Transforming Health Care and Health Professions Education in Times of War, Pandemic, and Disaster: Lessons from Two Founding Mothers

 From the 5/7/2021 newsletter

Director’s Corner

 

 

Transforming Health Care and Health Professions Education in Times of War, Pandemic, and Disaster: Lessons from Two Founding Mothers   

 

 

By Adina Kalet, MD MPH

 

 

This week, the Transformational Times celebrates National Nurses Week with contributions from MCW nurses and nurse practitioners. Dr. Kalet reflects on the lives and contributions of the founding mothers of the modern nursing profession, and how they remain exemplars of the character, caring, persistence, and grit needed to emerge from the COVID-19 pandemic with a health care system that is both more humane and scientifically cutting edge …

 

 

As a little girl, I was enthralled with biographies. I read a slew of stories with simplified messages where the “(s)hero” triumphed over adversity, had eureka moments, left the world a better place, and – usually - lived happily ever after. Two of these stories have stuck with me. Clara Barton and Florence Nightingale, both self-educated, 19^th century nurses, profoundly transformed health care and health professions education during times of crisis.  

  

Two amazing, transforming women

Clara Barton - a American public-school educator, humanitarian, and abolitionist who knew Susan B. Anthony, Frederick Douglass, and several presidents - is recognized for being remarkably clinically innovative in the face of scarce resources and overwhelming need during and after the Civil War. For her omnipresence and habit of reading to and writing letters for wounded soldiers, she was known as the “angel of the battlefield.”  Barton went on to found the American Red Cross and establish its preeminence in international disaster response and relief starting with the horrific Johnstown Flood of 1889.

Florence Nightingale - an upper-class British social reformer - became an icon of Victorian era British society for her work organizing care for wounded soldiers during the Crimean War. At the time, she was dubbed, “the lady with the lamp,” for her tireless, ever present, compassionate, and attentive individualized care to those in need. The image was sensationalized in the press, but Nightingale’s true brilliance was as a statistician, epidemiologist, and transformative educational leader. Her "Diagram of the causes of mortality in the army in the East," a complex pie chart defining the field of hospital epidemiology, was a remarkable distillation of data that remains among the first health infographics (along with Charles Joseph Minard’s “Napoleon’s March to Moscow Map”). Her work is credited with driving dramatic reductions in deaths from hospital acquired infections long before the discovery of antibiotics. For this intellectual accomplishment, she should be, but is not, called the mother of medical informatics. 

Barton and Nightingale were unlikely leaders. They shared the experience of nursing very ill family members early in their lives. As privileged women from wealthy families, they were likely expected to marry well and raise families but, because they were both unusually well-educated and independent, they forged their own paths. They each had rare access to political influence. They carried deep convictions about social justice issues and displayed unusually fierce empathy and compassion for the poor and oppressed. They both were “out of the box” thinkers, unafraid of hard work, eager to try new things, meticulous and scientific in their methods, and able to persuade others to support and join them in their work. They both served bravely under awful wartime conditions for extended periods of time, and continued to serve faithfully through long, productive careers despite obstacles, challenges to their leadership, and their own personal quirks (Barton was known to be “difficult”). Both remained single and, as far as I can tell, supported themselves through their work (I ordered a few books and will let you know).

The same years Clara Barton was designing, funding, supplying, and running mobile battlefield hospitals, Nightingale was establishing the first secular nursing school in the world at St Thomas' Hospital in London. Although each was a prolific writer and lecturer, they never met but likely did know of each other’s work.

In honor of their legacies and brilliance, newly minted nurses all over the world take the Nightingale Pledge on graduation and Clara Barton remains among the most celebrated of American women of all times, both as a nurse and as a leader. 

  

Who will lead us through the post-COVID-19 transformation?

Why tell these stories during National Nurses Week (which begins on May 6^th and ends on Nightingale's birthday on May 12^th)? Is it because I am a feminist history nerd?  Perhaps, but I also see them as role models for anyone who seeks to do the transformative work that will surely emerge from the COVID-19 pandemic.  Cataclysmic events, such as wars and pandemics, can accelerate innovation and change in both health care and education, but only with the right kind of leadership.

 

The COVID-19 pandemic is not a war

The national zeitgeist in spring of 2020 made us all want to celebrate the mighty battles against the virus and the heroism of our health care professionals and frontline workers. As a society, we look to our COVID-19 heroes the way the Victorians raised up the “Lady with a Lamp” or the “Angel on the Battlefield.” Those of us working away from the front lines express gratitude for the sacrifice of others.

