Advice for Surgical Residents

From the 7/9/2021 newsletter

 

Perspective/Opinion

 

Advice for Surgical Residents

 

Compiled by Bruce H Campbell, MD FACS

 

Dr. Campbell, who entered a surgical field decades ago, asked his current residents what they have learned to keep themselves whole and able to function despite living in high-stress times and working under pressure. Here is some of what he learned from them, and about “grit” in surgical residents …

 

 

What sorts of things have surgical residents discovered that allow them to survive as trainees? Here is a list from current otolaryngology residents (and their friends):

• Everyone expects surgeons to be arrogant. Surprise people in a good way.

• Ask the right questions and listen carefully - often this will tell you more about a patient's condition than any test or image can.

• Get to know your patients beyond their chief complaint.

• Learn to understand and appreciate the environment that your patient came from, and you will glean so much more. “For the secret of the care of the patient is in caring for the patient.” - Francis Peabody (“The Care of the Patient,” JAMA 1927)

• Listen to the nurses. Learn their names. They are the ears, eyes, and heart of the floor. They spend more time at the bedside than any physician or care team member.

• Be forgiving of yourself and your colleagues. We all have one common goal, and that is to provide healing and nurturing for our patients.

• Mistakes are an inevitable part of medicine. Always be honest, show empathy, and commit yourself to a lifelong endeavor of learning.

• Practice self-care. “Just as a car can’t go as fast on a flat tire, you can’t give your best effort if you aren’t mentally, physically, and spiritually running on all cylinders." - U.S. Surgeon General Jerome Adams

• Find yourself a good pair of shoes. This will take you far, literally!

• Do not forget why you are doing what you do. Our profession is unique, people trust us with their lives, and we cannot take that for granted.

• Do not forget that each of your patients is a person first and a patient second.

• Informed consent is a process and a relationship, not a piece of paper.

• Stay up-to-date on your administrative paperwork and be kind to the residency program coordinator.

• Always act in the best interest of the patient.

• Stay humble.

• Just keep showing up even when you feel like you’re not doing well. It always gets better.

• See the patient before calling a consult.

• Stay current on your surgical case logs.

• Before ending any conversation with a patient, always ask, “Do you have any other questions?” That usually elicits their deepest concern.

• Knowing when to operate is at least as important as knowing how to operate.

• Balance humility and ego. It’s not easy. 

• Remember to enjoy simple wins and to learn from loss.

• Sleep when you can, eat when you can. 

• Wipe your feet of the day before you walk into your home to greet your family. 

• Be an organized junior resident but ask for help. Remember you’re human, too.

• Each patient is experiencing something at the same time you are, so even if this is your hundredth consult of the night at 3:00 a.m., try to bring compassion to the encounter. 

• Remember, at the end of the day, you are a team.

• Check for speckles of blood on your scrubs, booties, face, and mask before going to talk to patients’ families.

• Surgical training is uniquely stressful. Stay self-aware. Reach out for help. Watch for warning signs in others.

• Know your stuff, do the right thing, and ask for help when you need it.

• Don't forget to engage in things that make you happy, as residency will trick you into thinking success must cost you joy.

• Residency can unmask underlying vulnerabilities.  Don't be afraid to lean on your co-residents (and even attendings), either professionally or personally. 

• An ICU consult is better than a rapid response, and a rapid response is better than a code.

• There are two kinds of residents: the ones who write it down, and the ones who forget.

• Trust no one, expect sabotage, and always have a backup plan.

• Stay current. There is no glory in being technically adept and doing the same, wrong operation every day for the next thirty-five years.

 

On a related note, a recent article in JAMA Surgery confirms that grit, as a personality characteristic, is a good thing. Grit is defined as “perseverance and passion for long-term goals,” and is measured with a standardized GRIT-S questionnaire that asks about a person’s ability to concentrate on a project, their reaction to setbacks, their constancy in pursuing goals and interests, their self-identified work ethic and diligence, and their ability to thrive in the face of challenges. General surgery residents with higher “Grit” scores were less likely to report burnout, thoughts of leaving their training programs, concerns about their career choice, and suicidal ideation than residents with lower Grit scores. Grit scores were higher in women, more senior residents, and in married residents. The authors recommended that programs do what they can to bolster their residents’ grit.

