Remembering the Earliest Days of the Pandemic: The Institute Responds to Times of Transition

From the April 24, 2020 issue of the Transformational Times

Remembering the Earliest Days of the Pandemic: The Institute Responds to Times of Transition

Adina Kalet, MD, MPH

This April 2020 essay was originally published six weeks after classes shut down at MCW. Despite the unknown risks, our physicians, nurses, and front line workers stayed on the job. 

During the very earliest days of the COVID-19 pandemic, we were all scared for our lives; the danger was very, very real and the future was uncertain. Despite this, the Kern Institute's leaders and educators shifted the Institute's focus to make certain students were supported and prepared. As you read, recall those days when we worried about the transitions and the future. 

In the coming months, the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education will transition again. Those of us associated with the Institute hope that whatever iteration emerges will continue to provide a sustained, innovative, and character-driven platform that influences the future of health sciences education. 

 

The COVID-19 pandemic has hit our economy hard. On our own campuses, saving and protecting lives has caused unprecedented revenue shortfalls within our community, to our hospitals, and to the Medical College of Wisconsin. Ironically, just when health care provision, education, and research are needed most, our work is threatened. Those on the “front line” of the pandemic deserve hazard pay for taking on risks for the rest of us, yet our staff is facing salary reductions and furloughs. 

Along with many of our peer institutions, MCW is implementing a financial austerity plan. We have hit a very rough patch and more changes are coming. Our futures are uncertain. People are scared. In this context, the Kern Institute is working to be good citizens by aligning emerging needs with our resources.

There can be opportunity in adversity

Historians point out that even devastating crises offer opportunities to societies. We have already seen unprecedented innovations in the face of immediate problems. Unable to deliver required clinical rotations, faculty and students are co-creating ways to fill curricular gaps through telehealth and service learning. New levels of collaboration and cooperation among medical schools and with accreditors have broken-down traditional silos, suddenly changing systems and shifting long-held policies. 

We must leverage these transformative opportunities for the better. If we work together to retain our senses of mission, purpose, and meaning, we will increase our individual and organizational well-being and resiliency. 

Pivoting what we do, yet remaining thoughtful

In our pre COVID-19 lives, the Kern Institute had been working to clarify our philosophy of medical education transformation. We referred to this as our “topology of transformation,” seeking to best understand why we are doing what we are doing. By thinking, dialoging, reading, and writing, we wrestled with uncovering which experiences are essential as a student transforms into the “good physician.” Then, and only then, would we allow ourselves to talk about the instructional or pedagogical evidence that drives the design and implementation of programs that achieve this transformation. For most of us, especially impatient physicians, it takes discipline not to jump into the “doing” too soon.

Suddenly, COVID-19 accelerated our work

Plato is credited with the phrase, “Necessity is the mother of invention,” sometimes translated more literally as, “Our need will be the real creator." While I prefer the more feminine flourish, now is the time when innovation is needed most. Over the past few weeks, Kern has pivoted to assist MCW’s rapidly transforming educational programs in response to immediate needs and we are designing ways to streamline and sustain the best of these changes. 

We are collaborating with partners in Academic Affairs and Student Affairs to support well-being, prepare students to meet their graduation requirements, provide meaningful clinical experiences, sustain and strengthen MCW’s long-term investments in diversity and inclusion, and speed the design and implementation of a dynamic, state of-the-art fully virtual curriculum.

Some things are the same in both 2020 and 2024

These are historic times globally and locally. As we adapt our educational work to the new reality, we will study the outcomes, learn from our successes and shortcomings, and look for the new topology of transformation. 

The essay was originally published on April 24, 2020 as, "Transforming Educational Strategies on a Dime."

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.

Dr. Kalet Wins the 2023 AAMC Award for Excellence in Medical Education

From the November 10, 2023 issue of the Transformational Times

Our Friend, Dr. Kalet, Wins the 2023 AAMC Award for Excellence in Medical Education

By the Transformational Times editors

Sometimes, it turns out that our friend is pretty spectacular. 

Our editorial group, including Adina Kalet, MD MPH, developed the Transformational Times during COVID and has kept TT’s wheels on the tracks over the past three years. As we did so, we became accustomed to Dr. Kalet’s insightful comments and wise direction at our weekly virtual meetings. We devoured her Director’s Corners. We tracked down content contributors that she suggested. With her unfailing humor and insight, she talked us through each issue and kept things moving forward. 

