The When and Why of my Good Trouble in Medical Education

From the 8/21/2020 newsletter 
Personal Opinion / Perspective 
 
The When and Why of my Good Trouble in Medical Education

 
Jeff Fritz, PhD – MCW-Central Wisconsin (MCW-CW) faculty member

 
Dr. Fritz, a founding member of the MCW-Central Wisconsin faculty, finds inspiration in old books and documents that push us in the direction of  “good trouble.” In this essay, he points to some areas where he believes we need to make changes …

 
 

I enjoy old documents. One of my hobbies is finding old books – like ones that explain medical treatments – with copyright dates prior to 1900. I keep searching for older and older volumes of the drawings by Dr. Frank Netter and the first editions by Dr. William Osler. 
 
My family asks me why I keep exploring for things that could be found on the internet. For me, holding these works provides inspiration. Older documents let me adopt the perspective of the writer, give me a glimpse of their experiences, and encourage me to continue to look for solutions to age-old problems. 
 
Often, older documents tell me when and why I need to act – they illuminate those areas where I need to get into “good trouble.”  Two documents of which I hope to someday add older copies to my collection are the Declaration of Independence and the Constitution. The Declaration reminds me to take a stand and join the cause for those experiencing limitations to “life, liberty and the pursuit of happiness.” My favorite phrase in the preamble is “it is the Right of the People to alter or abolish [the government], and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness.”For me, this is a call to action to serve those around me when they share their personal struggles, injustices, or failures to overcome institutional roadblocks. The Declaration of Independence guides my energies when I need to get into good trouble. 
 
In addition to these documents telling me when to get into good trouble, the Constitution begins by telling me why. “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.” This tells us why we expend our energies when it is time to get into good trouble. I think it challenges us to form more perfect institutions, improving upon our structures so that those around us can better flourish.   
 
What does my personal hobby have to do with medical education?  As a faculty member on a regional campus, I get to work at a medical school while still remaining in my rural community. Twenty years ago, my spouse and I left our familiar academic environment of Nashville, Tennessee to support her rural medical practice and to focus on our growing family. Trust me, I thought the opportunity to engage with medical students was a thing of my past! But thanks to many courageous leaders willing to develop regional campuses and get into good trouble, I can both support my spouse’s pursuit of happiness and, once again, pursue my own dream as a medical educator. I want more people to experience the joy I experience as an MCW-CW team member and as part of the Kern Institute faculty. 
 
As I begin my fifth year at MCW-CW, I feel it is time to respond to concerns raised by our learners, inform our leaders, hold myself accountable, and create some good trouble to benefit both our learners and our institution. 
 
Here are areas where I hope to make some good trouble this year.
 

 Area 1 – Admissions
I have been on the MCW Admission Committee for four years and will encourage our team to more fully embrace the challenges to transform our admissions process. We must admit cohorts of learners that more dynamically represent the communities we serve. 
 
To my friends on the Admissions Committee and within the Student Pillar at the Kern Institute: I know the energy it takes each year to screen, interview, and admit a new cohort of students, but I challenge us to get into some good trouble and develop a better system that will lead us to becoming a more inclusive, antiracist institution. Hold my feet to the fire and hold me accountable – let this year be the year we develop a more robust, holistic, and inclusive admissions process. 
 

Area 2 – Curriculum
My primary role at MCW-CW is to assist instruction throughout the first year of our current foundational science curriculum. Over the past four years, I have watched learners succeed as well as struggle. I feel our curricular structure could do more to ease the suffering of our students. I have watched our institution embrace the good trouble of student, faculty and staff well-being and make great strides in a short period of time. However, we have so much more to do in revolutionizing our curriculum to meet the need of our learners on each of our campuses and those we would like to invite onto our campuses as learners. 
 
To my friends on the Curriculum and Faculty pillars at the Kern Institute: Now is the time we put forward a curricular design with the flexibility and inclusivity to ease the suffering of our learners on all of our campuses and helps them feel supported, safe and justly treated.  
 

