Radical Candor in Medical Education

From the August 4, 2023 issue of the Transformational Times

Radical Candor in Medical Education 

 

Kathlyn E. Fletcher, MD MA – Program Director, Internal Medicine Residency 

 

 
Dr. Fletcher highlights a Kern offering to new interns to prepare them for their role as educators. These sessions took place during orientation and combined a workshop on how to show learners that they matter with a workshop on how to give effective feedback.  These are the building blocks of medical education radical candor ...

 

My introduction to radical candor 

 

I first heard the concept of radical candor from my sister Julia, who is a retired Navy intelligence officer. I must have been talking with her about how hard I thought it was to give feedback, when she got out a piece of paper. She drew a 2 x 2 table that is the central figure in a book about how to be a great supervisor. She explained that to give impactful feedback, you must 1) care about the person you are talking to and 2) be honest.  

 

I proceeded in my usual path to change -- somewhat slowly. I bought the book Julia was referring to called Radical Candor by Kim Scott and started reading it. I got about halfway through before I dropped it in the bathtub and decided that I had read enough to “get” it.

 

A few concepts in the book specifically resonated with me.  

 

First, the quadrant in which we care about the person, and we are honest is called “radical candor.”  The quadrant in which we care about the person, and we are NOT honest is called “ruinous empathy.”  

Ruinous empathy struck a chord because I thought about all the times that I had convinced myself I didn’t need to be completely honest in my feedback. Phrases went through my brain like, “I’m sure she will get better; it is so hard being a July intern.” Or “It’s impossible to know everything as a third year medical student; I am sure he will fill in that knowledge eventually.”  I spent SO MUCH time in ruinous empathy.   

 

As I began trying out radical candor, I came to see that if I believed in someone’s ability to improve, then I had to be honest about how they could do so. I started framing my feedback by saying “I wouldn’t suggest this to you if I didn’t think you were capable of it.” I think many learners were grateful for the careful attention to how they could improve. 

 

Developing medical education radical candor skills in the residents 

 

For the second year in a row, the Kern Institute has sponsored half-day workshops for incoming residents to allow them time to focus on their skills as teachers. In 2022, interns from five residency programs participated. In 2023, thirteen programs participated.  

 

These workshops focused on two skills: how to make learners feel like they matter and how to give effective feedback. Medical education radical candor skills!  

 

The two sessions on “mattering” this year were run by Karen Marcdante/Rachel Ashworth and Andrea Maxwell/Caitlin Patten. 

 

When the facilitators asked participants to describe times on clinical teams when they felt like they didn’t matter, the interns shared poignant moments that have stayed with them for years. The interns also described times that they knew they mattered. 

 

As I sat through these sessions, I noticed how small things made a big difference toward making someone feel that they mattered: calling them by name, giving them meaningful work to do, asking them about their life. Importantly, it doesn’t take long to establish that you care. You can set the stage in less than a minute, which means you can give honest feedback without waiting days or weeks to assure yourself that learners know you care about them.  

 

After the mattering sessions, interns learned how to give effective feedback. Himanshu Agrawal ran one workshop on feedback this year, and Seth Bodden ran the other. Their frameworks for how to give effective feedback included being timely, actionable, and (of course) honest. As with mattering, the intern participants could recall both helpful and not helpful feedback (“read more,” “good job”). Making time and finding space to give personalized feedback is itself an act of caring. 

 

The concept of radical candor reminds us to show learners that we care and that we must be honest in our feedback.  

 

I would take it one step further and say that giving honest, effective feedback is an extension of our caring and demonstrates our belief in the learner’s potential for flourishing in medicine. 

 

It was so freeing for me to realize that if I cared, then I had to be honest. No more ruinous empathy. Bring on the radical candor.  

 

 

Kathlyn E. Fletcher, MD, MA, is a professor in the Department of Internal Medicine at MCW. She is the program director for the Internal Medicine residency program and co-director of the GME pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.  

 

 

 

 

 

 

 

 

Building a Culture of Health in Health Care and our Community

From the August 4, 2023 issue of the Transformational Times

 

Building a Culture of Health in Health Care and our Community 

Kajua Lor, PharmD, BCACP 

 

We as healthcare professionals and leaders need to recognize that to build a culture of health, we must take off our white coats and meet the community… The neighborhoods we live in, the places we work and play, impact the health of our community…

George Floyd. A Black man who died on May 25, 2020, as a white police officer in Minneapolis knelt on his neck for nearly nine minutes. A name that goes does down in history as a flashpoint of inequities faced by people of color and vulnerable communities. A death captured by a bystander on a video that went viral and sparked one of the largest protest movements in U.S. history, as well as a movement within health care.   

Together, George Floyd and the COVID-19 pandemic revealed the true colors of our broken healthcare systems and the inequities faced by people of color and people disadvantaged by the system.   

 

 

My experience as a Hmong American refugee 

 

As a Hmong American refugee growing up here in Wisconsin, I was oftentimes the only person of color in the room, the only woman in the room, the only pharmacist in the room. I struggled with my identities and many times would feel like I was “lucky,” and I was the “underdog” in many of the spaces that I was in personally and professionally. 

 

Being the “first” and or the “only” person made me question if I could be my own authentic self in the spaces that I was in. Early on in my professional career, I would hide myself and my identities as I felt that showing any vulnerability would mean that I may not be good enough.  

 

Since the COVID-19 pandemic, I’ve learned that life is so precious, that there are so many things to be grateful for, that I can show up as my own authentic self and that I need to know my allies, people who support and are able to create positive influences around me.    

 

When I saw the video of George Floyd’s death, I was shocked, angry and, then, sad. I felt disappointed in humanity. How can I influence change? Where is the love for humankind? What can I do to make things better where I live, work, and play? 