Surgeons have unique roles and responsibilities in society; what can compare to the trust someone displays by allowing another human being to render them completely defenseless and then rummage around their insides? As an institution, it is our responsibility to prepare our residents to enter the world as character-driven, compassionate, and skilled surgeons.

Thanks to my “gritty” residents for sharing the lessons they have learned.

 

Bruce H Campbell, MD FACS is a Professor in the Department of Otolaryngology & Communication Sciences and in the Institute for Health and Equity at MCW. He is editor-in-chief of the Transformational Times. 

Top Ten Tips for Thriving During M3 Clerkships

From the 7/9/2021 newsletter

 

Perspective/Opinion

  

Top Ten Tips for Thriving During M3 Clerkships

  

Compiled by Scott Lamm

 

 Mr. Lamm and his colleagues offer some sage advice to the incoming third-year medical students …

  

• Be proactive! Pay attention on rounds and create a to-do list for each patient. Instead of asking for tasks from your resident, let them know what tasks you are comfortable with doing and if it is okay for you to complete them.

•  For Surgery – invest in a pair of compression stockings. Your feet at the end of the day will thank you.

• It’s okay to say, “I Don’t Know.” No one knows everything, and this gives you an opportunity to do the research and look it up for the next time you are with your attending or residents that asked the question.

• Nurses and CNA’s are your best friends. They know the patients better than anyone. Talk with them each morning. Update them after rounds. They will be very appreciative.

• Know what you are charting! If you copy forward a note, ensure that everything in that note is something you did that day. You will most likely not do a comprehensive physical exam every morning, so ensure you only chart what you did.

• Children’s’ Cafeteria Buffalo Chicken Ranch Wrap is the best! On nights, you can get it toasted mmmmm… Also, Children’s’ breakfast is the best pick me up in the morning after a call day.

•  Learn from your patients – they are the experts in their own life experiences. You will have a lot more time to devote to each of your patients than the residents, so spend the time. You will be surprised at how a good relationship can help the team exponentially.

• Calling consults can be nerve-wracking – write down the most pertinent points, lab values, and imaging results so you don’t forget them. Consultants will be very impressed when you have this information right away instead of making them search the EMR after the call.

•  Make sure to eat! Time moves fast and it’s easy to forget about lunch. A working mind requires a happy belly. Bring snacks, meal prep.  Sometimes it may feel like there’s no time in between cases or after rounds, but two minutes is enough to scarf down a granola bar.

• Have fun! Third year is full of surprises. There will be good days and there will be bad days. Step back and reflect when you have the chance. The connections you will make with attendings, residents, and especially patients will transform you are a physician. Step into each rotation with an open mind.  And do not hesitate to ask for help.

 

Sincerely,

The Class of 2022

 

 

 

Scott Lamm is a fourth-year medical student at MCW and member of the Transformational Times editorial board.

 

Advice for Incoming Housestaff

From the 7/9/2021 newsletter

 

Perspective/Opinion

  

Advice for Incoming Housestaff

 

 By Jennifer Popies, MS, RN, CCRN-K, ACNS-BC; and Ashley Herman, BSN, RN, CNRN

 

 Ms. Popies and Ms. Herman give advice to incoming housestaff from the nursing perspective…

 

Jennifer Popies:

• DO ask the nurse caring for your patients about their perspective on what is going well and what any outstanding needs are that they see should be addressed – this goes a long way in building true collaboration!

• DO bring food for the nurses on the floor you are most frequently working with – this also goes a long way to building true collaboration J!

• DO use order sets to help guide your patient management – many disciplines have spent a long time on each one trying to help make sure best practices are incorporated.  You can always tailor it to your patient’s needs, but use it to your advantage to help ensure best care so things don’t get missed!

• DO clean up after yourself when performing bedside procedures.  Nursing staff does enough “cleanup” for other reasons in the process of patient care!

• DON’T be afraid to say you don’t know something!  Everyone is human and nurses (and others) will respect you more for knowing your limitations.

• DON’T forget to take care of yourself – and if you need to talk, you can reach out to a nurse, a social worker, a chaplain, etc….it doesn’t just have to be a fellow MD!

 

 

Ashley Herman:

 

Some advice to residents and fellows that come into the NICU that I have learned in the many years in the ICU:

• We are all about the “team” approach and want to do the best for our patients. It’s important to get a multidisciplinary approach to cares for a patient so that it is well-rounded care.

