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.  

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. 

Focus on Genetics: Lessons from Uncle Dave

 From the December 9, 2022 Genetic Counseling Issue of the Transformational Times  

Focus on Genetics:  Lessons from Uncle Dave

By Wendy Peltier, MD

Dr. Peltier shares the candid story of how her uncle brought early inspiration to pursue a career in Medicine, and also opened her eyes to the personal challenges and opportunities of genetic testing as he faced a rare, progressive lung disease …

 

My uncle, Dr. David Pogue, worked as a cardiologist for twenty-nine years in the small community of Wichita Falls, Texas.  He inspired me very early on, to pursue a career in Medicine.  As “Yankees” from Illinois, my family lived far away from Texas, and holiday time together with the Pogue clan was truly a gift. I have wonderful memories of my brother and I connecting with our three cousins, all of similar age, and giggling together around the big table at family meals as our parents had spirited discussions.  At one of these memorable visits, my uncle took me on hospital rounds, where I observed his kindness and generosity with his patients and staff.  There were no Hospitalist services in those days, so “checking in” on his patients was common practice, even on a holiday weekend.  I can bring in my mind’s eye his long white coat, gentle smile, and patience as he carefully listed to heart sounds and reviewed care plans with his patients.  

He answered all my questions, sparked my interest in science, and empowered me that being a doctor was not just far away dream, but in reach if I was willing to put in the hard work.

Fast forward a decade or so, when I was in medical school, we got the news that he was ill.  After exhaustive testing for shortness of breath with exercise, he was found to have a rare form of emphysema, alpha-1 antitrypsin deficiency, a progressive and incurable genetic disorder.  This condition, which is expressed most severely in patients carrying two recessive alleles, causes a spectrum of lung disease that can manifest as progressive emphysema, chronic bronchitis or asthma, and can also affect the liver, pancreas and gallbladder.  Carriers of this gene can pass on risk to their children.  What a bitter irony that Uncle Dave would have emphysema after spending so much of his time trying to convince others to stop smoking!  I had just started learning about genetics and DNA in school, our bodies’ “phone book.”  I was particularly fascinated by how science allowed us to track these missing “addresses” that tied so eloquently to understanding of a disease process.  Genetic discoveries were just starting to have clinical impact, and the thought of gene therapy still a far away dream. 

 It seemed quite unbelievable that a genetic disorder could be in my family.  Could I be a carrier? Would I want to know? Would it impact major decisions in my life?

As was his brave and humble nature, my uncle learned everything he could about his condition, what to expect, and opportunities to contribute to research.  Pre-symptomatic genetic testing was not readily available at the time, but he sought resources for anonymous testing for his siblings.  I keenly remember what it was like to wait for my Mom’s results.  My uncle deeply believed in science and the power of research.  He knew that having this type of information could mean receiving early preventative treatments, once they were developed.  He also actively sought information about his prognosis, so he could make plans for his family to be supported, and to make his own careful decisions about future therapies with a lung transplant or other interventions.  He became very involved in the Alpha-1 Foundation.

As his disease slowly progressed, he made the necessary changes to his medical practice and sought continued opportunities to serve.  Using his background in cardiac rehab, he took a very diligent approach to his own health and was able to far outlive his prognosis, despite declining a lung transplant.  During this time, I was starting my career as a neuromuscular neurologist (despite his multiple attempts to convince me that Cardiology was a superior discipline!) and found myself often in the position of counseling families about genetic testing for muscular dystrophies and other progressive neurologic conditions. 

It was my good fortune to do this shoulder-to-shoulder with exceptionally talented genetic counselors.  Their knowledge, wisdom, and kindness in approach to all our patients and families, regardless of their health literacy, was a true inspiration.  

I knew, first-hand, how challenging decisions about testing could be, and the emotional impact to affected individuals in navigating this, sometimes with complex family relationships.  I did my best to provide balanced options, educate about the cautions of asymptomatic testing, and link families to important resources through the Muscular Dystrophy Association (MDA).  Incredible scientific progress was being made at this time in understanding the molecular biology and genetics of muscular dystrophies, previously named by the famous neurologists who described the syndromes (Becker’s, Duchenne’s, Emery-Dreifuss, etc.) now re-labeled by the specific type of gene defect or “address.”  Genetic testing became more available and allowed diagnostic accuracy without necessarily having patients go through painful muscle biopsies.  Gene therapy seemed closer in reach.

