"Black Swans": Bad Doctors Reveal our Vulnerabilities and Opportunities in Medical Education

From the 7/31/2020 newsletter

Director's Corner

Bad Doctors, Rare but Devastating, Reveal our Vulnerabilities and Opportunities to Create Robust Character and Professionalism in Medical Education

Adina Kalet, MD, MPH

In this week’s Directors Corner, Dr. Kalet highlights what “black swans” or “bad apples” reveal about our vulnerabilities in medical education and what we need to do to ensure the public’s trust …

My heart sinks every time. In an era when trust in medicine and science is put to the test every single day, we do not need another “bad doctor” story. But there it is in the New York Times. Dr. Sapan Desai, who founded a company named Surgisphere while he was a surgery resident at Duke, provided aggregated, unverifiable – and likely falsified – data for two COVID-19 hydroxychloroquine studies published by Harvard Medical School researchers in Lancet and the New England Journal of Medicine. Dr. Desai refused to release the raw data when scientists around the world questioned the veracity of the studies. Both papers were rapidly retracted.

This type of “fake science” does immeasurable harm. It creates confusion. Critical public health messaging is interrupted, making the dissemination of actual findings more difficult. It threatens public confidence in much needed, ongoing clinical trials. It ruins trust in the medical profession. But while we would like to demonize this one “bad apple,” he is not the only one to blame. We must examine the system that enabled him to thrive.

Black Swans in Medicine

Misconduct by scientists and physicians is thought to be rare (although emerging evidence suggests otherwise). For the sake of argument, let’s say bad doctors are as rare as black swans. In the “black swan theory,” seemingly unpredictable events – like a physician willing to lie, falsify data, and harm patients – will have major negative effects. Institutional responses to individual bad actors are often weak and inadequate because of their supposed rarity. However, as philosopher Nassim Nicholas Taleb points out in two best-selling books (The Black Swan: The Impact of the Highly Improbable and Antifragile: Things that Gain from Disorder), systems should not dismiss the existence of black swans as rare, unpreventable aberrations but, rather, build robust systems that rise up and do not fail in the face of the unexpected or unimaginable. Creating such a system is healthy, lifesaving, and trust enhancing.

In the New York Times article, journalists Ellen Gabler and Roni Caryn Rabin interviewed dozens of people who either worked with or supervised Dr. Desai at different points in his pre-medical, medical, and surgical education (he is now a practicing fellowship-trained vascular surgeon). They described him as “a man in a hurry, a former whiz kid willing to cut corners, misrepresent information or embellish his credentials as he pursued his ambitions.” Nurses and fellow residents reported their concerns to leadership about Dr. Desai’s untrustworthiness and his routine dishonesty about everything from patient care to his whereabouts. He once lied that he didn’t answer pages because he had been performing a rare surgical procedure. Why wasn’t he stopped from progressing through training? Why would a residency, and then a fellowship, allow such a physician to graduate, effectively recommending him to the world for a lifetime of medical practice? What possible justification exists?

It Gets Worse

Dr. Desai did come close to being expelled from his vascular surgery fellowship at the University of Texas Health Science Center. His career was saved when a faculty member with whom he was doing research argued that the frequent complaints were a result of “personality differences and professional jealousy, not substantive deficiencies in surgical skill or patient care.” Unfortunately, this defense that others are merely envious is typical for “black swan” physicians and would have been a tip-off for anyone familiar with dealing with certain types of personality disorders.

He was given the opportunity to remediate his communication skills and went on to finish the program and enter practice. Not surprisingly, Dr. Desai soon had three malpractice claims against him at the community hospital in Illinois where he worked as a vascular surgeon before he left “for personal reasons.”

Remediation Works for Some, but Not All

As an expert in medical professionalism remediation, I have met many students, residents and colleagues who behaved in ways that “hit the radar” at least once. They have cheated on exams, plagiarized patient write-ups, had another student sign them into required sessions, or been disrespectful to members of the staff or of the faculty. I have even met a student or two who falsified scientific data; it is rare, but it happens. When confronted, the vast majority of these trainees show insight, are remorseful, remediate, and sincerely apologize to whomever they hurt including – and especially – their peers. In my experience, these are good prognostic signs. These students learn from remediation and never demonstrate egregious behavior again. Talk to me about the strategies that work.

However, some trainees – the superficially charming black swans – are exceedingly arrogant, disrespectful, and dismissive. They lack empathy for others and fiercely resist feedback. Occasionally, I have met a trainee who is unwilling to engage in any meaningful discussion about their behavior. As was apparently the case with Dr. Desai, if the person is especially brilliant or “awe- inspiring,” they are given second, third, and fourth passes even when their behavior imperils patient safety. Even though their behavior patterns satisfy diagnostic criteria for serious, difficult to treat personality disorders, their supervisors make excuses and justify choices by believing themselves compassionate.

Of course, we want all of our students to succeed, but truly bad behavior is corrosive. When a medical education program tolerates borderline clinical competence and unprofessional behavior, the community of peers notices. A lack of action is toxic to the educational and patient care environments. We run the risk of losing the trust of our other trainees and our communities if we fail to respond to lapses in professional behavior.

This Must Change. It is an Issue of Character.

Medical educators must face up to the challenge and work to ensure that consistent standards of competence, character, and caring are met by our trainees and ourselves. I believe educators in general do not openly address these issues because we feel we have neither the effective low-stakes, formative strategies nor the institutional support to tackle them when they arise. These barriers contribute to the “hidden curriculum” which tolerates a range of unprofessional behaviors.

Evidence to support remediation practices is mounting rapidly. In a recent review of the evidence, we and a group of international colleagues summarized what we do and don’t know about remediation. We concluded that well-run, effective remediation programs are reassuring to both the students who need them and to those who don’t. This takes some investment, but it is critical.

Our Obligation to the Future

Everyone’s professional judgement can lapse from time-to-time, especially when under unprecedented stress. There is, however, a very big difference between someone who lapses occasionally and someone with long-term patterns of unacceptable behavior.