Sure, we knew that she had other responsibilities. After all, she was running the Institute. She had published three books, fourteen book chapters, and over 200 highly cited scientific articles. We knew she was principal investigator on NIH and NSF grants. Of course we were aware of her multi-institutional educational trials. Yeah, she seemed to know absolutely everyone in medical education on every continent. But, to us, she was just Adina, y’know? 

Of course, we probably should have had a clue that she was a superstar. After all, she did receive the National Award for Career Achievement in Medical Education from the Society for General Internal Medicine in 2019. She was given the National Board of Medical Examiners John P. Hubbard Award in 2023, recognizing her extensive contributions to the field of assessment in medical education. But, during our weekly meetings, she remained the epitome of a collegial servant leader.

The AAMC’s most prestigious award

It turns out that our friend is pretty amazing. On October 25, 2023, MCW gathered to watch as Adina’s reputation and body of work were recognized by the American Association of Medical College with the AAMC’s Award for Excellence in Medical Education. The award recognizes the “highest standards in medical education,” and honors an individual or a team “whose contributions have had a demonstrable impact on advancing medical education. It “recognizes the highest standards in medical education.” 

More than once, we heard that the Award for Excellence in Medical Education is the AAMC’s “most prestigious award.”

Adina’s comments

Unsurprisingly, Adina’s prerecorded acceptance comments focused on students, colleagues, and learners rather than on herself. “We are educating physicians,” she said. “That matters.”  She continued that, “academic medicine has been so good to me because I could be a physician, leader, scholar, and innovator all within the same career. That’s really a gift of the academic medical center environment.” She added, “I’m very moved to have been nominated. If you look back at the numerous people who have won this award, they are my heroes and role models. It is the team I want to be on.” 

It was delightful to see our friend’s effectiveness, thought leadership, and hard work recognized by her peers in medical education. She really is a superstar working among us and, we are certain, she is nowhere near the peak of her remarkable path. We are fortunate to have front row seats as she continues on a journey that will improve physician education now and far into the future. 

From the rest of the Transformational Times editorial team, including Himanshu Agrwawal, MD, Wendy Peltier, MD, Bruce Campbell, MD, Kathlyn Fletcher, MD, Karen Herzog, and Joy Wick.

The Transformational Times is Taking a Sabbatical (although the blog will continue)

From the September 29, 2023 issue of the Transformational Times

Take Our Survey

The Transformational Times is Taking a Sabbatical

Adina Kalet, MD, MPH

Born on the fly to keep our medical community thoughtfully connected through the pandemic, the Transformational Times--like the rest of the world--is establishing its “new normal.” To do this, we are pausing weekly publication to gather reader input and intentionally consider how best to serve our community while continuing to reflect the transformational work at the Medical College of Wisconsin around character and caring alongside clinical excellence. Dr. Kalet shares what will happen behind the scenes, and invites readers to help shape the future of this thoughtful, medical education publication by participating in our survey ...

 

Dear Readers,

September is a time for renewal. Kids are back in school, the summer has come to an end, and in my faith, we gather to celebrate the birth of the world through our “high holy days.” At the Kern Institute we have been taking time to reflect and plan. We spent a day in retreat a couple of weeks ago, to contemplate where we have been and consider where are going next. In that spirit, the Transformational Times team is taking a short sabbatical to refresh our processes, update our vision and begin again.

 

The Transformational Times was born during the first days of the COVID-19 pandemic in March 2020, when the Medical College of Wisconsin (MCW) sent all of the students and many faculty and staff members home. As I have recounted before, we decided to transition our existing quarterly newsletter into a weekly offering, and rename it the Transformational Times. We hoped this would keep our work alive and support our medical education community.

 

As those early weeks turned into months then years, we kept up our pace, publishing 178 weekly issues of the Transformational Times and two curated books. We have taken only a handful of holiday weeks “off.” We are proud we have helped people share personal stories about their work and worlds. The tagline to be “delivering stories of hope, community, caring and resilience to our community,” has largely been honored.

 

The Transformational Times has been a success in many ways. We have grown our readership both inside and outside of MCW and received a great deal of supportive feedback and a few critical comments; we take all of our feedback very seriously. Through these efforts, we have hosted a hardy, broad conversation around the transformation of medical education and accelerated the expansive acceptance at MCW and beyond of new models for educating physicians that embody the character and caring essential to health and health care. This is the mission of the Kern Institute.