I will never forget attending my Uncle Dave’s funeral.  All of his family members had been carefully prepared for the event.  His favorite band, The Mad Medics, were playing Dixieland music as folks entered the church.  As my Uncle Don stood to give his eulogy he remarked, “I was given very strict instructions as to how this event will be, short and happy.”  And it was. So many people from the community attended to pay respects.  My aunt had a video camera in the church library, where attendees could sit and share a story in remembrance of the beloved Dr. Pogue.  One of my favorites was from one of his former nurses, who was a smoker.  She and her colleagues would occasionally sneak down to the smoking room during breaks.  She recalls seeing little paper airplanes floating down through the ceiling vent, and retrieving them only to see anonymous, hand-written random facts, about the health risks of tobacco use.  There was no electronic record back then, so of course she recognized his handwriting!  She described this as a true act of caring, without being judgmental.

He was remembered by his community and colleagues for his tireless service, a mission trip to Africa with the Peace Corps, starting the first cardiac rehab unit at the Clinics of North Texas, a Distinguished Service Award from the Wichita County Medical Society, and for being a proud charter member of the Wichita Runner’s Club. 

My Uncle Dave remains a steady presence and source of inspiration to me at challenging times, despite the many years that have passed since his death.  

For me, it’s not as much the professional accolades, as the memory of his kind, humble, and funny spirit, and ability to make “good trouble” in his work as a physician.  As a patient, he was always looking for opportunities to help others despite his own personal challenges. 

I recently connected with my aunt Georgia about these memories.  She was touched by this tribute and shared that one of the things she most admired about Dave as a doctor was how deeply he cared for his patients as people and recognized the importance of giving time to them during visits, something that she sees as a rarity now in medial encounters.  

There has been miraculous progress in science since my days in medical school to make gene therapy a reality.  Uncle Dave would be proud.

Wendy Peltier, MD, is a Professor of Medicine in the Division of Geriatric and Palliative Medicine at MCW.  She serves on the Faculty Pillar for the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and on the editorial board of the Kern Transformational Times.

Chest Pain Relieved by Antacids: My Last Night as a Resident

 From the 7/9/2021 newsletter

Director’s Corner

 

 

Chest Pain Relieved by Antacids: My Last Night as a Resident

 

 

Adina Kalet, MD MPH

 

 

 

In this Transformational Times devoted to transitions Dr. Kalet recalls the final night of her residency at Bellevue Hospital in New York City …

 

 

The astute intern standing next to me, noticing the beads of sweat forming on my forehead and my clenched fist rubbing my breastbone, walked to the medicine locker, grabbed a little blue bottle of antacid and handed it to me. “If this works, I won’t have to admit you on your last night on call as a resident!” he said cheerfully.

 

I slugged the chalky, mint flavored substance and almost immediately felt the chest pain—which I hadn’t even fully noticed until then—resolve. “Thanks,” I said, “You’re gonna be a great resident in a few hours!” I glanced at my watch. 4:00 a.m. on June 30. My last day as a house officer.

 

 

“4344 Stat!!” the crackling voice of the Bellevue Hospital operator cried from one of two cigarette box size beepers hanging off the waist band of my white pants.  This dedicated “code beeper” was calling me to the emergency room where, luckily, I already was standing, ready to help my colleagues who were conducting a cardiac resuscitation on the patient in the “slot.”  This was not the cause of my heartburn. I loved this part. I was trained to do this, my movements were smooth and assured, the decision-making was practiced and honed. I felt competent and proud of my colleagues as we surrounded this patient, a man brought in by ambulance from Pennsylvania Station awake and alert, experiencing substernal chest pain and shortness of breath, who now needed us to save his life. And save his life we most likely would. This was quintessential doctoring, one patient at a time. 

 

My heartburn was a result of the other beeper. The “medical consult” beeper was insisting, with the exact same urgency, that I call “bed board” (the office that managed the 400 adult beds in the hospital) and 17 West and 16 East and the Surgical ICU all at the same time. I added the call back numbers to the pink sheet on my clipboard. I made eye contact with the senior resident running the code to signal I was there if he needed me and picked up the wall phone.

 

This part of the job made my stomach acid churn. After a year of med consult call, all of us senior residents had mastered—but did not have a positive attitude about—what we called the “hotel management” or “traffic cop” aspects of the job. We disliked assigning admitted patients to medical teams and working with the hospital administrator (“bed board”) and nursing leadership to assign beds to those patients. It was a hard and thankless three-dimensional chess game. I didn’t feel particularly good at or prepared for these logic puzzles. But I engaged because it was my job on the team that night. 

