“Ah! Bach!” and other Confessions of a “Humanities in Medical Education” Cynic, Converted

From the 4/16/2021 newsletter

Director’s Corner 

“Ah! Bach!” and other Confessions of a “Humanities in Medical Education” Cynic, Converted

Adina Kalet, MD MPH

In this Director’s Corner, Dr. Kalet admits to her own early arrogance about the introduction of the humanities in medicine and challenges us to find a rich and inspiring way forward using a character and caring framework …

Did you know that M*A*S*H, the comedy-drama television series that ran on CBS from 1972 to 1983 and based on a movie of the same name, is one of the most highly rated US television shows in history? For the few who are unfamiliar, this remarkable ensemble piece told the fictional story of the 4077th Mobile Army Surgical Hospital, in Uijeongbu, South Korea, during the Korean War (1950–53). It ran for eleven seasons, spanning the final years of the Vietnam War and into the Cold War. There were 256 thirty-minute episodes. It was a literal modern War and Peace. As does most great art, M*A*S*H grappled with the most controversial political and humanistic issues of all times. The theme song, “Suicide is Painless,” is an indicator of how deeply philosophical the writing was, and how accessible the insights. In my estimation, it is the best medical drama ever written and performed. To each his/her own, right? 

For me, a child of the 1960s and 1970s, M*A*S*H was formative. I wanted to be “Hawkeye” Pierce. Even though he was a womanizing, sarcastic, sometimes cruel practical trickster, he was also an artfully skilled, lifesaving, courageous, compassionate, and empathic physician and colleague. I was drawn to his deliciously complex character - both in the theatrical and philosophical sense - and strong moral presence. In one of my most memorable episodes, Hawkeye gives seduction advice to Walter “Radar” O’Reilly, the eerily perceptive, dewy-eyed, camp administrative savant, farm boy from Ottumwa, Iowa. Hawkeye coaches him on how to fake his knowledge of classical music to win the affections of a nurse (nurses were all women) in camp by saying “Ah! Bach!” with a dreamy look and expressive hand motions. The superficiality of the gesture has me on the floor laughing even now. Will they stop at nothing to get the girl into bed?

This represented how I felt, as a medical student and resident about the rather clumsy early efforts made by medical educators in the 1980s to seduce medical students into self-awareness through incorporating the “arts and humanities” into medicine. 

Not every humanities experience is meaningful for medical students 

Curricula which required engagement with selected works of art to view or read without much guidance or structure, felt like a manipulative and superficial ploy to get me to feel something I did not (or would not) and do something I could not yet do. I am not proud of this; I know now I was wrong. I was young and insecure. But it is still a common point of view of trainees. 

As Art Derse shares in his history of the humanities in medicine at MCW I, too, have occasionally heard students say, “I didn’t come to medical school to read poetry (insert: write stories, look at art, or watch movies).”  I think that these students are right and, yet, deeply wrong. 

They are right because medical training is hard enough and – given the great variation in how each of us prefers to access our own humanity, empathy and compassion – being required to engage with a particular work of art is too vague. Students who hold this view are deeply wrong because they misunderstand the point of the exercise. 

I personally have great difficulty connecting with poetry. For me, it is hard work and, therefore, not entertaining enough. But, of course, I now know I must do the hard work to reap the most profound lessons the humanities have to offer. And it is almost impossible to do this work on our own. We need facilitators and guides. The work of art is just the “trigger” for reflection, a starting point to get oneself to challenge assumptions, see the wart’s, face the fears. This is both hard work and not guaranteed to lead to the intended learning. 

“If you haven’t read Thomas Mann’s Magic Mountain you should not be allowed to be a physician!” 

