The Messy

From the 8/28/2020 newsletter

The Messy 

Cassie Ferguson, MD - Kern Student Pillar Director

Dr. Ferguson describes how clinicians must embrace their capacity for compassion to overcome the challenges of working in a messy world …

One very late night during my pediatric residency, I sat in the middle of the pediatric intensive care unit with my supervising fellow and the hospital chaplain. A teenager we had been caring for had just chosen to be decannulated (that is, have her tracheotomy tube removed) and be allowed to die. She was 16 years old and had lived with a rare neuromuscular disease that had progressed to the point that she could not breathe without the aid of a ventilator and, more devastatingly, could no longer paint or draw.

“Some days,” the chaplain said, “some days, we are called to the messy.”

Through the course of my career, I have been advised on how to wade through this mess; how to tend to the hardship, the pain, and the trauma experienced by the humans that we are called to care for and about. Well-meaning mentors have warned me to keep an emotional distance from my patients. Burnout experts warn us all of “compassion fatigue.” Even the language we subconsciously revert to in the emergency department (ED) urges separation from human suffering — we care for “the broken arm in room 12” and “the non-accidental trauma in 5.”

This perspective seems, to me, to arise from our deeply ingrained “culture of scarcity”; we can never have enough, know enough, be enough. We fear that our compassion is finite but that we just weren’t told exactly when it would run out. So, we keep pushing and pushing, rightfully unwilling to ration it. 

“Our capacity for compassion is endless” 

I would like to offer a different perspective. I believe that our capacity for compassion is endless; that we can hold and attend to both the joy and the pain of our work; and that we can find meaning in and be transformed by the suffering we witness. For me, this begins with recognizing the limitations of empathy. 

In a study using EEGs and MRIs, a team of social neuroscientists examined the differences between empathy and compassion. In one experiment, the French Buddhist monk, Matteau Ricard, was asked to listen to recorded sounds of a woman screaming with the specific instruction to feel her distress but do nothing more. The pain centers of his brain were active, and he struggled to continue. Then he was instructed to listen to the same sounds, but to also engage in compassion meditation — to repeat phrases offering up safety, health, and ease to this person. His pain centers remained activated but so, too, were the neural networks associated with love and other positive emotions. He felt that he could continue to do this indefinitely. 

Empathy is affective resonance with someone else; it allows you to feel suffering when they suffer and to feel joy when they feel joy. Empathic resonance alone, however, can lead to emotional distress and burnout. “Empathy,” Ricard writes, “should take place within the much vaster space” of compassion and love. 

It is important to unpack this term with the intention of understanding what it is, how it serves our patients, and how we cultivate it. Ricard wrote beautifully that “compassion is nothing else than love applied to suffering.” Empathy directs our attention to where it hurts; compassion calls us to work to understand the levels of pain, and the manifest and latent causes of it, so that we might effectively help and empower. Compassion calls us to act; to engage with our patients and with our communities. 

Cultivating this compassion and sustaining it through the demands of our profession is effortful; caring for self while caring for others should be a daily practice held with the same reverence that you hold doctoring. That practice will look differently for each of you. But I urge you to keep these key components in mind: 

• First, pause frequently. Intentionally make space for rest, recovery, and being still. For me, this has looked like asking our team to pause together after a death in the ED and taking back some of the hours lost to my smartphone to be in solitude.
• Second, stay fully present in your experience no matter how difficult. This is as straightforward as stopping to notice and name the emotions coming up for you during patient encounters. After sitting with a mom who just learned her 5-year-old has leukemia, it is easy to do what Brene Brown calls “overfunction”; rather than recognize how our emotions are impacting us, we jump to reassure, and to fix, and to plan. If I sit and say to myself, “I am feeling fear,” or “I am feeling anger,” I can remain present for her and let compassion guide my actions instead. 
• And lastly, as the meditation teacher Jack Kornfield wrote, “If your compassion does not include yourself, it is incomplete.” 

Compassion in practice 

A few weeks ago, I sat with a student during their dismissal hearing. The experience was understandably distressing for them, and I struggled to help. So, I consciously engaged in a practice that I use nearly every shift in the ED, one that some of you have heard me talk about before; I sat across from them and noticed my breathing. With every inhale I thought about breathing in compassion for myself, and with every exhale I breathed out compassion for them. I know that even this small departure from focusing on others makes some of us uncomfortable and makes us feel as if we our abandoning our mission as caretakers. But in that moment, with that student, rather than feeling overwhelmed and reflexively pulling away or trying to fix, I felt only love. And love, far from sentimentality, is the force that undergirds the most important and transformative moments in humankind’s history. 

Love is also the way through; we must harness it if we are to continue to alleviate the suffering of others, fight for social justice, and care for our communities and our planet in a sustainable and intentional way. As I have learned often during my career, patients, caregivers and the world around us are all wading through “the messy.” They each deserve my best efforts to provide them my mindful attention, my love, and my compassion. 

Dr. Ferguson initially delivered this talk as the invited speaker at the MCW Gold Humanism Honor Society induction ceremony in June, 2020. 

