Writing is a Deep Conversation

Originally published in the 10/29/2021 issue of the Transformational Times

 

 

Writing is a Deep Conversation

 

Adina Kalet, MD MPH

 

 

Dr. Kalet, who recently published the latest edition of her book, Remediation in Medical Education: A Mid-Course Correction, which she coedited with UCSF faculty member, Calvin Chou, MD, shares her feelings about the value of writing together with others, and why authorship is among the most complex and critical aspects of what we do. She proposes that, if we can do it well, solid writing opens important conversations and can be deeply satisfying …

 

 

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

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

 

 

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

 

 

I didn’t always love to write

 

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

 

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

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

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

Learning the value of writing with others rather than alone

 

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

 

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

 

 

Now, I am an enthusiastic writing coach

 

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

 

 

Ode to our TT editorial team

 

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

 

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

 

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

 

 

So, let’s get writing!

 

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

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

 

 

 

Reposted: Our Ancestors’ Wildest Dreams: From Slave & Immigrant Families to Ivy League Residents

Updated and reposted from the April 21, 2023 issue of the Transformational Times

Our Ancestors’ Wildest Dreams: From Slave & Immigrant Families to Ivy League Residents  

British Fields, MD and Adriana Perez, MD 

 

Drs. Fields and Perez are two first-generation, underrepresented in medicine (URiM) physicians who navigated a system that once didn’t accept people that looked like them. They describe creating a space of advocacy for patients and future generations of Black and Brown medical students ...

 

“No, I’m not the interpreter. No, I’m not the cleaning staff. I’m a student doctor.” These phrases became all too familiar to us as we embarked on the journey to becoming physicians. We had gone from being praised for being the first doctors in our families, to countless encounters with patients and medical staff assuming we weren't the student doctor because of the color of our skin.  

 

The Culture Shock 

Being first-generation medical students came with a lot more struggles than we anticipated. One of the hardest challenges to overcome was that of being financially disadvantaged. Who knew there would be a whole hidden curriculum requirement? Spending money to get on an equal footing seemed like an impossible task as our families didn’t understand that there was much to becoming a doctor than what was taught in lectures.  

We both soon realized we weren’t in Kansas anymore. The rigor of medical school was something we did not fully grasp until we both failed the first quiz after two weeks of nonstop studying. After many failed exams, we spiraled into four years of secret self-doubt, self-loathing, and imposter syndrome.   

Although these feelings became ingrained in us, we knew that there was a bigger purpose at play here as our patients said “¡Si se puede hermanita, necesitamos mas doctores como tu!” (You can do it little sister; we need more doctors like you!). 

 

Our Commitment to Changing Culture 

While we knew coming into medical school that we were not in the majority, the differences in our identities and background were further amplified. Although these feelings initially weighed us down, we learned to harness and use them as fuel to support each other and other students throughout our journey. We quickly became involved with different organizations at MCW that shared goals of supporting students who are racially/ethnically and economically disadvantaged at the institution, in the community, and eventually at a national level through the Student National Medical Association (SNMA), Latinx Medical Student Association (LMSA), and White Coats for Black Lives (WC4BL).  

 It didn’t always feel like we were having an impact, but we were reminded to continue our work when we heard comments like, “Your story inspired me to take a gap year to retake the MCAT and apply next year!” 

We also sought ways to increase our involvement in caring for historically marginalized and vulnerable communities in Milwaukee. Through the Saturday Clinic for the Uninsured (SCU) and Walker’s Point Community Clinic (WPCC), we were reinvigorated to solidify our place in medicine as patients told us, “You’re the first doctor I’ve had that looks like me.” These were the times that inspired us to keep pushing in moments of self-doubt on patient rounds or failed exams.  

  

The Light at the End of the Tunnel 

At MCW, we found the things that we are most passionate about, mentors who believed in us, and served as role models. We gained the exposure and the tools necessary to continue to pursue our work in addressing healthcare disparities through research and within medical education through teaching and mentoring students at all levels of training.  

No, we are not just future physicians. We are advocates, teachers, mentors, change agents, and hermanas (sisters).  

 

British Fields, MD graduated from MCW in 2023 and is now a Pediatric resident at Harvard University’s Boston Combined Residency Program in the Leadership in Equity and Advocacy Track. 

Adriana Perez, MD graduated from MCW in 2023 and is now a resident in the Yale University School of Medicine Department of Anesthesiology. 

