The Messy

From the 8/28/2020 newsletter

The Messy 

Cassie Ferguson, MD - Kern Student Pillar Director

Dr. Ferguson describes how clinicians must embrace their capacity for compassion to overcome the challenges of working in a messy world …

One very late night during my pediatric residency, I sat in the middle of the pediatric intensive care unit with my supervising fellow and the hospital chaplain. A teenager we had been caring for had just chosen to be decannulated (that is, have her tracheotomy tube removed) and be allowed to die. She was 16 years old and had lived with a rare neuromuscular disease that had progressed to the point that she could not breathe without the aid of a ventilator and, more devastatingly, could no longer paint or draw.

“Some days,” the chaplain said, “some days, we are called to the messy.”

Through the course of my career, I have been advised on how to wade through this mess; how to tend to the hardship, the pain, and the trauma experienced by the humans that we are called to care for and about. Well-meaning mentors have warned me to keep an emotional distance from my patients. Burnout experts warn us all of “compassion fatigue.” Even the language we subconsciously revert to in the emergency department (ED) urges separation from human suffering — we care for “the broken arm in room 12” and “the non-accidental trauma in 5.”

This perspective seems, to me, to arise from our deeply ingrained “culture of scarcity”; we can never have enough, know enough, be enough. We fear that our compassion is finite but that we just weren’t told exactly when it would run out. So, we keep pushing and pushing, rightfully unwilling to ration it. 

“Our capacity for compassion is endless” 

I would like to offer a different perspective. I believe that our capacity for compassion is endless; that we can hold and attend to both the joy and the pain of our work; and that we can find meaning in and be transformed by the suffering we witness. For me, this begins with recognizing the limitations of empathy. 

In a study using EEGs and MRIs, a team of social neuroscientists examined the differences between empathy and compassion. In one experiment, the French Buddhist monk, Matteau Ricard, was asked to listen to recorded sounds of a woman screaming with the specific instruction to feel her distress but do nothing more. The pain centers of his brain were active, and he struggled to continue. Then he was instructed to listen to the same sounds, but to also engage in compassion meditation — to repeat phrases offering up safety, health, and ease to this person. His pain centers remained activated but so, too, were the neural networks associated with love and other positive emotions. He felt that he could continue to do this indefinitely. 

Empathy is affective resonance with someone else; it allows you to feel suffering when they suffer and to feel joy when they feel joy. Empathic resonance alone, however, can lead to emotional distress and burnout. “Empathy,” Ricard writes, “should take place within the much vaster space” of compassion and love. 

It is important to unpack this term with the intention of understanding what it is, how it serves our patients, and how we cultivate it. Ricard wrote beautifully that “compassion is nothing else than love applied to suffering.” Empathy directs our attention to where it hurts; compassion calls us to work to understand the levels of pain, and the manifest and latent causes of it, so that we might effectively help and empower. Compassion calls us to act; to engage with our patients and with our communities. 

Cultivating this compassion and sustaining it through the demands of our profession is effortful; caring for self while caring for others should be a daily practice held with the same reverence that you hold doctoring. That practice will look differently for each of you. But I urge you to keep these key components in mind: 

• First, pause frequently. Intentionally make space for rest, recovery, and being still. For me, this has looked like asking our team to pause together after a death in the ED and taking back some of the hours lost to my smartphone to be in solitude.
• Second, stay fully present in your experience no matter how difficult. This is as straightforward as stopping to notice and name the emotions coming up for you during patient encounters. After sitting with a mom who just learned her 5-year-old has leukemia, it is easy to do what Brene Brown calls “overfunction”; rather than recognize how our emotions are impacting us, we jump to reassure, and to fix, and to plan. If I sit and say to myself, “I am feeling fear,” or “I am feeling anger,” I can remain present for her and let compassion guide my actions instead. 
• And lastly, as the meditation teacher Jack Kornfield wrote, “If your compassion does not include yourself, it is incomplete.” 

Compassion in practice 

A few weeks ago, I sat with a student during their dismissal hearing. The experience was understandably distressing for them, and I struggled to help. So, I consciously engaged in a practice that I use nearly every shift in the ED, one that some of you have heard me talk about before; I sat across from them and noticed my breathing. With every inhale I thought about breathing in compassion for myself, and with every exhale I breathed out compassion for them. I know that even this small departure from focusing on others makes some of us uncomfortable and makes us feel as if we our abandoning our mission as caretakers. But in that moment, with that student, rather than feeling overwhelmed and reflexively pulling away or trying to fix, I felt only love. And love, far from sentimentality, is the force that undergirds the most important and transformative moments in humankind’s history. 