 

What to expect in the future

With the pandemic largely in the rear-view mirror, we are taking a break to reimagine the Transformational Times. Over the next few weeks, under the leadership of our new Co-Editors-in-Chief Wendy Peltier, MD and Himanshu Agrawal, MD, we will seek input from our readers. Our Editorial Board will ensure we continue to prioritize creating community and encouraging storytelling that promotes the ideas and discourse at the heart of health professions education.

 

Drs. Peltier and Agrawal will do this work along with our multidisciplinary editorial board which includes Bruce Campbell, MD (founding Editor-in-Chief); Kathlyn Fletcher, MD; Adina Kalet, MD, MPH; Karen Herzog (Milwaukee-based journalist); Justine Espisito, (Kern Institute staff); Joy Wick, (Kern Institute Communications Consultant); William Graft. Jr., MD (Resident, Internal Medicine/Psychiatry); and medical students Julia Bosco, Linda Nwumeh, Wolf Pulsiano, Sophie Voss and Emelyn Zaworski.

 

Our immediate goals are to work with Kern Institute members and the MCW leadership to:

• Refine our processes, policies, and submission guidelines
• Publish regular, theme-based issues that engage broad swaths of our community
• Leverage our Philosophies of Medical Education Transformation Lab (PMETaL) to build a civil discourse framework that enables diverse and profound conversations about our professions
• Have our editing team, including two former journalists, actively assist and encourage writers of all comfort levels
• Explore more flexible publishing platforms (video, audio, social formats, etc.)
• Integrate our work with the Kern Institute Podcast Network

 

We plan to continue and expand popular features of the Transformational Times, including:

• Themed issues for special days (e.g., Veteran’s Day, Valentine’s Day, Thanksgiving) and events in the medical education year (e.g., The White Coat Ceremony, Match Day, Graduation)
• Programmatic reports from the Institute, including The Learner Continuum Hub, Educator Development Hub, and the Medical Education Data Science, Human Centered Design, and the Philosophies of Medical Education Transformation labs
• Project reports from the Transformational Innovations (TI2), KINETIC3, and the MCWFusion curriculum, including Learning Communities, The Good Doctor Course, the Character and Professionalism Thread, and Learning Dashboards
• Works-in-progress on medical school to residency transitions, character measurement, and professional identity formation
• Summaries of Qualitative Research Methods, the Kern Institute Collaboration Scholarship (KICS) group journal clubs and collaborations, the Medical Education Matters Podcast, and our Medical Education Transformation book series
• Collaboration reports with Academic Affairs, the MCW Affiliated Hospitals (MCWAH) GME programs, MCW-Central Wisconsin, MCW-Green Bay, Thrive on King, the School of Pharmacy, the Physician Assistants Program, Genetic Counselling, Anesthesia Assistant Program, and the Graduate School
• Reflection on and coverage of the emerging issues of our times

Please Provide Input

While we won’t be publishing for a few weeks, we will be accepting submissions, and we encourage you to reach out to us with your ideas.

 

We want to hear from you! Whether this is your first or your 178th time reading the Transformational Times, please provide us feedback by taking our survey. If you have advice, opinions, or critiques, please reach out with your thoughts and feelings during this time. And thank you for reading, sharing, and caring.

 

In the meanwhile, watch this space for announcements of our Kern Institute events and related content.

Take Our Survey

Sincerely,

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.

Adina Kalet, MD, MPH Honored with the 2023 NBME Hubbard Award

Adina Kalet, MD, MPH Honored with the 2023 NBME Hubbard Award

Dr. Kalet, Director of the Kern Institute, is receiving the Hubbard Award from the National Board of Medical Examiners (NBME) at their 2023 meeting. In lieu of an in-person acceptance speeech, she created this video that encapsulates the trajectory of her educational research, asking the critical question, "Is trust an educationally sensitigve patient outcome?"

We hope you find this remarkable talk enlightening. The link is below in the NBME's announcement. 