 

There was also the “consultation” part of the job, which sounds like an opportunity to engage in erudite conversation with residents on other services about how to best care for patients, but that wasn’t how things worked. The attending physicians did that part. Most often, we residents engaged in tense discussions demanding to transfer patients from their service to ours or vice versa. Too often, we debated whose “job” it was to adjust antibiotics or blood pressure medications. I would argue that any physician could handle this simple task with a little advice from us, but they would argue that their job was complete, and the patient now belonged on our team. We would argue where the patient with ominous abdominal pain should be monitored; our team contending that the physicians who could provide definitive surgical therapy would be best positioned to manage the patient, while they argued that until an intervention was needed, the patient should stay with us. On and on. Over and over.

 

Senior residents developed reputations as being a “wall”—staving off patient transfers by playing expert, impenetrable defense, or being a “sieve”—easily persuaded to accept the transfer. I won’t tell you which reputation I had, except to hint that I did accept transfers to our service only when it was obvious that a patient would be best cared for on our team. This was a judgment call, and I trusted both team to do right by the patient.

 

It was also true that I didn’t have the courage or tenacity to insist that other teams handle problems outside of their comfort zones. I have since gotten over that.

 

Physician professional identity formation, in those days, was in a very tribal stage of development. We worked on teams and, as teams, we defended our boundaries. As soon-to-be attending physicians, our main developmental challenge was to balance team loyalty and identity with a much more subtle discernment about “what is best for the patient.” These situations were very complex; a single correct answer was unlikely. Beyond the formidable technical aspects of our disciplines, we attempted to discern what was really, wholistically best for each patient right now and under these circumstances. Without realizing it at the time, we were developing the practical wisdom needed to thrive as a physician for a lifetime.

 

This critical learning process literally gave me chest pain.

 

Eventually the new consult resident, in a fresh scrub shirt and white pants, came by to take over the beepers. She listened carefully to my recitation, jotting down the names, locations, and vital facts about the consults still to be seen and for those who needed follow up. We reviewed the remaining “bed board” issues. I asked her to check on the freshly resuscitated patient; finding him a hospital bed was a priority. The resident had been at our class’s graduation ceremony the week before, so she knew of my plans for a year abroad for medical education research and my ensuing fellowship. She wished me luck.

 

I found myself wistful and sentimental about her very first med consult shift and envious of her freshness and eagerness to do right and good. I hoped she would develop the wisdom needed to navigate the complexities in the best interests of our patients, without spending much time seriously considering being either a wall or a sieve. But we didn’t have any time to discuss this, both beepers were already sounding.

 

I cleared out my locker and packed up the remaining books, toiletries, and other odds and ends. Gathering up fresh beeper batteries and few single dose bottles of antacid I had pilfered from the nurse’s station, I left them on the table in the on-call room. Someone would need them sooner rather than later.

 

 

 

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.

Practical Wisdom in Medical Education: A Student Perspective

 From the 4/23/2021 newsletter

Perspective/Opinion

 

Practical Wisdom in Medical Education: A Student Perspective

 

Clara Bosco – MCW-Milwaukee Class of 2022

 

Ms. Bosco explains how reframing the role of the medical student from “observer” to “an apprentice acquiring practical wisdom” can shift the relationships between faculty and learners in a meaningful, growth-centered way …

 

In the case of the virtues…we acquire them as a result of prior activities; and this is like the case of the arts, for that which we are to perform by art after learning, we first learn by performing, e.g., we become builders by building and lyre-players by playing the lyre. Similarly, we become just by doing what is just, temperate by doing what is temperate, and brave by doing brave deeds. (Aristotle, Nicomachean Ethics, 1103a 31-1103b 25).

 

 

 “You really should be coming into every room,” scolded my attending. Ugh, day one on internal medicine service and I’m already in trouble. “...all I mean is that there are important, sometimes difficult, conversations you should witness, even if they’re not technically your patient,” she concluded. I didn’t realize the importance of this aspect of clinical training until experiencing a later conversation, my very first family meeting at the VA.

This Monday morning meeting included our primary team, palliative care, social work, and the wife and daughters of our patient. The meeting was intended to convince the family of the gravity of the patient’s condition, a medical reality they had been resistant to thus far. The palliative care physician, due to her expertise in goals of care conversations, led the call with such decorum and grace. I was struck by her collected interaction with the distraught family, who parroted cosigned phrases like, “but he’s not like everyone else,” and “he’s a fighter” in response to the news that their loved one had only around six months to live. To these retorts, the palliative care physician recited a phrase I will never forget: “We have patients who surprise us on both ends of the spectrum, some living shorter or a lot longer.” Oddly enough, this admittance of uncertainty consoled the family, who now felt comfortable with our team’s recommendation for hospice care. The family agreed, the call ended, and arrangements were made; the patient was discharged on Wednesday and died on Sunday morning.