Area 3 – The cost of medical education
I’d also like to see us embrace a new way to support our students with the cost of medical school, but I fear this is out of my sphere of influence ; after all, you can only throw the tea into the harbor off of the boats onto which you can board. While I explore a more direct means to influence our financial approach to medical education, I challenge us all to expand our funding horizons as an institution. We need to take up the good trouble of eliminating the hurdle and fears surrounding the cost of medical education.

We need to acknowledge how these costs limit our ability to fully develop a diverse and inclusive cohort of learners and faculty. We need to tackle the cost of medical education, both financially and culturally, as it continues to exclude those that remain outside our community. I’m looking for ways to dump the tea overboard on current system and explore a new and better way to constitute financial aid.

13,000 Days on the Hamster Wheel: Finding Meaning on the Way to Retirement

 From the 8/21/2020 newsletter
 
 
13,000 Days on the Hamster Wheel: Finding Meaning on the Way to Retirement
 
 
Bruce H Campbell, MD FACS – Editor, Transformational Times 
 
 
Dr. Campbell reflects on how the self-care trajectory on which we place our students and residents will carry them beyond their careers …
 

 
Medicine differs from many other professions. Once a physician joins a practice, it is possible to become a perpetual-motion machine, working day-after-day, seeing patients and generating revenue. As long as the physician directly or indirectly generates enough cash flow to pay salaries, keep the lights on, and move the enterprise forward, the process can continue unabated. Theoretically, this hamster-on-a-wheel activity can continue for around 13,000 days. That’s thirty-five years. Then the hamster retires, and another is recruited to keep the wheel turning. 
 
Of course, I don’t usually view myself, our students, or our residents as hamsters, but there have been days when the thought crossed my mind. Still, what can medical educators do to prepare the next generation of physicians in ways that will enrich – rather than deaden – their lives and careers? And how do we help our trainees step back and begin to grasp the arc of their journeys from graduation to retirement?
 
 
Talking with trainees about their careers
 
Recently, I held a session on retirement with our otolaryngology residents. We read an article where the authors asked Johns Hopkins internal medicine residents in the very first weeks of their internships to write down and then share what they thought a colleague would say about them at their retirement celebration many years down the road. I also asked our residents to imagine what others would say about them at retirement, which of their character strengths would be most noticeable in their careers (from the list at www.viacharacter.org/), what they think they will miss about their careers after they retire, and what aspects of retirement they are thinking about now. 
 
Not surprisingly, the residents in the article and our otolaryngology residents all see the distance from where they are now to retirement as being an incredibly long time. The brand-new interns hoped that their colleagues would see that they had lived out their core values, been accomplished in their careers, and been good teammates. Among possible character traits, our residents hope that they would have been most admired for their dedication to teamwork and their humility. They anticipate that they will find their greatest personal satisfaction – and what they think they will miss the most – from being part of a team focused on helping others in times of great need. Like the interns in the study, our residents worried about retirement but, being so far off in the future, they could not imagine what it will feel like to get there.
 
Our residents realized that they differed from the internal medicine interns in the study. Although they know they will miss many things, they believed they will be able to replace professional relationships, the joy of helping others, and stimulating conversations with other post-retirement activities. As surgeons, though, they worried that they will have difficulty replacing the unique privilege of performing surgery. As one resident said, “I can’t imagine not operating again. That’s why we went into this.” Everyone agreed. 
 
Our residents, having been in training longer than the interns in the Hopkins study, focused on how quickly time passes, even in training. “I am already realizing how much I will miss my fellow residents,” one of older trainees noted. “I’m sure my career will seem to pass by just as quickly.”
 
