The Kern Institute Learns to Blow our Shofar!

From the January 13, 2023 issue of the Transformational Times

The Kern Institute Learns to Blow our Shofar!  

By Adina Kalet, MD, MPH

In this week’s Director’s Corner, Dr. Kalet describes what she learned about transformational leadership while drinking coffee on a beach overlooking the Mediterranean Sea …

 

The beginning is the most important part of the work.

-Plato

In December 2018, I traveled to Israel to meet with palliative care physician and medical educator Dr. Dafna Meitar and educational psychologist and philosopher Dr. Daniel Marom. We talked about the Mandel Leadership Institute’s Leadership in Medical Education Program, a sophisticated, unique, year-long, philosophically-framed, intensive training they were creating in Jerusalem. We spent a whole day in a café in the coastal city of Herzliya, looking out over the Mediterranean, drinking coffee, eating pita, hummus, and diced salad, and discussing medical education. Ideas flew back and forth. We shared serious ideas, stories, and jokes. We gesticulated wildly. I got a tan and furiously took notes in multiple colors. 

When there was a lull in the conversation, I asked their advice about the job opportunity I was contemplating in Milwaukee. Daniel asked solemnly, “When you take this job, what will you mean by ‘transforming medical education’?” 

I talked unintelligently for a few minutes, reciting the laundry list of things I intended to do, but the look on their faces made it clear I hadn’t answered his question. “You must develop your shofar!” he said, cutting me off. “You must articulate the why of your work before  you will be ready to decide on the what.” He assumed that I would—although I had not yet decided to—take the job. 

Soon after that conversation, I accepted the offer. 

A shofar is an ancient musical instrument made from a ram’s horn. It was used like a modern bugle to call the community together for important announcements and discussion, to proclaim important calendar events, and to note solemn occasions. In modern times, the shofar is used during the Jewish High Holidays. In my community, the shofar can be—and is—blown by any member of the community with the proper embouchure. It is considered an honor and a source of pride to be able to “blow shofar.” 

I find the sound of the shofar stirring and meaningful. It accompanies those moments during the religious services when, in community, we are contemplating past errors, seeking forgiveness, and feeling humble. In awe, we formulate our resolutions for the future. I knew that by linking my career change to the shofar, Daniel was challenging me to think deeply and then “blast a horn” to get the attention of like-minded others so we could articulate a manifesto that would transform medical education. I had no clue what that would require, but I was reassured that Daniel and Dafna would be there to accompany me.

Once I joined the Kern Institute in fall 2019, I saw that our members were very busy. They had rolled up their sleeves and were solving problems. The KI had launched a robust faculty development program (KINETIC3), a well-being curriculum for students (REACH), and the Transformational Initiatives (TI2) program. However, I sensed that our members, our community within MCW, and the community beyond our walls did not clearly understand why we were doing what we were doing. I searched for ways to dedicate time to rest from all the doing and engage in some deep thinking. 

COVID-19 changed everything, and we wrote (and we wrote...)

As they say, be careful what you wish for! In March 2020, with the pandemic on our heels,  we launched the Transformational Times and have published weekly ever since. Once a collection of quality essays built over the first year-and-a-half, we published them in Character and Caring: A Pandemic Year in Medical Education at the end of 2021. 

Now, as we have continued our work and our writing, we present our new book, Character and Caring: Medical Education Emerge From the Pandemic, which was released on  January 2nd, 2023!  See Dr. Fletcher’s essay in this issue detailing the history of our work. 

Please consider purchasing the two volume Character and Caring  set (at a special price) for your favorite health professional. This is our shofar! It is a good read. Every member of the Kern Institute is expected to write regularly. The Transformational Times and the books call us all together for the deep conversations. In addition, we are publishing contributions from an enlarging group of local and national stakeholders and fellow travelers. 

Many have heard the “blast.” We receive emails from our readers and have regular literal and virtual hallway conversations stimulated by the essays. The responses are mostly expressions of appreciation for the opportunity to hear our why; the newsletter and books allow people to know us and know our work. Readers regularly share their own stories. There has been an occasional friendly debate and rarely a pointed disagreement. We welcome it all.  

Beyond the transactional to the transformational

We have a much more to learn from Drs. Marom and Meitar. Their deep and abiding respect for educators is intoxicating. They believe that educational leaders, through their work, define and design their professional community and, therefore, are responsible for giving expression to the values that comprise what medical sociologist, Eliot Freidson, PhD, called the "soul of their profession." Their approach to leadership development is guided by a clearly articulated framework they call a “typology” made up of five interrelated levels. The typology frames everything they do to facilitate—and provides a language for ensuring—that leaders understand why we are doing what we are doing. This, in turn, greatly enhances the likelihood that these motivated and committed individuals will have an impact that goes well beyond the transactional toward the transformational. 

All the work in the Leadership in Medical Education Program is done in peer groups and supported by coaching. Through discourse, readings, and reflective writing, senior medical educators wrestle first with core philosophical ideas surrounding human health and sickness (Level 1 of the typology) followed by questions surrounding the larger aims of the education of physicians (Level two). Then, and only then, are they allowed to dive into the implications of all this for educational theory (Level 3), implementation of new educational practice (Level 4) and, finally, evaluation of outcomes of that practice to measure success (Level 5). 

For most physicians who are very action-oriented, it takes discipline not to jump into the “doing” (Level 3) too soon. But, with practice and experience, most of Meitar and Marom’s participants internalize the discipline needed to seriously engage with the philosophical questions underpinning medical education before jumping into or designing and/or implementing programs. 

 Over the past few years, as I have worked with the five medical schools in Israel (more on that another time). I have had the honor of meeting many of the nearly fifty medical educators who have completed the Mandel Institute’s Leadership in Medical Education Program. After experiencing a very old-fashioned medical education themselves, most of them light up when discussing the pleasure in having the opportunity to engage with their peers intellectually and personally through this program. They are inspired to lead the change that is needed, even though it will be difficult, even though it will be resisted, and even though resources are very limited. Many of these graduates are now moving into positions of influence in their medical schools. 

Marom and Meitar are having an impact on the future of the whole country. I continue to take notes in multiple colors and have tried to bring these renderings into our work in the Kern Institute.  

Checking in again

After a couple of years in lockdown, I recently returned to a beach café in Israel to meet with Dafna and Daniel, both of whom are now affiliate faculty of the Kern Institute. They read our Transformational Times. They are still working to lift up medical education in their country as we are in ours. We discussed how the Kern Institute’s shofar is going and shared our successes and challenges. It is my hope to bring them to Milwaukee very soon (in the warm season) to teach us a thing or two about medical education leadership. I will take them—and as many of you as can join us—to the South Shore Terrace Kitchen & Beer Garden for a campfire, some s’mores, and a view of Lake Michigan. 