In light of the above anecdote, what is the significance of bearing witness as an apprentice? As a medical student, oftentimes, it entails feelings of floundering, imposing, and space-wasting, as we unreflectively trail in and out of patient rooms on the heels of actually useful attendings and residents. But, for Aristotle, apprenticeship is a cardinal experience since it is the vehicle to become practically wise in a field like medicine where “practical wisdom” is defined as “the art of deliberating well, to make the appropriate choice and to establish the right means through a specific action in order to achieve a particular moral end.” It is through witness of expert physicians interacting with patients that we, as trainees, can move beyond our pre-clinical, theoretical understanding of the human body to a patient-centric, bio-pyscho-socially driven medical practice.

To further elucidate the role of practical wisdom in clinical medicine, consider how an oncologist might deliberate whether to pursue chemotherapy vs. surgery to treat a patient’s cancer. Theoretical wisdom, i.e., knowledge of cellular mechanisms, surgical technique, etc., is certainly necessary to best treat a disease. However, theoretical considerations alone may not be sufficient to best treat a particular patient’s illness. For example, does the patient have certain comorbidities that exclude them from surgery? Do they have health insurance? Do they have reliable means of transport for serial chemotherapy sessions? Are they able to take off work for surgery and do they have some to care for them? These considerations illuminate the numerous extra-scientific dimensions that must be weighed, via practical wisdom, to achieve the best treatment plan for a particular patient.

From an educational standpoint, integrating foundational concepts like practical wisdom into medical school could prove to be useful for both trainers, and, especially, trainees. For educators, practical wisdom could provide the foundation for effective role-modeling and mentorship. For students, introducing practical wisdom early and often in medical school could provide a much-needed conceptual framework for students to better understand their role as an apprentice. The long hours at the hospital, the feelings of “shadowing,” and uselessness to the team are stressful realities of medical students that certainly contribute to burnout. However, if these challenging experiences were reframed as formative to developing one’s own practical wisdom surrounding clinical reasoning and patient care, a new sense of purpose and ownership of the apprentice role may be encouraged among medical students.

 

 

Clara Bosco is a third-year medical student at MCW-Milwaukee. She is interested in the philosophy of medicine, bioethics, and artificial intelligence and works with Fabrice Jotterand, Ph.D. Director of the Philosophies of Medical Education Transformation Laboratory (P-METaL) in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

The Kern Institute Hosts a Conference - A Year Late but a Lot More Wise

 From the 4/30/2021 newsletter

Director’s Corner

 

The Kern Institute Hosts a Conference - A Year Late but a Lot More Wise

 

Adina Kalet, MD MPH

 

Today, the Kern Institute hosts the “Understanding Medical Professional Identity and Character Formation,” a conference originally scheduled for April 16, 2020 but postponed by the pandemic. Dr. Kalet reflects on how the havoc wreaked by COVID-19 has sharpened our focus on what matters and provides both challenges and opportunities for the work at hand …

 

 

In the run-up to April 2020, attendees and speakers were readying to fly into Milwaukee from across the country and around the world for a two-day conference on medical professional identity and character formation. The plenary was to be given by Dr. Muriel Bebeau, a moral psychologist and a scholar of professional identity formation. Workshops and poster presentations were firming up. Hotel rooms were booked. Conference rooms were reserved, food had been ordered, and Institute staff were finalizing details like an army prepares for tactical maneuvers. We planned an evening symposium where, over a fine dinner in the Alumni Center, attendees would discuss what they had learned and ponder how this field of study and practice could transform medical education. I was stoked. This was going to be fabulous! 

Planning such an event has much in common with preparing for a wedding or bar mitzvah - both of which I have some experience with and for which I claim no special skills - but without the music and ceremonial component. Working to remain calm, I attended to many details. This would be the Institute’s first large conference and the first of many to come.

 

That was, as we say now, in the “before times.”

 

Then COVID-19 started spreading. Asian and European attendees cancelled their trips as borders closed. Not wanting Dr. Bebeau to fly (after all, she is a “senior” statewoman), colleagues planned to drive her from Minneapolis to Milwaukee.

As the full force of COVID-19 bore down, our excitement turned to dread and then to resignation. After resisting as long as we could, we canceled. Soon, the nation hunkered down, and we learned what it meant to “stay at home.” When it appeared that interstate travel would soon be banned, and with all of the Kern Institute staff working virtually, I boarded a sparsely occupied early morning flight from Mitchell to LaGuardia to shelter at home with my family.