One other thing: We need longitudinal data if we are to spot patterns. How do we know if there are ongoing concerns if we don’t “feed forward” professional behavior information about individual students and trainees? Only half of US medical schools have policies that support feeding forward while the other half feel strongly that to do so violates educational privacy. It is rare that a medical school provides honest information to residency training programs about lapses in professionalism or that these programs provide detailed information to future employers.

The best way to build robust, non-fragile systems is to take the assessment of professionalism and character development as seriously as we take the assessment of knowledge. Once we do this, we can build hardy, rigorous, and effective remediation programs for those who don’t meet the standards.

It should go without saying that not every medical student should become a physician, particularly when they exhibit patterns of egregious, life-threatening behavior. We must create systems that consistently harness judgment and courage to identify and confront the black swans. Those who lack the character strengths to be a physician should be dismissed.

I know that this is an exceedingly complicated issue, but I also know that this is one way we meet our societal obligation to care for the next generation by transforming medical education. Future patients, the integrity of science, and society will all suffer if we fail to act.

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

Racial Discrimination in Academic Surgery: A Webinar Presented by the Association for Academic Surgery

From the 7/24/2020 newsletter

Racial Discrimination in Academic Surgery: 

A Webinar Presented by the Association for Academic Surgery

Eileen Peterson, MD Candidate 2023

Associate Editor

Background

This webinar was one in a series of town halls with the goal of changing the landscape of academic surgery. The town hall was led by two session moderators, Callisia Clarke, MD of the Medical College of Wisconsin and Colin Martin, MD of the University of Alabama Birmingham, and five panelists from across the nation. As the chair of the Diversity, Equity, and Inclusion (DEI) Task Force for AAS, Dr. Clarke stated that the AAS is looking for “not just discussions but solutions” within the academic surgical workforce.

Speaker 1 – Yue-Yung Hu, MD

Dr. Yue-Yung Hu, a pediatric surgeon at Northwestern University, spoke on the prevalence of racial discrimination amongst surgical trainees. Dr. Hu discussed data published in JAMA Surgery in April 2020, which was collected from 6,956 resident surveys after the 2019 ABSITE exam with an 85.6% response rate. Of note, the study found that 41% of non-white general surgery residents reported racial or ethnic discrimination. Of those who reported discrimination, 71% were Black, 46% were Asian, and 25% were Hispanic. In addition, discrimination is associated with higher rates of burnout, thoughts of attrition, and suicidality.

Hu also discussed the SECOND Trial. This is a prospective randomized trial across 215 residency programs to assess diversity and resident well being while providing a toolkit of strategies to improve the learning environment for residents. The SECOND Trial is also currently compiling resources on implicit bias training.

Speaker 2 – Erika Adams Newman, MD 

“We will look back and our children will look back and say, ‘How did we respond, what did we do, what changes were we engaged in?’ both individually, within our institutions, and within our organizations.” Erika Adams Newman, MD, a pediatric surgeon at Michigan Medicine, discussed faculty-level racial discrimination as it leads to barriers to retention and promotion. When looking to improve equity and reduce discrimination, Dr. Newman encourages departments to look at their demographics and ask what message it sends by having only a few people of color and also fewer women within a department.

Newman suggested Grand Rounds as a great way to increase diversity, raise consciousness, and push the envelope. Through the introduction of The Michigan Promise in 2017, Michigan’s Department of Surgery has diversified their recruitment committee, increased mentorship, and implemented bias and cultural competence training in order to seek out sustained change. 

These are just a few ideas for programs. Dr. Newman stated that good intentions are not enough because “how can we achieve excellence without being diverse?”

Speaker 3 – Justin Brigham Dimick, MD, MPH

Justin Brigham Dimick, MD, MPH, the Department of Surgery Chair at Michigan Medicine, posed reflective questions for non-minority audience members on the topic of earning the title of bystander or ally.

1. Have you come to terms with your privilege? If you can see an event in the news and be complicit, returning to work and acting like nothing has happened, that is privilege. Educate yourself. Read any of the bestselling novels about racism and discrimination. Don’t ask the minorities in your department to teach you.

2. Do you see implicit bias everywhere you look? What are you doing to interrupt  and remove these biases from the workplace?

3. Who are you mentoring and sponsoring? Do your mentees look like you? What signals are you sending when broadcasting your mentoring?

4. If you are a leader, are you creating space in your program’s curriculum for discussing implicit bias?

5. Are you able to go beyond the title of bystander and work to become an upstander? As an upstander, you can use your power and platform to change policies and procedures to be equitable.

Speaker 4 – Oluwadamilola “Lola” Fayanju, MD, MA, MPHS

Oluwadamilola “Lola” Fayanju, MD, MA, a surgical oncologist at Duke University, discussed surgeons’ obligation to address healthcare disparities  through research. Dr. Fayanju stated that currently, African-Americans and Latinx are overrepresented in Phase I Trials and underrepresented in Phase III trials, suggesting failure to convey goals of Phase I studies and enrollment bias in Phase III trials. More efforts need to be taken to prioritize recruitment and inclusion of racial/ethnic minority patients who are disproportionately affected by various diseases. In addition, disparities need to be incorporated into  studies at concept inception rather than tacked on during statistical analysis. 

Dr.Fayanju offered three suggestions for researchers going forward: 

1. Be humble: Get more training.

2. Be collaborative.

3. Be intentional: Who are your collaborators, statisticians, and study team members? Who is at the table when decisions are being made?

Speaker 5 – Eugene Kim, MD

Eugene Kim, MD, a pediatric surgeon at Keck School of Medicine of USC and President of AAS, discussed the AAS Commitment to Addressing Racial Discrimination in Academic Surgery. Recent efforts by the AAS include the creation of the DEI Task Force in 2019 as well as implementing open elections and self-nomination for committee chairs. Within the Executive Council,  the AAS has seen increased diversity at the levels of institutional, surgical specialty, and research background, but the AAS still needs to see more diversity  in race and gender within committee appointments and chairs. The AAS is also

increasing their mentorship efforts. They will be hosting sessions for underrepresented minority surgeons-in-training to meet with AAS leadership.

