The Kern Institute Learns to Blow our Shofar!

From the January 13, 2023 issue of the Transformational Times

The Kern Institute Learns to Blow our Shofar!  

By Adina Kalet, MD, MPH

In this week’s Director’s Corner, Dr. Kalet describes what she learned about transformational leadership while drinking coffee on a beach overlooking the Mediterranean Sea …

 

The beginning is the most important part of the work.

-Plato

In December 2018, I traveled to Israel to meet with palliative care physician and medical educator Dr. Dafna Meitar and educational psychologist and philosopher Dr. Daniel Marom. We talked about the Mandel Leadership Institute’s Leadership in Medical Education Program, a sophisticated, unique, year-long, philosophically-framed, intensive training they were creating in Jerusalem. We spent a whole day in a café in the coastal city of Herzliya, looking out over the Mediterranean, drinking coffee, eating pita, hummus, and diced salad, and discussing medical education. Ideas flew back and forth. We shared serious ideas, stories, and jokes. We gesticulated wildly. I got a tan and furiously took notes in multiple colors. 

When there was a lull in the conversation, I asked their advice about the job opportunity I was contemplating in Milwaukee. Daniel asked solemnly, “When you take this job, what will you mean by ‘transforming medical education’?” 

I talked unintelligently for a few minutes, reciting the laundry list of things I intended to do, but the look on their faces made it clear I hadn’t answered his question. “You must develop your shofar!” he said, cutting me off. “You must articulate the why of your work before  you will be ready to decide on the what.” He assumed that I would—although I had not yet decided to—take the job. 

Soon after that conversation, I accepted the offer. 

A shofar is an ancient musical instrument made from a ram’s horn. It was used like a modern bugle to call the community together for important announcements and discussion, to proclaim important calendar events, and to note solemn occasions. In modern times, the shofar is used during the Jewish High Holidays. In my community, the shofar can be—and is—blown by any member of the community with the proper embouchure. It is considered an honor and a source of pride to be able to “blow shofar.” 

I find the sound of the shofar stirring and meaningful. It accompanies those moments during the religious services when, in community, we are contemplating past errors, seeking forgiveness, and feeling humble. In awe, we formulate our resolutions for the future. I knew that by linking my career change to the shofar, Daniel was challenging me to think deeply and then “blast a horn” to get the attention of like-minded others so we could articulate a manifesto that would transform medical education. I had no clue what that would require, but I was reassured that Daniel and Dafna would be there to accompany me.

Once I joined the Kern Institute in fall 2019, I saw that our members were very busy. They had rolled up their sleeves and were solving problems. The KI had launched a robust faculty development program (KINETIC3), a well-being curriculum for students (REACH), and the Transformational Initiatives (TI2) program. However, I sensed that our members, our community within MCW, and the community beyond our walls did not clearly understand why we were doing what we were doing. I searched for ways to dedicate time to rest from all the doing and engage in some deep thinking. 

COVID-19 changed everything, and we wrote (and we wrote...)

As they say, be careful what you wish for! In March 2020, with the pandemic on our heels,  we launched the Transformational Times and have published weekly ever since. Once a collection of quality essays built over the first year-and-a-half, we published them in Character and Caring: A Pandemic Year in Medical Education at the end of 2021. 

Now, as we have continued our work and our writing, we present our new book, Character and Caring: Medical Education Emerge From the Pandemic, which was released on  January 2nd, 2023!  See Dr. Fletcher’s essay in this issue detailing the history of our work. 

Please consider purchasing the two volume Character and Caring  set (at a special price) for your favorite health professional. This is our shofar! It is a good read. Every member of the Kern Institute is expected to write regularly. The Transformational Times and the books call us all together for the deep conversations. In addition, we are publishing contributions from an enlarging group of local and national stakeholders and fellow travelers. 

Many have heard the “blast.” We receive emails from our readers and have regular literal and virtual hallway conversations stimulated by the essays. The responses are mostly expressions of appreciation for the opportunity to hear our why; the newsletter and books allow people to know us and know our work. Readers regularly share their own stories. There has been an occasional friendly debate and rarely a pointed disagreement. We welcome it all.  

Beyond the transactional to the transformational

We have a much more to learn from Drs. Marom and Meitar. Their deep and abiding respect for educators is intoxicating. They believe that educational leaders, through their work, define and design their professional community and, therefore, are responsible for giving expression to the values that comprise what medical sociologist, Eliot Freidson, PhD, called the "soul of their profession." Their approach to leadership development is guided by a clearly articulated framework they call a “typology” made up of five interrelated levels. The typology frames everything they do to facilitate—and provides a language for ensuring—that leaders understand why we are doing what we are doing. This, in turn, greatly enhances the likelihood that these motivated and committed individuals will have an impact that goes well beyond the transactional toward the transformational. 

All the work in the Leadership in Medical Education Program is done in peer groups and supported by coaching. Through discourse, readings, and reflective writing, senior medical educators wrestle first with core philosophical ideas surrounding human health and sickness (Level 1 of the typology) followed by questions surrounding the larger aims of the education of physicians (Level two). Then, and only then, are they allowed to dive into the implications of all this for educational theory (Level 3), implementation of new educational practice (Level 4) and, finally, evaluation of outcomes of that practice to measure success (Level 5). 

For most physicians who are very action-oriented, it takes discipline not to jump into the “doing” (Level 3) too soon. But, with practice and experience, most of Meitar and Marom’s participants internalize the discipline needed to seriously engage with the philosophical questions underpinning medical education before jumping into or designing and/or implementing programs. 

