Writing is a Deep Conversation

From the 10/29/2021 newsletter

Director’s Corner

 

 

Writing is a Deep Conversation

 

 

Adina Kalet, MD MPH

 

 

In this special “Authorship” issue of the Transformational Times, Dr. Kalet shares her feelings about the value of writing together with others, and why authorship is among the most complex and critical aspects of what we do. She proposes that, if we can do it well, solid writing opens important conversations and can be deeply satisfying …

 

 

If writing seems hard, it is because it is hard. It is one of the hardest things people do.

-William Zinsser, On Writing Well: The Classic Guide to Writing Nonfiction

 

 

As an early-career physician and clinical educator, I felt none of the traditional “publish or perish” academic pressures because, for most of my working life, I had no particular desire to be promoted. So, you may ask, why do I spend so much of my time writing now? The answer to this has evolved. I write to work things out and begin dialogues, much as Joan Didion hinted when she said, “I write entirely to find out what I am thinking.” Once a concept or project has been committed to the page, I am better equipped to engage in conversations about the things that matter to me. 

 

 

I didn’t always love to write

 

Thanks to a few generous mentors, editors, and spell checkers, I now love to write. This was not predictable. Despite a good-enough elementary education, it never occurred to me that writing could be a deeply satisfying communal experience. Like most of us, I learned the rules of grammar, parts of speech, sentence, paragraph, and essay structure, and how to appropriately use quotations and citations to passively draw on the ideas of others. It was all done in a dry, uninteresting, and lonely way. It wasn’t until I discovered, through writing for publication, that one was entering into deep, complex, and important conversations with others, that I became willing and eager to do the hard work. And it is very hard work. But luckily, it is almost never a solo pursuit. 

 

As medical education scholar, Lorelei Lingard, asserts in her stupendous new book Story, Not Study: 30 Brief Lessons to Inspire Health Researchers as Writers (Springer International, 2021): 

 “Medical education moves forward because we share insights, question methods, argue the relevance of emerging ideas and build on one another’s efforts. All of this is possible in large part because of writing, and it explains why writing is such a highly valued currency ….”

Dr. Lingard has taught me through her “writing about writing” to think of the process as a way of entering critical conversations to clarify our thinking. We converse with those who came before us by reading the relevant literature, we converse with those with whom we work by writing together (not easy by any stretch of the imagination, more on that later), we converse or spar with editors and peer reviewers and, finally if we are lucky, we get to converse with our readers. It is a cacophony of conversations. 

Learning the value of writing with others rather than alone

 

One of my most beloved mentors, medical sociologist Jo Anne Earp, ScD, had a framed picture in her office which, literally, is how I really learned to write.  It is a line drawing of a young child on tippy toes, holding a bright red crayon, caught in the act of crossing out and rewriting the statement, “A good mentor accepts ,expects, respects a first draft.” Sitting in her office, struck dumb by the anxiety of having to write about my work, facing that picture, I truly understood for the first time that writing could be a collaborative process. I was paralyzed as I tried to start writing my very first 300-word abstract to submit to a professional meeting. Recognizing my predicament, Jo Anne took her pen and lined yellow pad in hand and asked, “What should we title this?”  I dictated; she wrote. We switched roles.  Sentence by sentence, we polished the words until we were done. It took one hour, an hour in which I learned the key to collaborative writing—what I now call “yoked pair” writing—a process that I use with my colleagues and mentees almost every day. Now, we sit in front of a computer screen and ask each other, “What do we think?” 

 

Writing is hard. No question. Yet now I see that writing can also be a highly valuable, satisfying, and fundamentally communal experience. Since I learned the value of writing collaboratively with others, my writing partners will tell you I am relentless in extoling its virtues. This is because I believe that writing together is the best way to think clearly and develop ideas. 