Photography and the Medical Humanities

 From the 4/9/2021 edition of the Transformational Times

Photography and the Medical Humanities

Carlyle Chan, MD

Dr. Chan served on the AAMC Arts and Humanities Integration Committee that drafted the FRAHME (Fundamental Role of Arts and Humanities in Medical Education) report. He shares how a deeper dive into the humanities, and photography in particular, can teach physicians to be better observers and help “defy acceleration” in their lives …

“The arts teach creative means of expression, understanding of different perspectives, an awareness of knowledge and emotions throughout the human experience, and the sharing of perceptions through artistic creation and practices in the expressive world.”

“The humanities teach close reading practices as an essential tool, an appreciation for context across time and space, qualitative analysis of social structures and relationships, the importance of perspective, the capacity for empathic understanding analysis of the structure of an argument…”

-NASEM 2018

Similar to the NASEM (National Academies of Sciences, Engineering, and Medicine) report, the object of the AAMC FRAHME (Fundamental Role of Arts and Humanities in Medical Education) initiative was to “improve the education, practice, and well-being of physicians through deeper integrative experiences with the arts and humanities.”

Photography is a visual art that consists of many sub-categories including, but not limited to, landscape, fine art, portrait, street, food, and photojournalism.  Like other visual arts a photograph can evoke very different personal responses from each individual viewing an image.  Photographer Minor White utilizes the term Equivalence to describe this response.   In psychiatry, we might describe this as a form of transference.  That is, we bring our past experiences into our present-day life.  

For the photographer, photographs have a magical element.  In a fleeting moment, a person can preserve a scene in perpetuity.  As the saying goes, “Take a picture.  It lasts longer.”  However, the camera is not as sensitive as the human eye.  With the exception of photojournalism, adjusting an image after capturing one (a.k.a. postproduction) allows the photographer the creative freedom to better represent what was seen in the mind’s eye.  This is not unlike a painter who may add clouds and move objects to improve a scene’s composition.  Both these activities, picture taking and postproduction, are creative processes.  The former requires, among other skills, powers of observation, perspective taking, composition, and appreciation of lighting.  The latter includes the same skill sets plus technical ones to help develop the final product.  

It has been said that one way to relieve stress is to find an activity that defies acceleration.  Taking and processing photos does slow down the pace of life.  One views and studies the scene to be captured and similarly views and studies the image to be rendered.  Engaging in photography not only provides a diversion from the demands of clinical practice and a respite from life pressures, but also an outlet for creative endeavors.  Photographs are another vehicle for implementing Visual Thinking Strategies while helping avoid burnout.  Parenthetically, the best camera to have is the one you have with you, be it a professional grade SLR or one on a smartphone.  Lastly, and perhaps most importantly, photography is fun.

Carlyle Chan, MD, is Professor and Vice Chair for Professional Development and Educational Outreach in the Department of Psychiatry and Behavioral Medicine at MCW. 

Remediation: A Story About Maryam

Reprinted from the January 27, 2023 issue of the Transformational Times

Remediation: A Story About Maryam 

Cassie Ferguson, MD 

 

Dr. Ferguson, who is a reknowned mentor and educator at MCW, tells the story of one student who came to her when on the edge of academic despair ...

The most rewarding mentoring relationship I’ve had with a medical student began the day she came to see me in my office to tell me about her experiences on academic leave. Maryam* had heard that I started a task force to learn about our school’s remediation process and wanted to share her story with me. I now know her to be a fierce, determined daughter of immigrants, but that day in my office she sat hesitantly on the very edge of her chair, backpack on, and glanced frequently at the door, as if she hadn’t yet decided to stay. Her voice was flat, and she rarely made eye contact when she spoke. She told me that after failing a course by less than a percentage point, she was asked to take an academic leave of absence before her first year ended. She might be able to come back, she was told, in the fall and repeat her entire first year. What she was not told was that when she drove to school the day after her leave began, her student ID would not work, and she would not be let into the school’s parking lot.  

“They just threw me away,” she said.   

Maryam’s story—her whole story—would take me years to learn. How she was diagnosed with multiple sclerosis during her first year of medical school after months of attributing her symptoms to stress. How she learned that she was dyslexic in her second year of medical school. How intense test-taking anxiety finally drove her to seek help from a psychologist. That information would be given to me in pieces as she grew to trust me, and I have slowly and carefully put those pieces together. Even now, four years after we met for the first time and three years of meeting with her every other week, I know that Maryam has not revealed all the pain she felt during that time, or during the struggles she has had since. I believe that this is in part because of her reluctance to seem as if she is making excuses, in part because of the intense shame that accompanies failing in medical school, and in part out of deference for the archaic medical hierarchy that still hangs over our profession, and the accompanying perception that my time is somehow more valuable than hers.  

That hurt we embrace becomes joy. / Call it to your arms where it can change.

