Diagnostic Reasoning – A Call for Faculty Engagement

From the August 12, 2022 issue of the Transformational Times newsletter

Diagnostic Reasoning – A Call for Faculty Engagement 

  

By Jayshil J. Patel, MD - Director of MCW's curriculum "Critical Thinking in Medicine" thread

  

Dr. Patel shares, in earnest, this call to interested clinical faculty to engage in the diagnostic reasoning curriculum.  In many ways, our patients and posterity depend on it ... 

 

As many of you know, threads will be woven into the new medical school curriculum.  The Critical Thinking in Medicine thread will be a synergistic marriage between diagnostic reasoning and evidence-based medicine which, I think, are the key constituents for deliberately practicing medicine in today’s clinical environments and setting learners on paths towards diagnostic expertise.  Over the past few years, components of the curriculum have been tried and tested in various venues throughout undergraduate and graduate medical education and many learners have embraced and incorporated the language of the diagnostic process into their medical lexicon. Some have left training equipped with skills to metacognate.   

I am thrilled the curriculum will become a staple of undergraduate medical education at the Medical College of Wisconsin, but the initial implementation and sustainability of any curriculum, let alone ours, relies on an acceptance and participation from learners and faculty.  Thus, faculty development will be crucial.    

If, at this point, you’re asking, “Well, how are you going to do that?” Don’t fret. I share your line of questioning.  My honest answer is that I don’t know.   Or rather, I haven’t figured it out yet.   

But before embarking on a journey to capacitate and train the trainers, I would like to share why I think clinical faculty members would benefit from engagement, including becoming fluent in the semantics, scientific underpinnings, and metacognitive strategies related to the diagnostic process.  Here, I outline the impact (and really benefit) for three key stakeholders. 

For the sake of patients: Reducing medical errors by teaching how to arrive at a correct diagnosis 

Clearly, the goal for many front-line specialties is to get an accurate and timely diagnosis.  Without it, management is ineffective, wasteful, and potentially harmful.  With an accurate diagnosis, management and prognosis are guided.   

A diagnostic error is defined as a “failure to develop an accurate explanation for a patient’s health problem and/or failure to communicate that explanation,” and studies of autopsies, secondary reviews, and voluntary reports suggest diagnostic errors occur in up to 15% of cases, culminating in adverse events in up to 90% of cases.  It turns out cognitive errors are by far the most common cause of diagnostic error. An analysis of 583 physician-reported diagnostic errors suggested a failure/delay in considering diagnosis, suboptimal weighing of information, or too much emphasis placed on competing diagnoses were the most common reasons for “what went wrong.”  

As a result, patients may be subject to unnecessary testing and incorrect therapies, which may subsequently lead to psychologic/physical harm, toxicity, prolonged hospitalization, financial distress, and even death. Therefore, if the primary goal during an initial undifferentiated patient encounter is to arrive at a diagnosis, shouldn’t medical education, for the sake of patient care, strive to teach learners how to arrive at a diagnosis by explicating the diagnostic process into discrete teachable components to be deliberately practiced? And in doing so, is it possible to reduce diagnostic errors?   

While I can’t cite literature, and even if the answer is “no,” I opine, from a philosophical standpoint, that there’s intrinsic value, for doctoring and the doctor-patient relationship, in better understanding the diagnostic process.  

For the sake of learners: Giving them tools to build their diagnostic expertise 

It is not uncommon for novice learners to be “full of facts.”  However, they may have a difficult time “putting it all together.”  In fact, the diagnostic process is often considered a “black box” where learners can see what goes in (the data) and what comes out (the eventual diagnosis) but may not be able to articulate (in written or verbal communication) the intermediate steps.  And in some cases, the diagnoses are often drawn from a grab bag of differential diagnoses, which are verbalized using reflexive and biologically unlinked thinking.   

Instead of just creating competent graduates, what if we aim to set learners on a path towards diagnostic expertise?  After all, and as stated earlier, nothing good happens without an accurate diagnosis.  And so, what if the learner could: 

(a) Recognize how to appropriately utilize and toggle between different systems of thinking 

(b) Recognize when their cognitive load is high 

(c) Utilize different approaches to problems (e.g., hypothetical-deductive versus inductive approach) 

(d) Acquire a template for knowledge storage, expansion, and retrieval 

(e) Learn to conduct a cognitive autopsy and scan their environment for cognitive pitfalls 

(f) Learn to calibrate their thinking for future similar but not identical cases 

It is not a stretch of the imagination, and in fact, when we launched this curriculum in the internal medicine residency program, these components were exactly what learners desired out of their training.  For learners to grasp and deliberately practice these components, they’ll need their faculty counterparts to share their understanding of the diagnostic process (or at minimum, speak the same language). 

For the sake of faculty: Creating a culture where they can share their skills 

A few years ago, before delineating the components of a diagnostic reasoning curriculum, I began with the end in mind.  Assuming resources abound, I envisioned a Center for Diagnostic Reasoning (and Evidence-Based Medicine). It would be a place where educators would encourage learners to think aloud, deliberately dissect clinical cases into aliquots, and expound systematic approaches. They would approach problems embedded in a patient context and within a consciousness of the scientific underpinnings of decision-making and evidence-based medicine, all the while reflecting and calibrating their thinking.  The Center would be magnetic, attracting educators into the logos of diagnostic reasoning, creating sustainability.   