I heard this repeatedly from one of the most erudite and revered clinicians in my department in New York City in the 1990s. What he meant to communicate was that physicians should read great literature in order to develop empathy for and access to the deepest, most complex and conflictual aspects of the “illness experience.” But what he said and represented, sounded crude, insensitive and, frankly, terrifying to my modern ears. Would this powerful man really limit access to the profession based on this one book? I believed he would. I tried to talk with him about it many times. He dismissed my concerns and was openly derisive when I insisted that we focus on skills building and personal reflection as a path to ensuring all physicians have the communication skills – including empathy – to elicit the patient’s story and to build a therapeutic rapport. He absolutely despised any mention of Standardized Patients (SPs). He felt – without any direct experience, by the way - that using professional actors trained to portray patients, assess trainees’ communication skills, and provide them feedback was “fake” and manipulative. 

Given his great love of using the arts to instill empathy, this perplexed me. In my experience, SPs are highly disciplined artists willing to engage with our trainees to ensure that all patients have caring and competent physicians.  He also dismissed my choices of “great” literature, which ran more toward Toni Morrison, Alice Walker, Margaret Attwood, Jamaica Kincaid, Alice Munro, Marilynne Robinson, Tillie Olsen, Virginia Woolf, than toward Thomas Mann (as of a month ago, I have yet to get past page 300 of Magic Mountain. I am still struggling, though). And this was the leader of our Humanities in Medicine program. 

Initially, I rebelled. We needed more than simply a trigger for deep thought that was unguided and self-congratulatory.  Over the years, with many pedagogical advances and an openness to a broader range of humanities, my view has softened. My colleague was a man of his times; what other choice did he have? But we must make other choices, expand the canon, and make use of the humanities to open our minds and hearts. Not easy.   

So, where do we begin?

This past Sunday morning, my husband left the New York Times on the table opened to the Op Ed entitled “A Once-in-a-Century Crisis Can Help Educate Doctors.” I “girded my loins,” ready for a diatribe, another “humanist” telling us in medical education what we must add to an already overwhelming experience of medical training. 

But I was relieved. In this piece, Molly Worthen, a historian at UNC-Chapel Hill who writes about higher education, points out that the pandemic has given us an opportunity to transform medical education because it has forced health professionals and medical schools to look beyond the particulars of modern medicine and think more broadly about how we prepare doctors. She says, and I agree, that COVID has provided us “a pilot project to demonstrate that the humanities are an essential part of what a medical education should be — not just a luxury, but foundational.” 

She celebrates the strides we have made away from the early “humanities in medicine” days of museum visits and the “great novels,” as we move toward a true integration of the humanities at many medical centers and in many programs. The humanities force practitioners to be clear eyed even as they evaluate seemingly empirical data. “Humanists take evidence so seriously that they emphasize viewing it from multiple vantage points and recognizing one’s own limited perspective.”  

Worthen finishes, reminding us all of where we began our medical journeys days, years, or even decades ago. She says our students “grasp intuitively that medicine is not a science but an art that uses science as one of many tools.” 

Embracing Ambiguity

There is so much work to do. In this and in the last issue of the Transformational Times, we have highlighted the many ways these efforts are happening at MCW and beyond. Despite this, there is no clear path to integrate the humanities into medicine. Yet, maybe not knowing exactly how, yet embracing, the ambiguity of that task will bring us closer. Maybe that is the point. Ah! Bach!

In his own way, even Hawkeye knew that the humanities were important while working in the M*A*S*H unit. He once told an interviewer that he brought every single book ever written in English with him when he was sent to Korea. How? Well, he responded, “I brought the dictionary. I figure it's got all the other books in it.” Not a very high brow answer for a man named after Benjamin Franklin and nicknamed after a character from James Fenimore Cooper’s The Last of the Mohicans. I can’t say I agree with everything Hawkeye said, but this, at least, was right on target.  

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.

Building a New Curriculum for MCW

From the 4/2/2021 newsletter

Director’s Corner

Building a New Curriculum for MCW

Adina Kalet, MD MPH

Dr. Kalet focuses on how we must change our educational strategies to achieve the most important work we have as educators: To prepare medical students to become caring, character-driven physicians that can manage a rapidly expanding knowledge base in rapidly evolving health care systems …

As you will read in this week’s Transformational Times, MCW Academic Affairs has been engaged in a process of reimagining the medical school curriculum. 