Love is also the way through; we must harness it if we are to continue to alleviate the suffering of others, fight for social justice, and care for our communities and our planet in a sustainable and intentional way. As I have learned often during my career, patients, caregivers and the world around us are all wading through “the messy.” They each deserve my best efforts to provide them my mindful attention, my love, and my compassion. 

Dr. Ferguson initially delivered this talk as the invited speaker at the MCW Gold Humanism Honor Society induction ceremony in June, 2020. 

Cassie Ferguson, MD is an Associate Professor of Pediatrics (Emergency Medicine) at MCW. She leads the MCW M1 and M2 REACH curriculum focused on promoting wellness. She is the director of the Student Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Lessons Learned in Character Education: Don’t be Intimidated

From the 8/28/2020 newsletter

 
Lessons Learned in Character Education: Don’t be Intimidated
 
 
Ryan Spellecy, PhD – Bioethics and Medical Humanities
 
 
Dr. Spellecy, who trained in Philosophy, talks about the challenges and rewards seeking to understand and implement the concept of “character in medical education” …
 
 

In the first months after the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education was launched, I attended, as a Kern representative, the annual meeting of the Association for Moral Education. Our goal was to present our initial work on “character” in medical education. The Kern Institute was a new player in the world of character and, since we were the first medical school to attend that conference in its forty-three year history, we were the first to delve into national and international scholarship on character education.  It was clear, even at that early stage, that role models are – and would be – essential in character education.  
 
In fact, medical education has known for years that role models shape our learners.  We call it the “hidden curriculum,” and it has often achieved the opposite effect of what we would want.  
 
At that meeting, I learned important lessons about role models and moral development: we must be mindful of the moral paralysis that can occur when we place role models on pedestals.  If we hold our moral heroes in too high esteem, we become paralyzed, unable to imagine how we could ever be “good enough.”  The result is that we – and our students – don’t begin working on character development because we cannot see how to start toward such a lofty goal.
 
 
Making mistakes is fine
 
So, how do we get past our moral paralysis and make progress?  When Professor James Arthur visited the Kern Institute, he shared a quote from Abraham Lincoln.  “It has been my experience that folks who have no vices have very few virtues.”  Or, as our own definition of character in medical education states, having good character does not mean one never makes mistakes or has lapses.  Rather, people of good character learn from mistakes. Our moral heroes are more like us that we think. To me, this means we must keep moving – and must help our students keep moving – toward character development. 
 
Think about some of your moral heroes.  If they are famous, they likely have had some shortcomings – perhaps even large ones – over the course of their lives.  Despite this, they can still have much to teach us, and by the same token, we can develop character and flourish even if we make mistakes and, at times, fall short. 
 
 
We all have different strengths to offer
 
The second lesson I learned at the meeting is that we are all unique and bring unique sets of strengths, including character strengths.  There is no one character profile for the successful pediatrician, surgeon, or even philosopher.  Rather, what the character literature has shown is that we can leverage our unique constellations of character strengths to achieve goal, often as a team. 
 
Still, do we need to look for certain character strengths as we consider building new, holistic medical school admissions processes? Initially, I believed that we would need to discern which strengths are necessary for medical students to excel at being physicians. I am certain that understanding applicants’ characters will still be a useful endeavor, but I am stuck in my philosophical training that emphasizes the value of specialization.  The recent psychology and education literature on character confirms that each of us is different and unique. This diversity is a good thing.  
 
For instance, I might low be low in “self-control,” and you might be high in the same.  We can complement one another to achieve a task.  More importantly, I can use a character strength that is particularly strong for me to help us both tackle a problem from different angles.
 
 
Understanding and educating for character
 
Of course, successful physicians need equanimity just as successful philosophers need good judgement.  However, our individual character constellations around these fundamental strengths makes us unique and enables us to complement – and even strengthen – each other on teams.
 
Even the same character strengths can manifest differently. In perusing the book, Character Strengths Interventions: A Field Guide for Practitioners by Ryan Niemec, I noticed that the activities recommended to work on the character strength “Zest” did not include things like, “Quit your job and hike around Europe for a month.” Rather, one suggestion was to choose a physical activity you enjoy, follow a plan to do it regularly, and write about the experience, including the benefits and feelings it evokes. Seems like great advice for anyone. 
 
