Why We Need More Black Male Physicians

From the 8/7/2020 newsletter

Resident Reflection 

Why We Need More Black Male Physicians

Victor Redmon, MD - MCW Med-Peds resident 

Dr. Redmon shares some of his experiences as both a medical student and a resident physician, followed by his reflections regarding the encounters…

My name is Victor Redmon. I was born and raised in Florida – and although I was well-traveled, I had never lived outside of the state until I came to MCW for medical school in 2013. I stayed here for internal medicine-pediatrics (Med-Peds) residency, for which I am now in my fourth and final year. I will be serving as chief resident of MCW’s Med-Peds program for the academic year of 2021-22.

 June 2016 – A Black Patient and His Family 

I am at the end of my third year in medical school and one week into my acting internship in the VA ICU. The ICU fellow receives a call to transfer a patient from the acute care floor to the ICU due to concerns for sepsis in a cancer patient. As the “intern” on the team, I eagerly accept the responsibility of taking the admission. I do a brief chart review and go to meet the patient and to gather more history. He is a Black male veteran, early 50s, frail and cachectic (characterized by physical wasting with loss of weight and muscle mass due to disease). 

I introduce myself to him. “Hello, I am Victor Redmon and I will be part of the ICU team caring for you downstairs.” He looks me up and down. 

He responds, “You mean I’ll actually have a Black doctor taking care of me? Well that’s all right,” he says with a smile. 

I meet various members of his family over the ensuing weeks, most of whom shared the pride and adoration that they had a Black male caring for their loved one. I continue to take care of this patient for the remainder of the month. He had a long and complicated ICU course, as he was dying and at the end stage of his cancer course. 

We conduct several family meetings to discuss goals of care and code status. The ICU attendings and fellows did an excellent job facilitating the meetings and the family felt well informed. I was called to his bedside after one of these meetings. “I was told you had some questions for me,” I said as I entered the room. “Hi! We just wanted your medical opinion on what we discussed during the family meeting. What do you think we should do?” 

Being a medical student at the time, I was completely caught off guard with such a heavy question. I responded with the same answers my attending and fellow provided earlier. 

The family says, “Okay, thank you, doctor. We just wanted to hear it from you because you are one of us.” The patient passed away on my last day of the rotation. 

April 2020 – A Black Hospital Employee and His Words 

I am now a third-year resident serving as a senior resident for one of the inpatient pediatric teams. Like most days in the hospital, it has been very busy with admissions and duties on the medical floor. I had also not eaten breakfast or lunch and was starving by midday. I informed my interns that I was headed to the cafeteria for lunch and would be back soon. I head to the elevator and notice an environmental services worker waiting as well. He was a Black man, likely early to mid-20s. The elevator arrives and I gesture for the worker to get on first, since he had equipment to haul around. He says, “Thank you, doc” and gets on the elevator. 

I notice him staring at me and decide to make some small talk. I ask, “So how is the day going for you so far?” 

He responds, “Not too bad, just another day. Are they treating you well here?” 

I respond, “My work is busy, but all things considered I am very happy here.” 

He says, “Good, I am glad to hear it. Do you know how rare it is to see a Black male doctor?” The elevator dings and the worker says to me as he exits, “I’ll see you around, doc. Keep up the good work. I am proud of you, I really am.” 

I respond, “Thank you, brother. I’ll keep doing the best I can.” The elevator doors close. I am alone. 

July 2020 – A Reflection on What Needs to Change 

 I have had numerous interactions similar to what I’ve described above, but these two encounters I remember very vividly. As a medical student, I viewed these interactions as a source of pride and empowerment. My Black patients truly trusted me and related to me in a different way than they could with my non-Black colleagues. I have come to recognize the position I am in. No longer am I just any medical student and no longer am I just another resident or trainee. I represent a source of pride and encouragement for the Black community. Truly, this is humbling. However, as I matriculate through my training, I ask myself more and more, “How and why?” Although I still feel a sense of pride and encouragement, I also have feelings of disappointment, sorrow and isolation. 

Through my experiences in training, I have become increasingly aware of the impact of underrepresented in medicine (URM) physicians when taking care of their representative patient population. Of course, this is not a new concept. Many medical schools and graduate medical education programs, including MCW and Medical College of Wisconsin Affiliated Hospitals (MCWAH), have initiatives and policies in place that are centered around diversity. Yet, I believe that largely there has been little to no progress. 

