Let’s Renegotiate the “Social Contract” in a Way that Promotes Human Flourishing

From the 2/26/2021 newsletter

Director’s Corner

Let’s Renegotiate the “Social Contract” in a Way that Promotes Human Flourishing 

Adina Kalet, MD MPH

This week Dr. Kalet wonders how we might reimagine the relationships among society, the profession, and healthcare systems to ensure the ability to pursue human flourishing for us all …

Toward the end of his life, my father-in-law needed a generalist physician to provide real primary care, but he had neither an engaged, attentive physician, nor a system that was prepared to enable this type of attentive oversight. 

A couple of years before his death, a hurricane hit the region where he lived on the east coast of Florida. Unable to contact him and knowing that the area had lost electricity, my husband flew down from New York the next day. Mark found his father sitting in a dark, warm, damp apartment struggling for breath. Mark’s dad had experienced a significant myocardial infarction and was in florid heart failure. 

Over the next few months, my father-in-law’s physician-son and nurse-daughter scrambled to manage his health care needs as he deteriorated. He required prolonged hospitalizations in a cardiac rehab facility utilizing resources up to the full limit of what Medicare would allow. When he returned home, none of Dad’s specialist physicians offered to take responsibility for coordinating his care or arranging for homecare. Luckily for Dad, his son and daughter-in-law were physicians, and his daughter and son-in-law were nurses. My husband attempted to manage things from a thousand miles away by phone, fax, and email, and eventually was able to hire a wonderful aide who stopped by for a few hours each day to help with the activities of daily life and a private care coordinator. Despite the fact that he could hardly walk or drive, Dad’s local physicians insisted that he come to their offices for regular weight checks and refills. He missed many appointments, was confused about his medications, and was disgusted with the whole thing. We would have paid dearly to offer Dad the level of medical care coordination my husband is able to provide his own patients through the VA System, our largest publicly financed, national health care model.

We REALLY need more primary care physicians and compassionate teams

Last week in this space, I outlined why and how medical schools need to train more primary care physicians. Data have shown that access to good primary care in accessible, coordinated, integrated, and globally funded systems is associated with the best outcomes and lower costs; these paradigms offer benefits to communities and to patients like my father-in-law who have chronic medical conditions. Without a solid primary care physician, even patients like my father-in-law with excellent insurance and attentive social support, have less-than-ideal outcomes. 

I think we need to come together to make things better for us all. I am convinced that if my father-in-law had had a generalist physician practicing in a coordinated and supportive healthcare system, he would have received more competent, coordinated, and compassionate care.  Dad and his family would have had a better quality of life over those final couple of years, less confusion and stress, fewer days in high-cost care, and a “better death.” No doubt, there would have been significant cost savings. While many systems strive to do this and many medical schools work toward preparing students to enter competent health care systems, this is not the reality for most of the country.

Rethinking how care is provided by reviewing an imperfect model

Recently, a friend shared an email she received from the primary care physician to whom I had referred her many years ago. This well-established physician was transforming her practice from an insurance-based to a “membership” model. In exchange for an annual retainer (relatively modest compared with similar arrangements), she offered herself to be personally accessible 24/7 for telehealth visits, promised next day appointments, and provided office visits that were three times the length of what she had been able to schedule before (thirty v. eleven minutes). For patients like my father-in-law, she offered to proactively oversee home care, ensure medications are delivered and taken appropriately, and stay in touch with the patient, healthcare team members, and family. She would serve as the team’s quarterback, providing the leadership that winning teams need. 

At first, I was critical of this Executive Model - what some call “concierge” medicine - where wealthier patients with health insurance pay for the kind of consistent, high quality access I believe everyone deserves. But, as I thought about what this change in practice model said about the physician’s well-being, my heart broke. This wonderful woman had always practiced “cognitive” medicine in a fee-for-service model where the only way she could generate revenue was by seeing office patients. In her old system, her “success” was measured by seeing more-and-more patients for shorter-and-shorter visits.  By embracing the new model, she would likely enhance her income while practicing medicine the way she knew it should be done. 

Numbers matter though. One serious problem with this type of “tiered” model of care is that, unless there is a dramatic increase in the number of primary care physicians, even fewer people and communities will have access to quality primary care. This shift will have the greatest impact on those who live in poverty, are disproportionately affected by the social determinants of health, have increased rates of comorbidities, and have little or no insurance. Yet, this is exactly the population that stands to benefit most from ready access to compassionate, attentive, and highly coordinated primary care.  

The divide between cognitive and procedural physicians is making the situation worse 

Part of the problem with workforce distribution and balance is the widening income differential between cognitive and procedural physicians. Since 1980, the median salary of cognitivists has increased at the rate of inflation, while the median salary of physicians who perform procedures has doubled. This gap translates into a $3-$5 million lifetime advantage for proceduralists. This economic power allows proceduralists to benefit more readily from modern practice management (e.g., partnering with advanced practice nurses or physician assistants, medical scribes, and other documentation technology), thereby gaining efficiency, further widening the gap, and increasing their personal salaries. Meanwhile, cognitivist physicians can only increase their efficiency by giving up what is most meaningful and valuable in their work: communicating with patients in the context of strong relationships, taking time to figure out complex problems, and committing to longitudinal care. Under the current models, cognitivists cannot optimize their practices without trading off what is most satisfying in their work. 

We need to rethink the social contract between physicians and society

Many (including me) have pointed out that medical professionalism is the basis of medicine’s social contract. But as things change, we see that this simplistic view of the contract is a poor metaphor for the complex physician-patient relationship. The COVID-19 pandemic has given the medical profession a reprieve from decades of society’s eroding trust as we move from a predominately solo practice model to a more systems-based model. Physicians around the world have demonstrated that we will serve, run toward disaster, and care for the sick even when our own health is threatened. It is time that the old, implicit sets of agreements between society and the profession be aired out and reimagined. The moment to reexamine the details of the social contract is here. 

As a country, we spend enormous amounts of money for healthcare, yet the outcomes, both for physicians and society, are far from optimal. Taxpayers provide $20 Billion annually to support graduate medical education, and support all aspects of medical education through public insurance, yet the average physician and their family sacrifices for years in order to join the profession and accumulates significant debt. We need real, granular conversations about the cost of medical school (of all school), effective practice models that balance outcomes with efficiencies in care, and ways to enable physicians and patients to spend more time together, engaged in doing the meaningful work that promotes wellness. If we don’t put our heads together and find a better way to improve public health while creating a healthy, physician workforce, both society and physicians will continue to suffer.

Human Flourishing 

In a perfect medical world, healthy physicians would expect to learn and work at the highest intellectual and technical levels while they spend their careers doing both what they ought to be doing but also what they want to do for its own sake. The environment would allow them to perform their callings at the level of the “highest human good,” what Aristotle called εὐδαιμονία or Eudemonia, translated as human flourishing. Ensuring these kinds of environments should be goals for both physicians and society as we renegotiate the social contract. 