Looking out over the water, we will pick up our conversations from where we left off. 

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.

Diagnostic Reasoning – A Call for Faculty Engagement

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

Diagnostic Reasoning – A Call for Faculty Engagement 

  

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

  

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

(b) Recognize when their cognitive load is high 

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

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

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

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

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

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

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

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

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

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

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

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

If You had a Blank Slate, How Would You Integrate Narrative into Medical Education?

From the 6/18/2021 newsletter

Three Questions for Dr. Deepthiman Gowda

If You had a Blank Slate, How Would You Integrate Narrative into Medical Education?

Deepthiman Gowda, MD MPH MS, is a nationally recognized expert on Narrative Medicine and the founding Assistant Dean for Medical Education at the newly opened Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena CA. He spoke to Transformational Times editor, Bruce Campbell …

Transformational Times: In what ways is narrative integrated into the curriculum at the Kaiser Permanente Bernard J. Tyson School of Medicine? 

Dr. Gowda: The School of Medicine's curriculum was intentionally built on the three co-equal pillars of the Biomedical, Clinical, and Health Systems Sciences. By emphasizing the value of deep dives into health systems along with the other disciplines, students discover that organ dysfunction, illness, and suffering always occur within social and societal contexts, and that nuanced and effective “doctor-patient relationships” require students to understand and address often obscure, external forces. Through our “spiral” model of learning, students revisit these key areas and concepts repeatedly and with increasing sophistication throughout the four years. 

In addition, we identified core values we consider essential for meaningful participation in high-functioning healthcare and turned these into four reappearing curricular “threads.” These are: 

• Equity, Inclusion, and Diversity
• Health Promotion
• Interprofessional Collaboration 
• Advocacy and Leadership

Narrative Medicine and its pedagogical cousins fit nicely within this curricular approach.  For example, patients are often powerfully affected by the social determinants of health and experience their illnesses and healthcare interactions within larger narrative frameworks. These moments provide wonderful opportunities for our students to explore and respond to stories. On a personal level, providers benefit when they have guided, protected time to investigate their own narratives. Finally, interprofessional teams and interpersonal relationships function better when people understand each other’s stories. 

To enable these moments, we built many opportunities for narrative into our curriculum. We worked with the foundational scientists and clinicians to provide narrative opportunities at “moments of attention,” such as with cadaver dissection, pelvic and breast exam sessions, and challenging experiences. Over the four years, each student participates in regular REACH sessions (Reflection, Education, Assessment, Coaching, Health and Well-Being), that occur in one-week blocks, four times each in Years One and Two and three time each in Years Three and Four. REACH incorporates dedicated time to explore health, well-being, and resilience skills. Students participate in close reading, writing-to-a-prompt, and conversation, facilitated by trained faculty mentors who remain with the same groups of six students throughout the four years. The sessions also include goal setting, professional identity formation activities, and the creation of critical reflective essays. 

Transformational Times: How have the students taken to this emphasis on narrative in the curriculum? 

Dr. Gowda: Students these days expect curricula to address health systems issues in ways that were not explored in the past. There was great local and national engagement around the Black Lives Matter movement and how implicit bias is manifest in medicine. Our school is small, only about fifty students per class, but the learners are enthusiastic about narrative opportunities. About one-quarter are part of our Medical Humanities Interest Group, for example. The M2s will soon head to one of the local art museums. 

Student-led initiatives have been key. For example, the students organized StoryTime, a monthly storytelling event that is much like The Moth. Each event includes volunteer student, staff, and faculty storytellers and is built around a theme, such as Solidarity, Community, or Mental Health. These events provide a glue for our community. 

Transformational Times: What barriers are there to incorporating narrative meaningfully into the curriculum?

Dr. Gowda: Well, first of all, it is relatively simple to bring narrative to topics such as well-being, professional identity formation, and diversity & inclusion. Students understand the inherent value of reflecting on - and learning from - their own experiences and struggles. For these types of narrative experiences, they engage easily. 

Other areas of study can be more challenging. Employing narrative techniques to unwrap broader issues within health systems science are also valuable but can be difficult, particularly when trying to make sense of large, amorphous structures and bureaucracies. Finding ways to integrate narrative into foundational sciences can be the most difficult, requiring commitment and engagement by both faculty and students. But it can be done. 

All of us in the field struggle with metrics. In other words, how do we demonstrate the value of narrative in the curriculum? There are rubrics for scoring reflective activities, but we don’t always know if they are measuring what we think they are. We also worry that if students believe they are being “graded” on their reflections, that might suck the joy out of the process. Reflection fatigue is real, and students are smart enough to “write to the test,” even with reflective essays. 

We need to understand the students’ growth along the spectrum - as my colleague at Columbia University, Maura Spiegel, describes - between “thin” and “thick” narratives. In this sense, growth occurs when students demonstrate shifts from stories that focus on a single aspect of identity to stories that reflect multiple points of view and enriched contexts. The ability to create these “thickened narratives” might be important in understanding our learners’ narrative progress and competence. 

As they graduate, we need to make certain that our efforts have helped them become compassionate, team-based, and resilient physicians who possess narrative humility. We believe narrative is part of that, but we are still deciding how best to understand and measure progress in a competency-based system.

The transformation of medical education is a difficult but necessary challenge. I have been here at Kaiser Permanente for two years and have never worked harder in my career. It is a huge, exciting task and there is much left to do. 

 

Deepthiman Gowda, MD MPH MS, is the Assistant Dean for Medical Education and Associate Professor of Medicine at the Kaiser Permanente Bernard J. Tyson School of Medicine. He also serves at the Director of Clinical Practice of the Columbia University Irving Medical Center Division of Narrative Medicine. 

Welcoming the Kern Institute’s Inaugural Medical Education Transformation Collaboratories!

 From the 6/4/2021 newsletter

Director's Corner

Welcoming the Kern Institute’s Inaugural Medical Education Transformation Collaboratories! 

Adina Kalet, MD, MPH 

The word “collaboratory,” a mash-up between “collaboration” and “laboratory,” was originally coined in the 1980’s with the ascendence of the internet and emergence of collaboration software (think Google docs). Cogburn (2003) who states that “a collaboratory … is a new networked organizational form that also includes social processes; collaboration techniques; formal and informal communication; and agreement on norms, principles, values, and rules.” It has come to describe an open space, creative process where a group of people work together - in real-time, often virtually - to generate solutions to complex problems. And there is no doubt that transforming medical education is one such “thorny problem” deserving this kind of focused attention …

The Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education at the Medical College of Wisconsin is proud to announce our first cohort of Medical Education Transformation Collaboratories. These seven groups listed below represent cross-institutional, multi- and inter-disciplinary, multiple stakeholder communities of practice that will work together in a sustained effort around a shared project to transform medical education by engaging in both innovation and scholarship. Each of the funded collaboratories was selected after a highly competitive merit review process (See below for the list of reviewers). This group includes forty-five individuals from an array of academic disciplines plus a community representative, affiliated with twenty-two health professions education institutions, including medical and nursing schools in many regions of the United States and Canada. Four of the seven include an MCW partner! Members of these collaboratories will meet together in July 2021 and Winter 2022, as well as having regular subgroups meet throughout the year to share progress and resources, address challenges, plan for knowledge dissemination, and learn together. We will implement a process to determine eligibility for a second year of funding. They will update their progress regularly in the Transformational Times.