Cassie Ferguson, MD is an Associate Professor of Pediatrics (Emergency Medicine) at MCW. She leads the MCW M1 and M2 REACH curriculum focused on promoting wellness. She is the director of the Student Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Lessons Learned in Character Education: Don’t be Intimidated

From the 8/28/2020 newsletter

 
Lessons Learned in Character Education: Don’t be Intimidated
 
 
Ryan Spellecy, PhD – Bioethics and Medical Humanities
 
 
Dr. Spellecy, who trained in Philosophy, talks about the challenges and rewards seeking to understand and implement the concept of “character in medical education” …
 
 

In the first months after the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education was launched, I attended, as a Kern representative, the annual meeting of the Association for Moral Education. Our goal was to present our initial work on “character” in medical education. The Kern Institute was a new player in the world of character and, since we were the first medical school to attend that conference in its forty-three year history, we were the first to delve into national and international scholarship on character education.  It was clear, even at that early stage, that role models are – and would be – essential in character education.  
 
In fact, medical education has known for years that role models shape our learners.  We call it the “hidden curriculum,” and it has often achieved the opposite effect of what we would want.  
 
At that meeting, I learned important lessons about role models and moral development: we must be mindful of the moral paralysis that can occur when we place role models on pedestals.  If we hold our moral heroes in too high esteem, we become paralyzed, unable to imagine how we could ever be “good enough.”  The result is that we – and our students – don’t begin working on character development because we cannot see how to start toward such a lofty goal.
 
 
Making mistakes is fine
 
So, how do we get past our moral paralysis and make progress?  When Professor James Arthur visited the Kern Institute, he shared a quote from Abraham Lincoln.  “It has been my experience that folks who have no vices have very few virtues.”  Or, as our own definition of character in medical education states, having good character does not mean one never makes mistakes or has lapses.  Rather, people of good character learn from mistakes. Our moral heroes are more like us that we think. To me, this means we must keep moving – and must help our students keep moving – toward character development. 
 
Think about some of your moral heroes.  If they are famous, they likely have had some shortcomings – perhaps even large ones – over the course of their lives.  Despite this, they can still have much to teach us, and by the same token, we can develop character and flourish even if we make mistakes and, at times, fall short. 
 
 
We all have different strengths to offer
 
The second lesson I learned at the meeting is that we are all unique and bring unique sets of strengths, including character strengths.  There is no one character profile for the successful pediatrician, surgeon, or even philosopher.  Rather, what the character literature has shown is that we can leverage our unique constellations of character strengths to achieve goal, often as a team. 
 
Still, do we need to look for certain character strengths as we consider building new, holistic medical school admissions processes? Initially, I believed that we would need to discern which strengths are necessary for medical students to excel at being physicians. I am certain that understanding applicants’ characters will still be a useful endeavor, but I am stuck in my philosophical training that emphasizes the value of specialization.  The recent psychology and education literature on character confirms that each of us is different and unique. This diversity is a good thing.  
 
For instance, I might low be low in “self-control,” and you might be high in the same.  We can complement one another to achieve a task.  More importantly, I can use a character strength that is particularly strong for me to help us both tackle a problem from different angles.
 
 
Understanding and educating for character
 
Of course, successful physicians need equanimity just as successful philosophers need good judgement.  However, our individual character constellations around these fundamental strengths makes us unique and enables us to complement – and even strengthen – each other on teams.
 
Even the same character strengths can manifest differently. In perusing the book, Character Strengths Interventions: A Field Guide for Practitioners by Ryan Niemec, I noticed that the activities recommended to work on the character strength “Zest” did not include things like, “Quit your job and hike around Europe for a month.” Rather, one suggestion was to choose a physical activity you enjoy, follow a plan to do it regularly, and write about the experience, including the benefits and feelings it evokes. Seems like great advice for anyone. 
 
 
Since our first Kern discussions on character, we have added expertise and experiences from several institutions. As an organization that seeks to transform how we educate the next generation of physicians, I believe it is critical to understanding how we best help students develop their professional character.  To be honest, the things our students see and hear while in the classroom, in the hallway, and at the bedside are already central to their character development, even if we call it by a different name. We rarely reflect on the process and certainly don’t fully understand it. 
 
This is not an inconsequential task. We aim to educate physicians who will, by nature, perform wise behaviors and trustworthy acts. We believe that the goal of understanding and then educating for character is not out of our reach, regardless of where we stand with our own moral development, the shortcomings we might have, or the character strengths that we feel are not as strong as they might be. It is exciting to be “early-in” as we explore this important field in medical education together.  
 
 
 
 
Ryan Spellecy, PhD is the Ursula von der Ruhr Chair in Bioethics and Professor of Bioethics and Medical Humanities and Professor of Psychiatry and Behavioral Health at MCW. He leads a National Transformation Network group seeking to define character in medical education. He is part of the Kern Practical Wisdom Workgroup. He is a member of the Kern Philosophies of Medical Education Transformation Laboratory.
 

How Medical Humanities Can Help Save Lives -- Including Ours

From the 8/28/2020 newsletter
 
 
How Medical Humanities Can Help Save Lives -- Including Ours
 
 
 
Arthur R. Derse, MD, JD – Director, Center for Bioethics and Medical Humanities
 
 

Dr. Derse describes how philosophers, poets, and physician-writers all help us to develop equanimity … 
 
 
The Wall Street Journal recently featured a story that asked the question, “What would Aristotle do in a pandemic?” It’s not such an odd question. Philosophy is part of the humanities, academic disciplines that ask important questions about our human lives. Ancient writers may have wisdom to share with modern day physicians who have to face the challenges of COVID-19. 
 
For Aristotle, character was paramount. Character is demonstrated through traits that included courage and perseverance in the face of adversity. Courage is a laudable character trait, though Aristotle also recognized that courage had to be appropriate to the situation. The character trait of prudence helps recognize when courage is appropriate to the situation that lies between cowardice and foolhardiness. Those teachings from millennia ago can guide us in today’s pandemic crisis. 
 