• Always give your rationale about things, especially if the nurse questions the reasoning for things. Most nurses just want to know the “why” behind things and aren’t just trying to be difficult. Nurses love new knowledge. Healthcare is always transforming, and nurses like to hear the most updated evidenced-based practice/research.

• Have open communication with different teams and welcome their expertise.

• Communicate any changes to the nurse if he/she isn’t in the room while you are updating families. Many times, the family/patient relies on the nurse to explain further about information and it’s always best when the nurse isn’t surprised hearing new information from the patient about what the doctor discussed.

• We all deserve respect…times can be tough and emotions can run high, especially in the ICU. If there is miscommunication or words spoken in the heat of the moment, it isn’t weakness to say, “I’m sorry.”

• You can always win nurses over with snacks, haha J.

• Keep things “light” when appropriate, laughing is always the best medicine when the shifts are long.

 

Thank you and welcome to everyone!

 

Jennifer Popies, MS, RN, CCRN-K, ACNS-BC, is a Clinical Nurse Specialist – CVICU at Froedtert & the Medical College of Wisconsin.

 

Ashley Herman, BSN, RN, CNRN, is a Neuro ICU Educator at Froedtert & The Medical College of Wisconsin.

 

 

 

Reflections on New Beginnings

From the 6/18/2021 newsletter

Perspective/Opinion 

Reflections on New Beginnings 

By Olivia Davies, MD; and Brieana Rodriquez, MD 

 Drs. Olivia Davies and Brieana Rodriquez reflect on moving cross county to begin their new journeys for residency… 

Dr. Olivia Davies: 

I have lived in Wisconsin for most of my life. I did undergrad at Madison and medical school at MCW, when I shut the door on my 20-foot U-Haul and locked it for the long drive out to Boston I couldn’t believe I had fit my whole life in there.

But the truth is, I hadn’t. Leaving Wisconsin meant we were leaving my family and my fiancé’s family behind. When we arrived in Boston, I was nervous, would our apartment look like it did in the photos? Would the movers arrive on time? Would our couch fit? It did, they didn’t, it didn’t. I cried. I wanted to go home. My couch didn’t fit and neither did I. This busy city felt new, too new, and not mine. I woke up from a mattress on the floor the next day and reluctantly pulled on my tennis shoes, we had no food yet and I knew I just needed to go for a walk. I walked for hours that morning, a croissant here, a coffee there, I started to recognize streets I passed, I saw my new hospital, I realized the river path was five minutes from our apartment door and I let a long sigh out. I thought it might actually be ok. And it was.

Dr. Brieana Rodriquez: 

My “most extreme” feelings about moving across the country happened before I left. After match day I was so excited to start a new chapter of my life. I was ready! But after classes had finished and I had already bought my new house I was in this weird limbo state. The best way I could describe it was I felt like I had closed the Wisconsin book, but I wasn’t allowed to open the South Carolina book. My anxiety about moving was at an all-time high but it wasn’t because I was scared, it was because I wanted to move but couldn’t. But since I’ve gotten here there’s been nothing but excitement! Meeting my co-residents (and realizing I’d be able to make more best friends) has been so much fun! Exploring a new city has been so cool! When moving cross country for medical school I learned so much about myself. I grew so much personally and I’m ready to start experiencing that again. One of the reasons I chose to rank MUSC #1. Side note: I know the anxiety about starting work is going to kick in soon, but it hasn’t yet. 

Olivia Davies, MD, begins her Dermatology Residency at the Harvard University Combined Program on July 1st in Boston, MA. During her time as an MCW medical student, she was an associate editor of the Transformational Times. 

Brieana Rodriguez, MD, begins her Emergency Medicine Residency at the Medical University of South Carolina on July 1st in Charleston, SC. 

From Medical Student to Trusted Physician: Growing with a Confident Humility

 From the 6/18/2021 newsletter

Director’s Corner

 

 

From Medical Student to Trusted Physician: Growing with a Confident Humility

 

 

Adina Kalet, MD MPH

 

 

Dr. Kalet shares one of the “hidden” tasks that each new resident is facing: the need to develop competence without risking becoming overconfident. She shares some of the pitfalls and invites our newest house staff to be part of the journey.

