Integrating the Humanities into Medical Education

From the 4/9/2021 newsletter

Editor’s Corner

Integrating the Humanities into Medical Education

Bruce H Campbell, MD FACS - Transformational Times Editor

Dr. Campbell writes about how building observational and representational skills through the humanities translates into more empathetic and effective patient care …

Stories are the primordial means through which we make sense of, and convey the meaning of, our lives.

- Rita Charon and Craig Irvine

 My medical student group gathered to debrief and discuss their very first experiences observing physicians caring for patients.  One student presented a case of a teenager she saw in her clinical mentor’s office with mild muscle aches. This teen had a couple of relatives who were afflicted with a rare, devastating inherited disease. The boy’s few vague symptoms could, possibly, represent the disorder’s very earliest manifestations. Or the symptoms might be nothing, at all.  

“What did you decide to do?” I asked. 

“We told him to exercise and take Advil. We also ordered genetic testing and asked him to come back in a few weeks to check the results.” 

 “Thanks. That was a very complete presentation,” I responded. “Does anyone have any questions?” Someone wanted to know more about the genetic testing. Someone else asked about other potential diagnoses. We discussed those. 

“A couple more questions,” I said. “Did the doctor find out how all this might be affecting the young man? Is he aware that he might have the same disease his relatives have? What’s do you think is going on inside his head?”   

The student’s eyes widened. “I don’t know. We didn’t ask.”

I could not help but wonder whether the students might have been more curious about this teenager’s underlying story had they heard it a few months before they started medical school instead of a few months after. 

Empathy levels will decrease. How soon does that happen? 

As a profession, we lose our “vicarious empathy,” or our ability to have a visceral empathic response to another person’s stressful experience, very early on. A 2008 study from the University of Arkansas for Medical Sciences (UAMS) demonstrated significant drops in empathy during medical school, especially during the first and third years. Men (like me) who chose surgical specialties had the greatest loss of vicarious empathy. 

Of course, no one plans to jettison their empathy along the way from being a normal person to becoming a physician. The losses likely occur as we seek to model ourselves after people who are a step or two ahead of us along the path. When I talk to first year students in MCW’s Healer’s Art course, they all affirm that they will listen to their patients, think first and foremost of the patient’s well-being, and always act with justice and equanimity. Yet, some would not recognize the people that they will become once they emerge, transformed, from residency a few years later.

Professionalism vs. Humanism

How do we address this nearly imperceptible transformation from empathic lay person to crusty physician? 

One way is to reflect on the values of both “Professionalism” and “Humanism.” In medical schools, we strive to nurture professionals, which we might define as “physicians with attributes, skills, and demeanors with which they will practice high-quality medicine with integrity and empathy.” This is, of course, an admirable goal. “Humanism,” on the other hand, is broader than professionalism. These are the qualities we hope every physician brings to the table from childhood and that must be nurtured and enhanced, not lost, throughout the process of becoming a physician. 

This is where integrating the humanities into medical education and training comes in. 

Broadly defined, the medical humanities are interdisciplinary endeavors that draw on the creative and intellectual strengths of diverse disciplines, including the humanities, social science, and the arts in pursuit of becoming a good physician. They tap into literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology, and history. It’s basically the intersection of Medicine with Everything Creative. The goal is to draw on the humanities to expand a physician’s capacity to be humanistic, compassionate, and empathetic. 

Think of an example from your own life: 

Remember a novel you read and loved in high school. If the narrative grabbed you, you dove into the protagonist’s story and couldn’t put the book down. You didn’t worry that you “cared too much” for the protagonist or their struggles. You actively attempted to understand what each character was thinking, and you figured out why they did the things they did, even when their actions might have seemed, at first, inexplicable. Your heart rate soared when you anticipated danger and you wiped your eyes when they suffered. Your blood boiled when they were betrayed. When you finished the book, you encapsulated the arc of the story and shared it with your best friend. You paid attention to the story. You were able to retell it to others. It changed you. 

Ideally, as physicians, we should be similarly curious and fearless as we delve into our patient’s narratives. We safely encountered narratives in the library. We should be able to do it at the bedside, as well.  Right?

Yeah, but does reading a novel really make me a better doctor? 

It does, actually. In an 2013 article in Science entitled, “Reading Literary Fiction Improves Theory of the Mind,” the authors studied people who read literary fiction, popular fiction, nonfiction, or nothing at all. They discovered that those who read literary fiction demonstrated improved “theory of the mind,” that is, “the human capacity to comprehend that other people hold beliefs and desires and that these may differ from one’s own beliefs and desires.” The article further showed that the same readers had stronger “theory of the mind” in both cognitive (the ability to understand others’ beliefs and ideas) and affective (the ability to understand others’ emotions or have empathy) realms. These were exactly the attributes that were lost during medical training in the UAMS study. 

Narrative Medicine: Attention. Representation. Affiliation.

Rita Charon, MD PhD, and her colleagues at Columbia University developed the field of Narrative Medicine over twenty years ago bringing their “close reading” approach to clinics, classrooms, patients, ICUs, and bedsides. Participants first read and discuss a short story, poem, piece of artwork, or other creative work. Then for a few minutes, they each respond in writing to a simple but ambiguous prompt “in the shadow” of the piece they shared.  Then they each read aloud what they have created and discuss as a group what they have learned through this process. 