 

I remember a white coworker who said to me, “I don’t understand why those Black people are so angry.” And I thought about my own privilege as an Asian American. Why did they feel comfortable speaking with me? Was it because I was Asian American?

 

I remember being part of a virtual listening circle to create safe spaces to hear from others from the MCW community after the death of George Floyd. I volunteered to participate as a note taker for the circle. I appreciated being a part of this circle as I learned from others in the room about their stories. As the only person of color, I realized that this was a safe space with many allies, raised my “virtual” hand, and said, “As an Asian American woman and leader, I experience microaggressions almost every day at MCW. There hasn’t been one week that I have not had a microaggression.”  

 

Microaggressions happen and are real. Psychologist Derald Wing Sue, who has written two books on microaggressions, defines the term: "The everyday slights, indignities, put-downs, and insults that people of color, women, LGBT populations, or those who are marginalized experience in their day-to-day interactions with people.” 

 

Research has shown that microaggressions, although seemingly small and sometimes innocent offenses, can take a real psychological toll on the mental health of their recipients. This toll can lead to anger and depression and can even lower work productivity and problem-solving abilities. 

 

Some microaggressions I have experienced:  

 

• Patients asking me “Where are you from?”  
• Direct reports seeking recognition from male leadership as my recognition as a woman leader was not “good enough.” 
• After returning from maternity leave, a coworker stated, “hope you had a nice vacation.” 
• A staff member referring to Asian Americans as “Oriental.”  
• After sharing that I was attending a blessing ceremony over the weekend, a colleague saying, “Oooooo! Spooky”  
• A staff member’s written comment about a candidate that they “didn’t speak English good enough.” 

 

Mountain or mole hill? I’ve learned to pick my battles. Will I be working with them in the long term? Is it worth it to say anything?  

 

I learned that one of the officers in the video who was a bystander, watching the death of George Floyd, was Hmong. I remember the hatred toward the Hmong community for letting George Floyd’s death happen. Many Hmong were targeted with death threats. It seemed that there was a perception the inaction by one member of the Hmong community reflected the entire Hmong community. 

 

How do we create change with people who “don’t see color?” How do we change when there are differences in opinion on the approach to building inclusion and belonging? How do we learn from one another and embrace our differences? How can we move forward when we remain behind in the work that we do? 

 

Race was created as a social construct, not a biological construct. 

 

We as healthcare professionals and leaders need to recognize that to build a culture of health, we must take off our white coats and meet the community. 

 

According to the Robert Wood Johnson Foundation, “Building a Culture of Health means working together to dismantle structural racism and other barriers so that everyone has the chance to live the healthiest life possible.” 

 

The neighborhoods we live in, the places we work and play, impact the health of our community.  

 

I’ve learned over the years, working with community, that I can be my own authentic self in the spaces that I’m in and that I need to show up when times get tough as an ally for others. 

 

Each of us has a different story and a different walk of life. We need to embrace each other as humans to be able to “see” one another and develop a deeper understanding -- to learn from one another to be able to move forward.  

 

 

Take action: Practice inclusive leadership  

 

Has the needle moved? Progress has been made; however, the journey has just begun and will continue to be a long one. Many hospitals and healthcare systems have expanded positions and resources to support health equity efforts. Many organizations have provided more budgetary resources and infrastructure in efforts to build health equity.   

 

At MCW, the Office of Diversity and Inclusion developed the Inclusive Excellence Framework. This framework showcases how we all can create communities of safe spaces for others to ensure all feel they belong.   

 

We must develop inclusive leadership skills. Inclusive leadership is defined as “leadership that assures that all community members feel they are treated respectfully and fairly, are valued and sense that they belong, and are confident and inspired.” (“Workplace Inclusion Network – Reflections from our Virtual Roundtables ...”) 

 

Strategies to practice inclusive leadership:  

• Take time to make a personal connection with your team and your patients (if applicable). 
• Develop topic discussions with your team that incorporate inclusive leadership principles. 
• Describe resources for health and well-being. 
• Address fears – listen with empathy. 
• Cultivate compassion for yourself and others.  

 

Spend some time to reflect on equity, diversity, and inclusion:  

• What does diversity mean to me?  
• "When have I or someone else been treated equally, but should have been treated equitably?" (“Discussion Guide DEI: The Basics – Part 1”)  
• Think of a time when you felt excluded. What were your feelings? How did they impact you?  
• Think of a time when you felt included. What were your feelings? How did they impact you?  
• How can I help others to be/feel included? Valued? 

 

Take action:  

In the next month, what one action will I commit to that promotes diversity, equity, and/or inclusion? (i.e., “I will engage in a conversation with someone whose opinions differ from my own.”) (“Discussion Guide DEI: The Basics – Part 1”)  

 

For further exploration: 

 

• This Day in History: George Floyd is Killed by a Police Officer
• Robert Wood Johnson Foundation: Why Build a Culture of Health?

Resources from the MCW Office of Diversity and Inclusion: 

• MCW Office of Community Engagement Introduction and "Quick Links"
• Inclusive Excellence Resources
• Resources to Read and Watch
• MCW Anti-Racism, Equity, Diversity, & Inclusion Glossary

Videos: 

• Reggie Jackson: A History of Race 

Kajua Lor, PharmD, BCACP, is Founding Chair/Associate Professor in the Department of Clinical Sciences at MCW School of Pharmacy. She is a clinical pharmacist at Sixteenth Street Clinic, a federally qualified healthcare center serving Spanish-speaking communities one day per week. Dr. Lor was a fellow of the Robert Wood Johnson Foundation Clinical Scholars Program from 2017 – 2020, a leadership program to build healthier and equitable communities. She is a community-engaged researcher building a culture of health with Hmong refugees.  