You may email Dr. Kim at eugeneskim@chla.usc.edu with your thoughts and ideas on increasing diversity of AAS.

 

Conclusions

Reach out to Dr. Clarke on Twitter @DrCNClarke with suggestions, ideas, or questions. The full AAS webinar can be accessed at https://www.aasurg.org/racial-discrimination-in-academic-surgery/

Eileen Peterson is a medical student at the Medical College of Wisconsin and serves as an Associate Editor for the Transformational Times.

Mentoring Toward Purpose and Meaning: Helping our students retain their passion for medicine by asking Why?

From the 7/24/2020 newsletter

Mentoring Toward Purpose and Meaning: Helping our students retain their passion for medicine by asking Why?

Adina Kalet, MD, MPH

In this week’s Directors Corner, Dr. Kalet reminds us that focusing on well-being alone is not enough. Our students want and need mentoring on how to make a purposeful and meaningful life in medicine, especially in these tumultuous times …

“...Tell me, what is it you plan to do with your one wild and precious life?” 

From "The Summer Day" by Mary Oliver

Becoming a physician is challenging in all ways. And yet it is a choice. Even the most optimistic medical student will have moments of great distress and doubt, and they will - and should - seriously question their choice of life path from time to time. After all, while it is a privilege to join a profession which offers the possibility of a lifetime of meaningful work, it is not a career for everyone. There are many ways to make a satisfying life. Pursing the practice of medicine when it is not what you really want to do can be tragic for the practitioner, their family and their patients.

While we are sometimes faced with trainees and colleagues who need compassionate off-ramps from medical training or practice, the vast majority of our matriculating students can safely assume they will become practicing physicians. This is why regular opportunities for recommitment to, and for the reexamination of life goals, is as much a critical wellness practice as taking time to exercise, eating healthfully, practicing mindfulness and compassion, and laughing regularly. But, like other wellness practices, most of us need support and encouragement to do what is good for us.

Get to the Heart of the Matter by asking Why? Why? Why?

I first participated in an exercise call "The History of the Future" in 2010, as a participant in the Hedwig van Ameringen Executive Leadership in Academic Medicine® (ELAM®) program, and have since used it hundreds of times with students and colleagues since then. This is a simple practice to help a student or colleague plan well for their future. It goes as follows:

I hand them a piece of paper on which I have scribbled today’s date at the bottom and this same day five years from now on the top with six dates in between as follows:

My History of the Future

July 24, 2025: Celebrate what? With whom? 

July 24, 2024:

July 24, 2023:

July 24, 2022

July 24, 2021:

6 months from today: 

2 months from today: July 24, 2020 (today)

I hand them a pen and give the following instructions:

"Imagine it is exactly five years from today, you are celebrating a personal accomplishment. What are you celebrating? And who are you with? Write these things next to the date. Then work backwards in time, down the page. Make brief notes on what you will need to be doing on those dates in order to make sure you have something to celebrate in five years."

Then I stand up and prepare to leave the mentee alone with the task for at least ten minutes.

Invariably, before I can leave the room they ask, “Do you mean a personal or professional celebration?” I turn back and say, “Yes! Both! And by the way, don’t hold yourself back or feel intimidated, because this is pure fantasy, the future never happens as we plan, so don’t sweat it.”

Then I go get a cup of coffee. When I return, they are either writing furiously, or tapping their pen on the desk looking pissed. I sit across from them and ask, “So tell me, what are you celebrating and with whom?”

I have found that debriefing this exercise almost always helps mentees imagine and plan for a desirable, purposeful future. Even when - especially when - they have no idea what they want! It also always guides me away from the common mentor pitfalls of talking too much and providing well-intended but irrelevant advice. According to the leaders of the Center for Applied Research who taught me this approach, research suggests that people develop more vivid stories when asked to think about a situation in the past tense. Doing this helps individuals think more concretely and realistically about how to create the future they want, especially because it enables them to think about weaving together different strands of growth and development - like personal and professional goals - that need to occur to achieve that future. This method is similar to strategies used successfully with other mastery-oriented competitive athletes, gamers (like Chess Olympiads) and concert musicians.

There is a trick to getting to the heart of the matter in very brief conversations. When the mentee describes their “celebration” and describes who they are celebrating with, I listen carefully. Only then do I ask, as benignly as possible, “Why?”

There is often a long silence. Eventually the student gives an answer, “Because I am my parents’ only child,” or “Because I want a big family," or “Because I have worked for this my whole life," or “Because, I am an introvert and much prefer very small gatherings.” No matter what they offer, I nod, encouraging them to elaborate until I can reasonably again ask, “Why?” And so on, until we have done this at least five times (The 5 Whys). With each cycle the answers get deeper and more authentic. Almost always we end up discussing if and how they will be courageous enough to stay the course or choose a new path, perhaps the one “less traveled by” that will be worth their “one wild and precious life.”

Once we are sure we understand why the student wants to be celebrating what they are celebrating we drop down the page to the line that reads “two months from today,” and talk about possible next steps. At that point I might give some advice. I always recommend they keep the piece of paper. These are career conversations worth having from time to time.

Learning Environments that are Communities

It is our obligation as medical educators to graduate people ready and able to practice medicine in a rapidly changing environment. What does this mean? I believe that in addition to ensuring mastery over the knowledge and skills required - a tall order in and of itself - we must also attend to the character and spirit of the developing physician. This is because every one of us deserves a physician who is capable of both deep thinking, technical skill and feeling, an individual who has the capacity to care for us even if we do not share a culture, color or gender, through a wide range of personal health challenges, across a lifetime. We need physicians capable of empathy and with a strong sense of purpose and meaning in their work. This is not a guaranteed outcome of our medical education system, it takes a community of committed students, their families, educators, staff and patients willing to have those deeper, more difficult conversations. There will be a necessary dialectic between this idealistic vision and the practical realities - but we need both to ensure progress and accountability toward a better set of outcomes for the health of our communities.

