Learners and Justice: Our Present and Future
Joseph Kerschner, MD – Dean, EVP, and Provost of the Medical College of Wisconsin
In a Leadership Plenary Address as the Chair of the Board of Directors of the Association of American Medical Colleges (AAMC), Dr. Kerschner explains the importance of listening to our learners, creating culture change, focusing on diversity, committing to being anti-racist, and transforming medical education.
Dr. Kerschner gave his address on November 17th, 2020 and the video of his full address is available here and the complete transcript is available here.
The AAMC is a unique organization with a unique position to influence medical education, research, and our nation’s health. I have always tried during my leadership year on the AAMC Board to put learner topics front and center, because at the very core of the AAMC, our organization needs to be about our medical students and residents who, after all, represent – not only our future – but our present. And, when given a voice, they provide important insights and identify solutions to our current challenges. Below are three topics students identified as the most important areas for emphasis by our medical schools, academic health systems, and the AAMC.
The first area we must tackle is learner well-being
This is at the top of my list. We simply cannot be satisfied with the state of our overall learner well-being. Although there are encouraging trends, the level of depression and distress for physicians (and other health care professionals) remains enormously high, and difficulties become manifest early in one’s journey to becoming a physician. There is not a single one of us who does not have a personal responsibility to actively reduce barriers to mental health access and to remove the stigma for those seeking healing as they struggle with mental health, addiction, and other related concerns.
Changes to curricula and assessment are making a difference. We must improve learning environments and assess how we provide instruction and evaluation. I personally believe that the recent change to pass/fail for the Step 1 exam will have a positive impact.
But we must do more to explore access to mental health resources, financial support, and milestone-based curricula that will provide more flexibility to our learners as they progress in their development. I believe we must provide the ability for a student to finish medical school and residency in less time – or more time – than the “standard number of years,” depending upon her or his previous experiences and aptitude.
Changing the culture to address well-being
We can change our cultures, in part, simply by bringing the conversations forward and highlighting the importance of engaging in this manner. The currency of leadership is time — and, as leaders, if we do not spend time on this issue, we will devalue the importance of well-being. Have we stressed the importance of taking time for oneself and one’s loved ones with the same passion that we have stressed completion of the latest research project or preparation for the next presentation on rounds? Do we intentionally “clear the deck” to talk to our struggling colleagues to provide guidance, resources, and support?
Well-being and mental health are broad topics that demand systemic approaches, yet I believe that the most critical systems change we need — throughout medicine and education — is a change in our culture. Until we enable our culture to truly see those who are suffering, remove all negative connotations, and offer what is needed to support our colleagues, we will continue to risk our own and our colleagues’ mental health and wellness.
A favorite saying of mine is, “Our attitudes influence our perceptions, which in turn create our realities.” The message here is that we can change our culture so that the health and well-being of our learners — and, really, all who pursue health and science careers — will improve!
The second area we must tackle is student debt and transition to residency
Often linked to well-being for our learners is overall debt and residency opportunities — or competitiveness. I will focus here mostly on the overall debt of our learners.
The US is an anomaly in the world, in which those who have chosen to dedicate their lives to the practice of medicine are often asked to take on an enormous debt burden before they even begin to see patients. We have resisted solutions, because, the thought process goes, physicians are well-compensated and can afford to pay back loans. In addition, many medical students come from relatively privileged backgrounds. There is some truth in these assertions. However, if we seek to encourage diversity among our medical workforce, how many potential students from less advantaged socioeconomic backgrounds never even consider medicine because, early on, they learn of the overwhelming cost and debt?
I believe that if medical school debt could be limited through means-based support of those with fewer economic advantages, we would see progress in well-being and a more diverse workforce. A legislative solution would require a realization that medical students are a national treasure that deserves our support.
The third area we must tackle is student diversity
Our students view medical school diversity as a critical area to strengthen education, improve health outcomes, and bring much needed racial and social justice to our society. As a nation, we simply have not made enough progress in this regard. For example, the matriculation rate for Black and African American men has not made any appreciable progress in fifty years!
