Practical Wisdom in Medical Education: A Student Perspective

 From the 4/23/2021 newsletter

Perspective/Opinion

 

Practical Wisdom in Medical Education: A Student Perspective

 

Clara Bosco – MCW-Milwaukee Class of 2022

 

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

 

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

 

 

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

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

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

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

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

 

 

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

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

From the 4/30/2021 newsletter

Three Questions for Jose Franco, MD

Perspectives on the Transformation of Medical Education

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

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

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

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

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

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

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

For students:

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

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

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

For faculty:

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

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

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

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

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

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

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

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

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

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

The second major area of concern is the timeline. 

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

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

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

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

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

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

 From the 4/30/2021 newsletter

Director’s Corner

 

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

 

Adina Kalet, MD MPH

 

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

 

 

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

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

 

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

 

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

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

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

 

So much has changed

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

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

 

The pandemic has changed how we view identity and character formation

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

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

 

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

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

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

 

Challenges and opportunities

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

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

 

 

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

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

From the 4/23/2021 newsletter

Director’s Corner

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The “writing prescriptions for food” lecture 

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

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

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

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

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

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

 From the 4/16/2021 newsletter

  MCW Curriculum Re-imagined

 

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

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

 

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

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

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

 

1) What surprised you most about the session?

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

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

 

2) Did you feel your voice was heard?

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

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

 

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

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

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

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

Design:

1. Discovery Curriculum Exploration Project

2. Human-Centered Design Lab

 

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

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

“Ah! Bach!” and other Confessions of a “Humanities in Medical Education” Cynic, Converted

From the 4/16/2021 newsletter

Director’s Corner 

“Ah! Bach!” and other Confessions of a “Humanities in Medical Education” Cynic, Converted

Adina Kalet, MD MPH

In this Director’s Corner, Dr. Kalet admits to her own early arrogance about the introduction of the humanities in medicine and challenges us to find a rich and inspiring way forward using a character and caring framework …

Did you know that M*A*S*H, the comedy-drama television series that ran on CBS from 1972 to 1983 and based on a movie of the same name, is one of the most highly rated US television shows in history? For the few who are unfamiliar, this remarkable ensemble piece told the fictional story of the 4077th Mobile Army Surgical Hospital, in Uijeongbu, South Korea, during the Korean War (1950–53). It ran for eleven seasons, spanning the final years of the Vietnam War and into the Cold War. There were 256 thirty-minute episodes. It was a literal modern War and Peace. As does most great art, M*A*S*H grappled with the most controversial political and humanistic issues of all times. The theme song, “Suicide is Painless,” is an indicator of how deeply philosophical the writing was, and how accessible the insights. In my estimation, it is the best medical drama ever written and performed. To each his/her own, right? 

For me, a child of the 1960s and 1970s, M*A*S*H was formative. I wanted to be “Hawkeye” Pierce. Even though he was a womanizing, sarcastic, sometimes cruel practical trickster, he was also an artfully skilled, lifesaving, courageous, compassionate, and empathic physician and colleague. I was drawn to his deliciously complex character - both in the theatrical and philosophical sense - and strong moral presence. In one of my most memorable episodes, Hawkeye gives seduction advice to Walter “Radar” O’Reilly, the eerily perceptive, dewy-eyed, camp administrative savant, farm boy from Ottumwa, Iowa. Hawkeye coaches him on how to fake his knowledge of classical music to win the affections of a nurse (nurses were all women) in camp by saying “Ah! Bach!” with a dreamy look and expressive hand motions. The superficiality of the gesture has me on the floor laughing even now. Will they stop at nothing to get the girl into bed?

This represented how I felt, as a medical student and resident about the rather clumsy early efforts made by medical educators in the 1980s to seduce medical students into self-awareness through incorporating the “arts and humanities” into medicine. 

Not every humanities experience is meaningful for medical students 

Curricula which required engagement with selected works of art to view or read without much guidance or structure, felt like a manipulative and superficial ploy to get me to feel something I did not (or would not) and do something I could not yet do. I am not proud of this; I know now I was wrong. I was young and insecure. But it is still a common point of view of trainees. 

