Racial Discrimination in Academic Surgery: A Webinar Presented by the Association for Academic Surgery

From the 7/24/2020 newsletter

Racial Discrimination in Academic Surgery: 

A Webinar Presented by the Association for Academic Surgery

Eileen Peterson, MD Candidate 2023

Associate Editor

Background

This webinar was one in a series of town halls with the goal of changing the landscape of academic surgery. The town hall was led by two session moderators, Callisia Clarke, MD of the Medical College of Wisconsin and Colin Martin, MD of the University of Alabama Birmingham, and five panelists from across the nation. As the chair of the Diversity, Equity, and Inclusion (DEI) Task Force for AAS, Dr. Clarke stated that the AAS is looking for “not just discussions but solutions” within the academic surgical workforce.

Speaker 1 – Yue-Yung Hu, MD

Dr. Yue-Yung Hu, a pediatric surgeon at Northwestern University, spoke on the prevalence of racial discrimination amongst surgical trainees. Dr. Hu discussed data published in JAMA Surgery in April 2020, which was collected from 6,956 resident surveys after the 2019 ABSITE exam with an 85.6% response rate. Of note, the study found that 41% of non-white general surgery residents reported racial or ethnic discrimination. Of those who reported discrimination, 71% were Black, 46% were Asian, and 25% were Hispanic. In addition, discrimination is associated with higher rates of burnout, thoughts of attrition, and suicidality.

Hu also discussed the SECOND Trial. This is a prospective randomized trial across 215 residency programs to assess diversity and resident well being while providing a toolkit of strategies to improve the learning environment for residents. The SECOND Trial is also currently compiling resources on implicit bias training.

Speaker 2 – Erika Adams Newman, MD 

“We will look back and our children will look back and say, ‘How did we respond, what did we do, what changes were we engaged in?’ both individually, within our institutions, and within our organizations.” Erika Adams Newman, MD, a pediatric surgeon at Michigan Medicine, discussed faculty-level racial discrimination as it leads to barriers to retention and promotion. When looking to improve equity and reduce discrimination, Dr. Newman encourages departments to look at their demographics and ask what message it sends by having only a few people of color and also fewer women within a department.

Newman suggested Grand Rounds as a great way to increase diversity, raise consciousness, and push the envelope. Through the introduction of The Michigan Promise in 2017, Michigan’s Department of Surgery has diversified their recruitment committee, increased mentorship, and implemented bias and cultural competence training in order to seek out sustained change. 

These are just a few ideas for programs. Dr. Newman stated that good intentions are not enough because “how can we achieve excellence without being diverse?”

Speaker 3 – Justin Brigham Dimick, MD, MPH

Justin Brigham Dimick, MD, MPH, the Department of Surgery Chair at Michigan Medicine, posed reflective questions for non-minority audience members on the topic of earning the title of bystander or ally.

1. Have you come to terms with your privilege? If you can see an event in the news and be complicit, returning to work and acting like nothing has happened, that is privilege. Educate yourself. Read any of the bestselling novels about racism and discrimination. Don’t ask the minorities in your department to teach you.

2. Do you see implicit bias everywhere you look? What are you doing to interrupt  and remove these biases from the workplace?

3. Who are you mentoring and sponsoring? Do your mentees look like you? What signals are you sending when broadcasting your mentoring?

4. If you are a leader, are you creating space in your program’s curriculum for discussing implicit bias?

5. Are you able to go beyond the title of bystander and work to become an upstander? As an upstander, you can use your power and platform to change policies and procedures to be equitable.

Speaker 4 – Oluwadamilola “Lola” Fayanju, MD, MA, MPHS

Oluwadamilola “Lola” Fayanju, MD, MA, a surgical oncologist at Duke University, discussed surgeons’ obligation to address healthcare disparities  through research. Dr. Fayanju stated that currently, African-Americans and Latinx are overrepresented in Phase I Trials and underrepresented in Phase III trials, suggesting failure to convey goals of Phase I studies and enrollment bias in Phase III trials. More efforts need to be taken to prioritize recruitment and inclusion of racial/ethnic minority patients who are disproportionately affected by various diseases. In addition, disparities need to be incorporated into  studies at concept inception rather than tacked on during statistical analysis. 

