of research scientists. In her free time, she enjoys backpacking, biking, and canvassing for progressive candidates in Western Pennsylvania. Rita, Yael, and I are committed to assuring that the 2021 SGIM Annual Meeting continues to serve its members by making connections and creating community. We look forward to sharing plans with you over the coming months.


  1. Bennett N, Lemoine JG. What VUCA really means for you. Harvard Business Review. Published January-February 2014.
  2. Kraaijenbrink J. What does VUCA really mean? Forbes. Published December 19, 2018. Accessed May 15, 2020.
  3. Johnston K, Coughlin C, Berger JG. Leading in complexity: What makes complexity different and how can leaders respond effectively? Cultivating Leadership. Published May 2014.
  4. Dooley KJ. A complex adaptive systems model of organization change. Nonlinear Dynamics Psychol Life Sci. 1, 69-97 (1997).


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