Dr. Charon teaches that these short, group-based exercises sharpen learners’ listening capacities and drive the “self” to engage in new ways with the “other.” “Reading and listening are muscular acts,” Dr. Charon writes. “It makes us wonder about the spaces between the lines and forces us to join with the storyteller to enter the world they describe.” 

I have shared close reading exercises with MCW medical students, residents, and faculty over the years. These opportunities to read and write together have been gratifyingly well received. Other faculty, staff, and students have developed programs featuring writing, storytelling, art, improv, music, and other creative endeavors. 

Many students embrace these approaches, and faculty members deeply enjoy the engagement, but we still struggle, as have many other medical schools, to truly integrate the humanities into medical education for all our trainees. 

Where do we begin to integrate the humanities into medical education?

In 2020, the Association of American Medical Colleges (AAMC) released a report on the Fundamental Role of Arts and Humanities in Medical Education. The AAMC recognizes that the “arts and humanities are essential to the human experience,” and by “integrating arts and humanities throughout medical education, trainees and physicians can learn to be better observers and interpreters.” The report offers resources and examples for students and educators who want to explore the topic. As Deepthiman Gowda, MD, the Assistant Dean for Medical Education at the Kaiser Permanente Bernard J. Tyson School of Medicine has said, “Humanities have a role in addressing the problems in health care.” 

There is, too often, a chasm between physicians and patients, and medical training, paradoxically, seems to widen that chasm. The humanities, well used, can assist in bridging this gap. Substantively integrating the humanities into medical education could sustain and enhance the empathy students bring to medical training and provide them tools to remain resilient, deeply compassionate, attentive caregivers. 

Curricular change is hard. We will know we have succeeded when our youngest colleagues hold onto their empathy even when it sometimes seems easier to let it go. 

 For more reading:

Principles and Practice of Narrative Medicine. Rita Charon, Sayantani DasGupta, Nellie Hermann, Craig Irvine, Eric R. Marcus, Edgar Rivera Colón, Danielle Spencer, and Maura Spiegel, eds. Oxford Press. 2016

Howley L, Gaufberg E, King B. The Fundamental Role of the Arts and Humanities in Medical Education. Washington, DC: AAMC; 2020.

Bruce H. Campbell, MD FACS is editor of the Kern Transformational Times. He is a Professor of Otolaryngology & Communication Sciences and is on the faculty of the Center for Bioethics & Medical Humanities at MCW. He is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

Photography and Medical Humanities

From the 4/9/2021 newsletter

Perspective/Opinion

Photography and 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. 

“Yes, and…”: How Improv Techniques Enhance Medical Training

From the 4/9/2021 newsletter

Medical Humanities Perspective/Opinion

“Yes, and…”: How Improv Techniques Enhance Medical Training

Erica Chou, MD and Sara Lauck, MD

Drs. Chou and Lauck discuss the parallels between interpersonal interactions in theater improv and at the bedside. Improv offers a way to hone critical clinical skills …

Attunement, affirmation, and advancement. These are the core skills of improv, and of all interpersonal interactions. Attunement means to be present and focused, deeply listening. Affirmation is to acknowledge the other person's truth and to find common ground, even at times of disagreement. Advancement uses that common ground to move the conversation and interaction forward. In short, these skills embody the “yes, and” tenant of improv. 

These same skills are essential in the practice of medicine. Good communication with patients, families and healthcare team members requires active listening and adaptability. A quality of empathy is recognizing others’ perspectives as their truths. Listening, acknowledging, and responding productively are the foundation of creating psychological safety on a team. The relevancy and applicability of improv in healthcare is where medical improv comes into play. 

Here’s an example of Medical Improv

Medical improv is the adaptation of theater improv skills and principles to the healthcare setting. It is a type of experiential learning, where learners participate in improv exercises and then debrief afterwards. While the exercises themselves teach learners to be spontaneous and think on their feet, it is the unpacking of their actions, behaviors and feelings during the exercises that allows learners to reflect and make connections to medicine and other aspects of their lives. 

An example is an exercise called Word at a Time Story. In this exercise five to six people stand in a line. They are given the title of a story and asked to make up a story together where each person says one word at a time. This exercise is incredibly challenging. The natural tendency is for everyone to think of their own story and to try to plan what word they are going to say when it is their turn. But then the sentences that are created make no sense grammatically and the story does not come together. To be successful with this exercise, participants need to focus, be present and listen intently; and if they do these things, then they can trust that when it is their turn to speak, they will say a word that aligns and advances the story.  

How does this relate to medicine?

These same skills can be applied when obtaining a patient history. Rather than approaching the patient encounter with a list of pre-prepared questions to ask, students learn with medical improv to listen and respond to their patients, and to embrace the path the conversation takes.

After attending the 5th International Medical Improv Train-the-Trainer Workshop in 2018, we developed a two hour-long medical improv workshop based on Katie Watson’s Playing Doctor course at Northwestern University Feinberg School of Medicine.2 Our workshop includes the above exercise, as well as several other improv exercises that explore the concept of “yes, and,” emotions, leading/following, and status. We have presented our workshop for a variety of different audiences, including high school, undergraduate and medical students, residents, faculty, staff and interprofessional teams. 

