Reflection on Residency and the ACGME during a Pandemic

 From the 6/11/2021 newsletter

Take 3 with Eric Holmboe, MD

 

 

Reflection on Residency and the ACGME during a Pandemic

 

 

Eric Holmboe, MD, MACP, FRCP-Chief Research, Milestone Development, and Evaluation Officer, Accreditation Council for Graduate Medical Education (ACGME)

 

 

 

Dr. Holmboe, a leader in graduate medical education, describes an important lesson he learned during training, covers what the ACGME has done to adapt to the pandemic, and gives this year’s graduates some sage advice. He was interviewed by Transformational Times editor, Kathlyn Fletcher, MD MA.

 

 

 

Transformational Times: Tell me a story about something that occurred during residency that was influenced the development of your character as a doctor and a person.   

Dr. Holmboe: One moment that stands out is from my chief residency.  The chief of service at the West Haven VA was Asghar Rastegar.  One day he asked me how the year was going.  I told him that it was great but that I always felt as though I didn’t know enough.  He leaned back in his chair and said, “Eric, I hope you never stop feeling that way.”  I realized then that Asghar was the epitome of that kind of doctor.  He role modeled that desire to always be learning and was explicit about how important it was.  He said “I don’t know” when he didn’t know.  He was a co-learner with others, even though he was brilliant.  I realize now that those are the people that I admire the most.  They are humble and quiet and always learning.  

 

Transformational Times: What do you think was the most important role the ACGME played during the past year?  Was that something you (as a group) explicitly decided?

Dr. Holmboe: The ACGME made an explicit decision to be flexible and to respond quickly as the pandemic unfolded.  We wanted to provide programs with relief and give them flexibility to do what they needed to do, but we also wanted to hold firm on things like duty hours.  We created first a tiered pandemic status, then revised the program to an “emergency status” so institutions could have sufficient flexibility to meet the demands of COVID surges in their communities, including moving residents and fellows around to help with the evolving patient care needs. 

A specific intervention that proved to be very helpful was setting up routine national DIO (designated institutional official) calls by our Sponsoring Institution team to provide the DIOs with information and also to get input and feedback from them about what was happening on the ground.   We also quickly put together a supplemental survey for the annual update so that we could better understand what was happening around teaching and the health impacts of the pandemic.  It was good that we did all that work in the spring because the winter surge was so much worse.

We also routinely asked ourselves, “How can we be more helpful?”  We tried to be deliberate and proactive. For example, we moved our faculty development assessment courses from in-person to online and also made the courses free.  In the end, we know that the GME community made many sacrifices, including residents and faculty that got sick, and some that died.  One faculty member from Geisinger contracted COVID19, was on ECMO and ultimately needed a double lung transplant.  His story can be seen in this public service announcement, encouraging people to get vaccinated.  The ACGME recognizes the loss and sacrifice that occurred in our community.  

 

Transformational Times: What words of wisdom would you share with the residents who are graduating this month?

Dr. Holmboe: Remain curious.  Take care of yourself (I didn’t do it as well).  I do try to avoid nostalgialitis imperfecta profunda (the “profoundly imperfect recollection of or yearning for the past”).  I loved my training but would not repeat it. 

Stay involved.  Your generation has already been amazing in this regard.  Continue with your advocacy for yourselves and others. 

Humility is really important.  Medicine suffers from arrogance.  You are a member of a team, an interprofessional team.  You are not the most important person on a team – the patient and family are and remember they are also part of the team. 

Always remain patient- and family-centered.  Think about your community, outside the hospital walls.  Your goal is to positively impact the lives of others through service.

Co-produce your work; co-produce your assessments; co-create learning. 

 

To Kill A Year - Poetry by Olivia Davies

 From the 5/6/2021 newsletter

Poetry by Olivia Davies

To Kill A Year

I wish I could show you in news clips

The loud clang of the beginning,

The silent empty of the middle,

The painful drone of the end

I wish I could show you in pictures the loss, 

But it was hidden behind, between, below

masks

the most deafening silence

the most provocative noise

I wish I’d never have to show you at all.

Olivia Davies is a graduating 4th year medical student who will be starting her residency training at Massachusetts General Hospital this summer. Her poem, To Kill A Year, will be featured in the upcoming edition of MCW’s Auscult: A Literary and Arts Journal.

Ms. Davies is an Associate Editor of The Transformational Times. 

COVID-19 Vaccination Clinic Reflections from MCW’s Research and Clinical Nurses

From the 5/6/2021 newsletter

Perspective/Opinion

COVID-19 Vaccination Clinic Reflections from MCW’s Research and Clinical Nurses 

Compiled by Hope Campbell, MSN RN 

Ms. Campbell, a research nurse in the Department of Neurology, volunteered in the MCW COVID-19 Vaccination Clinic. In honor of National Nurses Week, she offers her reflections on that experience and has compiled messages and thoughts from several other nurse-volunteers … 

Happy Nurses Week to all the MCW nurses and nurse practitioners! 

When I started working remotely in March 2020, I felt helpless and guilty that I was in the position of being able to work from home while my nurse friends were working on the front lines in emergency departments and ICUs.  I felt like I should be out there alongside other nurses caring for the very sick. My position as a research nurse made me feel like an imposter.  