In this issue of the Transformational Times, Cassie Ferguson, MD, Kurt Pfeifer, MD, Marty Muntz, MD, Cassidy Berns, and Kaicey von Stockhausen share the justification and basic plan for building a Learning Community structure for MCW. This is one doable way that we can keep trainees in touch with why they have chosen their path.

My 2010 "History of the Future" still hangs on the refrigerator door to remind me of the old saying “best laid plans of mice and men often go awry.” While the details were fantasy, I remain on the path to ensuring all of us have access to remarkable physicians.

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

Becoming Uncomfortable

From the 7/17/2020 newsletter

 

 

Becoming Uncomfortable

 

 

Bruce H Campbell, MD 

 

 

Dr. Campbell sees parallels in how societal dynamics are at play in two different realms of his life …  

 

 

As a surgeon, I have made mistakes that have hurt people. I hope that this fact is not surprising to anyone since, besides being a surgeon, I am also a human being. I have never hurt anyone in the operating room intentionally but, over the years, I am certain that there have been more people harmed than I realized. 

 

What happened? Certainly, I never deliberately waded into cases where I knew I was in over my head, but there have been instances where I was inadequately or improperly prepared. Maybe there was a gap in my training. Perhaps I missed a critical experience along the way that would have led me down a different path. Maybe I overlooked an article. Maybe the science had not yet taught us the proper way to care for a specific problem. Maybe I blundered or slipped or got lost. Maybe I should have operated but recommended against it. Or vice versa. Over the course of a thirty-year career and thousands of surgical procedures and patient encounters, I have done my best. I know, however, that for  some people, my decisions have led to harm. 

 

 

To reassure myself, I have tried to stay at the top of my game. I attend regular Morbidity and Mortality (“M&M”) Conference to discuss complications. I participate in “root cause analyses” to find systemic problems that lead to errors. I listen to patients, families, and staff when there are concerns. I have enlisted others to watch and make certain that my skills remain up to the task even as I age. I believe, along with Hippocrates, that all physicians should live by the dictum: primum non nocere, or “first, do no harm.”  

 

Nevertheless, I live with the knowledge that there are people out there who will always remember me as the person who hurt them. I always considered this to be part of what I do for a living.

 

 

The instances of physical harm I have caused during my surgical career have come to mind recently as I have engaged in conversations about how our implicit racial biases also cause harm. Like many white people, I have never thought of myself as racist. I am an older, white, cis-gendered, straight, abled male recipient of a suburban white-privilege upbringing. I knew (and had spoken to) very few African Americans until I got out of high school even though my youth was spent in a suburban region actively trying to integrate. On the other hand, my parents were in a club that allowed full membership only to men and, until I was older, included no Blacks, Catholics, or Jews. That seemed normal to me.

 

As a teenager back in the early 1970s, I worked as an orderly in a hospital emergency room on the border between my white suburb and a Black city neighborhood. Although I rarely noticed, my role models – the physicians, nurses, and police officers – treated Black patients and employees differently than they did white ones. I watched and learned. That seemed normal to me. 

 

I do have a vivid memory of a conversation I had with a white police officer whom I knew well. I must have been uncomfortable with how he approached a Black patient; I don’t remember the circumstances, but I do remember what he said. “Y’know,” he told me, “you suburban kids love the race but hate the individual. I love the individual and hate the race.” Oh, I thought. That seemed normal to me. 

 

One day, one of the other Emergency Room orderlies, a Black man, walked in on the tail end of my comments about a Black patient. I stopped abruptly. I remember the sinking feeling in my stomach. What had I said? I wondered. Did he hear that? We never talked about it. 

 

As I matured, I had more Black friends, acquaintances, trainees, students, and colleagues. In retrospect, I don’t remember ever speaking of race with any of them. Just as with surgery, I know I made mistakes. 

 

I have committed microaggressions. I have remained silent when hearing others make remarks that should have been called out. I am certain I have made thoughtless – what I considered at the time, innocent – comments. Although there were never any M&M conferences or formal reviews of mistakes I made as I interacted with Black people, I tried to approach the racial divide between us in the same way I approached surgery: I hoped each opportunity would make me better. I saw nothing wrong with what I was doing. It was “about me,” after all.

 

 

Then I read Ijeoma Oluo’s book, So You Want to Talk About Race. She challenged me to look at myself in new ways and set me straight. Here is what she writes: 

 

“To many white people, it appears, there is absolutely nothing worse than being called a racist, or someone insinuating you might be racist, or someone saying something you did was racist, or someone calling someone you identify with a racist. … 

 

“You may be now insisting that you do not have a racist bone in your body, but that is simply not true. You have been racist, and will be in the future, even if less so.  … 

 

“You cannot tell someone to deny the harm you’ve done to them … It sucks to know that to some people you will forever be the person who harmed them.” 

 

 

Ms. Oluo helped me realize in a new, convicted way how my life experiences have shaped me in ways I never before perceived, both as a person who grew up with white privilege and as a physician afforded the upper hand in doctor-patient relationships. I have hurt people and failed to pause and fully recognize the damage I have caused. I have not always taken ownership of the consequences of my actions. Even though I have “felt bad” at times both in medicine and in life, I now realize how easy it has been to forgive myself and move on.

 

 

I suspect I am not alone. It is time to check our privilege. It is time to become more comfortable with being uncomfortable. It is time to apologize. It is time to be an ally. 

Bruce H Campbell, MD FACS is a Professor of Otolaryngology and Communication Sciences and Associate Director of the MCW Medical Humanities Program. He is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He serves as Editor of the Kern Transformational Times newsletter.

