Teaching About Implicit Bias in the Classroom

 From the 3/5/2021 newsletter

Perspective/Opinion

Teaching About Implicit Bias in the Classroom

 

by Sandra Pfister, PhD, and Kerrie Quirk, MEd

 

Dr. Pfister and Ms. Quirk describe the course they co-lead in the KINETIC3 program which helps faculty recognize and mitigate their implicit bias when teaching...

 

The definition of implicit bias is: “the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.” Let's use a True/False question to see what you think: True or False? I have no implicit bias.  Correct answer: FALSE. Every one of us has implicit bias because that's a function of how our brains work. What happens when implicit bias takes over when we are teaching? Maybe you say that women don't have heart disease. Not said with intention, but isn't heart disease a man's disease? Or when teaching about skin disease, maybe you only show images from white patients. Not done with intention, but maybe because those were the same images used when you were a student.

Using a combination of didactics and active learning, our KINETIC3 course is structured to allow participants to explore their own implicit bias. Prework is to take the Implicit Association Test (IAT). IAT begins to connect learners with attitudes and beliefs they may not know they have (unconscious or implicit bias). The IAT website gives this example: "You may believe that women and men should be equally associated with science, but your automatic associations could show that you (like many others) associate men with science more than you associate women with science." Each KINETIC3 learner is given the opportunity to discuss their own experience with the IAT. 

This course also offers a more in-depth discussion on the meaning of implicit bias, and we delve into the role of the brain. Think FAST. Think SLOW. Think FAST involves those parts of our brain outside of conscious awareness. For example, let's say you stop your car at a red light. When the light turns green, you know to go. This mental association requires no conscious or effortful thought. In contrast, Think SLOW is the brain's conscious processing. It's what we use for mental tasks that require concentration, such as a taking an exam. Together, Think FAST and Think SLOW parts of the brain help us make sense of the world. But it is also the Think FAST parts of our brain that contribute to unconscious bias. This session looks at times when unconscious bias is activated in our brains and shows up in our teaching (when we are rushed, when we are fatigued, or when we are unprepared) and offers strategies to help. We also show a video clip from a PBS special to highlight how medical education has contributed to systemic racism and the role of institutions in contributing to implicit bias. Through small group break-out rooms, learners are given the chance to reflect on their own role as medical educators to ensure a diverse and inclusive representation in clinical case-based material.

This KINETIC3 course aligns with a Kern Institute Transformational Ideas Initiative (TI2) project led by Kerrie Quirk to design a reflection check list for faculty to assess the clinical cases currently being used in the preclinical curriculum. The project is called Identifying Bias in Classroom Clinical Cases: A Structured Approach to Make Clinical Cases More Diverse and Inclusive. Since no KINETIC3 course is complete without a chance to spin the Character Wheel, we end the session with discussion on how specific character traits can play a role in mitigating our own implicit bias. 

Sandra Pfister, PhD, is a Professor in the Department of Pharmacology & Toxicology at MCW. She is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

Kerrie Quirk, MEd, is a Program Manager in MCW’s Office of Educational Improvement.

Love to teach and recognize that learning is what really matters!

 From the 3/5/2021 newsletter

Director’s Corner

 

 

Love to teach and recognize that learning is what really matters!

 

By Adina Kalet, MD MPH

 

 

In this issue of the Transformational Times, we celebrate the Kern Institute’s KINETIC 3 Faculty Development program. Dr. Kalet thinks about how engaging with a faculty development “Community of Practice” transformed her from just another good teacher into an educator ...

 

 

I have always loved to teach. Ask my little brother about the forced spelling lessons when he was a toddler. In high school and college, I taught dance to peers and little kids at a day camp. But it was not until I became a clinical teacher that I realized that it was not enough to just love to teach. If we want to educate masterful physicians, we needed to focus on learning.

  

One night as an Intern …

 It was the dead of winter. Mr. M was admitted to my care for hypothermia and impending delirium tremens, a life-threatening consequence of alcohol withdrawal.  Joe, “my” medical student, followed me to the ER. As expected, Mr. M smelled rank and was talking gibberish (confabulating), his eyes were bright yellow where the “whites” should have been (icterus). Vitamins had been given to stave off a full-blown encephalopathy, and the first of many milligrams of Librium were already flowing into his veins along with warmed fluids. Blood was drawn and sent to the lab. The ER nurse had donned protective gear ready, on my say so, to give Mr. M a warm water bath that would not only warm him up but also wash away the dirt caked most prominently on his feet and to treat the overwhelming case of pediculosis capitis (“head lice”). As I engaged with his incoherence and gently examined Mr. M, I sensed Joe drift as far away from the bedside as he could possibly get. I was miffed that he did not show greater interest.

 Later in the evening, after ensuring that the now fresh-smelling, no longer tremulous, Mr. M had a close-to-normal body temperature, Joe and I sat side-by-side in the Doctors Station. I wrote the admission note and orders, reviewed Mr. M’s extensive medical chart, and pondered the deranged blood chemistries, his chest X-ray and the ECG. Typically, medical students overflow with questions; Joe, oddly, showed little interest and sat quietly while I worked.

 Irritated with his passivity yet wanting to wake his curiosity to the wonders of medicine, I decided to do some “teaching.” I walked to the green board, took up the chalk, and began a wide-ranging lecture. I discussed alcohol as a direct and indirect toxin, with acute and chronic manifestations in every organ in the body. I “pimped” Joe on the physical exam findings and labs which he dutifully reported. I pressed him to discuss why Mr. M was irritable but still charming even while his words did not make much sense. I pushed on. Why does he have yellow skin, tremors, an enlarged heart, a huge belly, but skinny limbs? Why does he have few red blood cells in a wide range of sizes, altered liver function in that particular pattern, and the irregularly irregular cardiac arrythmia? And finally, Why does he have this the remarkable number of ER visits, abominable hygiene and nutrition, no home, no money, no family? 