When the opportunity arose to administer vaccines at the newly created MCW COVID-19 vaccine clinic, I knew that I wanted to be part of the effort.  After the MCW pharmacy students, who were “first-in” vaccinators, had to return to their classes, our group of MCW nurses and nurse practitioners volunteered on a regular basis to work alongside the pharmacists, pharmacy students, medical students, physicians, and medical assistants to staff the clinic.   

I’ve worked on this campus for almost twenty years but have only been employed at MCW for three. Meeting people and being able to volunteer was incredible.  All of us had other duties within our departments, but still made the time to volunteer because it felt great to be a part of something so meaningful.  

During the vaccination clinic, I met coworkers face-to-face that I had previously met only via email.  I had emotional conversations with community members coming in for vaccines that had not spoken to another person out of their “bubble” in eight months. After a year of being apart, families would now be planning get-togethers, thanks to the MCW vaccine clinic.  I even had the opportunity to vaccinate my parents and my sister.  I listened to stories of family members that had died of COVID-19 and how thankful the person sitting in front of me was that they could get the vaccine. I’m thankful for these short but powerful conversations that were had. They will stick with me for a long time.  

The beautiful thing about being a nurse is we can serve and provide care in so many ways.  That doesn’t make us any less of a nurse if we aren’t a front-line worker. I’m so proud to have been involved in the clinic even if it was a small role.    

Here are the thoughts from some of the MCW nurses that volunteered in the clinic:

Barbara Shimada-Krouwer, RN, BSN

I’ve been an RN for over thirty-six years. I felt that being a nurse was my “calling” since I was five years old. I’ve specialized in neuro, cardiovascular, and clinical research. 

During my career, I’ve cared for hundreds of patients, from post-op spinal fusion and stroke patients to CABG and post-cardiac catheterization patients.  I have been part of countless research studies that were designed to provide new advances in pharmaceuticals, treatments, and devices to treat a myriad of diseases. I have even treated COVID-19 positive patients involved in clinical trials.

The thanks and tears of gratitude that I have received from those that I have vaccinated will forever be part of me. People were grateful for many things: 

Vaccinated to see their first grandchild. Vaccinated to be able to hold their elderly parent in a nursing home. Vaccinated to be able to go back to work. Vaccinated to save their life. 

Because of the sheer gravity of this pandemic, I feel that I have been able to contribute at least a small part in getting this infection under control. The vaccination team coordinators were truly amazing. It was inspiring to work alongside so many dedicated professionals that shared the same goal of getting people vaccinated!

Being able to be part of the COVID-19 vaccine clinic has been the most important nursing role that I have ever performed. The countless lives saved, and illness prevented is why I am a nurse. 

Karen Schmidt, RN, CCRC

As a nurse who has been out of acute care and unable to help in the direct care of COVID-19 patients, this was a great opportunity for me to utilize my nursing skills to help be part of the solution to this pandemic.

It was a joy to help out in the vaccine clinic!  I loved meeting all the very appreciative vaccine recipients and volunteers from all over campus.  I really appreciated how well the clinic was run, and the focus on teaching whether it was educating recipients on the vaccine or watching the pharmacy and medical students learn how to give their first IM injections.

Roxanne Pritchard, RN, BSN

I was honored and excited to be able to volunteer in the vaccine clinic and appreciated the support I received from my department which allowed me to volunteer in the clinic during normal work hours.

I looked forward to meeting those who were being vaccinated – to hear their stories, discuss their concerns, address their questions and ensure their safety and well-being.  These experiences reminded me why I became a nurse.

I was in awe of the number of faculty and staff who volunteered their time in the clinic and was proud to be a part of a very organized process involving multiple departments within MCW. 

Sonya Carpenter, RN

While my role was primarily administering the vaccine, I was impressed to see what it took to run a clinic comprised of volunteers to take on this huge task. Everyone involved, from front door screeners to the staff preparing the vaccine and monitoring the vaccine expiration time (six hours from drawing up to in a person’s arm) to those cleaning the workstations after every participant to the vaccinators, to the volunteers monitoring the patients for 15-30 mins afterwards for risk of anaphylaxis were wonderful. I was very honored to be part of a team that included volunteers of all areas MDs, pharmacists, nurses, medical assistants and administrative staff. This vaccination clinic has vaccinated over 10, 000 people.

To prepare, I read up on patient education for the participants (what to expect after receiving vaccine). Still, I was surprised by the number of questions people asked. Many people had gotten their information on social media and from news outlets. Unfortunately, a lot of what they had learned was not from reputable sources, so my advice was often to check with their healthcare providers, the CDC, the Wisconsin Department of Health Services, and other reputable sources. 

I consider myself very fortunate that, as a front line worker, I was in one of the first groups to receive the vaccine. The people to whom I administered the vaccines were primarily over sixty-five, educators, childcare workers, police, fire, and correctional staff. Many of them were so grateful and humbled to be able to receive this vaccine. It was rewarding to be part of that.