To me, that is aspirational and exciting.  Here’s why.  Sure, for young learners, the acquired skillsets are meant to promote lifelong learning and equip them to stay on the path towards diagnostic expertise.  But for clinical faculty, the acquired skillsets provide an opportunity to illuminate their thinking and provide a window (for learners) into their mind, within a culture of democratized rounds where both learners and faculty are encouraged to say, “I don’t know,” without the worry of perceived failure.   

Faculty might be overwhelmed and say, “I just don’t have time to do this.”  I will submit to you that you (faculty) are already, some in an extemporaneous manner, reasoning; however, the addition of semantic and scientific structure may provide greater clarity for learners (and yourself).   

Importantly, such a culture would enable the expression of virtues such as courage, prudence, empathy, grace, and humility.  For example, it takes courage and humility to say, “I don’t know.”  The manifestation of these virtues is central for the success of the hidden curriculum, which has far-reaching implications, perhaps more than the exposed curriculum.  And an explicated awareness of an individual’s thinking may be the key in accruing tacit knowledge.   

After all, it was Aristotle who said, Knowing yourself is the beginning of all wisdom. 

Jayshil J. Patel, MD, is an Associate Professor of Medicine in the Department of Medicine at MCW.  He is on the Learning Environment Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and the Critical Thinking in Medicine Thread Director at MCW. 

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Sit Down, Get Paged, Repeat

From the December 23, 2022 issue of the Transformational Times 

 

Sit Down, Get Paged, Repeat

 

By Laura Slykhouse, MD

 

At this time of year, we celebrate and thank our hard-working residents and hospital staff that work through the nights, weekends, and holidays. Dr. Slykhouse, a resident in Internal Medicine, recounts a call night that was also her birthday. She shares some moments which are specific to being in the hospital overnight… 

 

Birthdays have a way of getting less and less exciting each year. Yes, there are some milestone birthdays we celebrate as we get older; but, as the years march on, enthusiasm lacks compared to a sweet sixteenth or a twenty-first birthday. This year, I see my schedule for June and of course, I’ll be celebrating my birthday at Froedtert at the end of a twenty-eight-hour shift. 

I readjust my expectations and wish for a calm night, good cross-cover, no ICU transfers, and friends to make the time go faster. The night is off to a good start when my favorite co-resident is pulled in to cover the night portion of the shift with me. I was obviously more excited than she was, but the night was looking promising.  

We get sign-out, nothing exciting. Then we start brainstorming our evening – what kind of food are we going to order, which movies do we hope to watch in the team room and what music should we listen to. We’re not even five minutes into our planning when two pages come through – it’s the admitting medical officer (AMO) with two outside hospital transfers who are already on the floor: one with metastatic lesions to the brain and concern for increased intracranial pressure, the other one for AMS (altered mental status) in an elderly woman. This would be the last quiet moment of the evening.  

We decide to see the patient with concern for increased intracranial pressure first. He does not appear as sick as his labs and imaging have detailed. This is one of those times in residency where I feel the sense that a patient could decompensate quickly, but next steps are not clear. I feel uneasy about this patient. We call the neurosurgical team, and they also share our concerns and take over care of the patient in the Neuro ICU. The patient and his wife are very grateful for our small contribution to his care.  

Then the cross-cover begins. Two stroke calls, status epilepticus, a transfer to the Neuro ICU and Medical ICU. This is not the night I had planned when the shift started. However, time is passing quickly as we try to triage the patients and deal with one situation at a time.  

It’s now midnight, and I’m happy there are still a few options left on Door Dash, as I have been craving Mexican food the whole night. This would not be a night for a movie. The chaos continues throughout the night, page after page, almost comical with the timing – sit down, page, sit down, page. The food delivery has been there for hours, but something about a lukewarm burrito at 4:00 AM is less appetizing.  

The last crisis of the night is the elderly woman admitted for AMS. She has dementia and hypercalcemia. We give IV calcitonin and a bisphosphonate which causes diffuse body aches. She speaks both German and English intermittently. I find myself drawn to her. I’m not sure if it’s because she reminds me of my grandma or because I feel guilty that our treatment has caused her pain. I hold her hand for a while, and she seems to feel some relief from the IV pain medication. Just this small point of contact makes the night seem less frenetic. It reminds me why I enjoy what I’m doing, even during the difficult nights, the missed holidays and celebrations.  

It’s 6:00 AM and we re-group in the team room. The window for sleeping has passed, and it’s evident I’ll need a significant amount of coffee to make it through rounds. We debrief quickly, cold burritos are half-eaten and abandoned next to the computers, and I feel proud. I learned a lot, we gave the best care that we could, and another call shift is over.  

 

Laura Slykhouse, MD, is a PGY3 Internal Medicine resident at MCW who is planning to start her career in hospital medicine.   