A year later, our conference will finally happen in a virtual space. Since Dr. Bebeau prefers not to talk to her computer screen (how can we blame her?), I will deliver the plenary talk in honor of her contributions to the field.

 

So much has changed

The topic for today’s conference has become much more poignant and important and less simply “academic” as a consequence of the pandemic. The understanding of character and professional development of health professionals has evolved while the public watched physicians and all healthcare workers rush to the front lines. Although data on the public’s level of trust in our profession had been declining up until last year, they have soared as it became clear that we perform our duty, show up, and care in the face of unknowable risks. Health professionals are seen as people who possess talent, energy, resolve, and character. As medical educators, our work is to help students be, not only exquisitely competent, but also brimming with extraordinary sensitivity and humanity.

Many of our exhausted students, residents, and frontline faculty have been through rapid-fire, anguishing, morally ambiguous experiences over the past several months. They have put their own lives - and their families’ lives - at risk. They have witnessed people dying separated from their loved ones. They have seen how social determinants of health impact real people with real names. They have dealt with their own crazy uncles and social media acquaintances who doubt the data. And the pandemic is far from over.

 

The pandemic has changed how we view identity and character formation

Later today, I will speak about how we might ensure that our trainees and faculty possess mature, internalized professional identities, because solidity of identity prepares each of us to hone the character, conscientiousness, courage, and wisdom needed to act in accordance with our principles under highly complex circumstances. While nothing can replace the experiential learning at the bedside and in the clinic, most of the preparation for character development must happen in the classroom. Interactive discussions, reflection, theoretical analyses, and rehearsals best prepare us and our students for unpredictable future events.

This is work we must do, because the alternative is to allow everyone to learn only through experience which means many will simply “react” to situations, without exercising the habits required to make principled decisions under stress. Expecting our trainees to make good choices without helping them develop the tools to act with moral agency is unacceptable. We must try to educate and measure professional identity and character.

 

Hopefully, there will be many chances to talk with the over 120 conference attendees about how to best support the development of practical wisdom in physicians, nurses, respiratory therapists, and others when, for instance, they are deciding how long to stay at the bedside with a terrified spouse or convincing someone they need a vaccine even though they have every reason not to trust the medical establishment.

I am hoping to talk about how we - teachers and students together - determine when a trainee can be “entrusted” to care for patients with less and less supervision. You see, we can measure a student’s competence to do the basic skills of doctoring, but we can’t be absolutely certain that an individual student - when faced with a real-life circumstance - will actually perform competently. As we try to determine whether our students have what it takes to do the right thing every time and when it matters, we make educated guesses buoyed by our experience but, too often, we depend simply on our subjective judgement of their character. I hope to provide a framework for thinking about these “trust judgments” as a matter of both character and competence of both the learner and the teacher.

It is interesting - and worrisome - that our “educated guesses” are very idiosyncratic; we rarely agree on what it means to be a competent physician. Yet, with experience and benchmarked performance metrics in the context of good relationships with our learners, we can make accurate judgments about who will be a trustworthy physician. Identifying trustworthiness and good judgement in a student is a harbinger of their future character, courage, and caring.

 

Challenges and opportunities

While far from over in the US, the pandemic is currently having a devastating impact in India and parts of Africa. Our sister and brother health care professionals in those countries are struggling to do the work they were trained to do under very difficult circumstances. In addition to concrete support, we send them our respect for their courage and professionalism.

I am grateful for the opportunity to host this conference at this inflection point in our understanding of character development and professional identity formation. The pandemic has given us both challenges and opportunities. Winston Churchill once said, “Never let a good crisis go to waste.” I hope that his sentiment will guide our work.

 

 

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.

Growth Mindset and Wellbeing: Getting off of the Roller Coaster

 From the 2/5/2021 newsletter

Perspective

 

Growth Mindset and Wellbeing: Getting off of the Roller Coaster

 

David J. Cipriano, Ph.D.

 

 

Dr. Cipriano shares that developing a “growth mindset” can help learners smooth the bumps along the way, viewing setbacks as opportunities rather than signs of failure …

 

 

“Tell a story about you at your best.”  

 

“Now, tell a story about you at your worst.” 

 

For many, there would be a sharp decline in mood with the second part of this exercise.  But not for people with a growth mindset – for them, both outcomes would be taken in stride.  Both scenarios would be followed with, “What did I learn from this?” and the worst scenario would be followed by, “What will I do differently next time?”  Growth mindset – the belief in our capacity to change and grow our abilities, not just our skills or effort, but our supposedly innate abilities – is a natural self-esteem preserver.