As Art Derse shares in his history of the humanities in medicine at MCW I, too, have occasionally heard students say, “I didn’t come to medical school to read poetry (insert: write stories, look at art, or watch movies).”  I think that these students are right and, yet, deeply wrong. 

They are right because medical training is hard enough and – given the great variation in how each of us prefers to access our own humanity, empathy and compassion – being required to engage with a particular work of art is too vague. Students who hold this view are deeply wrong because they misunderstand the point of the exercise. 

I personally have great difficulty connecting with poetry. For me, it is hard work and, therefore, not entertaining enough. But, of course, I now know I must do the hard work to reap the most profound lessons the humanities have to offer. And it is almost impossible to do this work on our own. We need facilitators and guides. The work of art is just the “trigger” for reflection, a starting point to get oneself to challenge assumptions, see the wart’s, face the fears. This is both hard work and not guaranteed to lead to the intended learning. 

“If you haven’t read Thomas Mann’s Magic Mountain you should not be allowed to be a physician!” 

I heard this repeatedly from one of the most erudite and revered clinicians in my department in New York City in the 1990s. What he meant to communicate was that physicians should read great literature in order to develop empathy for and access to the deepest, most complex and conflictual aspects of the “illness experience.” But what he said and represented, sounded crude, insensitive and, frankly, terrifying to my modern ears. Would this powerful man really limit access to the profession based on this one book? I believed he would. I tried to talk with him about it many times. He dismissed my concerns and was openly derisive when I insisted that we focus on skills building and personal reflection as a path to ensuring all physicians have the communication skills – including empathy – to elicit the patient’s story and to build a therapeutic rapport. He absolutely despised any mention of Standardized Patients (SPs). He felt – without any direct experience, by the way - that using professional actors trained to portray patients, assess trainees’ communication skills, and provide them feedback was “fake” and manipulative. 

Given his great love of using the arts to instill empathy, this perplexed me. In my experience, SPs are highly disciplined artists willing to engage with our trainees to ensure that all patients have caring and competent physicians.  He also dismissed my choices of “great” literature, which ran more toward Toni Morrison, Alice Walker, Margaret Attwood, Jamaica Kincaid, Alice Munro, Marilynne Robinson, Tillie Olsen, Virginia Woolf, than toward Thomas Mann (as of a month ago, I have yet to get past page 300 of Magic Mountain. I am still struggling, though). And this was the leader of our Humanities in Medicine program. 

Initially, I rebelled. We needed more than simply a trigger for deep thought that was unguided and self-congratulatory.  Over the years, with many pedagogical advances and an openness to a broader range of humanities, my view has softened. My colleague was a man of his times; what other choice did he have? But we must make other choices, expand the canon, and make use of the humanities to open our minds and hearts. Not easy.   

So, where do we begin?

This past Sunday morning, my husband left the New York Times on the table opened to the Op Ed entitled “A Once-in-a-Century Crisis Can Help Educate Doctors.” I “girded my loins,” ready for a diatribe, another “humanist” telling us in medical education what we must add to an already overwhelming experience of medical training. 

But I was relieved. In this piece, Molly Worthen, a historian at UNC-Chapel Hill who writes about higher education, points out that the pandemic has given us an opportunity to transform medical education because it has forced health professionals and medical schools to look beyond the particulars of modern medicine and think more broadly about how we prepare doctors. She says, and I agree, that COVID has provided us “a pilot project to demonstrate that the humanities are an essential part of what a medical education should be — not just a luxury, but foundational.” 

She celebrates the strides we have made away from the early “humanities in medicine” days of museum visits and the “great novels,” as we move toward a true integration of the humanities at many medical centers and in many programs. The humanities force practitioners to be clear eyed even as they evaluate seemingly empirical data. “Humanists take evidence so seriously that they emphasize viewing it from multiple vantage points and recognizing one’s own limited perspective.”  

Worthen finishes, reminding us all of where we began our medical journeys days, years, or even decades ago. She says our students “grasp intuitively that medicine is not a science but an art that uses science as one of many tools.” 

