Lessons Learned While Caring for Dying Veterans

Originally published in the July 22, 2022 issue of the Transformational Times (Focus: Geriatric and Palliative Medicine)

Lessons Learned While Caring for Dying Veterans 

Adrienne Klement, MD

Dr. Klement, who completed a fellowship in Hospice and Palliative Medicine, cares for Veterans at the Zablocki VAMC in Milwaukee. As we approach Veteran's Day, she shares two stories from the COVID-19 pandemic that show some of the lessons she has learned caring for her patients…

“These doctors have the hardest job in the world.” It was a cold January evening during the pandemic, and the Milwaukee VA ICU was buzzing with a symphony of ventilator alarms, bedside monitor alerts, the closing and opening of isolation carts, and staff conversing about patient care needs. 

Visitor restrictions were in full force. Despite the noise, the unit felt empty and stark with closed doors and without families at bedside, except for one room. I gowned up and greeted our dying patient, Mr. D, and his family. 

There were several grandchildren joining on Facetime. We (they) had twenty minutes. We all had to speak loudly through our N95s to be heard over the Vapotherm. Mr. D acknowledged he was very sick. We talked about his hopes and wishes, and he gave his loving family all the appreciation he could muster. He just wanted to hug his grandchildren. At the end of the conversation, his son hovered in close to him and said, “Dad, these doctors have the hardest job in the world—they have done everything they can to help you. You are going to die soon, we are here now, and we love you.”

Lesson number one: Sometimes, the best way to reach a patient is through a trusted and familiar face.

I could tell Mr. D was holding back tears throughout our conversation. I wondered if this suppression of emotion was something he had learned in the military, and what trauma he had been through in the past. Was it a sign of weakness to admit feelings of fear or sadness? Was he trying to stay strong in front of his family as a way to bear their grief? I noticed a few quiet tears of my own while in the room, and I couldn’t help but wonder if my reaction was acceptable, or if it was detrimental to my roles as comforter and healer. 

When I got home later that evening, I started to unpack my (unexpected) reaction further, realizing that my tears were complex. They were a reflection of empathy, as I recalled holding my mother’s hand as a teenager when she took her last breath. They embodied frustration with the end-of-life isolation protocols. And they were tears of immense gratitude for the life of service Mr. D gave to our country, and for the care given by his Oncology and ICU teams.

Lesson number two: Showing emotion in front of patients, colleagues, or families is part of healing, for all of us.

The appreciation given to us by our Veterans and their families is transformative. Medical training is a long road that comes with many sacrifices, but also deep bonds and human connection. 

I had the privilege of helping to take care of Mr. R, who had end-stage leukemia, in both a consultative role, and also as his primary Medicine attending. It was so special to me as a teacher, to witness my resident-in-training also provide exceptional care and supportive listening. Mr. R and his wife expressed their deep appreciation for the unique care that he gave, and all that our VA providers gave through to his dying day. 

As an educator, I felt fulfilled in witnessing our team experience the most rewarding aspect of practicing medicine, relationships with patients. Mr. R’s military and life stories were therapeutic for all of us, and he reminded us daily that we are caring for some of the most selfless and resilient servants in the world.

Lesson number three: Reflecting on our Veterans’ acts of service and life experiences through attentive listening and presence cultivates gratitude for our work.

I am grateful every day for the meaning that my work brings me. I am most thankful for our Veterans who have served our country, and from whom we have much more to learn.

Adrienne Klement, MD, is an Assistant Professor in the Department of Medicine, and is a faculty member in the Division of Geriatric and Palliative Medicine at MCW. She attends on the inpatient Internal Medicine and Palliative Care consult services at the Zablocki VAMC, where she was recognized in 2022 as "Employee of the Year."

There is No Success Alone

From the 1/20/2023 issue of the Transformational Times

There is No Success Alone 

By Cassie Ferguson, MD – Associate Director of the Kern Institute 

 

 

"Talent wins games, but teamwork and intelligence win championships." 