I suspect many of you have similar tales to the one I shared about my father-in-law. Many people shake their heads talking about care lapses for elderly loved ones or other family members. These all-too-common stories reflect the perverse incentives, inefficiency, waste, burnout, and lack of attention that can emerge from our current bureaucratic models of care. Sometimes, it feels as though character-driven, compassionate care is the exception, not the rule. 

At the Kern Institute, we are committed to transformation, and today’s issue explores how we hope to promote human flourishing. If things are to change for the coming generations, physicians, who - as a group - have always demonstrated the willingness to be there, must be given the moral agency to do their work in safe and well-equipped environments while pursuing professional fulfillment, well-being, joy, and collaboration with other healers. We must commit to exploring new approaches where society can expect a healthy workforce, and every family knows who to call when that time comes for a prepared, highly competent, and compassionate hand on the wheel.

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. 

Coming Home

From the 2/19/2021 newsletter

Coming Home

Allison McLellan, MD

Dr. McLellan, a current Pediatrics resident at MCW, describes connecting her past and future through an instant and deep love of rural Alaska...

The fact that I was sobbing as the plane landed in Anchorage didn’t make sense. I was a fourth-year medical student about to interview for a residency spot; the crying would have made sense if it was due to nerves but that wasn’t the reason for my tears. I was treated to a monochrome view from my window- ice, sky, trees and snow, all grey. It was the most beautiful thing I had ever seen. I was struck by the feeling that I was going home again, which is odd, since I’d never been there before. 

Like most scientists, I trust the things I can see and hear; the things I can quantify and catalogue. The fact that I was trying to sob quietly into the sleeve of my hoodie so the man sitting next to me didn’t assume I was insane solely because of a “feeling” seemed odd. 

My childhood involved moving from place to place often enough that most people assume one or both of my parents are in the military. In reality, my father’s engineering degree and mining background allowed us to make the move from the northern Ontario mining town where I was born to the US. We went back to Canada constantly while I was growing up because we were the only members of our family in the US. We made trips once or twice a year to ice fish, camp, and see our relatives. 

I loved everything about it, until I didn’t. I thought things changed too quickly; people moved, houses were torn down, trees were cut and childhood memories vanished. In reality, I was the one who had changed but the end result was the same - Canada had stopped being my home.

This was fine; after all, I was now an adult. I didn’t need a home base - I inherited an adventurer’s spirit from my parents. The home I had I would make and carry with me. I had dreams and plans - go to medical school, become a doctor. I planned on being the doctor my grandfather had deserved as a child, rather than the one he had. He’d grown up in a remote area of Canada where medical care was sparse even for white children. For Native children like him, it was almost non-existent. 

I still retained a fondness for the north, much to the chagrin of my Florida medical school, who assured me it would be much easier to match to a residency in Florida. “Why even try to leave the state for residency? It is so difficult, and you could risk not matching,” they told me. I did everything they told me not to. I did multiple away rotations as far north as I could get. I applied for residency in every state that wasn’t Florida, and I applied for programs that were considered to be out of my league by my medical school. I didn’t care. I wrote my personal statement about my grandfather and my desire to care for people that needed it the most - those living in places others didn’t want to live, or those people that are often deemed “lesser than” due to the color of their skin or their genetic makeup. I wanted to be the pediatrician that my grandfather never had, and I wanted to find a town where I could do that and also find my home. I did not match into a residency program that granted me an all-access pass to Alaska, but that didn’t stop me. I had called my husband from the bathroom of Ted Stevens International Airport in Anchorage and asked if I could just not come home. 

We’d settled on a pact - I would do everything I could to get back to Alaska, and he was up for the challenge. I was absolutely relentless - I had seen the light and found my home after only spending three days there. I talked about it incessantly, researched where I could work and where my husband and I could live. I structured my whole residency around the plan that I was going to get to Alaska, come hell or high water, come earthquakes or global pandemics. 

The next time the plane landed in Anchorage, it was after midnight. No view of the water or snow or sky, just lights in the darkness. Thomas Wolfe said, “you can’t go home again,” and I honestly believed him. What if I didn’t have that feeling again? 

My husband knew that I had started crying before I did. I don’t know when it happened; probably when the plane turned in the same spot it had three years ago and I was treated to the lights reflecting off the snow of the city below me. My heart pounded, my mouth went dry, and I squeezed my husband’s hand until the plane landed. 

Allison McLellan, MD is a PGY3 resident in the Department of Pediatrics at MCW. 

Some Questions for Lisa Grill Dodson, MD - Dean, MCW-Central Wisconsin Campus

 From the 2/19/2021 newsletter

Some Questions for…

Lisa Grill Dodson, MD - Dean, MCW-Central Wisconsin Campus

Rural hospitals have long faced tight funding, declining resources, challenging recruitment/retention issues, and low volumes/reimbursements, yet they are expected to be ready to care for the full-range of health issues including opioid / methamphetamine addiction, obstetrical care, COVID-19, refractory mental health issues, farm machinery accidents, and high-speed vehicular trauma. We spoke to Lisa Dodson, MD, the Dean of the MCW-Central Wisconsin Campus in Wausau, about the challenges facing her campus and the future of rural healthcare …

Transformational Times: How does a regional campus help address some of the challenges of rural health care?  

Dr. Dodson: Regional campuses play several roles as we address the unique challenges of rural health. First and foremost, a regional campus can directly impact workforce availability. Students who grow up away from large urban areas, train in smaller cities, and are accustomed to the lifestyle are more likely to practice in less densely populated, underserved counties. These students have the extra level of resilience needed to survive and thrive and will be ready for the constant challenges in both pathology and policy that have an oversize effect on rural communities. 

TT: What can you tell us about students that are drawn to regional campuses?

Dr. Dodson: First of all, they are truly unique. Students coming from rural areas to medical school are unbelievably underrepresented. Nationally, medical schools  currently have the smallest percentage of students coming from rural backgrounds since records have been kept and most medical students in urban areas will never meet a rural mentor or have any rural experience. So, we actively look for students from rural areas, believing they have a greater likelihood of going back to the same or similar communities. 

The mentors these students meet are critical. They show the students that that they don’t have to be “saints” or “missionaries” to go into rural medicine. These are great, fun, rewarding jobs. Intrinsically motivated, curious, and pragmatic students find great challenge and reward in these settings. 

Because of their backgrounds and the backgrounds of their teachers, regional campus students might be less susceptible to the overt and subtle messages aimed at discouraging them from pursuing smaller community primary care careers. These students tell me that they are often subjected to comments asking them why they don’t want to “aim higher.” They hear that a lot but, fortunately, they also see how satisfied their mentors are. The students learn to say, “Thanks for the advice but this is what I want to do.” They learn to believe in themselves and their choices. Our goal is to support them to make the right choices for themselves. 

Think about the challenge: 

It is nearly impossible to convince a student to enter primary care in a small town if they have come to medical school from an urban/suburban background, have only seen urban medicine, and are convinced they want to be a subspecialist in a large city. The system is designed to take students who want to be family physicians and steer them toward specialties; rarely, does it work in the opposite direction. 

Recruiting students from less populated areas isn’t foolproof, of course. Some students from small towns will see medical school as their “ticket out of Dodge.” Finding students who will commit to return to a small town after having been through medical school and residency training is special. 