This has been an almost two year-long, deliberative, and creative process. As part of the comprehensive Liaison Committee of Medical Education (LCME) self-study we do every eight years for reaccreditation, MCW launched small group curriculum conversations. Robust discussions in key stakeholder working groups were bracketed by two full-day retreats. We defined key curricular principles and outlined a new three-phase structure and its predominant instructional designs (case-based sessions, spiral weeks, etc.).  This is important work and no small task. 

I have also been told that MCW has had both successful and unsuccessful experiences with curriculum reform in the past. We are not alone in this, Yet, I have participated in a number curriculum renewal cycles in medical schools around the world. I can attest that our approach has been well managed. The process and outcomes have been inspiring and the team has embraced a road-tested model for organizational and curriculum change to guide their work. The principles and concepts are evidence-based and well understood. There is a nice balance between ancient wisdom (e.g., “learning from patients”) and newer ideas (e.g., Programmatic Assessment of Master Adaptive Learners). 

It seems as though everyone is reforming their curricula (again)

The LCME began accrediting US medical schools in 1942. Since then, most US medical schools have engaged in significant changes in their curriculum about every ten or so years. Lately, the frequency of major curricular updates has been accelerating toward   but has not yet arrived at   a robust continuous quality improvement process. 

In 2018, only 15% of US medical schools were either not planning or had recently implemented a major curriculum change. 35% were in the planning phase and 31% in the implementation phase of a major curriculum reform. The majority of the schools engaged in curriculum change were deliberately moving away from the early 20th century Flexnerian “2 + 2 model,” with two years of predominately pre-clerkship basic sciences followed by two years of immersive clinical experiences. On the whole, they were moving toward more integrated models where students spend less time in classrooms and more time learning the foundational sciences while mastering the cognitive aspects of clinical work. 

Curricula were forced to change as hospital practices changed

This is not a revolution, but more of an evolution. Change, however, has been slow in coming. Why is this? Plenty of schools have attempted the switch. There is ample evidence that students learn best in well-integrated curricula with early and rich exposure to the real-world applications (e.g. written cases, simulated cases, early actual patient experiences). Students demonstrate knowledge and skills when held to very high standards and cultivate their developing medical identities while supporting their well-being as future physicians. 

Change is hard because, traditionally, medical educators have been “curriculum agnostic.” When I was a resident, Saul J. Farber was both our the chair of the department of medicine and dean of the medical school. He was an absolute legendary bedside teacher who was fond of saying that the formal curriculum was irrelevant. He believed that the most important thing we could do as a medical school was choose the right “kids” and then engage them (he said, “throw them”) into caring for patients in our large inner city, safety net hospital. 

For his time, Dean Farber was not wrong, but he wasn’t right, either. In his era   what we often referred to tongue-in-cheek as, “the days of the giants” (he was chairman of medicine for thirty-two years, after all!)   people were hospitalized for weeks at a time while they underwent diagnosis and treatment.

This pace was slow enough that students and teachers could spend a great deal of time together with patients, eliciting their histories and conducting detailed physical exams and bedside maneuvers. The students in that generation before mine witnessed the “natural course” of disease processes, and were able to then spent hours in the hospital library, the laboratories, and reading rooms, reviewing radiological images and having midnight meals where cases were discussed in detail. Using a slow, deliberate, iterative process, their role models showed the students how to integrate all the material and choose courses of action. 

This held true for surgical specialties, as well. Patients who were to undergo an operation were routinely admitted to the hospital the afternoon prior to their procedure. This allowed enough time for them to undergo work-ups by the junior medical student, the senior medical student, the intern, and the surgical resident ahead of time. Postoperative patients stayed in the hospital for weeks prior to the development of rehabilitation centers and long-term care facilities. 