 

 

This is the time of year when thousands and thousands of newly minted physicians move somewhere to begin residency training. At MCW, we welcome all our new residents, many of whom are moving to Milwaukee for the first time. This is a poignant, anxiety-provoking, and exciting time, a new beginning, and a critical transition on the journey of becoming a seasoned and caring physician.

 

Incoming residents are embarking on the steepest leg of their learning curves. Not only have many of them just moved to a new city, found a new home, and located a new grocery store, each new day brings them an avalanche of firsts: the first patient, the first procedure, and the first time they need to find the cafeteria or the bathroom or the emergency room. Many important components of their new professional identify will take shape in these first summer weeks. Our newest physicians will work to discern how best to balance confidence and humility. Getting this equilibrium right is crucial, and I think MCW is an especially wonderful place to foster this process.

 

The difference between confidence and competence

As physicians on the front line, residents are expected to develop enough confidence to quickly analyze data, make crucial decisions, and act decisively. Think about how difficult and fraught that task can be! We want physicians to make critical judgements under emotionally charged and complex conditions. Even drawing blood for routine laboratory testing (a task interns do daily) means facing an anxious, fearful, suffering person, and causing them some pain. Confidence is critical, yet—to ensure that our teams provide the highest quality and safest health care—we stay on the lookout for overconfidence in ourselves and in others because of the complex and paradoxical relationship between confidence and competence.

The Dunning-Kruger effect, described in 1999, elegantly summarizes this complexity. Stated simply, people with low ability tend to overestimate their competence and, therefore, become overconfident. Conversely, people with high ability tend to be underconfident in their ability. Even worse, poor performers are often unable to recognize their own limitations, and overconfidence is especially pronounced for those at the lowest end of the ability scale. As ability improves with practice, confidence, paradoxically, can take a nose-dive because the difficult journey can create humility and self-awareness. This sense of deflation can feel terrible at the time but, in the long run, is good since it can lead to insight and growth.  

Numerous studies have confirmed that humans are just not good at objectively evaluating their own level of competence, but by honing one’s own metacognitive awareness or being observant—like a scientist—of one’s own thinking and feeling, a novice can guard against using his or her own confidence as an indicator of competence. As teachers, we must avoid making our trust judgements based on a trainee’s confidence alone. As Ronald Reagan was wont to say, we must, “Trust but verify.” Confidence is good, but we must guard against allowing our feelings of confidence to blind us to our own ignorance.

 

 

“Confident humility”

 

In his new book, Think Again: The Power of Knowing What You Don't Know, organizational psychologist Adam Grant reminds us how critical it is to cultivate a mindset “confident humility.” From this stance, one can act even when they are not certain of what is right, but they act with a scientist’s curiosity and perspective, seeking evidence that might refute their current beliefs. Grant reviews the accumulating evidence that intelligence does not protect us from common human foibles. In fact, many researchers have pointed out that smarter, more tenacious people (like many medical students and residents) are prone to blindness to changing conditions and may have a harder time adjusting to new circumstances. They have difficulty admitting when they are wrong. Stubborn, inflexible physicians will run into obstacles when trying to provide competent, character-driven medical care.
 
If, however, a hypothesis survives repeated attacks, it becomes the working theory until such time as it can be disproven. Approaching one’s own competence in this rigorous way—repeatedly challenging beliefs and understandings—keeps a person humble, curious, adaptable, and learning. It is the key to deep, durable, and lifelong learning. 

 

The remarkable value of working in an institution defined by confident humility

 

Like many of us, I am a transplant from elsewhere, having arrived barely two years ago. I have traveled extensively and have lived and worked in other institutions in the northern and southeastern United States. To my delight, I have come to know MCW as a uniquely confident, humble place to work and learn. It is remarkable to me—given the excellence in clinical care and research—how little our institution tolerates the everyday self-promoting arrogance typical at many of our peer institutions. This institutional culture is a towering strength and I believe is one of the many reasons we have adapted and thrived for a century and a quarter. 

As Mark Twain warned, “It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” Adam Grant points out that a hallmark of wisdom is knowing when it’s time to rethink and collect data that might refute and, therefore, cause you to abandon what you think you know and who you think you are. This habit of honest reflection and an openness, or even a delight in learning when you are wrong, is a path toward a deeply satisfying confidence. It’s true in business and especially true in medicine.

