A COVID-19 Conversation

From the 7/10/2020 newsletter

A COVID-19 Conversation 

Bruce H. Campbell, MD

A patient gets his news from different sources than does Dr. Campbell…

My patient and his wife have braved the outpatient clinic restrictions imposed by COVID-19 to return for his cancer follow-up. Over the past couple of years, I have operated on him twice, each time for a malignancy that keeps recurring. He is a delightful and – as even he would admit – a bit exasperating. He speaks his mind and has strong opinions about everything, including his medical care.

When the cancer recurred after the first operation, I suggested that he see one of the radiation oncologists to hear what she might have to offer. “No way. I had a terrible experience last time,” he said at the time. “Even if you recommend radiation after this next operation, I’ll say ‘no’ again. End of conversation.” So, we returned to the operating room for more surgery.

Now, a few weeks later, he is back in the office. I wear my mask and have him lower his so I can examine his mouth and throat. I am relieved. So far, so good. We review his CT scan. “The exam and the scan are both fine. No signs of cancer. Great news!” I say. “All is well.”

He nods and tugs up his mask again. “Good, good.” Then, he cocks his head and looks at me. “So, do you mind if I ask you a couple of questions?”

“Sure,” I say, although I’m not sure where this is heading. “Fire away.”

He glances toward his wife and then back to me. “What do you think of this coronavirus?"

I tense a bit. Based on his previous comments, I know precisely where he stands on the political spectrum. Uh, oh, I think to myself. His favorite media outlets are known for skepticism about wearing masks and maintaining social distancing. Nevertheless, he seems to be genuinely interested.

“Well,” I respond, “It’s dangerous. Based on the science, we should be very cautious. There’s too much risk of the virus spreading and people dying needlessly.” There, I hope. Maybe that’s that.

He starts down his list. “Yeah, but just in other places, right? I hear it’s not bad in Milwaukee.” In fact, our hospital doesn’t publish admission and ICU data, but I am able to tell him in general terms that the numbers of patients admitted and seriously ill with COVID-19 has been climbing over the past several days. “Really?” he asks. “I’m surprised.”

“It’s real,” I say.

“Well then, what do you think about these things I heard on the news?” I cringe slightly as he proceeds through the series of narratives that have found life on the internet. I try to keep up. No, COVID-19 is not like a “regular” flu. Yes, people are dying, and some who recover stay sick for a long time. It’s true that people don’t have to appear ill to be infectious. No, there is no evidence that it was a biological weapon developed in a Chinese lab. No, I’m not aware of any studies that show that more people will die of a stalled economy. No, I don’t believe that it will fade over the coming months and magically disappear after the presidential election. The best studies show that hydroxychloroquine does not extend hospitalized patients’ lives. Yes, masks, hand washing, socialdistancing, and staying home are the best ways to slow the spread. Yes, vaccines will be the best way to return to “normal” and they will take a long time to develop. No, I’m not surprised that Dr. Fauci and the other health experts change their recommendations from time-to-time since scientific evidence continues to evolve. I don’t believe that there is a “scientific deep state.” We go down his list and I do my best to address each concern.

I tell him what I know of the 1918 Flu Pandemic and how the “second wave” killed more than the first. Bringing it closer to home, I share how construction of some of our hospital buildings, which are on part of the old Milwaukee County Grounds, required the exhumation, study, and re-interment of more than two thousand people buried between 1882 and 1925, including many who died and were haphazardly buried anonymously during epidemics. It can happen again.

“Tamping down the virus is personal,” I tell him. “Two of my four children work in healthcare. I’m over sixty. We are all at risk and wearing a mask is the most gracious thing anyone can do,” I say. “It’s a gift we give to others.”

After a deep breath, I realize, gratefully, that they are both still engaged. They have asked honest questions and I have done my best to respond. I have discovered how challenging it is to encapsulate evolving science into respectful, careful, honest, and evidence-based answers for people who might not be inclined to believe people like me. On topics where there are knowledge gaps or shifting data, I see why they might be skeptical.

This is the first meaningful face-to-face conversation I have had with people who spend their days gathering news from sources other than the ones I peruse, and it differs from conversations on Facebook with folks that already agree with me. I am grateful they listened and appreciate the opportunity to better understand their perspectives, even if just for a moment.