Please contact Erica Chou echou@mcw.edu or Sara Lauck slauck@mcw.edu if you are interested in having a medical improv workshop for your learners, section or team. 

For more reading

Belinda Fu (2019) Common Ground: Frameworks for Teaching Improvisational Ability in Medical Education, Teaching and Learning in Medicine, 31:3, 342- 355, DOI: 10.1080/10401334.2018.1537880 

Katie Watson (2011) Perspective: Serious Play: Teaching Medical Skills with Improvisational Theater Techniques, Academic Medicine, 86:10, 1260-1265, DOI: 10.1097/ACM.0b013e31822cf858

Erica Chou, MD is an Assistant Professor of Pediatrics (Hospital Medicine) at MCW. She is a member of the Curriculum Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

Sara Lauck, MD is an Assistant Professor of Pediatrics (Hospital Medicine) at MCW and the Pediatrics Clerkship Director.

Dartmouth's Arts & Humanities in Healthcare - 1/29/2021 8:00 - 2:00 CST

 Dartmouth's Arts & Humanities in Healthcare - 1/29/2021 8:00 - 2:00 CST

Here is a link to a day celebrating Dartmouth's Medical Humanities work and research.

Dartmouth-Hitchcock 2nd Annual Arts and Humanities in Healthcare Symposium

Symposium link will be sent out the morning of the event.

Schedule

NOTE: TIMES LISTED ARE LOCAL TIMES IN VERMONT

9:45  Musical prelude Margaret Stephens, Therapeutic Harpist, Dartmouth-Hitchcock

10:00  Welcome and introductions
Lara Ronan, MD, FAAN Associate Professor of Neurology and Medicine Geisel School of Medicine, Vice Chair of Education Dartmouth-Hitchcock Department of Neurology

10:05  Creative arts intervention for patients with refractory epilepsy: A preliminary report
Lara Ronan, MD, FAAN Associate Professor of Neurology and Medicine Geisel School of Medicine, Vice Chair of Education Dartmouth-Hitchcock Department of Neurology

10:15  Telling Our Stories Reinvented: Turning an in-person event into an engaging virtual experience
Andrea Buccellato, Manager, Patient and Family Support Services, Dartmouth-Hitchcock Norris Cotton Cancer Center

10:25  ‘Art at Work’ Repurposed: Adaptations and accomplishments
Marion L. Cate, MEd, CHES, CWWPM, CHC Manager, Health Improvement Program, Employee Wellness, Instructor in Medicine Geisel School of Medicine

10:35  Virtual Perspectives: Art and conversation for people living with memory loss
Claire Lyon, Docent Hood Museum of Art Neely McNulty,
Hood Foundation Associate Curator of Education

10:50  Expressive writing exercise
Marv Klassen-Landis, Creative Writing Specialist, Dartmouth-Hitchcock

11:05  Picturing Contagion: Contextualizing visual iconographies around COVID-19
Emily Luy Tan, Dartmouth College, Class of 2020

11:25  Evidence Based Design in Health: A COVID College Semester 
Erin McGee Ferrell, Professional Artist, Art Educator, University of New England Cancer Patient Advocate National Cancer Institute

11:40  Science, Values and the Novel
Alan Hartford, MD, PhD, Associate Professor of Medicine, Geisel School of Medicine

11:55  Lunch break and musical prelude
Margaret Stephens, Therapeutic Harpist, Dartmouth-Hitchcock

12:15  Keynote: Arts in health research in a post-COVID world
Jill Sonke, PhD, Director, University of Florida Center for Arts in Medicine

1:15  Passages of Writes: Medical students fostering connections through shared reading
Christopher LaRocca, MD, FAAFP, Clinical Associate Professor of Community and Family Medicine, Geisel School of Medicine, Aya Bashi, MS2,Lindsay Becker, MS2, Rachel Brown, MS2, Zachary Panton, MS2

1:30  Mindful art project
Kim Wenger Hall, Visual Artist, Dartmouth-Hitchcock

1:45  What about clinician burnout, anxiety, and PTSD during COVID-19? What are the arts bringing to support them?
Alan Siegel, MD, Director, Art of Health and Healing, Founding Board Member NOAH

2:15  2020 Arts-based initiatives at Walter Reed National Military Medical Center
Mallory Van Fossen, ATR-BC, LCPAT, LPC, Art Therapist, Clinical Coordinator of Walter Reed National Military Medical Center’s Arts in Health Program

2:45  Closing remarks

Learning Outcome:

At the conclusion of this learning activity, participants will be able to recognize the value and impact of the arts and humanities on health and well being.

Editor's Corner: Narrative Medicine, Reflection, and Patient Care

From the 12/30/2020 newsletter

Editor’s Corner

 

 

Narrative Medicine, Reflection, and Patient Care

 

 

Bruce H. Campbell, MD FACS – Editor-in-Chief of the Transformational Times

 

 

Dr. Campbell, who has a background in Narrative Medicine, shares how the basics of Close Reading (Attention, Representation, and Affiliation) serve us well, both in medicine and in life ...

Jamaica Kincaid’s short story, Girl, is a list of forty-eight instructions and life lessons that the narrator, a Caribbean mother, is passing along to her daughter. 