 

So, to our incoming house staff, I say, “welcome!” You have several difficult tasks ahead, not the least of which is to master your chosen field. You will grow as you learn to work in teams, experience ambiguity, become lifelong learners, and bring your intellect and compassion together to tend the sick and heal the suffering. You will thrive if you tend to your own wellness and character. These are huge tasks responsibilities. We wish you all the best and are here to support you.

 

 

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.

 

 

 

 

 

 

 

Maintaining your Principles while Moving from One Institution to Another

 From the 6/18/2020 newsletter

Questions for John Raymond, MD

Maintaining your Principles while Moving from One Institution to Another

John R. Raymond, Sr., MD is the President and CEO of MCW. He was born and raised in northeastern Ohio and received his medical degree from The Ohio State University. He completed his residency training and nephrology fellowship at Duke University before joining Duke’s faculty. In 1996, he moved to the Medical University of South Carolina (MUSC), performing research, caring for patients, and serving as chief of nephrology at the Ralph H. Johnson VAMC, eventually rising to become Associate Provost for Research and, finally, Vice President for Academic Affairs and Provost. He was recruited in 2010 to became MCW’s sixth President.

Dr. Raymond has changed institutions during his celebrated career. He recently spoke to Transformational Times editor, Bruce Campbell, about the process of moving and starting fresh.

Transformational Times: What it was like for you to move from South Carolina to MCW?

Dr. Raymond: The move was exciting. Since I grew up in northeast Ohio, moving to Wisconsin felt a lot like coming home. I spent twenty-eight years in the Carolinas, first at Duke and then at MUSC. The people there are great, but the south has a different feel and culture. Moving back to a place that felt more like home was wonderful. It was also exciting to come into the new role here and build on the types of positions I had held before.

Like most people, taking on so many new responsibilities initially led to a sense of “Imposter Syndrome.” There were certainly some early challenges. Before long, though, I settled in and found a supportive, dedicated community.

Transformational Times: In what ways is MCW unique and/or different from other institutions where you have worked?

Dr. Raymond: I learned that people at MCW are unusually modest, and that the institution has many programs could be characterized as having “understated excellence.” Folks are doing wonderful work yet, throughout MCW, I have found that people don’t like to brag and often avoid personal accolades. There is a sense that we all want to do the right thing with a deep sense of collegiality and civility. This trait is culturally deeply engrained. People at other institutions seem to be more likely to seek the limelight.

This natural modesty and natural inclination toward teamwork and mutual support has been a good thing, especially as the institution and country have experienced unprecedented stressors and challenges in the past months. We have a natural proclivity to work together and foster each other’s success.

In addition, I find that the structure of our academic medical center requires me to spend much more of my time intentionally managing relationships than was needed at either Duke or MUSC. I have worked hard to invest in relationships across our partner institutions, sharing perspectives, and intentionally identifying and pursuing shared goals.

Transformational Times: What have you learned about effectively acclimating to a new institution?

Dr. Raymond: With each major move during my career, I tried to remember to be a good listener. I was always asking questions. I made certain that I tried to learn from my experiences every day.

I also worked to identify with my new institution and fully invest in my new opportunities. I found it was rarely helpful to start a sentence with, “But at Duke…” or “We always did this at MUSC.” Those approaches don’t help. I quickly identified with MCW as “us,” rather than as “you.” This allowed me to be curious, engaged, and ready for challenges.

My pathway to the presidency was not traditional since many people in positions like mine have previously been medical school deans or senior department chairs. My background was in running the research enterprise at MUSC and serving as a VA service chief. I think my experiences gave me valuable perspectives into what institutions can and should offer to its wide range of stakeholders and constituents both inside and outside the university.

Transformational Times: Talk about your work with the state’s government.  

I had significant experience working with local and state governments at MUSC where as provost, I also served as a key legislative liaison. Here is Wisconsin, we have had frequent and productive contact with the governor’s office (both with Governor Walker and Governor Evers), the State assembly, the State senate, municipal and county officials, and leaders from both political parties. It is fair to say that Wisconsin’s political landscape is highly partisan. Nevertheless, leaders of both parties have demonstrated strong commitments to MCW and our roles in protecting and improving the wellbeing of the state’s citizens. Our regional campuses and residency programs have also cultivated supporters in other parts of the state.