In that earlier era, many teaching hospital physicians also conducted basic science research. It was common (even into my era) that students would walk to the clinician-scientist’s lab to discuss the relevant physiology, microbiology or biochemistry and receive a quick “chalk talk” about the scientific principles underlying their patients’ condition and treatment. 

By the time I was a resident in the early 1980s, the pace of hospital work had revved up, and patients were either very acutely ill or hospitalized very briefly. Most diagnoses and therapeutics moved outside of the inpatient setting and, therefore, outside the view of most medical students. Science was conducted at a distance from the clinical environments. Fewer and fewer scientists were clinicians and fewer clinicians did science. To ensure adequate preparation for practice, medical schools were forced (they were reluctant at first) to create ambulatory care experiences for students and residents. This was only one of many major shifts in medical school curricula. 

Some new and some old elements will create a relevant curriculum for the new healthcare environment

Hospitals now run 24/7/365 and stress the constant downward pressure on “length of stay.” While hospitals are exciting, most medicine is practiced in clinics and community settings. New sciences have become critical to being a physician.  We are constantly struggling to keep our educational structure, content, process and outcomes relevant.  

At the same time, medical school curriculum requirements have become more and more structured and complex. Dean Farber would be aghast. Where are those “midnight meals”? Where is the time to learn through discussing cases and sitting with patients and families? It all seems hopelessly romantic and out of touch with modern reality. But I think we do better by holding firm to core principles and innovating. 

So, what are the non-negotiables elements as we move forward? 

We can protect the “baby” (integrative learning processes essential to becoming a physician) as we consider “spilling out the bathwater” (experiences that don’t lead to deep learning). 

First, we have to build curricula around the knowledge that a physician’s most profound and long-lasting learning occurs while thinking about and interacting with patients. Second, we must recognize and support great teachers who care about learning, are knowledgeable, remain optimistic, and know how to motivate. Third, we must set and hold everyone to measurable high standards. 

This is where Dean Farber got it right. Take excellent, motivated students and mix them up with great teachers with a range of content expertise and provide them with endless “clinical material” against which to demonstrate their growing mastery. Voila! Medical education alchemy. 

Engaging and caring for our stakeholders

Based on educational research and our desire to create new, vibrant approaches, we believe that a strong medical school curriculum will enable groups of students and faculty to learn by puzzling together through a wide range of cases. That is our goal. 

As we create the new educational environment, the students who are still in the current curriculum will need to be cared for and educated. They will be invited to engage in the planning for, and piloting of, new curricular and assessment elements. If we do this right, our students will be the main beneficiaries, yet some will likely feel and express discontent. 

Faculty will need to take new roles, learn new skills and feel like novices again. We will need to work closely with small groups of students across many content domains outside of our own content expertise. We will have more interaction and, therefore, more collaboration between scientists and clinicians. Those of us who are excellent lecturers will lecture on topics best communicated that way. The rest of us will learn new ways. This will be difficult for some. 

The bumps in the road will be smoothed out by working together

Like all medical schools, MCW is a complex organization with many missions and complex governance. We will need both design and change strategies as we anticipate and prepare for predictable challenges both within and without.

A strong leadership team and communication plans are emerging.  Creating and implementing a cutting edge, locally relevant curriculum will take significant effort, cooperation, forbearance, respectful debate, a wide range of expertise, and extraordinary program management skills. While I hope we will be doing a lot of celebrating, I also know this will we stressful. 

The Kern Institute will be there to support faculty development, administrative savvy, and complex and integrated assessment. In a few years, we will have the infrastructure in place to continually improve the curriculum so that future changes will be incremental rather than revolutionary. 

I believe we are long overdue for an upgrade and that the time is now. Even Dean Farber would likely see the wisdom in that.

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.