Embracing Ambiguity

There is so much work to do. In this and in the last issue of the Transformational Times, we have highlighted the many ways these efforts are happening at MCW and beyond. Despite this, there is no clear path to integrate the humanities into medicine. Yet, maybe not knowing exactly how, yet embracing, the ambiguity of that task will bring us closer. Maybe that is the point. Ah! Bach!

In his own way, even Hawkeye knew that the humanities were important while working in the M*A*S*H unit. He once told an interviewer that he brought every single book ever written in English with him when he was sent to Korea. How? Well, he responded, “I brought the dictionary. I figure it's got all the other books in it.” Not a very high brow answer for a man named after Benjamin Franklin and nicknamed after a character from James Fenimore Cooper’s The Last of the Mohicans. I can’t say I agree with everything Hawkeye said, but this, at least, was right on target.  

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.

Integrating the Humanities into Medical Education

From the 4/9/2021 newsletter

Editor’s Corner

Integrating the Humanities into Medical Education

Bruce H Campbell, MD FACS - Transformational Times Editor

Dr. Campbell writes about how building observational and representational skills through the humanities translates into more empathetic and effective patient care …

Stories are the primordial means through which we make sense of, and convey the meaning of, our lives.

- Rita Charon and Craig Irvine

 My medical student group gathered to debrief and discuss their very first experiences observing physicians caring for patients.  One student presented a case of a teenager she saw in her clinical mentor’s office with mild muscle aches. This teen had a couple of relatives who were afflicted with a rare, devastating inherited disease. The boy’s few vague symptoms could, possibly, represent the disorder’s very earliest manifestations. Or the symptoms might be nothing, at all.  

“What did you decide to do?” I asked. 

“We told him to exercise and take Advil. We also ordered genetic testing and asked him to come back in a few weeks to check the results.” 

 “Thanks. That was a very complete presentation,” I responded. “Does anyone have any questions?” Someone wanted to know more about the genetic testing. Someone else asked about other potential diagnoses. We discussed those. 

“A couple more questions,” I said. “Did the doctor find out how all this might be affecting the young man? Is he aware that he might have the same disease his relatives have? What’s do you think is going on inside his head?”   

The student’s eyes widened. “I don’t know. We didn’t ask.”

I could not help but wonder whether the students might have been more curious about this teenager’s underlying story had they heard it a few months before they started medical school instead of a few months after. 

Empathy levels will decrease. How soon does that happen? 

As a profession, we lose our “vicarious empathy,” or our ability to have a visceral empathic response to another person’s stressful experience, very early on. A 2008 study from the University of Arkansas for Medical Sciences (UAMS) demonstrated significant drops in empathy during medical school, especially during the first and third years. Men (like me) who chose surgical specialties had the greatest loss of vicarious empathy. 

Of course, no one plans to jettison their empathy along the way from being a normal person to becoming a physician. The losses likely occur as we seek to model ourselves after people who are a step or two ahead of us along the path. When I talk to first year students in MCW’s Healer’s Art course, they all affirm that they will listen to their patients, think first and foremost of the patient’s well-being, and always act with justice and equanimity. Yet, some would not recognize the people that they will become once they emerge, transformed, from residency a few years later.

Professionalism vs. Humanism

How do we address this nearly imperceptible transformation from empathic lay person to crusty physician? 

One way is to reflect on the values of both “Professionalism” and “Humanism.” In medical schools, we strive to nurture professionals, which we might define as “physicians with attributes, skills, and demeanors with which they will practice high-quality medicine with integrity and empathy.” This is, of course, an admirable goal. “Humanism,” on the other hand, is broader than professionalism. These are the qualities we hope every physician brings to the table from childhood and that must be nurtured and enhanced, not lost, throughout the process of becoming a physician. 

This is where integrating the humanities into medical education and training comes in. 

Broadly defined, the medical humanities are interdisciplinary endeavors that draw on the creative and intellectual strengths of diverse disciplines, including the humanities, social science, and the arts in pursuit of becoming a good physician. They tap into literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology, and history. It’s basically the intersection of Medicine with Everything Creative. The goal is to draw on the humanities to expand a physician’s capacity to be humanistic, compassionate, and empathetic. 