Never Waste a Crisis! Now is the Time to Build Learning Communities

 From the 7/17/2020 newsletter

 

Director’s Corner

 

 

Never Waste a Crisis! Now is the Time to Build Learning Communities

 

 

Adina Kalet, MD MPH

 

 

 “In this week’s Director’s Corner, Adina Kalet argues that we must embrace the moment by making educational technology work for us and ensuring that the learning communities we create put our students on the path to becoming masterful physicians…”

 

 

We face an existential crisis in education. Because of the pandemic and social distancing, educators need to focus on the essentials: life, health, and the creation of robust learning communities designed to enable our students, teachers and institutions to thrive during these tumultuous times. 

 

The strategies to accomplish this are well understood and readily available, but there are unknowns. The federal government is insisting that all K-12 schools must open this Fall. In fact, any rapid recovery of the economy, if possible, will depend on children returning to the classroom so that parents can return to work. However, completely reopening all schools may put children’s and adult’s lives at risk. 

 

As of last week, two-thirds of US colleges had decided to reopen their campuses for the Fall term. My daughter, niece, and nephews will be on-campus soon, anticipating and needing social connections with peers and teachers. Faculty and students thrive in active learning communities, but university faculty are concerned that reopening might lead to life-threatening consequences. 

 

Can colleges and universities create meaningful learning communities at a “distance”? Although some depend less on tuition dollars for short term survival than others, many schools are justifiably worried that education will suffer and that students will balk at paying full tuition for an “online only” education. Evidence demonstrates, though, that people value (and therefore will pay for) high-quality distance learning. Virtual education fails if it simply deliver lectures and other routine elements of existing curricula to laptop screens filled with squares of bored faces. High-quality distance learning maximizes learning by deploying carefully crafted instruction in a socially nurturing community even if the learners rarely, if ever, meet face-to-face. It focuses on both individual and collaborative peer learning and enables close, meaningful connections with teachers. 

 

 

Teaching virtually

 

I am experiencing high-quality cyberspace learning, right now. 

 

I co-direct the US site for a premier international Master’s in Health Professions Education (MHPE) program which has been predominately virtual for almost thirty years. It is organized into twelve units, two of which are designed to be synchronous in-person experiences, while the other ten units remain open until all assignments are submitted and the final grade awarded. While the program is designed as a two-year, thesis-required program, students have up to five years to complete the degree.  

 

At this moment, I am teaching in an intensive, full-time, three-week course in qualitative and quantitative research methods. Although my class was designed to be taught in a classroom, we are meeting entirely on Zoom. This has turned out to be as much fun as being in a room together. I have been delighted to see that the virtual platform leads to as much if not more learning when compared to my face-to-face experiences over the past five summers. 

 

Despite the fact that my students and I are rarely in the same place, I know them well. I was involved in recruiting them into the program and I taught them last year in the introductory medical education unit. I provide feedback in our ePortfolio. I have mentored a couple of them one-on-one, heard about their progress at weekly faculty meetings, and will follow each of their thesis projects from now until graduation. 

 

Although the students work in different institutions, health professions, clinical disciplines, and time zones, they also know each other well. They started this two-year program together as a cohort and continue to collaborate on assignments. They take advantage of Google Docs (free). They support each other, share questions, frustrations, and personal celebrations on What’s App (free), Facebook (free), and other social network platforms. In Zoom, they are respectful of each other, smile a lot, and share inside jokes. The student who is pregnant with twins gets advice, support, and empathy. 

 

Working virtually has not dampened collaboration. Each of the students works independently on their thesis project, but they share their work with the group at weekly seminars. They work in pairs and threes on reading and writing assignments. They meet one-on-one with mentors and thesis advisors. I lead the course and attend as many of the group sessions as possible to monitor each student’s growth and make connections across the course material. The six faculty – some compensated and some volunteer – teach as a team. We have our own relationships with the students and with each other. We are – the teachers, students and staff – a “learning community.” 

 

 

Harnessing and enhancing technology

 

Technology bridges continents. Many of the most agile US universities and medical schools have globally distributed campuses where students in New York City or Boston share classes and faculty members with students in Shanghai, Abu Dhabi, Paris, Prague, or Brooklyn. Our own MCW students in Central Wisconsin and Green Bay attend synchronous foundational medical sciences lectures with their peers in Milwaukee. The infrastructure and comfort with technology is available. 

 

The “new normal,” though, can lead to a sense of grief and loss and many, if not most, traditional educators believe being physically present with their students enhances their craft, effectiveness, and satisfaction. I agree! I love to dance across the stage and draw on the board while making eye contact and inviting individuals to engage in the material about which I am passionate. 

 

Putting face-masked professors behind Lucite-barriered podiums with students dotted at six-foot intervals is not the answer, but our current distance learning alternatives are not perfect, either. For example, when our regional campus students are linked into the lecture halls in Milwaukee, they sometimes report that camera angles make them feel as though they are “in the cheap seats,” and find that some lecturers forget that the off-site students are watching. We can find better ways.

 

Contrast this with how the BU Executive MBA brings teachers and students into close virtual contact at almost life-size, enabling teachers to physically move, write on the board and read non-verbal expressions. The Kern Institute is building a learning lab where ideas like these can be turned into working models and studied. Faculty can be nurtured to enhance their capacity to connect with students. With some investment, we can address the need for educational engagement without endangering lives or hog-tying professors. By working together intentionally, we will develop prototypes of relationally sophisticated and technologically-sufficient learning communities.  

 

 

Building learning communities

 

With careful attention to explicitly building learning communities that attend to the social and emotional needs of both learners and teachers, education can be a very exciting enterprise even when we can’t all be together in the same room for long periods of time. 

 

Learning communities are not a new idea in medical education. Since being first introduced at the University of Iowa Carver College of Medicine in the early 1990s, over forty US medical schools have embraced this approach to create effective, supportive learning environments which structure longitudinal personal relationships between learners and teachers for the purpose of integrating knowledge and clinical skills. The community nurtures the growth and development of a healthy professional identity essential to becoming a masterful physician. 