 

…when buying cotton to make yourself a nice blouse, be sure that it doesn’t have gum in it, because that way it won’t hold up well after a wash; soak salt fish overnight before you cook it; … always eat your food in such a way that it won’t turn someone else’s stomach; on Sundays try to walk like a lady …; this is how you sweep a yard; this is how you smile to someone you don’t like too much; this is how you smile to someone you don’t like at all; …

 

The list allows the reader glimpses into the spoken and unspoken cultural traditions from a place far away. 

 

 

Exploring fiction and the arts with students and residents 

 

During a December Zoom-based narrative workshop, I read “Girl” aloud with the entire third-year medical school class. The students had just completed their first six months of clinical rotations, and I knew that the short story would seem to be set a million miles away from their recent lives: 

 

…this is how you grow okra—far from the house, because okra tree harbors red ants; don’t sing benna in Sunday school; you mustn’t speak to wharf-rat boys, not even to give directions …

 

The students broke into small groups to talk about the story, its structure, the narrator, and outside allusions. I asked them to think about how they themselves might fit into the story, and if they felt any obligations having read the text. 

 

Now, it was time to make it relevant. “Having experienced this story,” I said, “we will write for five minutes in its shadow. Here is your prompt: Create instructions on how to be a medical student.” What they discovered from their writing was remarkable. They made their own lists. They wrote about experiences. They went back and spoke to their pre-medical school selves. The responses were varied and heartfelt. 

  

Earlier this fall, I taught a Narrative Medicine elective course for fourth-year medical students. We watched videos, looked at visual arts, listened to music, shared poetry, and read fiction by writers including Albert Camus, Rafael Campo, Flannery O’Connor, and Richard Selzer. On the surface, many of the pieces seemed entirely divorced from medicine yet, in every case, we found ways to respond to prompts in the shadow of the works, either in writing or other forms of creativity. 

 

 

This week, I watched Gabriel Osorio Vargas’ Oscar-winning video short, Bear Story, with our otolaryngology residents. The animated film, which is neither medical nor political, is a wordless story-within-a-story about things that are left unspoken. After a conversation about the history of the piece and our initial reactions, I asked the residents to write in its shadow about a time when things might have had more than one ending. As physicians, we could all relate. 

 

The relevance of Narrative Medicine

 

In each of experience, the students and the residents gamely read fiction or experienced other forms of creative expression. Although some likely viewed it merely as a pleasant distraction from lives that are constantly focused on science, clinical knowledge, and patient care, my goal was to get them to practice “close reading,” a narrative technique centered around the precepts of paying close attention, creating a representation of each story so it can be told to someone else, and being committed to an affiliation with the artist or storyteller. Narrative Medicine (as developed at Columbia University) teaches that enhancing the skills needed to “close read” a piece of literary fiction, a painting, or any other form of creativity, encourages clinicians to build the exact same skills that we exercise when we deeply engage with the stories our patients entrust to us. The more we practice, the better we get.  

 

When I work with students, I routinely ask them whether they value writing, reflective, and narrative exercises in their medical education. The majority believe that these activities are important, yet many believe that their peers view reflective exercises as a waste of time. In other words, “I think this is really great, but I doubt my classmates do.” Our data, as we found here and here, say they significantly overestimate their peers’ negative views. In reality, most can benefit from and appreciate this type of activity. 

 

 

As we work toward designing medical education for the future, we should find innovative, measurable ways to include narrative opportunities into the curriculum that build skills and encourage wellness. As one of the M3 participants wrote: 

 

At first, I was unsure how I would feel about spending my morning writing and reflecting with students, but I found this extremely useful … I wish we had more of this placed in our curriculum.

 

When given the opportunity, the students had no difficulty seeing the parallels between the girl in Jamaica Kincaid’s story and their own experiences running into medicine’s “hidden curriculum.” But, until the opportunity to reflect and write arose, the changes remained hidden. 

 

Next steps

At MCW, we have several narrative- and humanities-literate colleagues whose gifts remain hidden. There are unexplored community-based humanities partnerships and opportunities. It is time to explore how best to employ the medical humanities to foster character, enhance caring, expand patient care skills, and deeply enrich the lives of our students, trainees, staff, and faculty. 

 

 

Bruce H. Campbell, MD FACS is a Professor in the Department of Otolaryngology & Communication Sciences and in the Institute for Health and Equity (Bioethics & Medical Humanities). He is a member of the faculty pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

 

 

My Reflections on Professionalism - Jeff Fritz, PhD

 From the 10/16/2020 newsletter

Professionalism Perspective

My Reflections on Professionalism

Jeff Fritz, PhD – Winner, 2019 MCW Professionalism Enrichment Award

When I think about professionalism, three topics come to mind: personalities, people, and practices.

Professionalism and Personalities

If you could talk to anyone from the past who would it be? Each time I find myself posed with this question a long list of people come to mind. When pressed by those around me to select just one person, I usually find myself selecting someone that could guide me in my personal challenges that I’m facing in that moment.