Think of an example from your own life: 

Remember a novel you read and loved in high school. If the narrative grabbed you, you dove into the protagonist’s story and couldn’t put the book down. You didn’t worry that you “cared too much” for the protagonist or their struggles. You actively attempted to understand what each character was thinking, and you figured out why they did the things they did, even when their actions might have seemed, at first, inexplicable. Your heart rate soared when you anticipated danger and you wiped your eyes when they suffered. Your blood boiled when they were betrayed. When you finished the book, you encapsulated the arc of the story and shared it with your best friend. You paid attention to the story. You were able to retell it to others. It changed you. 

Ideally, as physicians, we should be similarly curious and fearless as we delve into our patient’s narratives. We safely encountered narratives in the library. We should be able to do it at the bedside, as well.  Right?

Yeah, but does reading a novel really make me a better doctor? 

It does, actually. In an 2013 article in Science entitled, “Reading Literary Fiction Improves Theory of the Mind,” the authors studied people who read literary fiction, popular fiction, nonfiction, or nothing at all. They discovered that those who read literary fiction demonstrated improved “theory of the mind,” that is, “the human capacity to comprehend that other people hold beliefs and desires and that these may differ from one’s own beliefs and desires.” The article further showed that the same readers had stronger “theory of the mind” in both cognitive (the ability to understand others’ beliefs and ideas) and affective (the ability to understand others’ emotions or have empathy) realms. These were exactly the attributes that were lost during medical training in the UAMS study. 

Narrative Medicine: Attention. Representation. Affiliation.

Rita Charon, MD PhD, and her colleagues at Columbia University developed the field of Narrative Medicine over twenty years ago bringing their “close reading” approach to clinics, classrooms, patients, ICUs, and bedsides. Participants first read and discuss a short story, poem, piece of artwork, or other creative work. Then for a few minutes, they each respond in writing to a simple but ambiguous prompt “in the shadow” of the piece they shared.  Then they each read aloud what they have created and discuss as a group what they have learned through this process. 

Dr. Charon teaches that these short, group-based exercises sharpen learners’ listening capacities and drive the “self” to engage in new ways with the “other.” “Reading and listening are muscular acts,” Dr. Charon writes. “It makes us wonder about the spaces between the lines and forces us to join with the storyteller to enter the world they describe.” 

I have shared close reading exercises with MCW medical students, residents, and faculty over the years. These opportunities to read and write together have been gratifyingly well received. Other faculty, staff, and students have developed programs featuring writing, storytelling, art, improv, music, and other creative endeavors. 

Many students embrace these approaches, and faculty members deeply enjoy the engagement, but we still struggle, as have many other medical schools, to truly integrate the humanities into medical education for all our trainees. 

Where do we begin to integrate the humanities into medical education?

In 2020, the Association of American Medical Colleges (AAMC) released a report on the Fundamental Role of Arts and Humanities in Medical Education. The AAMC recognizes that the “arts and humanities are essential to the human experience,” and by “integrating arts and humanities throughout medical education, trainees and physicians can learn to be better observers and interpreters.” The report offers resources and examples for students and educators who want to explore the topic. As Deepthiman Gowda, MD, the Assistant Dean for Medical Education at the Kaiser Permanente Bernard J. Tyson School of Medicine has said, “Humanities have a role in addressing the problems in health care.” 

There is, too often, a chasm between physicians and patients, and medical training, paradoxically, seems to widen that chasm. The humanities, well used, can assist in bridging this gap. Substantively integrating the humanities into medical education could sustain and enhance the empathy students bring to medical training and provide them tools to remain resilient, deeply compassionate, attentive caregivers. 

Curricular change is hard. We will know we have succeeded when our youngest colleagues hold onto their empathy even when it sometimes seems easier to let it go. 

 For more reading:

Principles and Practice of Narrative Medicine. Rita Charon, Sayantani DasGupta, Nellie Hermann, Craig Irvine, Eric R. Marcus, Edgar Rivera Colón, Danielle Spencer, and Maura Spiegel, eds. Oxford Press. 2016

Howley L, Gaufberg E, King B. The Fundamental Role of the Arts and Humanities in Medical Education. Washington, DC: AAMC; 2020.