 After reveling in a medical textbook’s worth of physiology, toxicology, neurology, psychology, pathology, and dermatology – all knowledge relevant to Mr. M’s care - I plopped down in the chair. Joe was clearly impressed. I was jazzed, astonishing even myself with how much I could recite with great enthusiasm and passion.

 It was a fun, self-satisfying performance but, I know now, that did not make it a great education.

 

Why not? First of all, I never stopped to assess what Joe already knew, what he felt, or what he made of the whole experience. I did not discern if he would walk away from my lecture being any more able to care for patients like Mr. M who disgusted or frightened him. Did he now understand how to approach difficult patients emotionally and intelligently? Would he deal with them employing care, competence, and compassion? I had no idea.

 In addition, I neither tried to understand why Joe was so passive about learning, nor did I have a clue how to help him become a more the engaged and motivated learner.

 The next day, it dawned on me that Joe likely had a powerful emotional reaction to Mr. M. Did he recognize a loved one or himself in the end stage alcoholism? I did not know. Did he question his ability help in the face of such suffering? I never asked. If true, then he could have left that evening emotionally overwhelmed, questioning his career choice. 

 As a result, it is possible that my “performance” lecture had the opposite of my intended effect; rather than filling him with knowledge, I might have left him intimidated and less confident. Although Joe might have given me a glowing evaluation based on the attention I gave him (not a bad thing), I realized that, in the long run, I might have failed him.

 

 The road to becoming an educator

 After that evening, I became much more interested in becoming a better educator. Being an educator would require me to both know a great deal, but also know how to share that knowledge effectively. Although I still cared about what I taught the students, I wanted to be able to ensure they would and could learn.

 It was then that one of my mentors sponsored me to attend a weeklong faculty development program for medical educators. We worked in small groups co-creating active learning tasks (e.g., role plays, bedside rounds, reflection writing, and dialogue) and engaging in facilitated “personal awareness” groups.  I shared the story of my experience with Joe, and we role played alternative versions of that “lecture.” This was a profound experience which prepared me to return to residency as a much more effective educator.

 Ultimately, I joined the Facilitators-in-Training (FIT) program of the Academy of Communication in Healthcare (ACH). A senior member of the ACH faculty served as my “Guide.”  In monthly meetings, she coached me to identify my own learning goals and strategies. Together, we facilitated small group learning at national faculty development courses where I honed my skills with her feedback. We worked together for almost seven years, at which point I went on to serve as a guide to others.

 For over thirty years, ACH had created a community of medical educators who share a passion for communication skills training in medical education. ACH members have created innovative curriculum at many institutions and healthcare systems, conducted key scholarship, published a newsletter, a journal, and textbooks, and continued to conduct faculty development.

  

The value of Communities of Practice (CoP) in medical education; Creating concentric circles

 Most faculty development activities in medical schools consist of lectures or one-off workshops. This strategy simply does not work. Instead, experts suggest that it is best to build a community of practice (CoP) situated in an authentic workplace (See “For Further Reading” at the end of this article or click on the article links: O’Sullivan and de Carvalho-Filho.) A CoP is a group of people who "share a concern or a passion for something they do and learn how to do it better as they interact regularly.”

 CoPs are based on learning theories first proposed by cognitive anthropologist Jean Lave and educational theorist Etienne Wenger who were studying what makes apprenticeships powerful learning experiences. At their best, apprenticeships are complex sets of social relationships in the context of a community which creates a living, dynamic curriculum. CoPs are organized in concentric circles with those most intensely involved and experts at its center. Novices initially participate in the periphery, sometimes simply “lurking,” while listening in without engaging. Facilitators actively communicate with and invite in those peripheral participants. Learning happens at all levels of the organization through structured coaching relationships among individuals. Learning is, however, most intense as individuals engage more and move toward the center of the CoP.  This is one of my favorite learning theories, because it provides evidence to guide the growth of our faculty development practice in the Kern Institute.

  

KINETIC3 and the road to developing MCW’s CoPs

The essays in this issue demonstrate the many ways in which the KINETIC 3 program has established and is enriching a Faculty Development CoP at MCW.  By attracting committed, passionate medical educators to engage together in shared learning and practice, we are building capacity to enhance the learning environment for all our students. We continue learning as we tie ourselves together in learning relationships around our shared work.

 While there are basic “teaching skills” components to the KINETIC3 offerings, the members of the Kern Faculty Pillar, under the Direction of Dr. Alexandra Harrington, are building the skills of faculty that improve teaching performance and develop impactful, life changing educators. KINETIC3 graduates are already sharing their skills with colleagues, creating eddies that will become the concentric circles of our own Communities of Practice.

At the Kern Institute, we hope every faculty member will consider applying for the KINETIC3 program during their career. As faculty, we all hope to be the best educators we can be as we share our knowledge and passions. Only then will we engage, prepare, and support every student, even the ones like Joe, who passes through our doors.

 

 

For Further Reading:

O'Sullivan, Patricia S. EdD; Irby, David M. PhD Reframing Research on Faculty Development, Academic Medicine: April 2011 - Volume 86 - Issue 4 - p 421-428 doi: 10.1097/ACM.0b013e31820dc058

de Carvalho-Filho, M. A., Tio, R. A., & Steinert, Y. (2020). Twelve tips for implementing a community of practice for faculty development. Medical Teacher, 42(2), 143-149.

 

 

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.