Sherin Uthuppan, RN

It was such an honor to be able to participate and to have played a part in bringing us closer to the end of this pandemic. I thought it was inspiring how nurses from all different fields heard the call for help and were able to come together quickly to save so many lives. Some were new grads. Some were non-clinical. Heck I’m sure there were nurses who came out of retirement! While working at the clinic, I met a lawyer whose first career was as an RN. He was so happy to finally have a chance to use his hands-on nursing skills for the first time in forever. I thought that was really cool! 

Jesus Chavez-Penaloza, LPN

I enjoyed assisting and getting to know different people from different departments.  I was inspired also by the new administration, to be a patriot and assist teachers, police, and other groups able to come in.  Even the non-clinical volunteers, such as the people who helped to clean those who double-checked the forms were great. I'm a team player and felt the need to assist and keep our associates safe and informed.  I wanted to absorb the information to share with my family.

We encountered challenges, such as when some people did not have access to email to receive a reminder to come in for the next appointment.  I really liked how Dr. Karen MacKinnon adjusted the flow to best serve the community. All in all, it took true team effort to make the clinic a success.  

Lindsay Ruiz, RN

I thought the atmosphere was overall very positive. It was amazing to be able to see people from all over come together for this one initiative. It was inspiring to hear people’s stories of hope and their motivation for getting the vaccine. Despite having some issues with staffing shortages, the volunteers seemed to have great teamwork attitudes and were motivated to get as many people the vaccine as possible. 

Renee Dex, RN, BSN

For me... it was so nice to be a "nurse" again as most of my days spent doing administration tasks. It was important for all of us to be a part of "something bigger" especially since we had been working so hard on COVID-19 clinical studies where we were involved with data collection, treatment protocols, and medication administration since we had returned to on-campus work in May 2020. 

I loved that we were able to meet so many people at MCW and in the community that we would not normally encounter and educate them about the vaccine and its importance. People were so grateful.  

Marking the Moment…and Continuing Forward Together

From the 5/6/2021 newsletter

Perspective/Opinion

Marking the Moment…and Continuing Forward Together

Jennifer Popies, MS, RN, ACNS-BC, CCRN-K; CVICU Clinical Nurse Specialist

Ms. Popies, a Clinical Nurse Specialist in the Cardiovascular ICU, writes about what it has been like to be part of the team caring for desperately ill patients with COVID-19 over the past year. Recently, the caregivers in the unit paused to reflect on the one-year anniversary of the pandemic and to bear witness to what the year has meant …

It is overwhelming, humbling, and simultaneously a source of pride - as well as pain - to think of all the precious nursing moments with patients and families that I have borne witness to or been entrusted with in heartfelt conversation over the past year.  Gestures that may seem like the smallest details of a patient’s care became some of the largest measures of bringing humanity to the bedside.  

Nurses staying in sweltering layers of PPE, including re-used N95 masks for a time, to hold the hand of patients who were scared, alone, and gasping for air. Serving as champions and cheerleaders for patients to encourage them to keep moving, to keep eating, to simply keep trying. Reading letters and cards sent by family members even though the patients were intubated and sedated so they could still have a chance to hear the words of their loved ones. Bathing and washing the hair of dying patients so they would look recognizable for a family’s last goodbye over an iPad. Making handprints of their patients to give to their families to have as tangible memories of their loved one when that is all we could leave them with.  

All roles deserve to be celebrated for their unique contributions to the wellbeing of those we collectively serve, but this Nurses Week, it is a special privilege to try to capture in some small way what it has meant - and continues to mean - to be a nurse in this pandemic.  Never before has the public, and perhaps even some of our healthcare colleagues, really understood so clearly that “Nursing is both a Science and an Art.”  

Deciding to mark our “anniversary” …

Before Nurses Week was approaching, a different date loomed:  March 18, 2021 – the date that marked the one-year “anniversary” of our CVICU accepting our first COVID-19 patient on Extracorporeal Membrane Oxygenation (ECMO).  Our nursing leadership team, along with our ECMO RN Coordinators, talked about how best to honor this. How should we acknowledge the losses our team suffered over the year and the triumphs we celebrated? Most of all, how do we truly recognize and express thanks for the talent, skill, dedication, and compassion of our staff?  

]We gathered feedback from our nurses and settled on brief “marking the moment” sessions - one during night shift at 0300 and another on day shift at 1100 - with a special message read from our leadership team, followed by an even more special compilation of video messages from prior COVID-19 ECMO patients who were successfully discharged from our care.  Then we set about getting the word out about these sessions and inviting all members of our interprofessional team to join in because, as nurses, we coordinate care and our care is not just for our patients, families, and each other, but for everyone on our team.

Hitting the mark …

The date came and, as happens in nursing, we had to adapt our plan slightly from 0300 to 0330 to accommodate a new ECMO patient just rolling in when we initially planned to start. We had to do “repeat” sessions throughout the morning and early afternoon so that we could ensure that all team members working that day could take the time to listen to our message and see the video.  It was worth everything, though, to be able to stand together and pause, to remember together, to tear up and laugh at the video messages together, and to feel the solidarity in our team to keep going, to keep persevering, to keep caring since we all recognize that our work is not over.  