FROM THE NBME ANNOUNCEMENT: Established in 1983, the John P. Hubbard Award recognizes individuals for their outstanding contributions to the pursuit of excellence in assessment in medical education. During his time at NBME, Dr. Hubbard led NBME into a new era of evaluation that resulted in the adoption of objective testing methods. The Hubbard Award recognizes individuals who have made a significant and sustained contribution to the assessment of professional competency and educational program development at any level along the continuum of medical education and delivery of healthcare. We are thrilled to announce the recipient of the 2023 John P. Hubbard Award is Adina Luba Kalet, MD, MPH. Please find below a link to Dr. Kalet's pre-recorded scholarly presentation: Click here to watch the 17-minute video.

The Kern Institute Learns to Blow our Shofar!

From the January 13, 2023 issue of the Transformational Times

The Kern Institute Learns to Blow our Shofar!  

By Adina Kalet, MD, MPH

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

 

The beginning is the most important part of the work.

-Plato

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

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

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

Soon after that conversation, I accepted the offer. 

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

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

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

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

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

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

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

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

Beyond the transactional to the transformational

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

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

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

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

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

Checking in again

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

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

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

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

From the 6/18/2021 newsletter

Three Questions for Dr. Deepthiman Gowda

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Coaching is Vital to Preventing Burnout in Physicians

From the 5/14/2021 newsletter

Perspective/Opinion

Coaching is Vital to Preventing Burnout in Physicians

Brett Linzer, MD

Dr. Linzer shares how some of his peers suffered, then explains how coaching and intentional support can build resilience, improve the work environment, and restore meaning in our work …

My internal medicine/pediatrics friend Alex Djuricich, MD killed himself a few years ago. He was one of my resident partners and eventually became the internal medicine/pediatrics program director at the Indiana University School of Medicine.  He was a mentor to many internal medicine/pediatrics physicians and a father of two teenage daughters. When he died, I promised myself that I would do what I could to help other physicians.  It has taken me a long time but, with some of the work I am doing, I feel as though I am making good on that promise. 

I spent years trying to figure out why doctors hurt themselves. I am not sure if I have figured out much, but I have learned a lot along the way.  

One of the most important things I have learned is that I do not have all the answers to my life. But, I found a lot of the answers through coaching.

Why is coaching important?

The idea that we, as physicians, can figure everything out on our own and not rely on others to help us is, at best, a poor strategy for success and, at worst, a dangerous myth. Physicians are highly trained and skilled in certain areas but may lack mastery in relationships and communication. After residency, there is little emphasis on personal growth and especially emotional development.

Coaching can bring wide-ranging benefits to any organization. Most experts agree the cost of replacing one physician, including lost revenue, can be around $1M. A well-coached physician is more likely to stay in their current position and, therefore, save the cost of recruiting a replacement. In addition, there is less physician burnout, improved mental health, more effective physician leadership, and more balanced and engaged physicians. When physicians are at their best, everyone wins.

The struggles hit close to home

During my training, I was no stranger to suicide. A medical school classmate killed himself. 

Then, an international graduate with two children and a family in China hanged himself during the second week of our internship. We all knew he was struggling but had not known what to do. We were treading water ourselves.  The next morning, the residency program director brought our group of ten interns into a room and talked to us. "This is bad,” he said. “We care about you.  Here is the card for the psychologist. Call if you need help." I looked around the room at the other confused faces and honestly thought, what does he mean by “need help”?  I said to myself, Look Brett, screw your head on straight. You are on call and have a busy service. You need to get back to work.  

Two years later, my chief resident shot himself. I thought he had all the answers. He was a smart guy and had a desirable GI fellowship lined up. At the funeral, I went up to people I knew. Do you understand this? Can you explain this to me? Can you please tell me he had some label or diagnosis or something that I do not have? Chronic depression, alcohol abuse, or schizophrenia? Something? Anything?  How do I know I am not next in line?  There is always a line. On average, one physician commits suicide every day in America.  Every day!

But I was not next in line. Next in line was my friend Alex. He was considered by many to be the ideal internal medicine/pediatrics academic physician. I went to his wedding.  He met his wife when she was a fellow intern with me and Alex was our resident.  He had a family.  He even looked like me. How are they different than me? How close was I to where they were?

Look Brett, I said to myself. Screw your head on right.  You have a lot of … wait … it is not working.  You cannot figure it out. Who's next in line?