Let’s Renegotiate the “Social Contract” in a Way that Promotes Human Flourishing

From the 2/26/2021 newsletter

Director’s Corner

Let’s Renegotiate the “Social Contract” in a Way that Promotes Human Flourishing 

Adina Kalet, MD MPH

This week Dr. Kalet wonders how we might reimagine the relationships among society, the profession, and healthcare systems to ensure the ability to pursue human flourishing for us all …

Toward the end of his life, my father-in-law needed a generalist physician to provide real primary care, but he had neither an engaged, attentive physician, nor a system that was prepared to enable this type of attentive oversight. 

A couple of years before his death, a hurricane hit the region where he lived on the east coast of Florida. Unable to contact him and knowing that the area had lost electricity, my husband flew down from New York the next day. Mark found his father sitting in a dark, warm, damp apartment struggling for breath. Mark’s dad had experienced a significant myocardial infarction and was in florid heart failure. 

Over the next few months, my father-in-law’s physician-son and nurse-daughter scrambled to manage his health care needs as he deteriorated. He required prolonged hospitalizations in a cardiac rehab facility utilizing resources up to the full limit of what Medicare would allow. When he returned home, none of Dad’s specialist physicians offered to take responsibility for coordinating his care or arranging for homecare. Luckily for Dad, his son and daughter-in-law were physicians, and his daughter and son-in-law were nurses. My husband attempted to manage things from a thousand miles away by phone, fax, and email, and eventually was able to hire a wonderful aide who stopped by for a few hours each day to help with the activities of daily life and a private care coordinator. Despite the fact that he could hardly walk or drive, Dad’s local physicians insisted that he come to their offices for regular weight checks and refills. He missed many appointments, was confused about his medications, and was disgusted with the whole thing. We would have paid dearly to offer Dad the level of medical care coordination my husband is able to provide his own patients through the VA System, our largest publicly financed, national health care model.

We REALLY need more primary care physicians and compassionate teams

Last week in this space, I outlined why and how medical schools need to train more primary care physicians. Data have shown that access to good primary care in accessible, coordinated, integrated, and globally funded systems is associated with the best outcomes and lower costs; these paradigms offer benefits to communities and to patients like my father-in-law who have chronic medical conditions. Without a solid primary care physician, even patients like my father-in-law with excellent insurance and attentive social support, have less-than-ideal outcomes. 

I think we need to come together to make things better for us all. I am convinced that if my father-in-law had had a generalist physician practicing in a coordinated and supportive healthcare system, he would have received more competent, coordinated, and compassionate care.  Dad and his family would have had a better quality of life over those final couple of years, less confusion and stress, fewer days in high-cost care, and a “better death.” No doubt, there would have been significant cost savings. While many systems strive to do this and many medical schools work toward preparing students to enter competent health care systems, this is not the reality for most of the country.

Rethinking how care is provided by reviewing an imperfect model

Recently, a friend shared an email she received from the primary care physician to whom I had referred her many years ago. This well-established physician was transforming her practice from an insurance-based to a “membership” model. In exchange for an annual retainer (relatively modest compared with similar arrangements), she offered herself to be personally accessible 24/7 for telehealth visits, promised next day appointments, and provided office visits that were three times the length of what she had been able to schedule before (thirty v. eleven minutes). For patients like my father-in-law, she offered to proactively oversee home care, ensure medications are delivered and taken appropriately, and stay in touch with the patient, healthcare team members, and family. She would serve as the team’s quarterback, providing the leadership that winning teams need. 

At first, I was critical of this Executive Model - what some call “concierge” medicine - where wealthier patients with health insurance pay for the kind of consistent, high quality access I believe everyone deserves. But, as I thought about what this change in practice model said about the physician’s well-being, my heart broke. This wonderful woman had always practiced “cognitive” medicine in a fee-for-service model where the only way she could generate revenue was by seeing office patients. In her old system, her “success” was measured by seeing more-and-more patients for shorter-and-shorter visits.  By embracing the new model, she would likely enhance her income while practicing medicine the way she knew it should be done. 

Numbers matter though. One serious problem with this type of “tiered” model of care is that, unless there is a dramatic increase in the number of primary care physicians, even fewer people and communities will have access to quality primary care. This shift will have the greatest impact on those who live in poverty, are disproportionately affected by the social determinants of health, have increased rates of comorbidities, and have little or no insurance. Yet, this is exactly the population that stands to benefit most from ready access to compassionate, attentive, and highly coordinated primary care.  

The divide between cognitive and procedural physicians is making the situation worse 

Part of the problem with workforce distribution and balance is the widening income differential between cognitive and procedural physicians. Since 1980, the median salary of cognitivists has increased at the rate of inflation, while the median salary of physicians who perform procedures has doubled. This gap translates into a $3-$5 million lifetime advantage for proceduralists. This economic power allows proceduralists to benefit more readily from modern practice management (e.g., partnering with advanced practice nurses or physician assistants, medical scribes, and other documentation technology), thereby gaining efficiency, further widening the gap, and increasing their personal salaries. Meanwhile, cognitivist physicians can only increase their efficiency by giving up what is most meaningful and valuable in their work: communicating with patients in the context of strong relationships, taking time to figure out complex problems, and committing to longitudinal care. Under the current models, cognitivists cannot optimize their practices without trading off what is most satisfying in their work. 

We need to rethink the social contract between physicians and society

Many (including me) have pointed out that medical professionalism is the basis of medicine’s social contract. But as things change, we see that this simplistic view of the contract is a poor metaphor for the complex physician-patient relationship. The COVID-19 pandemic has given the medical profession a reprieve from decades of society’s eroding trust as we move from a predominately solo practice model to a more systems-based model. Physicians around the world have demonstrated that we will serve, run toward disaster, and care for the sick even when our own health is threatened. It is time that the old, implicit sets of agreements between society and the profession be aired out and reimagined. The moment to reexamine the details of the social contract is here. 