Dr.Fayanju offered three suggestions for researchers going forward: 

1. Be humble: Get more training.

2. Be collaborative.

3. Be intentional: Who are your collaborators, statisticians, and study team members? Who is at the table when decisions are being made?

Speaker 5 – Eugene Kim, MD

Eugene Kim, MD, a pediatric surgeon at Keck School of Medicine of USC and President of AAS, discussed the AAS Commitment to Addressing Racial Discrimination in Academic Surgery. Recent efforts by the AAS include the creation of the DEI Task Force in 2019 as well as implementing open elections and self-nomination for committee chairs. Within the Executive Council,  the AAS has seen increased diversity at the levels of institutional, surgical specialty, and research background, but the AAS still needs to see more diversity  in race and gender within committee appointments and chairs. The AAS is also

increasing their mentorship efforts. They will be hosting sessions for underrepresented minority surgeons-in-training to meet with AAS leadership.

You may email Dr. Kim at eugeneskim@chla.usc.edu with your thoughts and ideas on increasing diversity of AAS.

 

Conclusions

Reach out to Dr. Clarke on Twitter @DrCNClarke with suggestions, ideas, or questions. The full AAS webinar can be accessed at https://www.aasurg.org/racial-discrimination-in-academic-surgery/

Eileen Peterson is a medical student at the Medical College of Wisconsin and serves as an Associate Editor for the Transformational Times.

Mentoring Toward Purpose and Meaning: Helping our students retain their passion for medicine by asking Why?

From the 7/24/2020 newsletter

Mentoring Toward Purpose and Meaning: Helping our students retain their passion for medicine by asking Why?

Adina Kalet, MD, MPH

In this week’s Directors Corner, Dr. Kalet reminds us that focusing on well-being alone is not enough. Our students want and need mentoring on how to make a purposeful and meaningful life in medicine, especially in these tumultuous times …

“...Tell me, what is it you plan to do with your one wild and precious life?” 

From "The Summer Day" by Mary Oliver

Becoming a physician is challenging in all ways. And yet it is a choice. Even the most optimistic medical student will have moments of great distress and doubt, and they will - and should - seriously question their choice of life path from time to time. After all, while it is a privilege to join a profession which offers the possibility of a lifetime of meaningful work, it is not a career for everyone. There are many ways to make a satisfying life. Pursing the practice of medicine when it is not what you really want to do can be tragic for the practitioner, their family and their patients.

While we are sometimes faced with trainees and colleagues who need compassionate off-ramps from medical training or practice, the vast majority of our matriculating students can safely assume they will become practicing physicians. This is why regular opportunities for recommitment to, and for the reexamination of life goals, is as much a critical wellness practice as taking time to exercise, eating healthfully, practicing mindfulness and compassion, and laughing regularly. But, like other wellness practices, most of us need support and encouragement to do what is good for us.

Get to the Heart of the Matter by asking Why? Why? Why?

I first participated in an exercise call "The History of the Future" in 2010, as a participant in the Hedwig van Ameringen Executive Leadership in Academic Medicine® (ELAM®) program, and have since used it hundreds of times with students and colleagues since then. This is a simple practice to help a student or colleague plan well for their future. It goes as follows:

I hand them a piece of paper on which I have scribbled today’s date at the bottom and this same day five years from now on the top with six dates in between as follows:

My History of the Future

July 24, 2025: Celebrate what? With whom? 

July 24, 2024:

July 24, 2023:

July 24, 2022

July 24, 2021:

6 months from today: 

2 months from today: July 24, 2020 (today)

I hand them a pen and give the following instructions:

"Imagine it is exactly five years from today, you are celebrating a personal accomplishment. What are you celebrating? And who are you with? Write these things next to the date. Then work backwards in time, down the page. Make brief notes on what you will need to be doing on those dates in order to make sure you have something to celebrate in five years."