-Michael Jordan 

The depth and breadth of our collective success in the Section of Pediatric Emergency Medicine is staggering. And the pride and reverence with which each of us holds these successes, regardless of the role we played in them, is a testament to the love we have for our patients and for one another.  

It also is a testament to our leader, Dr. David Brousseau.  

Our section begins 2023 with a goodbye to our chief of eleven years, whom we affectionately call D-bro. Dr. Brousseau is leaving for Delaware after 23 years of service to MCW, and I couldn't let him leave without trying my best to explain how much he has meant to me and to all of us – to our team. 

The Section of Pediatric Emergency Medicine is working to address food insecurity among our patient's families, improve patient health literacy and numeracy, strengthen the coordination between the Emergency Department (ED) and our EMS colleagues, decrease sexually transmitted infections in our adolescent patients, share our experience in pediatric sedation medicine with colleagues in under-resourced countries, sharpen our section’s bedside ultrasound skills, ensure all patients have access to life-saving flu vaccines, and give kids who have been victims of interpersonal violence a chance to go to summer camp. Among other things. 

Our team is committed to this challenging work. We also like to win. We are especially proud of wins that showcase our team’s ability to work together creativity – even when it has nothing to do with emergency medicine, and everything to do with teamwork. Even if it’s just for fun. 

For six of the seven years that the Children’s Specialty Group has held a Halloween costume contest at Children’s Wisconsin, the Section of Pediatric Emergency Medicine has either won first place or been in the top three (we don't count the year we were allegedly disqualified). This success is not by accident. Every year, months in advance, we vote on a theme and then each of us—faculty and staff—works on putting together our individual costume such that it fits into the theme. As an often overlooked and perhaps maligned department of the hospital (hey— we don’t like to call you to consult at 0300 either), winning this contest has become a source of pride, primarily because we do it together.  

All hail the Section of Pediatric Emergency Medicine’s Halloween Costume Dynasty. 

“How lucky I am to have something that makes saying goodbye so hard.” 

-A.A. Milne 

I admit this Associate Director's Corner is less an article than a love letter to my pediatric emergency medicine colleagues and to Dr. Brousseau. 

Twelve years ago, I was a new attending physician and had just moved back to Milwaukee with my husband, our three-year old son, and a newborn. I felt so lost. I remember wanting desperately to contribute and to feel useful, yet not knowing how. Within three years, I was co-directing the Quality Improvement and Patient Safety Scholarly Pathway for the medical school, was selected to participate in MCW’s Docere II teaching course and had begun an advanced improvement methods course at Cincinnati Children’s Hospital.  

I acknowledge this required a certain amount of work on my part, but I also know that none of it would have happened without Dr. Brousseau and those foundational opportunities that were key to me building what has become an incredibly fulfilling career. 

Even more meaningfully, for the past 12 years Dr. Brousseau has consistently reminded me what I am capable of and what I contribute, empowering me to take risks and to step into roles I thought were too big for me. 

As I look around at my section colleagues, and at what they have achieved, Dr. Brousseau’s legacy becomes very clear: His leadership has enabled us all to thrive. We are purpose-driven and optimistic; we are continuously learning and pushing for change; we know how we can contribute to the greater good of the section and our community at large and we are given the space to do so. Even in our section's darkest hours, instead of fear and uncertainty and anger tearing us apart, we rose together, becoming closer and more determined to navigate the darkness together. 

"The good leader is he who the people revere. The great leader is he who the people say, we did it ourselves."

-Lao Tzu 

In this country, we like to think of good leadership as big, bold and brash. Crashing through obstacles, pushing past limits. Loudly declaring itself. All-knowing. Strength of conviction is often more apparent than strength of character in the leaders we choose and in those chosen for us. 

Dr. Brousseau, however, has shown me leadership that enables thriving is quiet. It takes mindful, careful steps as if feeling the earth beneath its feet as it walks. This kind of leadership is inclusive. It widens our field of attention and helps us be aware of when we are being called to be more loving, more compassionate, more open hearted. It engenders trust -- not through convincing, but through presence. And it doesn’t get frustrated when it must explain how to calculate positive predictive value for the 1000th time during journal club. 