As a country, we spend enormous amounts of money for healthcare, yet the outcomes, both for physicians and society, are far from optimal. Taxpayers provide $20 Billion annually to support graduate medical education, and support all aspects of medical education through public insurance, yet the average physician and their family sacrifices for years in order to join the profession and accumulates significant debt. We need real, granular conversations about the cost of medical school (of all school), effective practice models that balance outcomes with efficiencies in care, and ways to enable physicians and patients to spend more time together, engaged in doing the meaningful work that promotes wellness. If we don’t put our heads together and find a better way to improve public health while creating a healthy, physician workforce, both society and physicians will continue to suffer.

Human Flourishing 

In a perfect medical world, healthy physicians would expect to learn and work at the highest intellectual and technical levels while they spend their careers doing both what they ought to be doing but also what they want to do for its own sake. The environment would allow them to perform their callings at the level of the “highest human good,” what Aristotle called εὐδαιμονία or Eudemonia, translated as human flourishing. Ensuring these kinds of environments should be goals for both physicians and society as we renegotiate the social contract. 

I suspect many of you have similar tales to the one I shared about my father-in-law. Many people shake their heads talking about care lapses for elderly loved ones or other family members. These all-too-common stories reflect the perverse incentives, inefficiency, waste, burnout, and lack of attention that can emerge from our current bureaucratic models of care. Sometimes, it feels as though character-driven, compassionate care is the exception, not the rule. 

At the Kern Institute, we are committed to transformation, and today’s issue explores how we hope to promote human flourishing. If things are to change for the coming generations, physicians, who - as a group - have always demonstrated the willingness to be there, must be given the moral agency to do their work in safe and well-equipped environments while pursuing professional fulfillment, well-being, joy, and collaboration with other healers. We must commit to exploring new approaches where society can expect a healthy workforce, and every family knows who to call when that time comes for a prepared, highly competent, and compassionate hand on the wheel.

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. 

Some Questions for … Matthew Hunsaker, MD - Dean, MCW- Green Bay Campus

From the 2/19/2021 newsletter

Some Questions for …

Matthew Hunsaker, MD - Dean, MCW- Green Bay Campus

Dr. Hunsaker, the inaugural Dean at MCW-Green Bay, talks about the regional campus and how its mission will improve the health of Wisconsin’s smaller towns and cities …

Transformational Times: How does a regional campus help address some of these challenges of rural health care? 

Dr. Hunsaker: It is atypical for a non-state university medical school to launch regional campuses. Although some might think of our community as small, Green Bay is the third-largest city in Wisconsin (population of 100,000) and has a total metropolitan population of 300,000. We have three health care systems, several institutions of higher learning, and sophisticated hospitals. And, of course, there is the Green Bay Packers football team and foundation that have been philanthropic supports of the school. That said, it does not take long to get from downtown to sparsely populated areas like Door County or Shawano.

As a regional campus, we have several unique opportunities to impact health care. 

First, we can recruit wonderful, talented students who have unique backgrounds. Many of our students are drawn from pools that “traditional” medical school admissions processes overlook. For example, some are non-traditional in the sense that they are the first of their families to enter medicine or even graduate from college. Many come from smaller towns and cities across Wisconsin. Many have graduated from smaller colleges and come from very modest backgrounds. 

Our focus and our approach to interviewing seek to identify those who have an affinity for primary care and psychiatry in non-urban settings. If a student at interview does not align well with those campus goals, we encourage them to consider our Milwaukee campus for other career paths that better align with their personal goals.

Once the admissions office has determined that an applicant has the aptitude to likely succeed in medical school, we rely on our Regional Applicant Advisory Committee (RAAC) to secondary screen and interview candidates and provide recommendations to the Admissions Committee. The RAAC members are trained by the admissions office in screening and interviewing. All are selected from the Green Bay community and represent a broad representation of Northeast Wisconsin. MCW-Green Bay is searching hard for their other qualities in addition to cognitive performance. We have people both the Admissions Committee and the Regional Applicant Advisory Committee screen each portfolio. The results of the local interview process are provided to the admissions committee who makes all the decisions about a candidate's status and extends offers to matriculate. Of the more than 2300 applications we received for Green Bay this year (including 275 Wisconsin) we are nearly finished interviewing eighty candidates from which to build the class. To flatten the inherent biases of one-on-one interviews, we have each applicant interview with a group of seven to ten people from the RAAC. This community-based interviewing approach provides us great feedback and a wonderful cohort of students. 

Next, we leverage our location and faculty to train outstanding physicians who will thrive in their careers, with a special emphasis on primary care and psychiatry in smaller communities across the state. We graduate students with the requisite skills for these practices who are equipped to focus on the central tenet of medicine, which is that a physician is merely a person who happens to have an advanced science degree helping another person improve or regain their health. Central to our program is the idea, nothing we teach should ever work to diminish the student’s ability to talk to another human being with empathy, compassion respect, and clarity. 

We want students to become part of the community. Each student participates in the Physician in the Community Scholarly Pathway. Students complete an IRB-approved Community Orientated Primary Care (COPC) research project while working with community-based organizations, to address local health problems. The student conceives the project, develops it with a local community organization, executes the project, and presents it to the community, their peers, and the local healthcare research forum. COPC requires them to participate in CITI research training, build research skills, community-based health care experience, interprofessional education exposure, and insights into health care challenges unique (and not so unique) to communities located away from academic medical center teaching environments. 

Many smaller communities and hospitals have huge problems with physician recruitment and retention, and a campus like ours can offer a pool of individuals already familiar with the region. Students who have rotated through, for example, Bellin or Prevea, might be drawn to work for these systems after they graduate. They can build connections even as they are in school or residency that lead to future career employment.