Design Thinking in Action: Medical Students Weigh-In on the Mobile Health Clinic

From the December 23, 2022 issue of the Transformational Times

Perspective/Opinion 

Design Thinking in Action: Medical Students Weigh-In on the Mobile Health Clinic 

 

By Emmy Lambert, BS – Medical Student 

Patient-centered care calls for patient-centered spaces. Medical students were given the opportunity to dust off their creative brains and ponder the details, big and small, of an exciting new mobile clinic…  

Human-Centered Design. It’s all around us. Or at least, it should be… 

Simply put, human-centered design is a method of empathy-based problem-solving. Through a three-phase design process of inspiration, ideation, and implementation, human-centered design tailors products towards those involved in their use – so-called “stakeholders.” These stakeholders are consulted and considered in every step of the design process to ensure the output will meet their needs. Truly an ingenious approach, if you ask me.   

They’re building a WHAT? A mobile clinic! 

In an effort to address preventative health screening disparities in certain zip codes in Milwaukee, there is a joint venture between the Population Health Department and OB/GYN Clinic at Froedtert Hospital, the Kern Institute’s Human-Centered Design (HCD) Lab, and the UW-Milwaukee Lubar Entrepreneurship Center to design and implement a Women’s* Mobile Health Clinic. The working timeline aims to complete research by the end of the 2022 calendar year, build the clinic in late spring of 2023, and begin providing care next fall.   

As part of the ongoing research process, the HCD lab hosted a design workshop for second-year medical students in the Health Systems Management & Policy Pathway. As a student member of the HCD lab for nearly a year, I had the privilege of facilitating this session with Dr. Ilya Avdeev and Dr. Lana Minshew. As a team, we guided students through a series of activities to stimulate creativity and prime their listening skills before conducting design research for the clinic.   

We asked the HSMP students to brainstorm the needs of a women’s mobile health clinic, identify stakeholders, and generate solutions to a few stakeholder concerns. Students collaborated in teams, writing furiously on sticky notes, whiteboards, and scrap paper. The room was abuzz with solution-oriented energy. Their knowledge of health systems and roles as medical students added a unique perspective to the ongoing project. Some of Dr. Avdeev’s graduate-level engineering students attended the session as well, lending a different angle of design understanding to the process.    

The students said they loved it! 

The session was well received by the students. Clayton Vesperman, M2, commented, “I thought that the Mobile Clinic Design session was one of the most unique and engaging sessions I have had as part of the Health Systems Management and Policy pathway. The opportunity to collaborate with Engineering students who had a background that was outside of the medical field was a great opportunity to learn how other fields approach problems as well as the types of issues they prioritize. As medical students, we have abundant opportunities to learn from other health professions, but learning to work alongside entirely different fields can be very beneficial as they can play a large impact in the patient experience even without directly influencing the patients’ healthcare.”  

Victoria Le, an M2 also in the HSMP Pathway, commented, “I thought it was interesting to see the process of working through nitty-gritty details of making an idea come to life. I liked how thorough it was, including the way we tried to anticipate different issues that would be roadblocks to the mobile clinic. I also thought it was a good way to balance the creative process with a more rigorous evaluation of ideas.”  

My takeaway? 

I was so impressed with the creativity and collaboration demonstrated by my peers! Their willingness to engage across disciplines, work together to problem solve, and experience medicine from the patient perspective is promising for the future of medicine. A few of the ideas presented at this workshop have been considered for the ultimate implementation of the mobile health clinic, which is set to hit the streets in the fall of 2023.   

Design with us! 

The Human-Centered Design lab is currently collaborating with the Lubar Entrepreneurship Center at the University of Wisconsin – Milwaukee and Froedtert hospital on a community-centered design project focused on designing two mobile health clinics to serve the greater Milwaukee area. To create the most effective community-centered design as possible, we invite community members to join the design team by sharing your experience with mobile healthcare or offering your ideas using a full-scale clinic design model. The model is in the first-floor cafeteria lobby of the MCW – Medical Education Building and will be open to everyone through January 31, 2023.   

Note: 

*The term “women” encompasses those who identify as female, possess female reproductive anatomy, or face female-related health issues. 

Emmy Lambert is currently an M2 at MCW Milwaukee. She is a student member of the Human-Centered Design Lab pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. She passionately co-runs the MCW Chapter of Medical Students for Choice, manages operations of MCW DOSE, and teaches Hatha and yin yoga classes at Collective Flow MKE.  

“Is There a Doctor Onboard?” Doctoring and Prayers at 35,000 Feet

From the December 16, 2022 Spiritually in Medicine issue of the Transformational Times

“Is There a Doctor Onboard?” Doctoring and Prayers at 35,000 Feet

By Adina Kalet, MD, MPH

Given the theme of Spirituality in Medicine in this week’s Transformational Times, Dr. Kalet shares the most recent of many experiences she has had answering the overhead call on airplanes. In this case, the faith traditions of both the doctor and of the patient led to series of surprises and unique styles of gratitude for caring and kindness expressed in prayer …

Given that I was listening to a movie through my headphones while my hands were busy knitting, the announcement just barely registered. We were three hours away from our destination, and a long, uncomfortable eight hours into our flight. After a few seconds delay, I untangled myself and headed toward the uniformed purser standing in the aisle. 