-Rumi 

Medical school is not for the faint of heart. As a result, supporting medical students—particularly those who are struggling—requires love, grit, and fierce compassion. I have learned both through my own experience with failure and from working with students like Maryam that if we are to live up to the titles of teacher, mentor, and advisor we must walk with our students; we must show up even when showing up is uncomfortable. It is precisely when things get hard that we need to lean in and wade through the uncertainty and pain with our students. This requires that we recognize that we have something to offer because of our own life experiences, but I believe the bigger imperative is that we acknowledge that the boundaries of our experiences limit our ability to know what our students are going through. The only way to begin to truly understand is to get very quiet and listen to their stories.  

When we listen to a story, research using fMRI demonstrates that our brain activity begins to synchronize with that of the storyteller; the greater our comprehension, the more closely our brain wave patterns mirror theirs. The areas of our brain involved in the processing of emotions arising from sounds are activated, particularly during the more emotional parts of the story. Even more amazingly, when we read a story, the networks of our brain involved in deciphering another person’s motives—in imagining what drives them—prompts us to take on another person’s perspective and even shift our core beliefs about the world. 

It is impossible to engage properly with a place or a person without engaging with all of the stories of that place or person.

-Chimamanda Ngozi Adichie 

These findings should not come as a surprise to those of us whose work includes caring for patients. As an emergency medicine physician, I have heard thousands of stories. Whether they are snapshots relayed through EMS of how a 14-year-old child was shot in the head at two in the morning on Milwaukee’s north side, an exquisitely detailed account of a 3-year-old’s fever and runny nose from her mother, or a reluctantly provided history of pain and despair that led a 12-year-old to try and kill himself, each of these stories should transform us. They should move us to want and do better for our patients, for our communities, and for our world.  

At the same time, it is essential that as physicians and educators we also recognize what Nigerian author Chimamanda Ngozi Adichie describes as the “danger of the single story.” As an emergency medicine physician, I only hear stories of peoples’ suffering; I am listening to them when they at their most vulnerable, on what may be the worst day of their life. I only hear of the tragedies that have befallen a neighborhood we serve. As an educator who mentors students who are struggling, I often miss out on their stories that are not about failure or crisis. Adichie warns that when we only listen for the single story, there is “no possibility of feelings more complex than pity, no possibility of a connection as human equals.”  

So then our charge as physicians, as educators, and as human beings is to make room for more than just a single story—to remember that all of us are much more than our worst moments, and that compassion and connection arise authentically when we recognize the full spectrum of humanity in one another.  

*Names have been changed.  

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

An LGBTQ+ Patient Asks: Can You Recommend a Good Primary Care Provider?

Originally published in the 12/18/2020 issue of the Transformational Times

An LGBTQ+ Patient Asks: Can You Recommend a Good Primary Care Provider?

Andy Petroll, MD

Dr. Petroll, who conceived and founded the Froedtert & MCW Inclusion Health Clinic, describes the role that the clinic plays to enhance services to the LGBTQ+ community in Milwaukee and beyond...

Since I began my career in medicine nearly twenty years ago, and as a member of the LGBTQ+ community, I would hear this question frequently. Usually, the next sentence was the questioner expressing a preference for a provider who was, themself, a member of the LGBTQ+ community, but stating that they would be willing to settle for someone who wasn’t. At minimum, they wanted a provider who would make them feel comfortable and would easily understand them when they talked about their sex life, their gender identity, or their relationships with their partner and families, while also providing them with the care they needed. I’d always do my best to make a recommendation, but I knew that what they were looking for was hard to find, especially if their insurance required them to stay within one health system or if they wanted a provider in a certain part of town. A handful of large and mid-sized cities had LGBTQ-focused clinics, many of which had been well-established for decades, but here in Wisconsin, there were none.

Identifying concerns for LGBTQ+ patients

What would often follow this question was a story about a negative experience in healthcare. Sometimes, their provider had not understood or had not wanted to hear about the kind of sex they were having. Maybe they were asked which parent was “really the mother.” Maybe they were called out of the waiting room by their legal name, rather than the name they actually used and that reflected their gender identity and appearance, sending shockwaves of embarrassment, anger, or fear through their bodies immediately before entering the exam room. Maybe they had asked for medication for HIV prevention and their provider was unfamiliar with or unwilling to learn about it or, worse, chastised them for even asking. In some cases, they had subsequently acquired HIV. Maybe they had had a good experience with their provider, only to have a staff member ask them an inappropriate question, or, horrifyingly, try to convince them that their sexual orientation or gender identity was immoral. Maybe their provider was “nice enough,” but “seemed uncomfortable” discussing sexual health, or never offered appropriate screening for STIs or certain kinds of cancers.