I learned early on that true collaboration is very challenging and worth doing

In 2005, I found myself co-principal investigator on a medical education research project funded by the National Science Foundation. By this time, I had already participated in a number of large scale multi-institutional collaborations among (only) medical educators, and I thought I knew what it meant to effectively collaborate. Boy, was I was wrong! My co-PIs on the WISE MD project, included a world class computer scientist (CS) from West Germany, an educational psychologist who led a lab exploring the use of technology in K-12 STEM education who was born in East Germany. Our project was focused on building a distributed network information system (with technology originally designed for the pornography “industry”) which would enable both delivering and studying the impact of a rich multimedia core surgery clerkship curriculum. Our team included CS and education graduate students from Korea, Turkey, and Israel, a MD/PhD in Medical Education from Canada, two fine artists (one Russian and one from New Jersey with a culture all its own), a British qualitative informatician (yes, that is a thing), a mostly US-based team of videographers and multimedia editors, surgery clerkship directors from seven medical schools from across the country, and advisory groups from the American College of Surgeons and the Association of Surgical Educators. 

Leading this project required that I danced as fast as I could. Although we were all fluent in English (at least the non-US born members were!), when we began, our team did not share a common scientific language (e.g., clinical surgery, medical education, computer science, learning science, technology, fine art, video production) or a common set of assumptions about what constituted education, learning, or successful research. We had widely divergent approaches to knowledge management (e.g., What do we name and where do we keep our shared documents? What are those funny formulas and code snippets? How the heck do we write about our work together?), or what it meant to do research and disseminate it (e.g., Do we meet in person? Teleconference? Email? IM? Use Slack? Write blogs, proceedings, or papers?). Oh, and we didn’t all sit in the same location. Some of us were one mile apart (which in Manhattan, could mean an hour commute), or across the country or overseas.

It was a remote Tower of Babel for the first year. It was also endlessly fascinating - interpersonally, culturally, politically, intellectually. Technology helped, but it was our commitment to spending the time to get to know each other as people, to have the patience to listen to all points of view before making decisions, define terms, write glossaries, and to tryand-fail, try-and-fail, and try-and-fail, that made this the most impactful project any of us have ever worked on. 

Despite going well down many blind alleys and surviving a good number of tense culture clashes, we figured it out. We had to, because we were accountable to our funders and each other to do innovative and creative work. In the end and as a team, we successfully garnered R01 funding from the NIH to conduct a randomized controlled trial to study WISE MD outcomes (WISE Trial). And consequently, the WISE MD program was one of the first rigorously studied, widely distributed digital medical education curricula in the world. This sparked building of many such curricula in wide use today. Whew! As they say, what doesn’t kill you makes you stronger. 

What it will take to transform medical education

Despite knowing how very difficult it was, the WISE Trial experience is why I believe that the key to transforming medical education will require a large number of intentional, and savvy collaborations across diverse groups of stake holders. While it is much easier to work with a group of like-minded people with whom you share a culture, background, and values, these small-scale projects are less likely to produce sustained meaningful change. It is just true. When you step far outside your comfort zone the risks are higher but so are the potential benefits.

The specific outcomes of the WISE Trial (which was a negative randomized controlled trial, by the way) were diverse and unexpected. We demonstrated the importance of context (Ellaway) and the difficulty conducing intra-institutional work (Sarpel). In addition, there were many sustained research, innovation and business collaborations that resulted. But, most important to me, were the close, life-long, intellectually stimulating relationships across a wide range of academic disciplines, world views, and working styles that developed. These colleagues keep me honest and brave enough to question assumptions. I learned to keep trying and failing until something wonderful happens. 

Why we need to transform medical education now 

We must take advantage of the available pedagogical principles and educational research to move the training of physicians from a 20th century to a 21st century model. Technology is irrevocably altering the practice of medicine. Artificial intelligence and robotics are disruptive. It is essential that our trainees need to engage with the technology and know both how to think and what to think about. 

In the US, despite having the most expensive health care system in the world, our health outcomes are poor. There is an unconscionable maldistribution of physicians - both in specially and geography - such that a great many of our citizens do not have access to or are able to afford basic medical care. There are many problems to address that we are not well prepared to address at this moment. It is time to pivot. We need to do this together, in collaboration. 

Collaboratory Titles, Descriptions, and Members

Here are the seven newly launched collaboratories:

Laying a Strong Foundation: How Do Medical Schools with and without Learning Communities Promote Character, Caring and Professional Identity Formation During Students' Pre-Clerkship Years? 

Team Lead: David Hatem, University of Massachusetts Medical School

Description: 
This project will “develop a greater understanding of the phenomenon of PIF as experienced by medical students early in their medical education” by including the voice of medical students and the role that organizational frameworks play in promoting PIF. 

Collaborators: 
Jennifer Quaintance, University of Missouri Kansas City
Marjorie Dean Wenrich, University of Washington
William Agbor-Baiyee, Chicago Medical School at Rosalind Franklin University
Mrinalini Kulkarni-Date, University of Texas/ Austin-Dell Medical School
Megan A McVancel, University of Iowa/Carver College of Medicine
Alejandro Moreno, University of Texas/ Austin-Dell Medical School
Thuy Lam Ngo, Johns Hopkins School of Medicine
Kurt Pfeifer, Medical College of Wisconsin
Elizabeth Yakes, Vanderbilt University School of Medicine

The Data Science of Character 

Team Lead: Debra Klamen, Southern Illinois University School of Medicine

Description: 
This project will establish a multifaceted, multi-level definition of character, a corresponding collection of behavioral measures of character, and draft a set of recommendations for cultivating character at the at the individual and institutional level.

Collaborators: 
Anna Cianciolo, Southern Illinois University School of Medicine
Collin Hitt, Southern Illinois University School of Medicine
John Mellinger, Southern Illinois University School of Medicine
Bridget O'Brien, UCSF
Robert Treat, Medical College of Wisconsin
Crystal Wilson, Southern Illinois University School of Medicine

Educating Educators to Serve as Change Agents through Professional Identify Formation 

Team Lead: William T Branch, Jr, Emory University

Description:
This project will create, implement, and evaluate a new longitudinal curriculum for interprofessional healthcare leaders based on five content areas associated with higher-order professional development and education leadership among faculty participants.