Shared Change is a Rigorous Process

From the 4/2/2021 newsletter

Perspective/Opinion

Shared Change is a Rigorous Process

Jeffrey Amundson, PhD, Travis Webb, MD, MHPE, Amy J. Prunuske, PhD, and Adina Kalet, MD, MPH

The team describes the development of the curriculum transformation working groups, reports on their recent activities, and looks forward to the Human-Centered Design approach that will clarify and accelerate the curriculum redesign …

 

Change is hard.  However, when change is a shared experience, many of the stakeholder concerns and expectations can be attenuated by communicating and demonstrating conscientious and prudent planning.  The process of curriculum change is a large-scale change that requires thoughtful organization of various stakeholders into manageable and effective teams.  

MCW is currently transforming our traditional 2 + 2 curriculum into one that integrates foundational science with clinical knowledge and skills through case-based, inquiry focused, individualized learning with an emphasis on inclusion and wellness.  To achieve this transformation, various change management strategies have been used including Kotter’s 8 Step process of change and components of Implementation Science to create a rigorous process of communication and structuring with stakeholders. 

Envisioning and building the team 

A common starting point in most models of change management is to communicate a vision of the most important reasons for change. In Kotter’s 8 Step process and similar models (e.g., ADKAR), shared vision is the foundational concept for change. 

This first step at MCW began when all course directors, chairs, education deans from all campuses, Curriculum and Evaluation Committee (CEC) members, selected education staff, and student representatives from all campuses were invited to a Curriculum Exploration retreat held on October 2, 2019.  This involved approximately 100 stakeholders who began an iterative process that developed principles to provide a foundation for medical school curriculum redesign at MCW.

The next step was to create a team of representative stakeholders responsible for coordinating and guiding teams through effective communication and activities. The Curriculum Exploration Steering Committee became this coalition, and included basic science and clinical chairs, course directors, administrative leaders, and Curriculum and Evaluation Committee (CEC) representatives. These same individuals were dispersed throughout the subcommittees to promote contiguity for effective communication and activities. Please see the steering committee and subcommittee rosters at the end of this article. 

Exploring the five principles

After ratifying the new curriculum principles, the steering committee charged subcommittees of key stakeholders to consider how to implement these principles into a comprehensive curriculum considering the complexity of the three-campus institution. Subcommittee members were recruited via email, InfoScope postings, and verbal communication. The kick-off meetings of the “Principle Groups” occurred September 9th and 10th, 2020.

A Principle Group subcommittee took charge of each of the following: 

• Principle 1: Integration of foundational and clinical science learning throughout all years of curriculum.
• Principle 2: A systematic approach and focus on assessment that drives learning and assures that students achieve desired competencies.
• Principle 3: Individualized approaches to learning that are ultimately tailored to student interest and career goals.
• Principle 4: A student-centered, inclusive culture with a focus on wellness.
• Principle 5: An evidence-based instructional approach that is inquiry driven and utilizes active learning.

The subcommittees provided monthly progress reports starting in September 2020 which culminated in final reports on January 1, 2021 (a link to the five principle group reports is available here from an MCW computer or through InfoScope). Additionally, as Lindsey Bowman, Senior Administrative Assistant for Curriculum noted, the guiding coalition efforts were a standing CEC agenda item during the 2020-2021 academic year. These updates provided opportunities for discussion at seven curriculum meetings over the 2020-21 academic year. The coalition communicated monthly with the CEC, its M1-2 subcommittee, its M3-4 subcommittee, and the executive committee. In addition, there were also quarterly meetings with the Directors of Medical Student Education, the M1-2 Course Directors and Coordinators, the Advanced Clinical Experience Committee, and the Clerkship Directors.  It is important to emphasize most of this rigorous process was undertaken while adapting to the impact of the pandemic.  

These individuals have done an outstanding job through the first steps and generated numerous short-term wins (another common component of “models of change”), including formulating a set of design principles from the final Principle Group reports (i.e., Core Content, Instructional Approaches, Assessment, and Faculty and Student Support).  These principles served as the next piece of the process to create a larger team of volunteers.  Additionally, as in many models of change, the next steps will include establishing reasonable targets and, in MCW’s case, using competencies, learning objectives, and suitable governance frameworks to reduce barriers for stakeholders to work across silos.  