But, if we stop to reflect, war imagery only partially defines what has occurred. Medicine is not a war. Most physicians, nurses, respiratory therapists, first responders, and other essential workers went to work because they had to, because that was what they were trained to do, and because that is what everyone expected. Our front line friends and colleagues remain vulnerable human beings that are called to head into the unknown, not in armor, but in PPE. Many of our colleagues experienced real consequences of their dedication.

We mourn those who became gravely ill or died. Too many colleagues suffer lingering physical, spiritual, and moral distress. As such, we must pledge to support our colleagues as they rest, recover, and take stock. I hope we can help them heal.

 

 MCW Nurses inspire

As Louis Pasteur reportedly said, “luck favors the prepared mind.” There is no doubt that there are many well-prepared Clara Bartons and Florence Nightingales out there who will emerge from our global pandemic experience and become leaders. We must provide them resources, break down barriers, watch them grow, and celebrate their work. Health care professionals are exquisitely prepared, well-educated, persuasive, and able to step up, serve, take advantage, and innovate when opportunities arise.

COVID-19 has already provided many opportunities. For some local examples, read Clinical Nurse Specialist Jennifer Popie’s inspiring description of about how the Froedtert & the Medical College of Wisconsin nursing leadership honors the exhausted staff members who persist, innovate, inspire, and provide compassionate care as the pandemic rages through the ICUs. Be prepared to be humbled by the vaccination clinic experiences of volunteer nurses, and consider joining Kelly Ayala, DNP, BSN, in a Hack-a-thon to address access to care issues.

 

 Thanks to our nurses!

For this year’s National Nurses Week, I personally extend my respect and appreciation for my hard-working nurse colleagues and family members (my brother, sister-in-law, and brother-in-law). I know it has been a remarkably difficult year and, despite all the spectacular innovation, it is not over yet. When the history of this time is written, I believe we will say with pride that we knew the heroic nurses and staff who showed up and, in the spirit of Clara Barton and Florence Nightingale, saw a need, pitched in, educated and rallied others to care for those who were suffering and created long lasting transformative institutions.  I know for a fact that our nursing colleagues make us all better because they showed up.  

 

 

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.

The MCW School of Pharmacy’s COVID-19 Immunization Program

 From the 4/23/2021 newsletter

Some questions for …

 

 George E. MacKinnon III, PhD, MS, RPh - MCW School of Pharmacy

 

 

The MCW School of Pharmacy’s COVID-19 Immunization Program

 

 

In what ways was the MCW School of Pharmacy well-positioned to quickly ramp up a response to the call for COVID-19 immunizers? 

Dr. MacKinnon: The School of Pharmacy ran several influenza clinics on the MCW Milwaukee Campus that well prepared faculty and student pharmacists to respond to the call for immunizers, albeit these were very small operations. In the fall of 2020, under the leadership of Professor Karen, MacKinnon, Director of Outreach in the School of Pharmacy, we expanded the influenza clinics and opened them to more individuals of MCW (all students, staff, and faculty). The intention was that these clinics would serve as the prototype for the COVID-19 Immunization Clinic for MCW. The MCW School of Pharmacy joined with the MCW Office or Research (led by Ann Nattinger, MD, MPH, Associate Provost for Research, Senior Associate Dean for Research, School of Medicine) to jointly lead the creation of a COVID-19 Vaccination Clinic on our Milwaukee Campus to administer the COVID-19 vaccine beginning December 22, 2020.

All eligible MCW student pharmacists are trained early in their education to administer vaccines, including the COVID-19 vaccine. They also receive training in the Doctor of Pharmacy (PharmD) program in point-of-care testing such as nasopharyngeal testing for coronavirus and strep throat testing, and thus were an asset to our clinical partners for COVID testing these past 12 months. Additionally, many of our pharmacy faculty have been trained in immunization administration over the years. Thus, we had a cadre of internal pharmacists and student pharmacist that were able and willing to participate in COVID-19 vaccine administration.

Pharmacists have expertise in planning for vaccine procurement, storage, distribution, preparation, administration, post immunization monitoring, and record keeping. Fortunately, the School of Pharmacy had just jointly hired Kristin Busse, PharmD, BCPS with the Office of Research when the pandemic emerged in early 2020. She came to us with years of experiences in investigational drug services at Froedtert and was an ideal pharmacist to lead the vaccine procurement and preparations (complying with all regulatory issues at federal and state levels for the emergency use authorization (EUA) vaccines that were to be released).

 

How quickly did you decide that you needed to be proactive with the Wisconsin state legislature to change the rules for oversight and delivery of vaccine? What was that process like?