 Over the past few years, as I have worked with the five medical schools in Israel (more on that another time). I have had the honor of meeting many of the nearly fifty medical educators who have completed the Mandel Institute’s Leadership in Medical Education Program. After experiencing a very old-fashioned medical education themselves, most of them light up when discussing the pleasure in having the opportunity to engage with their peers intellectually and personally through this program. They are inspired to lead the change that is needed, even though it will be difficult, even though it will be resisted, and even though resources are very limited. Many of these graduates are now moving into positions of influence in their medical schools. 

Marom and Meitar are having an impact on the future of the whole country. I continue to take notes in multiple colors and have tried to bring these renderings into our work in the Kern Institute.  

Checking in again

After a couple of years in lockdown, I recently returned to a beach café in Israel to meet with Dafna and Daniel, both of whom are now affiliate faculty of the Kern Institute. They read our Transformational Times. They are still working to lift up medical education in their country as we are in ours. We discussed how the Kern Institute’s shofar is going and shared our successes and challenges. It is my hope to bring them to Milwaukee very soon (in the warm season) to teach us a thing or two about medical education leadership. I will take them—and as many of you as can join us—to the South Shore Terrace Kitchen & Beer Garden for a campfire, some s’mores, and a view of Lake Michigan. 

Looking out over the water, we will pick up our conversations from where we left off. 

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.

Love in the Time of Medical School

From the December 30, 2022 issue of the Transformational Times

Perspective/Opinion

Love in the Time of Medical School

Nicholas Visser – MCW Class of 2023

Once a staple of the American social scene, swing dancing is a vigorous form of dance which requires exquisite rhythm and grace. Alternatively - as for my teenage self - it is a time in which a man can speak to a woman, providing he can keep left foot one and left foot two from colliding for a few minutes. I would like to think that night at a church fundraiser it was my comedic chops that proved myself worthy of a second date, but I have been assured it was how convinced I was that I did not look like a fool dancing the night away. In either case, it would be easy to say that the rest is history; however, there’s more to this story.

Finding one’s spouse in college is a story that has been told a thousand times. The joy of discovering freedom and responsibility. The winter break trips to each hometown, anxiously seeking parental approval. On some occasions, a shared career interest can add to the connection. In my case, a shared goal of medical school tested and formed it.

Surely, it was only a few months into dating that Anna and I become aware that we both intended to become physicians, but this desire did not weigh so heavily on our relationship until Fall 2018. I had graduated and elected to take a gap year, in part for the opportunity to apply in the same cycle. Anna was enjoying a thrilling senior year. We both had worked tirelessly on primary and secondary applications. But as interview invites were released, the dream of having the chance to study together in medical school was evaporating. As fall turned to winter, we had only two shared interviews and no shared acceptances.

The reality of having to choose between starting our lives together and both pursuing this career had become such a real possibility. In those moments – sharing long evenings discussing our values and priorities – I believe that the groundwork for a strong marriage was formed: listening and being open to working through any challenge together. Less than one week after one particularly moving discussion, I bought an engagement ring. Less than one week after that, we shared an acceptance to the Medical College of Wisconsin.

It is hard to say where we would be now had our cards not turned up so serendipitously, but I know that being willing to bet on our relationship and let career aspirations follow has strengthened rather than weakened us as individuals and as students. Focusing first on loving and serving one another has developed a habit of caring and hard work that benefits our patients and colleagues. As medical school gives way to the match, residency, and attending life, I know the rhythm of life may get more complicated, but I am confident I will be able to keep the beat with my till-death-do-us-dance partner by my side.

Nicholas Visser is a medical student at MCW-Milwaukee.

Editor's note: This essay, which originally appeared in the Transformational Time's Valentine's Day issue (2/11/2022), was one of the most popular of the year. 

Temperature

From the January 6, 2023 issue of the Transformational Times

Temperature

By David Nelson, PhD, MS

Temperature
36 degrees Fahrenheit.
AM? PM?
Breathe that stands out.
Feet to stand on – cold.
Concrete to stand on – cold.
It rains, and the feet on the concrete – are cold.
Head, shoulders, arms, waist, legs, wet and cold.
You are out and in need of everything.
Gratitude for those that come along to support.
Holding a sign with shaking hands from the cold.
Breathe or fog – we do not know.
AM? PM?
36 degrees Fahrenheit.







Author’s Notes

This day was memorable for all the wrong reasons. There are days in the city that are just glorious. Bluebird days with blue skies and moderate temperatures and a shining sun. Then, there are days like this one. Gray clouds, frosty-just-short-of-freezing air and rain. I do not remember exactly if the forecast predicted a day of the weather, but having been out on the streets doing outreach for many years, I thought it could be just like this all day long. I snapped a picture with my phone of the digital thermometer in the truck while stopping for a coffee up a coffee and it stood out. Only the temperature showed on the digital thermometer. For some reason I thought it might be the same temperature all day long and it turned out to be so. It was going to be a crap weather day.

A recurrent theme of the streets are shoes. Community members walk a lot. It is not unusual to for someone to walk five or six miles on a given day. On outreach, I look at a person’s feet first. The shoes tell me a lot about the person. I can also know their size and if they have feet issues by seeing how they wear their shoes out. Worn heels signify one issue, toe sticking straight up or to the side another issue and so on. The size comes from changing a lot of shoes over the years – the benefit of working in a shoe store for a season.

David Nelson, PhD MS is an Associate Professor of Family and Community Medicine at MCW. He leads many of MCW’s community engagement efforts, partnering with public and private organizations to enhance learning, research, patient care and the health of the community. Much of this work involves leaving campus and going to the places where the people he wants to help live, work and play. He serves on the board of Friedens Community Ministries, a local network of food pantries working to end hunger in the community.