 
Since our first Kern discussions on character, we have added expertise and experiences from several institutions. As an organization that seeks to transform how we educate the next generation of physicians, I believe it is critical to understanding how we best help students develop their professional character.  To be honest, the things our students see and hear while in the classroom, in the hallway, and at the bedside are already central to their character development, even if we call it by a different name. We rarely reflect on the process and certainly don’t fully understand it. 
 
This is not an inconsequential task. We aim to educate physicians who will, by nature, perform wise behaviors and trustworthy acts. We believe that the goal of understanding and then educating for character is not out of our reach, regardless of where we stand with our own moral development, the shortcomings we might have, or the character strengths that we feel are not as strong as they might be. It is exciting to be “early-in” as we explore this important field in medical education together.  
 
 
 
 
Ryan Spellecy, PhD is the Ursula von der Ruhr Chair in Bioethics and Professor of Bioethics and Medical Humanities and Professor of Psychiatry and Behavioral Health at MCW. He leads a National Transformation Network group seeking to define character in medical education. He is part of the Kern Practical Wisdom Workgroup. He is a member of the Kern Philosophies of Medical Education Transformation Laboratory.
 

How Medical Humanities Can Help Save Lives -- Including Ours

From the 8/28/2020 newsletter
 
 
How Medical Humanities Can Help Save Lives -- Including Ours
 
 
 
Arthur R. Derse, MD, JD – Director, Center for Bioethics and Medical Humanities
 
 

Dr. Derse describes how philosophers, poets, and physician-writers all help us to develop equanimity … 
 
 
The Wall Street Journal recently featured a story that asked the question, “What would Aristotle do in a pandemic?” It’s not such an odd question. Philosophy is part of the humanities, academic disciplines that ask important questions about our human lives. Ancient writers may have wisdom to share with modern day physicians who have to face the challenges of COVID-19. 
 
For Aristotle, character was paramount. Character is demonstrated through traits that included courage and perseverance in the face of adversity. Courage is a laudable character trait, though Aristotle also recognized that courage had to be appropriate to the situation. The character trait of prudence helps recognize when courage is appropriate to the situation that lies between cowardice and foolhardiness. Those teachings from millennia ago can guide us in today’s pandemic crisis. 
 
Physicians and trainees are being called to take risks in their roles as professionals. The risks are greater than usual and must be weighed in relationship to duties these individuals have to themselves, their families and their other patients. A firefighter’s job is to run into burning buildings. But the firefighter needs protective equipment in order to fight the fire. 
 
If a patient with COVID-19 suffers a cardiopulmonary arrest, physicians and nurses may wish to rush immediately into the room to begin CPR (if it might be beneficial to the patient in the circumstances), but caring for patients while protecting ourselves from the virus (that has already killed almost a thousand health care personnel in the US) and preventing transmission of the virus to other patients or our family calls for donning adequate personal protective equipment (PPE), even if it takes precious time to do so. 
 
Balancing appropriate courage and exercising prudence in caring for patients requires another character trait known as “practical wisdom.” Aristotle taught that practical wisdom was both necessary and sufficient for being virtuous. As you demonstrate your courage in striving to save the lives of others, knowing a little about Aristotle might help save your life and, in turn, those of your other patients and your loved ones.
 
Philosophy is not the only area of medical humanities that can provide help and comfort at this time. Literature can give us important, life-supporting and perhaps life-saving insights. Albert Camus, in The Plague, and Steward O’Nan, in A Prayer for the Dying, described the moral challenges facing physicians working in epidemics. 
 
Rafael Campo, MD, physician and poet who worked during the plague-like early years of HIV/AIDS, gives us the comfort of his own the poetry and shares with us his favorite poets - including physician-poet William Carlos Williams and hospital attendant Walt Whitman - to show that healers can get through this. Physician-writers can be role models that help us to be more empathetic and compassionate to our patients and may also soothe our understandable anxieties during this pandemic.
 
Emergency physician and essayist Jay Baruch, MD sends us missives from the frontline where he rails against the broken system that forces him to re-use single-use PPE while treating patients that put everyone at increased risk. The team members trust each another to keep themselves and their patients as safe as they can. His essay highlights the character strengths of teamwork and courage while acknowledge and advocating for the safety of the team. This pandemic challenges us to care for our patients while being responsible for the safety of each other.
 