Then I stand up and prepare to leave the mentee alone with the task for at least ten minutes.

Invariably, before I can leave the room they ask, “Do you mean a personal or professional celebration?” I turn back and say, “Yes! Both! And by the way, don’t hold yourself back or feel intimidated, because this is pure fantasy, the future never happens as we plan, so don’t sweat it.”

Then I go get a cup of coffee. When I return, they are either writing furiously, or tapping their pen on the desk looking pissed. I sit across from them and ask, “So tell me, what are you celebrating and with whom?”

I have found that debriefing this exercise almost always helps mentees imagine and plan for a desirable, purposeful future. Even when - especially when - they have no idea what they want! It also always guides me away from the common mentor pitfalls of talking too much and providing well-intended but irrelevant advice. According to the leaders of the Center for Applied Research who taught me this approach, research suggests that people develop more vivid stories when asked to think about a situation in the past tense. Doing this helps individuals think more concretely and realistically about how to create the future they want, especially because it enables them to think about weaving together different strands of growth and development - like personal and professional goals - that need to occur to achieve that future. This method is similar to strategies used successfully with other mastery-oriented competitive athletes, gamers (like Chess Olympiads) and concert musicians.

There is a trick to getting to the heart of the matter in very brief conversations. When the mentee describes their “celebration” and describes who they are celebrating with, I listen carefully. Only then do I ask, as benignly as possible, “Why?”

There is often a long silence. Eventually the student gives an answer, “Because I am my parents’ only child,” or “Because I want a big family," or “Because I have worked for this my whole life," or “Because, I am an introvert and much prefer very small gatherings.” No matter what they offer, I nod, encouraging them to elaborate until I can reasonably again ask, “Why?” And so on, until we have done this at least five times (The 5 Whys). With each cycle the answers get deeper and more authentic. Almost always we end up discussing if and how they will be courageous enough to stay the course or choose a new path, perhaps the one “less traveled by” that will be worth their “one wild and precious life.”

Once we are sure we understand why the student wants to be celebrating what they are celebrating we drop down the page to the line that reads “two months from today,” and talk about possible next steps. At that point I might give some advice. I always recommend they keep the piece of paper. These are career conversations worth having from time to time.

Learning Environments that are Communities

It is our obligation as medical educators to graduate people ready and able to practice medicine in a rapidly changing environment. What does this mean? I believe that in addition to ensuring mastery over the knowledge and skills required - a tall order in and of itself - we must also attend to the character and spirit of the developing physician. This is because every one of us deserves a physician who is capable of both deep thinking, technical skill and feeling, an individual who has the capacity to care for us even if we do not share a culture, color or gender, through a wide range of personal health challenges, across a lifetime. We need physicians capable of empathy and with a strong sense of purpose and meaning in their work. This is not a guaranteed outcome of our medical education system, it takes a community of committed students, their families, educators, staff and patients willing to have those deeper, more difficult conversations. There will be a necessary dialectic between this idealistic vision and the practical realities - but we need both to ensure progress and accountability toward a better set of outcomes for the health of our communities.

In this issue of the Transformational Times, Cassie Ferguson, MD, Kurt Pfeifer, MD, Marty Muntz, MD, Cassidy Berns, and Kaicey von Stockhausen share the justification and basic plan for building a Learning Community structure for MCW. This is one doable way that we can keep trainees in touch with why they have chosen their path.

My 2010 "History of the Future" still hangs on the refrigerator door to remind me of the old saying “best laid plans of mice and men often go awry.” While the details were fantasy, I remain on the path to ensuring all of us have access to remarkable physicians.

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.