We are not shy about letting political leaders know what is important to us, but we take a long view perspective of issues. We work behind the scenes when needed. I know that approach can appear hesitant at times, but it has allowed us to be effective and serves us well in the long run.

Transformational Times: What core principles have you worked most diligently to retain with each move?

Dr. Raymond: With each move, I have worked to get to know the institution. For example, I was a reader for Richard Katschke’s new book, Knowledge Changing Life: A History of the Medical College of Wisconsin, 1893-​2019. Highly recommended.

With each move, I re-committed to sharpening my active listening skills and to remembering that no one ever comes to a new job with all the answers.

I realized that I represent the institution with what I say and do. My words and my values have meaning. I strive to be candid, truthful, and respectful. I want to be seen as a leader who has, and acts on, an internal core of integrity.

I have always tried to deliver maximum value to all our stakeholders, including our students, staff, and faculty, as well as our institutional and community partners.

Finally, I have worked hard to show that, as a health sciences university and community partner, we are here to serve others. We must remember we are our best selves when we serve our neighbors who are experiencing disproportionate burdens of disease and who are affected negatively by the social determinants of health. Our allocation of attention and resources must demonstrate that we know that it is critical to serve our communities with compassion.

Transformational Times: What has surprised you?

Dr. Raymond: The process of moving brings mostly positive things. I am always surprised by both the breadth and depth of individual and collective talent when I explore a new institution. I am surprised by the joy of making new personal connections. Those aspects are fun and rewarding.

Recently, I have also been surprised by how our friends and colleagues at MCW reflect the divides that our community and country are also experiencing. The profound, fractious and political divides we see on television also exist here. A diversity of thought and opinion is good for a university, but we must encourage exploration, growth, conversation, and reconciliation. These issues are deeply political for some, and there are many people who feel unwelcome and uncomfortable expressing their points of view. I hope that can change.

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

From the 6/18/2021 newsletter

Three Questions for Dr. Deepthiman Gowda

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Painting: Dreaming of Home

 From the 6/11/2021 newsletter

Dreaming of Home

Kathleen Monahan, DO 

Kathleen Monahan, DO is a chief resident in the Department of Medicine at MCW.

Remember your residency family

 From the 6/11/2021 newsletter

Guest Director's Column

Remember your residency family

  

 Alicia Pilarski, DO

Kathlyn E. Fletcher, MD MA

 

 Doctors Alicia Pilarski and Kathlyn Fletcher share with today’s residents how their own experiences during residency led to lifelong, supportive, and important relationships.

  

From Dr. Fletcher:

 June is a time filled with so much nostalgia and excitement.  There are so many endings in June.  But of course, endings almost always make room for beginnings. This weekend, I (KF) had a Zoom call with members of the graduating class of 1996 from the University of Chicago’s Pritzker School of Medicine.  How can it have been twenty-five years since I graduated?  But that ending made way for the beginning of my residency which would ultimately become the most formative years of my professional life.  

I remember snippets of my own intern orientation week. In one particular memory, I was sitting on the 7^th floor of the hospital in the Internal Medicine residents’ respite area.  I was in the room that I would go to daily for three next years for morning report.  On that day, I looked around at my class of twenty-five interns, eight of whom had graduated from medical school with me and four of whom were my closest friends of the past four years.  We were doing an ice breaker meant to help us get to know each other, and I thought to myself, “Why am I doing this?  I already have plenty of friends in this program.”  Clearly, I had a lot to learn about the village needed to get me through residency.

Those four people remained close friends throughout residency and beyond; in fact, two of them were at my 50^th birthday party last year.  However, many of the others profoundly influenced me as well.  To call those who walk beside you through residency “friends” seems to be a gross underrepresentation of the role they play.  Co-residents are very much like siblings.  They are part of the daily rhythm of life.  They also bear witness to extraordinarily difficult moments, days, weeks.  My own co-residents ate ice cream with me when I needed it even when they didn’t (thanks Reggie!), patiently double checked my calculation of the rate of hypertonic saline for an obtunded hyponatremic patient in the ICU (thanks Jeff!), and cried with me for patient and other losses during those three years (thanks Erin!).  They debriefed, advised, bolstered, and encouraged.  They were my family.