Of course, the stories I heard were a skewed sample. People who were satisfied with their care wouldn’t have reason to ask me for a recommendation or tell me their story. Nonetheless, after years of these conversations, I knew there was a demand for better healthcare for LGBTQ+ people. People wanted a combination of things:

• A physical space that made them feel like they belonged

• Clinic staff that would understand them without having to explain themselves

• A provider who would know what preventive tests they needed and who would comfortably listen to and competently answer questions about their sexual health

• A provider who could explain and prescribe medications that would affirm their gender

A provider who would know that it may have taken extraordinary courage for them to even come to the appointment.

Meeting an unmet need

The hope to meet these expectations formed the vision for the F&MCW Inclusion Health Clinic. The journey from conceptualization to inauguration was long. Along the way, when presenting this idea to senior leadership, I was met with enthusiastic support beyond my expectations. Appropriately, we were asked to formulate business plans similar to any new, proposed venture. After revising our plans, assembling MCW providers with significant expertise, training staff, decorating our clinic space, developing of a webpage, and doing outreach at community events, the plans for the clinic were approved. After more than three years of planning, we opened the F&MCW Inclusion Health Clinic in July 2018.

The goal is for the clinic to deliver comprehensive care within a clinical space that feels familiar and welcoming by providers who are experienced with and passionate about LGBTQ+ health. The clinic opened with six providers from several specialties (Internal Medicine, Infectious Diseases, Obstetrics/Gynecology, Psychiatry). The clinic population grew steadily, limited only by the number of new patient openings we had available. Over time, we delightedly welcomed additional enthusiastic providers from additional specialties (Endocrine, GI) into the clinic. Recently, we onboarded two new primary care providers to help meet the demand for our services including,notably, the clinic’s first transgender physician, bringing the number of providers to twelve.

The response

Reactions to the clinic have been more positive than I had even imagined. Often, patients start their first visit by expressing gratitude that the clinic was opened, even before we have provided them any care. Others express that their visit to the IHC was the first time they felt truly comfortable in a healthcare setting. Some are elated to begin their journey of gender affirmation easily and without barriers. Parents have been relieved to finally find a place where their adolescent children (we see patients age 15 and older) can get the care they need and have their questions answered. Community organizations and major corporations have invited us to speak about the clinic and a national conference requested that we present on the process of opening it. Patients travel from Milwaukee, throughout Wisconsin, and at least two neighboring states to see us. Our patients have been integral in providing feedback that has helped us improve. Some have pointed out the flaws in the multitude of systems and personnel that constitute their experience in our healthcare system. Some wish they didn’t have to wait so long to see us (thankfully, now, they don’t!). We are grateful for all types of feedback. We view this clinic as a community resource that should be continuously shaped and grown through input and feedback from the community we serve.

Do we really need a specialized LGBTQ+ clinic? Shouldn’t every provider be able to provide care to this population?

These are appropriately challenging questions that I heard several times during the journey to develop the IHC. In theory, the questioners are right. Ideally, all clinics and providers should be able to provide competent, comprehensive, and affirming care to LGBTQ+ patients. In reality though, without purposeful efforts in every clinic, staff members who create a welcoming environment, and providers who become culturally fluent and clinically competent delivering LGBTQ+ healthcare, patients will continue to have the kinds of negative experiences I described above.

Reaching beyond our walls

In addition to striving to be a center of excellence for LGBTQ+ healthcare, we also view the IHC as a catalyst for improving LGBTQ+ health in our region. We regularly provide clinical education on LGBTQ+ health to providers in our system and our state. This semester, our newly approved M4 elective in LGBTQ+ health began offering MCW students the chance to graduate with a more in-depth understanding of how to provide LGBTQ+ healthcare. We also regularly provide clinical experiences for MCW housestaff. I hope that with continued educational efforts, there will come a day when a clinic like the IHC is no longer needed. Until then, the IHC, and other clinics like it, are essential for the lives, health, and dignity of LGBTQ+ people.

It has been an honor to be able to bring the IHC into being. I couldn’t possibly name all the people whose support and hard work were essential in developing the clinic. Nonetheless, I am extremely grateful for their work and their encouragement. I am humbled by the passion and dedication of my colleagues in the clinic, both providers and staff members, and by the administrators from multiple departments who pour their hearts into supporting this multispecialty clinic.

Our work will continue. We see many ways to expand the size and scope of the clinic to better meet our patients’ needs and will continuously pursue these ideas. We will continue to solicit and react to our patients’ feedback with the goal of optimizing their care. We will continue to educate learners to populate the healthcare professions with competent and enthusiastic providers of LGBTQ+ healthcare. We will know we achieved our goal when every LGBTQ+ person can walk confidently, without fear or hesitation, into our clinic, and every medical clinic, and receive outstanding, complete care, with the dignity they deserve.