There have been many published studies that reflect the lack of progress with diversifying the racial-ethnic population of the medical schools and academic medical centers since the 1990s. Similarly, there are well-published studies illustrating the positive impact URM physicians can have with both the underserved population and their representative population. URM physicians play a pivotal role in providing care where it is needed the most, which has been well documented and proven in several landmark studies. I believe there is a general intent to diversify our medical student and GME population in order to be more representative of the population we are serving. Yet, I consistently see that diversity takes a clear back seat to academic achievement, which is defined by grades and standardized test scores. 

My sentiments are not universal. There are many nonminority physicians who work extremely hard to provide excellent care to minority populations and underserved areas. There are even more people who work tirelessly on diversity and do not view diversity as an “extra” – but rather as “necessary.” I applaud and congratulate these people. I am blessed that I have been surrounded by individuals, many of whom are my colleagues and close friends, who truly feel that this is a critical area in medicine we need to improve upon. 

I chose this topic to provide clarity and shed light on how URM physicians may feel from day to day. Of course, I am not the sole voice for URM physicians – just a part of it – but I am not alone in my thoughts and experiences. I do not have a solution to the diversity dilemma, nor am I trying to give one. This is part of a larger socioeconomic discussion, which I believe traces back to our primary education system. As Americans, we are at a truly unique and critical point in our history. We are in the middle of a global pandemic that has caused a significant economic and social strain on our society. Our society as whole is in the middle of political strife with the Presidential election looming. We are in a unique era of social justice and potential social reform. I must say that I am worried about how racial relations may change as a result of what is currently happening in our country. I am proud of the principles that my parents have taught and instilled in me. I am proud to be a Black American. 

I am proud to be a husband and father. I am proud of, and grateful for, the training I have received and the relationships I have built here at MCW and MCWAH. I am hopeful for the future. 

Victor Redmon, MD is a fourth-year resident in the MCW combined medicine and pediatrics residency program. This essay was originally published on 8/3/2020 as part of an MCW “Monday Morning Coffee.”

“First Night-onCall” 2020: Preparing for Internship in the Face of a Pandemic

From the 8/7/2020 newsletter

Invited Commentary

 

 “First Night-onCall” 2020: Preparing for Internship in the Face of a Pandemic

 

Sondra Zabar, MD and Kinga Eliasz, PhD MS – New York University Grossman School of Medicine

 

Drs. Zabar and Eliasz are on the team that instituted the “First Night-OnCall” (FNOC) experience for trainees. In this essay, they describe the experience of modifying FNOC and running “FNOC 2020” in the pandemic era…

 

The transition from medical student to resident is difficult and dicey for patient safety in the best of times. In the US, virtually all recently-graduated medical students begin their residency training as interns on or about July 1. It has been reported that, in some academic settings, hospital-based risk-adjusted mortality rate goes up 4-8% in the first two months of a new residency year. While the cause of this bump in mortality is contested, we take seriously our responsibility to ensure all new house officers are as prepared as possible for unfamiliar clinical settings and dramatic increase in patient care responsibilities.

In COVID-19 times, everyone is looking at this transition through a new lens. Last spring, almost all near-graduate medical students across the country were pulled off their final clinical rotations. At the same time, these medical students needed to be ready to join the pandemic front lines on July 1 as interns. Special attention was needed for the safety of our patients, learners, staff, and faculty. We needed to design effective instruction to empower communities of learners with both the core values and outstanding diagnostic and communication skills that would be needed during a pandemic.

We knew that evidence-based orientation-to-residency strategies based on experiential learning and performance-based assessment are the most efficient and effective approaches to set expectations and build a resilient, unified workforce in this new era of practice.

How would we do this?

 

Adapting and Implementing First Night-onCall (FNOC) to the COVID-19 Era

We first created and implemented First Night-onCall (FNOC) at NYU Grossman School of Medicine (NYUGSOM) in 2017, a large-scale, authentic, immersive simulation developed to support incoming interns, address the hospital’s need to improve early escalation of seriously ill hospitalized patients, and cultivate our medical center’s culture of safety from Day One of residency. FNOC provided a collaborative, immersive “on call” simulation experience for all incoming interns across many of our largest residency programs. The program was so well-received by interns, faculty, and leadership, that it is now a core component of the residency orientation experience.