 

 

Growth mindset v. fixed mindset 

 

For folks with a fixed mindset – the opposite of a growth mindset – failure is a sign that they are not up to the task; that it’s time to pack it up and move on to something else.  For these people, failure, as a New York Times article points out, has been transformed from a verb (“I failed”) to a noun (“I am a failure”) and, indeed, an identity.  But there is an almost equally dangerous attribution for success among those with a fixed mindset – that this is proof of my God-given talent and validates my awesomeness!  Here’s the problem in Dr. Carol Dweck’s words: If you’re somebody when you’ve succeeded, what are you when you’re not successful?  

 

Dr. Dweck is the originator of this concept and she’s been at it for a while now.  Back in the 1970s, she began asking third graders why they thought they were struggling in math.  This research, firmly grounded in attribution theory led to the discovery that, depending on your belief about how changeable the outcome is, you would be more likely to persevere – and even come to enjoy – math.  People with a growth mindset attribute their failures mostly to effort, but even when they attribute to ability, they have the belief that this ability can grow.  People with a fixed mindset almost always attribute to ability, and without the added benefit of believing this can change.  So their destiny is set, there’s not much reason to consider how they might develop from this.

 

I’ve been steeped in this stuff nearly as long.  Back in the 1980s, my master’s thesis was based on attribution theory and my doctoral dissertation touched on it, as well.  I never thought I’d use these concepts in psychotherapy, though.  Back then, I was going to be a social psychologist and do research like Dr. Dweck.

 

Fast forward to the new century and I find myself working with medical, pharmacy, and graduate students, a high-octane group, to be sure!  When they’re succeeding, they’re great.  But, when they’ve failed, they don’t feel so great.  For people with a fixed mindset, failure can even lead to depression.  Now, failure stings for all of us, but it doesn’t have to define us. In psychotherapy with these folks, I examine the self-talk occurring, which is almost always self-recrimination and self-demeaning.  When I challenge this, I hear, “Being so hard on myself is how I’ve gotten where I am today!”  To which I say, “Your ‘self’ can only take so much of this beating, before it freezes and stops trying.”  

 

 

The fixed mindset leads to a “roller coaster” of self-esteem

 

Imagine the roller-coaster that their self-esteem is on.  If you have a fixed mindset, you’re more concerned about the judgment of others and more worried about making mistakes.  When you’re succeeding, it is confirmation that you are the superstar you’ve always been told that you are.  Feels great – especially if you don’t have to try – because having to try negates the notion of having a ‘gift.’  But, when you’ve had a setback or a failure, it is confirmation of your worst fears.

 

 

Getting from roller coaster to journey

 

A good therapeutic outcome with people stuck in this cycle is for them to separate out their identity from their performance – to rid them of that notion that “I am my grade,” or “My worth can be measured in my performance.”  

 

Imagine, instead of being stuck on a roller coaster, they are enjoying the journey.  Learning is savored, and not a threat.  Mood is stabilized in the knowledge that mistakes are to be expected and will make one even better.  Self-worth is preserved in the belief that there is value in getting knocked down and getting up and trying again.

 

 

For further reading:

Dweck, C.S. (2016). Mindset:  The New Psychology of Success.  Ballentine Books:  New York.

 

 

 

David J. Cipriano, Ph.D. is an Associate Professor in the MCW Department of Psychiatry and Behavioral Health and Director of Student and Resident Behavioral Health. He is a member of the Community Engagement Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

 

Can the Observation of Art Make us Better Clinicians?

From the 1/29/2021 newsletter 

Perspective/Opinion

 

 

Can the Observation of Art Make us Better Clinicians?

 

 

By Stephen Humphrey, MD, Valerie Carlberg, MD, Alexandria Bear, MD, and Arthur Derse, MD, JD

 

 

Drs. Humphrey, Carlberg, Bear, and Derse describe how teaching Visual Thinking Strategies can improve perspective, communication, and empathy …

 

 

When people think of medical education, they envision the sciences – biology, pharmacology, physiology, and anatomy – among others. Artistry, or the consideration of art, is typically not deemed relevant to the skills a physician must acquire.  Despite this, many trainees have heard the adage “medicine is an art.” This phrase typically arises after a nuanced physical exam finding, an innocuous but relevant comment in a patient history, or the success of a forgotten treatment modality for a recalcitrant condition. The term “art” in that context means the application of knowledge, skills, and judgment. The Oxford Dictionary also defines, “art,” however, as “the expression or application of human creative skill and imagination, typically in a visual form such as painting or sculpture.” If we agree that medicine is both a science and an art, can observation of art make us better physicians?