Finally Flourishing: A Long Journey to Living the Life She Was Meant to Live

From the January 6, 2023 issue of the Transformational Times

 
Finally Flourishing: A Long Journey to Living the Life She Was Meant to Live   

By Adina Kalet, MD, MPH 
 
 

This week Dr. Kalet shares (with permission) what she has learned from witnessing the life journey of a longtime colleague, a physician leader, and a transgender woman ... 
 
 

“Like so many trans people I don’t remember a time that I didn’t feel I was the wrong gender,” Joanne said recently, recalling growing up in the 1950s as a quiet, withdrawn, ‘super-confused’ boy. Until one day in sixth grade,” she continued, “I went to the library and found a few books about transexual people.” The image of a prepubescent boy laying on the concrete library floor reading a book flashed in my “mind’s eye.” I could imagine the deep relief she must have felt to put words to the feelings, learning, for the first time that there were others like her out there.   
 
She described her high school-aged self as a “super-introverted, mute, ashamed,” and very lonely teenager.   
 

Joanne first told me she was a woman in 1990 when she looked very much like the man she had been for the first forty years of her life. She was still the bearded and balding man I had known as my favorite fellowship officemate and partner in a research project on physician-patient risk communication. I was initially shocked by the matter-of-fact admission and graphic description of gender dysphoria. At that point in time, I had no experience talking openly with someone who was transgender. But because of our friendship, I quelled my confused panic and listened carefully. The story, hard to hear, shot through with sadness, depression, loneliness, awkward relationships and periods of self-hatred broke my heart. At the same time, I was struck by the absolute certainty of my friend's femaleness. “I am a woman. I have been all my life.”  
 
Those next few years were a low point. While still living as a man, raising young children, and married for a second time, Joanne and her wife worked hard to hold it together. They both completed their medical training, found meaningful clinical work, and raised their family. However, after being hospitalized for suicidal depression, they knew that moving forward would require Joanne living openly and honestly as a woman.   
 
 
A familiar voice  
 
Almost twenty-five years later, I stared up at the television set in the patient lounge, drawn by the familiar voice I had not heard in a long while.  It was October 24th, 2014, and I watched the all-too-common national news coverage of a mass shooting. The local Chief Medical Officer stood at the podium describing the teenagers in the ICU, who had suffered bullet wounds to the head delivered by a 14-year-old classmate who opened fire in the cafeteria at Marysville Pilchuck High School in a suburb north of Seattle. After describing the gruesome situation as tactfully, clinically, and calmly as possible, Dr. Joanne Roberts said, "Our community is going to mourn this for years." She went on, "I can tell you that we will all go home tonight and cry."  
 
I emailed her immediately. “I saw you. That was you, right?” (I had not seen her for years), “You were so beautiful. What a great communicator, leader, and public physician,” I continued to gush. She politely confirmed this was her and thanked me for the compliments. I realized too late that my comments on her physical beauty and poise could have seemed rather sexist given that she was clearly doing her job expertly as a senior, physician leader. But to be honest, my clumsiness resulted from the powerful relief I felt to see her looking so confident and relaxed in her own personal and professional identity and, truthfully, I was thankful that she was alive.   
 
 
The gift of being “Trans” 
 
Joanne is retired now, living a peaceful life as a single woman surrounded by many close friends. There were hard times after her transition. She and her wife divorced. She remains close with her children who have struggled from time to time with their “dad’s” gender transition but have moved on as she has. 
 
Her three careers, first as a journalist, then a practicing palliative care physician and, finally, her six years as Chief Medical Officer at a hospital in Washington State, have given her many opportunities to consider issues related to gender and work. Reflection, reading, and talking with others have made her wise.  
 
“In my career, it was a gift to be trans, to have been socialized as a boy, and to live as a woman was a gift,” she shared during a recent conversation.  “… after the shooting, for instance… leading as a woman but having the male socialization, allowed me to act with confidence (real or false), …and be strong with the press, families, and law enforcement.” She reflected on how the complex alchemy of her gender as well as her professional journey enabled her to serve the community, helping them face the horrific moment, “…having been a journalist, …. I trust the media; they want to get the news out to the community. It was easy for me to do.”  
 
And finally, she attributes being calm in a crisis, seeing opportunity in bad times, and listening more than talking, to her unique experience of being socialized as a boy and living as a woman. While she readily describes blatant discrimination, she finds ways to empathize with all perspectives and points of view.  
 
Her leadership skills were honed by the many surprises of her gender journey. “One of the biggest shocks of my transition was that my biggest supporters were my conservative friends,” she says, noting the irony. It turned out that the people with whom she had already had a relationship found it much easier to accept her as Joanne. “It is so easy to hate groups and hard to hate individuals,” she notes, “…knowing this has made me a much better leader…you inspire, one conversation at a time.”  
 
 
The depression is cured 
 
Joanne had always wanted to become a physician. In the 1980s, though, despite having finally found a therapist and physician willing to help with the transition using gender-affirming hormone therapy, and even though planning to fully transition surgically and live as a feminine woman, Joanne stopped the transition because many medical schools considered transsexuality a mental illness incompatible with being a physician. This was a fraught, nearly unbearable tradeoff.  
 
Eventually, she was able to transition. “The sadness is gone, it never gets dark, I haven’t had an episode of depression since transition.” The emotionality she gained being able to live as a woman, attributed both to female hormones and the experience of being treated by others as a woman, greatly enhanced her capacity to practice palliative care medicine. Although Joanne is not a highly vocal advocate for the “queer community,” she does supportive work through one-on-one mentoring. “I just want to fit in as a woman doctor. No need for advocacy…” Toward the end of her administrative career, there was no explicit discussion with her bosses about transition. “A lot of people know, and a lot don’t,” she reflected with a verbal shrug. This is what acceptance sounds like.  
 