Racial concordance between patients and providers can contribute to better patient communication, satisfaction, and trust — and that these attributes and others can provide at least a part of the solution to the lack of equity in health outcomes. We must construct our admissions processes, pipeline programs, and support systems to enable this reality. I believe that our medical schools and institutions must become truly anti-racist. We must establish institution-wide practices that address unconscious bias in all faculty, staff, and learners.
How I learned a diversity lesson
When I became Dean nearly a decade ago, there were many who were willing to work on equity, diversity, and inclusion; enhanced structures to measure pay equity; changes in policies influencing the manner in which inequities were handled; and institution-wide unconscious bias training for every leader, student, staff member, and faculty. We doubled the number of underrepresented in medicine matriculants. We enhanced our pipeline programs, and students of color specifically shared with me their heightened feelings of inclusion at MCW. Leadership diversity improved, thanks to conscious efforts in faculty hiring and leadership searches. On the financial side, an annual process was instituted to rectify gender-based and other inequities. And we were in the early stages of developing the Center for the Advancement of Women in Science and Medicine, which would soon become a reality. We were gaining momentum.
Then, six years ago, a group of MCW medical students raised their concerns about police brutality, the Black Lives Matter movement, and racial injustice. They requested support from my office for a local “White Coat Die-In” — a national initiative in 2014 that many listening today will remember. My office was supportive and helped arrange for the most prominent location at MCW’s Milwaukee campus for this to occur — the entrance to our Medical Education Building.
The event took place and received some local media coverage. Although I was well aware that MCW still had a great distance to travel, I remember believing that this student-led “die-in” was yet another example of MCW’s progress on its journey to becoming an anti-racist institution.
Fast-forward to 2020: Like the rest of the world, we watched the coverage of George Floyd’s senseless, horrific, and tragic death and read about the ongoing issues of police accountability. We convened a Town Hall meeting and panel, including expert opinions on racial justice and steps to move forward. The conversation was honest and, at times, raw, but action-oriented — qualities that I believe embody a maturing, questioning, and vibrant organization.
One of the panelists, a person of color who had been a student at MCW during the 2014 “die-in,” provided her impressions of the event. She stated that she felt the event was an enormous disappointment. Why? Because of low turnout; the overall lack of dialogue about the event by leaders and the broader MCW community; and a general sense that this issue was not important at MCW.
And she was right.
Hers was the true story — not the one I had told to myself six years before. It was not the “comfortable” narrative which I had constructed at the time of the die-in that rewarded my need to see progress.
I logged off the Town Hall and reflected on the “uncomfortable” place where I now was — and what I should have done differently. I cannot say it any better than did Bryan Stevenson, author of Just Mercy, when he suggested that we must “get proximate” to the issues at hand. My own misinterpretations of student reactions following the “die-in” in 2014 were partly a result of my lack of proximity. I needed to acknowledge the former student’s story and engage in additional dialogue. But, more importantly, I needed to take concrete and meaningful steps forward to make MCW an anti-racist institution.
My challenges to you
My ask of you is threefold:
- First, if you are in an educational leader, always ask, “How will this decision impact our learners?” but, before answering, actually listen to some students to ensure that you have it right.
- Second, if you are a learner who is worried about not being heard, find faculty allies. It might be hard, and might seem “risky,” but it is important.
- Third, if you are neither a major decision-maker nor a learner, ask how you can be a better ally for our learners, because they do matter.
How we listen and provide this support has the potential to change everything in medicine.
Every institution is trying to enhance social and racial justice. We still have a long way to go, and we have made far too little progress, but it is critical that we seize the moment now and not lose this momentum. If we hope to more rapidly “bend the arc of the moral universe toward justice,” as the Rev. Martin Luther King, Jr. so eloquently told us, we must all continue to engage in dialogue, thought, and action.
I would encourage us all to work to elevate the voices of others. We must increasingly see how the judgments we impart, the ways we consciously or unconsciously behave, and the decisions we make, will move us to make progress toward an inclusive, equitable, and healthy environment for all.
Joseph E Kerschner, MD is Dean, Executive Vice President, and Provost of the Medical College of Wisconsin. He is a Professor in the Departments of Otolaryngology & Communication Sciences and Microbiology & Immunology at MCW. These remarks are excerpted from a longer address delivered on November 17, 2020 at the 131st Association of American Medical Colleges (AAMC) meeting in his role as outgoing Chair of the Board of Directors.
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