 

In the Kern Institute, we have begun building the elements of this “learning community” approach through our REACH curriculum under the leadership of Catherine Fergusson, MD and the 4 C Coaching program led by Kurt Pfeifer, MD. Collaborating with Lisa Cirilo, PhD, the MCW Assistant Dean for Basic Science Curriculum, and the Office of Academic Affairs, we are working to rapidly integrate with existing programs so that students who come to campus (literally or virtually) over the next weeks will be welcomed into communities that provide a sense of belonging, caring and collaboration. 

 

 

The broader challenge

 

The past few months have proven that we do have the technology and educational science to enable smooth transitions to highly blended, largely virtual instructional environment. If we attend to making certain our students can afford and have access to the technology in safe settings and must come together only when “hands on” experiences are critical – such as in human anatomy labs and clinical skills instruction – we can learn from this moment and keep our learners and teachers safe. 

 

The day will come when we are all back in the classroom together. In the meantime, we must use this opportunity to harness technology, innovate educational approaches, build character, strengthen our learning communities, and transform medical education.  

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin. 

 

 

 

A COVID-19 Conversation

From the 7/10/2020 newsletter

A COVID-19 Conversation 

Bruce H. Campbell, MD

A patient gets his news from different sources than does Dr. Campbell…

My patient and his wife have braved the outpatient clinic restrictions imposed by COVID-19 to return for his cancer follow-up. Over the past couple of years, I have operated on him twice, each time for a malignancy that keeps recurring. He is a delightful and – as even he would admit – a bit exasperating. He speaks his mind and has strong opinions about everything, including his medical care.

When the cancer recurred after the first operation, I suggested that he see one of the radiation oncologists to hear what she might have to offer. “No way. I had a terrible experience last time,” he said at the time. “Even if you recommend radiation after this next operation, I’ll say ‘no’ again. End of conversation.” So, we returned to the operating room for more surgery.

Now, a few weeks later, he is back in the office. I wear my mask and have him lower his so I can examine his mouth and throat. I am relieved. So far, so good. We review his CT scan. “The exam and the scan are both fine. No signs of cancer. Great news!” I say. “All is well.”

He nods and tugs up his mask again. “Good, good.” Then, he cocks his head and looks at me. “So, do you mind if I ask you a couple of questions?”

“Sure,” I say, although I’m not sure where this is heading. “Fire away.”

He glances toward his wife and then back to me. “What do you think of this coronavirus?"

I tense a bit. Based on his previous comments, I know precisely where he stands on the political spectrum. Uh, oh, I think to myself. His favorite media outlets are known for skepticism about wearing masks and maintaining social distancing. Nevertheless, he seems to be genuinely interested.

“Well,” I respond, “It’s dangerous. Based on the science, we should be very cautious. There’s too much risk of the virus spreading and people dying needlessly.” There, I hope. Maybe that’s that.

He starts down his list. “Yeah, but just in other places, right? I hear it’s not bad in Milwaukee.” In fact, our hospital doesn’t publish admission and ICU data, but I am able to tell him in general terms that the numbers of patients admitted and seriously ill with COVID-19 has been climbing over the past several days. “Really?” he asks. “I’m surprised.”

“It’s real,” I say.

“Well then, what do you think about these things I heard on the news?” I cringe slightly as he proceeds through the series of narratives that have found life on the internet. I try to keep up. No, COVID-19 is not like a “regular” flu. Yes, people are dying, and some who recover stay sick for a long time. It’s true that people don’t have to appear ill to be infectious. No, there is no evidence that it was a biological weapon developed in a Chinese lab. No, I’m not aware of any studies that show that more people will die of a stalled economy. No, I don’t believe that it will fade over the coming months and magically disappear after the presidential election. The best studies show that hydroxychloroquine does not extend hospitalized patients’ lives. Yes, masks, hand washing, socialdistancing, and staying home are the best ways to slow the spread. Yes, vaccines will be the best way to return to “normal” and they will take a long time to develop. No, I’m not surprised that Dr. Fauci and the other health experts change their recommendations from time-to-time since scientific evidence continues to evolve. I don’t believe that there is a “scientific deep state.” We go down his list and I do my best to address each concern.

I tell him what I know of the 1918 Flu Pandemic and how the “second wave” killed more than the first. Bringing it closer to home, I share how construction of some of our hospital buildings, which are on part of the old Milwaukee County Grounds, required the exhumation, study, and re-interment of more than two thousand people buried between 1882 and 1925, including many who died and were haphazardly buried anonymously during epidemics. It can happen again.

“Tamping down the virus is personal,” I tell him. “Two of my four children work in healthcare. I’m over sixty. We are all at risk and wearing a mask is the most gracious thing anyone can do,” I say. “It’s a gift we give to others.”

After a deep breath, I realize, gratefully, that they are both still engaged. They have asked honest questions and I have done my best to respond. I have discovered how challenging it is to encapsulate evolving science into respectful, careful, honest, and evidence-based answers for people who might not be inclined to believe people like me. On topics where there are knowledge gaps or shifting data, I see why they might be skeptical.

This is the first meaningful face-to-face conversation I have had with people who spend their days gathering news from sources other than the ones I peruse, and it differs from conversations on Facebook with folks that already agree with me. I am grateful they listened and appreciate the opportunity to better understand their perspectives, even if just for a moment.

“Thanks, Doc,” he says finally. “You gave us some things to think about. I don’t need to come back for a recheck, do I?”

“Well, I would like to see you again in a few months, but I would be happy to see you anytime. Call if anything changes, okay? I know you will.”

“You got it.” We all bump elbows and they stand to leave. “Oh, yeah. And doesn’t abortion kill more people than COVID-19?” 

“Oh, look at the time! Really good to see you both,” I say. I sense our conversation will continue.

Bruce H Campbell, MD FACS is a Professor of Otolaryngology and Communication Sciences and Associate Director of the MCW Medical Humanities Program. He is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He serves as Editor of the Kern Transformational Times newsletter.