Collaborators:
Corrine Abraham, Emory University
Richard M. Frankel, Indiana University School of Medicine
Debra K Litzelman, Indiana University School of Medicine
Calvin Chou, University of California, San Francisco
Elizabeth A Rider, Harvard Medical School

NYU-UCSF Collaboratory to Advance URiM Faculty in Academic Medicine 

Team Lead: Richard E. Greene, NYU Grossman School of Medicine

Description:
This project will examine the impact and outcomes of a Faculty Leadership Development Program (FLDP) designed for junior faculty who are underrepresented in medicine (URiM) developed using a novel theory-based framework.

Collaborators:
Sarah Schaeffer, UCSF School of Medicine
Tiffany E. Cook, NYU Grossman School of Medicine
Joseph Ravenell, NYU Grossman School of Medicine
Walter Parrish, NYU Grossman School of Medicine
Sonille Liburd, NYU Grossman School of Medicine

Characterizing Cultures of Mattering in Health Care Education 

Team Lead: Julie Haizlip, UVA School of Nursing & Medicine

Description:
This project will learn how nursing and medical students matter, defined as adding value and feeling valued, in their learning environments. 

Collaborators: 
Natalie May, UVA School of Nursing & Medicine
Karen Marcdante, Medical College of Wisconsin
Caitlin Patten, Medical College of Wisconsin
Rana Higgins, Medical College of Wisconsin

Creating a Collaboratory to Map Medical Education’s Blind Spots 

Team Lead: Sean Tackett, Johns Hopkins Bayview Medical Center

Description:
This project will help the medical education community see its blind spots with clarity, identify structures and barriers that prevent progress, and define strategies to address blind spots.

Collaborators:
Scott Wright, Johns Hopkins Bayview Medical Center
Cynthia Whitehead, Wilson Centre
Yvonne Steinert, McGill
Darcy Reed, Mayo

A Model for Integration of Clinical Performance Measures into Residency Training Programs (Policy Paper) 

Team Lead: Abby Schuh, Medical College of Wisconsin

Description:
This project will address policy related to the challenges of linking educational innovations with clinical outcome measures through the use of meaningful clinical performance measures, harnessing the potential of the electronic health records to capture these data, as well as bridging the silos of medical education and health care quality improvement.

Collaborators:
Dan Schumacher, Cincinnati Children's Hospital Medical Center
Alina Smirnova, University of Calgary
Saad Chahine, Queens University

For further reading:

Ellaway, R. H., Pusic, M., Yavner, S., & Kalet, A. L. (2014). Context matters: emergent variability in an effectiveness trial of online teaching modules. Medical Education, 48(4), 386-396.

Sarpel, U., Hopkins, M., More, F., Yavner, S., Pusic, M., Nick, M., ... & Kalet, A. (2013). Medical students as human subjects in educational research. Medical Education Online, 18(1), 19524.

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 Healer’s Art Course: Preparing M1 Students for What Lies Ahead

From the 6/4/2021 newsletter

Perspective/Opinion

The Healer’s Art Course: Preparing M1 Students for What Lies Ahead

Julie Owen, MD

Dr. Owen, who co-directs MCW’s M1 Healer’s Art Course, describes the value of having students address wholeness, grief and loss, awe and mystery, and service as a way of life early in their medical school careers. She also talks about how important it was when an empathetic physician “bore witness” to grief and uncertainty in her own life …

“The core tasks… are helping the patient acknowledge, bear, and put into perspective feelings and painful life experiences.”

- Glen Gabbard, MD (Gabbard’s Treatments of Psychiatric Disorders, 2007) speaking about Elvin Semrad, MD, renowned psychiatrist at the Massachusetts Mental Health Center in Boston from 1956-1976, one of the nation’s oldest psychiatric hospitals

By the time I entered medical school, I had built an almost decade-long career as a professional actor, performing in regional musical theatre productions around the country after completing my undergraduate degrees. By the time I entered medical school, my professional identity had been firmly established as an “artist,” and transitioning to medicine precipitated a bit of an identity crisis. I happily discovered and immersed myself in the invaluable MCW Medical Humanities Program, recently described by Art Derse, MD, JD, in the Kern Institute’s Transformational Times. A prominent component of this program is the Healer’s Art elective course, introduced to MCW in 2007 by Dr. Derse and Julia Uihlein, MA.

The Healer’s Art curriculum was designed by Rachel Remen, MD, and the course was first taught at the University of California-San Francisco (UCSF) in 1992. Since 1992, it has been offered annually as a fifteen-hour elective, and its reach has expanded to over 100 medical schools across the country. It is currently offered at all three MCW campuses.

The Healer’s Art curriculum was designed as an antidote to physician (and medical student) burnout. As Bruce Campbell, MD, noted recently, a significant body of literature has demonstrated that empathy in medical students precipitously declines throughout the duration of their medical education. After medical school and training is complete, physicians not infrequently leave the practice of medicine, unable to maintain a sense of meaning, personal/professional satisfaction, and commitment to the profession. 

Topics explored during the Healer’s Art 

The topics covered in depth by the Healer’s Art course include maintaining one’s wholeness, grief and loss, awe and mystery, and service as a way of life. Faculty physicians gather with M1 students in a “Discovery Model,” process-based curriculum, in which the mutual sharing of personal experiences and beliefs create a unique professional support system and a safe space of “harmlessness” to explore these fundamental principles of life and of healing. 

One of the core principles of the course is the concept of generous listening. Our medical education teaches us to listen analytically, to ask questions that will allow us to generate a differential diagnosis. Dr. Remen emphasizes that generous listening is practiced not to diagnose, evaluate, fix, or even to understand the speaker; rather, it is the practice of listening only to know what is true for another person and to bear witness to that moment. 

As a psychiatrist, this brings to mind Dr. Semrad’s characterization of our work with patients — to acknowledge, bear, and put into perspective the (often painful) experiences of our patients. When I hear medical students remark that they feel they have little to offer patients, especially in their most vulnerable moments, I hope educational experiences like the Healer’s Art illustrate and nurture the tremendous power we all have as healers, no matter our level of training or practice, simply when we are present with the patient.

My own family’s experience with an artful healer

My husband and I recently “celebrated” the five-year anniversary of his cancer diagnosis and treatment initiation. As an M3, he was diagnosed with a large right frontal lobe tumor, a grade II-III oligodendroglioma, after he had a grand mal seizure during the last day of his surgery clerkship rotation (he fondly recalls that day as “going out with a bang”). His neurologist called us into his office during the lunch hour the day after he had his MRI, the final piece of his outpatient seizure work-up. I remember walking into Froedtert Hospital from the parking garage thinking, “This is one of those life-changing days… and I will never feel this way (read: blissfully ignorant) again.” 