“Thanks, Doc,” he says finally. “You gave us some things to think about. I don’t need to come back for a recheck, do I?”

“Well, I would like to see you again in a few months, but I would be happy to see you anytime. Call if anything changes, okay? I know you will.”

“You got it.” We all bump elbows and they stand to leave. “Oh, yeah. And doesn’t abortion kill more people than COVID-19?” 

“Oh, look at the time! Really good to see you both,” I say. I sense our conversation will continue.

Bruce H Campbell, MD FACS is a Professor of Otolaryngology and Communication Sciences and Associate Director of the MCW Medical Humanities Program. He is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He serves as Editor of the Kern Transformational Times newsletter.

Telehealth at the Saturday Clinic

From the 7/10/2020 newsletter

Student Perspective

Telehealth at the Saturday Clinic

Spenser Marting, SCU Board Chair, MD-Candidate

Medical Student and SCU Board Chair Marting reflects on the impact of COVID-19 on the Saturday Clinic for the Uninsured...

“I don’t know.” Just a few days after Milwaukee’s first confirmed case of COVID-19, I hesitated to give an authoritative answer on whether Saturday Clinic for the Uninsured (SCU) would close for an indefinite period. While the course of the pandemic was yet unclear, I felt it imperative that SCU continue to stand with the vulnerable communities it serves. This was also a commitment that Dr. Rebecca Lundh, the SCU Medical Director, was passionate about as well. After countless COVID-19 update emails, an emergency board meeting, and several phone calls with Dr. Lundh, the plans to offer Telehealth appointments in partnership with the MCW M3 Family Medicine Clerkship were set in motion.

The Start of Telehealth at SCU

The first week back from spring break was hectic. While M1s and M2s “returned” to classes and their studies after break, I was coordinating with other SCU Managers, many of whom were in other states, to adapt SCU services into a new workflow. We worked to provide guidance to M3s on how to conduct Telehealth appointments, which would all be precepted by Dr. Lundh on weekdays. As the week went on, we began communicating with our patients about the clinic’s COVID-19 changes, the M3s and a few former managers began “seeing” patients remotely, and we revised our Saturday operations to safely dispense medications and provide essential in-person care to patients seen by Telehealth in that same week.

Our system for Telehealth has continued to change since its inception in late March. Multiple clerkships have rotated through SCU Telehealth, and we modified our procedures based on their feedback. We trained volunteer physicians in Telehealth to ensure a more sustainable model. Clinic workflows were revised again to safely bring students back to clinic for limited in-person

care in June. And, last week, we finished training our first cohort of 14 M2s on SCU Telehealth, marking our transition from relying on clerkship students (who are now returning to more traditional clerkship settings) to bringing our peers alongside us to fulfill our mission. We continue to learn and adapt.

This has been a Team Effort

While developing this program and responding to the pandemic has – at times – been exhausting, SCU Telehealth has afforded myself and others the privilege of being proximate to patients. It has enabled me to witness the effect that this double pandemic of COVID-19 and racism has on the lives of individual SCU patients. That we have been able to continue providing uninterrupted care to patients during this pandemic is a success that I am deeply proud of. This has not been the case for most other student-run free clinics. Dr. Lundh has been instrumental in making SCU Telehealth a reality through her mentorship and inspiring dedication to health equity and patient care. We also build upon the work of SCU Boards who have gone before us and created a system that we could adapt to respond to this crisis. And, lastly – I am grateful for the 12 managers on our board and our volunteers. They have been asked to give more than they signed up for and have done so with much grace.

Next Steps

SCU Telehealth came together through a group of students and faculty who worked to address an immediate need. We invite you to join us in doing the same. SCU is looking forward to involving new M1 and P1 students in clinic this academic year, both in a variety of volunteer roles but also as clinic managers. To my rising M2 colleagues, in addition to on-site volunteer roles, please consider volunteering with SCU this Fall by conducting Telehealth visits since the majority of patients will likely be seen virtually rather than in-person. We always appreciate innovative ideas for Quality Improvement and Research and invite all members of the MCW community – faculty, student, and staff – to reach out to us with ideas for partnership.

Spenser Marting is an MCW-Milwaukee medical student and SCU Board Chair.