Becoming Uncomfortable

From the 7/17/2020 newsletter

 

 

Becoming Uncomfortable

 

 

Bruce H Campbell, MD 

 

 

Dr. Campbell sees parallels in how societal dynamics are at play in two different realms of his life …  

 

 

As a surgeon, I have made mistakes that have hurt people. I hope that this fact is not surprising to anyone since, besides being a surgeon, I am also a human being. I have never hurt anyone in the operating room intentionally but, over the years, I am certain that there have been more people harmed than I realized. 

 

What happened? Certainly, I never deliberately waded into cases where I knew I was in over my head, but there have been instances where I was inadequately or improperly prepared. Maybe there was a gap in my training. Perhaps I missed a critical experience along the way that would have led me down a different path. Maybe I overlooked an article. Maybe the science had not yet taught us the proper way to care for a specific problem. Maybe I blundered or slipped or got lost. Maybe I should have operated but recommended against it. Or vice versa. Over the course of a thirty-year career and thousands of surgical procedures and patient encounters, I have done my best. I know, however, that for  some people, my decisions have led to harm. 

 

 

To reassure myself, I have tried to stay at the top of my game. I attend regular Morbidity and Mortality (“M&M”) Conference to discuss complications. I participate in “root cause analyses” to find systemic problems that lead to errors. I listen to patients, families, and staff when there are concerns. I have enlisted others to watch and make certain that my skills remain up to the task even as I age. I believe, along with Hippocrates, that all physicians should live by the dictum: primum non nocere, or “first, do no harm.”  

 

Nevertheless, I live with the knowledge that there are people out there who will always remember me as the person who hurt them. I always considered this to be part of what I do for a living.

 

 

The instances of physical harm I have caused during my surgical career have come to mind recently as I have engaged in conversations about how our implicit racial biases also cause harm. Like many white people, I have never thought of myself as racist. I am an older, white, cis-gendered, straight, abled male recipient of a suburban white-privilege upbringing. I knew (and had spoken to) very few African Americans until I got out of high school even though my youth was spent in a suburban region actively trying to integrate. On the other hand, my parents were in a club that allowed full membership only to men and, until I was older, included no Blacks, Catholics, or Jews. That seemed normal to me.

 

As a teenager back in the early 1970s, I worked as an orderly in a hospital emergency room on the border between my white suburb and a Black city neighborhood. Although I rarely noticed, my role models – the physicians, nurses, and police officers – treated Black patients and employees differently than they did white ones. I watched and learned. That seemed normal to me. 

 

I do have a vivid memory of a conversation I had with a white police officer whom I knew well. I must have been uncomfortable with how he approached a Black patient; I don’t remember the circumstances, but I do remember what he said. “Y’know,” he told me, “you suburban kids love the race but hate the individual. I love the individual and hate the race.” Oh, I thought. That seemed normal to me. 

 

One day, one of the other Emergency Room orderlies, a Black man, walked in on the tail end of my comments about a Black patient. I stopped abruptly. I remember the sinking feeling in my stomach. What had I said? I wondered. Did he hear that? We never talked about it. 

 

As I matured, I had more Black friends, acquaintances, trainees, students, and colleagues. In retrospect, I don’t remember ever speaking of race with any of them. Just as with surgery, I know I made mistakes. 

 

I have committed microaggressions. I have remained silent when hearing others make remarks that should have been called out. I am certain I have made thoughtless – what I considered at the time, innocent – comments. Although there were never any M&M conferences or formal reviews of mistakes I made as I interacted with Black people, I tried to approach the racial divide between us in the same way I approached surgery: I hoped each opportunity would make me better. I saw nothing wrong with what I was doing. It was “about me,” after all.

 

 

Then I read Ijeoma Oluo’s book, So You Want to Talk About Race. She challenged me to look at myself in new ways and set me straight. Here is what she writes: 

 

“To many white people, it appears, there is absolutely nothing worse than being called a racist, or someone insinuating you might be racist, or someone saying something you did was racist, or someone calling someone you identify with a racist. … 

 

“You may be now insisting that you do not have a racist bone in your body, but that is simply not true. You have been racist, and will be in the future, even if less so.  … 

 

“You cannot tell someone to deny the harm you’ve done to them … It sucks to know that to some people you will forever be the person who harmed them.” 