Bruce H. Campbell, MD FACS is editor of the Kern Transformational Times. He is a Professor of Otolaryngology & Communication Sciences and is on the faculty of the Center for Bioethics & Medical Humanities at MCW. He is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

Shared Change is a Rigorous Process

From the 4/2/2021 newsletter

Perspective/Opinion

Shared Change is a Rigorous Process

Jeffrey Amundson, PhD, Travis Webb, MD, MHPE, Amy J. Prunuske, PhD, and Adina Kalet, MD, MPH

The team describes the development of the curriculum transformation working groups, reports on their recent activities, and looks forward to the Human-Centered Design approach that will clarify and accelerate the curriculum redesign …

 

Change is hard.  However, when change is a shared experience, many of the stakeholder concerns and expectations can be attenuated by communicating and demonstrating conscientious and prudent planning.  The process of curriculum change is a large-scale change that requires thoughtful organization of various stakeholders into manageable and effective teams.  

MCW is currently transforming our traditional 2 + 2 curriculum into one that integrates foundational science with clinical knowledge and skills through case-based, inquiry focused, individualized learning with an emphasis on inclusion and wellness.  To achieve this transformation, various change management strategies have been used including Kotter’s 8 Step process of change and components of Implementation Science to create a rigorous process of communication and structuring with stakeholders. 

Envisioning and building the team 

A common starting point in most models of change management is to communicate a vision of the most important reasons for change. In Kotter’s 8 Step process and similar models (e.g., ADKAR), shared vision is the foundational concept for change. 

This first step at MCW began when all course directors, chairs, education deans from all campuses, Curriculum and Evaluation Committee (CEC) members, selected education staff, and student representatives from all campuses were invited to a Curriculum Exploration retreat held on October 2, 2019.  This involved approximately 100 stakeholders who began an iterative process that developed principles to provide a foundation for medical school curriculum redesign at MCW.

The next step was to create a team of representative stakeholders responsible for coordinating and guiding teams through effective communication and activities. The Curriculum Exploration Steering Committee became this coalition, and included basic science and clinical chairs, course directors, administrative leaders, and Curriculum and Evaluation Committee (CEC) representatives. These same individuals were dispersed throughout the subcommittees to promote contiguity for effective communication and activities. Please see the steering committee and subcommittee rosters at the end of this article. 

Exploring the five principles

After ratifying the new curriculum principles, the steering committee charged subcommittees of key stakeholders to consider how to implement these principles into a comprehensive curriculum considering the complexity of the three-campus institution. Subcommittee members were recruited via email, InfoScope postings, and verbal communication. The kick-off meetings of the “Principle Groups” occurred September 9th and 10th, 2020.

A Principle Group subcommittee took charge of each of the following: 

• Principle 1: Integration of foundational and clinical science learning throughout all years of curriculum.
• Principle 2: A systematic approach and focus on assessment that drives learning and assures that students achieve desired competencies.
• Principle 3: Individualized approaches to learning that are ultimately tailored to student interest and career goals.
• Principle 4: A student-centered, inclusive culture with a focus on wellness.
• Principle 5: An evidence-based instructional approach that is inquiry driven and utilizes active learning.

The subcommittees provided monthly progress reports starting in September 2020 which culminated in final reports on January 1, 2021 (a link to the five principle group reports is available here from an MCW computer or through InfoScope). Additionally, as Lindsey Bowman, Senior Administrative Assistant for Curriculum noted, the guiding coalition efforts were a standing CEC agenda item during the 2020-2021 academic year. These updates provided opportunities for discussion at seven curriculum meetings over the 2020-21 academic year. The coalition communicated monthly with the CEC, its M1-2 subcommittee, its M3-4 subcommittee, and the executive committee. In addition, there were also quarterly meetings with the Directors of Medical Student Education, the M1-2 Course Directors and Coordinators, the Advanced Clinical Experience Committee, and the Clerkship Directors.  It is important to emphasize most of this rigorous process was undertaken while adapting to the impact of the pandemic.  