The next steps

The next stakeholder teams will clarify medical school learning objectives around: 

• Patient Care and the Health Care System
• Knowledge for Practice
• Communication 
• Personal and Professional Identity 

In models of change, this represents the transition from preparation to initiation of change.  

Importantly, these proposed changes rely heavily on stakeholder input so stakeholders can learn from mistakes and adjust the process as it moves from planning to implementation (as well as adjusting during implementation).  

MCW, with help from the Kern Institute’s Human Centered Design Lab, will capitalize on this input in the next steps.  Human-Centered Design is a team-based approach to problem-solving that uses empathy to develop a deep understanding of any problem.  This allows the problem to be clearly articulated, paving the way for the brainstorming of solutions, followed by prototyping the solution that is most impactful.  This will lead to a process of continuous and intentional short-cycle iterative improvement to the solutions design. 

Much work is yet to be done, and we hope that all faculty, staff, residents, fellows, and students will engage in this exciting process to achieve sustained acceleration (a very important component of change). Given the efforts put forth so far and with a continued rigorous process, the shared experience of change can achieve a fruitful transformation.

Jeffrey Amundson, PhD is a Postdoctoral Fellow in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. Travis Webb, MD, MHPE is a Professor in the Department of Surgery and Associate Dean for Curriculum at MCW. Amy J. Prunuske, PhD is an Associate Professor at MCW-Central Wisconsin. 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.

COMMITTEE AND SUBCOMMITTEE ROSTERS

Curriculum Exploration Steering Committee:  

Amy Prunuske, Travis Webb, José Franco, John Hayes, Alexandra Harrington, Malika Siker, Jonathan Marchant, Bill Hueston, Matthew Hunsaker, Lisa Dodson, Adina Kalet, Jon Lehrmann, Marty Muntz, Melinda Dwinell

Subcommittee Members (Faculty and Staff):

Jennifer Hinrichs, Joe Budovec, Marty Muntz, Mindy Dwinell, Jonathan Marchant, Craig Hanke  Sandra Pfister, Lisa Cirillo, Joe Brand, Hershel Raff, Steve Hargarten, Bipin Thapa, Beth Krippendorf, Marika Wroszek, Teresa Patitucci, Allen Last, Craig Young, Jeff Fritz, Maria Hintzke, Megan Waelti, Terra Pearson, Kathlyn Fletcher, Karen Marcdante, Brian Lewis, Lisa Dodson, John Meurer, Monica Shukla, Kerry J. Grosse, Catherine Thuruthumaly, Ankur Segon, Alan Bloom, Ellen Schuman, Karin Swartz, Carley Sauter, Leslie Ruffalo, Robert Treat, Erin Green, Mary Ann Gilligan, Tavinder Ark, José Franco, John Hayes, Paul Knudson, Elizabeth Hopp, Bill Hueston, Jules Blank, Roy Long, David Brousseau, Pat Foy, Kathleen Beckmann, Brian Law, Jordan Cannon, Johnny Neist, Dan Stein, Jon Lehrman, Malika Siker, Cassie Ferguson, Himanshu Agrawal, Theresa Maatman, Kurt Pfeifer, Kristina Kaljo, Linda Meurer, Anita Bublik-Anderson, Becky Bernstein, Jean Mallett, Adrienne German, Nicholas Yunez, Travis Webb, Ali Harrington, Ashley Cunningham, Amy Prunuske, Patrick McCarthy, Adina Kalet, Ellen Sayed, Ashley Zeidler, Art Derse, Jacob Prunuske, Erica Chou, Megan Schultz, Jay Patel, Joe Barbieri, Curt Sigmund, Matt Hodges

Subcommittee Members (Students):

Kelli Cole, Mario Castellanos, Marko Ivancich, Chase LaRue, Taylor Brockman, Haley Pysick, Gopika SenthilKumar, Alec McCann, Colton Brown, Emily Nordin, Jess Sachs, Connor McCarthy; Syndey Newt, Emily Schaefer, Phil Hartfield