By observing their mentors, students recognize that working in smaller communities will allow them to practice closer to their full potential, functioning at the “top of their licensure and appropriate training,” that is, a family physician in a small town is more likely to deliver babies, perform GI endoscopies, and do minor procedures than one who works in the shadow of an urban institution with multiple subspecialists. They experience the satisfaction of providing services that would not otherwise be available in their zip code. 

TT: What challenges do you see in the rural health care workforce and rural health care in the coming decade? 

Dr. Hunsaker: Smaller hospitals and their health care systems face many of the same problems faced by their urban counterparts but have fewer resources, less flexibility, and greater risks as they attempt to meet the mandates and challenges. For example, the implementation of computerized medical records, enormous data and reporting systems, and the costs of health care delivery have had disproportionate effects on smaller hospitals. They simply cannot scale up as easily and the larger systems in many cases. As mergers and acquisitions are predicted to continue, smaller systems will likely continue to consolidate; towns like Green Bay which currently has three, might soon have fewer systems at some point in the future and if predictions are correct, alignment with other system-level resources. As physicians, we have seen the intrusion of “business activities” and documentation requirements at the bedside and we need to protect and champion the importance of meaningful interactions that preserve patient respect, dignity, and quality of care. Not long ago, I heard from a community member that they were disturbed that scheduling the visit on the phone took longer than the time spent with their physician. Who we train and how we train them will prevent “transaction” from overtaking the sanctity of meaningful doctor-patient interactions.

That said, all hospitals are facing increased mandated requirements and decreased margins. Rural hospitals will likely continue to adapt, and larger systems should identify the mutual engagements that encourage a healthy state. MCW-Green Bay’s efforts to recruit, train and support a workforce with appropriate primary care specialty distribution and geographic distribution are key to a sustainable future. 

Here is an analogy: 

We, as a society, have made the decision that every community, regardless of size or income, deserves clean water. If the water is bad or tainted, we will not tolerate it. Think of Flint, Michigan. 

We have similar beliefs surrounding public health. Generations ago, we decided that sanitation and clean water were basic rights. Over the past fifty years, we have added vaccination as being critical for human health. Over the past twenty years, we added health care screenings, as well. We began pivoting from disease treatment alone to screening and early detection. We are accustomed to believing that basic interventions like these decrease every person’s morbidity and improve everyone’s wellbeing. 

So, how do we extend this analogy of basic health care services to our rural areas? What types of interventions and sacrifices should we, as a medical school, contribute to ensure care reaches all of Wisconsin’s citizens? How do we assure equity to access and treatment despite where a person lives? How do we deliver services that are not easily scalable? Rural and Urban disparities are often similar in terms of workforce and accessible services.

These are huge challenges for our smaller towns and cities. It is a consideration for each of us to contemplate and participate in developing solutions.

TT: As a Dean, what have you discovered?

Dr. Hunsaker: Since our class sizes are smaller, I can schedule meetings with each of the medical students individually for half an hour each year and twice in their final year, all in addition to their career counseling, mentorship, and future planning provided elsewhere. As I meet with them, I realize we can measure their knowledge, but that we have a much more difficult time measuring and influencing character growth and the non-cognitive aspects of who they are becoming, yet these are critical to their success and happiness as physicians. The development of character and robust mentoring are key factors to success in and beyond medical school. 

TT: Any other advice?

Dr. Hunsaker: I have enjoyed my journey from working as a family physician in a small town in downstate Illinois to my decade at the University of Illinois College of Medicine at Rockford to now my work as Dean at MCW-Green Bay.

 I believe that our task as a physician is straightforward. It is to help people live longer, or feel better. If our advice and care fall outside of those goals, we need to contemplate what forces in medicine or society are driving our decision-making.

I believe that good doctors are the most aware of their biases, judgment, and care outcomes. Less successful doctors, on the other hand, wait for others to criticize or react to concerns from others. Pay attention to where the criticism comes from. As medical educators, we must incorporate this in our educational models so that the future peer is knowledgeable, successful, and one with whom their patients, and we as colleagues enjoy working.

Matthew L. Hunsaker MD, is the founding dean for MCW-Green Bay. Dr. Hunsaker provides overall leadership and management of MCW’s regional campus.

Interview by Bruce H. Campbell, MD

The Fauci Effect: An unprecedented rise in applications to medical school provides an opportunity, but might we miss it?

From the 2/19/2021 newsletter

Director’s Corner

The Fauci Effect: An unprecedented rise in applications to medical school provides an opportunity, but might we miss it?

Adina Kalet, MD MPH

Applications to medical school are at an all-time high. In this week’s issue focusing on Rural Health and Medical Education, Dr. Kalet considers the opportunities this may afford us to address the significant geographic and specialty maldistribution among the physician workforce and, thus, address health disparities.  Or not …

When I entered medical training in 1978 at the Sophie Davis School for Biomedical Education at the City College of New York (now the City University School of Medicine), I signed a contract committing me to practice in a medically underserved urban community. I thought I wanted to be a physician (What did I know? I was 17 years old!) and, compared to what I had heard about the competitive grind of the typical pre-medical pathway, the social mission of the six-year accelerated BS/MD program I was entering appealed to me. My classmates were typical inner city public college folks, over 30% of us were Black and Latino, most were from lower middle class and working poor families, and many were immigrants or first-generation Americans. As I discovered later in my training, ours was not the typical make up of a medical school class. 