 

 

Now, I am an enthusiastic writing coach

 

I regularly share my inner writing nerd. On my shelf is a stack of slim books which I both read and give away. My favorites are the latest edition of Strunk and White’s The Elements of Style illustrated by Maira Kalman (I adore the Basset Hound on the cover), Stylish Academic Writing and The Writer’s Diet both by Helen Sword (where I first discovered that I was a “flabby” writer  - yikes!), the hilarious Eats, Shoots & Leaves: The Zero Tolerance Approach to Punctuation! by Lynne Truss from whom I finally understood commas; How to Write a Sentence and How to Read One by Stanley Fish and, now, Lingard’s Story Not Study, which is an expansion of a series of papers she edited for the journal Perspectives in Medical Education entitled the “Writer’s Craft.” Of course, writers must also be readers and must have very good editors! 

 

 

Ode to Bruce Campbell

 

This is my sixty-seventh Transformational Times Director’s Corner. Before March 2020, all the writing I had done had been as part of a team. I had never published an essay as a single author. When the newsletter was launched and I committed to writing a weekly column, Bruce Campbell became my editor. It requires great talent and generosity to craft someone else’s words. Bruce has done this for me almost every week for the past eighteen months as an act of kindness and compassion despite his surgical and clinic schedules, the publication of a book, and the responsibilities of a professor of otolaryngology at MCW. 

 

I experience his editing as I do an honest conversation with a close colleague.  What he does is the writing equivalent of “active listening.” By reading and rearranging my words, he is saying, “I hear you. Now let me restate that a bit and see if we can make it truer and clearer.”

 

This has been a profound learning experience. At the beginning, my drafts were “messier” and he had to push up his sleeves, often late at night, to find the wheat and eliminate the chaff. By rereading my words with his edits, I have learned how to write in this short essay format.  Originally, he did a heavy edit, rewriting sentences, reorganizing paragraphs and titling sections to hammer the piece into a readable form. Now he takes a lighter touch, refining the words, aligning the tenses, shortening the sentences, and very occasionally rearranging the paragraphs. We have learned to write together, and this has made all the difference.  

 

 

So, let’s get writing!

 

As the Kern Institute moves the mission to transform medical education forward, we must define, refine, and share our ideas. Writing and publishing are critical to this process. Consider writing as a team sport! I hope you enjoy this issue of the Transformational Times as we examine the highs and lows—and the nuts and bolts—of academic publishing. 

 

 

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.

 

 

 

Chest Pain Relieved by Antacids: My Last Night as a Resident

 From the 7/9/2021 newsletter

Director’s Corner

 

 

Chest Pain Relieved by Antacids: My Last Night as a Resident

 

 

Adina Kalet, MD MPH

 

 

 

In this Transformational Times devoted to transitions Dr. Kalet recalls the final night of her residency at Bellevue Hospital in New York City …

 

 

The astute intern standing next to me, noticing the beads of sweat forming on my forehead and my clenched fist rubbing my breastbone, walked to the medicine locker, grabbed a little blue bottle of antacid and handed it to me. “If this works, I won’t have to admit you on your last night on call as a resident!” he said cheerfully.

 

I slugged the chalky, mint flavored substance and almost immediately felt the chest pain—which I hadn’t even fully noticed until then—resolve. “Thanks,” I said, “You’re gonna be a great resident in a few hours!” I glanced at my watch. 4:00 a.m. on June 30. My last day as a house officer.

 

 

“4344 Stat!!” the crackling voice of the Bellevue Hospital operator cried from one of two cigarette box size beepers hanging off the waist band of my white pants.  This dedicated “code beeper” was calling me to the emergency room where, luckily, I already was standing, ready to help my colleagues who were conducting a cardiac resuscitation on the patient in the “slot.”  This was not the cause of my heartburn. I loved this part. I was trained to do this, my movements were smooth and assured, the decision-making was practiced and honed. I felt competent and proud of my colleagues as we surrounded this patient, a man brought in by ambulance from Pennsylvania Station awake and alert, experiencing substernal chest pain and shortness of breath, who now needed us to save his life. And save his life we most likely would. This was quintessential doctoring, one patient at a time. 

 

My heartburn was a result of the other beeper. The “medical consult” beeper was insisting, with the exact same urgency, that I call “bed board” (the office that managed the 400 adult beds in the hospital) and 17 West and 16 East and the Surgical ICU all at the same time. I added the call back numbers to the pink sheet on my clipboard. I made eye contact with the senior resident running the code to signal I was there if he needed me and picked up the wall phone.