During one of the moments seared into my memory, I am sitting with my husband hearing the news we feared most, and his neurologist is sitting silently with us, tears in his eyes, as we took it all in. Bearing witness. Acknowledging our pain. That moment, more than any other from that whirlwind time period, is forever imprinted in my brain; this physician showed his compassion and his humanity merely by giving us the gift of his quiet. These are the superpowers of a true healer… ones we all possess, if we have the courage to use them.

Julie Owen, MD is an Assistant Professor in the Department of Psychiatry and Behavioral Medicine at MCW. She codirects the M1 Healer’s Art course. 

The MCW Healer’s Art course runs each year over five Wednesday evenings during January through March. Faculty who would like to discuss volunteering as facilitators can contact Dr. Owen through her MCW email address. 

The Hogwarts Model: Putting it all Together in Learning Communities is Foundational to the New Medical School Curriculum

From the 5/21/2021 newsletter

Director’s Corner

The Hogwarts Model: Putting it all Together in Learning Communities is Foundational to the New Medical School Curriculum  

Adina Kalet, MD MPH

Dr. Kalet discusses how MCW’s Learning Community (LC) model has the potential to benefit students and faculty members, addressing our desire to build character and caring, while strengthening both academic and social opportunities for our learners …

Last spring, in anticipation of a rough, rapidly evolving, and socially isolating year, the MCW School of Medicine built a learning community (LC) structure for the entering M1 class to ensure social cohesion and engagement. We wanted students to weather the pandemic with regularly scheduled and academically meaningful structured connections with their peers and between students and faculty members. We accomplished this by weaving together the required REACH (Recognize, Empathize, Allow, Care, Hold Each Other Up) Curriculum and the voluntary 4C Academic Coaching Program. We wanted the students to experience a sense of continuity and have sufficient time to establish true collegiality and strong bonds through “cyberspace.” 

A targeted, sophisticated faculty development process was devised and implemented to train over seventy MCW faculty and staff and twenty-seven students to be leaders. Now, a year later, we are in the process of analyzing the data and can report that the experiment was a success. Preliminary student feedback is inspiring. Similar to experiences at other schools with LCs, the participants report that they gained a great deal. The LC has become a central component of the evolving proposal for the new MCW medical school curriculum. 

This issue of the Transformational Times describes the process and amplifies the voices of both students and faculty participants. I hope you will read the descriptions and enjoy the personal stories they share.   

"It matters not what someone in born, but what they grow to be." 

– Professor Albus Dumbledore

The most well-known learning community model is Hogwarts School of Witchcraft and Wizardry, that secondary boarding school administered by the British Ministry of Magic in an unlocatable spot in the Scottish Highlands.  Upon arrival at Hogwarts, new students are assigned by the sorting hat - based on a magical mash up of personality, character traits, and a bit of “destiny” – to one of the four houses, Ravenclaw, and Gryffindor, Hufflepuff, or Slytherin, named for their founders. Just in case you are one of the few people alive who doesn’t know what I am talking about, read the seven volume Harry Potter series by JK Rowling for more details (or watch the movies). You will learn that once assigned to a house, students are pretty much set for years of mostly healthy academic and athletic competition and a great deal of intrigue. At Hogwarts, as in many idealized academic settings, students develop lifelong bonds with housemates by studying, eating, living, and having innumerable terrifying adventures together. 

This identity setting framework is very important to individuals and to the whole Wizarding community. Increasingly, medical schools - as well as many other higher education environments – are embracing this rather “ancient” model to redress the persistent concerns about lack of academic continuity and  inconsistent mentoring, and to provide the healthy social connections that enhance lifelong resilience. 

What are Learning Communities? 

Learning communities are not “extracurricular,” but fully integrated foundational components of the curriculum. Each LC is a group of people who share common academic goals and attitudes and meet regularly to collaborate on learning activities. While it has all of the “student life” benefits in common with advisory colleges, “eating clubs,” dorms organized by affiliations, sororities, or fraternities, an LC goes well beyond simply providing a rich social structure. They are best thought of as an advanced pedagogical design. Medical schools around the world are adopting this model, the highest profile among the early adopters have been Harvard and Johns Hopkins. 

Rather than considering the individual learner as the only relevant unit of instruction and performance assessment, these “communities of practice” explicitly acknowledge that education is a shared cultural activity with a significant communal component. This sociocultural approach is not a new idea, but it remains a challenge to implement effectively. At its best, the LC model provides a means to structure medical education in truly relationship-centered - as opposed to course-centered – ways.   

In our proposed LC model, academic coaching is fundamental. This inextricably links the cognitive and non-cognitive components of learning on the road to becoming a physician, and put relationships among members of the community at the center of that learning and professional identity formation. 

As part of the Kern Institute’s Understanding Medical Identity and Character Formation Symposium (see my Director’s Corner on April 30, 2021), a group of national leaders discussed “The Nature of Learning Communities and the Goals of Medical Education.” David Hatem, MD (University of Massachusetts), William Agbor-Baiyee, PhD (Rosalind Franklin University), Maya G. Sardesai, MD MEd (University of Washington), and our own Kurt Pfeifer MD, explored how their LC structures explicitly address students’ acculturation to both medical school and the profession of medicine. They reported how a healthy learning environment counters the noxious impacts of the “hidden curriculum,” while supporting students on their professional journeys during medical school, aiming to ensure that students are ready for, and will thrive in, a lifetime of practice as a physician.  

The panelists also shared the collective experience of the  forty-seven medical school members of the Learning Communities Institute (LCI), reviewing the essential characteristics LCs must possess to foster character, caring, and the development of a mature and hardy professional identity. These include:

• Committing dedicated medical school resources and time in curriculum 
• Assigning buildings or spaces that allow students to gather to form relationships (Johns Hopkins constructed a building dedicated to their learning communities) 
• Aligning espoused professional values with values that are practiced by promoting the skills of doctoring while intentionally countering the learning climate’s unsavory elements and its hidden curriculum  
• Promoting longitudinal relationships between mentors and students from beginning to end of medical school, thus enabling mentors to simultaneously support learners while holding them to high professional and academic standards
• Supporting character formation through peer mentoring programs and career decision making

With these guidelines to inspire us, and seeking the collaboration with and approval of the MCW’s Curriculum and Evaluation Committee and the Faculty Council, we intend to build LCs tailored to our institutional culture and strengths. For more, see the essay in this week’s newsletter entitled, “Learning Communities at MCW – A Vision for the Future.”  