In the area of professionalism that person would be Sir William Osler. Dr. Osler was on the forefront in many areas of medical education. Before there was a Flexner Report, he encouraged integration of foundational scientific knowledge with clinical practice (Osler is one of the founders of medical student learning knowledge and practice skills by the patient’s bedside); he encouraged nurses and physicians to be trained together (an early forerunner of Inter-Professional Education or IPE); he was a vocal advocate for the advancement of women in medicine; and he was passionate about physicians embracing their role to ease human suffering with a concept he termed Aequanimitas1. Unfortunately, I think this concept can be easily misinterpreted to mean emotional disconnection, but as I read Sir William’s writings, he clearly encourages us to seek emotional engagement and connection with others in a fashion that best meets the needs of the situation. Equanimity, from Osler’s perspective, is the discerned application of emotion in the process of easing the suffering of those around us.

Professionalism and People

As we celebrate Professionalism Week at MCW and as I reflect upon professionalism, the first thing that comes to mind is gratitude for the variety and skills of the mentors and coaches who have invested in my development. Having a constellation of people to support my development and encourage me to do more than I imagined has been critical in my development as a person and a professional.

Many thanks to my past and current mentors, coaches, and peers who have had the courage to approach me with difficult growth fronts, support me through those transitions, and encourage me to move beyond my comfort zone. I thank all of you who had the courage to tell me when I had broccoli stuck between my teeth, or adjusted my color of tie before a speaking engagement.

Professionalism and Practices

I do not really spend much time each day thinking about being/acting professional or the long list of professional behaviors but, when I do think of the practice of professionalism, three words come to mind: discernment, compassion and equanimity.

As I progress through each day, I hope to approach each interaction as an opportunity to extend compassion. The challenge comes in the form of my two personal growth fronts: (1) Can I discern the proper application of compassion to the situation at hand? and (2) Given the emotions of the situation, Can I practice equanimity as I work through the process of discernment, thereby sharing the form of compassion dictated by the situation?

Compassion

Before I forget, let me share my understanding of compassion. Compassion sometimes means fighting for justice, sometimes it means standing down, sometimes it means something as simple as helping someone carry stuff from their car to the office. Compassion is not a weak term, but a varied term that aims to ease the burdens of those around us. In this crucible of discernment, equanimity, and compassion is the core of my practice of professionalism. The focus is sharing compassion (easing burdens and suffering), while trying to discern the proper, emotionally appropriate application to the situation (equanimity).

I do not feel by any stretch that I have arrived at some level of noteworthiness in my practice of professionalism. I simply acknowledge that I continue to try and to improve.

Again, my thanks to all who have been patient and encouraged my growth. If I have any encouragement to share regarding the practice of professionalism, it would be to encourage everyone to find a team of supportive people, to focus on extending compassion, and to develop discernment and equanimity in the light of situations that call on us to adapt and grow. To some extent professionalism is the daily practice of character traits, that in my case I’ve simplified to three domains – discernment, equanimity and compassion – which are supported and developed by my constellation of coaches.

Personally, it was humbling to receive the Professionalism Enrichment Award as I feel like I still have a long way to go to discerning the proper application of extending compassion to those around me. My final thought is a quote from Sir William Osler as he addressed a graduating class of health care professionals: “that we are here to add what we can to, not get what we can from, Life.”

1Olser W, Doctor and Nurse, No. II in: Aequanimitas and other Addresses June 4, 1891.

Jeff Fritz, PhD is an Associate Professor in the Department of Cell Biology, Neurobiology and Anatomy at the MCW-Central Wisconsin campus. He is a member of the Curriculum, Faculty & Student Pillars of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

How Medical Humanities Can Help Save Lives -- Including Ours

From the 8/28/2020 newsletter
 
 
How Medical Humanities Can Help Save Lives -- Including Ours
 
 
 
Arthur R. Derse, MD, JD – Director, Center for Bioethics and Medical Humanities
 
 

Dr. Derse describes how philosophers, poets, and physician-writers all help us to develop equanimity … 
 
 
The Wall Street Journal recently featured a story that asked the question, “What would Aristotle do in a pandemic?” It’s not such an odd question. Philosophy is part of the humanities, academic disciplines that ask important questions about our human lives. Ancient writers may have wisdom to share with modern day physicians who have to face the challenges of COVID-19. 
 
For Aristotle, character was paramount. Character is demonstrated through traits that included courage and perseverance in the face of adversity. Courage is a laudable character trait, though Aristotle also recognized that courage had to be appropriate to the situation. The character trait of prudence helps recognize when courage is appropriate to the situation that lies between cowardice and foolhardiness. Those teachings from millennia ago can guide us in today’s pandemic crisis. 
 
Physicians and trainees are being called to take risks in their roles as professionals. The risks are greater than usual and must be weighed in relationship to duties these individuals have to themselves, their families and their other patients. A firefighter’s job is to run into burning buildings. But the firefighter needs protective equipment in order to fight the fire. 
 
If a patient with COVID-19 suffers a cardiopulmonary arrest, physicians and nurses may wish to rush immediately into the room to begin CPR (if it might be beneficial to the patient in the circumstances), but caring for patients while protecting ourselves from the virus (that has already killed almost a thousand health care personnel in the US) and preventing transmission of the virus to other patients or our family calls for donning adequate personal protective equipment (PPE), even if it takes precious time to do so. 
 
Balancing appropriate courage and exercising prudence in caring for patients requires another character trait known as “practical wisdom.” Aristotle taught that practical wisdom was both necessary and sufficient for being virtuous. As you demonstrate your courage in striving to save the lives of others, knowing a little about Aristotle might help save your life and, in turn, those of your other patients and your loved ones.
 