 

This part of the job made my stomach acid churn. After a year of med consult call, all of us senior residents had mastered—but did not have a positive attitude about—what we called the “hotel management” or “traffic cop” aspects of the job. We disliked assigning admitted patients to medical teams and working with the hospital administrator (“bed board”) and nursing leadership to assign beds to those patients. It was a hard and thankless three-dimensional chess game. I didn’t feel particularly good at or prepared for these logic puzzles. But I engaged because it was my job on the team that night. 

 

There was also the “consultation” part of the job, which sounds like an opportunity to engage in erudite conversation with residents on other services about how to best care for patients, but that wasn’t how things worked. The attending physicians did that part. Most often, we residents engaged in tense discussions demanding to transfer patients from their service to ours or vice versa. Too often, we debated whose “job” it was to adjust antibiotics or blood pressure medications. I would argue that any physician could handle this simple task with a little advice from us, but they would argue that their job was complete, and the patient now belonged on our team. We would argue where the patient with ominous abdominal pain should be monitored; our team contending that the physicians who could provide definitive surgical therapy would be best positioned to manage the patient, while they argued that until an intervention was needed, the patient should stay with us. On and on. Over and over.

 

Senior residents developed reputations as being a “wall”—staving off patient transfers by playing expert, impenetrable defense, or being a “sieve”—easily persuaded to accept the transfer. I won’t tell you which reputation I had, except to hint that I did accept transfers to our service only when it was obvious that a patient would be best cared for on our team. This was a judgment call, and I trusted both team to do right by the patient.

 

It was also true that I didn’t have the courage or tenacity to insist that other teams handle problems outside of their comfort zones. I have since gotten over that.

 

Physician professional identity formation, in those days, was in a very tribal stage of development. We worked on teams and, as teams, we defended our boundaries. As soon-to-be attending physicians, our main developmental challenge was to balance team loyalty and identity with a much more subtle discernment about “what is best for the patient.” These situations were very complex; a single correct answer was unlikely. Beyond the formidable technical aspects of our disciplines, we attempted to discern what was really, wholistically best for each patient right now and under these circumstances. Without realizing it at the time, we were developing the practical wisdom needed to thrive as a physician for a lifetime.

 

This critical learning process literally gave me chest pain.

 

Eventually the new consult resident, in a fresh scrub shirt and white pants, came by to take over the beepers. She listened carefully to my recitation, jotting down the names, locations, and vital facts about the consults still to be seen and for those who needed follow up. We reviewed the remaining “bed board” issues. I asked her to check on the freshly resuscitated patient; finding him a hospital bed was a priority. The resident had been at our class’s graduation ceremony the week before, so she knew of my plans for a year abroad for medical education research and my ensuing fellowship. She wished me luck.

 

I found myself wistful and sentimental about her very first med consult shift and envious of her freshness and eagerness to do right and good. I hoped she would develop the wisdom needed to navigate the complexities in the best interests of our patients, without spending much time seriously considering being either a wall or a sieve. But we didn’t have any time to discuss this, both beepers were already sounding.

 

I cleared out my locker and packed up the remaining books, toiletries, and other odds and ends. Gathering up fresh beeper batteries and few single dose bottles of antacid I had pilfered from the nurse’s station, I left them on the table in the on-call room. Someone would need them sooner rather than later.

 

 

 

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.

Advice to Interns from Program Directors

 From the 7/9/2021 newsletter

Perspective/Opinion

 

Advice to Interns from Program Directors

 

Compiled by Kathlyn Fletcher, MD MA

 

 

Dr. Fletcher asked several residency program directors from MCWAH to provide their advice to new interns: practical, funny, or both. Here is what they had to say …

 

 

Chad Carlson, MD, FAAN

Professor and Vice Chair – Education

Program Director, Neurology Residency

Program Director, Clinical Neurophysiology & Epilepsy Fellowships

• If you crave a tasty (soft) cookie, check out the Hub.
• It is never too early to start identifying and talking to potential mentors.
• Completing medical notes is not like enjoying a fine wine; notes do not benefit from letting them age or breathe, so complete them in a timely manner.