Telehealth at the Saturday Clinic

From the 7/10/2020 newsletter

Student Perspective

Telehealth at the Saturday Clinic

Spenser Marting, SCU Board Chair, MD-Candidate

Medical Student and SCU Board Chair Marting reflects on the impact of COVID-19 on the Saturday Clinic for the Uninsured...

“I don’t know.” Just a few days after Milwaukee’s first confirmed case of COVID-19, I hesitated to give an authoritative answer on whether Saturday Clinic for the Uninsured (SCU) would close for an indefinite period. While the course of the pandemic was yet unclear, I felt it imperative that SCU continue to stand with the vulnerable communities it serves. This was also a commitment that Dr. Rebecca Lundh, the SCU Medical Director, was passionate about as well. After countless COVID-19 update emails, an emergency board meeting, and several phone calls with Dr. Lundh, the plans to offer Telehealth appointments in partnership with the MCW M3 Family Medicine Clerkship were set in motion.

The Start of Telehealth at SCU

The first week back from spring break was hectic. While M1s and M2s “returned” to classes and their studies after break, I was coordinating with other SCU Managers, many of whom were in other states, to adapt SCU services into a new workflow. We worked to provide guidance to M3s on how to conduct Telehealth appointments, which would all be precepted by Dr. Lundh on weekdays. As the week went on, we began communicating with our patients about the clinic’s COVID-19 changes, the M3s and a few former managers began “seeing” patients remotely, and we revised our Saturday operations to safely dispense medications and provide essential in-person care to patients seen by Telehealth in that same week.

Our system for Telehealth has continued to change since its inception in late March. Multiple clerkships have rotated through SCU Telehealth, and we modified our procedures based on their feedback. We trained volunteer physicians in Telehealth to ensure a more sustainable model. Clinic workflows were revised again to safely bring students back to clinic for limited in-person

care in June. And, last week, we finished training our first cohort of 14 M2s on SCU Telehealth, marking our transition from relying on clerkship students (who are now returning to more traditional clerkship settings) to bringing our peers alongside us to fulfill our mission. We continue to learn and adapt.

This has been a Team Effort

While developing this program and responding to the pandemic has – at times – been exhausting, SCU Telehealth has afforded myself and others the privilege of being proximate to patients. It has enabled me to witness the effect that this double pandemic of COVID-19 and racism has on the lives of individual SCU patients. That we have been able to continue providing uninterrupted care to patients during this pandemic is a success that I am deeply proud of. This has not been the case for most other student-run free clinics. Dr. Lundh has been instrumental in making SCU Telehealth a reality through her mentorship and inspiring dedication to health equity and patient care. We also build upon the work of SCU Boards who have gone before us and created a system that we could adapt to respond to this crisis. And, lastly – I am grateful for the 12 managers on our board and our volunteers. They have been asked to give more than they signed up for and have done so with much grace.

Next Steps

SCU Telehealth came together through a group of students and faculty who worked to address an immediate need. We invite you to join us in doing the same. SCU is looking forward to involving new M1 and P1 students in clinic this academic year, both in a variety of volunteer roles but also as clinic managers. To my rising M2 colleagues, in addition to on-site volunteer roles, please consider volunteering with SCU this Fall by conducting Telehealth visits since the majority of patients will likely be seen virtually rather than in-person. We always appreciate innovative ideas for Quality Improvement and Research and invite all members of the MCW community – faculty, student, and staff – to reach out to us with ideas for partnership.

Spenser Marting is an MCW-Milwaukee medical student and SCU Board Chair.

The Issues of Bostock and the Supreme Court Ruling on LGBTQ Health

From the 7/10/2020 newsletter

The Issues of Bostock and the Supreme Court Ruling on LGBTQ Health

Jesse M. Ehrenfeld, MD, MPH, FAMIA, FASA

Dr. Ehrenfeld explains what the recent US Supreme Court decision – Bostick v. Clayton County – does and does not mean for people who identify as LGBTQ, and offers ways to get involved at MCW and beyond…

On June 15, 2020, the U.S. Supreme Court announced a historic ruling that has catapulted America and LGBTQ equality forward by guaranteeing equal opportunity for LGBTQ people in employment. The 6-3 Bostock v. Clayton County decision is likely to lead to more changes in courts at all levels across the nation in the coming weeks and months. I’ve been asked to give some perspective on the impact of the ruling, and what this means on the journey for complete LGBTQ freedom in America.

What We Won

The Supreme Court ruled that Title VII prohibits workplace discrimination based on sexual orientation or gender identity. This is an important change in that while Title VII has long prohibited sex discrimination, the Supreme Court has now interpreted the law more broadly to protect LGBTQ people. The ruling indicates that sex discrimination includes discrimination on the basis of sexual orientation or gender identity.

Because of this expansion of how sex discrimination is now interpreted in relation to Title VII, I expect that a number of other in-progress lawsuits around the nation will also soon provide important nondiscrimination protections in similar laws where sex discrimination is banned. Key examples include health insurance (Affordable Care Act), housing (Fair Housing Act), credit & lending (Equal Credit Opportunity Act), and higher education funding (Title IX). These are a few examples that are among dozens which are embedded in other state and federal laws which prohibit sex discrimination.

What We Didn’t Win

There are a number of areas where LGBTQ people still lack any protection in federal law, because sex discrimination is still not prohibited by statute. Within the Civil Rights Act, Title II covers business services and public accommodations. Unfortunately, Title II does not provide any protection against discrimination on the basis of sex – and therefore is not likely to be interpreted as providing protections for discrimination against LGBTQ people.

There are also no protections for sex discrimination in Title VI, which is the federal law that bans discrimination across all federally funded programs and services. Again, since it has no prohibitions against sex discrimination, there are no current protections for LGBTQ people in the important areas covered by Title VI – which are effectively any program that receives federal funding (including thousands of state and local government-sponsored programs and activities).

It should be clear then why there is still an important, urgent need for federal legislation that codifies the Bostock decision and provides nondiscrimination protections to sex, sexual orientation, and gender identity. The Supreme Court ruling also does not provide any guarantee of equal opportunity for military service for transgender individuals – an issue near and dear to my heart (see link).