This year, FNOC – developed in collaboration with our simulation center (NYSIM) and core GME faculty – was adapted to the COVID-19 pandemic with the following goals:

1. Demonstrate the institution’s commitment to supporting both intern and patient safety.
2. Solidify each intern’s core knowledge base using WISE-onCall (WOC) Modules, a transition-to-residency curriculum on common safety issues which is part of the Aquifer collection of online clinical learning tools.
3. Reinforce the importance to patient safety of checking two patient identifiers and the appropriate escalation of urgent care.
4. Ensure each intern could properly “don and doff” Personal Protective Equipment (PPE).
5. Address interns’ concerns and comfort with caring for COVID-19 patients.
6. Provide a forum for interns to meet their peers and leaders, voice their concerns, and understand resources available to them.

To accomplish these goals, “FNOC 2020 COVID Edition” orientation included the following features:

1. Priming pre-work:  Incoming interns were asked to complete at least five out of the available twelve WISE-onCall online modules.
2. Shortened, in-person three-hour immersive simulations: New interns, in small groups, were challenged to:

o   Don/doff PPE and engage in a mannequin-based team simulation.

o   Evaluate a decompensating, hypotensive patient and activate a rapid response team (escalation) using remote standardized patient and nurse interactions, where learners were assessed using behaviorally-anchored checklists.

o   Recognize a mislabeled blood culture bottle.

o   Conduct an effective patient handoff.

o   Engage in a faculty facilitated debriefing of the entire experience emphasizing COVID-19 specific concerns.

 

Assessing Interns’ Concerns Prior to FNOC 2020

At the start of FNOC, interns reported being concerned about having adequate access to appropriate PPE. They worried about virus exposure despite the use of PPE. They felt unprepared, uncomfortable, intimidated, and anxious. They recognized they needed additional PPE don/doffing training and ventilator management. Despite their concerns and skills deficits, they were committed to caring for COVID-19 patients and were eager to learn current care protocols, and care for patients. 

Prior to FNOC 2020 COVID Edition, only 13% of the 215 participating interns from twenty-two residency programs reported having had seen, and only 19% felt comfortable with, providing care for a COVID-19 patient. Although 42% of the brand-new interns reported having ever witnessed a medical error, only 26% reported any formal patient safety training, and only 2% had any experience reporting a medical error.

 

FNOC 2020 was successful

Assessing and addressing our new interns’ knowledge and attitude regarding caring for COVID-19 patients was critical.

The impact of the session was reassuring for our institution.  80% of the interns reported greater comfort caring for a COVID-19 patient. This year, for the first time, 94% of entering interns completed more than the required number of WISE-onCall modules and over 90% agreed that the modules increased readiness-for-internship by providing a framework to organize clinical information. Almost all interns endorsed that FNOC 2020 was an effective, fun, and engaging way to learn patient safety, and 100% felt that it was an overall good approach to improve readiness-for-internship.

Patient safety awareness was also improved. They were reminded of the importance of checking two patient identifiers, and properly donning/doffing PPE. After FNOC 2020, 91% of interns reported that they were more comfortable speaking to a supervisor, to escalate an urgent situation and report a medical error.

 

As medical educators we must challenge ourselves to create engaging, immersive, innovative, and flexible simulation group experiences such as FNOC that can be rapidly adapted to the educational needs of any level of learners. In our experience, a deliberately-designed experiential orientation reduces the variability seen in entering interns, builds community and instills aspirational institutional norms – generating a culture of safety for patients.

 

 

Sondra Zabar, MD is a Professor of Medicine and Director of the Division of General Internal Medicine at the NYU Grossman School of Medicine, and Affiliate Professor of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. She is a national award-winning medical education researcher with expertise in performance-based assessment of clinical competence.

Kinga Eliasz, PhD MS is a Postdoctoral Research Scientist and Assessment and Evaluation Analyst in the Research on Medical Education and Outcomes (ROMEO) Unit of the Program for Medical Education Innovation and Research (PrMEIR), Division of General Internal Medicine and Clinical Innovation, NYU Grossman School of Medicine. She is also a Deputy Editor of Teaching and Learning in Medicine: An International Journal.

How to Be an Antiracist by Ibram X. Kendi Chosen as the MCW Common Read

 From the 8/7/2020 newsletter 

 

 

How to Be an Antiracist by Ibram X. Kendi Chosen as the MCW Common Read

 

Anna Janke, MCW Class of 2023

Associate Editor

 

Ms. Janke discusses the process and outcome of this year’s search for the book that will be the MCW Common Read…

 

It took us the entire school year to choose this upcoming year’s Common Read selection. Led by then-M4 Sophia Lindekugel, the Book Selection Committee read dozens of books suggested by MCW community members to pick a book that would be timely, readable for a wide audience, and actionable to spark meaningful change. As a lifelong reader and now a member of the Book Selection Committee, I really enjoyed reading books that opened my eyes to topics I had not explored in depth before, ranging from the opioid epidemic, to the Flint water crisis, to the individual and societal impacts of sexual assault.