 
We have work to do…  
 
Less than 1% of physicians and matriculating medical students identify as Transgender or Non-Binary (TGNB). Most practicing physicians have persistent gaps in their knowledge about even the most mundane routine care for TGNB patients despite the increasing number of patients requiring that care.  
 
The public has become more accepting of gender diversity. A GLAAD—the world's largest Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) advocacy organization—survey from 2016 showed that nearly 12% of millennials identified as TGNB. Despite the increase in visibility and acceptance, those who identify as TGNB continue to be marginalized in their communities and vulnerable to high rates of depression, self-harm, homelessness, substance abuse, and sexually transmitted infections. Many healthcare settings continue to perpetuate intolerance by denying TGNB patients access to a clinician knowledgeable about gender-affirming care or treating sexual minorities with disrespect.  
 
As medical schools, we have a role to play in diversifying the physician workforce and ensuring that the workforce meets the needs of the communities we serve. We do this by becoming actively inclusive. We recruit students from gender minority groups, make efforts to feature TGNB students and physicians in public messaging, and encourage our current students, staff, and physicians to see themselves in the curriculum, the work, research, community engagement, and social events. We offer clinical care tailored for the LGBTQ+ community.  
 
While Joanne is delighted and envious that the world has become a much safer place for young people to explore their many identities, she hopes that this will lead to more character and caring. She worries that we are not socializing our young doctors “to have integrity, to develop wisdom.” She challenges us to remain clear about why we do this work. “I found in my leadership career when I was younger, I focused on the doctors, when I got older, I focused on patients again…we come to work to serve them…” That is what matters most.  
 

 
For further reading: 
 
https://www.aamc.org/news-insights/we-need-more-transgender-and-gender-nonbinary-doctors  
 
Westafer LM, Freiermuth CE, Lall MD, Muder SJ, Ragone EL, Jarman AF. Experiences of Transgender and Gender Expansive Physicians. JAMA New Open. 2022;5(6):e2219791. doi:10.1001/jamanetworkopen.2022.19791  
 
https://www.aamc.org/media/9641/download?attachment 
 
https://www.aafp.org/news/practice-professional-issues/20181214transgendercare.html 
 
https://www.glaad.org/publications/accelerating-acceptance-2016 
 
 

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. 
 
 
 
 
 

So, You Want to Publish Your Medical Education Paper in Academic Medicine - The @AcadMedJournal Editors Share Their Tips

So, You Want to Publish Your Medical Education Paper in Academic Medicine - The @AcadMedJournal Editors Share Their Tips

By Bruce H. Campbell, MD FACS

Dr. Campbell, who curates the blog, shares highlights of a recent podcast moderated by Toni Gallo, the Academic Medicine staff editor, with practical tips that will smooth your way into publishing in the journal ...

Happy New Year! Maybe one of your resolutions this year is to publish a MedEd article in a top-tier journal. You can do it!

To make it more likely, the editors of Academic Medicine created an Academic Medicine Podcast (12/19/2022) where the people who help decide what will get into print offer a peak behind the curtain. The episode is entitled “Writing Effectively and Navigating the Publication Process."

First of all, here are links to online medical writing resources: 

• Fostering Scholarship in Medical Education: Resources for Authors and Reviewers
• The Conducting Research in Health Professions Education: From Idea to Publication eBook
• The Writer’s Craft section in the journal Perspectives on Medical Education  
• Review Criteria for Research Manuscripts
• Scholarly Publishing Webinar Series

Below are tips and suggestions that each editor offers. As you prepare your manuscript, remember that folks like these editors will eventually be reading it. 

Colin West, MD, PhD (Deputy Editor, Professor of Medicine, Medical Education, and Biostatistics, Mayo Clinic) 

Three things to think about when preparing a manuscript:

• Be clear on how a practical application of your work bridges the gap from theory to practice without overstating your findings
• Be clear about the paper’s place in the field of study
• Be honest and thoughtful about the paper’s limitations

Jonathan Michael Amiel, MD (Assistant Editor, Professor of Psychiatry and Senior Associate Dean for Innovation in Health Professions Education, Columbia University)

Things he hopes to see when reviewing a submission:

• A clear demonstration of how the work helps make medical education better
• The paper doesn’t overreach; rather it takes a “small bite” and rigorously addresses the problem

Laura E. Hirschfield, PhD (Assistant Editor, Associate Professor of Medical Education and Sociology, University of Illinois-Chicago) 

Things she looks for when reviewing a submission:

• A clear demonstration that the authors have engaged with the foundational papers and authors in relevant fields, even if outside the traditional MedEd disciplines. 
• A well-demonstrated link between the research question or topic and the research design 

Gustavo Patino, MD, PhD (Assistant Editor, Associate Professor of Neuroscience, Oakland University William Beaumont School of Medicine) 

Questions he asks as a reviewer:

• Do the authors clearly articulate the research question?
• Have they described the knowledge gap? 
• What was the genesis of the idea? 
• Why is it important that this question be answered? 
• Are the research methods and study design appropriate to answer the question? 
• In the Discussion, are the claims and takeaway points consistent with the Methods and Results? 

Dan Schumacher, MD, PhD, Med (Assistant Editor, Associate Professor, University of Cincinnati)

His advice to authors:

• Pay attention to Lorelei Lingard’s idea of “It’s a Story, Not a Study.” Tell the reader why it’s important, what you found, and why what you found is important.
• Rely on well-crafted research questions and matching methodologies. 
• Write with clarity.