 

 

Ms. Oluo helped me realize in a new, convicted way how my life experiences have shaped me in ways I never before perceived, both as a person who grew up with white privilege and as a physician afforded the upper hand in doctor-patient relationships. I have hurt people and failed to pause and fully recognize the damage I have caused. I have not always taken ownership of the consequences of my actions. Even though I have “felt bad” at times both in medicine and in life, I now realize how easy it has been to forgive myself and move on.

 

 

I suspect I am not alone. It is time to check our privilege. It is time to become more comfortable with being uncomfortable. It is time to apologize. It is time to be an ally. 

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.

Never Waste a Crisis! Now is the Time to Build Learning Communities

 From the 7/17/2020 newsletter

 

Director’s Corner

 

 

Never Waste a Crisis! Now is the Time to Build Learning Communities

 

 

Adina Kalet, MD MPH

 

 

 “In this week’s Director’s Corner, Adina Kalet argues that we must embrace the moment by making educational technology work for us and ensuring that the learning communities we create put our students on the path to becoming masterful physicians…”

 

 

We face an existential crisis in education. Because of the pandemic and social distancing, educators need to focus on the essentials: life, health, and the creation of robust learning communities designed to enable our students, teachers and institutions to thrive during these tumultuous times. 

 

The strategies to accomplish this are well understood and readily available, but there are unknowns. The federal government is insisting that all K-12 schools must open this Fall. In fact, any rapid recovery of the economy, if possible, will depend on children returning to the classroom so that parents can return to work. However, completely reopening all schools may put children’s and adult’s lives at risk. 

 

As of last week, two-thirds of US colleges had decided to reopen their campuses for the Fall term. My daughter, niece, and nephews will be on-campus soon, anticipating and needing social connections with peers and teachers. Faculty and students thrive in active learning communities, but university faculty are concerned that reopening might lead to life-threatening consequences. 

 

Can colleges and universities create meaningful learning communities at a “distance”? Although some depend less on tuition dollars for short term survival than others, many schools are justifiably worried that education will suffer and that students will balk at paying full tuition for an “online only” education. Evidence demonstrates, though, that people value (and therefore will pay for) high-quality distance learning. Virtual education fails if it simply deliver lectures and other routine elements of existing curricula to laptop screens filled with squares of bored faces. High-quality distance learning maximizes learning by deploying carefully crafted instruction in a socially nurturing community even if the learners rarely, if ever, meet face-to-face. It focuses on both individual and collaborative peer learning and enables close, meaningful connections with teachers. 

 

 

Teaching virtually

 

I am experiencing high-quality cyberspace learning, right now. 

 

I co-direct the US site for a premier international Master’s in Health Professions Education (MHPE) program which has been predominately virtual for almost thirty years. It is organized into twelve units, two of which are designed to be synchronous in-person experiences, while the other ten units remain open until all assignments are submitted and the final grade awarded. While the program is designed as a two-year, thesis-required program, students have up to five years to complete the degree.  

 

At this moment, I am teaching in an intensive, full-time, three-week course in qualitative and quantitative research methods. Although my class was designed to be taught in a classroom, we are meeting entirely on Zoom. This has turned out to be as much fun as being in a room together. I have been delighted to see that the virtual platform leads to as much if not more learning when compared to my face-to-face experiences over the past five summers. 

 

Despite the fact that my students and I are rarely in the same place, I know them well. I was involved in recruiting them into the program and I taught them last year in the introductory medical education unit. I provide feedback in our ePortfolio. I have mentored a couple of them one-on-one, heard about their progress at weekly faculty meetings, and will follow each of their thesis projects from now until graduation. 