 

From Dr. Pilarski:

 I (AP) had an incredibly similar experience to Dr. Fletcher during my time in residency. The highest highs and the lowest lows were shared with my seven other Emergency Medicine (EM) residents. Getting my first solo intubation during a code on the floor and celebrating with a margarita that night (thanks, Peter!), late nights in the Trauma ICU trying to keep our sickest patients alive (thanks, Troy!), and experiencing my first medical error and having my co-chief there to help support me through it (thank you, Josh!).

One of my fondest memory was when we created a calendar of photos that we gifted to our faculty and the ED nurses upon graduation. Clearly, we believed our faculty and nurses would always remember us as the “best” EM residency class, and so we felt it was our responsibility to remind them of that fact for at least the next year. We staged photos in various locations throughout the hospital and around town, many of which resulted in hysterical situations and additional photos that were deemed “too inappropriate” for the final product. At the end of the day, our faces hurt from smiling and laughing so hard. But then it became very real that our time together was ending, and in a few short days we would be spread out across the country in new emergency departments. I tried to manage the excitement about the next chapter in my career with the immense sadness I was feeling from being separated from my residency family that I had formed such a unique and special bond with over the past three years. I worried that the bond we had created would be lost to distance, new colleagues, busy schedules, or elapsed time. But I knew it was time to move on for all of us. 

We stayed in touch for the first year via text and then, slowly, our chats became less frequent. It was bound to happen, right? But then, COVID hit. And on March 16, 2020, our first group text in several years started that bond all over again: “Checking in with all of you. We are just starting to get hit with COVID. Thinking of all of you and hope you are all staying healthy.” What followed were numerous texts about our fears and anxieties, what each of our respective EDs and hospital systems were doing, what PPE we had, how we would decontaminate after a shift, how we planned to keep our families safe, and what we knew about this novel virus. And then we shared pictures of our kids, dogs, ourselves in N95s and CAPRs, and other funny pictures from when we were in residency (including some from that calendar we made!). And those texts continued through the year and into this year. They are now more focused on celebratory messages and pictures of things like vacations and group photos with friends.

We had gone through another immensely stressful, challenging, and formative phase of our lives again. What I came to realize was that distance, new jobs, busy lives and time did not break that bond. It was always there this whole time, and it was stronger than I could have ever imagined.

 

In this issue of the Transformational Times, we hear from three graduating residents who tell their stories of the formative experiences of residency, what they learned and what they hope to carry forward.  Like all of us who persevered through residency (or another professional equivalent), they had personal journeys marked by small and big moments.  We also hear from Dr. Ken Simons, who leads the GME enterprise at Medical College of Wisconsin Affiliated Hospitals.  He offers a poignant reflection on the last sixteen months and how that time has shaped the worldviews of all of us, especially the residents.  Finally, Dr. Eric Holmboe, from the Accreditation Council of Graduate Medical Education, offers additional insight into what to carry forward from residency.  There is even a piece of original artwork for you to contemplate.  We hope that you enjoy it!

To all the graduating residents across MCWAH, we are incredibly grateful for your work during residency.  You have healed patients, listened to families, taught students, comforted each other, and grown personally and professionally.  Whether you believe it or not, you are ready for this ending and the beginning that follows it.  Remember your residency family and lean on them when you need to.  Know that many people are proud of you and believe in you.  We can’t wait to see how you move our profession toward the ideal we all know is possible.   

 

Alicia Pilarski, DO is an Associate Professor of Emergency Medicine, Associate Chief Medical Officer of Froedtert Hospital, Co-Pillar Director for Kern Institute GME Pillar, Co-Medical Director for the F&MCW “Supporting our Staff” Peer Support Program.

 

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

 

 

Words of gratitude, encouragement and strength from the Senior Associate Dean for Graduate Medical Education

 Freom the 6/11/2021 newsletter

Perspective/Opinion

 

Words of gratitude, encouragement and strength from the Senior Associate Dean for Graduate Medical Education

Kenneth B. Simons, MD

 

Dr. Simons, MCWAH Executive Director & DIO, MCW Senior Associate Dean for Graduate Medical Education and Accreditation, offers this message of congratulations and best wishes to all of the residency and fellowship graduates, reminding them that, while their knowledge and skills are important, it is their humanity, compassion, and caring that their patients and families will remember …

 

The journey of a thousand miles begins with one step.