The unprecedented times are not yet done, and we know that our work to share this gratitude for the care that all nurses have given - and continue to give - in every unit, not just ours, is not done.  Indeed, our work to let all our healthcare team members in all departments   no matter their role   know they are appreciated for what they have contributed and continue to give, is not done.  It is in that spirit that I share below a slightly modified version of the message we wrote for and read to our nurses and our team, in the hopes that it will also hold reflection and meaning for you who are reading this.  It is truly meant for each of you, too.

To our nurses and our teams:

In March 2020, when we learned that we would be receiving our first COVID patient at Froedtert, none of us could have fathomed what this past year would bring.  We hear the numbers all around us of what the pandemic has done in America – millions infected, more than 540,000 lives lost - and yet they still somehow fall short of capturing the enormity of what we have personally experienced as a team in just one hospital, in one city, in one state, in one country.

The challenges and changes that we have seen in just this one year are startling to list.  We donned and doffed according to rapidly changing guidelines, we implemented reusing PPE and sending it for UV light disinfecting to try to protect ourselves and each other, and then learned to use other PPE that we had never had to learn before like PAPRs and CAPRs and Elastomeric masks.  We implemented airway teams, proning teams, AGP guidelines, and the use of extension tubing to run IV pumps outside of rooms.  We cross-trained floor nurses and uptrained Resource Pool nurses.  We developed and implemented guidelines for putting patients onto ECMO and other treatments for COVID and adapted them as we learned more with every passing month.  We tried different therapies - hydroxychloroquine, convalescent plasma, remdesivir, and Cytosorb to name a few - all while learning to tolerate O2 sat levels and lab levels we could never previously have imagined.  We adapted different ways to try to help patients handle the symptom burden and isolation of this virus – medication regimens at doses we weren’t used to, partnering with trauma psych despite not being trauma units, learning to use iPads with WebEx for everything from routine family connection time to family conferences to harps of comfort music sessions to end of life moments.

Specific to COVID-19, we have collectively cared for hundreds of patients.  We have lost some of these patients, despite our best efforts, despite exceptional care, despite our deepest hopes to give them back to their loved ones...but these efforts were not in vain simply because they died.  Their families noticed, their communities noticed the care they received, and we will remember them; caring for them changed us.  Please join me in a moment of silent remembrance for them now...

We have also been able to celebrate incredible triumphs, moments of seeing our patients stand for the first time in many weeks, be freed from their tether to an ECMO machine or a ventilator, roll out of our ICUs to other floors or facilities or home with us cheering them on.  None of that would have been possible without each of you, without each member of our team, whether your role was directly caring for COVID patients or caring for our other acutely ill patients who required our specialized care.  One shining, crystal clear truth that has never changed over the past year is this:  When we stand together, we stand stronger - for our patients and for each other.  

As a leadership team, we have marveled at what has been accomplished this year and are incredibly proud of the care you have delivered and continue to deliver despite personal struggles and the professional challenges that have been faced.  There are simply not enough words to express our gratitude, our deepest thanks for everything that you have done and who you have shown yourselves to be as the Froedtert team in caring for all the patients and families that we have served over this past year.  Please know that you are seen, you are valued, you are our Froedtert Family!  Thank you from the bottom of our hearts!

Jennifer Popies, MS, RN, ACNS-BC, CCRN-K is a Clinical Nurse Specialist in the Cardiovascular Intensive Care Unit at Froedtert & the Medical College of Wisconsin. 

Transforming Health Care and Health Professions Education in Times of War, Pandemic, and Disaster: Lessons from Two Founding Mothers

 From the 5/7/2021 newsletter

Director’s Corner

 

 

Transforming Health Care and Health Professions Education in Times of War, Pandemic, and Disaster: Lessons from Two Founding Mothers   

 

 

By Adina Kalet, MD MPH

 

 

This week, the Transformational Times celebrates National Nurses Week with contributions from MCW nurses and nurse practitioners. Dr. Kalet reflects on the lives and contributions of the founding mothers of the modern nursing profession, and how they remain exemplars of the character, caring, persistence, and grit needed to emerge from the COVID-19 pandemic with a health care system that is both more humane and scientifically cutting edge …

 

 

As a little girl, I was enthralled with biographies. I read a slew of stories with simplified messages where the “(s)hero” triumphed over adversity, had eureka moments, left the world a better place, and – usually - lived happily ever after. Two of these stories have stuck with me. Clara Barton and Florence Nightingale, both self-educated, 19^th century nurses, profoundly transformed health care and health professions education during times of crisis.  

  

Two amazing, transforming women

Clara Barton - a American public-school educator, humanitarian, and abolitionist who knew Susan B. Anthony, Frederick Douglass, and several presidents - is recognized for being remarkably clinically innovative in the face of scarce resources and overwhelming need during and after the Civil War. For her omnipresence and habit of reading to and writing letters for wounded soldiers, she was known as the “angel of the battlefield.”  Barton went on to found the American Red Cross and establish its preeminence in international disaster response and relief starting with the horrific Johnstown Flood of 1889.