 
The challenges of helping students, residents, and faculty gain insight into themselves and others
 
There are data that strong relationships and lifelong self-care habits can yield benefits much later in life. MCW faculty members and the Kern Institute are building a portfolio of curricular and extracurricular opportunities that encourage resilience and insight including the REACH curriculum, the KINETIC³ Teaching Academy, MCW Common Read, and a variety of transformational initiatives (see a partial list at the end of this article.) The challenge is to make these types of offerings available, appealing, and effective. Baking caring and self-care into the institutional culture and the curriculum creates opportunities for both transformation and scholarship. 
 
But, let’s get real. Finding time for reflection, creativity, and long-range personal planning is difficult and, frankly, of low priority for busy students, residents, and faculty. Institutions can readily measure clinic slots, RVUs, grant funding, and margins, but we don’t (yet) have metrics that measure sustained empathy, strengthened character, and successful prevention of burnout. If we cannot demonstrate that these habits can be nurtured, or if they aren’t seen as valuable, our interventions will have little impact and won’t be sustained. 
 
Yet, raise your hand if you think that a graduate who is unprepared to thrive in practice will also be less likely to thrive in retirement. 
 
 
Retirement isn’t for sissies
 
Over the decades that I have been at MCW, dozens of colleagues have retired. I have noted that the end of a career rarely goes exactly as planned. Some have retired amid accolades for lives and careers well-spent while others have left baffled and reluctant, having no idea what they would be doing a week later. Some, after long and productive careers, were forced out after bitter disputes. Some packed up and left in disgrace. Some became ill or died before they had the opportunity to retire. Some, unfortunately, held on too long. Some left huge holes in the institution when they retired. Others barely caused a ripple. 
 
Guiding our students and trainees toward rewarding careers and eventual retirements carries responsibility. We must do more than suggest they be financially responsible and keep track of their retirement account outlook. We have equally important responsibilities to help them develop well-rounded professional identities, “seize the day” mentalities, and careers as reflective, empathic, and mindful physicians. If they enter practice self-aware and focusing on character and caring, they should have a better chance of emerging into retirement possessing the same values. 
 
 
Living each day
 
The act of living intentionally came to mind when I read a story in an interview with Duke University’s director of medical humanities, theologian, and pediatric oncologist, Raymond Barfield, MD: 
 

“Think of each day as a gold coin that you are required to trade for something. You’ll never get that coin back, so whatever you trade it for had better be worth it. You also don’t know how many coins you have left to trade, and you don’t know what will happen when your bag is empty.”

 
My career has shot past me like a rocket since I completed my fellowship and joined the MCW faculty 12,043 days ago. I now wish I had learned early on to treat each day like a gold coin. 
 
Whenever I do retire, I know I will carry memories of my colleagues and mentors with me and try to take advantage of the self-care and reflective skills I have acquired along the way. And, as I look back, I will be grateful for how rarely my career made me feel like that hamster running on a wheel. 
 
 
 
Bruce H Campbell, MD FACS is a Professor in the MCW Department of Otolaryngology and Communication Sciences and in the MCW Institute for Health and Equity (Bioethics and Medical Humanities). He is on the Faculty Pillar of The Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He serves as the editor of the Transformational Times. 
 
 
 
 
 
PARTIAL LIST OF SELF-CARE, CREATIVE, AND REFLECTIVE OPPORTUNITIES AT MCW
 
At the risk of leaving out many important opportunities for MCW students, trainees, and faculty to develop a longer view of a life in medicine, here are a few of which I am aware:  
 