Medical education is never simply a straight path an individual takes toward their clearly articulated career goal. Most medical school applicants share a desire to serve others, but few have a clear idea of what that really means, much less have any specific ideas of what they want to do. Instead, medical school and residencies expose trainees to a variety of opportunities while the curricula (both the explicit and hidden) mold, shape, and guide them. There are twists and turns along the way. Career choices evolve. Role models inspire and disappoint. Exposure to challenging societal and public health issues can leave deep impressions. Outside events intervene. Powerful forces influence choices and address societal challenges. 

Why are more students than ever interested in becoming physicians? 

This year, even as applications to colleges and universities have been falling, we are seeing an unprecedented 18% overall increase in the number applications to medical school. Some are calling this the “Fauci Effect,” attributing the increase to the inspiration provided to young people by Anthony Fauci, the physician, scientist, director of the National Institute of Allergy and Infectious Diseases (NIAID), and voice of science and reason during the  COVID-19 pandemic. When the history of this remarkable time is written, Dr. Fauci may well have a special place as the single most trustworthy public advisor of our era. With his comforting, thick Brooklyn accent, he expertly translates “science” into accessible language, giving advice to a broad national audience and demonstrating the courage to be truthful, objective, and - when appropriate - uncertain about the future. He has become the nation’s physician. 

Of course, there could be other explanations for the dramatic rise in applications. Perhaps a large number of recent college graduates simply have more time on their hands to complete the complex application process and study for MCATs. They are inspired by the heroism demonstrated by health professionals who - at risk to their own health and well-being - have cared unselfishly for others through their own physical and emotional exhaustion. This altruism should be harnessed and focused on what ails us. 

Why it is important to improve the primary care physician work force

Today at the Transformational Times, we turn our attention to rural health and our regional campuses. Small cities and towns face projected life-threatening shortages of physicians over the coming decades.  Despite an overall increase of 35% in the number of students graduated annually from US medical schools, the American Association of Medical Colleges (AAMC) is projecting a shortage of up to 139,000 physicians by 2033. More than two out of every five doctors now practicing will reach retirement age over the next ten years and this loss will disproportionately reduce access to primary care in rural communities. 

More worrisome, and despite evidence that greater primary care physician supply is associated with lower mortality, the density of primary care physicians has decreased by 11% over the past decade, leading to an increase in the number of deaths from preventable causes. For every ten additional primary care physicians per 100,000 population, the associated deaths from cardiovascular, cancer, and respiratory mortality dropped by 0.9% to 1.4%. Life expectancy improvement was more than 2.5 times that associated with a similar increase in non–primary care physicians.  Programs explicitly focused on training, attracting and sustaining the primary care physician supply should be a national policy priority. Medical schools are an important part of this equation.

Read the inspiring interviews with Deans Lisa Dodson of MCW-Central Wisconsin and Mathew Hunsaker of MCW-Green Bay. Look at their “soup-to-nuts” explanations of how recruitment, admissions, curriculum, financial aid, and social support can intentionally address the needs of rural populations. These smaller, mission-oriented programs demonstrate there are many paths toward educating excellent physicians. We are listening to them and learning from them. As we recover from the pandemic, the seeds they have sown might offer us great opportunities to mark the beginning of a new era in medical education. 

This year’s unusually large and more diverse applicant pool provides us opportunities to accelerate workforce diversification. Compared to the same time last year, the number of students representing racial and ethnic minorities who are taking advantage of the AAMC’s needs-based application costs is higher than ever, enriching an applicant pool with individuals from lower socioeconomic status. If, in addition, we attract more individuals who grew up in rural communities, and who are the first in their families to pursue professional education, we could begin to reverse the geographic and specially maldistributions which contribute to health disparities. Admissions committees can assemble medical school classes more likely to meet the missions of both the school and society. 

Debt affects career choices …

Of course, admission criteria alone are not enough. Medical school graduates finish with, on average, a staggering $241,560 of student loan debt, discouraging many from pursuing medical careers. Among those who do, indebtedness pressures students away from choosing lower-paid specialties even when they would find a career in primary care highly satisfying. A comprehensive set of incentives, dramatic increase in scholarship money and loan repayment, and payment and practice reform, to name a few, would be needed to dramatically improve access to primary doctors for those in rural communities.

I graduated medical school with about $25, 000 in debt, less than a third of debt typical of the newly minted physicians graduating that year, and one-tenth of typical debt today. I never took MCATs (medical school admission was guaranteed to all of us who maintained passing grades), calculus, or organic chemistry (we started with Biochemistry). And despite a great deal of initial angst (“Was I being brainwashed?”), I enthusiastically served for ten years as a Primary Care Internist in a publicaly funded ambulatory care center on the Lower East Side of Manhattan in one of the poorest neighborhoods in New York City. No one ever reached out to confirm if I had honored my contract; they didn’t have to; my education and mentors had prepared me and had ensured I would. Many, but not all, of my classmates did, as well. 

Alongside the usual foundational and clinical sciences, I took a course entitled “Community Health and Social Medicine” as a college freshman; this would be called Population Health Science in today’s parlance. Among other things, I worked in a clinic for homeless pregnant teenagers teaching basic health courses and spent a summer doing a community mapping and survey project for the Navajo Nation Health Foundation in Ganado, Arizona, a place as far from New York and as rural as one could get. The education in public health and the practical experiences I had with the people in these underserved areas opened my eyes and changed my life. 

… but, so do role models

Dr. Fauci isn’t so certain that he is the reason that medical school admissions are soaring. “It's very flattering," he said recently. "Probably a more realistic assessment is that, rather than the Fauci Effect, it's the effect of a physician who is trying to and hopefully succeeding in having an important impact on an individual's health, as well as on global health. So if it works to get more young individuals into medical school, go ahead and use my name. Be my guest."