These individuals have done an outstanding job through the first steps and generated numerous short-term wins (another common component of “models of change”), including formulating a set of design principles from the final Principle Group reports (i.e., Core Content, Instructional Approaches, Assessment, and Faculty and Student Support).  These principles served as the next piece of the process to create a larger team of volunteers.  Additionally, as in many models of change, the next steps will include establishing reasonable targets and, in MCW’s case, using competencies, learning objectives, and suitable governance frameworks to reduce barriers for stakeholders to work across silos.  

The next steps

The next stakeholder teams will clarify medical school learning objectives around: 

• Patient Care and the Health Care System
• Knowledge for Practice
• Communication 
• Personal and Professional Identity 

In models of change, this represents the transition from preparation to initiation of change.  

Importantly, these proposed changes rely heavily on stakeholder input so stakeholders can learn from mistakes and adjust the process as it moves from planning to implementation (as well as adjusting during implementation).  

MCW, with help from the Kern Institute’s Human Centered Design Lab, will capitalize on this input in the next steps.  Human-Centered Design is a team-based approach to problem-solving that uses empathy to develop a deep understanding of any problem.  This allows the problem to be clearly articulated, paving the way for the brainstorming of solutions, followed by prototyping the solution that is most impactful.  This will lead to a process of continuous and intentional short-cycle iterative improvement to the solutions design. 

Much work is yet to be done, and we hope that all faculty, staff, residents, fellows, and students will engage in this exciting process to achieve sustained acceleration (a very important component of change). Given the efforts put forth so far and with a continued rigorous process, the shared experience of change can achieve a fruitful transformation.

Jeffrey Amundson, PhD is a Postdoctoral Fellow in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. Travis Webb, MD, MHPE is a Professor in the Department of Surgery and Associate Dean for Curriculum at MCW. Amy J. Prunuske, PhD is an Associate Professor at MCW-Central Wisconsin. 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.

COMMITTEE AND SUBCOMMITTEE ROSTERS

Curriculum Exploration Steering Committee:  

Amy Prunuske, Travis Webb, José Franco, John Hayes, Alexandra Harrington, Malika Siker, Jonathan Marchant, Bill Hueston, Matthew Hunsaker, Lisa Dodson, Adina Kalet, Jon Lehrmann, Marty Muntz, Melinda Dwinell

Subcommittee Members (Faculty and Staff):

Jennifer Hinrichs, Joe Budovec, Marty Muntz, Mindy Dwinell, Jonathan Marchant, Craig Hanke  Sandra Pfister, Lisa Cirillo, Joe Brand, Hershel Raff, Steve Hargarten, Bipin Thapa, Beth Krippendorf, Marika Wroszek, Teresa Patitucci, Allen Last, Craig Young, Jeff Fritz, Maria Hintzke, Megan Waelti, Terra Pearson, Kathlyn Fletcher, Karen Marcdante, Brian Lewis, Lisa Dodson, John Meurer, Monica Shukla, Kerry J. Grosse, Catherine Thuruthumaly, Ankur Segon, Alan Bloom, Ellen Schuman, Karin Swartz, Carley Sauter, Leslie Ruffalo, Robert Treat, Erin Green, Mary Ann Gilligan, Tavinder Ark, José Franco, John Hayes, Paul Knudson, Elizabeth Hopp, Bill Hueston, Jules Blank, Roy Long, David Brousseau, Pat Foy, Kathleen Beckmann, Brian Law, Jordan Cannon, Johnny Neist, Dan Stein, Jon Lehrman, Malika Siker, Cassie Ferguson, Himanshu Agrawal, Theresa Maatman, Kurt Pfeifer, Kristina Kaljo, Linda Meurer, Anita Bublik-Anderson, Becky Bernstein, Jean Mallett, Adrienne German, Nicholas Yunez, Travis Webb, Ali Harrington, Ashley Cunningham, Amy Prunuske, Patrick McCarthy, Adina Kalet, Ellen Sayed, Ashley Zeidler, Art Derse, Jacob Prunuske, Erica Chou, Megan Schultz, Jay Patel, Joe Barbieri, Curt Sigmund, Matt Hodges

Subcommittee Members (Students):