John H. Coverdale, MD (Associate Editor, Professor of Psychiatry and Behavioral Sciences, Baylor College of Medicine)

His advice to authors:

• For both qualitative and quantitative research, make the Methods section crystal clear.  Explain how the design relates to the research question or hypothesis, including how it is appropriate to the question.

Mary Beth DeVilbiss (Managing editor)

What she likes to see in the visuals:

• Exhibits, tables, figures, charts should have a clear purpose and add value.
• Visuals that enhance and illuminate the text, but never repeat it. 

Teresa Chan, MD, MHPE (Associate editor)

How she describes the Academic Medicine "Innovation Reports": 

• They are a first stab at a new way of doing things that builds on previous literature but then tweaks it in a novel way. Outline the problem, outline the approach, and always provide a reflective component.

Bridget O’Brien, PhD (Deputy editor, Adjunct Professor of Medicine, UCSF)

Things she suggests to authors before they submit a manuscript: 

• Read through the manuscript three times before submitting. 
• Read as an author. Make certain arguments flow and that essential details are covered. 
• Read as a reviewer. Try to apply the manuscript review criteria you use to your own work. 
• Read as a reader. Is it interesting? Do you skip sections? Does it make sense?
• Then ask others to read your manuscript from these perspectives, as well. 

Tony Artino, PhD (Assistant Editor for Last Pages, Professor at the George Washington School of Medicine and Health Sciences)

Reactions he suggests you have if you are asked to “revise and resubmit”:

• A revision request is a win, right? Don’t be discouraged! It is better to get it right before publication than after.
• Revisions always result in a better paper. 
• (Tongue-in-cheek) Editors and reviewers are always right. Realize that arguing only delays getting your manuscript into print. 
• Remember that medical and health professions education is a very small world. Your work might end up in the hands of the same reviewers if you re-submit to another journal. So, be gracious.

That should get you started. Happy writing!

Bruce H. Campbell, MD, FACS, is a Professor in the Department of Otolaryngology and Communication Sciences and in the Institute for Health and Equity (Bioethics and Medical Humanities) at MCW. He is on the editorial board of the Transformational Times and a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He has published two Innovation Reports in Academic Medicine and still learned some stuff listening to and summarizing this podcast. 

Diagnostic Reasoning – A Call for Faculty Engagement

From the August 12, 2022 issue of the Transformational Times newsletter

Diagnostic Reasoning – A Call for Faculty Engagement 

  

By Jayshil J. Patel, MD - Director of MCW's curriculum "Critical Thinking in Medicine" thread

  

Dr. Patel shares, in earnest, this call to interested clinical faculty to engage in the diagnostic reasoning curriculum.  In many ways, our patients and posterity depend on it ... 

 

As many of you know, threads will be woven into the new medical school curriculum.  The Critical Thinking in Medicine thread will be a synergistic marriage between diagnostic reasoning and evidence-based medicine which, I think, are the key constituents for deliberately practicing medicine in today’s clinical environments and setting learners on paths towards diagnostic expertise.  Over the past few years, components of the curriculum have been tried and tested in various venues throughout undergraduate and graduate medical education and many learners have embraced and incorporated the language of the diagnostic process into their medical lexicon. Some have left training equipped with skills to metacognate.   

I am thrilled the curriculum will become a staple of undergraduate medical education at the Medical College of Wisconsin, but the initial implementation and sustainability of any curriculum, let alone ours, relies on an acceptance and participation from learners and faculty.  Thus, faculty development will be crucial.    

If, at this point, you’re asking, “Well, how are you going to do that?” Don’t fret. I share your line of questioning.  My honest answer is that I don’t know.   Or rather, I haven’t figured it out yet.   

But before embarking on a journey to capacitate and train the trainers, I would like to share why I think clinical faculty members would benefit from engagement, including becoming fluent in the semantics, scientific underpinnings, and metacognitive strategies related to the diagnostic process.  Here, I outline the impact (and really benefit) for three key stakeholders. 

For the sake of patients: Reducing medical errors by teaching how to arrive at a correct diagnosis 

Clearly, the goal for many front-line specialties is to get an accurate and timely diagnosis.  Without it, management is ineffective, wasteful, and potentially harmful.  With an accurate diagnosis, management and prognosis are guided.   

A diagnostic error is defined as a “failure to develop an accurate explanation for a patient’s health problem and/or failure to communicate that explanation,” and studies of autopsies, secondary reviews, and voluntary reports suggest diagnostic errors occur in up to 15% of cases, culminating in adverse events in up to 90% of cases.  It turns out cognitive errors are by far the most common cause of diagnostic error. An analysis of 583 physician-reported diagnostic errors suggested a failure/delay in considering diagnosis, suboptimal weighing of information, or too much emphasis placed on competing diagnoses were the most common reasons for “what went wrong.”  

As a result, patients may be subject to unnecessary testing and incorrect therapies, which may subsequently lead to psychologic/physical harm, toxicity, prolonged hospitalization, financial distress, and even death. Therefore, if the primary goal during an initial undifferentiated patient encounter is to arrive at a diagnosis, shouldn’t medical education, for the sake of patient care, strive to teach learners how to arrive at a diagnosis by explicating the diagnostic process into discrete teachable components to be deliberately practiced? And in doing so, is it possible to reduce diagnostic errors?   

While I can’t cite literature, and even if the answer is “no,” I opine, from a philosophical standpoint, that there’s intrinsic value, for doctoring and the doctor-patient relationship, in better understanding the diagnostic process.  