Florence Nightingale - an upper-class British social reformer - became an icon of Victorian era British society for her work organizing care for wounded soldiers during the Crimean War. At the time, she was dubbed, “the lady with the lamp,” for her tireless, ever present, compassionate, and attentive individualized care to those in need. The image was sensationalized in the press, but Nightingale’s true brilliance was as a statistician, epidemiologist, and transformative educational leader. Her "Diagram of the causes of mortality in the army in the East," a complex pie chart defining the field of hospital epidemiology, was a remarkable distillation of data that remains among the first health infographics (along with Charles Joseph Minard’s “Napoleon’s March to Moscow Map”). Her work is credited with driving dramatic reductions in deaths from hospital acquired infections long before the discovery of antibiotics. For this intellectual accomplishment, she should be, but is not, called the mother of medical informatics. 

Barton and Nightingale were unlikely leaders. They shared the experience of nursing very ill family members early in their lives. As privileged women from wealthy families, they were likely expected to marry well and raise families but, because they were both unusually well-educated and independent, they forged their own paths. They each had rare access to political influence. They carried deep convictions about social justice issues and displayed unusually fierce empathy and compassion for the poor and oppressed. They both were “out of the box” thinkers, unafraid of hard work, eager to try new things, meticulous and scientific in their methods, and able to persuade others to support and join them in their work. They both served bravely under awful wartime conditions for extended periods of time, and continued to serve faithfully through long, productive careers despite obstacles, challenges to their leadership, and their own personal quirks (Barton was known to be “difficult”). Both remained single and, as far as I can tell, supported themselves through their work (I ordered a few books and will let you know).

The same years Clara Barton was designing, funding, supplying, and running mobile battlefield hospitals, Nightingale was establishing the first secular nursing school in the world at St Thomas' Hospital in London. Although each was a prolific writer and lecturer, they never met but likely did know of each other’s work.

In honor of their legacies and brilliance, newly minted nurses all over the world take the Nightingale Pledge on graduation and Clara Barton remains among the most celebrated of American women of all times, both as a nurse and as a leader. 

  

Who will lead us through the post-COVID-19 transformation?

Why tell these stories during National Nurses Week (which begins on May 6^th and ends on Nightingale's birthday on May 12^th)? Is it because I am a feminist history nerd?  Perhaps, but I also see them as role models for anyone who seeks to do the transformative work that will surely emerge from the COVID-19 pandemic.  Cataclysmic events, such as wars and pandemics, can accelerate innovation and change in both health care and education, but only with the right kind of leadership.

 

The COVID-19 pandemic is not a war

The national zeitgeist in spring of 2020 made us all want to celebrate the mighty battles against the virus and the heroism of our health care professionals and frontline workers. As a society, we look to our COVID-19 heroes the way the Victorians raised up the “Lady with a Lamp” or the “Angel on the Battlefield.” Those of us working away from the front lines express gratitude for the sacrifice of others.

But, if we stop to reflect, war imagery only partially defines what has occurred. Medicine is not a war. Most physicians, nurses, respiratory therapists, first responders, and other essential workers went to work because they had to, because that was what they were trained to do, and because that is what everyone expected. Our front line friends and colleagues remain vulnerable human beings that are called to head into the unknown, not in armor, but in PPE. Many of our colleagues experienced real consequences of their dedication.

We mourn those who became gravely ill or died. Too many colleagues suffer lingering physical, spiritual, and moral distress. As such, we must pledge to support our colleagues as they rest, recover, and take stock. I hope we can help them heal.

 

 MCW Nurses inspire

As Louis Pasteur reportedly said, “luck favors the prepared mind.” There is no doubt that there are many well-prepared Clara Bartons and Florence Nightingales out there who will emerge from our global pandemic experience and become leaders. We must provide them resources, break down barriers, watch them grow, and celebrate their work. Health care professionals are exquisitely prepared, well-educated, persuasive, and able to step up, serve, take advantage, and innovate when opportunities arise.

COVID-19 has already provided many opportunities. For some local examples, read Clinical Nurse Specialist Jennifer Popie’s inspiring description of about how the Froedtert & the Medical College of Wisconsin nursing leadership honors the exhausted staff members who persist, innovate, inspire, and provide compassionate care as the pandemic rages through the ICUs. Be prepared to be humbled by the vaccination clinic experiences of volunteer nurses, and consider joining Kelly Ayala, DNP, BSN, in a Hack-a-thon to address access to care issues.

 

 Thanks to our nurses!

For this year’s National Nurses Week, I personally extend my respect and appreciation for my hard-working nurse colleagues and family members (my brother, sister-in-law, and brother-in-law). I know it has been a remarkably difficult year and, despite all the spectacular innovation, it is not over yet. When the history of this time is written, I believe we will say with pride that we knew the heroic nurses and staff who showed up and, in the spirit of Clara Barton and Florence Nightingale, saw a need, pitched in, educated and rallied others to care for those who were suffering and created long lasting transformative institutions.  I know for a fact that our nursing colleagues make us all better because they showed up.  

 

 

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 MCW School of Pharmacy’s COVID-19 Immunization Program

 From the 4/23/2021 newsletter

Some questions for …

 

 George E. MacKinnon III, PhD, MS, RPh - MCW School of Pharmacy

 

 

The MCW School of Pharmacy’s COVID-19 Immunization Program

 

 

In what ways was the MCW School of Pharmacy well-positioned to quickly ramp up a response to the call for COVID-19 immunizers? 