TT: What challenges do you see in the rural health care workforce and in rural health care in the coming decade? 

Dr. Dodson: Over the coming decade, we need to better understand and develop pipelines for all rural populations into health care professions. For example, we have an Advancing Healthier Wisconsin grant that is targeted to increasing matriculation for Hmong students. We hope to expand to other groups. One successful example in Wisconsin is the UW-Madison Native American Center for Health Professions which was founded by Dr. Erik Brodt (View the We are Healers website here). 

To attract and retain rural students into our communities, we are partnering with Aspirus, a local health system. The Aspirus Scholars program provides full-tuition scholarships to medical students in exchange for a commitment to return to work in the area for at least five years. There are fifteen current or recently graduated Aspirus Scholars at MCW-Central Wisconsin.

Political and policy changes are imperative. Policy makers must refocus on community engagement, health equity, population health for all populations throughout the state. Unfortunately, the solutions that work in urban regions don’t always work in smaller towns. Both areas need access to equitable public health. Both areas need access to quality care in trauma, medical emergencies, and obstetrics. Even though they might not be needed often and the volumes of patients are low, the systems - and society writ large - need to make certain that these services and properly trained staff are available when needed. When someone is in urgent need, you can’t always just “drive to the next town.” Keeping these services available is a larger problem than any one town or county, and the loss of small-town hospitals across the region is a concern.  

We could think of the need for healthcare in the region the way our predecessors faced the need for electricity when it first became available. In those days, rural areas developed public utilities. There was a societal decision that everyone should have access to electricity because the benefits outweighed the costs of getting wiring to remote regions - a concept with which we all agree. To reach rural areas, utilities required federal and state funding, but still maintained local control. Medicine, like electricity, could be delivered to all people in need, not to the highest bidder.  

We need to advocate for our communities. If school systems are underfunded and failing, it will be hard to recruit physicians with young families. If infrastructure is not maintained, there will not be enough people to support practices and physicians will not have enough resources to provide care.  

TT: What challenges do you see in your accelerated curriculum, and in medical school curricula, in general? 

Dr. Dodson: We do need to build different curricula. A compressed medical school curriculum like ours does not easily fit for someone who intends to enter subspecialty surgery; there just isn’t sufficient time for them to get the exposure they need to be a competitive applicant for residency. On the other hand, not every student needs the same length of time to master what they will need to succeed. We need to stop thinking of medical school duration in terms of  “integers”; curricula should be more flexible than exactly three, four, or even five years. In competency-based curricula, students finish when they have displayed mastery. I have seen students who are close, but not quite ready, after their three years. Some need a few extra months beyond three years to be prepared, but not a full year. Curriculum reform should focus on using time to optimize student preparation and not as “remediation.” 

TT: What has surprised you most in your position? 

Dr. Dodson: Being a dean is a weird job! It’s like having a baby. Nothing is every quite what you planned or thought it would be. You hit surprises. You hit roadblocks. For example, when I arrived, there were great physicians here, but we needed to launch into faculty development to turn them into teachers. It was harder than anticipated but very gratifying.

It has been rewarding to see how much our community physicians clearly enjoy the opportunity to give back to the next generation. Since the classes are small, we find the chance to work with the students to be very engaging. They challenge us. They want to know, Why do you do things that way? The students bring ideas, keep us fresh, and keep the job rewarding. 

I have been surprised by how difficult it can be to recruit physicians. Wausau isn’t that small of a town and we are close to major metropolitan regions. The area is amazing. We really need neurologists, but the system has been unable to get people to look.  It’s hard. So we’ll grow our own. 

TT: Any final words?

Dr. Dodson: I have loved seeing how in rural areas we all depend on each other in ways that aren’t always seen in larger urban areas. A small town will find out what you can do and put you to work. In my first rural practice, the hospital hired my husband (a chemical engineer) to install their first computer system. Once that project was completed, he was been hired to do regional economic development, also something out of his core area of expertise. Rural communities work together. 

I think being part of a regional campus has given me a unique perspective on the current state of medical school education. Too often, schools focus on what doctors need and want. “We want more specialty training!” At our regional campus, we also focus on what the community and society need. That is more rewarding and is, I believe, where medical education needs to turn. When we ask, “What do the neighbors need?” we think about where best to place our resources. Regional campus can demonstrate this. We listen and respond. 

Lisa Grill Dodson, MD is the Sentry Dean and Founding Dean at MCW-Central Wisconsin, a position to which she was appointed in August 2014. She completed her family medicine residency and fellowship at the Oregon Health Sciences University. 

Interview conducted by Bruce H. Campbell, MD.

How Graduating from an MCW’s Regional Campus Prepared me for Residency

 From the 2/19/2021 newsletter

Perspective/Opinion

How Graduating from an MCW’s Regional Campus Prepared me for Residency

Bradley Zastrow, MD

Dr. Zastrow, a current resident in MCW’s psychiatry residency program explains how attending medical school at the MCW-Green Bay campus provided him with several unique experiences that better prepared him for his journey …

Prior to attending medical school at MCW – Green Bay, I lived in Milwaukee for six years. While applying to medical schools, I knew I wanted to work with underserved populations outside of the relatively resource-rich city during medical school. Access to mental health treatment in rural Wisconsin is currently one of the most pressing issues facing our state. My experience training in a rural location was the first necessary step in preparing to help try to remedy this issue.

At its core, medical school calls on us to adapt to learn and work in a variety of settings. The most obvious example is rotating through different specialties. When primarily training at an academic center, students are typically restricted to rotation sites within a short drive of the main hospital. By completing medical school at a rural campus, however, I was able to rotate within a variety of hospital systems throughout northeastern Wisconsin. Family medicine in Oconto Falls, inpatient neurology in Appleton, and acute care surgery in Door County were just a few. What solidified my pursuit of psychiatry was the opportunity to rotate at the Wisconsin Resource Center (WRC) in Oshkosh, a joint effort between the Department of Health Services and the Department of Corrections, that serves the state prison population.  Patients in this setting require specialized mental health services. Without the unique access provided by a rural campus, the opportunity for medical students to learn in this innovative setting would not be possible.

 The expanded set of rotation sites at MCW – Green Bay afforded me the chance to work with several underserved populations. From members of the Oneida tribe to veterans in northern Michigan making their way to Green Bay’s VA outpatient clinic, I saw firsthand the healthcare disparities facing those who live outside of an urban or suburban setting. For example, where I completed my outpatient pediatrics rotation in Sturgeon Bay, the county lacked any formal child psychiatry services. As a result, this pediatric clinic was responsible for managing all patients with psychiatric conditions in addition to their general medical concerns. To contrast, in Milwaukee, these patients are routinely followed by, or at least have access to, a fellowship-trained child psychiatrist. My preceptor in the Door County clinic dedicated years of medical education credits to learn how to better serve this population. She was one of many physicians I met dedicated to expanding their scope and caring for those who needed it most.

