Milwaukee is Special; Let’s Make Some “Good Trouble, Necessary Trouble”
Adina Kalet, MD MPH
Dr. Kalet shares how the message of Representative John Lewis’s farewell letter to the American people resonates with how the Kern Institute must take up the challenge to create inclusive, equitable medical education systems …
On the day of his funeral, John Lewis, the civil rights warrior and seventeen-term Congressman from Georgia’s 5thCongressional District, published a love letter to the American people in the New York Times. He wrote his inspired and inspiring essay while dying of cancer, knowing that the country he loved was in crisis. “You filled me with hope about the next chapter of the great American story when you used your power to make a difference in our society.”
Lewis reminds us that “Redeeming the Soul of Our Nation” will require a “long view” which, I believe, is also our approach as we redesign medical education to create a new physician work force. Doing meaningful and important work is a process, not an outcome. As an ancient Jewish ethicist reminds us, we are not responsible for finishing the work of "perfecting the world,” but neither are we free to stop trying.
Our home: Milwaukee is a very segregated city
We have some complex work to do in our own hometown.
Milwaukee has the long-standing, dubious distinction of being among the worst places in America to be Black. A black child born into poverty in Milwaukee is more likely to continue to be poor than in any other large city in the country. Deeply entrenched, persistent and concentrated poverty, extreme racial segregation, and exclusionary zoning or “redlining” have been blamed for the poor social mobility for our children. There are endless, complex explanations for this “special” status.
Research studies confirm that health disparities are both directly and indirectly linked to these social determinants of poor health. Scientists from multiple institutions have identified that the incremental, accumulated physical effects of racism over a lifetime contribute to health inequities. Recently, this disparity has included the disproportionate illness and death of Black Milwaukeeans from COVID-19. No matter how you assess the current situation, things appears bleak.
Yet, John Lewis – a Black man who lost as many battles for racial justice as he won and who was beaten and arrested over fifty times for engaging in militantly non-violent protest against racial injustice – was optimistic when he died.
Lewis believed in us. He exhorted us to be aspirational. He wrote “Ordinary people with extraordinary vision can redeem the soul of America by getting in what I call good trouble, necessary trouble.” It is time for those of us in medical education to do some significant envisioning. But where do you look for the leadership? Inward?
Time to make some good and necessary trouble
As the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, I am always on the lookout for opportunities to think boldly and make a bit of good and necessary trouble!
I am proud of MCW and its 125-year history of being an anchor institution in Milwaukee and the region. In John Raymond’s most recent Letter from the President, he reviews a list of the substantive ways in which MCW has been an exemplary institutional citizen of the city, the region, and the state over the past decade. He also invites all of us to join in the conversation and contribute to the MCW 2025 Strategic Framework as we set a new vision and as we rise to current challenges; we must “… think boldly and to share how you would reimagine MCW.” How do we prepare to make changes?
Be bold. Set audacious goals.
Many years ago, my mentor diverted me from an unproductive tirade by saying, playfully, “Don’t get mad. Get data.” This admonition literally was the birth of my academic career. Below, I offer an example of people who will change Milwaukee by first gathering data.
The African American Leadership Alliance MKE (AALAM) was founded in 2017 to link influential individuals dedicated to making Milwaukee a place where African Americans thrive. AALAM has set the audacious goal of putting Milwaukee into the top ten US cities for African Americans by 2025! That is when our current first-year students will be interns.
Recognizing the need for benchmarks for their work and seeking to identify the levers to drive positive change, AALAM commissioned the UW-Milwaukee Center for Economic Development (UWMCED) to produce the study, “The State of Black Milwaukee in National Perspective: Racial Inequality in the Nation’s 50 Largest Metropolitan Areas.” The study was funded by the Greater Milwaukee Foundation. Here is an interview with the study lead, Professor Marc Levine.
As part of their work, the UWMCED team created a “Composite Index of African American Well-Being.” The index synthesized thirty indicators of community well-being, typically studied individually – for example, employment, income, poverty, social and community health, and conditions specific to youth and children – into a single number allowing big picture comparisons and holistic analyses across large metropolitan areas of the country. Milwaukee ranked 50th out of 50.
The study pinpoints three inter-related drivers for change:
· Reducing racial segregation
· Enhancing Black educational attainment
· Increasing the numbers of Black executives and managers at Milwaukee companies, including MCW
These actions will help make strides toward racial equity. For AALAM and the rest of us, it is a call to action, a time to make some good and necessary trouble.
Building trust and taking action
On July 22, 2020, Drs. Lenard E. Egede and Rebecca J. Walker from the MCW Division of General Internal Medicine Center for Population Health published a perspective in the New England Journal of Medicine identifying six recommended action items for mitigating structural racism. Directly in our Kern Institute lane is the recommendation to “be consistent in efforts by health systems to build trust in vulnerable communities.”
How do we build trust? We must commit to long-term, trustworthy partnerships in “pipeline to the health professions” programs that will measurably accelerate the diversification of the health workforce in Milwaukee. We must intentionally and assertively recruit and support students, residents, faculty, and staff from underrepresented minority (URM) communities making special effort to identify those from economically deprived backgrounds. And as our leaders are seeking to do, we must support, listen to, and engage with all of MCW’s URM community-including all levels of staff- to be the kind of employer where everyone feels they belong, have an influence and can create a meaningful work life. This will require carefully examining how we traditionally have approached fairness, as compared with equity, in admissions and hiring processes.
How do we prepare our trainees to practice medicine so that it is experienced by communities as trustworthy? Beyond a curriculum which provides the critical historical context for the distrust of the health care system by vulnerable communities, we must provide meaningful ways for our students and residents to work with and in communities. I have been involved with many “patient-as-teacher” programs. These programs train and employ community members- to be medical school teachers. With their active participation, for instance as standardized patients student can learn clinical material practice skills and receive critical feedback. With community guides and coaches students and residents can contribute to research and engage in community social action. These experiences need to be substantive, rigorous and longitudinal allowing for the development of strong trustworthy relationships. This is making some good trouble!
In his essay, John Lewis wrote that he once heard the voice of Martin Luther King on the radio. “He said we are all complicit when we tolerate injustice. He said it is not enough to say it will get better by and by. He said each of us has a moral obligation to stand up, speak up and speak out. When you see something that is not right, you must say something. You must do something. … I urge you to answer the highest calling of your heart and stand up for what you truly believe.”
If we are truly committed to transforming medical education – as well as society writ large – we must reshape our own community, focus on character and caring, and offer to partner with organizations, like AALAM, that carry visions of a better, diverse, equitable world. Our entire community will benefit.
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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