Dr. MacKinnon: The School of Pharmacy ran several influenza clinics on the MCW Milwaukee Campus that well prepared faculty and student pharmacists to respond to the call for immunizers, albeit these were very small operations. In the fall of 2020, under the leadership of Professor Karen, MacKinnon, Director of Outreach in the School of Pharmacy, we expanded the influenza clinics and opened them to more individuals of MCW (all students, staff, and faculty). The intention was that these clinics would serve as the prototype for the COVID-19 Immunization Clinic for MCW. The MCW School of Pharmacy joined with the MCW Office or Research (led by Ann Nattinger, MD, MPH, Associate Provost for Research, Senior Associate Dean for Research, School of Medicine) to jointly lead the creation of a COVID-19 Vaccination Clinic on our Milwaukee Campus to administer the COVID-19 vaccine beginning December 22, 2020.

All eligible MCW student pharmacists are trained early in their education to administer vaccines, including the COVID-19 vaccine. They also receive training in the Doctor of Pharmacy (PharmD) program in point-of-care testing such as nasopharyngeal testing for coronavirus and strep throat testing, and thus were an asset to our clinical partners for COVID testing these past 12 months. Additionally, many of our pharmacy faculty have been trained in immunization administration over the years. Thus, we had a cadre of internal pharmacists and student pharmacist that were able and willing to participate in COVID-19 vaccine administration.

Pharmacists have expertise in planning for vaccine procurement, storage, distribution, preparation, administration, post immunization monitoring, and record keeping. Fortunately, the School of Pharmacy had just jointly hired Kristin Busse, PharmD, BCPS with the Office of Research when the pandemic emerged in early 2020. She came to us with years of experiences in investigational drug services at Froedtert and was an ideal pharmacist to lead the vaccine procurement and preparations (complying with all regulatory issues at federal and state levels for the emergency use authorization (EUA) vaccines that were to be released).

 

How quickly did you decide that you needed to be proactive with the Wisconsin state legislature to change the rules for oversight and delivery of vaccine? What was that process like?

Dr. MacKinnon: When we began to develop our PharmD curriculum in 2015, we identified that we would be unable to include immunization training early on in the program and had to wait until the second year of the program. We did meet with MCW Office of Government Relations but realized that this was a statutory change needing intervention from the state legislature. Over the past four years, we also met with the Pharmacy Society of Wisconsin (PSW) expressing our desire to gather support as we believe that having a state statue dictate the timing of curriculum delivery in a PharmD Program is overly prescriptive, limiting, and antiquated.

As it became apparent that in late 2020 a COVID-19 vaccine would likely be available, we again brought up this topic with PSW and brought the other two schools of pharmacy in the state into the discussion. Our position was simple, during a pandemic, when all appropriately credentialed providers are needed, such arbitrary distinctions would hinder our full deployment of life-saving vaccines now and into the future.

During this process we also requested an additional language change that would allow student pharmacists to be supervised by any health care provider authorized to administer vaccines (e.g., nurses, physicians). As was previously written in statute, a student pharmacist must have been overseen by only a pharmacist in the administration of an immunization. In fact, we used LCME accreditation language to help support our position and draw an analogy to medical education. With the Legislature’s bipartisan bill and the Governors approval, our suggested changes were enacted in late February 2021. Thus, we have been able to support a team-based approach to healthcare in concert at the regulatory and professional levels, at least with respect to immunizations.

 

When the next pandemic arrives (as it likely will!), what will we do differently?

Dr. MacKinnon: Certainly, there were identified process improvements along the way. The clinic, while conceptually the same in December, has grown and matured to an efficient operation. This sentiment was echoed by the many individuals that came to staff the clinic or be immunized. The credit to this goes to the blended teams from the MCW Office of Research (led by Dr. Nattinger) and the School of Pharmacy (led by Dr. MacKinnon) via the MCW COVID-19 Vaccine Program Team Leads as follows:

Vaccine and program logistics:

Leads: Kristin Busse and Lisa Henk

Clinic Supervision and orientation:

Leads:  Karen MacKinnon and Susan Mauermann

Scheduling and planning:

Leads: Jayne Jungmann and AshLeigh Sanchez

Reporting and maintenance of records:

Leads:  Jen Brown and Theresa Dobrowski

Personnel Eligibility and Invitations:

Leads: Katie Kassulke and Ann Nattinger

MCW COVID Administrative Response Team:

Leads: Dan Wickeham and Adrienne Mitchell

As the vaccine goes through the phases of roll-out into our communities, the role of a pharmacist is critical, as pharmacists have specific knowledge about immunization and pharmacists’ accessibility can help address issues surrounding vaccine hesitancy in the public. We need to continue the public health discussion surrounding the value of all immunizations to preventing diseases, disability and death.

 

What reactions did you get from the SOP students, faculty, and staff to the process? 

Dr. MacKinnon: The School of Pharmacy mission is to: Advance the health of our communities through innovative pharmacy education, continuous public and professional service, and diverse scholarly collaborations. So, our desire to contribute to abating the pandemic was right in line with our mission all along.  We were able to get 100% participation from our faculty and staff. With respect to engagement, overall, there were 95 individuals (faculty, staff and students) from the School of Pharmacy that contributed over 4,500 hours in clinic over the 45 days of clinic operations.