Kelli Cole, Mario Castellanos, Marko Ivancich, Chase LaRue, Taylor Brockman, Haley Pysick, Gopika SenthilKumar, Alec McCann, Colton Brown, Emily Nordin, Jess Sachs, Connor McCarthy; Syndey Newt, Emily Schaefer, Phil Hartfield  

Work and Career in that Order: Residency is Just the Next Step in the Life of a Physician

 From the 3/19/2021 newsletter

Director’s Corner

 

Work and Career in that Order: Residency is Just the Next Step in the Life of a Physician

 

By Adina Kalet, MD MPH

 

Dr.Kalet celebrates Match Day 2021 by exploring how residency, as difficult as it can be, offers opportunities for growth and a path to a rewarding career …

 

Later today, more than 48,000 medical students will find out where they will begin residency training in July.

While the numbers vary, about half of students matched to their top choice, and about two-thirds to one of their top three. About 5% of all applicants did not match and have spent the week working with deans and faculty to “scramble” into open slots. There will be disappointments and not everyone will be thrilled.

In normal times, MCW-Milwaukee would be hosting our 200 students, their families, and their friends in an Alumni Center celebration with balloons, short speeches, finger food, intense excitement, and identical “I MATCHED!!!” t-shirts. Even still, today’s celebration and energy will be shared on social media and over the internet when, at 12:00 noon EDT, students open the e-equivalent of an “envelope” and learn for the first time to which program they have matched.

Today is one of the most significant watershed moments in each of their lives. They will, finally, be able to glimpse more clearly the outlines of their future selves.

 

The importance of “place” in residency training

Where a physician trains does matters. Residency takes each young physician to a city or town where they are committed to stay for a while and, although it varies by specialty, over 50% of physicians end up practicing in the state where they complete training. The shared experience of residency builds profound and lifelong friendships forged during long nights-on-call and the intellectual, physical, and emotional challenges inherent with the transition from medical student to practicing physician. Clinical “habits” are formed and imprinted for a lifetime.

I am amazed how intense the experiences I had during my own residency remain. While I have not drawn blood cultures, done a lumbar puncture, or placed central intravenous line in the subclavian vein in three decades, I still recall the rhythm of each procedure, the proper aseptic techniques, the positioning of the patient, the feel of the cannulas and needles, and the proper documentation. My fingers remember the sensation of the needle overcoming resistance, piercing the skin, and finding the proper space. During my residency, I learned to rehearse “delivering bad news,” and still do so as I walk toward a difficult conversation. Facing an emergency, I still summon courage the same way I did when I was wearing the “code beeper” and running toward, rather than away from, the crisis. Always take the stairs. Never wait for the elevator. Hope the nurses are already there with the cart. Will the medical student by my side be ready to do chest compressions? I learned to be ready when I arrived. 

 

Looking for meaning during residency training

Some things have changed about the match since I was in medical school. While many of my classmates in the early 1980’s applied to only one type of residency, a sizable minority listed more than one type of program on their match lists, allowing the algorithm to determine whether they would end up as an internist, pediatrician, dermatologist, or orthopedist. I share this because I now know how this approach worked out. These peripatetic students understood something the rest of us did not, and here is the lesson: It is much more important to choose what kind of career you want to have, than which clinical discipline or “tribe” you seek to join. They understood that there are, for most of us, many paths to a satisfying life as a physician.

Here are some examples. One friend knew she wanted to spend her career in women’s health, so she applied to and ranked OB/Gyn, family medicine, and internal medicine programs. Another close colleague, hoping for a quiet, suburban, “Marcus Welby” type of practice, applied to both family medicine and internal medicine. They let the match decide their specialty, knowing that each path would lead to their goals. Other classmates were so committed to where they wanted to live that they applied to several different specialties in the same city, believing that the type of residency was secondary.

This type of flexibility seems very old fashioned now and there are reasons for this. Over the past decades, for example, the increase in medical school graduates has far outpaced the increase in first-year residency positions, placing an intense “What if I don’t match?” pressure on students that we never experienced. Today, certain clinical fields are so competitive that students feel the need to plan far ahead, take time off to complete specialty-focused research, concentrate on doing things that will make them more attractive for the few spots, and audition extensively. Back when each residency program had its own pen-and-paper application form, we applied to ten or so institutions and ranked five to eight. These days, the number of electronic applications submitted by each applicant continues to climb, and it is not unusual for a medical student to apply to over sixty programs hoping for a handful of interviews. Different times, for sure. But instructive. Life as a physician has always been a journey with many choices, and residency is just the next step after medical school.