RESOURCES:

• If you want to learn more about the Inclusion Health Clinic, visit Froedtert.com/lgbtq

• If you are interested in having our group provide LGBTQ health training for your clinic or department, please contact me.

  
  

If you are interested in self-directed learning on LGBTQ health, I recommend the National LGBTQIA+ Health Education Center (https://www.lgbtqiahealtheducation.org/) which has dozens of high- quality learning modules.

Andrew Petroll, MS, MD, is a Professor in the Division of Infectious Diseases in the Department of Medicine at MCW. He is Medical Director of the Inclusion Health Clinic.

The Difference Between Confidence and Competence: Growing with a Confident Humility

Originally publishsed in the June 18, 2021 issue of the Transformational Times

 

The Difference Between Confidence and Competence: Growing with a Confident Humility

 

 

Adina Kalet, MD MPH

 

 

Dr. Kalet shares one of the “hidden” tasks that each new resident faces: the need to develop competence without risking becoming overconfident. In this encore essay, she shares some of the pitfalls and invites housestaff to be part of the journey ...

 

 

“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” 

- Mark Twain

Thousands and thousands of newly minted physicians begin residency training each year. At MCW, we welcomed our new residents in July, many of whom movied to Milwaukee for the first time. This is a poignant, anxiety-provoking, and exciting time, a new beginning, and a critical transition on the journey of becoming a seasoned and caring physician.

 

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

 

The difference between confidence and competence

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

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

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

“Confident humility”

In his book, Think Again: The Power of Knowing What You Don't Know, organizational psychologist Adam Grant reminds us how critical it is to cultivate a mindset “confident humility.” From this stance, one can act even when they are not certain of what is right, but they act with a scientist’s curiosity and perspective, seeking evidence that might refute their current beliefs. Grant reviews the accumulating evidence that intelligence does not protect us from common human foibles. In fact, many researchers have pointed out that smarter, more tenacious people (like many medical students and residents) are prone to blindness to changing conditions and may have a harder time adjusting to new circumstances. They have difficulty admitting when they are wrong. Stubborn, inflexible physicians will run into obstacles when trying to provide competent, character-driven medical care.

 
If, however, a hypothesis survives repeated attacks, it becomes the working theory until such time as it can be disproven. Approaching one’s own competence in this rigorous way—repeatedly challenging beliefs and understandings—keeps a person humble, curious, adaptable, and learning. It is the key to deep, durable, and lifelong learning. 

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

 

Like many of us, I am a transplant from elsewhere, having arrived in 2019. I have traveled extensively and have lived and worked in other institutions in the northern and southeastern United States. To my delight, I have come to know MCW as a uniquely confident, humble place to work and learn. It is remarkable to me—given the excellence in clinical care and research—how little our institution tolerates the everyday self-promoting arrogance typical at many of our peer institutions. This institutional culture is a towering strength and I believe is one of the many reasons we have adapted and thrived for a century and a quarter. 

Adam Grant points out that a hallmark of wisdom is knowing when it’s time to rethink and collect data that might refute and, therefore, cause you to abandon what you think you know and who you think you are. This habit of honest reflection and an openness, or even a delight in learning when you are wrong, is a path toward a deeply satisfying confidence. It’s true in business and especially true in medicine.

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

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

Reimagine: It’s Easy if You Try

 From the 1/15/2021 issue of the Transformational Times

Reimagine: It’s Easy if You Try




Balaraman Kalyanaraman, PhD – Professor, MCW Department of Biophysics






This amazing, prescient essay was originally published almost three years ago! We hope you can sense Dr. Kalyanaraman's excitement about Katalin Karikó, PhD and her research. Dr. Kariko and her team were just awarded the 2023 Nobel Prize in Physiology or Medicine for their work laying the groundwork for an mRNA COVID-19 vaccine ...

“Anything you do I can do better, but only if you do it first. That’s because I have no imagination, only a re-imagination.”
–Andrew Keith Walker

Right now, I bet you are telling someone, or have been asked, to reimagine some aspect of your work or life. Or perhaps you are reading about or watching an advertisement focused on reimagining. But what does reimagine mean? According to Merriam-Webster, the first use of the word was in 1825, and it is now among the top 1% of words that are looked up. I don’t know about you, but the word “imagine” makes me happy; hearing it frees up space in my brain. Conversely, the word “reimagine” makes me feel tense and anxious; it sounds task oriented and somewhat contrived! Well, the more I’ve pondered the word “reimagine,” the more I’ve realized I do not have to feel this way!