Philosophy is not the only area of medical humanities that can provide help and comfort at this time. Literature can give us important, life-supporting and perhaps life-saving insights. Albert Camus, in The Plague, and Steward O’Nan, in A Prayer for the Dying, described the moral challenges facing physicians working in epidemics. 
 
Rafael Campo, MD, physician and poet who worked during the plague-like early years of HIV/AIDS, gives us the comfort of his own the poetry and shares with us his favorite poets - including physician-poet William Carlos Williams and hospital attendant Walt Whitman - to show that healers can get through this. Physician-writers can be role models that help us to be more empathetic and compassionate to our patients and may also soothe our understandable anxieties during this pandemic.
 
Emergency physician and essayist Jay Baruch, MD sends us missives from the frontline where he rails against the broken system that forces him to re-use single-use PPE while treating patients that put everyone at increased risk. The team members trust each another to keep themselves and their patients as safe as they can. His essay highlights the character strengths of teamwork and courage while acknowledge and advocating for the safety of the team. This pandemic challenges us to care for our patients while being responsible for the safety of each other.
 
The humanities can be expressed in many ways in medicine. Colleen Farrell, MD, is an example of a physician who balances her professional responsibilities with humanism and love of medical humanities. She is an internist who recently began a critical care fellowship in July. She treats patients valiantly in the ICU even as she advocates for the protective equipment that residents need to care for patients. She shares her grief and her tears with friends when she loses patients to the pandemic. She played the violin (while appropriately masked) at a memorial service for a nurse felled while treating patients by COVID-19, and plays when she can for her own self-care. And she hosts a biweekly Twitter discussion on medical humanities.
 
Medical humanities help us develop equanimity - the character trait William Osler said was most important to physicians - by maintaining balance and judgment in chaotic and unpredictable circumstances. We exercise practical wisdom by acting on the knowledge of when to do the right thing at the right time in the right manner for the patients to whose good we are dedicated.
 
A recent profile considered whether the extensive grounding in the humanities including philosophy that Dr. Anthony Fauci pursued in his education has shaped the physician, scientist and leader that he is today. Dr. Fauci is an exemplar for humanities in medicine, helping us face the COVID-19 challenge with equanimity as he does now, and did when our nation first faced HIV/AIDS.
 
Medical humanities can indeed help in clarity, insight and comfort during this challenging time. And might just save lives, including ours.
 
 
 
Arthur R. Derse, MD, JD FACEP is Julia and David Chair in Medical Humanities, Professor of Bioethics and Emergency Medicine, and Director of the Center for Bioethics and Medical Humanities and the MCW Medical Humanities Program in the Institute for Health and Equity. He is faculty in the Philosophies of Medical Education Transformation Laboratory of The Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

The When and Why of my Good Trouble in Medical Education

From the 8/21/2020 newsletter 
Personal Opinion / Perspective 
 
The When and Why of my Good Trouble in Medical Education

 
Jeff Fritz, PhD – MCW-Central Wisconsin (MCW-CW) faculty member

 
Dr. Fritz, a founding member of the MCW-Central Wisconsin faculty, finds inspiration in old books and documents that push us in the direction of  “good trouble.” In this essay, he points to some areas where he believes we need to make changes …

 
 

I enjoy old documents. One of my hobbies is finding old books – like ones that explain medical treatments – with copyright dates prior to 1900. I keep searching for older and older volumes of the drawings by Dr. Frank Netter and the first editions by Dr. William Osler. 
 
My family asks me why I keep exploring for things that could be found on the internet. For me, holding these works provides inspiration. Older documents let me adopt the perspective of the writer, give me a glimpse of their experiences, and encourage me to continue to look for solutions to age-old problems. 
 
Often, older documents tell me when and why I need to act – they illuminate those areas where I need to get into “good trouble.”  Two documents of which I hope to someday add older copies to my collection are the Declaration of Independence and the Constitution. The Declaration reminds me to take a stand and join the cause for those experiencing limitations to “life, liberty and the pursuit of happiness.” My favorite phrase in the preamble is “it is the Right of the People to alter or abolish [the government], and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness.”For me, this is a call to action to serve those around me when they share their personal struggles, injustices, or failures to overcome institutional roadblocks. The Declaration of Independence guides my energies when I need to get into good trouble. 
 
In addition to these documents telling me when to get into good trouble, the Constitution begins by telling me why. “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.” This tells us why we expend our energies when it is time to get into good trouble. I think it challenges us to form more perfect institutions, improving upon our structures so that those around us can better flourish.   
 
What does my personal hobby have to do with medical education?  As a faculty member on a regional campus, I get to work at a medical school while still remaining in my rural community. Twenty years ago, my spouse and I left our familiar academic environment of Nashville, Tennessee to support her rural medical practice and to focus on our growing family. Trust me, I thought the opportunity to engage with medical students was a thing of my past! But thanks to many courageous leaders willing to develop regional campuses and get into good trouble, I can both support my spouse’s pursuit of happiness and, once again, pursue my own dream as a medical educator. I want more people to experience the joy I experience as an MCW-CW team member and as part of the Kern Institute faculty. 
 