However, after selecting a book with which we were all thrilled to announce, these plans were pivoted once we noticed, and joined in on, the outcry surrounding the deaths of George Floyd, Breonna Taylor, and far too many others. The MCW Common Read Leadership felt that it was necessary to shift this year’s Common Read to one that would center around race and race relations in America, shelving our previous selection for another year.

While the time allotted to select a book was now much shorter after the decision to pivot, many inspiring voices came forward to recommend titles that would spark discussions throughout the MCW community about race. It was humbling to realize that we have been late to join this movement; The MCW Office of Diversity and Inclusion (ODI), Student National Medical Association (SNMA), and the Center for the Advancement of Women in Science and Medicine (AWSM), among others, have been leading MCW for decades towards progress in health equity, workplace climate, and the dignity of every person.

In the end, we wanted as many community voices to be heard as possible for this year’s Common Read. We met with key stakeholders, including representatives from the aforementioned groups, to select three books from which MCW would vote. After 548 people weighed in, we are thrilled to have How to Be an Antiracist by Ibram X. Kendi as the 2020-2021 MCW Common Read.

While I am both elated and terrified to be a Co-Chair for this year’s programming, I am confident that the Common Read Leadership and the rest of the MCW community will come together to get our hands dirty and make mistakes so we can learn from those mistakes and take important steps forward in the lifelong journey that is Antiracism.

 

  

Anna Janke is an MD Candidate in the MCW Class of 2023. She serves as an Associate Editor of the Tranformational Times.

Milwaukee is Special; Let’s Make Some “Good Trouble, Necessary Trouble”

From the 8/7/2020 newsletter

 

Milwaukee is Special; Let’s Make Some “Good Trouble, Necessary Trouble”

 

Adina Kalet, MD MPH

 

 

Dr. Kalet shares how the message of Representative John Lewis’s farewell letter to the American people resonates with how the Kern Institute must take up the challenge to create inclusive, equitable medical education systems …

 

 

On the day of his funeral, John Lewis, the civil rights warrior and seventeen-term Congressman from Georgia’s 5^thCongressional District, published a love letter to the American people in the New York Times. He wrote his inspired and inspiring essay while dying of cancer, knowing that the country he loved was in crisis. “You filled me with hope about the next chapter of the great American story when you used your power to make a difference in our society.” 

 

Lewis reminds us that “Redeeming the Soul of Our Nation” will require a “long view” which, I believe, is also our approach as we redesign medical education to create a new physician work force. Doing meaningful and important work is a process, not an outcome.  As an ancient Jewish ethicist reminds us, we are not responsible for finishing the work of "perfecting the world,” but neither are we free to stop trying. 

 

 

Our home: Milwaukee is a very segregated city

 

We have some complex work to do in our own hometown.

 

Milwaukee has the long-standing, dubious distinction of being among the worst places in America to be Black. A black child born into poverty in Milwaukee is more likely to continue to be poor than in any other large city in the country. Deeply entrenched, persistent and concentrated poverty, extreme racial segregation, and exclusionary zoning or “redlining” have been blamed for the poor social mobility for our children. There are endless, complex explanations for this “special” status. 

 

Research studies confirm that health disparities are both directly and indirectly linked to these social determinants of poor health. Scientists from multiple institutions have identified that the incremental, accumulated physical effects of racism over a lifetime contribute to health inequities. Recently, this disparity has included the disproportionate illness and death of Black Milwaukeeans from COVID-19. No matter how you assess the current situation, things appears bleak. 

 

Yet, John Lewis – a Black man who lost as many battles for racial justice as he won and who was beaten and arrested over fifty times for engaging in militantly non-violent protest against racial injustice – was optimistic when he died. 

 

Lewis believed in us. He exhorted us to be aspirational. He wrote “Ordinary people with extraordinary vision can redeem the soul of America by getting in what I call good trouble, necessary trouble.” It is time for those of us in medical education to do some significant envisioning. But where do you look for the leadership? Inward? 

 

 

Time to make some good and necessary trouble

 

As the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, I am always on the lookout for opportunities to think boldly and make a bit of good and necessary trouble! 