The critical importance of continuity - Putting it all together

Throughout my career as a medical educator, I have been involved in efforts to structure close student-faculty engagement and mentoring through small group learning structures. This has included decades of teaching in small groups in an introduction to clinical medicine course for M1 and 2s and being an Internal Medicine “Firm Chief” responsible for successive cohorts of clinical clerks (M3s) while leading an Advisory College style program. These learning structures have often been profoundly satisfying for students, my colleagues, and for me as we provided meaningful educational experiences and mentoring. But none of these experiences provided students with truly longitudinal - admission to graduation - integrated coaching or mentoring. I always knew we could be doing better. I fully believe that the LC model promises a real opportunity for the continuity the current system lacks. 

There is benefit to the faculty, as well

There is no better way for faculty to develop wisdom as medical educators than by committing to a longitudinal process. I started my career focused on residency education and got to know wave after wave of trainees as individuals. These relationships showed me the common developmental trajectories and predictors of success or failure and, therefore, made me a more patient, accurate, and persistent coach. For example, I noticed that the first year residents who worked most slowly in clinic, staying later than peers to finish their patient care sessions, often grew into skillful and efficient clinicians, and were more likely to be eventually selected as chief residents. Knowing this made me more patient and kept me from “taking over” to get their patients “out the door.” I let the novices struggle a bit, confident that their patients were receiving better, more attentive care. It was personally rewarding to know that my patience helped to nurture some wonderful, future colleagues, but I only knew this because I had provided years of longitudinal mentorship. 

Medical school should be a guided experience toward a life in medicine. Learning communities offer a framework for “putting it all together,” providing solutions to many of our modern challenges in medical education while enabling the magical relationships with the student’s peers and faculty. Our goal is to create opportunities for discovery and growth because, as Professor McGonagall once noted, “We teachers are rather good at magic, you know.”

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.

Three Questions for Jose Franco, MD: Perspectives on the Transformation of Medical Education

From the 4/30/2021 newsletter

Three Questions for Jose Franco, MD

Perspectives on the Transformation of Medical Education

The Kern Institute celebrates the appointment of our colleague, Jose Franco, MD to his new role as MCW’s Interim Senior Associate Dean for Academic Affairs. Dr. Franco has been part of the Kern Institute since its inception and has held major leadership roles. As he assumes his new position, he is stepping away from his Kern responsibilities. In this interview, he describes his journey with Kern and his hopes as MCW enters a time of curriculum redesign … 

Transformational Times: Tell us about your journey with the Kern Institute. 

Dr. Franco: Dr. Cheryl Maurana, the institute’s inaugural director, asked me to be the associate director of the Kern Institute at its inception after MCW received the Kern Foundation grant in 2017. During the first year, we were busy with planning and defining the role of the institute. When the four “pillars” were created (students, faculty, curriculum, culture), we developed the “cross-pillar” team that would focus on areas that were important but which none of the pillars owned; areas like wellness, character, and caring. Under Ryan Spellecy’s leadership, for example, we ran focus groups and developed scholarship around “character” in medical education.

When Dr. Adina Kalet became the institute director in 2019, she saw a need to connect more intentionally within the institution and with our urban community, so the cross-pillar activities evolved into community and institutional engagement roles in ways that focused on education. I took on a more active role with event planning, recruiting speakers and panelists, and hosting Grand Rounds, Kern Connection Cafes, and Journal Clubs. It has all been a virtual-reality challenge over the past year.

While this has been going on, I have retained my clinical identity in hepatology and continued to engage with students at all levels. I still look forward to my days in clinic working with our entire group of physicians, students, trainees, PAs, and NPs. They are a great team! I enjoy teaching M1 gastrointestinal physiology, hepatology in the M2 GI nutrition unit and clinical hepatology to the M3 students rotating on internal medicine. I often work with M4 students on electives. I spend time on the wards and in clinic with internal medicine and general surgery residents and fellows. I am fortunate to work with medical students and trainees along every point of the training spectrum. I enjoy that.

Transformational Times: What do you see as your most urgent tasks as you move into your new role as Senior Associate Dean?

Dr. Franco: First of all, we have to define who constitutes our customers in Academic Affairs. Our customers are the students and the faculty. 

For students:

Academic Affairs focuses on curriculum. We must ask ourselves: Is our curriculum really preparing the students for the next phase of their careers? We do a great job covering the basic and clinical sciences but could do a better job with the social sciences. For example, students must leave MCW with a robust understanding and engagement with issues surrounding social determinants of health, and the wellbeing of marginalized populations. Those educational and experiential areas need attention. 

As an educational institution, we must do a better job fostering an inclusive, diverse environment. We are fortunate to have students who identify as being from underrepresented in medicine groups. We must ensure that they feel welcome, included, and empowered. There are, of course, great people at MCW doing this already and I hope Academic Affairs will enhance these efforts. Diversity makes us all better. 

Focusing our efforts on student wellness and wellbeing will be critical. The gaps here constitute a national crisis. When students and young physicians are in crisis, they will “fall out of love” with medicine. Too often, physicians end up seeing medicine as a “job” and not a “calling.” We must explore how we can prepare students and residents to be fully engaged and resilient for their entire careers. I would love to play a part helping students optimize their physical, mental, and spiritual health as human beings. 

For faculty:

I sense that faculty often see the Office of Academic Affairs as a “black hole.” I believe that the Kern Institute has worked to inform the faculty what it does through regular engagement and communication. In much the same way, Academic Affairs needs to let the faculty know what it does. 

The office has many resources that can help the faculty perform their roles as teachers and mentors. We have expertise in instructional design and educational technology, for example. We need to let the faculty know what is available, who to talk to, and how they can be the best educators possible. 

Transformational Times: How do you see the current status of the curriculum redesign?

Dr. Franco: The answer to that changes from week-to-week. MCW’s faculty are well aware that there is no perfect curriculum and that there is always room to make improvements. That said, we have been through change before and, even though we know there is a need to make adjustments, these processes always cause anxiety. The process will always feel like a curveball.

First of all, I am certain that we will be given the resources to do the curriculum redesign correctly. Senior leadership is onboard, responsive, and wants this to succeed.

What is our goal? Let’s start by saying that our goal is to work together to deliver a quality product. We could, of course, put out something tomorrow, but would it be quality? 

I sense that there are two major faculty concerns as the process moves forward:

The first major area of concern revolves around faculty development and preparation for the redesign. 

MCW’s preclinical curriculum has often relied heavily on the traditional fifty-minute lecture format with few interactive opportunities. If we plan to institute a flipped-classroom, case-based teaching approach, we must have a fully engaged and prepared faculty. We must better understand how long it will take to bring everyone up to speed. 

We need to engage the clinicians who will be expected to take on new teaching responsibilities. Clinicians will be increasingly integrated into the process and the proposals will require different approaches that will expand their teaching approaches and challenge their skill sets. 

The second major area of concern is the timeline. 