As I begin my fifth year at MCW-CW, I feel it is time to respond to concerns raised by our learners, inform our leaders, hold myself accountable, and create some good trouble to benefit both our learners and our institution. 
 
Here are areas where I hope to make some good trouble this year.
 

 Area 1 – Admissions
I have been on the MCW Admission Committee for four years and will encourage our team to more fully embrace the challenges to transform our admissions process. We must admit cohorts of learners that more dynamically represent the communities we serve. 
 
To my friends on the Admissions Committee and within the Student Pillar at the Kern Institute: I know the energy it takes each year to screen, interview, and admit a new cohort of students, but I challenge us to get into some good trouble and develop a better system that will lead us to becoming a more inclusive, antiracist institution. Hold my feet to the fire and hold me accountable – let this year be the year we develop a more robust, holistic, and inclusive admissions process. 
 

Area 2 – Curriculum
My primary role at MCW-CW is to assist instruction throughout the first year of our current foundational science curriculum. Over the past four years, I have watched learners succeed as well as struggle. I feel our curricular structure could do more to ease the suffering of our students. I have watched our institution embrace the good trouble of student, faculty and staff well-being and make great strides in a short period of time. However, we have so much more to do in revolutionizing our curriculum to meet the need of our learners on each of our campuses and those we would like to invite onto our campuses as learners. 
 
To my friends on the Curriculum and Faculty pillars at the Kern Institute: Now is the time we put forward a curricular design with the flexibility and inclusivity to ease the suffering of our learners on all of our campuses and helps them feel supported, safe and justly treated.  
 

Area 3 – The cost of medical education
I’d also like to see us embrace a new way to support our students with the cost of medical school, but I fear this is out of my sphere of influence ; after all, you can only throw the tea into the harbor off of the boats onto which you can board. While I explore a more direct means to influence our financial approach to medical education, I challenge us all to expand our funding horizons as an institution. We need to take up the good trouble of eliminating the hurdle and fears surrounding the cost of medical education.

We need to acknowledge how these costs limit our ability to fully develop a diverse and inclusive cohort of learners and faculty. We need to tackle the cost of medical education, both financially and culturally, as it continues to exclude those that remain outside our community. I’m looking for ways to dump the tea overboard on current system and explore a new and better way to constitute financial aid.

13,000 Days on the Hamster Wheel: Finding Meaning on the Way to Retirement

 From the 8/21/2020 newsletter
 
 
13,000 Days on the Hamster Wheel: Finding Meaning on the Way to Retirement
 
 
Bruce H Campbell, MD FACS – Editor, Transformational Times 
 
 
Dr. Campbell reflects on how the self-care trajectory on which we place our students and residents will carry them beyond their careers …
 

 
Medicine differs from many other professions. Once a physician joins a practice, it is possible to become a perpetual-motion machine, working day-after-day, seeing patients and generating revenue. As long as the physician directly or indirectly generates enough cash flow to pay salaries, keep the lights on, and move the enterprise forward, the process can continue unabated. Theoretically, this hamster-on-a-wheel activity can continue for around 13,000 days. That’s thirty-five years. Then the hamster retires, and another is recruited to keep the wheel turning. 
 
Of course, I don’t usually view myself, our students, or our residents as hamsters, but there have been days when the thought crossed my mind. Still, what can medical educators do to prepare the next generation of physicians in ways that will enrich – rather than deaden – their lives and careers? And how do we help our trainees step back and begin to grasp the arc of their journeys from graduation to retirement?
 
 
Talking with trainees about their careers
 
Recently, I held a session on retirement with our otolaryngology residents. We read an article where the authors asked Johns Hopkins internal medicine residents in the very first weeks of their internships to write down and then share what they thought a colleague would say about them at their retirement celebration many years down the road. I also asked our residents to imagine what others would say about them at retirement, which of their character strengths would be most noticeable in their careers (from the list at www.viacharacter.org/), what they think they will miss about their careers after they retire, and what aspects of retirement they are thinking about now. 
 
Not surprisingly, the residents in the article and our otolaryngology residents all see the distance from where they are now to retirement as being an incredibly long time. The brand-new interns hoped that their colleagues would see that they had lived out their core values, been accomplished in their careers, and been good teammates. Among possible character traits, our residents hope that they would have been most admired for their dedication to teamwork and their humility. They anticipate that they will find their greatest personal satisfaction – and what they think they will miss the most – from being part of a team focused on helping others in times of great need. Like the interns in the study, our residents worried about retirement but, being so far off in the future, they could not imagine what it will feel like to get there.
 
Our residents realized that they differed from the internal medicine interns in the study. Although they know they will miss many things, they believed they will be able to replace professional relationships, the joy of helping others, and stimulating conversations with other post-retirement activities. As surgeons, though, they worried that they will have difficulty replacing the unique privilege of performing surgery. As one resident said, “I can’t imagine not operating again. That’s why we went into this.” Everyone agreed. 
 
Our residents, having been in training longer than the interns in the Hopkins study, focused on how quickly time passes, even in training. “I am already realizing how much I will miss my fellow residents,” one of older trainees noted. “I’m sure my career will seem to pass by just as quickly.”
 