 

I am proud of MCW and its 125-year history of being an anchor institution in Milwaukee and the region. In John Raymond’s most recent Letter from the President, he reviews a list of the substantive ways in which MCW has been an exemplary institutional citizen of the city, the region, and the state over the past decade. He also invites all of us to join in the conversation and contribute to the MCW 2025 Strategic Framework as we set a new vision and as we rise to current challenges; we must “… think boldly and to share how you would reimagine MCW.” How do we prepare to make changes? 

 

 

Be bold. Set audacious goals. 

 

Many years ago, my mentor diverted me from an unproductive tirade by saying, playfully, “Don’t get mad. Get data.” This admonition literally was the birth of my academic career. Below, I offer an example of people who will change Milwaukee by first gathering data. 

 

The African American Leadership Alliance MKE (AALAM) was founded in 2017 to link influential individuals dedicated to making Milwaukee a place where African Americans thrive. AALAM has set the audacious goal of putting Milwaukee into the top ten US cities for African Americans by 2025! That is when our current first-year students will be interns. 

 

Recognizing the need for benchmarks for their work and seeking to identify the levers to drive positive change, AALAM commissioned the UW-Milwaukee Center for Economic Development (UWMCED) to produce  the study, “The State of Black Milwaukee in National Perspective: Racial Inequality in the Nation’s 50 Largest Metropolitan Areas.” The study was funded by the Greater Milwaukee Foundation. Here is an interview with the study lead, Professor Marc Levine.

 

As part of their work, the UWMCED team created a “Composite Index of African American Well-Being.” The index synthesized thirty indicators of community well-being, typically studied individually – for example, employment, income, poverty, social and community health, and conditions specific to youth and children – into a single number allowing big picture comparisons and holistic analyses across large metropolitan areas of the country. Milwaukee ranked 50^th out of 50. 

 

The study pinpoints three inter-related drivers for change: 

·      Reducing racial segregation

·      Enhancing Black educational attainment

·      Increasing the numbers of Black executives and managers at Milwaukee companies, including MCW

 

These actions will help make strides toward racial equity. For AALAM and the rest of us, it is a call to action, a time to make some good and necessary trouble. 

 

 

Building trust and taking action

 

On July 22, 2020, Drs. Lenard E. Egede and Rebecca J. Walker from the MCW Division of General Internal Medicine Center for Population Health published a perspective in the New England Journal of Medicine identifying six recommended action items for mitigating structural racism. Directly in our Kern Institute lane is the recommendation to “be consistent in efforts by health systems to build trust in vulnerable communities.”

 

How do we build trust? We must commit to long-term, trustworthy partnerships in “pipeline to the health professions” programs that will measurably accelerate the diversification of the health workforce in Milwaukee. We must intentionally and assertively recruit and support students, residents, faculty, and staff from underrepresented minority (URM) communities making special effort to identify those from economically deprived backgrounds. And as our leaders are seeking to do, we must support, listen to, and engage with all of MCW’s URM community-including all levels of staff- to be the kind of employer where everyone feels they belong, have an influence and can create a meaningful work life. This will require carefully examining how we traditionally have approached fairness, as compared with equity, in admissions and hiring processes. 

 

How do we prepare our trainees to practice medicine so that it is experienced by communities as trustworthy? Beyond a curriculum which provides the critical historical context for the distrust of the health care system by vulnerable communities, we must provide meaningful ways for our students and residents to work with and in communities. I have been involved with many “patient-as-teacher” programs. These programs train and employ community members- to be medical school teachers. With their active participation, for instance as standardized patients student can learn clinical material practice skills and receive critical feedback. With community guides and coaches students and residents can contribute to research and engage in  community social action. These experiences need to be substantive, rigorous and longitudinal allowing for the development of strong trustworthy relationships.  This is making some good trouble! 

 

In his essay, John Lewis wrote that he once heard the voice of Martin Luther King on the radio. “He said we are all complicit when we tolerate injustice. He said it is not enough to say it will get better by and by. He said each of us has a moral obligation to stand up, speak up and speak out. When you see something that is not right, you must say something. You must do something. … I urge you to answer the highest calling of your heart and stand up for what you truly believe.”

 

If we are truly committed to transforming medical education – as well as society writ large – we must reshape our own community, focus on character and caring, and offer to partner with organizations, like AALAM, that carry visions of a better, diverse, equitable world. Our entire community will benefit. 

 

 

 

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.