Dr. MacKinnon: When we began to develop our PharmD curriculum in 2015, we identified that we would be unable to include immunization training early on in the program and had to wait until the second year of the program. We did meet with MCW Office of Government Relations but realized that this was a statutory change needing intervention from the state legislature. Over the past four years, we also met with the Pharmacy Society of Wisconsin (PSW) expressing our desire to gather support as we believe that having a state statue dictate the timing of curriculum delivery in a PharmD Program is overly prescriptive, limiting, and antiquated.

As it became apparent that in late 2020 a COVID-19 vaccine would likely be available, we again brought up this topic with PSW and brought the other two schools of pharmacy in the state into the discussion. Our position was simple, during a pandemic, when all appropriately credentialed providers are needed, such arbitrary distinctions would hinder our full deployment of life-saving vaccines now and into the future.

During this process we also requested an additional language change that would allow student pharmacists to be supervised by any health care provider authorized to administer vaccines (e.g., nurses, physicians). As was previously written in statute, a student pharmacist must have been overseen by only a pharmacist in the administration of an immunization. In fact, we used LCME accreditation language to help support our position and draw an analogy to medical education. With the Legislature’s bipartisan bill and the Governors approval, our suggested changes were enacted in late February 2021. Thus, we have been able to support a team-based approach to healthcare in concert at the regulatory and professional levels, at least with respect to immunizations.

 

When the next pandemic arrives (as it likely will!), what will we do differently?

Dr. MacKinnon: Certainly, there were identified process improvements along the way. The clinic, while conceptually the same in December, has grown and matured to an efficient operation. This sentiment was echoed by the many individuals that came to staff the clinic or be immunized. The credit to this goes to the blended teams from the MCW Office of Research (led by Dr. Nattinger) and the School of Pharmacy (led by Dr. MacKinnon) via the MCW COVID-19 Vaccine Program Team Leads as follows:

Vaccine and program logistics:

Leads: Kristin Busse and Lisa Henk

Clinic Supervision and orientation:

Leads:  Karen MacKinnon and Susan Mauermann

Scheduling and planning:

Leads: Jayne Jungmann and AshLeigh Sanchez

Reporting and maintenance of records:

Leads:  Jen Brown and Theresa Dobrowski

Personnel Eligibility and Invitations:

Leads: Katie Kassulke and Ann Nattinger

MCW COVID Administrative Response Team:

Leads: Dan Wickeham and Adrienne Mitchell

As the vaccine goes through the phases of roll-out into our communities, the role of a pharmacist is critical, as pharmacists have specific knowledge about immunization and pharmacists’ accessibility can help address issues surrounding vaccine hesitancy in the public. We need to continue the public health discussion surrounding the value of all immunizations to preventing diseases, disability and death.

 

What reactions did you get from the SOP students, faculty, and staff to the process? 

Dr. MacKinnon: The School of Pharmacy mission is to: Advance the health of our communities through innovative pharmacy education, continuous public and professional service, and diverse scholarly collaborations. So, our desire to contribute to abating the pandemic was right in line with our mission all along.  We were able to get 100% participation from our faculty and staff. With respect to engagement, overall, there were 95 individuals (faculty, staff and students) from the School of Pharmacy that contributed over 4,500 hours in clinic over the 45 days of clinic operations.

 

 

What surprised you most in all of this?

Dr. MacKinnon: Two things in particular stand out, though none as real surprises but rather gratitude.  

First was the initial influx of staffing for the first phase of the COVID-19 Clinic from School of Pharmacy faculty, staff and student pharmacists and staff from the Office of Research over the typical holiday break. Many individuals changed their personal plans to staff the clinic. As time went on many individuals were putting in 12-hour days at the clinic and catching up on their regular responsibilities on weekends, it became apparent that more assistance would be needed. Student pharmacists needed to return to classes and faculty had responsibilities to attend to as well. This is when the entire MCW campus rallied to support the clinic with medical students, having been trained in immunization, joining forces with physicians, nurses, physician assistants, and medical assistants as immunizers. There too was an outpouring of support from the basic sciences as individuals with the requisite technical skillset and experiences were able to prepare the syringes filled with vaccines.  

Next was the outpouring of support that came from all members of the extended MCW Community including Board members and the significant others and family of faculty and staff. Frankly people had been isolated for so long because of the pandemic and they just wanted to do their part to assist in the clinic. We welcomed them with open arms. Everyone’s contributions were essential to so many tasks that needed to be accomplished including the planning, delivery and ongoing operation of the Clinic. 

As the saying goes, culture eats strategic planning every day for lunch. Thus, we can plan and strategize all that we want, but the culture of collegiality and respect that we initiated through the COVID-19 Immunization Clinic is what emerged that allowed us to be successful. This developing culture will have a long-standing impact to MCW in years ahead as it emerges into a health science university. I am certain that the COVID-19 Immunization Clinic will be a defining moment in this transformation internally and externally as others in the community recognize what a resource and gem that MCW is to all.