Physicians and trainees are being called to take risks in their roles as professionals. The risks are greater than usual and must be weighed in relationship to duties these individuals have to themselves, their families and their other patients. A firefighter’s job is to run into burning buildings. But the firefighter needs protective equipment in order to fight the fire. 
 
If a patient with COVID-19 suffers a cardiopulmonary arrest, physicians and nurses may wish to rush immediately into the room to begin CPR (if it might be beneficial to the patient in the circumstances), but caring for patients while protecting ourselves from the virus (that has already killed almost a thousand health care personnel in the US) and preventing transmission of the virus to other patients or our family calls for donning adequate personal protective equipment (PPE), even if it takes precious time to do so. 
 
Balancing appropriate courage and exercising prudence in caring for patients requires another character trait known as “practical wisdom.” Aristotle taught that practical wisdom was both necessary and sufficient for being virtuous. As you demonstrate your courage in striving to save the lives of others, knowing a little about Aristotle might help save your life and, in turn, those of your other patients and your loved ones.
 
Philosophy is not the only area of medical humanities that can provide help and comfort at this time. Literature can give us important, life-supporting and perhaps life-saving insights. Albert Camus, in The Plague, and Steward O’Nan, in A Prayer for the Dying, described the moral challenges facing physicians working in epidemics. 
 
Rafael Campo, MD, physician and poet who worked during the plague-like early years of HIV/AIDS, gives us the comfort of his own the poetry and shares with us his favorite poets - including physician-poet William Carlos Williams and hospital attendant Walt Whitman - to show that healers can get through this. Physician-writers can be role models that help us to be more empathetic and compassionate to our patients and may also soothe our understandable anxieties during this pandemic.
 
Emergency physician and essayist Jay Baruch, MD sends us missives from the frontline where he rails against the broken system that forces him to re-use single-use PPE while treating patients that put everyone at increased risk. The team members trust each another to keep themselves and their patients as safe as they can. His essay highlights the character strengths of teamwork and courage while acknowledge and advocating for the safety of the team. This pandemic challenges us to care for our patients while being responsible for the safety of each other.
 
The humanities can be expressed in many ways in medicine. Colleen Farrell, MD, is an example of a physician who balances her professional responsibilities with humanism and love of medical humanities. She is an internist who recently began a critical care fellowship in July. She treats patients valiantly in the ICU even as she advocates for the protective equipment that residents need to care for patients. She shares her grief and her tears with friends when she loses patients to the pandemic. She played the violin (while appropriately masked) at a memorial service for a nurse felled while treating patients by COVID-19, and plays when she can for her own self-care. And she hosts a biweekly Twitter discussion on medical humanities.
 
Medical humanities help us develop equanimity - the character trait William Osler said was most important to physicians - by maintaining balance and judgment in chaotic and unpredictable circumstances. We exercise practical wisdom by acting on the knowledge of when to do the right thing at the right time in the right manner for the patients to whose good we are dedicated.
 
A recent profile considered whether the extensive grounding in the humanities including philosophy that Dr. Anthony Fauci pursued in his education has shaped the physician, scientist and leader that he is today. Dr. Fauci is an exemplar for humanities in medicine, helping us face the COVID-19 challenge with equanimity as he does now, and did when our nation first faced HIV/AIDS.
 
Medical humanities can indeed help in clarity, insight and comfort during this challenging time. And might just save lives, including ours.
 
 
 
Arthur R. Derse, MD, JD FACEP is Julia and David Chair in Medical Humanities, Professor of Bioethics and Emergency Medicine, and Director of the Center for Bioethics and Medical Humanities and the MCW Medical Humanities Program in the Institute for Health and Equity. He is faculty in the Philosophies of Medical Education Transformation Laboratory of The Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

It Starts with Faculty

 From the 8/28/2020 newsletter

Guest Director’s Corner
 
 
It Starts with Faculty 
 
 
Ali Harrington, MD – Director, Faculty Pillar, Kern Institute
 
 
Dr. Harrington shows how the Kern Institute’s emphasis on character can influence how we respond to our callings ….
 
 

I was upset. We had just clicked “End Meeting” for our weekly Zoom Tumor Board. During the meeting, conflict arose between a few of us, which is never a comfortable situation; and some of us, including me, felt disrespected. Now this feeling is not a unique one for me as a pathologist, as I have learned to live with the slight that I sometimes experience for my chosen profession. Nonetheless, as the division director, I had to assert leadership in the moment and respond to the tensions, so I picked up the phone to talk with my colleague. My impulse was to react, to say how I felt, and to defend my position. And I started there, but I quickly backed off and used self-regulation to “check” my emotions. A few seconds into the conversation, it was clear I needed to listen. I was hearing things I had not considered before. I needed to use perspective – one of my character strengths. Since our conversation, I have deliberated on how I can use empathy and my character strengths to help resolve future conflicts. (Of course, I will also need to deal with my suppressed emotions, something I am not so good at.)    

“Start with the adults.”

“The adult culture matters.”

Some of you may have seen me reference these learnings in an earlier Transformational Times essay, when I described our recent participation in a character education program sponsored by the Kern Family Foundation. This Convening, as it was called, brought together those of us with a personal stake in character development in our learners and included many K-12 educators and leaders and a few partners in the adult learner space. We were there to learn what others are doing and best practices and to share our journey in character education at the Medical College of Wisconsin. It was through this program that I learned that success of character education is dependent on faculty, otherwise known as the “adults” in the K-12 world. So, that means me, and that means you, are key to building impactful character development curricula.