 

 

 

Yvonne Chiu, MD

Professor of Dermatology and Pediatrics

Program Director, Dermatology Residency

• Use the same password for your work (MCW, Froedtert, VA, and Children’s) accounts and change them all at the same time. Makes it easier to remember what your current password is when you move between sites.
• Bring your lunch when you can. You eat healthier when you are not relying on cafeteria food.
• For those residents who take home call and need to call patients, download the Doximity app. It allows you to call patients using the hospital name and phone number in the caller ID.

 

 

 

Sriram Darisetty, MD, FACP

Assistant Professor of Medicine
Program Director, Transitional Year Residency Program, MCWAH- St Joseph.

• Try not to be under-confident, but absolutely avoid being over-confident. 
• Autonomy is earned, not given.

 

 

 

Stacy L. Fairbanks, MD

Associate Professor of Anesthesiology

Program Director, Core Anesthesiology Residency 

• Prioritize sleep or you won’t get it.  Sleep 7-9 hours per night whenever possible. 
• Study a little bit every day.  Gaining the knowledge you need to pass certifying exams is a marathon, not a sprint.

 

 

 

Kathlyn Fletcher, MD MA

Professor of Internal Medicine

Program Director, Internal Medicine Residency Program

• Always do what is in the best interest of your patient. I actually borrowed this one from a former mentor, Dr. Arthur Rubenstein.
• The quality of your day is directly proportional to how many people you say “hello” to on your way into work.  I have no data to prove this, but I am pretty sure I am right.
• Patients want to believe that you care about them beyond your professional obligation to care.  I do have evidence to back this up and would be happy to provide it to anyone who is interested.

 

 

Camille Garrison, MD

Associate Professor, Medical College of WI, DFCM

Program Director, Ascension Columbia St. Mary’s Family Medicine Residency Program

• Don’t put emojis in a patient’s chart… 😊
• The patients you see are not a means to an end. It is an honor and privilege to care for them.
• Take advantage of every opportunity to grow while in residency, both personally and professionally. What you get out of residency, has a lot to do with what you put in.

 

 

 

 

Matthew Goldblatt, MD

Professor of Surgery

Program Director, General Surgery Residency

• Find good bathrooms

 

 

 

 

Alisa Hayes, MD

Professor of Emergency Medicine

Program Director, Emergency Medicine

• Give yourself enough time to park and arrive on time. Your PD will get a notification if you park illegally.
• The Froedtert finder app can help you navigate the hospital and find rooms / locations as well as notify security when you are leaving the hospital at odd hours.

 

 

 

Heather Toth, MD

Professor of Internal Medicine and Pediatrics

Program Director, Internal Medicine/Pediatrics combined program

• We are all here for you! Please reach out to us as we have all been interns at some point in our lives.
• Remember to stay in touch with family, friends, colleagues, hobbies and things you love.

 

 

 

 

Kathlyn E. Fletcher, MD MA is a Professor and residency program director in the Department of Medicine at MCW. She is the co-Director of the Graduate Medical Education Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Advice for Surgical Residents

From the 7/9/2021 newsletter

 

Perspective/Opinion

 

Advice for Surgical Residents

 

Compiled by Bruce H Campbell, MD FACS

 

Dr. Campbell, who entered a surgical field decades ago, asked his current residents what they have learned to keep themselves whole and able to function despite living in high-stress times and working under pressure. Here is some of what he learned from them, and about “grit” in surgical residents …

 

 

What sorts of things have surgical residents discovered that allow them to survive as trainees? Here is a list from current otolaryngology residents (and their friends):

• Everyone expects surgeons to be arrogant. Surprise people in a good way.

• Ask the right questions and listen carefully - often this will tell you more about a patient's condition than any test or image can.

• Get to know your patients beyond their chief complaint.

• Learn to understand and appreciate the environment that your patient came from, and you will glean so much more. “For the secret of the care of the patient is in caring for the patient.” - Francis Peabody (“The Care of the Patient,” JAMA 1927)

• Listen to the nurses. Learn their names. They are the ears, eyes, and heart of the floor. They spend more time at the bedside than any physician or care team member.