 

 

 

 

 

A Reflection on the Impact of George Floyd at MCW

From the July 28, 2023 issue of the Transformational Times

Perspective/Opinion

Has Anything Changed? A Reflection on the Impact of George Floyd at MCW

Precious Anyanwu & Chiemerie Ogbonnaya, Class of 2026

Three years after the murder of George Floyd, medical students Anyanwu and Ogbonnaya offer their perspective on the shortcomings of the American healthcare system, and the racial and ethnic injustices that perpetuate them...

NOTE: Tear gas can be neutralized with about three tablespoons of baking soda mixed with eight ounces of water. It is important to have this mixture in hand before you arrive at a protest because when the gas hits, there will be no time to waste. Remember to carry enough to help wash the eyes of your peers. But most importantly, get out immediately.

This simple recipe has spread from crowds of protestors in Hong Kong to civil activists in Washington DC, all fighting for the preservation of their people.

In the wake of the unjust murder of George Floyd, protesters sought justice at the steps of our government. Instead, they were met with controlled violence in the form of tear gas and police batons. Even with the gas burning their throats, protesters continued to scream for justice. The pain they experienced in that moment was incomparable to the agony of watching yet another Black man lose his life to institutional injustice.

Long before the shocking event that transpired on May 25, 2020, the lives of persons in Black and Brown communities were undervalued and endangered in America. The death of George Floyd, combined with the simultaneous COVID-19 pandemic, amplified how deeply ethnic discrimination and racial inequities are rooted in key American structures. The pandemic disproportionately impacted marginalized communities because of longstanding, systemic inequalities.

Numerous studies have proven that the American healthcare system does not prioritize cultural understanding for ethnic communities. This neglect contributes to an overall decrease in the standard of care and a notable increase in poor health outcomes. Justified mistrust of the healthcare system by these communities is ingrained in history. America’s past is riddled with medical exploitations of racially marginalized communities; recall the Tuskegee experiments and Henrietta Lacks.

The cycle of medical abuse and healthcare avoidance perpetuates chronic illness and shortened lifespans in Black and Brown communities. If American institutions continue to discriminate against marginalized populations under the guise of extenuating circumstances, they will never restore faith in the system and America will remain tainted by its sordid history.

Change starts at the grassroots

Although we have a substantial amount of progress to make as a country, it is important to acknowledge that change starts at the grassroots. In response to George Floyd’s death, the Medical College of Wisconsin implemented several changes to its surgery department centered around prioritizing the principles of diversity, equity, and inclusion.

These changes brought the opinions of marginalized groups to the forefront, introducing pertinent cultural topics that may not have been considered otherwise.

With this seemingly minor adjustment, disadvantaged communities now have advocates speaking on their behalf in spaces that can implement true change. Some cities also chose to pursue action after George Floyd’s passing. For example, Minneapolis reallocated $8 million from its police department to expand mental health crisis response services and Boston chose to invest $12 million into expanding public and social health services.

White Coats for Black Lives

White Coats for Black Lives originated from the national outcry for justice in response to the murder of George Floyd. We aim to safeguard the well-being of our future patients by advocating for the elimination of racialized medicine.

Our ultimate goal is for government officials and civilians across the country to recognize the need for restructuring how America operates fundamentally.

Tangible action against racial inequities is needed. History cannot be rewritten, and the lives lost from injustice cannot be resurrected, but the future can be changed. 

For further reading: 

1. MCW’s Department of Surgery’s response to George Floyd’s death. https://www.mcw.edu/- /media/MCW/Departments/Surgery/DOS-Statement-Racism-Disparities-DSiversity-6-12- 2020.pdf

2. Vasquez Reyes M. The Disproportional Impact of COVID-19 on African Americans. Health Hum Rights. 2020 Dec;22(2):299-307. PMID: 33390715; PMCID: PMC7762908. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762908/

3. Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, Aug. 2021). https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror- 2021-reflecting- poorly#:~:text=The%20U.S.%20ranks%20last%20on,on%20measures%20of%20care%20process

Precious Anyanwu and Chiemerie Ogbonnaya are in their second year of medical school at the Medical College of Wisconsin. They are currently serving as Co-Presidents of the White Coats for Black Lives organization. Their work emphasizes the importance of outreach and intervention to provide a lifelong space for Black and Brown communities in healthcare.

The Right to Breathe

From the July 28, 2023 issue of the Transformational Times

The Right to Breathe

Michael N. Levas, MD, MS

A pediatric emergency medicine physician advocates for comprehensive and compassionate care in the broader context that health is more than biology – that it encompasses people’s lived experience, their trials, their strengths. As a leader of several diversity, equity, and inclusion initiatives at Medical College of Wisconsin, he also reflects on recent shifts he has observed in institutional culture, and reminds health care providers to be mindful of the social pressures that burden patients and colleagues...

“I can’t breathe.”

These were some of George Floyd’s final words, captured in a bystander video. Through this video, we as a nation also witnessed a dying man call out for his mother.

I often see youth who are scared, and some who feel like they are dying, as a pediatric emergency medicine physician who practices at Children’s Wisconsin. They say, “I can’t breathe” and they ask for their mothers. Watching the video of George Floyd, I felt powerless. But in the emergency room, there are situations where I can do something — I can help their difficulty breathing, we can find their mothers and get them to their bedside.

The risk of becoming numb to social injustices is real. It can lead to harmful health outcomes, even death. The continued traumas our nation experiences are seemingly endless.

Mobilization and hope

There has been a movement within MCW to increase advocacy addressing diversity, equity, and inclusion, including the development of DEI councils within residency programs and clinical departments.