Then, one of my best friends and close partners left our organization. I had difficulty understanding why he left and felt the effects even more acutely when I had to absorb a number of his patients. This was the height of the opiate epidemic and some of the patients were very difficult. I did not know how to manage them well. In addition, I had an unmotivated, depressed medical assistant working with me and I did not know how to communicate with her. The triage nurse in our small clinic was not motivated to do her job. I was not comfortable with conflict, so I avoided her and did extra triage work. The clinic manager was too scared to confront the problems. The administration was well-meaning but not helpful. 

I felt like I was playing a new game and I did not know how to play it well.  I did not even know how to tell if I was successful.  Press Ganey surveys did not do it for me. About this time, Epic came online, and I struggled with efficiency. My wife had chronic debilitating migraines and we had three teenagers at home with no family support. I had extended family challenges. I was cut off from my emotions and I unknowingly built walls to contain them, not knowing I was cutting off my good emotions as well. 

A turning point and finding help

In 2014, my survival skills were not serving me. Life was closing in. I was tired, frustrated, angry, irritable, confused, fearful, and more. I took care of depressed patients and I prescribed SSRIs for them.  Would an SSRI help me?  I did not even have a doctor. Maybe counseling would help, but I did not know where to turn.  I did not have the time. 

I was too scared. During one particularly rough patch, I asked myself if I was suicidal. 

One night, I was sitting at home and finishing Epic charts. My wife handed me a card that said, "I think you need some help." I looked at the card that suggested I contact Dike Drummond, MD from the burnout prevention program,  www.TheHappyMD.com 

I said to her, “Don’t worry.  I just need more time. I can figure this out on my own. I just need to work harder.” 

My wife had heard me say this before. She was losing patience and my words were not as convincing to me as they had been before.

I asked myself, “Am I depressed?” 

I called Dike and set up a discovery session. This is a free one-hour “get to know you” session with the burnout counselor. At that point, I still did not trust him or anyone else. More than once, I almost cancelled the call. I thought, he does not know me. I am a very private, introverted person with my special problems.  

The next week, I completed the call and was shocked to discover within twenty minutes that he could see right through my walls and defenses. He saw the scared kid behind the walls. He saw and knew my patterns of behavior and thought. He knew where that place was, because he had been there. I broke down and agreed to work with him.

Dike explained that many of my patterns of behavior and emotion were not unique to me. There are patterns that are unique to physicians and emerge from our training.  Many of these are survival adaptations. This stunned me and was so reassuring. He told me I was not broken. There were patterns I could learn about and then modify.

Here are some of the typical patterns and misconceptions that Dr. Drummond described that physicians adopt that lead to burnout:

• If I just work harder, things will work out.  
• I am a smart guy/girl, so I will figure it out.
• I need to do it all by myself.
• I do not want to deal with this difficult patient, nurse, etc.
• Compassion is important for other people but not for me.
• My emotions are not safe.  I need to protect myself.
• I feel like an impostor.

My work with Dike centered around twice-a-month one-hour coaching calls where we worked on emotional and skill development. We started every call with five minutes of gratitude and appreciation. What would I like to congratulate myself for?  What did I do right?  This was actually hard for me because I was more in the habit of beating myself up for what I had done wrong. I could easily list all the negatives, but I had trouble seeing the positives. After that, we would complete the work for the day. Some of the emotional work involved processing difficult emotions like shame, fear, anger.  I realized I had a lot of shame. For example, we discussed:

• How to gain better access to my emotions and feelings.  
• How to trust myself and others.  
• How to have more self-compassion and more compassion for others.  
• How to absorb positive feedback and not deflect it away.  
• How to have a soft front and a strong back.

The area of skill development was wide-ranging. Communication skills were huge. I realized if I could be a better communicator, I could save a lot of time and prevent a lot of negative emotions. As I became better, I noticed how ninety-minute disagreements could turn into fifteen minutes. Three meetings could be one if I was more effective. Three-day arguments could be resolved in thirty minutes with deep listening and full presence.  

We did in-depth personality testing and self-awareness, and I learned how to more effectively interact with different personality types. I learned how to deal with difficult people like the nurses and patients. We did role-play and scripting.  

I realized that as I took more responsibility for the interactions, I developed new skills and the nurses changed their behaviors. In the past, I had believed that my role was to give the right answers, but I learned it was more important to develop the art of asking the right questions. I discovered how to run an effective meeting. What is the goal?  How do we know if we achieved the goal?  Can we stop after thirty minutes and consider it a success if we reached our goal?  I mastered Epic documentation techniques, created succinct, appropriate notes, learned stress management breathing techniques, mastered time management/batching approaches, practiced delegation, adopted marriage skills, enhanced my communications, and made firm dates on the calendar. I had been transformed.