• Be forgiving of yourself and your colleagues. We all have one common goal, and that is to provide healing and nurturing for our patients.

• Mistakes are an inevitable part of medicine. Always be honest, show empathy, and commit yourself to a lifelong endeavor of learning.

• Practice self-care. “Just as a car can’t go as fast on a flat tire, you can’t give your best effort if you aren’t mentally, physically, and spiritually running on all cylinders." - U.S. Surgeon General Jerome Adams

• Find yourself a good pair of shoes. This will take you far, literally!

• Do not forget why you are doing what you do. Our profession is unique, people trust us with their lives, and we cannot take that for granted.

• Do not forget that each of your patients is a person first and a patient second.

• Informed consent is a process and a relationship, not a piece of paper.

• Stay up-to-date on your administrative paperwork and be kind to the residency program coordinator.

• Always act in the best interest of the patient.

• Stay humble.

• Just keep showing up even when you feel like you’re not doing well. It always gets better.

• See the patient before calling a consult.

• Stay current on your surgical case logs.

• Before ending any conversation with a patient, always ask, “Do you have any other questions?” That usually elicits their deepest concern.

• Knowing when to operate is at least as important as knowing how to operate.

• Balance humility and ego. It’s not easy. 

• Remember to enjoy simple wins and to learn from loss.

• Sleep when you can, eat when you can. 

• Wipe your feet of the day before you walk into your home to greet your family. 

• Be an organized junior resident but ask for help. Remember you’re human, too.

• Each patient is experiencing something at the same time you are, so even if this is your hundredth consult of the night at 3:00 a.m., try to bring compassion to the encounter. 

• Remember, at the end of the day, you are a team.

• Check for speckles of blood on your scrubs, booties, face, and mask before going to talk to patients’ families.

• Surgical training is uniquely stressful. Stay self-aware. Reach out for help. Watch for warning signs in others.

• Know your stuff, do the right thing, and ask for help when you need it.

• Don't forget to engage in things that make you happy, as residency will trick you into thinking success must cost you joy.

• Residency can unmask underlying vulnerabilities.  Don't be afraid to lean on your co-residents (and even attendings), either professionally or personally. 

• An ICU consult is better than a rapid response, and a rapid response is better than a code.

• There are two kinds of residents: the ones who write it down, and the ones who forget.

• Trust no one, expect sabotage, and always have a backup plan.

• Stay current. There is no glory in being technically adept and doing the same, wrong operation every day for the next thirty-five years.

 

On a related note, a recent article in JAMA Surgery confirms that grit, as a personality characteristic, is a good thing. Grit is defined as “perseverance and passion for long-term goals,” and is measured with a standardized GRIT-S questionnaire that asks about a person’s ability to concentrate on a project, their reaction to setbacks, their constancy in pursuing goals and interests, their self-identified work ethic and diligence, and their ability to thrive in the face of challenges. General surgery residents with higher “Grit” scores were less likely to report burnout, thoughts of leaving their training programs, concerns about their career choice, and suicidal ideation than residents with lower Grit scores. Grit scores were higher in women, more senior residents, and in married residents. The authors recommended that programs do what they can to bolster their residents’ grit.

Surgeons have unique roles and responsibilities in society; what can compare to the trust someone displays by allowing another human being to render them completely defenseless and then rummage around their insides? As an institution, it is our responsibility to prepare our residents to enter the world as character-driven, compassionate, and skilled surgeons.

Thanks to my “gritty” residents for sharing the lessons they have learned.

 

Bruce H Campbell, MD FACS is a Professor in the Department of Otolaryngology & Communication Sciences and in the Institute for Health and Equity at MCW. He is editor-in-chief of the Transformational Times. 

Top Ten Tips for Thriving During M3 Clerkships

From the 7/9/2021 newsletter

 

Perspective/Opinion

  

Top Ten Tips for Thriving During M3 Clerkships

  

Compiled by Scott Lamm

 

 Mr. Lamm and his colleagues offer some sage advice to the incoming third-year medical students …

  

• Be proactive! Pay attention on rounds and create a to-do list for each patient. Instead of asking for tasks from your resident, let them know what tasks you are comfortable with doing and if it is okay for you to complete them.