Lao Tzu

 

The journey of becoming a physician is a difficult one; quite understandable given the importance of what the responsibilities are. Thus, completion of the residency or fellowship training portion of this journey in “normal” times is a remarkable achievement. In extraordinary times such as this, it is a feat of incalculable proportions. You, the 2021 graduates of our 98 ACGME accredited programs along with our non-accredited GME programs have been tested like no other prior graduates. The COVID-19 pandemic was your crucible and pushed you in every possible way. Professionally, while your didactic education became virtual, your responsibilities to be physically present to care for patients never did, other than some telemedicine encounters. You wore your PPE as battle armor and you came to work every day to do what you were born to do; care for the sick who required your expertise and more importantly, use your compassion as you learned and practiced your craft under the supervision of faculty. Some of you in fulfilling your responsibilities to patients actually developed the disease, and we are all very grateful that you survived in contradistinction to the 597,000+ dead in the US and 3,730,000+ worldwide.  And to your great credit and remarkably, more than 95% of you received one of the vaccines, demonstrating to your patients and the world that science is real and that it matters.

 

Beyond having to deal with a viral pandemic, something that hadn’t happened in more than 100 years, you also had to deal with our country’s latest and critical reckoning with health care inequities and systemic racism. America’s shameful legacy of slavery and the institutionalization of racist behavior was placed on international display as a result of the murder of George Floyd which fortunately, was filmed by a brave 17 year old woman, assisted by others who watched and confronted the officers who forsook their oath to protect and serve, something you never have and would never do, given each of you took an oath to care for all who come to you in need of your expertise. Mr. Floyd was not the only black person who was killed or maimed this past year as a result of excessive force by police and racist thugs and it is incumbent upon us to remember all of them. In addition, you witnessed a rise in violence against our Pan-Asian community as a result of the pandemic and the hateful, ignorant rhetoric spewed by some “leaders.” Through it all, you did the right thing for patients, your communities and yourselves. You participated in peaceful demonstrations, you knelt for nearly nine minutes, you wore pins that said Black Lives Matter and others with rainbows, demonstrating to everyone that you cared about your fellow human beings in a committed, real way and that diversity, equity and inclusion aren’t just words in a mission statement, but words to be lived by in a visible, tangible way, each and every day.  As you leave here, it is incumbent on you to continue making society healthier for all, better for all and to eliminate racism in all its forms. 

 

The word doctor comes from the Latin docere and means “to teach.” Throughout your tenure here, you taught medical and other students, your peers, the staff and the faculty that actions do speak louder than words; all while reading about your patients and their conditions to enhance your knowledge for the benefit of your future patients. And as impressive as all of this is, you accomplished this while also caring for your own families and other loved ones, and as such, they clearly share this august accomplishment with you. In your heart you know better than anyone that without them and their support, this accomplishment would not be as sweet, nor would it have been possible. Their assistance, encouragement and unconditional love during this challenging time was critical to your achievement. They, along with your many teachers and mentors throughout the years, coupled with your own efforts, brought you to this moment and they will always be with you, either in spirit or in reality.

 

So, years from now when you look back on your time in training and reflect on what you did during one of the most difficult times in medical history and that of our country, remember that you stood tall and did far more than you probably thought was even possible. Your legacy in MCWAH is secure and represented by the following two stories: Two upper level housestaff volunteered to form a COVID-19 intubation team to “protect our older faculty and younger, less experienced colleagues” and by a mother, a first year resident, who said “while it will be a hardship to leave my young child for a month, it’s nice to go to a place where I will be needed and can make a difference.”

 

You, the graduating housestaff, are inspiring, and you are going to be amazing doctors to whom your patients will look for assistance during what can easily be considered some of the most trying times in their lives: when they are dealing with and overcoming illness. Always remember that while your knowledge and skills are important, it is your humanity, compassion and caring that your patients and their families will remember during those times. It is now time for you to practice independent of supervision and take the next steps on your journey. Godspeed and know that you are ready and we are with you always. Remember, “Your journey never ends. Life has a way of changing things in incredible ways.” Alexander Volkov

 

Best always,

 

 

Kenneth B. Simons, MD

 

Dr. Simons is the Executive Director & DIO, MCWAH, Inc. and the Senior Associate Dean for GME and Accreditation, MCW.  He is also Professor of Ophthalmology and Pathology (tenure) at MCW.