The Kern Institute is leading several programs that have character education, either explicitly or implicitly at their core: KINETIC3 (Kern INstitute’s Educational Transformation in Character, Caring, and Competence), the REACH curriculum, Transformative Ideas Initiative (TI2), and Learning communities. Each of these programs has a focus on faculty development, ranging from an entire program devoted to faculty skill building in KINETIC3 to coach, mentor, navigate, and facilitate training in the others. For those of us leading these programs, faculty development has been critical to implementation of our programming; however, it has served a much greater purpose. And that purpose is to feed culture.

In our KINETIC3 program, we start each year with a Character in Medicine workshop. In this workshop, we explore character development for self (yes, self!) and for one’s learners. We start from a place of inquiry, asking participants to share their impressions of character education in medical education. We hear a gamut of responses at this point, ranging from endorsements (yes, we can all inspire to a better self!) to tentativeness (I'm not sure I’m buying this!) to disbelief (our character is fixed by the time we are adults). We then introduce the topic with a positive psychology focus, using tools from the Values in Action Institute on Character (viacharacter.org), specifically, the Science of Character video to inspire an interest in practical application of character strength development. We ask our participants to share their strengths and how they display those with their learners, families or co-workers. We ask them to consider Carol Dweck’s “growth mindset” as a premise upon which we can continue to develop our character strengths well into adulthood. Transitioning to character educational efforts for our learners, we present K-12 constructs and resources, including CASEL and character.org and advance to reflections on the relationship of character to existing constructs in medical education, such as professionalism and professional identity formation. We then conclude the workshop sharing Dr. Jeff Fritz’s reflective exercises in Anatomy as an example of a character development activity and have the faculty plan out their own character development activity for their learners.

Our KINETIC3 participants respond positively, uniformly, to the Character workshop. Some eagerly share their designed character activities. Others reflect after the session and share: “This is when I realized that I have multiple times to discuss/teach/implement character into every day, clinical teaching,” and “I realized how I've been really interested in character in medicine without actually thinking about it. It's something that I've been trying to learn how to teach, and this class immensely helped!” We try to integrate character development into other workshops in the program to varying success. And this year, we have launched even more character-focused curriculum, including inspiring creativity, growth mindset, culturally responsive teaching, the science of gratitude, role modeling, empathizing with your learners, supporting our students, learner and teacher well-being, psychological safety, and using reflection and narrative stories. Each workshop has the potential to develop one’s own character and influence that of his/her students.

Let us return to the topic of influencing culture. Character.org has published a guideline document, entitled “11 Principles of Character Guidebook,” which serves as a resource for cultivating a character culture within a K-12 school. These principles are equally relevant to our task of building a character culture in medical education at MCW and beyond.

Two of these principles deserve some discussion. The first, “core values are defined, implemented, and embedded into school culture,” asserts that all stakeholders, from staff to faculty to students, can describe the unique, shared values of the school, as these values are ubiquitously adopted, displayed, and practiced. The second is particularly relevant to this discussion on the importance of faculty engagement and development: “all staff share the responsibility for developing, implementing, and modeling ethical character.” This means that we need widespread faculty and staff buy-in and support for character development and that each of us, needs to “walk the walk.” How about we start by choosing to work on our own character?

But what does character education look like in medicine and in medical school? That is, of course, our charge. To create. To experiment. To iterate. We do not have all the answers, but we are working on bits of them. Personally, I think character development in medical education looks like multiple petals forming a beautiful bloom: professional identity formation, well-being, communication, leadership, social intelligence, empathy, professionalism, ethics, and advocacy. This is an oversimplification and may be insufficient for many; but it is practical and offers an outline through which we develop our character strengths for the purpose of becoming our best self, providing the best care for our patients, and contributing to a flourishing society.

I share my story of Tumor Board with you (yes to be vulnerable, Dr. Ferguson) and to provide an example of how each of us is still molding our best self. Building a character culture will take time. It will not be easy. But it starts with us.

“Start with the adults.”



Alexandra Harrington, MD, MT (ASCP) is a Professor of Pathology and Director of Hematopathology in the MCW Department of Pathology. She serves as Director of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

The When and Why of my Good Trouble in Medical Education

From the 8/21/2020 newsletter 
Personal Opinion / Perspective 
 
The When and Why of my Good Trouble in Medical Education

 
Jeff Fritz, PhD – MCW-Central Wisconsin (MCW-CW) faculty member

 
Dr. Fritz, a founding member of the MCW-Central Wisconsin faculty, finds inspiration in old books and documents that push us in the direction of  “good trouble.” In this essay, he points to some areas where he believes we need to make changes …

 
 

I enjoy old documents. One of my hobbies is finding old books – like ones that explain medical treatments – with copyright dates prior to 1900. I keep searching for older and older volumes of the drawings by Dr. Frank Netter and the first editions by Dr. William Osler. 
 
My family asks me why I keep exploring for things that could be found on the internet. For me, holding these works provides inspiration. Older documents let me adopt the perspective of the writer, give me a glimpse of their experiences, and encourage me to continue to look for solutions to age-old problems. 
 
Often, older documents tell me when and why I need to act – they illuminate those areas where I need to get into “good trouble.”  Two documents of which I hope to someday add older copies to my collection are the Declaration of Independence and the Constitution. The Declaration reminds me to take a stand and join the cause for those experiencing limitations to “life, liberty and the pursuit of happiness.” My favorite phrase in the preamble is “it is the Right of the People to alter or abolish [the government], and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness.”For me, this is a call to action to serve those around me when they share their personal struggles, injustices, or failures to overcome institutional roadblocks. The Declaration of Independence guides my energies when I need to get into good trouble. 
 