Is the timeline for deploying the newly redesigned curriculum in August 2022 realistic and optimal? Although it is over a year away, we have a much shorter time to make a decision, since we will begin interviewing the entering class of students late this summer. They are the “customers,” as it were, of the new curriculum. They are the ones who will have to decide if they want to come and experience what we will be offering. We need to be clear with them as to what the curriculum will look like. 

I know that many of the faculty have expressed strong opinions. We must work together and make certain we are all ready and onboard. 

The curriculum belongs to the faculty and the Curriculum and Evaluation Committee (CEC) has the critical role here. I had the good fortune to be chair of the CEC when the pilot integrated curriculum was approved. A few years later, I brought proposals for curricular change to the CEC. I have been on both sides of the table. As a result, I hope I will be in a good position to listen to peoples’ concerns. What excites them? What worries them?

I am excited to take on this role at this important time for our students and our faculty. 

Jose Franco, MD is the Interim Senior Associate Dean for Academic Affairs. He is a Professor in the Department of Medicine (Gastroenterology and Hepatology) at MCW. He previously held leadership roles in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

Remembering H. Jack Geiger, a Role Model and Troublemaker I wish I Had Known

From the 4/23/2021 newsletter

Director’s Corner

Remembering H. Jack Geiger, a Role Model and Troublemaker I wish I Had Known  

This week, Dr. Kalet struggles with her regret at not humanizing her “heroes” when she had the chance ... 

It was with deep regret that I read his obituary because I never had the courage to get to know H. Jack Geiger as a person. Despite having him as a role model for decades, I missed the opportunity to have him as a mentor or friend, and I am poorer for it.  

Geiger, a graduate of UW-Madison, Case Western Reserve, and Harvard, was a physician, civil rights and antiwar activist, journalist, founder of social medicine in the US. He made lots of “good trouble” in his life. He believed that physicians must use their full capacities, their knowledge and skills, and the moral authority that comes with the profession, to improve the social and geopolitical conditions that threatened health. 

Dr. Geiger died this past December, after living for almost a century. While I knew some of his story, the obituaries - and there were many including a beautiful one in the New England Journal of Medicine - pointed out that he excelled at being an iconoclastic rabble rouser. They describe how he was, more than once, sanctioned by his medical institutions for speaking out to “raise the bar” for our profession, but he persistent none-the-less. 

He was not like most of us.  A preternaturally brilliant, child of immigrant German Jewish parents, who were a physician (dad), and a scientist (mom), he finished high school at fourteen and ran away from home (with his parents’ permission!), to live in Harlem among actors, musicians, and the celebrated authors of the time. He entered the University of Wisconsin as undergraduate and wrote for the Capital Times in Madison before he was eighteen years old. He never took any straight paths, following his instincts and his strong moral compass. 

Both Dr. Geiger and I began at the Sophie Davis School for Biomedical Education (now the City University of New York Medical School) in 1978. I was a college freshman, and he a remarkably accomplished physician, social activist and newly minted Arthur C. Logan Professor of Community Medicine. I wish I had invited him for a cup of coffee or a beer. I never considered it; it was too intimidating I was convinced he would be “too busy”. Later, I wish I had visited him at his home in Brooklyn during his last decades when he stopped traveling, became frail, and had failing vison. I certainly could have. I am now certain that he would have made time to talk with me. He might have even enjoyed meeting a former student. But I never called.  Instead, I took the easier route and had conversations and debates with him in my head. It is hard to learn anything that way!

The problem of being afraid of our role models is this: they remain on pedestals and exist mostly in our imaginations. We try to understand them and learn from their examples. We watch them and read about them, but we never know them in their full humanity, warts and all.  

Of course, this “hero at a distance” is often all that is available to us. Our role models may not be proximate. They may be long gone, or they may be entirely fictional. But I now believe that if opportunities arise to transform role models into mentors, one should take full advantage, even though there might be risks. To truly know a remarkable person is invaluable, and the privilege to be known by someone who has done heroic things is rare. 

When I was in college, we knew only vaguely of his many accomplishments to that point, (he had yet to win his two Nobel Prizes) and we were way too self-absorbed and naïve to truly appreciate how unusual a physician he was. Although we heard him lecture occasionally, we were largely unaware of what a character, in all the senses of that word, he was. Boy, did we miss out! 

In fact, he was redefining what it meant to be a physician just as we were working very hard to become one. His example was destabilizing to our nascent professional identity formation. The lessons he represented, the moral exemplar he was, were lost on most of us.  Admittedly, it might have been difficult for us to truly appreciate what he had to teach us early in our careers, but we should have tried. Missing that opportunity was a great loss. Had we taken the risk and made the effort, we would have been the richer for it. 

How might my medical school have taken better advantage of this giant walking amongst us? I think there are “curriculum” lessons in this. In addition to the occasional lectures from him and about his work, the book chapters and New York Times editorials he wrote (but which we weren’t obligated to read), there should have been a way to understand him beyond the “hero” stories. Had we found ways to engage with him meaningfully as a person, it would have humanized this intimidating, moral exemplar and, perhaps, provided us each with more detailed career maps. What a remarkable “leadership training” program it might have been to talk with him informally, to hear his personal stories, his journey, and his views on his own coming of age! Besides reading about his work and hearing him speak, we would have been able to bring our questions, comments, and fears to him. 

It is also possible we might have been disappointed. That’s okay. After all, no role model is perfect. Many are not even particularly gifted in interpersonal skills. There might have been confrontations and rebukes. He might have initiated intellectual debates that rose well over our college-educated heads. This was a man who talked with Langston Hughes as a 14-year-old! But, had we the courage to engage, we might have learned more of what he had to offer in ways that would have challenged us and given our own embryonic careers direction. 

It is also true that he might have been too overwhelmingly engaged in other activities to be part of such a curriculum. Although he was only in his mid 50s when he came to the Sophie Davis School, he had already traveled to South Africa where he had studied their community health centers. He then brought this approach to the Mississippi Delta, sparking a movement that is credited with bringing basic health care access to tens of millions of Americans. At the same time, he was co-founding two Nobel Prize winning organizations, Physicians for Human Rights and Physicians for Social Responsibility. Sometimes, role models must be just that and nothing more; they have work to do and we should watch from the sidelines and take notes.  

The “writing prescriptions for food” lecture 

Every year, we gathered for the same “Geiger Lecture,” where he told the story of his work in rural Mississippi. The most memorable section was when he described the political battle into which he was drawn when funders realized that the program was writing, and then the federally subsidized community health center pharmacy was filling, prescriptions for food.  Every year he delivered the same punch line, describing how he won the battle. “I told them,” he said, “the last time I checked my textbooks, the specific therapy for malnutrition was, in fact, food.” 