For the first time since I was a medical student at MCW (many moons ago), I feel that it is okay to talk about biases, microaggressions, social determinants of health, and health equity.

In fact, health equity has become a theme of many clinical, educational, research and community efforts at MCW. More grand rounds across campus focus on racism’s impact on healthcare outcomes. Trainees are demanding health equity be woven into curricula. There is more acknowledgement that

health is much more than biology – that health encompasses people’s lived experience, their trials, their strengths.

Within the Department of Pediatrics, over 500 faculty and staff have participated in Implicit Bias Training. Other departments have requested this training, including Psychiatry and Behavioral Medicine, Anesthesiology, Physical Medicine & Rehab, the Admissions Committee, the Joint Fellowship Council, among others.

The Comprehensive Injury Center and Department of Pediatrics recently adopted policies recognizing MLK and Juneteenth as holidays by not scheduling recruitment, training, or lectures during those days.

Barriers are real

But two things are clear: inertia is real, and not everyone is happy with such activism. For every stride we make fighting for equity in health outcomes and health education, a counter narrative is threatened by change.

While we are deliberating about what efforts to implement or back as institutions, youth are dying from firearms, families are losing their homes, and transgender youth are losing faith in the healthcare community.

Some changes that need to be made do not require repeated meetings or committees to implement. Unfortunately, our current healthcare environment has become accustomed to that approach, driven by fear of retribution rather than focus on doing what is right.

“The time is always right to do the right thing,” is my favorite quote from Dr. Martin Luther King Jr. We cannot become numb to the trials that our patients face. We cannot ignore the social pressures that burden our patients and colleagues.

Despite continued barriers and bureaucracy, as health care professionals we must continue to model comprehensive and compassionate care. We need to have the courage to use our privilege as health care providers to speak out against social injustices and our expertise to show the evidence-based approaches that lead to less disparities.

Every living human has the right to breathe.

We need to breathe to stay alive.

We need to breathe life into policies that strive for health equity.

We need to help others to pause and breathe before they are threatened by ideas that lean towards justice.

We need to breathe for those who no longer can.

Dr. Michael N. Levas, MD, MS, is a professor of Pediatric Emergency Medicine, Vice Chair of Diversity, Equity, and Inclusion for the Department of Pediatrics, Medical Director of Project Ujima, Associate Director of the Comprehensive Injury Center, Faculty Advisor for the Latino Medical Student Association, and MCW Faculty Advisor for White Coats for Black Lives.

On Inclusion, Diversity, and Why Black Lives Matter, Too

 From the July 21, 2023 issue of the Transformational Times - "A Look Back"

On Inclusion, Diversity, and Why Black Lives Matter, Too: What our MCW Community BLM Protests Mean to our Colleagues of Color

Leroy J. Seymour, MD, MS

Editor’s Note: Dr. Seymour, currently an incoming Chief Resident in Internal Medicine, was an intern at MCW when he wrote this essay for the Sept 11, 2020 issue of the Transformational Times following Black Lives Matter protests on campus in response to the shooting of Jacob Blake in Kenosha, WI. In giving permission for us to re-publish his essay today, he also shared reflections on what has changed, which are captured in a footnote.

On Wednesday, September 2, 2020 at 5:11pm, members of the Medical College of Wisconsin community held a Black Lives Matter protest to help shine a light on the frequent propensity for violence against people of color. This latest protest is one of hundreds of protests against police brutality and racial injustice that have been occurring in various cities, states, and countries, most recently triggered by the murder of George Floyd on May 25th 2020, in Minneapolis, MN.

So many people have demonstrated peacefully and expressed their voices, all vying for the same dream Martin Luther King Jr. expressed to the world. Almost every aspect of the world’s population has provided an overwhelming outpouring of support of the Black Lives Matter movement; taking the baton and relaying the message that “Black Lives Matter, too” to widespread media coverage and the political stage.

MCW faculty, residents, and medical students alike raised their voices in support of the Black Lives Matter movement. This stance informed the world that MCW and the Froedtert medical community will not tolerate racism, and that racism itself is a pandemic that needs to be eradicated. The Sept. 2nd protest involved holding seven minutes of sustained silence, each minute representing every bullet aimed at the back of Jacob Blake, an African-American man returning to his vehicle, by Rusten Sheskey, a Kenosha WI police officer.

Mere seconds after violence left a man paralyzed, the world responded with outrage and exhaustion, yet another example of the unfair mistreatment of people of color when interacting with those with a perceived position of authority.

Many of us have protested these injustices before. I've protested it before. Our parents protested it before. Our grandparents protested it before. Our ancestors survived and protested it. I’ve stood face to face with the Ku Klux Klan, neo-Nazis, and individuals who have all decided that racial slurs and anger were the best response when asked why they hate people of color or different sexual orientation.

Nobody should have to be afraid to walk outside or live in their own homes. People should not be judged by the color of their skin or their sexual orientation, but by the content of their character. People of every ethnicity, background, or creed, should not have to be afraid for their lives when interacting with police.

With the many communities, committees, social circles, and groups that I belong to, I can single-handedly attest to the importance of diversity, the inclusive nature of MCW, and why having people of varying backgrounds, experiences, and cultures is so critically important to both the health of a community and a medicine brain trust.

As a new internal medicine resident and as an African American, I have witnessed firsthand the most beautiful sides of humanity, and the darkest corners of vitriol. I have cared for patients who have been incredibly appreciative and receptive of my presence, feeling more at ease with talking about their privileged information because I am a person of color. I have also had patients turn me away for the exact same reason.