In addition to these documents telling me when to get into good trouble, the Constitution begins by telling me why. “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.” This tells us why we expend our energies when it is time to get into good trouble. I think it challenges us to form more perfect institutions, improving upon our structures so that those around us can better flourish.   
 
What does my personal hobby have to do with medical education?  As a faculty member on a regional campus, I get to work at a medical school while still remaining in my rural community. Twenty years ago, my spouse and I left our familiar academic environment of Nashville, Tennessee to support her rural medical practice and to focus on our growing family. Trust me, I thought the opportunity to engage with medical students was a thing of my past! But thanks to many courageous leaders willing to develop regional campuses and get into good trouble, I can both support my spouse’s pursuit of happiness and, once again, pursue my own dream as a medical educator. I want more people to experience the joy I experience as an MCW-CW team member and as part of the Kern Institute faculty. 
 
As I begin my fifth year at MCW-CW, I feel it is time to respond to concerns raised by our learners, inform our leaders, hold myself accountable, and create some good trouble to benefit both our learners and our institution. 
 
Here are areas where I hope to make some good trouble this year.
 

 Area 1 – Admissions
I have been on the MCW Admission Committee for four years and will encourage our team to more fully embrace the challenges to transform our admissions process. We must admit cohorts of learners that more dynamically represent the communities we serve. 
 
To my friends on the Admissions Committee and within the Student Pillar at the Kern Institute: I know the energy it takes each year to screen, interview, and admit a new cohort of students, but I challenge us to get into some good trouble and develop a better system that will lead us to becoming a more inclusive, antiracist institution. Hold my feet to the fire and hold me accountable – let this year be the year we develop a more robust, holistic, and inclusive admissions process. 
 

Area 2 – Curriculum
My primary role at MCW-CW is to assist instruction throughout the first year of our current foundational science curriculum. Over the past four years, I have watched learners succeed as well as struggle. I feel our curricular structure could do more to ease the suffering of our students. I have watched our institution embrace the good trouble of student, faculty and staff well-being and make great strides in a short period of time. However, we have so much more to do in revolutionizing our curriculum to meet the need of our learners on each of our campuses and those we would like to invite onto our campuses as learners. 
 
To my friends on the Curriculum and Faculty pillars at the Kern Institute: Now is the time we put forward a curricular design with the flexibility and inclusivity to ease the suffering of our learners on all of our campuses and helps them feel supported, safe and justly treated.  
 

Area 3 – The cost of medical education
I’d also like to see us embrace a new way to support our students with the cost of medical school, but I fear this is out of my sphere of influence ; after all, you can only throw the tea into the harbor off of the boats onto which you can board. While I explore a more direct means to influence our financial approach to medical education, I challenge us all to expand our funding horizons as an institution. We need to take up the good trouble of eliminating the hurdle and fears surrounding the cost of medical education.

We need to acknowledge how these costs limit our ability to fully develop a diverse and inclusive cohort of learners and faculty. We need to tackle the cost of medical education, both financially and culturally, as it continues to exclude those that remain outside our community. I’m looking for ways to dump the tea overboard on current system and explore a new and better way to constitute financial aid.

13,000 Days on the Hamster Wheel: Finding Meaning on the Way to Retirement

 From the 8/21/2020 newsletter
 
 
13,000 Days on the Hamster Wheel: Finding Meaning on the Way to Retirement
 
 
Bruce H Campbell, MD FACS – Editor, Transformational Times 
 
 
Dr. Campbell reflects on how the self-care trajectory on which we place our students and residents will carry them beyond their careers …
 

 
Medicine differs from many other professions. Once a physician joins a practice, it is possible to become a perpetual-motion machine, working day-after-day, seeing patients and generating revenue. As long as the physician directly or indirectly generates enough cash flow to pay salaries, keep the lights on, and move the enterprise forward, the process can continue unabated. Theoretically, this hamster-on-a-wheel activity can continue for around 13,000 days. That’s thirty-five years. Then the hamster retires, and another is recruited to keep the wheel turning. 
 
Of course, I don’t usually view myself, our students, or our residents as hamsters, but there have been days when the thought crossed my mind. Still, what can medical educators do to prepare the next generation of physicians in ways that will enrich – rather than deaden – their lives and careers? And how do we help our trainees step back and begin to grasp the arc of their journeys from graduation to retirement?
 
 
Talking with trainees about their careers
 
Recently, I held a session on retirement with our otolaryngology residents. We read an article where the authors asked Johns Hopkins internal medicine residents in the very first weeks of their internships to write down and then share what they thought a colleague would say about them at their retirement celebration many years down the road. I also asked our residents to imagine what others would say about them at retirement, which of their character strengths would be most noticeable in their careers (from the list at www.viacharacter.org/), what they think they will miss about their careers after they retire, and what aspects of retirement they are thinking about now. 
 
Not surprisingly, the residents in the article and our otolaryngology residents all see the distance from where they are now to retirement as being an incredibly long time. The brand-new interns hoped that their colleagues would see that they had lived out their core values, been accomplished in their careers, and been good teammates. Among possible character traits, our residents hope that they would have been most admired for their dedication to teamwork and their humility. They anticipate that they will find their greatest personal satisfaction – and what they think they will miss the most – from being part of a team focused on helping others in times of great need. Like the interns in the study, our residents worried about retirement but, being so far off in the future, they could not imagine what it will feel like to get there.
 