 

In fact, research shows the study of art in medical education improves visual literacy, diagnostic accuracy, communication, self-reflection, tolerance for ambiguity, and builds empathy. Visual Thinking Strategies (VTS) is a teaching method based on the research of psychologist, Abigail Housen, and museum educator, Philip Yenawine, that has been effectively integrated into the curriculum at several medical schools. 

 

 

Visual Thinking Strategies – Questions

 

VTS is a method of art observation in which students are presented with a piece of art and VTS facilitators utilize three sequential, open-ended questions: 

 

“What’s going on in this picture?”

“What do you see that makes you say that?”

“What more can we find?” 

 

The questions guide students’ critical thinking. Skills derived from VTS can be applied to diverse scenarios, including the physical examination as well as discussions with patients or colleagues. At institutions utilizing VTS, it is incorporated into elective or mandatory courses for medical students in all phases of training. Usually, the VTS curriculum is a longitudinal experience over the course of a month or months. Though less common, some studies show benefit from a solitary experience or the ability to integrate VTS over several years.

 

 

A collaboration between MCW and the Milwaukee Art Museum

 

During the 2019-2020 academic year, Drs. Valerie Carlberg, Alexandria Bear, and Stephen Humphrey introduced VTS at the Medical College of Wisconsin. Their project, entitled “The Art of Observation,” was supported by the Kern Institute’s Transformational Ideas Initiative (TI²) grant mentored by Dr. Arthur Derse, in a collaboration with the Milwaukee Art Museum. 

 

The first session was implemented as part of the “Art of Medicine Through the Humanities” elective directed by Dr. Derse. Fifteen fourth-year medical students participated. Students observed art and clinical images and recorded their observations. Pre- and post-session surveys were distributed and the quality and quantity of their responses was evaluated in a blinded fashion. Not surprisingly, the session led to a substantial increase in the number of observations and descriptors. Students reported that the session was valuable, citing that it enhanced their ability to analyze images critically, articulate observations, and understand multiple perspectives. We look forward to hosting more sessions post-COVID-19.

 

 

Opportunities

Within the last year, VTS has been described and celebrated in the AAMC’s Report on The Fundamental Role of the Arts and Humanities in Medical Education (FRAHME) (AAMC, 2020). In the future, we envision The Art of Observation taking place over three to six sessions with roughly ten to thirty students each. This would include an introduction to VTS followed by sessions evaluating portraits, landscapes, and abstract art. Expanded techniques would include the evaluation of medical photographs, “back-to-back” drawing, and asking students to serve as facilitators. We might later include residents, fellows, and faculty members, advancing the Kern Institute’s goals of character, competence, and caring. 

 

 

The carryover into clinical medicine

 

By sharing observations aloud, participants will build confidence in diagnostic reasoning. Through listening and paraphrasing others’ observations, students will develop appreciation for diverse perspectives and increased tolerance for situations where there is no clear answer. Additionally, students will self-reflect and evaluate their assumptions, values, bias, and stigma, thereby building cultural competency, social intelligence, and caring. 

 

At a time of great challenge throughout the world, The Art of Observation and VTS can empower physicians-in-training at MCW to embrace whatever situations arise with improved perspective, communication, and empathy.   

 

 

Drs. Humphrey and Carlberg are Assistant Professors of Dermatology (Pediatrics) at MCW.

 

Dr. Bear is Assistant Professor of Medicine (Hospice and Palliative Medicine) at MCW.

 

Dr. Derse is Professor and Director of the Center for Bioethics and Medical Humanities (Institute for Health and Equity), and a faculty member of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

What a week for Democracy! Great time for Kern to build community through a new funding opportunity

 From the 11/13/2020 newsletter
Director’s Corner
 
 
What a week for Democracy! Great time for Kern to build community through a new funding opportunity 
 
 
Adina Kalet, MD MPH
 
 

Dr. Kalet reflects on the past week’s events including the launch of the Kern Institute’s Medical Education Transformation Request for Proposals (RFP) and describes the RFP’s intention to stimulate collaboration, cooperation and communication as a way forward… 
 
 
What a week it has been! As expected, the presidential election results took four long days to reach a conclusion. Although frustrating, there was a beauty to watching our electoral system work at human speed, votes counted one at a time all over the country. When our new President-Elect and Vice President-Elect were finally able to make victory speeches on Saturday evening, the reality and symbolism of seeing a woman of color give the acceptance speech moved me to tears. 
 