Emerging from the other side

Coaching has changed me.  When physicians are at their best everyone wins.  As physicians, we need to trust, ask for help, and be supported along the way.  We need good leadership that makes coaching easily accessible, affordable, and encouraged.  We could spend one-tenth the amount it takes to replace one physician and invest it in the few hundred we already have. 

It is critical to understand that coaching programs are not just for impaired or problem physicians. These approaches are for growth minded, striving physicians who want to improve their lives and the lives around them. Highly achieving people in many fields have coaches.  Every sports superstar has a coach.  Most high-level business leaders have coaches.  Every coach I know has a coach of their own.  And the people at the top   the ones who train the other coaches - have networks of support and growth systems around the country.

It starts with each of us

Here is what you can do.  It all starts with you.  Take care of yourself and trust that others may be able to help you. Realize that you may not have all the answers to your life.  Reach out to others for connection and for mutual support.  Consider coaching for yourselves.   

Brett Linzer, MD is board certified in both internal medicine and pediatrics. He has been in practice with ProHealth Care for over twenty years. He has been a part of the Medical College for 18 years as a preceptor and mentor to 4th year students in his ambulatory clinic in Oconomowoc. He is the recipient of the Marvin Wagner preceptor award, ACP Wisconsin Community Physician and mentor award and the Milwaukee Academy of Medicine award for excellence in teaching. He can be reached at balinzer@phci.org 

Implementation Science and Medical Education Transformation

 From the 4/23/2021 newsletter

Perspective/Opinion

 

 

Implementation Science and Medical Education Transformation

 

 

Jeffrey Amundson, PhD, Michael Braun, PhD, and M. Chris Decker, MD

 

 

Drs. Amundson, Braun, and Decker provide an overview of the basic stages of Implementation Sciences, acknowledging that the process must attend to the people and culture where it occurs …

 

Implementation science - a thoughtful, structured rollout of a new initiative - can help make new programs more successful. In the April 2, 2021 issue of the Transformational Times, Drs. Amundson, Webb, Prunuske, and Kalet discussed the use of implementation science methods in the curriculum transformation process. As we move forward with this change, and with the broader transformation of medical education driven by the Kern Institute, let’s take some time to reflect on implementation science: why it’s important, and what it tells us about how and why to start off right.

 

Why are we talking about Implementation Science?

Successful implementation and maintenance of evidence-based practices for organizational changes or programs are a necessary precondition at Kern for providing successful programs, driving innovation at MCW and elsewhere, and generating scholarship. But there’s no guarantee that merely using an evidence-based practice (EBP) will lead to its adoption. For example, here is a story from Bauer and Kirchner’s (2020) article in Psychiatry Research:

“It was, by all estimations, a successful research effort. We had mounted a randomized, controlled clinical trial across eleven sites in the US Department of Veterans Affairs (USVA), testing an organization of care called the Collaborative Chronic Care Model (CCM) for bipolar disorder versus treatment as usual. Over three years of follow-up, the CCM showed significant positive impact on weeks in mood episode, mental health quality of life, social role function, and satisfaction with care - all at no increased cost to the healthcare system. In parallel, a two-year, four-site randomized controlled clinical trial of the bipolar CCM in the Group Health Cooperative of Puget Sound (now Kaiser Permanente), showed very similar outcomes at minimal cost, compared to treatment as usual. Both studies were published in the same year in mainstream psychiatric journals that are read and respected by mental health researchers, clinicians, and administrators. The CCM for bipolar disorders began to be endorsed by national clinical practice guidelines in the USVA and in Canada, and the bipolar CCM was listed on the US Substance Abuse and Mental Health Services Administration's prestigious National Registry of Evidence-Based Programs and Practices.

And yet, within a year of the end of the studies, none of the 15 sites had incorporated the CCM into their usual workflow. The clinicians who had participated in the CCM went back to their usual duties, and the individuals with bipolar disorder went back to receiving their usual form of care.” (Emphasis added)

Something more than sound evidence is needed for a program to be successful, and implementation science is an approach designed to address the how and the why of getting started right, once the “what” has been defined.