 

 

What surprised you most in all of this?

Dr. MacKinnon: Two things in particular stand out, though none as real surprises but rather gratitude.  

First was the initial influx of staffing for the first phase of the COVID-19 Clinic from School of Pharmacy faculty, staff and student pharmacists and staff from the Office of Research over the typical holiday break. Many individuals changed their personal plans to staff the clinic. As time went on many individuals were putting in 12-hour days at the clinic and catching up on their regular responsibilities on weekends, it became apparent that more assistance would be needed. Student pharmacists needed to return to classes and faculty had responsibilities to attend to as well. This is when the entire MCW campus rallied to support the clinic with medical students, having been trained in immunization, joining forces with physicians, nurses, physician assistants, and medical assistants as immunizers. There too was an outpouring of support from the basic sciences as individuals with the requisite technical skillset and experiences were able to prepare the syringes filled with vaccines.  

Next was the outpouring of support that came from all members of the extended MCW Community including Board members and the significant others and family of faculty and staff. Frankly people had been isolated for so long because of the pandemic and they just wanted to do their part to assist in the clinic. We welcomed them with open arms. Everyone’s contributions were essential to so many tasks that needed to be accomplished including the planning, delivery and ongoing operation of the Clinic. 

As the saying goes, culture eats strategic planning every day for lunch. Thus, we can plan and strategize all that we want, but the culture of collegiality and respect that we initiated through the COVID-19 Immunization Clinic is what emerged that allowed us to be successful. This developing culture will have a long-standing impact to MCW in years ahead as it emerges into a health science university. I am certain that the COVID-19 Immunization Clinic will be a defining moment in this transformation internally and externally as others in the community recognize what a resource and gem that MCW is to all.

 

George E. MacKinnon III, PhD, MS, RPh, FASHP, FNAP is the Founding Dean of the School of Pharmacy and Professor of Pharmacy at MCW.

 

 

Recruitment Season 2021: It’ll all be Worth it!

 From the 3/19/2021 newsletter

Perspective/Opinion

Recruitment Season 2021: It’ll all be Worth it!

Camille B. Garrison MD

Dr. Garrison describes how the Ascension Columbia St. Mary’s Family Medicine residency program adapted to the need for virtual interviews as they recruited their next cohort of residents, relying on social media, entertaining videos, and human interaction …

I had all the right people in place. From the perfect faculty leading the recruitment committee, the most enthusiastic residents set to attend our much-anticipated summer and fall recruitment fairs, the administrative team set with our new interview schedule, and an opportunity to pilot our new ranking system. I remember the heavy feeling of desperation that came over us when we heard that recruitment season and interviews would be transitioning to all things virtual. But once we got over the initial shock of what this would mean for our program, our team became energized and got to work. 

It was refreshing to have residents, faculty and administrative staff who were undaunted by the unknown, as COVID-19 likely prepared us for this moment too. We only had four months to prepare as our first recruitment event would take place in July, so we started to brainstorm which issues to tackle first: website edits, videos, social media and interviewing platforms, recruitment fair participation, visiting students, audition rotations, and finances. Looking back, this was a pretty significant list of issues, but all of the planning and effort that went into each of these areas has truly proven fruitful even without knowing the results of this year’s Match and, for that, I’m grateful.

As Program Director, I know that we have awesome faculty who teach Family Medicine excellently. I also know that we serve an amazing, underserved community and that we meet the community’s needs through clinical care and resident education. We also have a strong reputation of providing high quality care to our patients and their families. I felt like those qualities would not be that hard to convey to potential applicants in virtual format, even after all that the pandemic had brought to us. But the one thing that I was worried about not being able to convey adequately was the sense of family that people feel when they are at our program. 

When I was a medical student, I decided on Family Medicine after I rotated with our program in my fourth year. I remember sitting in rounds one day thinking, I could work with these people! It was the people who helped me see my calling in Family Medicine. It was the people who served as perfect role models for the type of physician I wanted to be. For me, the people included residents, faculty, clinic staff, administrative staff and the patients;  they are “the thing” that makes the program what it is and I wanted to let applicants know this before the interview day. Our goal was to effectively get people to sense “that thing” that I felt when I first came into contact with our program years ago. 

So, we decided to do what we did best, which was to be ourselves as we introduced people to our family. From the quirky, “80s-inspired public service announcement style” clinic tour to the Instagram page created and maintained by select residents, highlighting our team members and their favorite things. Our social media platforms helped us introduce people to our patient population and frequently displayed our commitment to social justice in light of current events. I, along with several residents, spent a lot of time talking with potential applicants during recruitment fairs and scheduled WebX meetings thereafter. We worked closely with our sponsoring institution ensuring that we would have a more professional video to introduce applicants to our hospital wards and clinical faculty, and that our website would be attractive and more appealing than our competition. We worked hard! We banded together as good families do. We were innovative problem solvers and had fun doing it. 