I am ashamed to say that my classmates and I rolled our eyes at this story, much like children sigh at the Thanksgiving table when Grandpa tells the same stories every year. But these stories are our legacy and, at the risk of boring the children, it is through the frequent retelling of these “hero stories” that communal values are transmitted. Of course, now I want to know more. Was he scared or anxious when he need to confront those with the authority to stop his important work? How had he prepared? What would he have done if they had pulled the funding? I would have wanted to hear about his failures and how he delt with those. But now I cannot. 

When my son was little, he was absolutely enthralled with superheroes (still is, I think). Batman and Superman costumes were festooned throughout our home, red capes and black masks everywhere. Through our many conversations about the thoughts and feelings of his role models, we landed on the conclusion that it was easier to know what the right thing to do was than to actually do it.  Our maxim became, “courage means being scared but doing the right thing anyway.”  It would have taken courage to reach out and insisted that H. Jack Geiger talk with me, but the privilege to have known him better would likely have been worth the effort.  

I will be reaching out more and connecting with my heroes. And the Kern Institute will do what it can to create proximity with the “s/heros” of our times, to the benefit of our students, our trainees, and ourselves.  

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.

‘Take 3’ Question and Answer: Report on a Human-Centered Design Sprint for the MCW Curriculum Re-imagined

 From the 4/16/2021 newsletter

  MCW Curriculum Re-imagined

 

‘Take 3’ Question and Answer:  Report on a Human-Centered Design Sprint for the MCW Curriculum Re-imagined

Dr. Wendy Peltier and second year medical student, Lauren Stippich, share their experience from participating in the first Virtual Design Sprint Workshop on the proposed MCW Curriculum, sharing perspectives through the eyes of a student and senior faculty.

 

The Kern Institute’s Human-Centered Design Lab facilitated a virtual design sprint last week with 77 participants, representing students, faculty, residents and staff from across our MCW community.  Amy Prunuske, PhD, and Travis Webb, MD provided a high-level overview of the key principles of the proposed curriculum, which involves development of learning communities and implementation of longitudinal, case-based and experiential teaching formats for foundational knowledge. The design sprint, led by Karen Marcdante, MD, Chris Decker, MD, and Julia Schmitt, provided an opportunity for participants to work in small groups to provide in-depth feedback on the curriculum proposal. This format ensured that every participant’s feedback was recorded, and all the information  has been qualitatively organized for the Curriculum Steering Committee’s use.   

The curriculum proposal would involve a major shift from our current, ‘2 by 2’ structure of separating basic science course work from clinical rotations. A potential timeline for approval, and detailed summary of background work over the last two years leading up to this proposal was provided. Dr Webb and Pronuske shared, ‘The goal of our curriculum is to produce competent well-rounded physicians who will be excellent clinicians in any specialty and are prepared to practice in the future health care environment’.

They acknowledged the contributions of many in developing this proposal, including Bill Hueston, MD, Jeff Amundson, PhD, and Jennifer Hinrichs.

 

1) What surprised you most about the session?

Lauren:  I was shocked by the high emotion from many of the participants! As students, we only see the ‘end product’ when a curriculum has been implemented, and I did not appreciate all the pre-work and planning that stands behind our course offerings.  It was eye-opening to hear the various worries and hesitations of key faculty for embarking on such a major change in teaching formats.  Frankly, it worried me that some of the comments seemed to go a bit too far, and without recognition for the immense amount of work that went into this workshop and the proposal itself .  This was my first time being part of such a broad group, and I quickly saw how important it will be to have buy-in from all our stakeholders to implement this change.

Wendy:  Must say, I anticipated the high emotions, having been at MCW during  the transition to the Discovery Curriculum, and from my experience with change management.  Hearing the plans for the first time in considerable detail, I was surprised and excited about the spirit behind bringing this new, student-centered approach to adult learning that is explicitly tied to promoting inquiry and innovation in our learners.

 

2) Did you feel your voice was heard?

Lauren:  The small group process really created an authentic, ‘safe space’, to both talk and listen, and we had enough time to review things in detail.  There was a basic science faculty in my group, and I developed an understanding for concerns that previously I did not appreciate even existed.  Some participants complained that the breakouts were too small with only three members each, stating they wanted to hear more opinions, but I understood the rationale behind this.  It is so important to hear all perspectives, and smaller sized groups help to ensure the collected conversations are representative of everyone, not just the most vocal members of a group.  This seems even more important in the virtual setting.  Being part of the workshop planning group, I also saw how the detailed feedback would be gathered, allowing the program leaders to have a full appreciation of all concerns.

Wendy:  My experience echoed Lauren’s.  The more ‘intimate’ breakout sessions created opportunity for in-depth discussion of the guided questions.  It was important to hear both the excitement for a new structure, but also concern and worry over the ‘heavy lift’ involved in implementing such a major change.  A strong theme that came through was need for culture change and to explicitly identify ways to honor educators in our community with protected time and recognition for teaching AND administrative efforts.

 

3) As we reimagine the MCW curriculum, what do you see as important     measures of success?

Lauren:  The new curriculum really excites me, particularly in the thoughtful and deliberate structures that promote student connection and support, as well as the spiral or ‘catch-up’ weeks, where students can take a breath, or refine and review important topics.  As a second year student, I can reflect on what a huge transition it was to enter medical school, and how the 4C Coaching program provided amazing support during this challenging time. I consider my participation in this program the most impactful activity of my M1 year—and I can see how the learning communities and small group activities will help that shine through in the new curriculum.  I would hope that students being more connected, and the environment continuing to be collaborative rather than competitive, despite our large class size, could be key outcomes. After participating in this workshop, I would also hope that all the faculty who contribute to teaching will feel supported, prepared and confident in launching the new changes.

Wendy:  My hope for success would first be a true, institution-wide, commitment to change with resources to manage the transition.  Success will be tied to students and faculty learning together, and for many of us, stepping outside our comfort zone.  The evidence behind the need for change, which is robust, indicates that this will be a much needed and important investment in preparing our graduates for future practice.  This year has certainly been one that highlights the challenges to our profession and current health delivery systems.  To me, training physicians who are prepared to speak up when needed, to care for themselves, and to seek innovation in their daily work, is something to promote and support.

To learn more about the MCW Curriculum Re-imagined and Human-Centered

Design:

1. Discovery Curriculum Exploration Project

2. Human-Centered Design Lab

 

Lauren Stippich is a Wisconsin native currently in her second year of medical school with interest in medical education and the Humanities.  Lauren is a student member of the Human-Centered Design Lab and this was her ‘first dive’ into a curriculum re-design process.  In her free time, Lauren enjoys reading books, time together with friends and a good game of spike-ball.

Wendy Peltier, MD is an Associate Professor of Neurology and Medicine, in the Division of Geriatric and Palliative Medicine at MCW. She is also a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. In her free time, she enjoys yoga, reading books and home-cooked meals by her husband and son.