For the sake of learners: Giving them tools to build their diagnostic expertise 

It is not uncommon for novice learners to be “full of facts.”  However, they may have a difficult time “putting it all together.”  In fact, the diagnostic process is often considered a “black box” where learners can see what goes in (the data) and what comes out (the eventual diagnosis) but may not be able to articulate (in written or verbal communication) the intermediate steps.  And in some cases, the diagnoses are often drawn from a grab bag of differential diagnoses, which are verbalized using reflexive and biologically unlinked thinking.   

Instead of just creating competent graduates, what if we aim to set learners on a path towards diagnostic expertise?  After all, and as stated earlier, nothing good happens without an accurate diagnosis.  And so, what if the learner could: 

(a) Recognize how to appropriately utilize and toggle between different systems of thinking 

(b) Recognize when their cognitive load is high 

(c) Utilize different approaches to problems (e.g., hypothetical-deductive versus inductive approach) 

(d) Acquire a template for knowledge storage, expansion, and retrieval 

(e) Learn to conduct a cognitive autopsy and scan their environment for cognitive pitfalls 

(f) Learn to calibrate their thinking for future similar but not identical cases 

It is not a stretch of the imagination, and in fact, when we launched this curriculum in the internal medicine residency program, these components were exactly what learners desired out of their training.  For learners to grasp and deliberately practice these components, they’ll need their faculty counterparts to share their understanding of the diagnostic process (or at minimum, speak the same language). 

For the sake of faculty: Creating a culture where they can share their skills 

A few years ago, before delineating the components of a diagnostic reasoning curriculum, I began with the end in mind.  Assuming resources abound, I envisioned a Center for Diagnostic Reasoning (and Evidence-Based Medicine). It would be a place where educators would encourage learners to think aloud, deliberately dissect clinical cases into aliquots, and expound systematic approaches. They would approach problems embedded in a patient context and within a consciousness of the scientific underpinnings of decision-making and evidence-based medicine, all the while reflecting and calibrating their thinking.  The Center would be magnetic, attracting educators into the logos of diagnostic reasoning, creating sustainability.   

To me, that is aspirational and exciting.  Here’s why.  Sure, for young learners, the acquired skillsets are meant to promote lifelong learning and equip them to stay on the path towards diagnostic expertise.  But for clinical faculty, the acquired skillsets provide an opportunity to illuminate their thinking and provide a window (for learners) into their mind, within a culture of democratized rounds where both learners and faculty are encouraged to say, “I don’t know,” without the worry of perceived failure.   

Faculty might be overwhelmed and say, “I just don’t have time to do this.”  I will submit to you that you (faculty) are already, some in an extemporaneous manner, reasoning; however, the addition of semantic and scientific structure may provide greater clarity for learners (and yourself).   

Importantly, such a culture would enable the expression of virtues such as courage, prudence, empathy, grace, and humility.  For example, it takes courage and humility to say, “I don’t know.”  The manifestation of these virtues is central for the success of the hidden curriculum, which has far-reaching implications, perhaps more than the exposed curriculum.  And an explicated awareness of an individual’s thinking may be the key in accruing tacit knowledge.   

After all, it was Aristotle who said, Knowing yourself is the beginning of all wisdom. 

Jayshil J. Patel, MD, is an Associate Professor of Medicine in the Department of Medicine at MCW.  He is on the Learning Environment Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and the Critical Thinking in Medicine Thread Director at MCW. 

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Sit Down, Get Paged, Repeat

From the December 23, 2022 issue of the Transformational Times 

 

Sit Down, Get Paged, Repeat

 

By Laura Slykhouse, MD

 

At this time of year, we celebrate and thank our hard-working residents and hospital staff that work through the nights, weekends, and holidays. Dr. Slykhouse, a resident in Internal Medicine, recounts a call night that was also her birthday. She shares some moments which are specific to being in the hospital overnight… 

 

Birthdays have a way of getting less and less exciting each year. Yes, there are some milestone birthdays we celebrate as we get older; but, as the years march on, enthusiasm lacks compared to a sweet sixteenth or a twenty-first birthday. This year, I see my schedule for June and of course, I’ll be celebrating my birthday at Froedtert at the end of a twenty-eight-hour shift. 

I readjust my expectations and wish for a calm night, good cross-cover, no ICU transfers, and friends to make the time go faster. The night is off to a good start when my favorite co-resident is pulled in to cover the night portion of the shift with me. I was obviously more excited than she was, but the night was looking promising.  

We get sign-out, nothing exciting. Then we start brainstorming our evening – what kind of food are we going to order, which movies do we hope to watch in the team room and what music should we listen to. We’re not even five minutes into our planning when two pages come through – it’s the admitting medical officer (AMO) with two outside hospital transfers who are already on the floor: one with metastatic lesions to the brain and concern for increased intracranial pressure, the other one for AMS (altered mental status) in an elderly woman. This would be the last quiet moment of the evening.  

We decide to see the patient with concern for increased intracranial pressure first. He does not appear as sick as his labs and imaging have detailed. This is one of those times in residency where I feel the sense that a patient could decompensate quickly, but next steps are not clear. I feel uneasy about this patient. We call the neurosurgical team, and they also share our concerns and take over care of the patient in the Neuro ICU. The patient and his wife are very grateful for our small contribution to his care.  

Then the cross-cover begins. Two stroke calls, status epilepticus, a transfer to the Neuro ICU and Medical ICU. This is not the night I had planned when the shift started. However, time is passing quickly as we try to triage the patients and deal with one situation at a time.  