While trying to understand “reimagine,” I came across this anecdote about imagination from the book The Element: How Finding Your Passion Changes Everything by Ken Robinson, PhD:

An elementary school teacher was giving a drawing class to a group of six-year-old children. At the back of the classroom sat a little girl who normally didn’t pay much attention in school. In the drawing class she did. For more than twenty minutes, the girl sat with her arms curled around her paper, totally absorbed in what she was doing. The teacher found this fascinating. Eventually, she asked the girl what she was drawing. Without looking up, the girl said, “I’m drawing a picture of God.”  

Surprised, the teacher said, “But nobody knows what God looks like.”

The girl said, “They will in a minute.”

The girl was making an image of something she could not feel with her senses but could feel in her heart!

Try to reimagine “Imagine” written by John Lennon and inspired by Yoko Ono:

Imagine there’s no heaven

It’s easy if you try

No hell below us

Above us, only sky

Imagine all the people

Living for today

Hmm, the song is not the same when reimagined, right?

Clearly, reimagination requires a lot more imagination with a lot more passion!
In business, people “think outside the box” and reimagine everything from A to Z! (Do you have a novel idea? Sorry! Amazon already claimed it.) I considered synonyms for reimagine: reconceptualize, re-envision, reinvent, rethink, refine, re-create, reevaluate, or reinterpret imaginatively. It seems that “reimagine” is a word meant to inspire us; it captures the essence of what we need to do together or in collaboration that builds upon our strength.

Below, I’ve given my thoughts on reimagining a few aspects of research and life that are personal to me, but I know there are plenty more that you can reimagine. Some of these also could be applicable to other areas, such as workplaces, social systems, communication, teaching, childcare, sports, and recreation.


Reimagining ideas in research

How does one reimagine research ideas? Here are some ways to get started:

• To find one good idea, you ought to begin with several ideas. It’s important, though, to work on only one idea at a time.
• Become obsessed with your idea. Believe in yourself but be prepared to modify your idea.
• Always be ready to talk about your research ideas passionately at different levels depending upon your audience.
• Don’t be afraid to talk to your colleagues about the grant that was not scored or did not score well enough to be funded, even if they are not in your field!
• Rejection happens to everyone, no matter your reputation in your field. Even Nobel laureates experience it. Ideas, new and old, are rejected all the time. What matters is how you respond to criticism and reshape your ideas!
• Even though you may have the most cutting-edge idea, your proposal may lack widespread approval in the study section and require tweaking. Sometimes you have not exactly read between the lines in the summary statement, and you keep resubmitting the same idea while expecting different results. This is when you really need to get out of your comfort zone and reimagine—consider a chemist/biochemist collaborating with an immunologist, a vaccine researcher (perhaps, an extreme example)!

A great example of reimagining - Katalin Karikó, PhD

Katalin Karikó, PhD, a Hungarian-born biochemist, first laid the foundation for the messenger RNA (mRNA) therapeutics that have been used to develop the COVID-19 vaccine. Messenger RNA transfers the information from DNA to ribosomes to make specific proteins in cells. Karikó hypothesized that if a genetically coded synthetic mRNA was injected into mice, the cells in the body would make the specific protein instructed by the synthetic mRNA. In the 1990s, when she was faculty at the University of Pennsylvania, Karikó submitted several grant proposals on this idea. The proposals were repeatedly rejected, as the reviewers’ thought this concept would not work because of the potential degradation of the synthetic mRNA in the body and the potentially dangerous inflammatory immune reaction.

Despite professional setbacks, Karikó believed in her idea and continued the work with little money. Karikó began collaborating with immunologist/mRNA vaccine researcher Drew Weissman, MD; together they came up with the idea to modify the structure of uridine, one of the four nucleosides of the building blocks of RNA. As they predicted, the modified mRNA encapsulated in a lipid nanoparticle was taken up by cells; Karikó and Weissman then extended this technology to deliver the synthetic mRNA in mice.

They published a paper in 2005 and obtained NIH funding, and this new technology was patented by the University of Pennsylvania. BioNTech, a German company known for developing vaccines, licensed this technology, as did Moderna, a biotech company in Boston.

Karikó is now the senior vice president of BioNTech RNA Pharmaceuticals. The Pfizer-BioNTech partnership developed an mRNA vaccine designed to induce neutralizing antibodies against a portion of the SARS-CoV-2 “spike” protein that the virus uses to gain access into human cells. The antibodies against the “spike” protein recognize and neutralize SARS-CoV-2, thus preventing the infection.

Although Karikó encountered early setbacks in her research, she never gave up and always “imagined how the synthetic mRNA approach could treat so many diseases.”