 

George E. MacKinnon III, PhD, MS, RPh, FASHP, FNAP is the Founding Dean of the School of Pharmacy and Professor of Pharmacy at MCW.

 

 

Implementation Science and Medical Education Transformation

 From the 4/23/2021 newsletter

Perspective/Opinion

 

 

Implementation Science and Medical Education Transformation

 

 

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

 

 

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

 

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

 

Why are we talking about Implementation Science?

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

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

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

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

 

What is Implementation Science?

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

 

Basic Stages of Implementation Science

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

 

Exploration – Needs, Options, and Partners

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

 

Installation - Who, What, When, and How

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

 

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

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

 

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

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

 

Sustainability - Financial and Programmatic

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

 

Attending to People and Culture

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

 

 

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

 

 

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

 

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

 

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

 

 

Transforming Today’s Medical Learners Into Tomorrow’s Global Health Leaders

 From the 4/23/2021 newsletter

Perspective/Opinion 

 Transforming Today’s Medical Learners Into Tomorrow’s Global Health Leaders 

Lee Ann Lau, MD, FACS

Dr. Lau describes the GME Scholars in Global Health Program, a two-year voluntary curriculum for residents interested in exploring issues of global health equity...

We have all witnessed the global nature of health through the lens of the current pandemic. It is timely that our globally engaged faculty along with the Medical College of Wisconsin Office of Global Health have started a new training program for residents and fellows to build character and competencies to enhance care for patients and their communities. 

Reviewed and supported by MCWAH’s GME Committee, the GME Scholars in Global Health program is a two-year curriculum created to teach global health principles and concepts to residents and fellows. It is designed to cultivate cultural sensitivity, allowing the Scholars to appreciate the global burden of disease and understand how they can use their specialty training to collaborate to address health care inequities and improve access to care from neighborhoods to nations. With multi-disciplinary interactive didactics and biannual deeper dive seminars, the program will emphasize leadership and networking while developing global health skills and knowledge.

The inaugural cohort includes thirty-seven residents and fellows from twelve medical and surgical specialties. Many Scholars are new to the field of global health, but some already have extensive experience they wish to strengthen. During the application process, GME Scholars expressed a desire to incorporate global health skills and knowledge into their future careers. Gaining a broader perspective on how cultural, psychosocial, and economic factors impact the illness and injury experience and outcomes was noted as a priority to provide better care, both locally and globally. Scholars also noted interest in research and obtaining a better understanding of how environment and infrastructure impact care delivery.

 The Scholars are invited to compliment the core curriculum with other experiential learning activities during MCW’s Global Health Week and by participating in the Consortium of Universities for Global Health Virtual Capitol Hill Day, which includes teaching for how to effectively engage legislators.

To launch the new training program in January 2021, the Scholars participated in a discussion about the definition of global health, led by Dr. Stephen Hargarten, Associate Dean for Global Health; and Tifany Frazer, Office of Global Health Manager. The group reviewed the Biden-Harris Administration’s Statement on Global Health Security and considered what recommendations they would make if given the opportunity to influence the new administration’s global health agenda. Not surprisingly, the cohort’s main priority was COVID19 treatment, pandemic management, and vaccine distribution. However, they raised many other important issues including health care equity, rejoining the World Health Organization, addressing climate change, promoting maternal fetal health, and infectious disease research, as noted in their combined word cloud.

The curriculum is co-lead by Drs. Mac Longo, Radiation Oncology; and Ashley Pavlik, Emergency Medicine. Evaluation lead is Dr. Stephen Humphrey, Dermatology; and scholar development lead is Dr. Steve Hargarten, Associate Dean for Global Healtha. The program receives input from eighteen faculty members from more than ten specialties who have dedicated their content expertise to the training program. The didactic lectures and discussions will include a wide range of topics with a global health focus, including noncommunicable diseases, travel medicine, global EMS and disaster medicine, tropical dermatology, private/public partnerships, trauma care, imaging considerations, and eye disease. This rich learning environment will foster the passion and creativity needed for tomorrow’s global health leaders, strengthening their competence, care, and character.

For questions about the program or to apply, please contact the Office of Global Health Manger, Tifany Frazer at tfrazer@mcw.edu.

 Lee Ann Lau, MD, FACS, is currently completing the Hospice and Palliative Medicine Fellowship at MCW after spending 13 years in private-practice general surgery. After graduation, she is planning to start a faculty position with MCW in the Department of Medicine’s Division of Geriatrics and Palliative Medicine.

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.