It’s now midnight, and I’m happy there are still a few options left on Door Dash, as I have been craving Mexican food the whole night. This would not be a night for a movie. The chaos continues throughout the night, page after page, almost comical with the timing – sit down, page, sit down, page. The food delivery has been there for hours, but something about a lukewarm burrito at 4:00 AM is less appetizing.  

The last crisis of the night is the elderly woman admitted for AMS. She has dementia and hypercalcemia. We give IV calcitonin and a bisphosphonate which causes diffuse body aches. She speaks both German and English intermittently. I find myself drawn to her. I’m not sure if it’s because she reminds me of my grandma or because I feel guilty that our treatment has caused her pain. I hold her hand for a while, and she seems to feel some relief from the IV pain medication. Just this small point of contact makes the night seem less frenetic. It reminds me why I enjoy what I’m doing, even during the difficult nights, the missed holidays and celebrations.  

It’s 6:00 AM and we re-group in the team room. The window for sleeping has passed, and it’s evident I’ll need a significant amount of coffee to make it through rounds. We debrief quickly, cold burritos are half-eaten and abandoned next to the computers, and I feel proud. I learned a lot, we gave the best care that we could, and another call shift is over.  

 

Laura Slykhouse, MD, is a PGY3 Internal Medicine resident at MCW who is planning to start her career in hospital medicine.   

Design Thinking in Action: Medical Students Weigh-In on the Mobile Health Clinic

From the December 23, 2022 issue of the Transformational Times

Perspective/Opinion 

Design Thinking in Action: Medical Students Weigh-In on the Mobile Health Clinic 

 

By Emmy Lambert, BS – Medical Student 

Patient-centered care calls for patient-centered spaces. Medical students were given the opportunity to dust off their creative brains and ponder the details, big and small, of an exciting new mobile clinic…  

Human-Centered Design. It’s all around us. Or at least, it should be… 

Simply put, human-centered design is a method of empathy-based problem-solving. Through a three-phase design process of inspiration, ideation, and implementation, human-centered design tailors products towards those involved in their use – so-called “stakeholders.” These stakeholders are consulted and considered in every step of the design process to ensure the output will meet their needs. Truly an ingenious approach, if you ask me.   

They’re building a WHAT? A mobile clinic! 

In an effort to address preventative health screening disparities in certain zip codes in Milwaukee, there is a joint venture between the Population Health Department and OB/GYN Clinic at Froedtert Hospital, the Kern Institute’s Human-Centered Design (HCD) Lab, and the UW-Milwaukee Lubar Entrepreneurship Center to design and implement a Women’s* Mobile Health Clinic. The working timeline aims to complete research by the end of the 2022 calendar year, build the clinic in late spring of 2023, and begin providing care next fall.   

As part of the ongoing research process, the HCD lab hosted a design workshop for second-year medical students in the Health Systems Management & Policy Pathway. As a student member of the HCD lab for nearly a year, I had the privilege of facilitating this session with Dr. Ilya Avdeev and Dr. Lana Minshew. As a team, we guided students through a series of activities to stimulate creativity and prime their listening skills before conducting design research for the clinic.   

We asked the HSMP students to brainstorm the needs of a women’s mobile health clinic, identify stakeholders, and generate solutions to a few stakeholder concerns. Students collaborated in teams, writing furiously on sticky notes, whiteboards, and scrap paper. The room was abuzz with solution-oriented energy. Their knowledge of health systems and roles as medical students added a unique perspective to the ongoing project. Some of Dr. Avdeev’s graduate-level engineering students attended the session as well, lending a different angle of design understanding to the process.    

The students said they loved it! 

The session was well received by the students. Clayton Vesperman, M2, commented, “I thought that the Mobile Clinic Design session was one of the most unique and engaging sessions I have had as part of the Health Systems Management and Policy pathway. The opportunity to collaborate with Engineering students who had a background that was outside of the medical field was a great opportunity to learn how other fields approach problems as well as the types of issues they prioritize. As medical students, we have abundant opportunities to learn from other health professions, but learning to work alongside entirely different fields can be very beneficial as they can play a large impact in the patient experience even without directly influencing the patients’ healthcare.”  

Victoria Le, an M2 also in the HSMP Pathway, commented, “I thought it was interesting to see the process of working through nitty-gritty details of making an idea come to life. I liked how thorough it was, including the way we tried to anticipate different issues that would be roadblocks to the mobile clinic. I also thought it was a good way to balance the creative process with a more rigorous evaluation of ideas.”  

My takeaway? 

I was so impressed with the creativity and collaboration demonstrated by my peers! Their willingness to engage across disciplines, work together to problem solve, and experience medicine from the patient perspective is promising for the future of medicine. A few of the ideas presented at this workshop have been considered for the ultimate implementation of the mobile health clinic, which is set to hit the streets in the fall of 2023.   

Design with us! 

The Human-Centered Design lab is currently collaborating with the Lubar Entrepreneurship Center at the University of Wisconsin – Milwaukee and Froedtert hospital on a community-centered design project focused on designing two mobile health clinics to serve the greater Milwaukee area. To create the most effective community-centered design as possible, we invite community members to join the design team by sharing your experience with mobile healthcare or offering your ideas using a full-scale clinic design model. The model is in the first-floor cafeteria lobby of the MCW – Medical Education Building and will be open to everyone through January 31, 2023.   

Note: 

*The term “women” encompasses those who identify as female, possess female reproductive anatomy, or face female-related health issues. 

Emmy Lambert is currently an M2 at MCW Milwaukee. She is a student member of the Human-Centered Design Lab pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. She passionately co-runs the MCW Chapter of Medical Students for Choice, manages operations of MCW DOSE, and teaches Hatha and yin yoga classes at Collective Flow MKE.  

