Mentoring Toward Purpose and Meaning: Helping our students retain their passion for medicine by asking Why?
Adina Kalet, MD, MPH
“...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.
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