Reimagining a work-life balance

Ideally, having a good work-life balance would give one satisfaction, fulfillment, a sense of purpose, and empathy.

During this pandemic, a barrier to optimal work-life balance exists for parents (more often mothers), particularly single parents, as they juggle work with childcare and home schooling.

People in the workforce are on different trajectories. Some just starting, some climbing up and trying to reach cruising altitude, some pushing the “reset” button, and some pushing the “rest” button. All too often, people (myself included) are too carried away in their work and give little attention to their life outside of work. Organizations conduct workshops to teach us ways to restructure our lives, which may not seem like rocket science, but it may be nearly as difficult. In what ways can we strike a good work-life balance?

I leave this to the experts to ponder. If we take the time to pause and contemplate it, we will be off to a great start.



Reimagining relationships

Professional advice on improving relationships is available everywhere, in workshops, talk shows, magazine articles. This is all well and good and may work for some people, but often we just need to reimagine the little things that are forgotten. Yes, I understand, “Physician, heal thyself,” and I think it goes well with “better late than never.” In his article, 10 Ways To Reimagine Your Relationship, Barton Goldsmith, PhD, says “doing new things together, and old things in new ways, makes your love stronger.” He proposes a number of ideas to reimagine relationships:

• Let go of the past. Learn to forgive and forget, and focus on the positives. Be grateful for each other and treat each day as a blessing. Write down at least one thing (daily or weekly) that you appreciate about your partner.
• Create your fantasy vacation. Daydreaming about your ideal vacation can be fun! During the pandemic, this may be hard to fathom, but things will get back to normal. And when you are able to take a vacation, you will be ready.
• Take a class together. Or do other activities with your partner: Take a virtual cooking class, learn CPR, learn a new language, take a walk through the park.
• Have lunch together once a week. This will help break the monotony.
• Ask your partner 20 questions. Show curiosity in your partner’s interests. What are some things you’ve always wanted to know about your partner but never took the time to ask?

To this list, I’ll add: Never be afraid to poke fun of yourself. Self-deprecating humor can ease those tense moments.

I am sure you can find many more fun things to add to this list.

Reimagining stress reduction through mindfulness

Emerging science convincingly shows that routine exercise, yoga, meditation, and mindful meditation can alleviate stress, anxiety, and depression. Herbert Benson, MD (Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital) pioneered the beneficial effects of meditation (e.g., lowering blood pressure and heart rate, and increasing brain activity). Functional MRI studies support the beneficial aspects of meditation to combat depression and anxiety.

Suzanne Westbrook, MD, a retired doctor of internal medicine, says, “our mind wanders all the time, either reviewing the past or planning for the future.” Mindfulness teaches the skill of paying attention to the present, and that life is in the moment. Mindfulness is not about trying to empty the mind; rather, it is about remaining present. It is a practice designed to improve brain health. Taking a slow deep breath through the nostrils (i.e., inhaling) and then slowly breathing out through the mouth (i.e., exhaling) will help you relax, reenergize, and reconnect. Repeat this inhalation/exhalation technique about 10 times. Use it as a “balance break” as needed during tense times (e.g., grant preparation). Mindfulness will improve your focus on the task at hand and face challenges with a healthy attitude, reduced stress, and increased energy. Mindfulness could be incorporated into many things—eating, conversation, listening. Some people practice 20–30 minutes of meditation that involves “mindful body scan,” during which one notices the sensations one is feeling without judgement. Indeed, mindfulness is presently at the top of the wellness universe as a stress reduction technique!


Let us imagine and then reimagine 2021! But not without first learning from 2020. Yes, hindsight is 20/20.



Balaraman Kalyanaraman, PhD, is Professor and former Chair of the Department of Biophysics at MCW.

The Transformational Times is Taking a Sabbatical (although the blog will continue)

From the September 29, 2023 issue of the Transformational Times

Take Our Survey

The Transformational Times is Taking a Sabbatical

Adina Kalet, MD, MPH

Born on the fly to keep our medical community thoughtfully connected through the pandemic, the Transformational Times--like the rest of the world--is establishing its “new normal.” To do this, we are pausing weekly publication to gather reader input and intentionally consider how best to serve our community while continuing to reflect the transformational work at the Medical College of Wisconsin around character and caring alongside clinical excellence. Dr. Kalet shares what will happen behind the scenes, and invites readers to help shape the future of this thoughtful, medical education publication by participating in our survey ...