 On Match Day, I was thrilled to learn I would be returning to Milwaukee for residency training. Thus far, I have found that my years of experience at the rural medical school campus complement my residency training in a more urban setting quite nicely.  During medical school I observed the challenges that patients and providers face with a lack of resources; in residency I am seeing programs and interventions that may help address those challenges.  As a psychiatry resident, I see patients at the Milwaukee County Behavioral Health Division with acute mental illness that I rarely encountered in the northern counties. Fortunately, Milwaukee County has developed resources to provide care for these patients who may not otherwise receive it. Within the county hospital, Psychiatric Crisis Services (PCS) provides an emergency department for this population, who may otherwise overwhelm the capabilities of other community emergency departments. The majority of the patients treated through PCS are those who would otherwise be unable to access mental health resources, whether that be due to lack of insurance, inability to navigate the system, or acuity of illness. This is one example of a program uniquely developed to triage and treat a highly underserved population.

 

In returning to Milwaukee, my goal has been to learn as much as I can from public health interventions already in place. I hope to take these and similar initiatives with me and adapt them to more rural populations, where I have seen how great the need is firsthand. Whether expanding access to patients waiting to establish or improving the access for those who already rely on our care, there is much we can take from models and programs in more urban areas like Milwaukee to improve psychiatric care throughout all of Wisconsin.

Bradley Zastrow, MD is a PGY2 resident in the Department of Psychiatry and Behavioral Medicine at MCW. He graduated in 2019 from the MCW-Green Bay campus.  

Some Questions for … Matthew Hunsaker, MD - Dean, MCW- Green Bay Campus

From the 2/19/2021 newsletter

Some Questions for …

Matthew Hunsaker, MD - Dean, MCW- Green Bay Campus

Dr. Hunsaker, the inaugural Dean at MCW-Green Bay, talks about the regional campus and how its mission will improve the health of Wisconsin’s smaller towns and cities …

Transformational Times: How does a regional campus help address some of these challenges of rural health care? 

Dr. Hunsaker: It is atypical for a non-state university medical school to launch regional campuses. Although some might think of our community as small, Green Bay is the third-largest city in Wisconsin (population of 100,000) and has a total metropolitan population of 300,000. We have three health care systems, several institutions of higher learning, and sophisticated hospitals. And, of course, there is the Green Bay Packers football team and foundation that have been philanthropic supports of the school. That said, it does not take long to get from downtown to sparsely populated areas like Door County or Shawano.

As a regional campus, we have several unique opportunities to impact health care. 

First, we can recruit wonderful, talented students who have unique backgrounds. Many of our students are drawn from pools that “traditional” medical school admissions processes overlook. For example, some are non-traditional in the sense that they are the first of their families to enter medicine or even graduate from college. Many come from smaller towns and cities across Wisconsin. Many have graduated from smaller colleges and come from very modest backgrounds. 

Our focus and our approach to interviewing seek to identify those who have an affinity for primary care and psychiatry in non-urban settings. If a student at interview does not align well with those campus goals, we encourage them to consider our Milwaukee campus for other career paths that better align with their personal goals.

Once the admissions office has determined that an applicant has the aptitude to likely succeed in medical school, we rely on our Regional Applicant Advisory Committee (RAAC) to secondary screen and interview candidates and provide recommendations to the Admissions Committee. The RAAC members are trained by the admissions office in screening and interviewing. All are selected from the Green Bay community and represent a broad representation of Northeast Wisconsin. MCW-Green Bay is searching hard for their other qualities in addition to cognitive performance. We have people both the Admissions Committee and the Regional Applicant Advisory Committee screen each portfolio. The results of the local interview process are provided to the admissions committee who makes all the decisions about a candidate's status and extends offers to matriculate. Of the more than 2300 applications we received for Green Bay this year (including 275 Wisconsin) we are nearly finished interviewing eighty candidates from which to build the class. To flatten the inherent biases of one-on-one interviews, we have each applicant interview with a group of seven to ten people from the RAAC. This community-based interviewing approach provides us great feedback and a wonderful cohort of students. 

Next, we leverage our location and faculty to train outstanding physicians who will thrive in their careers, with a special emphasis on primary care and psychiatry in smaller communities across the state. We graduate students with the requisite skills for these practices who are equipped to focus on the central tenet of medicine, which is that a physician is merely a person who happens to have an advanced science degree helping another person improve or regain their health. Central to our program is the idea, nothing we teach should ever work to diminish the student’s ability to talk to another human being with empathy, compassion respect, and clarity. 

We want students to become part of the community. Each student participates in the Physician in the Community Scholarly Pathway. Students complete an IRB-approved Community Orientated Primary Care (COPC) research project while working with community-based organizations, to address local health problems. The student conceives the project, develops it with a local community organization, executes the project, and presents it to the community, their peers, and the local healthcare research forum. COPC requires them to participate in CITI research training, build research skills, community-based health care experience, interprofessional education exposure, and insights into health care challenges unique (and not so unique) to communities located away from academic medical center teaching environments. 

Many smaller communities and hospitals have huge problems with physician recruitment and retention, and a campus like ours can offer a pool of individuals already familiar with the region. Students who have rotated through, for example, Bellin or Prevea, might be drawn to work for these systems after they graduate. They can build connections even as they are in school or residency that lead to future career employment.

By observing their mentors, students recognize that working in smaller communities will allow them to practice closer to their full potential, functioning at the “top of their licensure and appropriate training,” that is, a family physician in a small town is more likely to deliver babies, perform GI endoscopies, and do minor procedures than one who works in the shadow of an urban institution with multiple subspecialists. They experience the satisfaction of providing services that would not otherwise be available in their zip code. 

TT: What challenges do you see in the rural health care workforce and rural health care in the coming decade? 

Dr. Hunsaker: Smaller hospitals and their health care systems face many of the same problems faced by their urban counterparts but have fewer resources, less flexibility, and greater risks as they attempt to meet the mandates and challenges. For example, the implementation of computerized medical records, enormous data and reporting systems, and the costs of health care delivery have had disproportionate effects on smaller hospitals. They simply cannot scale up as easily and the larger systems in many cases. As mergers and acquisitions are predicted to continue, smaller systems will likely continue to consolidate; towns like Green Bay which currently has three, might soon have fewer systems at some point in the future and if predictions are correct, alignment with other system-level resources. As physicians, we have seen the intrusion of “business activities” and documentation requirements at the bedside and we need to protect and champion the importance of meaningful interactions that preserve patient respect, dignity, and quality of care. Not long ago, I heard from a community member that they were disturbed that scheduling the visit on the phone took longer than the time spent with their physician. Who we train and how we train them will prevent “transaction” from overtaking the sanctity of meaningful doctor-patient interactions.

That said, all hospitals are facing increased mandated requirements and decreased margins. Rural hospitals will likely continue to adapt, and larger systems should identify the mutual engagements that encourage a healthy state. MCW-Green Bay’s efforts to recruit, train and support a workforce with appropriate primary care specialty distribution and geographic distribution are key to a sustainable future. 

Here is an analogy: 

We, as a society, have made the decision that every community, regardless of size or income, deserves clean water. If the water is bad or tainted, we will not tolerate it. Think of Flint, Michigan. 