• Healer’s Art Course.  Julie Owen, MD and Art Derse, MD run this M1 elective that helps students explore their connections, tough issues such as loss and grief, their motivation for service, and reflect on their goals. 
• REACH (Recognize, Empathize, Allow, Care, Hold Each Other Up) Curriculum. Working with the Kern Institute, Cassie Ferguson, MD designed REACH. She, Joanne Bernstein, MD, and Theresa Maatman, MD are the program leaders. REACH provides a well-being thread of lectures and small-group activities through the M1 and M2 curriculum where students explore mindfulness, meditation, spirituality, self-compassion, “imposter syndrome,” belonging vs fitting in, stress, anxiety, empathy vs. compassion, setting boundaries, gratitude, relationships, communication, sympathetic joy, active constructive responding, and compassionate listening. 
• KINETIC³ Teaching Academy. The Kern Institute offers this curriculum that seeks – in addition to fostering teaching skills and building a community of educators – to promote faculty and student well-being.
• MCW Common Read. The program coordinates a campus-wide book selection and study. This year’s book is How to be an Antiracist by Ibram X. Kendi.  
• MCW MedMoth. This is a live storytelling event where MCW students and faculty are invited to share first-hand narratives of their medical journeys. 
• MCW Art Club. Developed by Teresa Patitucci, PhD, this Facebook page shares the talents of MCW family members. See the article in the July 24, 2020 Transformational Times.
• MCW Moving Pens. Offered by the Center for Bioethics and Medical Humanities, this facilitated group for writers of all skill levels and genres meets twice-per-month in partnership with Red Oak Writing. 
• MCW Physicians for the Arts -  Facebook page link here
• Auscult – MCW’s literary journal. Site link here
• Chordae Harmonae – MCW medical student acapella group. YouTube link here
• MCW Orchestra – Facebook page link here

 

How Do We Decide? Seeking Wisdom as We Reopen Schools

From the 7/14/2020 newsletter

How Do We Decide? Seeking Wisdom as We Reopen Schools

M. Paula Phillips

In this perspective, Ms. Phillips shares her thoughts on making decisions, both as a parent and as a member of the Board of School Directors for Milwaukee Public Schools. She also notes what we can learn from Daniel Tiger ...

All over the country, parents are scrambling to find adequate childcare during the COVID-19 pandemic. In Southeast Wisconsin, 61% of the providers in the licensed group category were closed, either temporarily or permanently since March and school districts across the state have varied reopening plans which has increased stress and desperation. As a school board member that represents nearly 74,000 students and 10,000 employees, I’ve poured over hundreds of letters from students, parents, and educators pleading that we consider how COVID-19 has altered our world and resolve to do what is best. Sentiments include:

My child is already falling behind! 

I miss my friends. 

How will I be safe?

I’m afraid.

As a parent, I have an undercurrent of anxiety with so many of my choices. Am I being selfish for sending N to daycare? What if my child gets sick? Should I be caring more for my own child instead of advocating for all of our children? How much Daniel Tiger is too much Daniel Tiger?

As a human, it isn’t easy for me to untangle the complexity of my emotions most days. I can find hope in our community’s ability to raise over $800,000 to connect our students to needed WiFi for the virtual start of the school year.
I can become enraged when I consider that the decision to reopen schools during a public health crisis is being delegated to local school board members instead of other levels of municipal, state, and/or federal government. There are times I am paralyzed by how big our problems are, and how small I feel in comparison.   

I’ve learned a lot about emotions as my little one has emerged as an active, curious, and emotional two-year-old. Like Tinkerbell, the moment N feels something, it takes over N’s entire body. Joy, anger, silliness, sadness – N feels it all and feels its fullness. Instead of dismissing my toddler’s emotions, I’ve headed the wisdom of Daniel Tiger:

• Feel your emotions (When you get so mad, that you want to roar)

• Use your breath to get back in your body (take a deep breath and count to four)

Taking moments to acknowledge emotions, get back to breathing, and letting one’s heart rate come down has been so helpful for my toddler and myself. My little one has shown me how vast and far reaching the human experience is and how resilient and capable we are of getting through it. When I take the time to be mindful and understand what I’m feeling and what my own fears are during these uncertain times, I can identify what I can control and what I cannot. When I stop to take a breath, I avoid vengefully responding to a nasty letter from someone that is questioning my character. When I can acknowledge the difficulty of this time for me as a person, I have greater empathy to lead, understanding how difficult it is for all of us.

It is imperative that all of us understand how uncertainty surrounding reopening schools is increasing the mental load of parents (mothers in particularly). In order to practice empathy, we must understand how the current moment is affecting ourselves. Then, we can ask our colleagues how they are navigating their children’s education and listen fully.