When I wanted to become a physician, I made a lifelong commitment to improving and protecting my community. I’ve vowed to provide a safe haven for those without a voice, to be a vanguard in the face of hatred, to be the lighthouse in someone else's storm. But when it is you, your family, your friends, or your community who is being harmed, harassed, and violently mistreated, it takes that community to heal the hurt.

It is hard to sustain a thriving and supportive community if that same community refuses to break bread with a particular subset of the population, even when everyone shares the same table.

I am proud to belong to a program and institution that takes a hard stance against institutionalized racism and is incrementally rolling out educational opportunities for those interested in, and in need of, anti-racism education. It is comforting to know that my colleagues and peers support the Black Lives Matter movement and understand the deeper inclusive meaning behind the statement.

However, supporting the movement is only the first step of a marathon many have been running for years. With many cities in various countries now protesting the same cause, only time will tell if our collective voices have resonated, and what changes will result from our collective stance against institutionalized racism and racist ideology.

Myself, my colleagues, and my peers at MCW have already decided which path we will walk, and that is hand in hand with our flourishing, diverse, and inclusive community.

July 21, 2023: I can look back at this essay with pride, as much as it saddens me that it came out of such intense anger for someone else’s suffering. It has been important to my healing to be part of many Diversity and Inclusion efforts at MCW since this was written. Much has been done, but our community isn’t perfect, and there is still much more to do. I am very proud to have been part of organizing events at the American Black Holocaust Museum in Milwaukee for incoming interns a few short weeks ago, and also attended and supported medical students there last fall, during programs that helped others better understand the experience of this historically under-represented population, and how this can frame our approach to providing better medical care. I think it is also remarkable that Juneteenth is now a National holiday, this is progress – Leroy J. Seymour, MD MS

Leroy J. Seymour, MD, MS, is a chief resident in the Department of Medicine at MCW. 

Reflecting on My Journey to Women’s Health Care a Year After Dobbs

From the July 14, 2023 issue of the Transformational Times - One Year post Dobbs

Reflecting on My Journey to Women’s Health Care a Year After Dobbs

Amy H Farkas, MD, MS

Dr. Farkas shares her longtime passion and perspective on the advances and freedoms in women’s health care, both locally and globally, as the nation marks one year since the Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization ended the constitutional right to abortion...

My path to women’s health care began in 9th grade world geography class. Mr. Nickels required us to report on a current world event each week, which meant I often found myself reading the world news section of the Kansas City Star. One day, as I read a story about the treatment of women by the Taliban in Afghanistan, I found myself wishing I could do more to help women around the world. Recognizing that I would not be traveling to Kabul any time soon, I decided to call my local Planned Parenthood to volunteer. I honestly can’t remember if I even knew what Planned Parenthood did, other than I had a vague understanding they were active in women’s health care and were a lot closer than Afghanistan.

My first job as a volunteer was to learn about local anti-abortion groups, specifically the Army of God, an organization known for acts of violence against abortion facilities and clinicians. I was shown pictures of known members in hopes that I could pick them out from the mostly peaceful protestors. Within a few weeks, I was the Saturday morning clinic escort. My main job was to stand opposite the protesters who showed up each Saturday and be a friendly face to women who were coming for care. Most Saturdays it was just me and the security guard standing across from five to fifteen protestors who were yelling and holding signs.

My time as a clinic escort was mostly uneventful. The police would frequently drive by and sometimes park across the street until everyone had gone home. But there were incidents of violence, real and threatened. One day, the clinic had to close when all its windows were shot out. Another day, it closed when someone committed suicide in the parking lot in protest. My fellow escort had a rock thrown at her head. Most staff at the facility had their pictures published on the internet by anti-abortion groups, and my picture might have been out there, too.

I remained a volunteer for Planned Parenthood throughout high school. In college, I founded a chapter of Planned Parenthood’s student advocacy organization. While I entered college as an international studies major, my time with the student advocacy organization grew my passion for women’s health care and specifically, reproductive care. It inspired me to pursue medicine.

I was fortunate in medical school to meet another educator, Dr. Melissa McNeil, a general internist, and leader in women’s health, who became my mentor. Throughout medical school, residency, and fellowship, she helped foster my knowledge and skills in clinical women’s health and the practice of academic medicine. She also connected me to the VA.

Since I began working at the VA in 2018, I have become convinced there is no other healthcare organization in the US more committed to serving women’s health care needs. You may find this surprising, given the military and VA's reputation for being male dominated.

Yet, women Veterans represent the fasting growing demographic group within VA, and the VA invests in their care across all its missions. It supports women’s health fellowships for physicians, researchers, psychologists, and nurses. This, in turn, helps grow the next generation leaders in academic medicine and women’s health. It funds research in contraception, maternal mortality, intimate partner violence, and breast cancer. It offers targeted educational programs for primary care teams, including physicians, APPs, and nurses to ensure they have the skills necessary to provide comprehensive, gender-specific care.

And in the post-Roe v. Wade world, the VA committed to ensuring women Veterans have access to the full range of reproductive health, including access to abortion care to “promote,preserve, or restore the health” of Veterans.

To achieve this goal, educators will be key to success. Educators will be the ones who translate government policy into clinical practice. They will teach clinicians who likely have never engaged in pregnancy options counseling and certainly not abortion care to provide compassionate and comprehensive reproductive health care. This change at VA will take time, and there are many pieces left to be figured out. But the VA's commitment to women’s health gives me hope that in the post-Roe world, medicine will not allow six justices to define health care.

The VA’s commitment to all aspects of women’s health care takes me back to my early passion to serve women’s health, both locally and globally. Thankfully, American women have far more options than were allowed to their counterparts living under the Taliban, both then and now. I am reminded that the advances and freedoms in women’s health remain only when we fight for them.