“I am a doctor. How can I help?” She looked me over and nodded discretely toward the young, pale, diaphoretic, and mildly distressed bearded man slumped in his seat. 

The flight attendant whispered, “He is asking for medication, but I can’t administer anything without a physicians order.” She gestured to her handheld device. “This is what we have available.” She looked back-and-forth from the man in the seat to me. “We are over land now, so if you decide…” Her voice trailed off, suggesting that, on my say-so, they were prepared to land the plane.

“Give me a minute to assess the situation,” I said. She offered to retrieve a blood pressure cuff and oxygen tank.  

My new patient’s religious garb, facial hair, and head covering told me that he was part of an Ultra-Orthodox Jewish family. I grabbed my sweater and covered my bare shoulders since, in his culture—one I know intimately—modesty is paramount. In his community’s view of the world, a secular appearing, barefooted and bareheaded woman might be dismissed or treated with suspicion. I assumed he would avoid eye contact and refuse to let me touch him. To be trusted enough to make an accurate medical assessment, I needed to minimize the barriers.  

Leaning over him, I introduced myself and asked him to tell me what was going on. I was happy to see that he was fully awake and alert, spoke fluent mildly-accented English, was willing to make eye contact, and seemed eager for my help. He described his weakness, dizziness, and nausea. After asking permission, I carefully and firmly ran my hand over the key locations (no belly, chest, or calf tenderness) landing on his wrist to feel for his radial pulse. I engaged him in conversation about his health and recent events as I monitored the cardiac rate and rhythm. He had been perfectly healthy  and described no ominous symptoms. 

The relatives surrounding him were eager to tell me that they had all spent the day before in a hospital emergency room with a beloved relative. As his uncle graphically described the details of how the old woman had fallen and had sustained a nasty, bloody gash, my patient became paler, his heart rate went up, and his pulse became “thready.” Before long, he was dry heaving into a plastic bag. Clearly, the stress of hearing the story again was taking a toll. I expressed my empathy for the upsetting situation to the group. My patient’s pulse slowed a bit. 

The flight attendant handed me the automatic blood pressure device. As I wrapped the cuff around his arm, I confirmed he had eaten little, had slept poorly, and had not had anything to drink during the flight because the options were not guaranteed to meet his religious requirements. The machine finished its reading and, although not dangerous, his blood pressure was quite low. 

We laid him as flat as the airplane seat would allow and elevated his legs. I assessed the width of the aisle just in case we needed to get him on his back. Happily, his blood pressure climbed a bit and his pulse headed toward normal. 

The flight attendant pointed out that we were seven miles above the Earth, and some supplemental oxygen might help. We put the mask on him and started the flow. He “pinked” up immediately, and his nausea resolved. Soon, he was able and eager to drink fluids. As time passed, his symptoms resolved, and he felt stronger. 

I spent a few minutes talking with his relatives, including the old woman with the fresh stitches and a bandage above her eye. I was able to fend off one of his aunts who offered several nonspecific pills she had in her carry-on bag. Everyone noticeably relaxed and soon I felt comfortable enough to return to my seat. 

The flight attendant stopped by, reporting that she had told the pilot we were not anticipating an emergency landing. She offered me a gift from the airline which I tried to refuse but, in the end, I accepted some extra miles for my frequent flyer account. 

After a while, the patient’s aunt came by, an emissary from the senior male members of the family. She thanked me profusely for my help, then said, “Your smile and gentleness are a blessing from G-d! You didn’t need to be kind, but you were.”  The family wanted to give me something in return for my kindness. 

“No!” I said. “That is very kind, but this is my work. There is no need for gifts.”

“Well, then,” she replied, “you will be in our daily prayers.” She nodded, thanked me again, and returned to her seat. I smiled, found my headphones, and went back to my knitting. 

I was relieved that things turned out so well; they don’t always. This was not my first rodeo. I have had  a few opportunities to answer “the call” on airplanes, at the theater, and on the sidewalk.  Given the settings, the medical intervention and decision-making options are severely limited. Had the situation worsened, and I had needed extra hands to help start an IV or do chest compressions, I suspect other healthcare workers might have appeared, or the trained crew members would have been there to assist. Depending on the acuity of the crisis, I might have recommended to the pilot that she land the plane.

But, on this day, that was not what was needed. In the end, what was most needed and appreciated was kindness. This experience, as well as medical student Sarah Root, in her essay in this issue of the Transformational Times, reminds me once again, through the the words of Sarah’s physician grandfather, “that medicine is not just a practice, but a privilege.”

We reached our destination and headed our separate ways. I am humbled to know that there is a family, not so very different from my own, that is prayerfully grateful for our moments together at 35,000 feet. 

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.

The Kern Institute Announces Publication of the Second Collection of Transformational Times Essays

 Book Presale - Character and Caring: Medical Education Emerges From the Pandemic

The Kern Institute Announces Publication of the Second Collection of Transformational Times Essays

Medical students, residents, physicians, and caregivers have struggled during the pandemic. The times in which we live will transform medicine. These essays, drawn from the Kern Institute’s Transformational Times newsletter, offer glimpses into what we have experienced and what might yet come. 
Each essay reveals remarkable insights and reflects the interplay of the world we inhabit with the present and future of medicine and healthcare.