We are on the cusp of changes in medical education and this unexpected bolus of applicants provides us a unique opportunity. Our country needs more primary care doctors. Our regional campuses have experience with matriculating classes of individuals who are more likely to enter careers in primary care working in regions that truly need them. We can learn from them. 

An active process is needed. We need deliberate planning and additional resources to recruit, matriculate, and support the “non-typical” medical school applicants who are statistically more likely to choose to practice in underserved areas. I think Dr. Fauci would tell us to plan, gather our resources, work together, and make a change. If we fail to act, it will be business as usual. 

For further reading

https://www.aamc.org/news-insights/applications-medical-school-are-all-time-high-what-does-mean-applicants-and-schools

Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015. JAMA Intern Med. 2019 Apr 1;179(4):506-514. doi: 10.1001/jamainternmed.2018.7624. PMID: 30776056; PMCID: PMC6450307.

Zabar S, Wallach A, Kalet A. The Future of Primary Care in the United States Depends on Payment Reform. JAMA Intern Med. 2019 Apr 1;179(4):515-516. doi: 10.1001/jamainternmed.2018.7623. PMID: 30776050. 

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.

Learning about Growth Mindset from our Students

From the 2/5/2021 newsletter

Learning about Growth Mindset from our Students

Marty Muntz, MD

Dr. Muntz shares how to recognize trainees with fixed mindset and shares how small group coaching exercises can be game changers …

How often have you heard someone say, “I believe my intelligence, personality, or character is inherent and static. Locked-down or fixed. My potential is determined at birth and doesn’t change”? Rarely, if ever, hopefully. But have you worked with a learner or colleague who hides failures, desires to look smart, sticks to what they know, avoids challenging tasks, seems threatened by the success of others, is intensely self-critical, or seems resistant to feedback? These behaviors, which may signify a fixed mindset that can limit achievement and ongoing improvement, are not uncommonly observed in our clinical learning environments. 

To address this phenomenon, coaches in the 4C (Coaching for Character, Caring, and Competence) Program are trained to foster a growth mindset in their students. In her book Mindset, Dr. Carol Dweck suggests that learners with a growth mindset are likely to confront uncertainties, embrace challenges, learn from failures, and find lessons and inspiration in the success of others. A growth mindset helps one realize that feedback is a statement about current skills – and an opportunity to improve – rather than a personal attack.  

Ellen Arndt and Katherine Lumetta, MCW-Milwaukee medical students and near-peer coaches in the 4C program, recently developed and taught an interactive faculty development session for our coaches and created the lesson plan for the small group coaching sessions. After learning about this concept, both students and coaches brainstormed barriers to employing a growth mindset during different phases of medical school training and their careers. Unfortunately yet unsurprisingly, the list is long and includes grades, awards, the hierarchical structure of our teams, competition for research and other opportunities, and the residency match. 

In their coaching groups, students were asked to compare and contrast challenging life experiences they approached with both fixed and growth mindsets – and consider how the outcomes may have changed with reversing their approach. The coaching groups also discussed student behaviors that might signal to teachers and teammates that learners are fully invested in their personal and professional development despite barriers. Our near-peer coaches shared how their perspectives have changed during clerkship and other clinical rotations, providing concrete examples from their experiences. 

We are confident that small group sessions like these with trusted peers and faculty coaching starting early in medical school will help our students enter clerkships with the confidence and skills to set and achieve lofty goals. This, coupled with faculty development in programs like KINETIC-3 and 4C to encourage growth mindset, can help transform our learning environments to more fully support our students in their individual journeys to identify and achieve their goals.  

Martin Muntz, MD is a Professor of Medicine (General Internal Medicine) at MCW. He is Director of the Curriculum Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Providing Space to Shed Tears may be Key to a Better Post-COVID Future

 From the 2/5/2021 newsletter

Director’s Corner

 

 

Providing Space to Shed Tears may be Key to a Better Post-COVID Future   

 

 

By Adina Kalet, MD MPH

 

 

COVID-19 is wreaking havoc in the lives of working women. In this Director’s Corner, Dr. Kalet shares some learnings from Dr. Ellinas’s work in the Center for the Advancement of Women in Science and Medicine (AWSM) and talks about what to do when someone cries …

 

 

Over the past couple of weeks, I have witnessed more tears among my colleagues and mentees than I normally see in a year. Even though I care deeply, I am not particularly worried about those who have cried. I find it reassuring that they reached out, seeking support and a reliable pep talk. I know that while shedding tears in someone else’s presence makes one vulnerable, it is also a sign of strength, resilience, and self-care. These individuals are bending under the prolonged pressures of the COVID pandemic but are unlikely to break. 

 

 

On January 21, 2021, Libby Ellinas, MD, Director of the MCW Center for the Advancement of Women in Science and Medicine (AWSM), Associate Dean for Women's Leadership, and Professor of Anesthesiology at MCW, gave Kern Institute Grand Rounds on Women in COVID. Her talk was a tour de force of cautionary tales and sobering data. She reminded us that the majority of people on the front lines of healthcare and education – and nearly half of our medical school faculty – are women. Data from multiple sources are consistent: women as a group are under special pressures during this pandemic. This poses a threat to both our medical education and health care systems. 

 

The ways in which COVID-19 has disproportionately affected women

 

Dr. Ellinas shared survey data from the USC Dornsife Center for Economic and Social Research confirming that the mental load – including concerns about the health of their families, themselves, and financial strain – is significantly higher among women compared with men. And while married men with children have the lowest mental distress, women with children have, by far, the highest. This is not news.  Sociologists have shown over-and-over that being married with children is associated with better health and more happiness for men while, for women, being married/partnered with children is associated with relatively high levels of stress and distress. Women do measurably more emotional work than men, both in families and at work. While often this work is energizing, it is a mental load that can overwhelm. 