 

Although the students work in different institutions, health professions, clinical disciplines, and time zones, they also know each other well. They started this two-year program together as a cohort and continue to collaborate on assignments. They take advantage of Google Docs (free). They support each other, share questions, frustrations, and personal celebrations on What’s App (free), Facebook (free), and other social network platforms. In Zoom, they are respectful of each other, smile a lot, and share inside jokes. The student who is pregnant with twins gets advice, support, and empathy. 

 

Working virtually has not dampened collaboration. Each of the students works independently on their thesis project, but they share their work with the group at weekly seminars. They work in pairs and threes on reading and writing assignments. They meet one-on-one with mentors and thesis advisors. I lead the course and attend as many of the group sessions as possible to monitor each student’s growth and make connections across the course material. The six faculty – some compensated and some volunteer – teach as a team. We have our own relationships with the students and with each other. We are – the teachers, students and staff – a “learning community.” 

 

 

Harnessing and enhancing technology

 

Technology bridges continents. Many of the most agile US universities and medical schools have globally distributed campuses where students in New York City or Boston share classes and faculty members with students in Shanghai, Abu Dhabi, Paris, Prague, or Brooklyn. Our own MCW students in Central Wisconsin and Green Bay attend synchronous foundational medical sciences lectures with their peers in Milwaukee. The infrastructure and comfort with technology is available. 

 

The “new normal,” though, can lead to a sense of grief and loss and many, if not most, traditional educators believe being physically present with their students enhances their craft, effectiveness, and satisfaction. I agree! I love to dance across the stage and draw on the board while making eye contact and inviting individuals to engage in the material about which I am passionate. 

 

Putting face-masked professors behind Lucite-barriered podiums with students dotted at six-foot intervals is not the answer, but our current distance learning alternatives are not perfect, either. For example, when our regional campus students are linked into the lecture halls in Milwaukee, they sometimes report that camera angles make them feel as though they are “in the cheap seats,” and find that some lecturers forget that the off-site students are watching. We can find better ways.

 

Contrast this with how the BU Executive MBA brings teachers and students into close virtual contact at almost life-size, enabling teachers to physically move, write on the board and read non-verbal expressions. The Kern Institute is building a learning lab where ideas like these can be turned into working models and studied. Faculty can be nurtured to enhance their capacity to connect with students. With some investment, we can address the need for educational engagement without endangering lives or hog-tying professors. By working together intentionally, we will develop prototypes of relationally sophisticated and technologically-sufficient learning communities.  

 

 

Building learning communities

 

With careful attention to explicitly building learning communities that attend to the social and emotional needs of both learners and teachers, education can be a very exciting enterprise even when we can’t all be together in the same room for long periods of time. 

 

Learning communities are not a new idea in medical education. Since being first introduced at the University of Iowa Carver College of Medicine in the early 1990s, over forty US medical schools have embraced this approach to create effective, supportive learning environments which structure longitudinal personal relationships between learners and teachers for the purpose of integrating knowledge and clinical skills. The community nurtures the growth and development of a healthy professional identity essential to becoming a masterful physician. 

 

In the Kern Institute, we have begun building the elements of this “learning community” approach through our REACH curriculum under the leadership of Catherine Fergusson, MD and the 4 C Coaching program led by Kurt Pfeifer, MD. Collaborating with Lisa Cirilo, PhD, the MCW Assistant Dean for Basic Science Curriculum, and the Office of Academic Affairs, we are working to rapidly integrate with existing programs so that students who come to campus (literally or virtually) over the next weeks will be welcomed into communities that provide a sense of belonging, caring and collaboration. 

 

 

The broader challenge

 

The past few months have proven that we do have the technology and educational science to enable smooth transitions to highly blended, largely virtual instructional environment. If we attend to making certain our students can afford and have access to the technology in safe settings and must come together only when “hands on” experiences are critical – such as in human anatomy labs and clinical skills instruction – we can learn from this moment and keep our learners and teachers safe. 

 

The day will come when we are all back in the classroom together. In the meantime, we must use this opportunity to harness technology, innovate educational approaches, build character, strengthen our learning communities, and transform medical education.  

 

 

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.