"Incredibly timely."
—Carol Bradford, MD FACS
“[This book] provides an unparalleled opportunity to bring one’s best self to the bedside and looks for the unexpected opportunities to impact the world.”
—Jesse Ehrenfeld, MD, MPH
“...a ready-made syllabus to embrace social, psychological, spiritual, and humanistic dimensions of medical education.”
—Louis N. Pangaro, MD, MACP
“...the art, as well as the science, of medicine are eloquently delivered, provoking the reader to reflect and see the world from new perspectives.”
—J. Larry Jameson, MD, PhD

In these pages, readers engage with unsettling realities unmasked by COVID-19, including workplace biases, inattention to wellness, residency-related stress, the loneliness of military responsibility, the inequity of the world around us, reproductive healthcare uncertainty, new educational realities, and the imperative for flourishing and practical wisdom in physicians.

To purchase a copy of Character and Caring: Medical Education Emerges From the Pandemic, click here. 

To purchase a copy of our our first book, Character and Caring: A Pandemic Year in Medical Education, click here.

Focus on Genetics: Lessons from Uncle Dave

 From the December 9, 2022 Genetic Counseling Issue of the Transformational Times  

Focus on Genetics:  Lessons from Uncle Dave

By Wendy Peltier, MD

Dr. Peltier shares the candid story of how her uncle brought early inspiration to pursue a career in Medicine, and also opened her eyes to the personal challenges and opportunities of genetic testing as he faced a rare, progressive lung disease …

 

My uncle, Dr. David Pogue, worked as a cardiologist for twenty-nine years in the small community of Wichita Falls, Texas.  He inspired me very early on, to pursue a career in Medicine.  As “Yankees” from Illinois, my family lived far away from Texas, and holiday time together with the Pogue clan was truly a gift. I have wonderful memories of my brother and I connecting with our three cousins, all of similar age, and giggling together around the big table at family meals as our parents had spirited discussions.  At one of these memorable visits, my uncle took me on hospital rounds, where I observed his kindness and generosity with his patients and staff.  There were no Hospitalist services in those days, so “checking in” on his patients was common practice, even on a holiday weekend.  I can bring in my mind’s eye his long white coat, gentle smile, and patience as he carefully listed to heart sounds and reviewed care plans with his patients.  

He answered all my questions, sparked my interest in science, and empowered me that being a doctor was not just far away dream, but in reach if I was willing to put in the hard work.

Fast forward a decade or so, when I was in medical school, we got the news that he was ill.  After exhaustive testing for shortness of breath with exercise, he was found to have a rare form of emphysema, alpha-1 antitrypsin deficiency, a progressive and incurable genetic disorder.  This condition, which is expressed most severely in patients carrying two recessive alleles, causes a spectrum of lung disease that can manifest as progressive emphysema, chronic bronchitis or asthma, and can also affect the liver, pancreas and gallbladder.  Carriers of this gene can pass on risk to their children.  What a bitter irony that Uncle Dave would have emphysema after spending so much of his time trying to convince others to stop smoking!  I had just started learning about genetics and DNA in school, our bodies’ “phone book.”  I was particularly fascinated by how science allowed us to track these missing “addresses” that tied so eloquently to understanding of a disease process.  Genetic discoveries were just starting to have clinical impact, and the thought of gene therapy still a far away dream. 

 It seemed quite unbelievable that a genetic disorder could be in my family.  Could I be a carrier? Would I want to know? Would it impact major decisions in my life?

As was his brave and humble nature, my uncle learned everything he could about his condition, what to expect, and opportunities to contribute to research.  Pre-symptomatic genetic testing was not readily available at the time, but he sought resources for anonymous testing for his siblings.  I keenly remember what it was like to wait for my Mom’s results.  My uncle deeply believed in science and the power of research.  He knew that having this type of information could mean receiving early preventative treatments, once they were developed.  He also actively sought information about his prognosis, so he could make plans for his family to be supported, and to make his own careful decisions about future therapies with a lung transplant or other interventions.  He became very involved in the Alpha-1 Foundation.

As his disease slowly progressed, he made the necessary changes to his medical practice and sought continued opportunities to serve.  Using his background in cardiac rehab, he took a very diligent approach to his own health and was able to far outlive his prognosis, despite declining a lung transplant.  During this time, I was starting my career as a neuromuscular neurologist (despite his multiple attempts to convince me that Cardiology was a superior discipline!) and found myself often in the position of counseling families about genetic testing for muscular dystrophies and other progressive neurologic conditions. 

It was my good fortune to do this shoulder-to-shoulder with exceptionally talented genetic counselors.  Their knowledge, wisdom, and kindness in approach to all our patients and families, regardless of their health literacy, was a true inspiration.  