“Goodbye always makes my throat hurt.” 

-Charlie Brown 

Whenever I sat down with Dr. Brousseau in his office for my annual faculty review, he always began our conversation by asking, "What is your favorite part of your job?"  

If I had that question to answer one more time, knowing that it would be our final faculty review and the last time I would have the chance to share my answer with him, I would say this: 

There are too many favorite parts to name them all. I love showing up to the ED and getting a hug from the person I’m getting sign-out from. I love that when I want to switch a shift so that I can see my kid’s baseball game, someone will instantly volunteer to help. I love that our section meetings never end on time because we are all so excited to see and talk to each other.

Perhaps most of all, I love that I have the freedom to do what I love to do with people I love, and the support and encouragement to keep doing it better.  

Thank you, Dr. Brousseau, for pushing us, for fighting for us, for holding us all together. For helping us to thrive.  

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

The Experience That Changed My Perspective on Everything

From the 6/11/2021 newsletter

Perspective/Opinion

The Experience That Changed My Perspective on Everything

Kaitlin Kirkpatrick, MD

Dr. Kirkpatrick writes movingly on how experiencing her own illness had a profound influence on how she sees others who suffer...

Four years of medical school, 2.5 years of residency under my belt, I entered spring of my 3rd year of residency as a confident and competent senior resident. I knew how to manage my inpatient team: which tests and procedures we needed to order right away, how to triage pages from nurses, and how much time we could allot to each patient we rounded - the essentials that kept us efficient and on top of our workload. Then one day I got sick, and everything changed.

Catching a variety of illnesses in residency seems to just come as part of the job, especially when you spend time in the pediatric emergency room. I remember when norovirus wiped out my team intern year, and I’ve had so many mild URIs over the years that I’ve lost count. That’s why when I started feeling ill one weekend, I felt guilty calling in the jeopardy resident but figured it would be quick. What I didn’t expect was to be barely conscious in the Moorland Reserve emergency room with blood pressures in the 70s/40s and the ER staff arguing about whether to start pressors now or let the ambulance take me straight to Froedtert’s surgical ICU.

The following days were a blur of overwhelming exhaustion, confusion, and fear, especially for my husband hearing words like “portal venous gas” and “likely sepsis” with little explanation of what it all meant. My memories come more in flashes. I recall crying when they told me they wanted to get an arterial blood gas. I remembered patients complaining of how much they hurt, but that had never stopped me from ordering them in the past. I've ordered so many nasogastric (NG) tubes during residency, that when they warned me that they were placing one on me, I assumed, “Okay, this can’t be that bad.” I was wrong. I was so tangled up in wires from my central line, a separate peripheral IV, telemetry wires, and a Foley. All of that was tolerable. 

The NG tube was not.

I suddenly became the patient that I used to dread. The surgical nurse practitioner came by and told me that we’d probably be able to take the NG tube out that day, but she had to run it past the attending first (a line I’ve used many times with my patients). Waiting for the attending doesn’t feel as easy when you’re the patient. Finally after telling the nurse I’d pull it out myself, she helped me remove it. For the first time that admission, I started to feel like things might be getting better. It was still another couple of days in the ICU consisting of sleep, echocardiograms, CT scans, more sleep, antibiotics/antifungals, the occasional pathetic walk around the unit, and more sleep before I finally got to transfer to the acute care floor. A few days after that I was able to discharge home, but it wasn’t until we picked up my 9-month-old son from his grandparents and made it back to the safety of our own home that I finally cried and began to process everything I endured. 

I still know the tests and procedures to order on my own patients, but now I’ve started to ask a little more often, “How badly do I need this test?” When my patient has something like an NG tube, I am much more conscientious about when it can come out. Will poking this patient for a lab really change what I’m doing or am I just ordering these tests out of routine? If the nurse is paging me, I try to be quicker to respond unless I truly am in the middle of an emergency. I understand now more how much they really are trying to advocate for their patients. Even now, I spend just a little more time at a patient’s bedside talking to them, to their family, trying to make a little bit of their hospitalization better, because I remember what it was like to be on the other side. 