Nearly half our fellow Americans are disappointed with the election’s outcome. It has never been more important for us to navigate forward gently but courageously, with respect and compassion. 
 
There is no doubt that we face a dramatic next two months. We can anticipate being schooled in the technical intricacies of our government. We will learn what guidance our constitution does and does not provide. In my house, we will read and listen to podcasts, watch news, documentaries and movies, and endlessly discuss the historical precedents for this moment. This will go on, all while we face what could be the worst of the COVID-19 pandemic here in Wisconsin. I do not have any answers, but I do want to consider the questions, together in community. 
 
 
Kern will fund “Collaboratories” that will transform medical education 
 
Into this context, on November 1, 2020, the Kern Institute launched our Medical Education Transformation Collaboratories Request for Proposals (RFP). The explicit purpose of the RFP is to incentivize groups of medical educators and scholars to seek each other out across disciplines, institutions, and other boundaries, to propose policy papers and projects that can contribute to transforming medical education. Letters of Intent are due before our winter holiday season. We have suggested some areas of interest: 

• Best Practices in Medical Education
• Data Science in Education
• Linking Medical Education and Patient Health 
• New Models for Structuring and Funding Medical Education 

 
We will give funding priority to members of the Kern National Network, groups that include patients as partners, and projects that have an explicit focus on evidence-based integration of character and caring in medical education. That said, we are open to all ideas. 
 
Proposals will describe in equal measure, a meaty problem or gap, an audacious idea, and a plan for assembling a small diverse group of partners in the work. We will require a clear and compelling description of the “problem to solve” as well as strong and convincing evidence that the group will work together effectively. This includes showing how the team will organize, communicate, plan, define roles and criteria for accountability and share credit generously.  These are some of the key features of strong “Collaboratories.”  
 
 
What is a Collaboratory?
 
I have been animated by the idea of Collaboratories since being introduced to the concept by a computer science colleague with whom I worked in the early 2000s. First described in the 1980s as a “laboratory without walls,” it was an idea which grew as technology enabled scientists living at great distances to work closely together, sharing techniques and equipment in real time. As we all have learned too well recently, nearly ubiquitous technology makes it is possible to be “socially networked,” yet the technology is necessary but not sufficient for success. Collaboratories are powerful when there is careful attention and lots of trial and error to establish “norms, principles, values, and rules” that enable both the things we have always done (teach, learn, meet, create) and to work together to generate solutions to complex new challenges. The future of medical education is a complex challenge and I believe Collaboratories is a good way forward. 
 
Hopefully, we will have at least a handful, if not a pile, of good proposals to review come January 2021. The money we have saved in Kern this past spring, when travel and sponsored events were cancelled one after another due to COVID-19, will now we put toward funding the Collaboratories. Those who receive funding will be expected to meet together regularly to discuss their work and, in this way, “cross-pollinate” other groups creating a densely intertwined medical education transformation community of practice. Even if can only fund some of the proposals we receive, the process of writing a letter of intent is, in my experience, never wasted. Good ideas, once articulated, are like genies released from their bottles. Magical things may happen. 
 
 
The collision of the COVID-19 spike, fatigue, and opportunity
The unseasonably balmy weather this past week has enabled many of us to manage the tension of the election by being active out-of-doors. In Wisconsin, especially, we could remain in denial, pushing off the inevitable few more months of sheltering at home as daily COVID-19 cases hit all-time highs. The situation with the pandemic is different from what it was in the spring. As our hospital census of COVID-19 patients ratchets up to unprecedented levels, we reap the benefit from what we have learned. We now know how to provide routine medical care safely. Scheduled procedures continue, telehealth has found its groove, our students and faculty are in a virtual routine. 
 
The downsides are also obvious. We are fatigued from mask wearing and yearn to be together physically without constant consciousness of the “social” distance. We will be working from home, forming “pods” with our close friends, and grieving family Thanksgiving dinners, winter vacation travel, and some outdoor sports. School-aged children’s schedules will change weekly, our college-aged children will be taking final exams remotely surrounded by family and not friends. We are exhausted from talking about testing, quarantining, and vaccine distribution plans, and from all the pivoting. An effective vaccine is likely to be implemented in a couple of months. For those of us who have lost loved ones, there is little comfort in this unprecedented scientific wonder. 
 
Now is the time to focus on building hardy communities. Now is the time to collaborate, cooperate and communicate as if our lives, work and future depends on it. At Kern, even as we live through upheaval, we look forward to being a catalyst for transforming medical education. 
 
 
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