“Is There a Doctor Onboard?” Doctoring and Prayers at 35,000 Feet

From the December 16, 2022 Spiritually in Medicine issue of the Transformational Times

“Is There a Doctor Onboard?” Doctoring and Prayers at 35,000 Feet

By Adina Kalet, MD, MPH

Given the theme of Spirituality in Medicine in this week’s Transformational Times, Dr. Kalet shares the most recent of many experiences she has had answering the overhead call on airplanes. In this case, the faith traditions of both the doctor and of the patient led to series of surprises and unique styles of gratitude for caring and kindness expressed in prayer …

Given that I was listening to a movie through my headphones while my hands were busy knitting, the announcement just barely registered. We were three hours away from our destination, and a long, uncomfortable eight hours into our flight. After a few seconds delay, I untangled myself and headed toward the uniformed purser standing in the aisle. 

“I am a doctor. How can I help?” She looked me over and nodded discretely toward the young, pale, diaphoretic, and mildly distressed bearded man slumped in his seat. 

The flight attendant whispered, “He is asking for medication, but I can’t administer anything without a physicians order.” She gestured to her handheld device. “This is what we have available.” She looked back-and-forth from the man in the seat to me. “We are over land now, so if you decide…” Her voice trailed off, suggesting that, on my say-so, they were prepared to land the plane.

“Give me a minute to assess the situation,” I said. She offered to retrieve a blood pressure cuff and oxygen tank.  

My new patient’s religious garb, facial hair, and head covering told me that he was part of an Ultra-Orthodox Jewish family. I grabbed my sweater and covered my bare shoulders since, in his culture—one I know intimately—modesty is paramount. In his community’s view of the world, a secular appearing, barefooted and bareheaded woman might be dismissed or treated with suspicion. I assumed he would avoid eye contact and refuse to let me touch him. To be trusted enough to make an accurate medical assessment, I needed to minimize the barriers.  

Leaning over him, I introduced myself and asked him to tell me what was going on. I was happy to see that he was fully awake and alert, spoke fluent mildly-accented English, was willing to make eye contact, and seemed eager for my help. He described his weakness, dizziness, and nausea. After asking permission, I carefully and firmly ran my hand over the key locations (no belly, chest, or calf tenderness) landing on his wrist to feel for his radial pulse. I engaged him in conversation about his health and recent events as I monitored the cardiac rate and rhythm. He had been perfectly healthy  and described no ominous symptoms. 

The relatives surrounding him were eager to tell me that they had all spent the day before in a hospital emergency room with a beloved relative. As his uncle graphically described the details of how the old woman had fallen and had sustained a nasty, bloody gash, my patient became paler, his heart rate went up, and his pulse became “thready.” Before long, he was dry heaving into a plastic bag. Clearly, the stress of hearing the story again was taking a toll. I expressed my empathy for the upsetting situation to the group. My patient’s pulse slowed a bit. 

The flight attendant handed me the automatic blood pressure device. As I wrapped the cuff around his arm, I confirmed he had eaten little, had slept poorly, and had not had anything to drink during the flight because the options were not guaranteed to meet his religious requirements. The machine finished its reading and, although not dangerous, his blood pressure was quite low. 

We laid him as flat as the airplane seat would allow and elevated his legs. I assessed the width of the aisle just in case we needed to get him on his back. Happily, his blood pressure climbed a bit and his pulse headed toward normal. 

The flight attendant pointed out that we were seven miles above the Earth, and some supplemental oxygen might help. We put the mask on him and started the flow. He “pinked” up immediately, and his nausea resolved. Soon, he was able and eager to drink fluids. As time passed, his symptoms resolved, and he felt stronger. 

I spent a few minutes talking with his relatives, including the old woman with the fresh stitches and a bandage above her eye. I was able to fend off one of his aunts who offered several nonspecific pills she had in her carry-on bag. Everyone noticeably relaxed and soon I felt comfortable enough to return to my seat. 

The flight attendant stopped by, reporting that she had told the pilot we were not anticipating an emergency landing. She offered me a gift from the airline which I tried to refuse but, in the end, I accepted some extra miles for my frequent flyer account. 

After a while, the patient’s aunt came by, an emissary from the senior male members of the family. She thanked me profusely for my help, then said, “Your smile and gentleness are a blessing from G-d! You didn’t need to be kind, but you were.”  The family wanted to give me something in return for my kindness. 

“No!” I said. “That is very kind, but this is my work. There is no need for gifts.”

“Well, then,” she replied, “you will be in our daily prayers.” She nodded, thanked me again, and returned to her seat. I smiled, found my headphones, and went back to my knitting. 

I was relieved that things turned out so well; they don’t always. This was not my first rodeo. I have had  a few opportunities to answer “the call” on airplanes, at the theater, and on the sidewalk.  Given the settings, the medical intervention and decision-making options are severely limited. Had the situation worsened, and I had needed extra hands to help start an IV or do chest compressions, I suspect other healthcare workers might have appeared, or the trained crew members would have been there to assist. Depending on the acuity of the crisis, I might have recommended to the pilot that she land the plane.

But, on this day, that was not what was needed. In the end, what was most needed and appreciated was kindness. This experience, as well as medical student Sarah Root, in her essay in this issue of the Transformational Times, reminds me once again, through the the words of Sarah’s physician grandfather, “that medicine is not just a practice, but a privilege.”

We reached our destination and headed our separate ways. I am humbled to know that there is a family, not so very different from my own, that is prayerfully grateful for our moments together at 35,000 feet. 

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.