 

What is Implementation Science?

Implementation science is the systematic study and practice of program implementation to increase chances of acceptance, adoption, fidelity, and success. For a new initiative, this means the program is supported and practiced by a broad range of practitioners and stakeholders. It also means the practice of the program adheres to the program’s tenets and dictates. And it means that the program achieves desired outcomes predicted by theory and evidence. Notably, this process involves many similar components of continuous quality improvement (CQI). CQI also involves the continual review of an ongoing program’s implementation, fidelity, and outcomes to adjust the program while it remains in operation.

 

Basic Stages of Implementation Science

There are numerous specific models of implementation, and all identify similar stages of the process. Here are five basic steps to the process of implementation as guided by implementation science.

 

Exploration – Needs, Options, and Partners

The implementation team is responsible for getting the stakeholders and learning environments ready. They explore and research different EBPs to share. This might involve reaching out to other organizations who have implemented similar practices, literature reviews, and mock learning environment experiences to familiarize stakeholders with what evidence-based approach looks and feels like. The implementation team develops needs-assessments to ready stakeholders for the next stage of Installation.

 

Installation - Who, What, When, and How

During this phase, the implementation team identifies human and operational resources that become part of an implementation plan. This plan lays out who will be using the new program, where it will be used, who will be asked to do their work differently. It anticipates necessary training to prepare others for changes and details how the new program will be evaluated.

 

Initial Implementation - Measurement, Meetings, Learning Environment, Support, and Observation

When practitioners use the innovation for the first time, implementation teams help develop competencies required by the EBP, help administrators adjust organization roles and functions, and help leaders fully support the process. During this process, the team is rolling out the implementation plan, sharing EBPs chosen to implement, and displaying and modeling the use of resources.  The team is using valid tools to measure effective EBPs, look-fors (things that represent expected strategies and outcomes), peer support opportunities, plans for observation, and plans for touch-base/how are things going meetings.

 

Full Implementation - How Many People? Fidelity, Good Outcomes, New Standard of Work

During this stage, stakeholders involved are using an effective intervention with fidelity and good outcomes. Notably, expected outcomes should be realistic and aligned with theoretical predictions. The new ways are now the standard ways of work and Implementation Teams ensure that the gains in the use of effective practices are maintained and improved over time and through transitions of leaders and staff. This can involve follow-up meetings with staff, review progress monitoring with educators and administrators to ensure fidelity.

 

Sustainability - Financial and Programmatic

Sustainability planning and activities need to be an active component of every stage. These activities can involve ensuring that the funding streams are established, adequate, and sustainable (financial sustainability, e.g., funding for educators, staff, and administrative time) and ensuring that the implementation infrastructure is established, reliable, effective, and sustainable (programmatic sustainability, e.g., vertical articulation with new stakeholders to identify what worked for which stakeholders).

 

Attending to People and Culture

Another critical dimension for successful implementation in every stage is the people and cultural changes required. Though we may discuss implementation science as a prescriptive way to implement a new program, we would be remiss if we ignored the fact that any change within an organization requires extraordinary commitment and sacrifice from the individuals who are asked to carry out the change and live with the consequences (both good and bad) from the change. These changes will impact personal mattering, professional identity, feelings of purpose, and other emotional elements and must be treated by all with humility, empathy, and compassion. And as organizations learn within the implementation, rate of implementation, which can add to the impact of change, is an important consideration. We look forward to exploring these elements of implementation science in a future article.

 

 

In sum, Implementation Science can help effectively identify and validate a need, strategically plan for change through implementation plans, and provide structure for data collection and reporting on the impact of the change. Engaging employees at all levels (e.g., faculty, staff, learners, etc.) early in the implementation process is key to aligning an EBP with the values and culture of the organization. In future issues of the Transformational Times, we look forward to writing about additional important elements of successful implementation and also about the transformational journey of the MCW curriculum reimagining. Stay tuned!

 

 

Jeffrey Amundson, PhD is a postdoctoral fellow in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

Michael Braun, PhD is a program manager with Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

M. Chris Decker, MD is Chief Transformation Officer and a Professor of Emergency Medicine at MCW. He is a member of the Human-Centered Design Lab, and has leadership roles in the Design Sprint Program and the Transformational Ideas Initiative (TI2) seed grant program for the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.