Consider the composition of your team – who has caregiving responsibilities and who doesn’t? What does equity in workload and flexibility look like? Childless employees cannot bear the full load – how are FY21 goals being created to prioritize the most essential things for MCW’s remedy and recovery while other priorities are adjusted for everyone’s work life balance?

Our solutions for childcare and reopening the economy during a global pandemic, economic recession, and racial uprising cannot be limited to individual families or school districts. As you piecemeal solutions for your family, advocate for broader childcare allocations from state and local governments. Demand that federal funding be provided for all schools to open safely. Remember to breathe and don’t stop until every child has access to a safe place and high-quality education.

M. Paula Phillips is the Program Manager of the MCW Center for the Advancement of Women in Science and Medicine (AWSM) and serves as the representative to the 7th District of the Milwaukee Board of School Directors.

 

Why Build a Kern Post-Doctoral Fellowship in Medical Education Transformation for “Basic” Scientists?

 From the 8/14/2020 newsletter

Director’s Corner 

 

Why Build a Kern Post-Doctoral Fellowship in Medical Education Transformation for “Basic” Scientists?

 

 

Adina Kalet, MD MPH

 

 

This week Dr. Kalet introduces a new Kern Institute program aimed at building capacity for transformational change at MCW and nationally, one teacher at a time… 

 

 

My grandmother, with her thick Eastern European accent, drove my uncle and me crazy. “Adina is the first ‘Doctor’ Kalet,” she would say, even though my uncle had a PhD in Engineering. He, in fact, had been the very first “Doctor” Kalet, but the family knew what she meant, right? I was the physician. Grandma loved both her son and granddaughter. But, to her, a PhD didn’t make you a “real” doctor. For her, it just wasn’t the same.

 

 

Those of us in medical education know, of course, that the education of physicians absolutely depends on basic scientists. Not only because scientists are the “transmitters” of an enormous fund of scientific knowledge to which physicians need access. They are critical because physicians need to experience – and engage with – how scientists think and what they do. For much of what physicians need to learn, scientists are both the content and process experts. Medical education research demonstrates that having scientists as teachers is critical both for practice and policy. 

 

Still, my grandmother’s attitude reflects one of the traditional barriers to the seamless integration of basic scientists into the education of future physicians; she, as well as many students and faculty, seem to value the basic and clinical scientists differently. 

 

 

This attitude stands in the way of optimizing how future physicians develop high quality clinical reasoning, since they must learn to integrate diverse basic, clinical, biopsychosocial, and contextual information, deeply and generously process these data, and then effectively perform the professional activities of medicine (diagnosis, management, caring, accompaniment, counseling, etc.). Unless students understand and respect the value of each data source, there are many opportunities for error. A full integration of basic scientists into medical education is critical to developing these skills. 

 

 

How has medical education tried to integrate foundational and clinical sciences?

 

Over the decades, different solutions have emerged. In 1910, Abraham Flexner made a compelling case for a science-based curriculum with the subsequently ubiquitous two years of “basic science” and two years of clinical rotations. He insisted that scientists teach the science. 

 

Medical schools have tried different models to blend basic and clinical science teaching in order to achieve cognitive conceptual coherence. Implementation of best practices to integrate the basic and clinical sciences has lagged, especially when it relied heavily on “traditional,” passive teaching methods such as lectures, “binge and purge” assessments, and multiple-choice examinations. These approaches get students to briefly grasp large knowledge bases, but they do not achieve the level of integration we seek in our learners.

 

Over the last five decades, medical schools have made inroads integrating the clinical and basic sciences with case- and team-based learning curricula. Integration, however, has often been viewed largely as a matter of structure rather than as a means to honor the value of the basic science or to focus on individual learning outcomes. 

 

In the end, the approaches have sometimes failed to improve clinical reasoning. We must move to the next level if we want to ensure that future physicians have the ability to accomplish these critical, complex cognitive tasks.