As a physician and educator, I can do my part in my clinic with my patients and in the classroom with students by helping to ensure the next generation of physicians have the necessary skills to provide comprehensive care to women. I’m grateful to have the VA as an ally in my own work to ensure health freedom for women.

Amy H Farkas, MD, MS, is an associate professor of Medicine at the Medical College of Wisconsin and works clinically as a women’s health primary care physician at the Milwaukee VA Medical Center. She also serves as faculty at the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, where she is Director of the KICS program and part of the GME Pillar.

Navigating Difficult Terrain One Year After Dobbs

From the July 14, 2023 issue of the Transformational Times

As Predicted, Things Have Gotten More Complex: Navigating Difficult Terrain One Year After Dobbs

Adina Kalet, MD, MPH and Elizabeth (Libby) Ellinas, MD, MS

It has been a year since the US Supreme Court ruled in Dobbs vs. Jackson Women’s Health Organization. As director of an institute dedicated to the transformation of medical education with character, caring, and competence and the leader of our institution’s Center for the Advancement of Women in Science and Medicine, we are monitoring the cascade of consequences these changes are having. We continue to believe that robust discussion, dialogue, and debate surrounding this complex issue is essential. In this spirit, we once again invited a range of authors to share their perspectives with the Transformational Times ...

In the June 24, 2022 issue of the Transformational Times, anticipating that the US Supreme Court would overturn federal protections of access to abortion, we predicted that the healthcare landscape would become more complex. We have not been disappointed. This ruling has already had significant nationwide impact. The intended and unintended consequences continue to evolve.  

The legislative pot continues to roil. Abortion is now illegal in thirteen states with a few going as far as criminalizing health professionals for offering abortion care. Sixteen states have voted to affirm some sort of abortion rights, with Michigan, California, and Vermont making abortion access part of their constitutions. As of June 13, 2023, nearly 700 abortion bills had been introduced, split evenly between those that would expand and those that would restrict access. This has significant implications for medical education and the health of the public. 

The Dobbs decision is affecting where physicians train and work

Physicians, as a group, are strongly committed to preserving professional autonomy. Independent of party and religious affiliation, data demonstrate that we suport ensuring patients receive the best individualized care possible. To the extent that physicians see abortion bans as interfering with the doctor-patient relationship—which is built on the trust that there will be absolute respect for privacy, confidentiality, and a commitment to shared decision making—physicians may choose to practice in places where they can share with their patients all available reproductive healthcare options.

In a recent survey of physicians (Vinekar, 2023), 82% of respondents reported that they preferred to work or train in states with preserved access to abortion. Seventy-five percent of both physician and trainee respondents report that they would not even apply for a job in a state that imposed legal consequences for providing abortion care. Early data from this last national residency match show fewer applications to residencies in the most restrictive states (across all specialties), although the residency program “fill rates” remain stable. There has been 5% drop in the number of students applying for OB/Gyn residencies. While it will take years to see how these trends manifest, they are especially worrisome for underserved rural states and urban areas already at risk.  

In states with strict abortion bans, access to healthcare was falling prior to the Dobbs decision. These are states with the fewest physicians per capita and places where rural hospitals have been closing at alarming rates over the past decade. Wyoming, Mississippi, West Virginia, and Kansas already lose more than 40% of college graduates to other states. This “brain drain” is predicted to worsen if young people perceive that their personal autonomy is threatened. 

One in four women in America will need a pregnancy-related procedure during her lifetime. As of August 2022, 44.8% of accredited OB/Gyn residency programs are in states moving to ban abortions. This means that a significant number of physicians who are committed to providing OB/Gyn care will need to travel to learn to do routine procedures. This has implications for medical education and health care nationwide. 

Medical education and physician organizations are advocates

In June 2022, the AAMC released a statement regarding the Dobbs decision, predicting that it would “significantly limit access for so many and increase health inequities across the country, ultimately putting women’s lives at risk, at the very time that we should be redoubling our commitment to patient-centered, evidence-based care that promotes better health for all individuals and communities.” In the ensuing year, the AAMC’s Group on Women in Medicine and Science (GWIMS) and Medical Education Senior Leaders (MESL) have create a joint Reproductive-Health Task Force which produced a white paper (look for it soon on the AAMC Reproductive Health web page), and a series of webinars to discuss those consequences to reproductive health. You can access a recording of the first webinar here and sign up for the second webinar, which looks at the Dobbs’ decision’s effect on education here.  

The AAMC is taking a data-driven approach to the effects of Dobbs on medical students, residents, and residency selection. The Task Force is considering adding two questions to the Graduate Questionnaire that is completed by all students as they finish medical school; those questions would assess whether and how the Dobbs decision influenced their choice of specialty and location. The AAMC sees reproductive health under Dobbs as “complex and challenging for patients, providers, and learners” and will continue to provide support to the academic medicine community as we continue to navigate that complexity.

Jesse Ehrenfeld, MD, MPH, the newly-installed President of the American Medical Association and a member of the MCW faculty, reiterated in his inaugural speech and in an interview, the AMA’s position. “Let me state unequivocally that we oppose strongly the interference of government in the practice of medicine. And we oppose strongly any law that prohibits a physician from providing evidence-based medical care that is in the best interest of their patients.” 

In our essay one year ago in the Transformational Times, we acknowledged that our salaries and status would allow us to travel out of state if we or our families ever needed restricted care, a privilege to which many others do not have access. Many, including the American Bar Association attest to this “exacerbation of wealth disparity.” In addition, not all insurance policies pay for contraception or abortion. These potential out-of-pocket expenses—plus travel, childcare, hotels, and meals—add up, and are prohibitive for many, especially when emotionally-fraught decisions must be made quickly, work issues managed, and resources gathered. In response to this need, some companies now offer abortion travel coverage for employees in states with restrictive laws, decreasing the costs for employees at those companies. 