I’m not the same physician I was prior to this experience, but I’d like to think that I am better than I was before. I do more critical thinking about testing and procedures, I try to be a more involved team player with my support staff. And most importantly, I’m more empathetic towards my patients and their families. I also try to make more time to take care of myself. Sometimes the mental healing takes longer than the physical. I’m lucky my husband and my residency program always supported me in finding the psychological support I needed to recover. I can’t say I’m thankful for having gone through it all, but I am grateful for the doctor it helped me become - the doctor I will continue to be as I graduate from residency this year and begin the next phase of my career. 

Kaitlin Kirkpatrick, MD, is a PGY4 Internal Medicine-Pediatrics resident.

Marking the Moment…and Continuing Forward Together

From the 5/6/2021 newsletter

Perspective/Opinion

Marking the Moment…and Continuing Forward Together

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

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

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

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

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

Deciding to mark our “anniversary” …

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

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

Hitting the mark …

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

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

To our nurses and our teams:

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

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

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

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

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

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

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

 From the 5/7/2021 newsletter

Director’s Corner

 

 

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

 

 

By Adina Kalet, MD MPH

 

 

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

 

 

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

  

Two amazing, transforming women

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

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

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

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

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

  

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

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

 

The COVID-19 pandemic is not a war

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

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

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

 

 MCW Nurses inspire

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

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

 

 Thanks to our nurses!

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

 

 

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

Beyond Competency: Setting a Path to [Diagnostic] Expertise

 From the. 1/22/2021 newsletter

Perspective/Opinion

 

 

Beyond Competency: Setting a Path to [Diagnostic] Expertise

 

 

By Jayshil Patel, MD and Paul Bergl, MD

 

 

Drs. Patel and Bergl, who have a keen interest in “how doctors think,” discuss their curriculum to improve clinical reasoning skills …

 

Think about the last time you or someone you know went to a doctor with a symptom.  What did you or they seek?  Did you want an explanation for the symptom?  Did you want an efficient, yet thoughtful evaluation in arriving at a diagnosis?

 

Accurate and timely diagnosis is the foundation of medicine.  With it, management strategies have the best potential to positively modify disease and outcome.  Without accurate diagnoses, however, management is unguided and both potentially wasteful and ineffective. Thus, we advocate for undergraduate and graduate medical education to invest in setting learners on a path towards diagnostic expertise. 

 

Expertise does not stem from a superior natural capacity to analyze new information.  Rather, expertise is an adaptation, rooted in the ability to efficiently recognize patterns and compare it to what has been accrued in an individual’s extensive knowledge domain in their long-term memory.  Expertise requires deliberate practice, a concept coined by psychologist Anders Ericsson to describe the modus operandi of expert development.  Deliberate practice requires systematic and forced attention for refining performance.  Experts set a stretch goal, deconstruct its components, and hone narrow aspects of their performance until achieving mastery. 

 

 

Deconstructing the “diagnostic process”

 

Fortunately, the diagnostic process can be deconstructed, and its steps deliberately practiced, thereby allowing the practitioner to remain on a pathway to diagnostic expertise. Unlike chess, music, or individual sports, however, measuring expertise in medicine is challenging.  Yet if we assume that consistency, efficiency, tolerance for uncertainty and ambiguity, and adaptability are key features to any form of expertise, then enhancing diagnostic performance would be aided by a rich understanding of the diagnostic process and mastery of its components.  With systematic and forced attention towards elements of the diagnostic process, knowledge (within the limits of working memory) becomes amenable to processing and reorganization into more meaningful units called “chunks.”  

 

When new information arises, the working memory rearranges its components into a coherent cognitive representation by connecting and cross-referencing this emerging knowledge with established “chunks” of information already stored in long-term memory, ready for rapid retrieval into working memory.  Not only do expert diagnosticians possess extensive knowledge, but through deliberate practice, they store this knowledge in well-organized schemata in the rapidly accessible long-term memory.   