 
The challenges of helping students, residents, and faculty gain insight into themselves and others
 
There are data that strong relationships and lifelong self-care habits can yield benefits much later in life. MCW faculty members and the Kern Institute are building a portfolio of curricular and extracurricular opportunities that encourage resilience and insight including the REACH curriculum, the KINETIC³ Teaching Academy, MCW Common Read, and a variety of transformational initiatives (see a partial list at the end of this article.) The challenge is to make these types of offerings available, appealing, and effective. Baking caring and self-care into the institutional culture and the curriculum creates opportunities for both transformation and scholarship. 
 
But, let’s get real. Finding time for reflection, creativity, and long-range personal planning is difficult and, frankly, of low priority for busy students, residents, and faculty. Institutions can readily measure clinic slots, RVUs, grant funding, and margins, but we don’t (yet) have metrics that measure sustained empathy, strengthened character, and successful prevention of burnout. If we cannot demonstrate that these habits can be nurtured, or if they aren’t seen as valuable, our interventions will have little impact and won’t be sustained. 
 
Yet, raise your hand if you think that a graduate who is unprepared to thrive in practice will also be less likely to thrive in retirement. 
 
 
Retirement isn’t for sissies
 
Over the decades that I have been at MCW, dozens of colleagues have retired. I have noted that the end of a career rarely goes exactly as planned. Some have retired amid accolades for lives and careers well-spent while others have left baffled and reluctant, having no idea what they would be doing a week later. Some, after long and productive careers, were forced out after bitter disputes. Some packed up and left in disgrace. Some became ill or died before they had the opportunity to retire. Some, unfortunately, held on too long. Some left huge holes in the institution when they retired. Others barely caused a ripple. 
 
Guiding our students and trainees toward rewarding careers and eventual retirements carries responsibility. We must do more than suggest they be financially responsible and keep track of their retirement account outlook. We have equally important responsibilities to help them develop well-rounded professional identities, “seize the day” mentalities, and careers as reflective, empathic, and mindful physicians. If they enter practice self-aware and focusing on character and caring, they should have a better chance of emerging into retirement possessing the same values. 
 
 
Living each day
 
The act of living intentionally came to mind when I read a story in an interview with Duke University’s director of medical humanities, theologian, and pediatric oncologist, Raymond Barfield, MD: 
 

“Think of each day as a gold coin that you are required to trade for something. You’ll never get that coin back, so whatever you trade it for had better be worth it. You also don’t know how many coins you have left to trade, and you don’t know what will happen when your bag is empty.”

 
My career has shot past me like a rocket since I completed my fellowship and joined the MCW faculty 12,043 days ago. I now wish I had learned early on to treat each day like a gold coin. 
 
Whenever I do retire, I know I will carry memories of my colleagues and mentors with me and try to take advantage of the self-care and reflective skills I have acquired along the way. And, as I look back, I will be grateful for how rarely my career made me feel like that hamster running on a wheel. 
 
 
 
Bruce H Campbell, MD FACS is a Professor in the MCW Department of Otolaryngology and Communication Sciences and in the MCW Institute for Health and Equity (Bioethics and Medical Humanities). He is on the Faculty Pillar of The Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He serves as the editor of the Transformational Times. 
 
 
 
 
 
PARTIAL LIST OF SELF-CARE, CREATIVE, AND REFLECTIVE OPPORTUNITIES AT MCW
 
At the risk of leaving out many important opportunities for MCW students, trainees, and faculty to develop a longer view of a life in medicine, here are a few of which I am aware:  
 

• Healer’s Art Course.  Julie Owen, MD and Art Derse, MD run this M1 elective that helps students explore their connections, tough issues such as loss and grief, their motivation for service, and reflect on their goals. 
• REACH (Recognize, Empathize, Allow, Care, Hold Each Other Up) Curriculum. Working with the Kern Institute, Cassie Ferguson, MD designed REACH. She, Joanne Bernstein, MD, and Theresa Maatman, MD are the program leaders. REACH provides a well-being thread of lectures and small-group activities through the M1 and M2 curriculum where students explore mindfulness, meditation, spirituality, self-compassion, “imposter syndrome,” belonging vs fitting in, stress, anxiety, empathy vs. compassion, setting boundaries, gratitude, relationships, communication, sympathetic joy, active constructive responding, and compassionate listening. 
• KINETIC³ Teaching Academy. The Kern Institute offers this curriculum that seeks – in addition to fostering teaching skills and building a community of educators – to promote faculty and student well-being.
• MCW Common Read. The program coordinates a campus-wide book selection and study. This year’s book is How to be an Antiracist by Ibram X. Kendi.  
• MCW MedMoth. This is a live storytelling event where MCW students and faculty are invited to share first-hand narratives of their medical journeys. 
• MCW Art Club. Developed by Teresa Patitucci, PhD, this Facebook page shares the talents of MCW family members. See the article in the July 24, 2020 Transformational Times.
• MCW Moving Pens. Offered by the Center for Bioethics and Medical Humanities, this facilitated group for writers of all skill levels and genres meets twice-per-month in partnership with Red Oak Writing. 
• MCW Physicians for the Arts -  Facebook page link here
• Auscult – MCW’s literary journal. Site link here
• Chordae Harmonae – MCW medical student acapella group. YouTube link here
• MCW Orchestra – Facebook page link here