I knew, first-hand, how challenging decisions about testing could be, and the emotional impact to affected individuals in navigating this, sometimes with complex family relationships.  I did my best to provide balanced options, educate about the cautions of asymptomatic testing, and link families to important resources through the Muscular Dystrophy Association (MDA).  Incredible scientific progress was being made at this time in understanding the molecular biology and genetics of muscular dystrophies, previously named by the famous neurologists who described the syndromes (Becker’s, Duchenne’s, Emery-Dreifuss, etc.) now re-labeled by the specific type of gene defect or “address.”  Genetic testing became more available and allowed diagnostic accuracy without necessarily having patients go through painful muscle biopsies.  Gene therapy seemed closer in reach.

I will never forget attending my Uncle Dave’s funeral.  All of his family members had been carefully prepared for the event.  His favorite band, The Mad Medics, were playing Dixieland music as folks entered the church.  As my Uncle Don stood to give his eulogy he remarked, “I was given very strict instructions as to how this event will be, short and happy.”  And it was. So many people from the community attended to pay respects.  My aunt had a video camera in the church library, where attendees could sit and share a story in remembrance of the beloved Dr. Pogue.  One of my favorites was from one of his former nurses, who was a smoker.  She and her colleagues would occasionally sneak down to the smoking room during breaks.  She recalls seeing little paper airplanes floating down through the ceiling vent, and retrieving them only to see anonymous, hand-written random facts, about the health risks of tobacco use.  There was no electronic record back then, so of course she recognized his handwriting!  She described this as a true act of caring, without being judgmental.

He was remembered by his community and colleagues for his tireless service, a mission trip to Africa with the Peace Corps, starting the first cardiac rehab unit at the Clinics of North Texas, a Distinguished Service Award from the Wichita County Medical Society, and for being a proud charter member of the Wichita Runner’s Club. 

My Uncle Dave remains a steady presence and source of inspiration to me at challenging times, despite the many years that have passed since his death.  

For me, it’s not as much the professional accolades, as the memory of his kind, humble, and funny spirit, and ability to make “good trouble” in his work as a physician.  As a patient, he was always looking for opportunities to help others despite his own personal challenges. 

I recently connected with my aunt Georgia about these memories.  She was touched by this tribute and shared that one of the things she most admired about Dave as a doctor was how deeply he cared for his patients as people and recognized the importance of giving time to them during visits, something that she sees as a rarity now in medial encounters.  

There has been miraculous progress in science since my days in medical school to make gene therapy a reality.  Uncle Dave would be proud.

Wendy Peltier, MD, is a Professor of Medicine in the Division of Geriatric and Palliative Medicine at MCW.  She serves on the Faculty Pillar for the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and on the editorial board of the Kern Transformational Times.

The Power of Story--When We Truly Listen

From the December 9, 2022 Genetic Counseling Issue of the Transformational Times

The Power of Story--When We Truly Listen 

 By Jenny Geurts, MS 

 

Jenny Geurts, who is the inaugural program director of the Master of Science in Genetic Counseling (MSGC) training program at MCW, reflects on her community engagement experiences and the impact volunteer work has on learners.  

This year, our genetic counseling program had the pleasure of engaging with the Sisters Network SE WI Chapter which is doing amazing work in the Black/African American community to increase access to resources and information, advocate for change, and provide supportive sisterhood.  While the invitation was for us to provide information about genetics to their group of cancer survivors and thrivers, I found myself on the receiving end of the knowledge….   

So many of our community members reported stories of never being told about genetic counseling for hereditary cancer prevention and early detection.  And worse, several were told they couldn’t have genetic testing, even when they were asking for it, never being referred to genetic counseling to assess their risk.  What use is all our advances in genetic technology, when it is being kept from those in our community who need it the most?   

The persisting health disparities in hereditary cancer faced by the Black/African-American population is the topic of a recent review article by Ambreen Khan, et al published in the Oncologist.   

Our community members have so much to teach us, if only we are willing to listen.  

The topic of my presentation at the 2022 Wisconsin Cancer Summit this year “Genetic Risk and Family History: How Sharing Stories Can Save Lives”, where it was heartwarming to see many members of the Sisters Network in person.  The Summit theme this year was “The Power of Story,” and brought together patients, advocates, care providers, public health workers, scientists, administrators and more. I can attest that the mission of the Summit was met: Together, we learned how storytelling can be used to improve cancer health outcomes, empower patients and providers, and help us connect, transform, learn, and heal. 

Sherri’s Story 

Due to the generous spirit of one our clinic patients, I was able to tell Sherri's story at this year’s Summit.  

A story where listening meant life or death….   

For years her doctors didn’t listen, which resulted in Sherri being faced with death.  

“...my father he was only 26 when he was diagnosed, his mother, brother, sister and my cousin, they all had it young…” 

 “I know this is not my normal — waking up tired, all day tired,” 

“…no, it’s not just about me getting older, it’s more than that…” 

The power of family history for cancer prevention was lost on Sherri, she would become a statistic in the widening health disparities seen in genetics and cancer care. 

However, because of her resolve, determination, and faith, she persisted…. until finally someone did listen.   

And this time listening resulted in the power of additional life to live, importantly a ~quality~ of life. 

Sherri graciously allows us to amplify her voice, how her life was saved when someone listened, because of genetic testing and immunotherapy.   