We have similar beliefs surrounding public health. Generations ago, we decided that sanitation and clean water were basic rights. Over the past fifty years, we have added vaccination as being critical for human health. Over the past twenty years, we added health care screenings, as well. We began pivoting from disease treatment alone to screening and early detection. We are accustomed to believing that basic interventions like these decrease every person’s morbidity and improve everyone’s wellbeing. 

So, how do we extend this analogy of basic health care services to our rural areas? What types of interventions and sacrifices should we, as a medical school, contribute to ensure care reaches all of Wisconsin’s citizens? How do we assure equity to access and treatment despite where a person lives? How do we deliver services that are not easily scalable? Rural and Urban disparities are often similar in terms of workforce and accessible services.

These are huge challenges for our smaller towns and cities. It is a consideration for each of us to contemplate and participate in developing solutions.

TT: As a Dean, what have you discovered?

Dr. Hunsaker: Since our class sizes are smaller, I can schedule meetings with each of the medical students individually for half an hour each year and twice in their final year, all in addition to their career counseling, mentorship, and future planning provided elsewhere. As I meet with them, I realize we can measure their knowledge, but that we have a much more difficult time measuring and influencing character growth and the non-cognitive aspects of who they are becoming, yet these are critical to their success and happiness as physicians. The development of character and robust mentoring are key factors to success in and beyond medical school. 

TT: Any other advice?

Dr. Hunsaker: I have enjoyed my journey from working as a family physician in a small town in downstate Illinois to my decade at the University of Illinois College of Medicine at Rockford to now my work as Dean at MCW-Green Bay.

 I believe that our task as a physician is straightforward. It is to help people live longer, or feel better. If our advice and care fall outside of those goals, we need to contemplate what forces in medicine or society are driving our decision-making.

I believe that good doctors are the most aware of their biases, judgment, and care outcomes. Less successful doctors, on the other hand, wait for others to criticize or react to concerns from others. Pay attention to where the criticism comes from. As medical educators, we must incorporate this in our educational models so that the future peer is knowledgeable, successful, and one with whom their patients, and we as colleagues enjoy working.

Matthew L. Hunsaker MD, is the founding dean for MCW-Green Bay. Dr. Hunsaker provides overall leadership and management of MCW’s regional campus.

Interview by Bruce H. Campbell, MD

The Fauci Effect: An unprecedented rise in applications to medical school provides an opportunity, but might we miss it?

From the 2/19/2021 newsletter

Director’s Corner

The Fauci Effect: An unprecedented rise in applications to medical school provides an opportunity, but might we miss it?

Adina Kalet, MD MPH

Applications to medical school are at an all-time high. In this week’s issue focusing on Rural Health and Medical Education, Dr. Kalet considers the opportunities this may afford us to address the significant geographic and specialty maldistribution among the physician workforce and, thus, address health disparities.  Or not …

When I entered medical training in 1978 at the Sophie Davis School for Biomedical Education at the City College of New York (now the City University School of Medicine), I signed a contract committing me to practice in a medically underserved urban community. I thought I wanted to be a physician (What did I know? I was 17 years old!) and, compared to what I had heard about the competitive grind of the typical pre-medical pathway, the social mission of the six-year accelerated BS/MD program I was entering appealed to me. My classmates were typical inner city public college folks, over 30% of us were Black and Latino, most were from lower middle class and working poor families, and many were immigrants or first-generation Americans. As I discovered later in my training, ours was not the typical make up of a medical school class. 

Medical education is never simply a straight path an individual takes toward their clearly articulated career goal. Most medical school applicants share a desire to serve others, but few have a clear idea of what that really means, much less have any specific ideas of what they want to do. Instead, medical school and residencies expose trainees to a variety of opportunities while the curricula (both the explicit and hidden) mold, shape, and guide them. There are twists and turns along the way. Career choices evolve. Role models inspire and disappoint. Exposure to challenging societal and public health issues can leave deep impressions. Outside events intervene. Powerful forces influence choices and address societal challenges. 

Why are more students than ever interested in becoming physicians? 

This year, even as applications to colleges and universities have been falling, we are seeing an unprecedented 18% overall increase in the number applications to medical school. Some are calling this the “Fauci Effect,” attributing the increase to the inspiration provided to young people by Anthony Fauci, the physician, scientist, director of the National Institute of Allergy and Infectious Diseases (NIAID), and voice of science and reason during the  COVID-19 pandemic. When the history of this remarkable time is written, Dr. Fauci may well have a special place as the single most trustworthy public advisor of our era. With his comforting, thick Brooklyn accent, he expertly translates “science” into accessible language, giving advice to a broad national audience and demonstrating the courage to be truthful, objective, and - when appropriate - uncertain about the future. He has become the nation’s physician. 

Of course, there could be other explanations for the dramatic rise in applications. Perhaps a large number of recent college graduates simply have more time on their hands to complete the complex application process and study for MCATs. They are inspired by the heroism demonstrated by health professionals who - at risk to their own health and well-being - have cared unselfishly for others through their own physical and emotional exhaustion. This altruism should be harnessed and focused on what ails us. 

Why it is important to improve the primary care physician work force

Today at the Transformational Times, we turn our attention to rural health and our regional campuses. Small cities and towns face projected life-threatening shortages of physicians over the coming decades.  Despite an overall increase of 35% in the number of students graduated annually from US medical schools, the American Association of Medical Colleges (AAMC) is projecting a shortage of up to 139,000 physicians by 2033. More than two out of every five doctors now practicing will reach retirement age over the next ten years and this loss will disproportionately reduce access to primary care in rural communities. 

More worrisome, and despite evidence that greater primary care physician supply is associated with lower mortality, the density of primary care physicians has decreased by 11% over the past decade, leading to an increase in the number of deaths from preventable causes. For every ten additional primary care physicians per 100,000 population, the associated deaths from cardiovascular, cancer, and respiratory mortality dropped by 0.9% to 1.4%. Life expectancy improvement was more than 2.5 times that associated with a similar increase in non–primary care physicians.  Programs explicitly focused on training, attracting and sustaining the primary care physician supply should be a national policy priority. Medical schools are an important part of this equation.

Read the inspiring interviews with Deans Lisa Dodson of MCW-Central Wisconsin and Mathew Hunsaker of MCW-Green Bay. Look at their “soup-to-nuts” explanations of how recruitment, admissions, curriculum, financial aid, and social support can intentionally address the needs of rural populations. These smaller, mission-oriented programs demonstrate there are many paths toward educating excellent physicians. We are listening to them and learning from them. As we recover from the pandemic, the seeds they have sown might offer us great opportunities to mark the beginning of a new era in medical education. 

This year’s unusually large and more diverse applicant pool provides us opportunities to accelerate workforce diversification. Compared to the same time last year, the number of students representing racial and ethnic minorities who are taking advantage of the AAMC’s needs-based application costs is higher than ever, enriching an applicant pool with individuals from lower socioeconomic status. If, in addition, we attract more individuals who grew up in rural communities, and who are the first in their families to pursue professional education, we could begin to reverse the geographic and specially maldistributions which contribute to health disparities. Admissions committees can assemble medical school classes more likely to meet the missions of both the school and society. 