•  For Surgery – invest in a pair of compression stockings. Your feet at the end of the day will thank you.

• It’s okay to say, “I Don’t Know.” No one knows everything, and this gives you an opportunity to do the research and look it up for the next time you are with your attending or residents that asked the question.

• Nurses and CNA’s are your best friends. They know the patients better than anyone. Talk with them each morning. Update them after rounds. They will be very appreciative.

• Know what you are charting! If you copy forward a note, ensure that everything in that note is something you did that day. You will most likely not do a comprehensive physical exam every morning, so ensure you only chart what you did.

• Children’s’ Cafeteria Buffalo Chicken Ranch Wrap is the best! On nights, you can get it toasted mmmmm… Also, Children’s’ breakfast is the best pick me up in the morning after a call day.

•  Learn from your patients – they are the experts in their own life experiences. You will have a lot more time to devote to each of your patients than the residents, so spend the time. You will be surprised at how a good relationship can help the team exponentially.

• Calling consults can be nerve-wracking – write down the most pertinent points, lab values, and imaging results so you don’t forget them. Consultants will be very impressed when you have this information right away instead of making them search the EMR after the call.

•  Make sure to eat! Time moves fast and it’s easy to forget about lunch. A working mind requires a happy belly. Bring snacks, meal prep.  Sometimes it may feel like there’s no time in between cases or after rounds, but two minutes is enough to scarf down a granola bar.

• Have fun! Third year is full of surprises. There will be good days and there will be bad days. Step back and reflect when you have the chance. The connections you will make with attendings, residents, and especially patients will transform you are a physician. Step into each rotation with an open mind.  And do not hesitate to ask for help.

 

Sincerely,

The Class of 2022

 

 

 

Scott Lamm is a fourth-year medical student at MCW and member of the Transformational Times editorial board.

 

Advice for Incoming Housestaff

From the 7/9/2021 newsletter

 

Perspective/Opinion

  

Advice for Incoming Housestaff

 

 By Jennifer Popies, MS, RN, CCRN-K, ACNS-BC; and Ashley Herman, BSN, RN, CNRN

 

 Ms. Popies and Ms. Herman give advice to incoming housestaff from the nursing perspective…

 

Jennifer Popies:

• DO ask the nurse caring for your patients about their perspective on what is going well and what any outstanding needs are that they see should be addressed – this goes a long way in building true collaboration!

• DO bring food for the nurses on the floor you are most frequently working with – this also goes a long way to building true collaboration J!

• DO use order sets to help guide your patient management – many disciplines have spent a long time on each one trying to help make sure best practices are incorporated.  You can always tailor it to your patient’s needs, but use it to your advantage to help ensure best care so things don’t get missed!

• DO clean up after yourself when performing bedside procedures.  Nursing staff does enough “cleanup” for other reasons in the process of patient care!

• DON’T be afraid to say you don’t know something!  Everyone is human and nurses (and others) will respect you more for knowing your limitations.

• DON’T forget to take care of yourself – and if you need to talk, you can reach out to a nurse, a social worker, a chaplain, etc….it doesn’t just have to be a fellow MD!

 

 

Ashley Herman:

 

Some advice to residents and fellows that come into the NICU that I have learned in the many years in the ICU:

• We are all about the “team” approach and want to do the best for our patients. It’s important to get a multidisciplinary approach to cares for a patient so that it is well-rounded care.

• Always give your rationale about things, especially if the nurse questions the reasoning for things. Most nurses just want to know the “why” behind things and aren’t just trying to be difficult. Nurses love new knowledge. Healthcare is always transforming, and nurses like to hear the most updated evidenced-based practice/research.

• Have open communication with different teams and welcome their expertise.

• Communicate any changes to the nurse if he/she isn’t in the room while you are updating families. Many times, the family/patient relies on the nurse to explain further about information and it’s always best when the nurse isn’t surprised hearing new information from the patient about what the doctor discussed.

• We all deserve respect…times can be tough and emotions can run high, especially in the ICU. If there is miscommunication or words spoken in the heat of the moment, it isn’t weakness to say, “I’m sorry.”