 

Among MCW faculty members, Dr. Ellinas demonstrated that the social isolation necessitated by the pandemic is wreaking havoc for working women. With schools inconsistently in session, direct childcare hours have increased for both men and women, but the number of additional hours per week has been greater for women. Data from an MCW AWSM COVID survey show that while nearly 60% of male faculty have spouses employed part-time or not at all, this is true for only 21% of female faculty. Thus, MCW working women with families are much less likely to have robust support systems than their male counterparts.

 

There is also heterogeneity in how COVID-19 increases stress. Some find value in working from home, but many do not. Clearly, working from home – for those privileged to be able to do so – allows more flexibility and autonomy, reduces time spent commuting, and decreases costs associated with working away from home. It might even provide unexpected “quality time” with family. However, especially for working women with school-aged children, working from home is associated with less sleep and decreased self-care. Adding to this, the intersectionality of race and gender can weigh even more heavily on Black and Brown women. 

 

And, as if that wasn’t challenging enough, there are signs that the COVID-19 pandemic negatively impacts the academic productivity of early-career women more that it does men. The long-term impact of this is worrisome and may lead to the reversal of recent gains in women’s academic status on the whole. These are challenges for us all. 

Institutional solutions are critical and complex

What did Dr. Ellinas recommend? She offered a number of institutional recommendations that are consistent with AWSM’s inspiring and audacious vision that “MCW will be a destination for women leaders, cultivating an inclusive and vibrant culture that supports all genders to grow and thrive in the health sciences,” and mission “to advance the careers of women at MCW through data-informed strategic projects that enhance opportunity and improve workplace climate.

• Evaluating leadership structures to ensure women are well represented in decision making
• Valuing parenting through generous parental leave and creative childcare
• Supporting women to “step forward” rather than depending on “step back” policies
• Valuing the hard work of mentoring, equity, diversity, and inclusion 
• Valorizing women role models for us all

 

We need policies that can be individualized and flexible over time. Extraordinary caregiving responsibilities may be acute, due to an illness or urgent need, chronic, as in having a child with special needs or an aging relative with evolving needs, or both, as in this stuttering pandemic. Community resources are distributed unevenly. Some people do not have enough help while others have what they need, if not to excess. Institutions like ours can improve the quality of life for our employees and community by offering concrete services, such as low-cost, high-quality childcare, sick childcare, food preparation and delivery, and help with chores. 

 

To support women (and men) whose academic careers have been impacted by the pandemic, some institutions have found ways to provide assistance that enable researchers to continue collecting and analyzing data while they tend to a “special” personal need. One program, the Doris Duke Fund for the Retention of Clinical Scientists (see “For Further Reading” below), has funded such efforts. Many workplaces provide access to high quality food, recreation, and other wellness services. Much can be done. 

 

How do we, as an institution, come out of COVID-19 better and stronger? We need a flexible range of options going forward that includes working from home. Our men need to engage. We all need to honestly complete surveys to have quality data that inform best solutions.  Men who have the relative privilege of having more support at home and at work – as well as having disproportionately higher salaries – need to be allies and advocates for equity and flexibility. No one should assume that they, alone, know what will work; we need to ask women. Don’t insist on “fairness” or “equality” until you have a full-thickness view of the situation. 

  

Back to crying

 

I have always kept a box of tissues on my desk. When seeing patients, the box was discretely tucked just out of view, easily slid toward the patient at the first glisten in the eyes. As a colleague and mentor, the box would be brought forward when the face flushed, the head dropped, and the tears rolled. It has been my experience that, most of the time, a good cry in the presence of an empathic other is the most efficient way to clear the air and help the words and problem-solving flow. People cry for all sorts of reasons. Sometimes it is sadness and grief, but just as often people cry because they are overwhelmed, angry or frustrated. I have come to believe that an effective mentor, like the good physician, must learn to invite and sit with the tears of others without needing to fix anything; just listen, sit quietly, check in.  Fighting back tears takes energy, blocks thinking, and keeps others away. Letting tears fall clears the air and loosens the voice. 

 

Did I say that it is mostly women who shed tears in my office? Well, it is. But occasionally, the men cry as well.  Three times in the past three weeks, I have spoken with distraught educational leaders, people who are deeply respected by colleagues and beloved by trainees. They were emotionally and physically exhausted from the expanding and rapidly evolving needs of school-aged children and elderly parents. They had less help from their working spouse than they needed. Their jobs presented new and growing demands on themselves and their trainees (e.g., being “deployed” to care for critically ill COVID-19 patients). They feared a loss of income. They were at the brink. 

 

In each case, I pushed the virtual box of tissues. Why doesn’t Zoom design a “tissue box” emoji?

I hope my message is clear: It is okay to cry here. I am not afraid of your tears. I will hear you out and empathize. You are not crazy, this is hard. I know you will find your way through this. I will help if I can.  

 

These folks do not need to be fixed, they just need a shoulder to cry on, a good night’s rest, regular meals, and an occasional walk in the woods. I think we can get them that. 

 

 

 

For further reading:

Jagsi, R, Jones, RD, Griffith, KA, Brady, KT, Brown, AJ, Davis, RD, ... & Myers, ER (2018). An innovative program to support gender equity and success in academic medicine: Early experiences from the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists. Annals of Internal Medicine, 169(2), 128-130.

 

Jones, RD, Miller, J, Vitous, CA, Krenz, C, Brady, KT, Brown, AJ, ... & Jagsi, R (2020). From Stigma to Validation: A Qualitative Assessment of a Novel National Program to Improve Retention of Physician-Scientists with Caregiving Responsibilities. Journal of Women's Health, 29(12), 1547-1558.

 

 

 

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.