If your curiosity is peaked and you’d like to learn more, I’d encourage you to check out the Summit Recap to access recorded presentations, view slide content and learn more about the Cancer Stories Performance, which is a powerful stage production from the Wisconsin Story Project that honors the personal stories of people affected by cancer.  The end result is profound, candid, and deeply human. 

Narrative Reflection Exercises  

We ended the two-day Summit event with a narrative medicine activity, led by Dr. Toby Campbell from the University of Wisconsin/Madison, where we attempted to capture the feelings about our experiences during the Summit with a six-word narrative.  I’d like to share my reflection with the Transformational Times readers: 

“Witnessed stories heal them….and me?” 

This experience allowed me to deepen the impact of the Summit experience and forge the patient stories into my consciousness, helping me make meaning of the toll cancer takes on so many families. I hope that the Transformational Times readers will consider the situations where their patients have been generous with them, in the stories they shared, and trust they instilled.  If only we are compassionate and humble enough to truly listen. 

As part of our Genetic Counseling Seminar course in the MSGC program, learners participate in community engagement volunteering to promote a deeper understanding of the patient experience.  Having just learned about another narrative exercise (the 55-word essay) at the Summit, I thought asking the students to try this activity might also help them further process their experiences in the community.  In this exercise the writer must choose exactly 55 words for their narrative, resulting in the need to be extremely intentional about their word choice. The power of the 55-word essay was not only impactful for them, but also for me, as it was a whole new way for me to have a transcendent vicarious experience through reading their reflections.  Several of my learners wrote 55 word reflections after participation in volunteer community events, and are highlighted within the Poetry Corner of this Transformational Times issue. 

Creating a MSGC Mission Statement 

When our program development started in early 2020, we were asked to create a mission statement, it was something we were obligated to do and at first felt very “corporate.”  I certainly couldn’t recall the mission statement of the school I attended, and I didn’t understand the relevance of it, other than “checking the box” of requirements.  But when we brought the team together to start working on it, that is when it really came alive to me. 

The several months of developing the mission statement were painstaking. However, the considerations we took, and process we went through to land on these twenty-one intentional words, was so rewarding to us.  We are delighted with our mission statement as we feel it truly represents what we are here to do.   

Words matter.   

This narrative exercise of creating a mission statement also really helped me understand the power of our words.  

We hope this mission statement resonates with you as well, as either a provider, an educator, a learner, and/or a member of the community.  

Acknowledgements 

Special shout out to the dedicated work of Dr. Sandra Underwood, Debra Nevels, Raul Romo, Sharon Brown, Stephanie Newsome, Gigi Sanchez, Dr. Melinda Stolley, Dr. Charles Rogers, and others who cultivate relationships to ensure the success of community outreach activities. 

Jenny Geurts is an Assistant Professor in the Institute of Health & Equity and serves as the Associate Director of Genetic Counseling in the Genomic Science and Precision Medicine Center at MCW. She has been in practice for over fifteen years and has specialized in a variety of genetic conditions including oncology, cardiology, neurology, gastroenterology, and endocrinology.  She most recently has provided clinical care with an emphasis on inherited cancer conditions at Froedtert and the Medical College of Wisconsin Clinical Cancer Center. She is board certified by the American Board of Genetic Counseling. 

Bike vs. Auto

 From the October 21, 2022 issue of the Transformational Times

Guest Director’s Corner 

Bike vs. Auto 

 By Cassie Ferguson, MD 

Dr. Ferguson discusses how empathy can lead to a deeper connection with patients… 

Two weeks ago, I got a call that no parent is truly ever prepared to get, even those of us who spend much of our lives “dress rehearsing tragedy” (Brené Brown, Dare to Lead). I was driving home from a shift in the Children’s emergency department (ED) when an unfamiliar number popped up on my phone. I immediately got a sinking feeling in my gut and answered quickly. It was my oldest son, Ben. 

“Mom, I got hit by a car but I’m okay. I just kind of hurt my leg.” 

Breathless, I paused and tried to find the next right thing to say. 

“Where are you, Benny? Who is with you?” 

“The police are here. Do you want to talk to them?” 

The police?? Suddenly the image I had in my mind of a minor accident was replaced by one that included lights, sirens, and caution tape and I could feel myself getting pulled into the mode I naturally revert to when I’m running a code: gather information quickly, prepare for the worstcase scenario, plan the next steps. I cleared my throat and spoke with the officer who explained what had happened in far more detail than my brain—now fully in flight or fight mode—was ready to hear. 

When I think back to that day, it is that retelling of exactly how my son was hit, how he rolled up onto the hood of the car, and how he was thrown back down to the ground, that still undoes me. It is hearing from Ben that he was riding his bike home from school and decided to turn to get a chocolate chip cookie from the neighborhood bakery just before he was hit that brings me to my knees. 

That night as my son and I sat in my own ED getting films and waiting to hear about the next steps, I thought about all the mothers whose injured children I’d cared for—children far more seriously injured than Ben. Children whose lives were forever changed by their injuries. Children who had died. I thought of all the exquisitely painful details those mothers had to hear and then live with for the days, weeks, and years that followed. And it struck me how little we do to prepare them for what it will feel like to live with those details. How little we prepare them for the searing anger that will suddenly take hold of you when you see your child wince in pain; for the welling up of sadness when you’re reminded of what your child will miss out on because of their injury; for the intense terror that will grab you when you drive by the scene of the accident. 