 

 

So, what is next?

 

Recently, cognitive scientists have argued for individualized, learner-centered, effortful, and assessment-driven strategies as the best road toward true integration. Students become more accurate diagnosticians if they experience basic science/clinical presentation “causal stories” rather than being given evidence-based algorithms or basic science explanations separate from clinical material. This causal integration is not just a handy memory aid. By linking basic sciences with clinical features in a cause-and-effect relationship, learners build “illness scripts” or schema. Students create frameworks within their long-term memories that organize information to be retrieved when needed. This is learning. 

 

Assessing whether students integrate basic science concepts in clinical situations is complex but possible. As medical educators, we should put our hearts and souls into designing experiences where our learners organize, conceptualize, retrieve, and then apply foundational medical sciences into the care of individual patients (and populations).  Scientists and clinicians must understand and face the gap that has traditionally remained between them.

 

 

Creating a fellowship to equip basic scientists to be educational leaders

 

To address this gap and to chart a course forward, the Kern Institute will recruit basic scientists into a medical educator post-doctoral fellowship. The first cohort of one or two fellows will begin this fall. The goals of the program are to: 

• Transform medical education by ensuring a steady pipeline of medical educator scientists ready, willing, and committed to implementing best practices in medical education.
• Build skills and confidence as the medical educator scientists integrate health science disciplines, design competency-based assessments, and collaborate with diverse stakeholders to train the next generation of health professionals.
• Create thought leaders as the medical educator scientists engage in curriculum reimagination and continuous quality improvement. 

 

To achieve these goals, each fellow will:

• Work closely with, and support, MCW scientists and clinical educators to reimagine foundational science education in curriculum planning, instructional design, faculty development, assessment, and evaluation. Become master teachers of medical and other health professions students under the supervision of experienced mentors/coaches. 
• Participate in medical school administrative leadership meetings as a means to understand academic medicine governance.
• Participate in the KINETIC3 faculty development program.
• Engage in scholarly work with the support of the Kern Institute’s Medical Education Data Science, Human Centered Design, and Philosophy Labs.
• Have financial support to do formal master’s level, or equivalent, training in health professions education.
• Engage with national and international leaders in the field.
• Write and submit high-quality abstracts, peer-reviewed manuscripts, and grants. 

 

As we developed this new fellowship, we reached out to the International Association for Medical Science Educators (IAMSE), an organization committed to “promoting excellence and innovation in teaching, student assessment, program evaluation, instructional technology, human simulation, and learner-centered education” and the Association for American Medical Colleges (AAMC). I personally sought advice from most of our basic science chairs, MCW basic science educators, deans, the provost, and members of our regional campus faculty.  With this program, we are creating a clear path to deeply satisfying careers for trained scientists in medical education; we aim to prime-the-pump for future educational leaders.  

 

 

I have other basic scientists in my family. My father’s first cousin was a professor of pharmacology at a prestigious medical school, yet he complained bitterly about teaching medical students. As a basic scientist, he didn’t feel appreciated. Being introverted, he didn’t enjoy lecturing. He was convinced that most medical students weren’t interested in discovering new treatments for diabetes and cancer. I wish there had been a way for him to better integrate into the medical curriculum and be appreciated for what he had to contribute. 

 

I will think of my basic science relatives as we work with our fellows. I hope our fellowship graduates will bridge the gap between the basic and clinical science worlds in ways that assure basic scientists of their critical role in medical education and show clinicians how much we depend on the scientists. Even my grandmother would have agreed with that goal.

 

 

 

Further reading:

Kulasegaram, Kulamakan Mahan; Martimianakis, Maria Athina, PhD; Mylopoulos, Maria, PhD; Whitehead, Cynthia R., MD, PhD; Woods, Nicole N., PhD Cognition Before Curriculum, Academic Medicine: October 2013 - Volume 88 - Issue 10 - p 1578-1585 doi: 10.1097/ACM.0b013e3182a45def