Our residents realized that they differed from the internal medicine interns in the study. Although they know they will miss many things, they believed they will be able to replace professional relationships, the joy of helping others, and stimulating conversations with other post-retirement activities. As surgeons, though, they worried that they will have difficulty replacing the unique privilege of performing surgery. As one resident said, “I can’t imagine not operating again. That’s why we went into this.” Everyone agreed. 
 
Our residents, having been in training longer than the interns in the Hopkins study, focused on how quickly time passes, even in training. “I am already realizing how much I will miss my fellow residents,” one of older trainees noted. “I’m sure my career will seem to pass by just as quickly.”
 
 
The challenges of helping students, residents, and faculty gain insight into themselves and others
 
There are data that strong relationships and lifelong self-care habits can yield benefits much later in life. MCW faculty members and the Kern Institute are building a portfolio of curricular and extracurricular opportunities that encourage resilience and insight including the REACH curriculum, the KINETIC³ Teaching Academy, MCW Common Read, and a variety of transformational initiatives (see a partial list at the end of this article.) The challenge is to make these types of offerings available, appealing, and effective. Baking caring and self-care into the institutional culture and the curriculum creates opportunities for both transformation and scholarship. 
 
But, let’s get real. Finding time for reflection, creativity, and long-range personal planning is difficult and, frankly, of low priority for busy students, residents, and faculty. Institutions can readily measure clinic slots, RVUs, grant funding, and margins, but we don’t (yet) have metrics that measure sustained empathy, strengthened character, and successful prevention of burnout. If we cannot demonstrate that these habits can be nurtured, or if they aren’t seen as valuable, our interventions will have little impact and won’t be sustained. 
 
Yet, raise your hand if you think that a graduate who is unprepared to thrive in practice will also be less likely to thrive in retirement. 
 
 
Retirement isn’t for sissies
 
Over the decades that I have been at MCW, dozens of colleagues have retired. I have noted that the end of a career rarely goes exactly as planned. Some have retired amid accolades for lives and careers well-spent while others have left baffled and reluctant, having no idea what they would be doing a week later. Some, after long and productive careers, were forced out after bitter disputes. Some packed up and left in disgrace. Some became ill or died before they had the opportunity to retire. Some, unfortunately, held on too long. Some left huge holes in the institution when they retired. Others barely caused a ripple. 
 
Guiding our students and trainees toward rewarding careers and eventual retirements carries responsibility. We must do more than suggest they be financially responsible and keep track of their retirement account outlook. We have equally important responsibilities to help them develop well-rounded professional identities, “seize the day” mentalities, and careers as reflective, empathic, and mindful physicians. If they enter practice self-aware and focusing on character and caring, they should have a better chance of emerging into retirement possessing the same values. 
 
 
Living each day
 
The act of living intentionally came to mind when I read a story in an interview with Duke University’s director of medical humanities, theologian, and pediatric oncologist, Raymond Barfield, MD: 
 

“Think of each day as a gold coin that you are required to trade for something. You’ll never get that coin back, so whatever you trade it for had better be worth it. You also don’t know how many coins you have left to trade, and you don’t know what will happen when your bag is empty.”

 
My career has shot past me like a rocket since I completed my fellowship and joined the MCW faculty 12,043 days ago. I now wish I had learned early on to treat each day like a gold coin. 
 
Whenever I do retire, I know I will carry memories of my colleagues and mentors with me and try to take advantage of the self-care and reflective skills I have acquired along the way. And, as I look back, I will be grateful for how rarely my career made me feel like that hamster running on a wheel. 
 
 
 
Bruce H Campbell, MD FACS is a Professor in the MCW Department of Otolaryngology and Communication Sciences and in the MCW Institute for Health and Equity (Bioethics and Medical Humanities). He is on the Faculty Pillar of The Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He serves as the editor of the Transformational Times. 
 
 
 
 
 
PARTIAL LIST OF SELF-CARE, CREATIVE, AND REFLECTIVE OPPORTUNITIES AT MCW
 
At the risk of leaving out many important opportunities for MCW students, trainees, and faculty to develop a longer view of a life in medicine, here are a few of which I am aware:  
 

• Healer’s Art Course.  Julie Owen, MD and Art Derse, MD run this M1 elective that helps students explore their connections, tough issues such as loss and grief, their motivation for service, and reflect on their goals. 
• REACH (Recognize, Empathize, Allow, Care, Hold Each Other Up) Curriculum. Working with the Kern Institute, Cassie Ferguson, MD designed REACH. She, Joanne Bernstein, MD, and Theresa Maatman, MD are the program leaders. REACH provides a well-being thread of lectures and small-group activities through the M1 and M2 curriculum where students explore mindfulness, meditation, spirituality, self-compassion, “imposter syndrome,” belonging vs fitting in, stress, anxiety, empathy vs. compassion, setting boundaries, gratitude, relationships, communication, sympathetic joy, active constructive responding, and compassionate listening. 
• KINETIC³ Teaching Academy. The Kern Institute offers this curriculum that seeks – in addition to fostering teaching skills and building a community of educators – to promote faculty and student well-being.
• MCW Common Read. The program coordinates a campus-wide book selection and study. This year’s book is How to be an Antiracist by Ibram X. Kendi.  
• MCW MedMoth. This is a live storytelling event where MCW students and faculty are invited to share first-hand narratives of their medical journeys. 
• MCW Art Club. Developed by Teresa Patitucci, PhD, this Facebook page shares the talents of MCW family members. See the article in the July 24, 2020 Transformational Times.
• MCW Moving Pens. Offered by the Center for Bioethics and Medical Humanities, this facilitated group for writers of all skill levels and genres meets twice-per-month in partnership with Red Oak Writing. 
• MCW Physicians for the Arts -  Facebook page link here
• Auscult – MCW’s literary journal. Site link here
• Chordae Harmonae – MCW medical student acapella group. YouTube link here
• MCW Orchestra – Facebook page link here

 

How Do We Decide? Seeking Wisdom as We Reopen Schools

From the 7/14/2020 newsletter

How Do We Decide? Seeking Wisdom as We Reopen Schools

M. Paula Phillips

In this perspective, Ms. Phillips shares her thoughts on making decisions, both as a parent and as a member of the Board of School Directors for Milwaukee Public Schools. She also notes what we can learn from Daniel Tiger ...