 

Consider the alternatives and consequences to deliberate practice.  Learners (or practicing clinicians) may “practice” medicine by logging thousands of hours seeing patients; however, without explicit knowledge of the diagnostic process or well-defined goals for the steps of that process, they are at risk of repeating habitual tasks and on the pathway towards arrested development.  Without coaching or reflection, unguided learners (or practitioners) may not recognize failures, and they may default to an intuitive mode of thinking, which when overutilized, is a key driver of diagnostic error. 

 

 

The mechanics of a diagnostic reasoning curriculum

 

Diagnostic reasoning curriculum ought to change learners’ attitudes of their growth potential, build knowledge around the language and science of reasoning, and enhance specific skills through deliberate practice and reflection.  Implementing deliberate practice across the training spectrum requires a fundamental shift in how we teach diagnostic reasoning in today’s complex clinical learning environment.  Learners may perceive diagnostic reasoning as an intimidating black box and expertise as unattainable.  For attitudinal change, we suggest explicitly defining and calling out the stretch goal, namely, to create expert diagnosticians.  

 

Changing language to include phrases like “expert development” and illuminating a deconstructed pathway to expertise may foster a growth mindset, one in which learners peer into the black box of diagnostic expertise and gain intimate access to its many inputs and outputs.  We suggest a vision for medicine training be to gain the foundational diagnostic knowledge and skills to independently care for patients while deliberately practicing them toward expertise.

 

To build knowledge, the stretch goal should be deconstructed into discreet, teachable components.  In our curriculum, we have deconstructed diagnostic reasoning into: 

 

[a] the semantics of the diagnostic process

[b] the science of thinking, learning, and decision-making

[c] mechanisms for reflecting and strategies which may enhance diagnostic accuracy

 

Before applying their knowledge, experts in non-medical fields like chess, tennis, and art learn and master a common language.  Likewise, before applying medical knowledge, students master the language where words like dorsum, ipsilateral, and morbilliform codify concepts we all understand.  Similarly, the steps and scientific concepts of diagnostic reasoning include well-defined terms like problem representation, illness script, diagnostic schema, dual process theory, and cognitive load.  We suggest educators and learners first master the language of clinical reasoning.  Without this language, we create competency scales that deem trainees ready for unsupervised practice if they merely “synthesize data to generate a prioritized differential diagnosis and problem list.”  Oblique references to diagnostic reasoning are confusing.  Furthermore, without a shared dialect, we cannot apply diagnostic reasoning knowledge nor expect learners to reflect or teachers to coach.

 

Next, teaching the science of thinking is crucial to optimize reflection, feedback, and clinical decision making.  In our curriculum, we differentiate normative from descriptive modes of decision-making by illustrating Bayesian principles and outlining System 1 and 2 thinking, respectively, using medical and non-medical examples.  Describing concepts like cognitive load and cognitive bias may enable trainees to recognize methods to optimize learning and limitations of human thinking, respectively.  Furthermore, the advantages and disadvantages to various types of reasoning can increase self-awareness and consciousness of the mode employed, empowering trainees to better calibrate their own thinking over time.  Faculty development in the science of thinking and learning may promote their ability to, for example, recognize a scenario where learners (or their teachers) may be experiencing high cognitive load, to then take the steps to minimize it by enhancing the clinical learning environment.

 

Explicitly granulating components of the diagnostic process provides targets for feedback and self-reflection.  For example, accessing and selecting illness scripts are steps in making a diagnosis.  Illness script components include epidemiology, pathophysiology, symptoms and signs, diagnostics, and response to treatment.  Our (unpublished) research shows almost all novice learners recall signs and symptoms of disease but often lack working epidemiological knowledge or pathophysiologic insults.

 

 

A clinical example

 

Consider a situation where a novice learner working in an intensive care unit identifies a patient with new thrombocytopenia.  The learner mentions the patient was receiving heparin and orders tests to evaluate for heparin-induced thrombocytopenia without mentioning its epidemiology or considering alternative etiologies.  Two days later, the patient was found to have disseminated intravascular coagulation.  During a feedback session, one form of feedback might be: “Read more about thrombocytopenia.” 