Finally, the ruling does not protect children from being subjected to conversion therapy, a practice that – while widely discredited by every major reputable medical society in the U.S. – still persists. Conversion therapy attempts to change an individual’s sexual orientation, sexual behaviors, or an individual’s gender. Underlying these techniques is the assumption that homosexuality and gender identity are mental disorders and that sexual orientation and gender identity can and should be changed. It is estimated that in the U.S. approximately 57,000 youths will receive these type of change efforts before they turn 18 years old.

What You Can Do

As physicians, health care professionals, educators, and trainees we must weigh in on these important issues around health equity and LGBTQ equality. Legislative action is needed to expand and codify protections against discrimination, and our voices are essential to this work.

Outside of legislative action we, as biomedical and population health researchers and health care providers, can continue to use science to push for progress. At the Advancing a Healthier Wisconsin Endowment, the statewide health philanthropy established by MCW, we invest in projects that are working to understand and address health disparities, including disparities among the LGBTQ population. We are striving to do more to build a healthier future for all marginalized populations, including LGBTQ people.

As educators, training the next generation of researchers and health care providers, we can insist on inclusive training standards. This is in fact the subject of a forthcoming perspective piece, in Academic Medicine, which will be published later this month.

As coworkers, supervisors, and mentors we must be visible allies and advocate for our LGBTQ colleagues. Add your name to the list of allies through the MCW Academic and Student Services webpage. Share with your entire departments the MCW employee resource groups available to support them, including the newly created MCW LGBTQ Resource Group (here are the announcement and contact information). Do everything you can to build a welcoming workplace where students, staff, and faculty can be their true selves each and every day.

We can take action today to make change. Otherwise, we may be waiting another hundred years for court cases to work their way through the judicial process.

Jesse M. Ehrenfeld MD MPH FAMIA FASA is a Professor of Anesthesiology at MCW. He serves as Senior Associate Dean & Director of the Advancing a Healthier Wisconsin Endowment.

Kern Institute Renovations Under Way! Three New Labs, One New Pillar, and a New Post-Doctoral Fellowship!

From the 7/10/2020 newsletter

Director's Corner

Kern Institute Renovations Under Way! Three New Labs, One New Pillar, and a New Post-Doctoral Fellowship! 

 

 

Adina Kalet, MD MPH

 

In this week’s Director’s Corner, Adina Kalet describes changes to the structure of the Kern Institute that will supercharge the transformational work of the Kern Institute... 

 

 

Laboratories

 

It is with great excitement that I announce that the Kern Institute will now have three new  laboratories: 

• Medical Education Data Science Lab led by Tavinder Ark, PhD and profiled in the Transformational Times on June 19^th,
• Human Centered Design Lab led by Chris Decker, MD and Julia Schmitt.
• Philosophies of Medical Education Transformation Lab led by Fabrice Jotterand, PhD. To learn more, see the “Director’s Corners” on Practical Wisdom (April 10^th) and A Philosophy of Medical Education Transformation (May 8^th). 

 

 

Laboratories are places where people work together to understand how the world works. They are also relatively small bands of people who – with a range of specialized expertise and sometimes funky new equipment and technology – work  together with stakeholders to engage in experimentation, teaching, and wide-ranging and deep conversations. Where cross-disciplinary scholarship is conducted and disseminated, graduate students as well as mid- and late-career colleagues are nurtured. 

 

According to Wikipedia, the earliest laboratory belonged to Pythagoras of Samos, the Greek philosopher and scientist, who conducted experiments that discerned the different sound tones produced by the vibration of string. So, we join an ancient tradition of enabling those with deep curiosity to ask important questions and seek answers.  

 

 

Pillars

Our pillars are just that: the mainstays of the Kern Institute. The equivalent of divisions in a clinical department, pillars represent our stakeholders. 

• The Student Pillar, led by Catherine “Cassie” Ferguson, MD and Cassidy Berns, designed, implemented and now leads the REACH curriculum. This pillar houses our work on Holistic Admissions. It focuses on enhancing equity and belonging for all our students in our effort to become an anti-racist organization.
• The Faculty Pillar, led by Alexandra Harrington, MD and Vivian Dondlinger, builds MCW’s capacity to transform medical education through the rigorous KINETIC³ faculty development program, and will be the home for our Kern signature coaching program.
• Under the guidance of Jose Franco, MD and Joan Weiss, the External and Internal Community Pillar (profiled in the “Director’s Corner” on May 1^st) will work to enthusiastically engage all of our communities – especially patients – in the work of educating the next generation of physicians.
• In his leadership of the Outcome Based Medical Education Pillar (formally known as the Curriculum Pillar), Martin Muntz, MD and Kaicey von Stockhausen express deep commitments to ensuring a culture of psychological safety while building systems and structures to support learners aspiring to become masterful physicians ready to serve in this rapidly evolving health care environment. 
• Moving forward we are adding a Graduate Medical Education Pillar that will engage this critical stakeholder group in the work of the Kern Institute and ensure we are working all across the medical education continuum to build strong institutional alliances. This pillar’s leadership will be announced soon.

 

 

 

Postdoctoral Fellowship

 

Finally, I want to ask for your help in identifying candidates for the new Kern Institute Postdoctoral Fellowship in Transformation of Medical Education. Creating this postdoc is a first step in building a nationwide capacity working to transform medical education. By defining enhanced career paths for PhD-prepared foundational scientists, we will create the next generation of leaders that will reimagination curricula and support cutting edge pedagogies to integrate foundational and clinical sciences. We want to attract an enthusiastic scientist and teacher who will roll up his or her sleeves and create effective, inspiring methods ensuring that future health professionals have solid foundations of scientific knowledge.  

 

The announcement for the position is here.

 

 

 

Stay engaged!

 

We invite you to read and to contribute to future issues of the Transformational Times as we collaborate and learn, working through our Pillars and Labs to turn aspirations into realities. 

 

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.