We have had so many people reach out to us since Ben was hurt, and the love that has surrounded him and our family has been incredible. I’ve observed that in these encounters the two words I hear the most from those intending to comfort and lift up are “at least.” At least he was wearing his helmet. At least he was not more badly injured. At least the driver stopped. At least… And that is all true. I am extraordinarily grateful that Ben is okay, and that his leg will heal. And I say those same words frequently in the ED intending to support my patients’ families after close calls with tragedy. I believe that while it is not necessarily in our nature, our culture prompts us to seek and point out the positive. As caregivers we are taught to be useful and provide hope—as a profession, we value optimism, grit, and resilience and these values are passed onto our patients. 

With some reflection, however, I can see that this approach is also a way to create separation between me and the person for whom I am caring; a way to put a safe distance between myself or my children and a similar, imagined tragedy. And yet empathy requires we get up close. It requires that we connect with something inside of ourselves that knows what it feels like to be them. This is not a knowing that comes from our own experiences or imagining what it would feel like to “walk in their shoes.” This is a deeper knowing that arises from vulnerability; from a willingness to be open to our own suffering, and to know our own darkness such that our care arises not from pity but from a shared sense of what it really is to be human. 

Up close we can just sit and let our presence be a signal that we are there and that we are paying attention. Up close we can use the sacred gift of touch to heal. Up close we can ask questions like, “What does it feel like to experience this as a mother?” If you asked me that question right now, I would tell you that I feel angry and sad and afraid. I would tell you that during the last two weeks I’ve experienced guilt, overwhelm, and anxiety. 

And we might notice, the two of us, that just by asking and answering that question, we can find some kind of relief, some sense of rest in the knowledge that we are not alone. 

Cassie Ferguson, MD, is an Associate Professor of Pediatrics (Emergency Medicine) at MCW and the Associate Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Mentorship is a Partnership

December 1, 2022

From the December 2, 2022 Global Health Issue of the Transformational Times

Perspective/Opinion 

Mentorship is a Partnership 

By Laura D. Cassidy, MS, PhD  

Dr. Cassidy, the Associate Dean of Global Health, has been a long-term mentor for the Dr. Elaine Kohler Summer Academy of Global Health Research program.   

Being flexible and resilient are important and unexpected skills that medical students develop as they embark upon global health research. Unlike a highly structured medical school experience, students learn to adapt when things do not go according to plans. They pause, engage in the culture, and practice patience and kindness. 

I learned as much from my medical students as they did from me—if not more.  I have enjoyed mentoring many PhD students and, in 2018, I had the wonderful opportunity to mentor my first medical students in the Dr. Elaine Kohler Summer Academy of Global Health Research Program. We traveled to Kigali, Rwanda to meet with my partners and then to Kampala, Uganda where Sarah Benett (M1) and Brittany Fickau (M1) participated in a research project with my colleagues at the Child and Family Youth Foundation. They learned many important and expected research skills, from how to design an international study, to working with clinicians, to administering the Malawi Developmental Assessment Tool (MDAT) in young children, to analyzing data, and to preparing a manuscript. 

I learned about the pressure that medical students impose upon themselves—their perception of needing to work twelve-hour days to being highly productive—and it was difficult for them to slow down and engage at African speed. An important unexpected skill that they developed was to pause and observe the culture.  In this crowded city in a low- to middle-income country (LMIC), being “punctual” takes on a new meaning. Someone can plan to be early for a meeting or clinic but if there is a bad traffic jam, they may sit for hours in traffic. The meeting may happen three hours later or not at all.  

At first, there was stress because of their internal pressure to be productive and, yet, they were dependent on a system and culture that they could not control. They learned to work with women and children in a clinic that served residents of informal settlements.  They did not speak the same language.  They were dependent on clinic staff and interpreters.  They learned to form meaningful relationships and to network.  There were reflections on how to be efficient with very limited resources and the importance of listening…even when you don’t speak the same language. One of the most import skills we all cultivated was flexibility. When things don’t go according to plan- pivot and be resilient. 

All these experiences became even more important in 2020 when the pandemic hit.  The next two M1 mentees, Lauren Tostrud and Hannah Racicot, were planning to do their summer research program in Rwanda. We did the best we could to zoom there frequently, and they worked diligently with our partners on important literature reviews about the effects of the Hutu genocide against the Tutsis. We stayed in our homes and watched movies about sub-Saharan Africa and the culture and discussed them.  Throughout the pandemic, they never complained, they remained excited about their work, and I learned about the ways they implemented the skills they acquired into their medical school training. 

I am honored to serve as a mentor to these bright and dedicated students and this role does not end after a semester or graduation. Together we learn, we support each other, and we thrive. 

Laura D. Cassidy, MS, PhD, is the Associate Dean of Global Health, Professor and Director of the Epidemiology & Social Sciences Division, and Founding Director of the Master of Science Program in Global Health Equity at MCW.