 

But, if the community of learners and educators speak a common language around diagnostic reasoning and understanding the science of thinking and learning, feedback may be transformed from a nebulous, “Read more about thrombocytopenia,” to  “I’d like you to work on the epidemiologic component of your illness script for heparin-induced thrombocytopenia and develop a pathophysiology-based diagnostic schema for thrombocytopenia.”  

 

 

Feedback tethered by the language and science of the diagnostic process has numerous benefits.  By delineating components of the diagnostic process, educators and learners can better assess diagnostic performance through targeted feedback, and in turn, deliberately practice towards, in this example, enriching an illness script.  From the perspective of an educator, awareness of what constitutes an illness script led to recognition of an incomplete script (lacking epidemiologic knowledge for heparin-induced thrombocytopenia).  By having knowledge of “how we think,” educators and learners can have a conversation to metacognate and identify cognitive bias leading to potential diagnostic error.  

 

In our example, the learner did not consider alternative etiologies for thrombocytopenia and anchored onto a diagnosis of heparin-induced thrombocytopenia.  As a result, educators construct remediation plans.  The learner was advised to develop a schema for thrombocytopenia (i.e., form a systematic approach to a clinical problem).  Consequently, longitudinal follow-up is established.  

 

On subsequent interactions, the educator can assess if the learner, indeed, developed a schema for thrombocytopenia. From the perspective a learner, such targeted feedback is constructive and actionable and serves as both a tool and a metric, in this case, to enrich the heparin-induced thrombocytopenia illness script and deliberately practice thrombocytopenia schema formation.  Importantly, the learner has a framework to self-reflect on how, why, and which cognitive bias(es) was invoked. 

 

 

Opportunities for incorporating clinical reasoning education into the clinical learning environment

 

To enhance reflection, skills, and reinforce effective habits for expertise, we suggest creatively infusing opportunities to deliberately practice components of the diagnostic process into our fast-paced, complex clinical environments that are fraught with actual or perceived barriers, like hand off medicine.  We advocate for dedicated undergraduate and graduate medical education didactic sessions that teach the language and science of diagnostic reasoning.  Morning report, morbidity and mortality conference, and clinical-pathologic correlation conferences could serve as ideal venues to deliberately practice diagnostic reasoning concepts and reap the benefits of crowdsourcing.  

 

As we have observed in our curriculum, infusing the language of clinical reasoning in one venue will invariably lead to utilization in other venues.  On the wards, when housestaff hand-off their patients, the face-to-face handoff period is an opportunity for a second opinion for the person giving the hand-off.  For the individual receiving it, it serves as an opportunity to practice diagnostic reasoning components, including refining problem representation as new data trickles in before rounds.  During rounds, we propose asking learners for why and how a diagnosis was ascertained, as opposed to just what. 

 

Democratizing rounds and asking all learners, not just the one presenting, promotes group discussion and creates a clinical learning environment where all learners can be empowered to think aloud.  For educators, asking learners to reason aloud promotes active reflection and generates opportunities for coaching and critical appraisal of their diagnostic reasoning.  Ideally, coaching would be longitudinal and intensive but, as demonstrated above, focused feedback need not be laborious.  Embedding problem representations followed by a reasoned diagnostic conclusion into electronic notes promotes script selection and real-time visualization of missing components, schema formation, and a tool for reflection since the diagnostic process is often evolutionary.  

 

 

The end game

 

The objectives for medical trainees are to “practice” good medicine and become lifelong learners, sentiments captured in a revered Oslerian axiom: “The art of the practice of medicine is to be learned only by experience; ‘tis not an inheritance; it cannot be revealed… Know that by practice alone you can become expert.”  Explicit in this epigraph is the need for experience.  Implicit, but especially relevant today, is the need for aspiring expert diagnosticians to deliberatelypractice the components of diagnostic reasoning.  Otherwise, carrying forward today’s practice habits creates a cadre of experienced but overconfident non-experts – a perfect recipe for stagnation, repeated errors, and adverse patient outcomes.