• You can always win nurses over with snacks, haha J.

• Keep things “light” when appropriate, laughing is always the best medicine when the shifts are long.

 

Thank you and welcome to everyone!

 

Jennifer Popies, MS, RN, CCRN-K, ACNS-BC, is a Clinical Nurse Specialist – CVICU at Froedtert & the Medical College of Wisconsin.

 

Ashley Herman, BSN, RN, CNRN, is a Neuro ICU Educator at Froedtert & The Medical College of Wisconsin.

 

 

 

Reflections on New Beginnings

From the 6/18/2021 newsletter

Perspective/Opinion 

Reflections on New Beginnings 

By Olivia Davies, MD; and Brieana Rodriquez, MD 

 Drs. Olivia Davies and Brieana Rodriquez reflect on moving cross county to begin their new journeys for residency… 

Dr. Olivia Davies: 

I have lived in Wisconsin for most of my life. I did undergrad at Madison and medical school at MCW, when I shut the door on my 20-foot U-Haul and locked it for the long drive out to Boston I couldn’t believe I had fit my whole life in there.

But the truth is, I hadn’t. Leaving Wisconsin meant we were leaving my family and my fiancé’s family behind. When we arrived in Boston, I was nervous, would our apartment look like it did in the photos? Would the movers arrive on time? Would our couch fit? It did, they didn’t, it didn’t. I cried. I wanted to go home. My couch didn’t fit and neither did I. This busy city felt new, too new, and not mine. I woke up from a mattress on the floor the next day and reluctantly pulled on my tennis shoes, we had no food yet and I knew I just needed to go for a walk. I walked for hours that morning, a croissant here, a coffee there, I started to recognize streets I passed, I saw my new hospital, I realized the river path was five minutes from our apartment door and I let a long sigh out. I thought it might actually be ok. And it was.

Dr. Brieana Rodriquez: 

My “most extreme” feelings about moving across the country happened before I left. After match day I was so excited to start a new chapter of my life. I was ready! But after classes had finished and I had already bought my new house I was in this weird limbo state. The best way I could describe it was I felt like I had closed the Wisconsin book, but I wasn’t allowed to open the South Carolina book. My anxiety about moving was at an all-time high but it wasn’t because I was scared, it was because I wanted to move but couldn’t. But since I’ve gotten here there’s been nothing but excitement! Meeting my co-residents (and realizing I’d be able to make more best friends) has been so much fun! Exploring a new city has been so cool! When moving cross country for medical school I learned so much about myself. I grew so much personally and I’m ready to start experiencing that again. One of the reasons I chose to rank MUSC #1. Side note: I know the anxiety about starting work is going to kick in soon, but it hasn’t yet. 

Olivia Davies, MD, begins her Dermatology Residency at the Harvard University Combined Program on July 1st in Boston, MA. During her time as an MCW medical student, she was an associate editor of the Transformational Times. 

Brieana Rodriguez, MD, begins her Emergency Medicine Residency at the Medical University of South Carolina on July 1st in Charleston, SC. 

From Medical Student to Trusted Physician: Growing with a Confident Humility

 From the 6/18/2021 newsletter

Director’s Corner

 

 

From Medical Student to Trusted Physician: Growing with a Confident Humility

 

 

Adina Kalet, MD MPH

 

 

Dr. Kalet shares one of the “hidden” tasks that each new resident is facing: the need to develop competence without risking becoming overconfident. She shares some of the pitfalls and invites our newest house staff to be part of the journey.

 

 

This is the time of year when thousands and thousands of newly minted physicians move somewhere to begin residency training. At MCW, we welcome all our new residents, many of whom are moving to Milwaukee for the first time. This is a poignant, anxiety-provoking, and exciting time, a new beginning, and a critical transition on the journey of becoming a seasoned and caring physician.

 

Incoming residents are embarking on the steepest leg of their learning curves. Not only have many of them just moved to a new city, found a new home, and located a new grocery store, each new day brings them an avalanche of firsts: the first patient, the first procedure, and the first time they need to find the cafeteria or the bathroom or the emergency room. Many important components of their new professional identify will take shape in these first summer weeks. Our newest physicians will work to discern how best to balance confidence and humility. Getting this equilibrium right is crucial, and I think MCW is an especially wonderful place to foster this process.