Preparing our students to be adaptable and engaged 

Times like these—defined by rapid change and complexity—can lead us to be both weary and wary. To care for our patients and educate our students, we need to monitor rapid changes in law, practice, and local regulation. This can make us weary. When the issue is as controversial as abortion, many of us become wary of being drawn into contentious, difficult conversations. However, we know that if physicians do not engage, the public will be worse off.  

Abortion is only one of many controversial, increasingly politicized concerns that will impact the practice of medicine over the coming era. To support our future healthcare professionals to flourish and lead, we will need to help them (and us) learn to adapt to—rather than simply comply with—rapidly evolving and challenging situations. 

Learning adaptive behavior requires intellectual skills best built through facilitated civil discourse. Woodruff (2023) at the Pritzker School of Medicine at the University of Chicago, developed a Growth Oriented Pedagogy aimed at enhancing adaption and based on a rigorous form of civil discourse. The curriculum prepares trainees to face complex real-world problems (such as well-being, career choices, and diversity, equity, and inclusion), and engages them as individuals in grappling with and learning to adapt to complex challenges. The pedagogy they have developed is both highly conceptual and pragmatic. It guides students to maintain their strong connections with the meaning and purpose in their chosen work, especially as the environment around them is undergoing rapid change. 

The Kern Institute’s Philosophies of Medical Education Transformation Lab (PMETaL), building on the work of Woodruff, is working to develop frameworks for, and faculty development to, support implementing such a growth oriented, civil discourse-based pedagogy for our new school of medicine curriculum.  

As healthcare providers, our opinions matter and we must communicate effectively to both policy makers and the public. In order to do so, our immediate work must include preparing students and physicians to engage in respectful and intellectually rigorous conversations that effectively cover difficult terrain. By doing so, we will improve the health of our communities, care for ourselves, and preserve the autonomy of the profession for future generations.  

For further reading:

Mengesha B, Zite N, Steinauer J. Implications of the Dobbs Decision for Medical Education: Inadequate Training and Moral Distress. JAMA 2022;328(17):1697–1698. doi:10.1001/jama.2022.19544

Grover A. A Physician Crisis in the Rural US May Be About to Get Worse. JAMA 2023;330(1):21–22. doi:10.1001/jama.2023.7138

Verma N, Grossman D. Obstacles to Care Mount 1 Year After Dobbs Decision. JAMA. Published online June 23, 2023. doi:10.1001/jama.2023.10151 

Vinekar, Kavita MD, MPH; Karlapudi, Aishwarya BS; Nathan, Lauren MD; Turk, Jema K. PhD, MPA; Rible, Radhika MD, MSc; Steinauer, Jody MD, PhD. Projected Implications of Overturning Roe v Wade on Abortion Training in U.S. Obstetrics and Gynecology Residency Programs. Obstetrics & Gynecology (August) 2022; 140(2):146-149. | DOI: 10.1097/AOG.0000000000004832

Woodruff, James N. MD1; Lee, Wei Wei MD, MPH2; Vela, Monica MD3; Davidson, Arnold I. PhD4. Beyond Compliance: Growth as the Guiding Value in Undergraduate Medical Education. Academic Medicine (June) 2023; 98(6S):S39-S45. | DOI: 10.1097/ACM.0000000000005190

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.

Libby Ellinas, MD, MS, is Professor of Anesthesiology, Associate Dean for Women’s Leadership, and Director of the Center for the Advancement of Women in Science and Medicine (AWSM) at the Medical College of Wisconsin.

The Measure of a Medical School: Who Gets In and What They Choose to Do

 From the July 7, 2023 issue of the Transformational Times

The Measure of a Medical School: Who Gets In and What They Choose to Do

Adina Kalet, MD, MPH

In this week’s Transformational Times, we share highlights from the Second Annual Equity in Education Summit co-sponsored by the Kern Institute and the Office of Student Diversity and Inclusion in April 2023. Dr. Kalet reminds us why we need to conference regularly to negotiate our social mission ...

 

A medical school addresses its social mission through its admission policies/practices, curriculum, and generational investments. In the US, medical education is a scare resource. Overall acceptance rates lately are around 43%, with some individual schools accepting fewer than 5% of applicants. Since almost all medical students who matriculate will eventually graduate, we have the awesome privilege and responsibility of composing the physician workforce through our selection of medical students from among a rich pool of academically qualified candidates. 

How should we decide who gets in? 

Honoring our social mission as a medical school is neither easy nor simple. We are expected, through our social contract, to align our educational, research, and service activities so that they address the health concerns of the local, regional, or national community we serve. But societal needs are vast, complex, and ever evolving. So how, year after year, do we consistently compose a class and educate future physicians who will attend to the health of the community and leave it better off? 

It is too simplistic to rely only on academic metrics to determine a candidate’s merit. That approach is not fair. The Medical College Admissions Test (MCAT) scores and undergraduate Grade Point Averages (GPA) are valuable when identifying the pool of students able to handle the academic rigor of the earliest stage of medical education, but numeric criteria predict neither who will make excellent physicians nor who will serve medicine’s social mission by practicing in diverse geographic locations or choosing specialty training based on the needs of the community. We need to be thoughtful when deciding who will fill our ranks.

Decades of rigorous research demonstrate that combinations of personal attributes can predict long term choices. Characteristics—such as gender, race, ethnicity, community of origin, and parental socioeconomic status—are associated with personal experiences of overcoming adversity and correlate with careers that address societal needs. 