The Issues of Bostock and the Supreme Court Ruling on LGBTQ Health

From the 7/10/2020 newsletter

The Issues of Bostock and the Supreme Court Ruling on LGBTQ Health

Jesse M. Ehrenfeld, MD, MPH, FAMIA, FASA

Dr. Ehrenfeld explains what the recent US Supreme Court decision – Bostick v. Clayton County – does and does not mean for people who identify as LGBTQ, and offers ways to get involved at MCW and beyond…

On June 15, 2020, the U.S. Supreme Court announced a historic ruling that has catapulted America and LGBTQ equality forward by guaranteeing equal opportunity for LGBTQ people in employment. The 6-3 Bostock v. Clayton County decision is likely to lead to more changes in courts at all levels across the nation in the coming weeks and months. I’ve been asked to give some perspective on the impact of the ruling, and what this means on the journey for complete LGBTQ freedom in America.

What We Won

The Supreme Court ruled that Title VII prohibits workplace discrimination based on sexual orientation or gender identity. This is an important change in that while Title VII has long prohibited sex discrimination, the Supreme Court has now interpreted the law more broadly to protect LGBTQ people. The ruling indicates that sex discrimination includes discrimination on the basis of sexual orientation or gender identity.

Because of this expansion of how sex discrimination is now interpreted in relation to Title VII, I expect that a number of other in-progress lawsuits around the nation will also soon provide important nondiscrimination protections in similar laws where sex discrimination is banned. Key examples include health insurance (Affordable Care Act), housing (Fair Housing Act), credit & lending (Equal Credit Opportunity Act), and higher education funding (Title IX). These are a few examples that are among dozens which are embedded in other state and federal laws which prohibit sex discrimination.

What We Didn’t Win

There are a number of areas where LGBTQ people still lack any protection in federal law, because sex discrimination is still not prohibited by statute. Within the Civil Rights Act, Title II covers business services and public accommodations. Unfortunately, Title II does not provide any protection against discrimination on the basis of sex – and therefore is not likely to be interpreted as providing protections for discrimination against LGBTQ people.

There are also no protections for sex discrimination in Title VI, which is the federal law that bans discrimination across all federally funded programs and services. Again, since it has no prohibitions against sex discrimination, there are no current protections for LGBTQ people in the important areas covered by Title VI – which are effectively any program that receives federal funding (including thousands of state and local government-sponsored programs and activities).

It should be clear then why there is still an important, urgent need for federal legislation that codifies the Bostock decision and provides nondiscrimination protections to sex, sexual orientation, and gender identity. The Supreme Court ruling also does not provide any guarantee of equal opportunity for military service for transgender individuals – an issue near and dear to my heart (see link).

Finally, the ruling does not protect children from being subjected to conversion therapy, a practice that – while widely discredited by every major reputable medical society in the U.S. – still persists. Conversion therapy attempts to change an individual’s sexual orientation, sexual behaviors, or an individual’s gender. Underlying these techniques is the assumption that homosexuality and gender identity are mental disorders and that sexual orientation and gender identity can and should be changed. It is estimated that in the U.S. approximately 57,000 youths will receive these type of change efforts before they turn 18 years old.

What You Can Do

As physicians, health care professionals, educators, and trainees we must weigh in on these important issues around health equity and LGBTQ equality. Legislative action is needed to expand and codify protections against discrimination, and our voices are essential to this work.

Outside of legislative action we, as biomedical and population health researchers and health care providers, can continue to use science to push for progress. At the Advancing a Healthier Wisconsin Endowment, the statewide health philanthropy established by MCW, we invest in projects that are working to understand and address health disparities, including disparities among the LGBTQ population. We are striving to do more to build a healthier future for all marginalized populations, including LGBTQ people.

As educators, training the next generation of researchers and health care providers, we can insist on inclusive training standards. This is in fact the subject of a forthcoming perspective piece, in Academic Medicine, which will be published later this month.

As coworkers, supervisors, and mentors we must be visible allies and advocate for our LGBTQ colleagues. Add your name to the list of allies through the MCW Academic and Student Services webpage. Share with your entire departments the MCW employee resource groups available to support them, including the newly created MCW LGBTQ Resource Group (here are the announcement and contact information). Do everything you can to build a welcoming workplace where students, staff, and faculty can be their true selves each and every day.