I truly believe that, this year, we interviewed more candidates who were genuinely interested in our program and our offerings and who had already done their research on us. Many of them spoke of how much they appreciated the details we put into our website and were able to vocalize those key details about us during their interviews. It was also great to hear that many of them loved that quirky, 80s-inspired video. Many applicants visited our social media platforms and were able to see the diversity within our program and surrounding community. I believe that the type of candidates we interviewed really seemed to have similar passions and interests which aligned well with our mission and commitment to Family Medicine. 

Overall, my goal is to always recruit individuals who have “that thing” that I was first attracted to when I was a student rotating at our program so I look forward to seeing who will join our team this year. This truly was an exciting recruitment season and I can’t wait until Match Day!

Camille B. Garrison MD is an Associate Professor in the Department of Family and Community Medicine at MCW and residency program director for the Ascension Columbia St. Mary’s Family Medicine Program.

Interviewing for Fellowships - My 2020 Experience

 From the 3/19/2021 newsletter

Perspective/Opinion

Interviewing for Fellowships - My 2020 Experience

David A. Campbell, MD - Department of Otolaryngology and Communication Sciences

Dr. Campbell, who will complete his otolaryngology residency in June 2021, talks about some of the plusses and minuses of interviewing for fellowships during the COVID-19 pandemic … 

“Please tell me you’re not in Atlanta yet!” 

It was March 12, 2020, the day before my first fellowship interview. In the days preceding, interviews dropped off the calendar one by one as travel restrictions tightened and hospital campuses closed their doors to non-essential workers. Some programs switched directly to virtual interviews, while others were hopeful they could have applicants in person by May or June (a wildly optimistic prospect, in hindsight). The Atlanta program finally shut their campus down and the coordinator was frantically trying to stop applicants from getting on flights. After being through medical school and residency interviews, I knew this would be very different. However, as I worked through nineteen virtual interviews spanning five months, I did find some surprises along the way.  

The first thought was how disappointing it was to be unable to visit the cities and hospitals I’d potentially be spending a year at. A very close second thought (in reality, probably a simultaneous thought) was how much money I’d save. Already, credit card bills were piling up and vacation days were evaporating. It was becoming clear that physically getting to 19 interviews was likely going to be impossible. However, on the virtual interview trail, I could attend a morning interview in Florida, an afternoon interview in California, and an evening Zoom social event in New York, all without leaving my apartment or spending a dime. Some programs scattered interviews over several days, meaning I could duck into a hospital workroom for 15 minutes at a time, using no vacation days at all. I’ll admit I did several interviews between cases wearing a suit coat and scrub pants.

Some aspects of the virtual process weren’t immediately obvious. One significant drawback was not meeting the other applicants. Otolaryngology is a small enough specialty that during the residency interview trail, applicants tend to run into each other several times. In the process of comparing notes on past and future interviews at social events or making small talk on the 10th hospital tour, many of us formed connections that only grew as we found each other at conferences throughout residency and will continue to grow as we move through our careers. The graduating ENT class of 2021 got to meet each other during the interview trail of 2016. Now, as I was virtually interviewing to enter the even smaller community of Head and Neck Surgical Oncology, I realized I was missing out on the opportunity to meet my soon-to-be colleagues. 

There were also some unexpected advantages to virtual interviews. As interviews approached, there was concern if programs and applicants could get to know each other as well on the virtual platforms. Similar to the residency match, the 10-to-15 minute interviews themselves are incredibly important for both applicant and program. A single awkward interaction vs. a meaningful connection can have huge impacts on how applicants and programs rank each other. Of course, there were the expected technological hiccups with lots of “I can hear you. Can you hear me?” However, I had several interviews that felt easier because they were virtual. While many physicians interviewed from their offices, I spoke to several world-famous Head and Neck surgeons from their homes. One particularly well-known surgeon was arriving home from work as the interview started. He greeted and introduced me to his wife and showed off the view from his yard (“This could be the type of view you get if you move here!”). From the applicant side, rather than being led into an office at an unfamiliar hospital after sleeping in a hotel bed, I was often interviewing from my apartment with my cats napping on my bed that was just steps away. While some ability to connect was undoubtedly lost with interviews being virtual, my guess is that both parties being in a familiar setting facilitated easier connections in a different way that would not have been possible in-person.  

I’ve heard the sentiment over and over that virtual interviews could never replace in-person interviews. In many ways, I agree with this. However, it was refreshing see people finding new ways to connect with each other when the world was turned upside down.

David A. Campbell, MD is a PGY5 in the Department of Otolaryngology and Communication Sciences at MCW. He will spend the 2021-2022 academic year as the Head and Neck Oncology - Microvascular Reconstructive Surgery Fellow at the Icahn School of Medicine at Mt. Sinai in New York City, a town which he has never actually visited. 

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

 From the 2/5/2021 newsletter

Director’s Corner

 

 

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

 

 

By Adina Kalet, MD MPH

 

 

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

 

 

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

 

 

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

 

The ways in which COVID-19 has disproportionately affected women

 

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

 

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

 

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

 

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

Institutional solutions are critical and complex

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

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

 

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

 

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

 

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

  

Back to crying

 

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

 

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

 

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

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

 

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

 

 

 

For further reading:

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

 

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

 

 

 

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