 

“Careers are made in retrospect”

Most of us can look back and see the paths we took, the opportunities we seized, and the roads not taken. But discerning the path that still lies ahead of us is impossible. It is rare to meet someone who, in retrospect, knew where they were going from the very beginning. Nearly half of the students who match today are entering different fields than they had envisioned for themselves when they started medical school. As many as 20% of residents switch fields before the end of their training. Mid-career physicians often retrain into new clinical specialties, seek advanced education, or pursue mid-career fellowships in a wide range of areas.

My woman’s health friend, for example, ended up happily doing groundbreaking immigrant health research. “Marcus Welby” is now a professor and urban health services researcher. Even though they did not end up where they might have predicted, their training gave them the flexibility to build satisfying and meaningful careers.

This is really good news. It means we can each feel free to be fully in the present. With reflection, mentorship, and opportunity, we can redirect our work. As the ancient Greeks advised: Know Thyself. Then move in that direction.

The wonder of a career in medicine is its flexibility and ever emerging opportunities. So how do we make good choices?

 

Residency is a learning experience, but it is also a job. Some advice …

Find work that matters. Look for the aspects of your new careers that intrigue you and get you out of bed in the morning. As novice physicians, you will learn about yourselves and your patients as you engage with both the well and the chronically ill. You will learn to prioritize and lead teams as you work through the daily tasks and confront the patients who decompensate in front of you. You will perform procedures that require significant manual dexterity and employ advanced technology. You will engage with colleagues, team members, and communities. You will collect and analyze data, peer through microscopes, study the results of sophisticated analyzers, and seek the truth and beauty hidden in a radiologic image. You will deal with unimaginable ambiguity. Learn to think, to feel, and to engage at various paces and rhythms — optimally, for your entire professional lifetime.

Take time to reflect and grow. Listen to others as they help you discern how your work impacts you. Find ways to stay well even as you do the hardest work in your life.

 

Residency is only one step on the path to a career

Training is extremely hard, and it can become a life of one challenge after another. Yet, as residents touch the lives of patients, learners, colleagues, friends, family, and the community, opportunities for growth, character development, and changemaking present themselves. Some residents will avoid these occasions while others will seek them out. To some, the work of residency will drive them forward into rich careers, dictating their goals and what they work on. For others, the opportunities will fade into the background while they are “busy making other plans.”

This is what continues to astonish me. While residency is an overwhelming experience, there are those who take full advantage of its opportunities. They learn early that training is only one step toward a career that will take unexpected twists along the way. As faculty, we must recognize their sacrifices, yet help them stop and consider: What do you want to be able to say you have done? How will you know you have done it, influenced others, engaged in those conversations, made the world just a little better? How might I help?

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The next group of residents will arrive soon. This week’s Transformational Times celebrates the agility, flexibility, and compromise inherent in recruiting the next cohort of residents during a pandemic. In this issue, you will read about how our MCW community of residency program directors, students, and residents have faced and embraced the special challenges this COVID-19 year. Airports, hotels, and long visit days filled with hospital tours and interviews were replaced with Zoom interviews, “1980’s style” videos, social media blitzes, all produced to give the potential residents a “feel” for the culture of the programs.

And there have been upsides! Programs saw the numbers of applicants increase. There was a more diverse applicant pool. Web pages were spiffy, social media campaigns were buffed, and all hands were on deck as residents showcased their program’s camaraderie and the wonders of living in Milwaukee. In some ways more exhausting (zoom fatigue) and in some ways more intimate, faculty and applicants got to see each other’s home offices and meet the family dog. No cheese curds, brats, and beer; instead, there were suit jackets, a clean shave, and a new house plant along with scrub pants and sneakers.

Creativity overflows. This is an important moment. Let’s take advantage of it.

 

 

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.