 

Dear Readers,

September is a time for renewal. Kids are back in school, the summer has come to an end, and in my faith, we gather to celebrate the birth of the world through our “high holy days.” At the Kern Institute we have been taking time to reflect and plan. We spent a day in retreat a couple of weeks ago, to contemplate where we have been and consider where are going next. In that spirit, the Transformational Times team is taking a short sabbatical to refresh our processes, update our vision and begin again.

 

The Transformational Times was born during the first days of the COVID-19 pandemic in March 2020, when the Medical College of Wisconsin (MCW) sent all of the students and many faculty and staff members home. As I have recounted before, we decided to transition our existing quarterly newsletter into a weekly offering, and rename it the Transformational Times. We hoped this would keep our work alive and support our medical education community.

 

As those early weeks turned into months then years, we kept up our pace, publishing 178 weekly issues of the Transformational Times and two curated books. We have taken only a handful of holiday weeks “off.” We are proud we have helped people share personal stories about their work and worlds. The tagline to be “delivering stories of hope, community, caring and resilience to our community,” has largely been honored.

 

The Transformational Times has been a success in many ways. We have grown our readership both inside and outside of MCW and received a great deal of supportive feedback and a few critical comments; we take all of our feedback very seriously. Through these efforts, we have hosted a hardy, broad conversation around the transformation of medical education and accelerated the expansive acceptance at MCW and beyond of new models for educating physicians that embody the character and caring essential to health and health care. This is the mission of the Kern Institute.

 

What to expect in the future

With the pandemic largely in the rear-view mirror, we are taking a break to reimagine the Transformational Times. Over the next few weeks, under the leadership of our new Co-Editors-in-Chief Wendy Peltier, MD and Himanshu Agrawal, MD, we will seek input from our readers. Our Editorial Board will ensure we continue to prioritize creating community and encouraging storytelling that promotes the ideas and discourse at the heart of health professions education.

 

Drs. Peltier and Agrawal will do this work along with our multidisciplinary editorial board which includes Bruce Campbell, MD (founding Editor-in-Chief); Kathlyn Fletcher, MD; Adina Kalet, MD, MPH; Karen Herzog (Milwaukee-based journalist); Justine Espisito, (Kern Institute staff); Joy Wick, (Kern Institute Communications Consultant); William Graft. Jr., MD (Resident, Internal Medicine/Psychiatry); and medical students Julia Bosco, Linda Nwumeh, Wolf Pulsiano, Sophie Voss and Emelyn Zaworski.

 

Our immediate goals are to work with Kern Institute members and the MCW leadership to:

• Refine our processes, policies, and submission guidelines
• Publish regular, theme-based issues that engage broad swaths of our community
• Leverage our Philosophies of Medical Education Transformation Lab (PMETaL) to build a civil discourse framework that enables diverse and profound conversations about our professions
• Have our editing team, including two former journalists, actively assist and encourage writers of all comfort levels
• Explore more flexible publishing platforms (video, audio, social formats, etc.)
• Integrate our work with the Kern Institute Podcast Network

 

We plan to continue and expand popular features of the Transformational Times, including:

• Themed issues for special days (e.g., Veteran’s Day, Valentine’s Day, Thanksgiving) and events in the medical education year (e.g., The White Coat Ceremony, Match Day, Graduation)
• Programmatic reports from the Institute, including The Learner Continuum Hub, Educator Development Hub, and the Medical Education Data Science, Human Centered Design, and the Philosophies of Medical Education Transformation labs
• Project reports from the Transformational Innovations (TI2), KINETIC3, and the MCWFusion curriculum, including Learning Communities, The Good Doctor Course, the Character and Professionalism Thread, and Learning Dashboards
• Works-in-progress on medical school to residency transitions, character measurement, and professional identity formation
• Summaries of Qualitative Research Methods, the Kern Institute Collaboration Scholarship (KICS) group journal clubs and collaborations, the Medical Education Matters Podcast, and our Medical Education Transformation book series
• Collaboration reports with Academic Affairs, the MCW Affiliated Hospitals (MCWAH) GME programs, MCW-Central Wisconsin, MCW-Green Bay, Thrive on King, the School of Pharmacy, the Physician Assistants Program, Genetic Counselling, Anesthesia Assistant Program, and the Graduate School
• Reflection on and coverage of the emerging issues of our times

Please Provide Input

While we won’t be publishing for a few weeks, we will be accepting submissions, and we encourage you to reach out to us with your ideas.

 

We want to hear from you! Whether this is your first or your 178th time reading the Transformational Times, please provide us feedback by taking our survey. If you have advice, opinions, or critiques, please reach out with your thoughts and feelings during this time. And thank you for reading, sharing, and caring.

 

In the meanwhile, watch this space for announcements of our Kern Institute events and related content.

Take Our Survey

Sincerely,

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.