 

The difference between confidence and competence

As physicians on the front line, residents are expected to develop enough confidence to quickly analyze data, make crucial decisions, and act decisively. Think about how difficult and fraught that task can be! We want physicians to make critical judgements under emotionally charged and complex conditions. Even drawing blood for routine laboratory testing (a task interns do daily) means facing an anxious, fearful, suffering person, and causing them some pain. Confidence is critical, yet—to ensure that our teams provide the highest quality and safest health care—we stay on the lookout for overconfidence in ourselves and in others because of the complex and paradoxical relationship between confidence and competence.

The Dunning-Kruger effect, described in 1999, elegantly summarizes this complexity. Stated simply, people with low ability tend to overestimate their competence and, therefore, become overconfident. Conversely, people with high ability tend to be underconfident in their ability. Even worse, poor performers are often unable to recognize their own limitations, and overconfidence is especially pronounced for those at the lowest end of the ability scale. As ability improves with practice, confidence, paradoxically, can take a nose-dive because the difficult journey can create humility and self-awareness. This sense of deflation can feel terrible at the time but, in the long run, is good since it can lead to insight and growth.  

Numerous studies have confirmed that humans are just not good at objectively evaluating their own level of competence, but by honing one’s own metacognitive awareness or being observant—like a scientist—of one’s own thinking and feeling, a novice can guard against using his or her own confidence as an indicator of competence. As teachers, we must avoid making our trust judgements based on a trainee’s confidence alone. As Ronald Reagan was wont to say, we must, “Trust but verify.” Confidence is good, but we must guard against allowing our feelings of confidence to blind us to our own ignorance.

 

 

“Confident humility”

 

In his new book, Think Again: The Power of Knowing What You Don't Know, organizational psychologist Adam Grant reminds us how critical it is to cultivate a mindset “confident humility.” From this stance, one can act even when they are not certain of what is right, but they act with a scientist’s curiosity and perspective, seeking evidence that might refute their current beliefs. Grant reviews the accumulating evidence that intelligence does not protect us from common human foibles. In fact, many researchers have pointed out that smarter, more tenacious people (like many medical students and residents) are prone to blindness to changing conditions and may have a harder time adjusting to new circumstances. They have difficulty admitting when they are wrong. Stubborn, inflexible physicians will run into obstacles when trying to provide competent, character-driven medical care.
 
If, however, a hypothesis survives repeated attacks, it becomes the working theory until such time as it can be disproven. Approaching one’s own competence in this rigorous way—repeatedly challenging beliefs and understandings—keeps a person humble, curious, adaptable, and learning. It is the key to deep, durable, and lifelong learning. 

 

The remarkable value of working in an institution defined by confident humility

 

Like many of us, I am a transplant from elsewhere, having arrived barely two years ago. I have traveled extensively and have lived and worked in other institutions in the northern and southeastern United States. To my delight, I have come to know MCW as a uniquely confident, humble place to work and learn. It is remarkable to me—given the excellence in clinical care and research—how little our institution tolerates the everyday self-promoting arrogance typical at many of our peer institutions. This institutional culture is a towering strength and I believe is one of the many reasons we have adapted and thrived for a century and a quarter. 

As Mark Twain warned, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” Adam Grant points out that a hallmark of wisdom is knowing when it’s time to rethink and collect data that might refute and, therefore, cause you to abandon what you think you know and who you think you are. This habit of honest reflection and an openness, or even a delight in learning when you are wrong, is a path toward a deeply satisfying confidence. It’s true in business and especially true in medicine.

 

So, to our incoming house staff, I say, “welcome!” You have several difficult tasks ahead, not the least of which is to master your chosen field. You will grow as you learn to work in teams, experience ambiguity, become lifelong learners, and bring your intellect and compassion together to tend the sick and heal the suffering. You will thrive if you tend to your own wellness and character. These are huge tasks responsibilities. We wish you all the best and are here to support you.

 

 

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.