Debt affects career choices …

Of course, admission criteria alone are not enough. Medical school graduates finish with, on average, a staggering $241,560 of student loan debt, discouraging many from pursuing medical careers. Among those who do, indebtedness pressures students away from choosing lower-paid specialties even when they would find a career in primary care highly satisfying. A comprehensive set of incentives, dramatic increase in scholarship money and loan repayment, and payment and practice reform, to name a few, would be needed to dramatically improve access to primary doctors for those in rural communities.

I graduated medical school with about $25, 000 in debt, less than a third of debt typical of the newly minted physicians graduating that year, and one-tenth of typical debt today. I never took MCATs (medical school admission was guaranteed to all of us who maintained passing grades), calculus, or organic chemistry (we started with Biochemistry). And despite a great deal of initial angst (“Was I being brainwashed?”), I enthusiastically served for ten years as a Primary Care Internist in a publicaly funded ambulatory care center on the Lower East Side of Manhattan in one of the poorest neighborhoods in New York City. No one ever reached out to confirm if I had honored my contract; they didn’t have to; my education and mentors had prepared me and had ensured I would. Many, but not all, of my classmates did, as well. 

Alongside the usual foundational and clinical sciences, I took a course entitled “Community Health and Social Medicine” as a college freshman; this would be called Population Health Science in today’s parlance. Among other things, I worked in a clinic for homeless pregnant teenagers teaching basic health courses and spent a summer doing a community mapping and survey project for the Navajo Nation Health Foundation in Ganado, Arizona, a place as far from New York and as rural as one could get. The education in public health and the practical experiences I had with the people in these underserved areas opened my eyes and changed my life. 

… but, so do role models

Dr. Fauci isn’t so certain that he is the reason that medical school admissions are soaring. “It's very flattering," he said recently. "Probably a more realistic assessment is that, rather than the Fauci Effect, it's the effect of a physician who is trying to and hopefully succeeding in having an important impact on an individual's health, as well as on global health. So if it works to get more young individuals into medical school, go ahead and use my name. Be my guest."

We are on the cusp of changes in medical education and this unexpected bolus of applicants provides us a unique opportunity. Our country needs more primary care doctors. Our regional campuses have experience with matriculating classes of individuals who are more likely to enter careers in primary care working in regions that truly need them. We can learn from them. 

An active process is needed. We need deliberate planning and additional resources to recruit, matriculate, and support the “non-typical” medical school applicants who are statistically more likely to choose to practice in underserved areas. I think Dr. Fauci would tell us to plan, gather our resources, work together, and make a change. If we fail to act, it will be business as usual. 

For further reading

https://www.aamc.org/news-insights/applications-medical-school-are-all-time-high-what-does-mean-applicants-and-schools

Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015. JAMA Intern Med. 2019 Apr 1;179(4):506-514. doi: 10.1001/jamainternmed.2018.7624. PMID: 30776056; PMCID: PMC6450307.

Zabar S, Wallach A, Kalet A. The Future of Primary Care in the United States Depends on Payment Reform. JAMA Intern Med. 2019 Apr 1;179(4):515-516. doi: 10.1001/jamainternmed.2018.7623. PMID: 30776050. 

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.

Valentine’s Day: I am Not (but, Thank Goodness, My Husband is) a Romantic

From the 2/12/2021 newsletter

Director’s Corner

Valentine’s Day: I am Not (but, Thank Goodness, My Husband is) a Romantic

By Adina Kalet, MD MPH

In this week’s Director’s Corner, Dr. Kalet talks about the links between love at home and high quality, world-changing science at work. She highlights the importance of strong, egalitarian partnerships in creating a life of meaning, purpose, and flourishing …

COVID-19 has highlighted the importance of having clinician investigators “on the ground” to care for both patients and populations. This group is the most likely to detect emerging disease variants, run innovative therapeutic trials, and move new discoveries to the bedside and into the community. Translational scientists save lives. We need to nurture these clinician investigators as they fulfill their vital scientific and societal roles and provide them with the resources they need to stay healthy and train the next generation of physician scientists. 

Despite their importance, though, over 40% of well-trained physician scientists leave academic medicine, causing a serious shortage of physician researchers and a resulting in a huge loss to the health science workforce. Given how exciting and important their work is, why do so many step off the track? 

I believe they leave because of the constant and recurring challenges these individuals face trying to balance their own lives while attempting to pursue meaningful clinical and research careers. Without solid, deep, and meaningful support both at home and at work, the challenging lives of clinician scientists can become overwhelming. 

What does this have to do with Valentine’s Day? 

In our recent paper entitled “Challenges, Joys, and Career Satisfaction of Women Graduates of the Robert Wood Johnson Clinical Scholars Program 1973–2011,” our group, including Dr. Kathlyn Fletcher, reported on a long-term study of the women graduates of this highly successful fellowship aimed at training change agents in the transformation of American healthcare quality. Among many findings, we identified that - of all these remarkably successful and influential women - the most satisfied were likely to describe their work as “…deeply meaningful and have egalitarian spousal relationships.” The views of these well-trained women clinician scientists offer important lessons to those interested in repairing the leaky pipeline of clinical researchers.

Most of the program graduates in our study were in committed, dual career, personal partnerships. What did “egalitarian spousal relationships” mean to them? It was very complex. We asked the women, some younger and some close to retirement, to reflect on the course of their working lives. On one hand, successful respondents noted that culturally determined and structurally maintained “traditional” gender social roles became flexible and negotiated over time as the needs of the couple changed. A small number of the women in our study reported that, during the child rearing stage of their lives, their partners were the primary parents while they were the sole employed spouse. Most women, though, were constantly juggling home and work. While some respondents reported satisfying lives of “serial monogamy,” divorce was uniformly reported as disruptive to careers and life satisfaction. 

Even as they support early career clinical investigators and scientists, funders such as the National Institutes of Health, the Robert Wood Johnson Foundation, and the Doris Duke Charitable Foundation, have not explicitly and formally addresses how to create, maintain, and sustain “egalitarian spousal relationships” that might be associated with a thriving, impactful, and flourishing life in medicine and science. This might be an area for future study.

What would a relationship curriculum for clinician scientists (and others) cover? 

Love relationships, although universally seen as positive and important are, typically, firmly in the personal and private domain. Most of us learn how to make a life from our own families, our particular cultural groups, or our close peers. Career-focused women in my generation, facing lives very different from that of our parents, had to be creative. We talked “offline” with our peers, scanned our mentors’ offices for evidence of outside lives (e.g., family photos, children’s artwork, dry cleaning, grocery lists), and asked directly when it seemed safe: “How do you do it all?” “Who does the laundry?” “When the kids are sick, who stays home?” “When do the grants get written?” “How do you decide if it is right to relocate?” 

When I was raising my own children, I loved gently interrogating medical students and residents who had “working mothers.” I asked about their experiences and views, hoping to learn anything that would improve my chance of being a good mother. Since then, there has been an accumulation of material to read and discuss. Role models are more common. We can now think about what a structured curriculum might include. 