 

 

 

 

Jayshil Patel, MD is an Associate Professor of Medicine (Pulmonary, Critical Care and Sleep Medicine) at MCW. He is a member of the Curriculum Pillar in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

Paul Bergl, MD is an Assistant Professor of Medicine (Pulmonary, Critical Care and Sleep Medicine) at MCW.

 

 

Thanksgiving is a Time for Gratitude and a Commitment

From the 11/20/2020 newsletter

 

 

Director’s Corner

 

 

 Thanksgiving is a Time for Gratitude and a Commitment to Making a Difference 

 

By Adina Kalet, MD MPH

 

 

Inspired by virtually attending the AAMC meeting this week, Dr. Kalet reflects on how the medical profession is embracing this transformative moment and why, after expressing thanks and gratitude, it’s time to roll up our sleeves up and do the hard and meaningful work ahead …

 

 

 

It is gratefulness that makes the soul great. 

-Abraham Joshua Heshel

 

How do we endure what we witness? 

-Anne Curry 

 

• Health disparities are a manifestation of structural racism which we must address to save lives and enhance human dignity and flourishing for us all.

• Without Black and Brown physicians, Black and Brown people will not receive the best medical care. 

• There are structural barriers to increasing the number of physicians of color. We must address these immediately.

• The strategies to creating supportive, nurturing academic environments for students of color seeking to become physicians are well known, as Historically Black Universities and Colleges (HBUCs) have educated 50% of all Black physician.

• MCAT scores reflect privilege in access to enriched education, “gap” year experiences, and expensive test preparation. These advantages are not available to all and therefore should not be used to limit access to medical education. European models of access to medical education are instructive here.  

• Zero sum thinking is keeping us from recognizing that investment in diversifying our profession will “float all boats.” Power is not a scarce resource; it is unlimited. 

• For our culture to “bend toward justice,” we must all be actively engaged. 

• Acknowledge the reality of privilege and its impact on maintaining white and wealth supremacy

• Seek expertise outside of the walls of the profession to help us address these issues  Bring our students to the table and listen to them 

• Communicate often and with authenticity and sincerity 

• “Get proximate” to the people we hope to serve and seek to see people as individuals with basic humanity

• Set audacious goals for change and get and maintain accurate data to guide change toward those goals

 

Thanksgiving 2020 will be unprecedented. Traditionally, Americans mark Thanksgiving with deep family connections, too much food, football, and moments of gratitude. This year, though, hospitals will be overwhelmed, and health care professionals will be working harder and under harsher circumstances than ever before. We will all be socially isolated. The adjustments will be difficult and promise to worsen. Because our residents are working incredibly hard, we want them to know how grateful we are for them. In collaboration with MCWAH, the Kern Institute will be providing “to-go” meals for our trainees on Thanksgiving. Oh, and we will be providing those amazing Kern Cookies, as well. 

 

There are many things for which we are grateful. In my family, we will replace the usual West Coast trip to see the in-laws with Zoom games and remote pie baking lessons. I am grateful for the opportunity to avoid airports on Thanksgiving! I might even start my “gratitude journal” because positive emotion is important when the days get short and cold. Expressing gratitude is associated with personal happiness and is, in part, necessary to create human flourishing (eudemonia in Greek), which Aristotle, philosophers, theologians, and psychologists considered the ultimate goal of a good life and a healthy society. 

 

 

I have also been grateful for and astonished by this week’s virtual Association of American Medical Colleges (AAMC) annual meeting, the largest gathering of medical educators in the world. Over the years, I had become disappointed by the diffuse and frankly self-absorbed nature of the meeting. But in this special year, under the leadership of President David Skorton and Chairman of the Board, our own Joseph Kerschner, the AAMC has found its soul! When needed more than any other time in history, there is a movement afoot for a powerful transformation in American medical education.