Health care workforce diversity is a critical determinant of health equity

Despite commitments made to the principles of diversity, equity, and inclusion, US medical schools fall short of achieving racial-ethnic or socioeconomic representation of the general US population among their student bodies. While race-conscious admissions policies are now prohibited as a matter of federal law many, if not most, medical schools have implemented holistic reviews of applicants. This is a mission-aligned selection processes that takes into consideration the “whole” applicant, including how they would contribute to the learning and practice environment and what career choices he or she might make. 

Who “deserves” to be a physician? We need to learn from history

Try this experiment. Ask anyone hailing from a culture (like mine) that reveres the medical profession, “How much pressure were you under to go to medical school?” There is often a lot of pressure! Access to medical education is seen as a social good in and of itself, besides being highly valued by applicants, their families, and their communities. It is a path to economically security and a high social status career. Some medical schools explicitly embrace a responsibility for providing an avenue for intergenerational social mobility as part of their social mission, and many applicants are highly motivated to seek admission to medical school as a way out of poverty or as a path to an “American way of life” for immigrants. 

As historians, economists, epidemiologists, and sociologists have elucidated, there have been many structural barriers keeping certain, identifiable groups out of medical education. Despite being very proud of our tradition of social mobility, American medical schools have a long and inglorious histories of socially-sanctioned discrimination by gender, religion, and race. 

Things have improved, but there is still room for improvement. Images from each medical school class at MCW and our predecessor institutions line the main floor hallways. A quick study of these photographs confirms that the number of women and underserved minority graduates began to increase only in the most recent decades. 

As a matter of social justice, we make commitments to provide pathways to educate individuals from communities historically excluded from higher education and the professions by investing in “pipeline” programs.

Continuing to educate the economically privileged, well-mentored, and informed students is easier and less costly in the short term. But successful strategies to address access to health care and disparities in health outcomes, as well as access to careers in the health professions, require significant long-term investments and a willingness to innovate and enliven current practices. Among many other things, this will include selecting students from communities that struggle with healthcare needs, locating programs in such communities, providing trainees with significant exposure to primary care settings, ensuring a robust social determinants of health curriculum, and ensuring social accountability and public service across the institution. 

UC Davis has shown that best practices can align admissions with social mission 

The medical school at University of California at Davis—a state where race conscious affirmative action has been illegal since 1996—is an exemplar of a school with a comprehensive mission-based admissions process. This school has accomplished unprecedented student body diversity, socioeconomically (35% qualify for the AAMC Fee Assistance Program, for example) and in race and ethnicity (55% of students are from groups who are underrepresented in medicine). They have done so by investing in significant outreach and recruitment and by using rigorous data-based strategies, including a socioeconomic disadvantage score which systematically assigns a value to a student’s lived experiences of economic or educational disadvantage as a proxy for grit, resilience, and perseverance, balancing these indicators of success as physicians with the traditional academic performance data. 

In addition to these alternative metrics, these schools use structured approaches to interviewing applicants (e.g., multiple mini-interviews) which have been demonstrated to be less biased and have proven to be predictive of success in clinical settings. They work closely with local colleges and academic enhancement programs. They support community-based pre-health initiatives and integrate otherwise siloed pathways to health professions programs. Through this coordinated and deliberate suite of approaches, UC Davis is more likely that other schools to educate physicians who will commit to serve their home communities. In this way, they fulfill their stated social mission.

Medical College of Wisconsin has made generational investments to attract students who will address our social mission

Tackling complex long standing challenges such as health disparities and poverty require sustained effort and a long-term outlook. At MCW, under the leadership of President and CEO John Raymond and Julia A. Uihlein, MA, Dean of the School of Medicine, Provost, and Executive Vice President Joseph Kerschner, we have made significant investments to boldly align our medical school’s practices with a bold social mission. For example:

MCW is committed to increasing its impact in Wisconsin’s rural regions:

With robust community collaboration, we have built two regional campuses, MCW-Central Wisconsin in Wausau and MCW-Green Bay. At these campuses, centered in communities with severe health care access challenges, the admissions policies and practices are in place to attract and select a class that will be motivated and educated to serve the community. Admissions procedures meaningfully involve community representatives, there is significant community outreach, and pipeline programs and highly innovative medical school curricula are tailored to ensure that a high proportion of graduates will want to serve as generalist physicians in these rural areas where the need is stark and projected to worsen. 

MCW is committed to increasing its impact in Wisconsin’s urban regions:

MCW is partnering with the Greater Milwaukee Foundation, in the Thrive On Collaboration, to restore, repurpose, and anchor the former Gimbels-Schuster’s building on Martin Luther King Boulevard. Situated at the intersection of three urban neighborhoods on the North side of Milwaukee (Halyard Park, Harambee, and Brewer’s Hill), this “place based” investment focuses on bringing economic, social and health benefits to communities that struggle with significant health disparities. When the building opens, within the next year, hundreds of MCW faculty, researchers, staff, and students (including representatives of the Kern Institute) will take up residence in the building and conduct highly engaged community work, including medical student education and pipeline programs. In collaboration with the Dean’s Office and the Thrive on Collaboration, the Kern Institute is building a Health Equity Scholars Program for medical students committed to careers that address health equity (more to come!). 

Did you catch our vision? 

If medicine is to be equally effective and responsive to all people, regardless of where they live, who their parents are, or what they have, we have to change who becomes a physician and how they are trained. That is ingrained in the mission of the Kern Institute. Medicine, one of the oldest professions, needs to be socially accountable by engaging in regular self-examination. 

We must innovate, implement, and continuously update meaningful, substantive policies and practices that make measurable changes for the people we educate and in the lives of the people we pledge to serve with caring and character for generations to come. 

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.