There is much to learn about finding love, building healthy relationships, and negotiating lives of meaning while not driving each other crazy! When I was starting out, it would have been great to have access to “paired” autobiographies, such as Michele Obama’s Becoming and Barak Obama’s A Promised Land, to gain insight from each partner’s point of view into how hard, but inspiring, it is to maintain a loving relationship under the pressures of “dueling” careers. We can learn from others as they cope with the types of accumulated, complex life experiences that author Nikos Kazantzakis had his protagonist, Zorba the Greek, lament when he said, “I'm a man, so I'm married. Wife, children, house--everything. The full catastrophe."

Ah, yes. The “full catastrophe.” 

A curriculum on creating egalitarian relationships might include exercises on how to determine if each partner shares values and a common view of the future. Children: yes or no? Bedroom window: open or closed? How important it is to “fight” fairly and forgive often? But in the end, it is not those issues alone that make a relationship work for the long haul. 

What might men in egalitarian relationships report? I suspect it would be very provocative but reassuring. To understand how best to create lives full of meaning, we must think deeply about how both people contribute to nurturing, sustained, and flexible loving partnerships. 

Let me tell you about my Valentine … 

My husband has received many “kudos” for playing nontraditional roles, yet when we both switched to four-day work weeks after the birth of our first child, colleagues were supportive of my choice but warned that it would “ruin his career.” (Today we are both tenured full professors.) When we share that he does most of the cooking, he gets showered with praise yet my years of boiling the water for pasta or broiling the fish still go unacknowledged. Thus, as my experience exemplifies, egalitarian relationships are better for both partners but still require different sorts of internal and external negotiations for men. Attention to this, with a reliable evidence base could lead to greater flourishing for all of us. 

Here comes my Valentine’s Day theme. I have had the benefit of such an “egalitarian” loving partnership, and it has made all the difference. I met Mark in July 1984 when we were the interns on the 16 East medical team at Bellevue Hospital. Needless to say, we became very interdependent that summer, meeting regularly in the ICU to replace central lines or draw blood cultures, writing progress notes side-by-side well into the wee hours. I suspect there are few ways to get to better know a person’s character than sharing a 2:00 a.m. cup of cold “food truck” coffee. That summer, well before we became a couple, we were partners.  

Mark recalls that time with much more “romance” than do I.  He has always been the cornier one. I am the “realist,” skeptical that romantic love even exists. I have been free with my feminist critique of all that life has thrown at us. He is the one who still believes in magic. 

Over thirty-three years of marriage, there has been lots of tension and compromise.  There were certainly many ways it could have - and almost did - go wrong. We have challenged assumptions, gained self-awareness, believed in and pushed each other, experimented, and occasionally jumped off the deep end.  We never seem to get it exactly right, but we have gotten better at getting it close enough. We have made a home, raised children, and had our share of adventures. Our egalitarian relationship is a perpetual work in progress, more of a constant juggle than a harmonious balance. We are both better people because of it and, I might add, we have both found rewarding roles as clinician scientists and administrators.

So, is this just good luck? Maybe. I certainly feel lucky. I know many of our junior colleagues think of us as a “dynamic duo.” My response when I hear this is “Forget the Marvel Comics version and come to dinner, see our messy but warm home, meet our kids and the cats, and watch us work it out.”    

For further reading:

Kalet, A, Lusk, P, Rockfeld, J, Schwartz, K, Fletcher, KE, Deng, R, & Bickell, NA (2020). The Challenges, Joys, and Career Satisfaction of Women Graduates of the Robert Wood Johnson Clinical Scholars Program 1973–2011. Journal of General internal Medicine, 35, 2258–2265.

Kalet, AL, Fletcher, KE, Ferdman, DJ, & Bickell, NA (2006). Defining, navigating, and negotiating success. Journal of General Internal Medicine, 21(9), 920-925.

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.

Learning about Growth Mindset from our Students

From the 2/5/2021 newsletter

Learning about Growth Mindset from our Students

Marty Muntz, MD

Dr. Muntz shares how to recognize trainees with fixed mindset and shares how small group coaching exercises can be game changers …

How often have you heard someone say, “I believe my intelligence, personality, or character is inherent and static. Locked-down or fixed. My potential is determined at birth and doesn’t change”? Rarely, if ever, hopefully. But have you worked with a learner or colleague who hides failures, desires to look smart, sticks to what they know, avoids challenging tasks, seems threatened by the success of others, is intensely self-critical, or seems resistant to feedback? These behaviors, which may signify a fixed mindset that can limit achievement and ongoing improvement, are not uncommonly observed in our clinical learning environments. 

To address this phenomenon, coaches in the 4C (Coaching for Character, Caring, and Competence) Program are trained to foster a growth mindset in their students. In her book Mindset, Dr. Carol Dweck suggests that learners with a growth mindset are likely to confront uncertainties, embrace challenges, learn from failures, and find lessons and inspiration in the success of others. A growth mindset helps one realize that feedback is a statement about current skills – and an opportunity to improve – rather than a personal attack.  

Ellen Arndt and Katherine Lumetta, MCW-Milwaukee medical students and near-peer coaches in the 4C program, recently developed and taught an interactive faculty development session for our coaches and created the lesson plan for the small group coaching sessions. After learning about this concept, both students and coaches brainstormed barriers to employing a growth mindset during different phases of medical school training and their careers. Unfortunately yet unsurprisingly, the list is long and includes grades, awards, the hierarchical structure of our teams, competition for research and other opportunities, and the residency match. 

In their coaching groups, students were asked to compare and contrast challenging life experiences they approached with both fixed and growth mindsets – and consider how the outcomes may have changed with reversing their approach. The coaching groups also discussed student behaviors that might signal to teachers and teammates that learners are fully invested in their personal and professional development despite barriers. Our near-peer coaches shared how their perspectives have changed during clerkship and other clinical rotations, providing concrete examples from their experiences. 

We are confident that small group sessions like these with trusted peers and faculty coaching starting early in medical school will help our students enter clerkships with the confidence and skills to set and achieve lofty goals. This, coupled with faculty development in programs like KINETIC-3 and 4C to encourage growth mindset, can help transform our learning environments to more fully support our students in their individual journeys to identify and achieve their goals.  

Martin Muntz, MD is a Professor of Medicine (General Internal Medicine) at MCW. He is Director of the Curriculum Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Providing Space to Shed Tears may be Key to a Better Post-COVID Future

 From the 2/5/2021 newsletter

Director’s Corner

 

 

Providing Space to Shed Tears may be Key to a Better Post-COVID Future   

 

 

By Adina Kalet, MD MPH

 

 

COVID-19 is wreaking havoc in the lives of working women. In this Director’s Corner, Dr. Kalet shares some learnings from Dr. Ellinas’s work in the Center for the Advancement of Women in Science and Medicine (AWSM) and talks about what to do when someone cries …

 

 

Over the past couple of weeks, I have witnessed more tears among my colleagues and mentees than I normally see in a year. Even though I care deeply, I am not particularly worried about those who have cried. I find it reassuring that they reached out, seeking support and a reliable pep talk. I know that while shedding tears in someone else’s presence makes one vulnerable, it is also a sign of strength, resilience, and self-care. These individuals are bending under the prolonged pressures of the COVID pandemic but are unlikely to break. 