All over the country, parents are scrambling to find adequate childcare during the COVID-19 pandemic. In Southeast Wisconsin, 61% of the providers in the licensed group category were closed, either temporarily or permanently since March and school districts across the state have varied reopening plans which has increased stress and desperation. As a school board member that represents nearly 74,000 students and 10,000 employees, I’ve poured over hundreds of letters from students, parents, and educators pleading that we consider how COVID-19 has altered our world and resolve to do what is best. Sentiments include:

My child is already falling behind! 

I miss my friends. 

How will I be safe?

I’m afraid.

As a parent, I have an undercurrent of anxiety with so many of my choices. Am I being selfish for sending N to daycare? What if my child gets sick? Should I be caring more for my own child instead of advocating for all of our children? How much Daniel Tiger is too much Daniel Tiger?

As a human, it isn’t easy for me to untangle the complexity of my emotions most days. I can find hope in our community’s ability to raise over $800,000 to connect our students to needed WiFi for the virtual start of the school year.
I can become enraged when I consider that the decision to reopen schools during a public health crisis is being delegated to local school board members instead of other levels of municipal, state, and/or federal government. There are times I am paralyzed by how big our problems are, and how small I feel in comparison.   

I’ve learned a lot about emotions as my little one has emerged as an active, curious, and emotional two-year-old. Like Tinkerbell, the moment N feels something, it takes over N’s entire body. Joy, anger, silliness, sadness – N feels it all and feels its fullness. Instead of dismissing my toddler’s emotions, I’ve headed the wisdom of Daniel Tiger:

• Feel your emotions (When you get so mad, that you want to roar)

• Use your breath to get back in your body (take a deep breath and count to four)

Taking moments to acknowledge emotions, get back to breathing, and letting one’s heart rate come down has been so helpful for my toddler and myself. My little one has shown me how vast and far reaching the human experience is and how resilient and capable we are of getting through it. When I take the time to be mindful and understand what I’m feeling and what my own fears are during these uncertain times, I can identify what I can control and what I cannot. When I stop to take a breath, I avoid vengefully responding to a nasty letter from someone that is questioning my character. When I can acknowledge the difficulty of this time for me as a person, I have greater empathy to lead, understanding how difficult it is for all of us.

It is imperative that all of us understand how uncertainty surrounding reopening schools is increasing the mental load of parents (mothers in particularly). In order to practice empathy, we must understand how the current moment is affecting ourselves. Then, we can ask our colleagues how they are navigating their children’s education and listen fully.

Consider the composition of your team – who has caregiving responsibilities and who doesn’t? What does equity in workload and flexibility look like? Childless employees cannot bear the full load – how are FY21 goals being created to prioritize the most essential things for MCW’s remedy and recovery while other priorities are adjusted for everyone’s work life balance?

Our solutions for childcare and reopening the economy during a global pandemic, economic recession, and racial uprising cannot be limited to individual families or school districts. As you piecemeal solutions for your family, advocate for broader childcare allocations from state and local governments. Demand that federal funding be provided for all schools to open safely. Remember to breathe and don’t stop until every child has access to a safe place and high-quality education.

M. Paula Phillips is the Program Manager of the MCW Center for the Advancement of Women in Science and Medicine (AWSM) and serves as the representative to the 7th District of the Milwaukee Board of School Directors.

 

Why Build a Kern Post-Doctoral Fellowship in Medical Education Transformation for “Basic” Scientists?

 From the 8/14/2020 newsletter

Director’s Corner 

 

Why Build a Kern Post-Doctoral Fellowship in Medical Education Transformation for “Basic” Scientists?

 

 

Adina Kalet, MD MPH

 

 

This week Dr. Kalet introduces a new Kern Institute program aimed at building capacity for transformational change at MCW and nationally, one teacher at a time… 

 

 

My grandmother, with her thick Eastern European accent, drove my uncle and me crazy. “Adina is the first ‘Doctor’ Kalet,” she would say, even though my uncle had a PhD in Engineering. He, in fact, had been the very first “Doctor” Kalet, but the family knew what she meant, right? I was the physician. Grandma loved both her son and granddaughter. But, to her, a PhD didn’t make you a “real” doctor. For her, it just wasn’t the same.

 

 

Those of us in medical education know, of course, that the education of physicians absolutely depends on basic scientists. Not only because scientists are the “transmitters” of an enormous fund of scientific knowledge to which physicians need access. They are critical because physicians need to experience – and engage with – how scientists think and what they do. For much of what physicians need to learn, scientists are both the content and process experts. Medical education research demonstrates that having scientists as teachers is critical both for practice and policy. 

 

Still, my grandmother’s attitude reflects one of the traditional barriers to the seamless integration of basic scientists into the education of future physicians; she, as well as many students and faculty, seem to value the basic and clinical scientists differently. 