 

 

AAMC addresses COVID-19 and structural racism

 

Compared with the usual AAMC meeting – thousands of medical educators from around the world in enormous, Jumbotron-enhanced ballrooms listening to leaders and topflight “inspirational” speakers – the virtual version is intimate and stirring. I sit in my living room while “Rock Stars” NIH Director Francis Collins, NIAID Director Anthony Fauci, and  CDC Principal Deputy Director Anne Schuchat remind us that COVID-19 is  far from over. The pandemic is terrible and getting worse. Thankfully, effective treatments are emerging and effective vaccines are in sight. I am grateful that there are world-class scientists and thought leaders at the helm, collecting valid data and communicating simply and honestly. I am grateful to be reminded that our role right now is to be trustworthy, courageous, risk taking leaders. 

 

Thankfully, AAMC also provided us with a conference chock-full of the “Rock Stars” of the national conscience.  Journalists Nikole Hannah-Jones and Ann Curry, educators and historians Ibram X. Kendi and Secretary of the Smithsonian Institute Lonnie Bunch, III, each in her or his own way challenged us to face reality head on and then act, every day in every way, to make concrete changes. 

 

But what to do to create change? Where do we engage?

 

 

If we think of racism as Stage 4 cancer, we would know what to do 

 

When educator and historian Ibram X. Kendi, was 37-years-old and writing his now iconic book, How to be an Antiracist(MCW’s Common Read this year), he was diagnosed with and battling Stage 4, widely metastatic colon cancer. 

 

Kendi is not only a national intellectual treasure, but a human face of race-based health disparities. Black Americans are 20% more likely to be diagnosed with cancer. Luckily, he is now disease-free, unlike Black Panther actor Chadwick Boseman, who died at 43 in August 2020 of  the same disease.  When compared to whites, Black men have a 40% higher death rate from this disease. Professor Kendi formulated the compelling analogy that racism in America is a Stage 4 metastatic cancer, sapping us of our vitality, threatening our lives, and stealing from us the future contributions of our greatest intellectuals and artists. But here is the silver lining: By widely sharing the particulars of his personal story, as well as his life’s work, Kendi allows us to imagine routing racism out of society for good.  

 

We in medicine know how to attack an aggressive disease, how to throw everything we have at it, to declare war on it. We know we must serve up the full commitment of intellectual, scientific, spiritual, and financial resources to prolong life and enhance quality of life while we search for a cure. This is important work, worth engaging in.  

 

But the cancer analogy doesn’t stop there. Kendi also provides guidance on how to create the “good life.” In an essay in The Atlantic, Kendi describes how the act of writing his book literally reduced his suffering and allowed him to put the physical and existential drama of his cancer battle in perspective. Work created a profound experience of well-being even during severe stress. This deep engagement with the act of work, what psychologist Mihaly Csikszentmihalyi calls “flow,” is a characteristic of “optimal” performance and profound well-being. In medicine, when we have such experiences, our work is purposeful and meaningful. 

 

 

Back to the AAMC

 

The meeting has been loaded with meaningful and important moments. Among the realities and takeaways: 

 

 

To make concrete, corrective, and transformative changes in medical education, we must:

 

 

Gratitude and commitment

 

I am now committed to a few, specific actions. This year, we must address equity in the medical school admissions process and we must redouble our efforts to transform the curriculum to both prepare future physicians for the challenges ahead and address the profound challenges to the well-being among our own. This will be hard work and we must face the realities and roadblocks head-on. If, we take on these challenges – in community – we will be rewarded with a sense of pride and thanksgiving for our courage to engage, take risks, and accomplish things that matter.

 

Many among us are profoundly fatigued from the pandemic and hope to feel a whisper of relief at this time of Thanksgiving. Let us take this time to be grateful for what we do have and for each other. Give thanks for and support to our colleagues who are engaged in the hard, hard work of patient care these days. Be grateful for the opportunities we have to change the future of medical education. 

 

Gratitude – and the opportunity to do meaningful, healing, and important work – is good for us all. Happy Thanksgiving.

 

 

 

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