 

 

On January 21, 2021, Libby Ellinas, MD, Director of the MCW Center for the Advancement of Women in Science and Medicine (AWSM), Associate Dean for Women's Leadership, and Professor of Anesthesiology at MCW, gave Kern Institute Grand Rounds on Women in COVID. Her talk was a tour de force of cautionary tales and sobering data. She reminded us that the majority of people on the front lines of healthcare and education – and nearly half of our medical school faculty – are women. Data from multiple sources are consistent: women as a group are under special pressures during this pandemic. This poses a threat to both our medical education and health care systems. 

 

The ways in which COVID-19 has disproportionately affected women

 

Dr. Ellinas shared survey data from the USC Dornsife Center for Economic and Social Research confirming that the mental load – including concerns about the health of their families, themselves, and financial strain – is significantly higher among women compared with men. And while married men with children have the lowest mental distress, women with children have, by far, the highest. This is not news.  Sociologists have shown over-and-over that being married with children is associated with better health and more happiness for men while, for women, being married/partnered with children is associated with relatively high levels of stress and distress. Women do measurably more emotional work than men, both in families and at work. While often this work is energizing, it is a mental load that can overwhelm. 

 

Among MCW faculty members, Dr. Ellinas demonstrated that the social isolation necessitated by the pandemic is wreaking havoc for working women. With schools inconsistently in session, direct childcare hours have increased for both men and women, but the number of additional hours per week has been greater for women. Data from an MCW AWSM COVID survey show that while nearly 60% of male faculty have spouses employed part-time or not at all, this is true for only 21% of female faculty. Thus, MCW working women with families are much less likely to have robust support systems than their male counterparts.

 

There is also heterogeneity in how COVID-19 increases stress. Some find value in working from home, but many do not. Clearly, working from home – for those privileged to be able to do so – allows more flexibility and autonomy, reduces time spent commuting, and decreases costs associated with working away from home. It might even provide unexpected “quality time” with family. However, especially for working women with school-aged children, working from home is associated with less sleep and decreased self-care. Adding to this, the intersectionality of race and gender can weigh even more heavily on Black and Brown women. 

 

And, as if that wasn’t challenging enough, there are signs that the COVID-19 pandemic negatively impacts the academic productivity of early-career women more that it does men. The long-term impact of this is worrisome and may lead to the reversal of recent gains in women’s academic status on the whole. These are challenges for us all. 

Institutional solutions are critical and complex

What did Dr. Ellinas recommend? She offered a number of institutional recommendations that are consistent with AWSM’s inspiring and audacious vision that “MCW will be a destination for women leaders, cultivating an inclusive and vibrant culture that supports all genders to grow and thrive in the health sciences,” and mission “to advance the careers of women at MCW through data-informed strategic projects that enhance opportunity and improve workplace climate.

• Evaluating leadership structures to ensure women are well represented in decision making
• Valuing parenting through generous parental leave and creative childcare
• Supporting women to “step forward” rather than depending on “step back” policies
• Valuing the hard work of mentoring, equity, diversity, and inclusion 
• Valorizing women role models for us all

 

We need policies that can be individualized and flexible over time. Extraordinary caregiving responsibilities may be acute, due to an illness or urgent need, chronic, as in having a child with special needs or an aging relative with evolving needs, or both, as in this stuttering pandemic. Community resources are distributed unevenly. Some people do not have enough help while others have what they need, if not to excess. Institutions like ours can improve the quality of life for our employees and community by offering concrete services, such as low-cost, high-quality childcare, sick childcare, food preparation and delivery, and help with chores. 

 

To support women (and men) whose academic careers have been impacted by the pandemic, some institutions have found ways to provide assistance that enable researchers to continue collecting and analyzing data while they tend to a “special” personal need. One program, the Doris Duke Fund for the Retention of Clinical Scientists (see “For Further Reading” below), has funded such efforts. Many workplaces provide access to high quality food, recreation, and other wellness services. Much can be done. 

 

How do we, as an institution, come out of COVID-19 better and stronger? We need a flexible range of options going forward that includes working from home. Our men need to engage. We all need to honestly complete surveys to have quality data that inform best solutions.  Men who have the relative privilege of having more support at home and at work – as well as having disproportionately higher salaries – need to be allies and advocates for equity and flexibility. No one should assume that they, alone, know what will work; we need to ask women. Don’t insist on “fairness” or “equality” until you have a full-thickness view of the situation. 

  

Back to crying

 

I have always kept a box of tissues on my desk. When seeing patients, the box was discretely tucked just out of view, easily slid toward the patient at the first glisten in the eyes. As a colleague and mentor, the box would be brought forward when the face flushed, the head dropped, and the tears rolled. It has been my experience that, most of the time, a good cry in the presence of an empathic other is the most efficient way to clear the air and help the words and problem-solving flow. People cry for all sorts of reasons. Sometimes it is sadness and grief, but just as often people cry because they are overwhelmed, angry or frustrated. I have come to believe that an effective mentor, like the good physician, must learn to invite and sit with the tears of others without needing to fix anything; just listen, sit quietly, check in.  Fighting back tears takes energy, blocks thinking, and keeps others away. Letting tears fall clears the air and loosens the voice. 

 

Did I say that it is mostly women who shed tears in my office? Well, it is. But occasionally, the men cry as well.  Three times in the past three weeks, I have spoken with distraught educational leaders, people who are deeply respected by colleagues and beloved by trainees. They were emotionally and physically exhausted from the expanding and rapidly evolving needs of school-aged children and elderly parents. They had less help from their working spouse than they needed. Their jobs presented new and growing demands on themselves and their trainees (e.g., being “deployed” to care for critically ill COVID-19 patients). They feared a loss of income. They were at the brink. 

 

In each case, I pushed the virtual box of tissues. Why doesn’t Zoom design a “tissue box” emoji?

I hope my message is clear: It is okay to cry here. I am not afraid of your tears. I will hear you out and empathize. You are not crazy, this is hard. I know you will find your way through this. I will help if I can.  

 

These folks do not need to be fixed, they just need a shoulder to cry on, a good night’s rest, regular meals, and an occasional walk in the woods. I think we can get them that. 

 

 

 

For further reading:

Jagsi, R, Jones, RD, Griffith, KA, Brady, KT, Brown, AJ, Davis, RD, ... & Myers, ER (2018). An innovative program to support gender equity and success in academic medicine: Early experiences from the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists. Annals of Internal Medicine, 169(2), 128-130.

 

Jones, RD, Miller, J, Vitous, CA, Krenz, C, Brady, KT, Brown, AJ, ... & Jagsi, R (2020). From Stigma to Validation: A Qualitative Assessment of a Novel National Program to Improve Retention of Physician-Scientists with Caregiving Responsibilities. Journal of Women's Health, 29(12), 1547-1558.

 

 

 

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.