 

 

This attitude stands in the way of optimizing how future physicians develop high quality clinical reasoning, since they must learn to integrate diverse basic, clinical, biopsychosocial, and contextual information, deeply and generously process these data, and then effectively perform the professional activities of medicine (diagnosis, management, caring, accompaniment, counseling, etc.). Unless students understand and respect the value of each data source, there are many opportunities for error. A full integration of basic scientists into medical education is critical to developing these skills. 

 

 

How has medical education tried to integrate foundational and clinical sciences?

 

Over the decades, different solutions have emerged. In 1910, Abraham Flexner made a compelling case for a science-based curriculum with the subsequently ubiquitous two years of “basic science” and two years of clinical rotations. He insisted that scientists teach the science. 

 

Medical schools have tried different models to blend basic and clinical science teaching in order to achieve cognitive conceptual coherence. Implementation of best practices to integrate the basic and clinical sciences has lagged, especially when it relied heavily on “traditional,” passive teaching methods such as lectures, “binge and purge” assessments, and multiple-choice examinations. These approaches get students to briefly grasp large knowledge bases, but they do not achieve the level of integration we seek in our learners.

 

Over the last five decades, medical schools have made inroads integrating the clinical and basic sciences with case- and team-based learning curricula. Integration, however, has often been viewed largely as a matter of structure rather than as a means to honor the value of the basic science or to focus on individual learning outcomes. 

 

In the end, the approaches have sometimes failed to improve clinical reasoning. We must move to the next level if we want to ensure that future physicians have the ability to accomplish these critical, complex cognitive tasks.

 

 

So, what is next?

 

Recently, cognitive scientists have argued for individualized, learner-centered, effortful, and assessment-driven strategies as the best road toward true integration. Students become more accurate diagnosticians if they experience basic science/clinical presentation “causal stories” rather than being given evidence-based algorithms or basic science explanations separate from clinical material. This causal integration is not just a handy memory aid. By linking basic sciences with clinical features in a cause-and-effect relationship, learners build “illness scripts” or schema. Students create frameworks within their long-term memories that organize information to be retrieved when needed. This is learning. 

 

Assessing whether students integrate basic science concepts in clinical situations is complex but possible. As medical educators, we should put our hearts and souls into designing experiences where our learners organize, conceptualize, retrieve, and then apply foundational medical sciences into the care of individual patients (and populations).  Scientists and clinicians must understand and face the gap that has traditionally remained between them.

 

 

Creating a fellowship to equip basic scientists to be educational leaders

 

To address this gap and to chart a course forward, the Kern Institute will recruit basic scientists into a medical educator post-doctoral fellowship. The first cohort of one or two fellows will begin this fall. The goals of the program are to: 

• Transform medical education by ensuring a steady pipeline of medical educator scientists ready, willing, and committed to implementing best practices in medical education.
• Build skills and confidence as the medical educator scientists integrate health science disciplines, design competency-based assessments, and collaborate with diverse stakeholders to train the next generation of health professionals.
• Create thought leaders as the medical educator scientists engage in curriculum reimagination and continuous quality improvement. 

 

To achieve these goals, each fellow will:

• Work closely with, and support, MCW scientists and clinical educators to reimagine foundational science education in curriculum planning, instructional design, faculty development, assessment, and evaluation. Become master teachers of medical and other health professions students under the supervision of experienced mentors/coaches. 
• Participate in medical school administrative leadership meetings as a means to understand academic medicine governance.
• Participate in the KINETIC3 faculty development program.
• Engage in scholarly work with the support of the Kern Institute’s Medical Education Data Science, Human Centered Design, and Philosophy Labs.
• Have financial support to do formal master’s level, or equivalent, training in health professions education.
• Engage with national and international leaders in the field.
• Write and submit high-quality abstracts, peer-reviewed manuscripts, and grants. 

 

As we developed this new fellowship, we reached out to the International Association for Medical Science Educators (IAMSE), an organization committed to “promoting excellence and innovation in teaching, student assessment, program evaluation, instructional technology, human simulation, and learner-centered education” and the Association for American Medical Colleges (AAMC). I personally sought advice from most of our basic science chairs, MCW basic science educators, deans, the provost, and members of our regional campus faculty.  With this program, we are creating a clear path to deeply satisfying careers for trained scientists in medical education; we aim to prime-the-pump for future educational leaders.  

 

 

I have other basic scientists in my family. My father’s first cousin was a professor of pharmacology at a prestigious medical school, yet he complained bitterly about teaching medical students. As a basic scientist, he didn’t feel appreciated. Being introverted, he didn’t enjoy lecturing. He was convinced that most medical students weren’t interested in discovering new treatments for diabetes and cancer. I wish there had been a way for him to better integrate into the medical curriculum and be appreciated for what he had to contribute. 

 

I will think of my basic science relatives as we work with our fellows. I hope our fellowship graduates will bridge the gap between the basic and clinical science worlds in ways that assure basic scientists of their critical role in medical education and show clinicians how much we depend on the scientists. Even my grandmother would have agreed with that goal.

 

 

 

Further reading:

Kulasegaram, Kulamakan Mahan; Martimianakis, Maria Athina, PhD; Mylopoulos, Maria, PhD; Whitehead, Cynthia R., MD, PhD; Woods, Nicole N., PhD Cognition Before Curriculum, Academic Medicine: October 2013 - Volume 88 - Issue 10 - p 1578-1585 doi: 10.1097/ACM.0b013e3182a45def