We can take action today to make change. Otherwise, we may be waiting another hundred years for court cases to work their way through the judicial process.

Jesse M. Ehrenfeld MD MPH FAMIA FASA is a Professor of Anesthesiology at MCW. He serves as Senior Associate Dean & Director of the Advancing a Healthier Wisconsin Endowment.

Kern Institute Renovations Under Way! Three New Labs, One New Pillar, and a New Post-Doctoral Fellowship!

From the 7/10/2020 newsletter

Director's Corner

Kern Institute Renovations Under Way! Three New Labs, One New Pillar, and a New Post-Doctoral Fellowship! 

 

 

Adina Kalet, MD MPH

 

In this week’s Director’s Corner, Adina Kalet describes changes to the structure of the Kern Institute that will supercharge the transformational work of the Kern Institute... 

 

 

Laboratories

 

It is with great excitement that I announce that the Kern Institute will now have three new  laboratories: 

• Medical Education Data Science Lab led by Tavinder Ark, PhD and profiled in the Transformational Times on June 19^th,
• Human Centered Design Lab led by Chris Decker, MD and Julia Schmitt.
• Philosophies of Medical Education Transformation Lab led by Fabrice Jotterand, PhD. To learn more, see the “Director’s Corners” on Practical Wisdom (April 10^th) and A Philosophy of Medical Education Transformation (May 8^th). 

 

 

Laboratories are places where people work together to understand how the world works. They are also relatively small bands of people who – with a range of specialized expertise and sometimes funky new equipment and technology – work  together with stakeholders to engage in experimentation, teaching, and wide-ranging and deep conversations. Where cross-disciplinary scholarship is conducted and disseminated, graduate students as well as mid- and late-career colleagues are nurtured. 

 

According to Wikipedia, the earliest laboratory belonged to Pythagoras of Samos, the Greek philosopher and scientist, who conducted experiments that discerned the different sound tones produced by the vibration of string. So, we join an ancient tradition of enabling those with deep curiosity to ask important questions and seek answers.  

 

 

Pillars

Our pillars are just that: the mainstays of the Kern Institute. The equivalent of divisions in a clinical department, pillars represent our stakeholders. 

• The Student Pillar, led by Catherine “Cassie” Ferguson, MD and Cassidy Berns, designed, implemented and now leads the REACH curriculum. This pillar houses our work on Holistic Admissions. It focuses on enhancing equity and belonging for all our students in our effort to become an anti-racist organization.
• The Faculty Pillar, led by Alexandra Harrington, MD and Vivian Dondlinger, builds MCW’s capacity to transform medical education through the rigorous KINETIC³ faculty development program, and will be the home for our Kern signature coaching program.
• Under the guidance of Jose Franco, MD and Joan Weiss, the External and Internal Community Pillar (profiled in the “Director’s Corner” on May 1^st) will work to enthusiastically engage all of our communities – especially patients – in the work of educating the next generation of physicians.
• In his leadership of the Outcome Based Medical Education Pillar (formally known as the Curriculum Pillar), Martin Muntz, MD and Kaicey von Stockhausen express deep commitments to ensuring a culture of psychological safety while building systems and structures to support learners aspiring to become masterful physicians ready to serve in this rapidly evolving health care environment. 
• Moving forward we are adding a Graduate Medical Education Pillar that will engage this critical stakeholder group in the work of the Kern Institute and ensure we are working all across the medical education continuum to build strong institutional alliances. This pillar’s leadership will be announced soon.

 

 

 

Postdoctoral Fellowship

 

Finally, I want to ask for your help in identifying candidates for the new Kern Institute Postdoctoral Fellowship in Transformation of Medical Education. Creating this postdoc is a first step in building a nationwide capacity working to transform medical education. By defining enhanced career paths for PhD-prepared foundational scientists, we will create the next generation of leaders that will reimagination curricula and support cutting edge pedagogies to integrate foundational and clinical sciences. We want to attract an enthusiastic scientist and teacher who will roll up his or her sleeves and create effective, inspiring methods ensuring that future health professionals have solid foundations of scientific knowledge.  

 

The announcement for the position is here.

 

 

 

Stay engaged!

 

We invite you to read and to contribute to future issues of the Transformational Times as we collaborate and learn, working through our Pillars and Labs to turn aspirations into realities. 

 

 

 

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.