The humanities can be expressed in many ways in medicine. Colleen Farrell, MD, is an example of a physician who balances her professional responsibilities with humanism and love of medical humanities. She is an internist who recently began a critical care fellowship in July. She treats patients valiantly in the ICU even as she advocates for the protective equipment that residents need to care for patients. She shares her grief and her tears with friends when she loses patients to the pandemic. She played the violin (while appropriately masked) at a memorial service for a nurse felled while treating patients by COVID-19, and plays when she can for her own self-care. And she hosts a biweekly Twitter discussion on medical humanities.
 
Medical humanities help us develop equanimity - the character trait William Osler said was most important to physicians - by maintaining balance and judgment in chaotic and unpredictable circumstances. We exercise practical wisdom by acting on the knowledge of when to do the right thing at the right time in the right manner for the patients to whose good we are dedicated.
 
A recent profile considered whether the extensive grounding in the humanities including philosophy that Dr. Anthony Fauci pursued in his education has shaped the physician, scientist and leader that he is today. Dr. Fauci is an exemplar for humanities in medicine, helping us face the COVID-19 challenge with equanimity as he does now, and did when our nation first faced HIV/AIDS.
 
Medical humanities can indeed help in clarity, insight and comfort during this challenging time. And might just save lives, including ours.
 
 
 
Arthur R. Derse, MD, JD FACEP is Julia and David Chair in Medical Humanities, Professor of Bioethics and Emergency Medicine, and Director of the Center for Bioethics and Medical Humanities and the MCW Medical Humanities Program in the Institute for Health and Equity. He is faculty in the Philosophies of Medical Education Transformation Laboratory of The Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

It Starts with Faculty

 From the 8/28/2020 newsletter

Guest Director’s Corner
 
 
It Starts with Faculty 
 
 
Ali Harrington, MD – Director, Faculty Pillar, Kern Institute
 
 
Dr. Harrington shows how the Kern Institute’s emphasis on character can influence how we respond to our callings ….
 
 

I was upset. We had just clicked “End Meeting” for our weekly Zoom Tumor Board. During the meeting, conflict arose between a few of us, which is never a comfortable situation; and some of us, including me, felt disrespected. Now this feeling is not a unique one for me as a pathologist, as I have learned to live with the slight that I sometimes experience for my chosen profession. Nonetheless, as the division director, I had to assert leadership in the moment and respond to the tensions, so I picked up the phone to talk with my colleague. My impulse was to react, to say how I felt, and to defend my position. And I started there, but I quickly backed off and used self-regulation to “check” my emotions. A few seconds into the conversation, it was clear I needed to listen. I was hearing things I had not considered before. I needed to use perspective – one of my character strengths. Since our conversation, I have deliberated on how I can use empathy and my character strengths to help resolve future conflicts. (Of course, I will also need to deal with my suppressed emotions, something I am not so good at.)    

“Start with the adults.”

“The adult culture matters.”

Some of you may have seen me reference these learnings in an earlier Transformational Times essay, when I described our recent participation in a character education program sponsored by the Kern Family Foundation. This Convening, as it was called, brought together those of us with a personal stake in character development in our learners and included many K-12 educators and leaders and a few partners in the adult learner space. We were there to learn what others are doing and best practices and to share our journey in character education at the Medical College of Wisconsin. It was through this program that I learned that success of character education is dependent on faculty, otherwise known as the “adults” in the K-12 world. So, that means me, and that means you, are key to building impactful character development curricula.

The Kern Institute is leading several programs that have character education, either explicitly or implicitly at their core: KINETIC3 (Kern INstitute’s Educational Transformation in Character, Caring, and Competence), the REACH curriculum, Transformative Ideas Initiative (TI2), and Learning communities. Each of these programs has a focus on faculty development, ranging from an entire program devoted to faculty skill building in KINETIC3 to coach, mentor, navigate, and facilitate training in the others. For those of us leading these programs, faculty development has been critical to implementation of our programming; however, it has served a much greater purpose. And that purpose is to feed culture.

In our KINETIC3 program, we start each year with a Character in Medicine workshop. In this workshop, we explore character development for self (yes, self!) and for one’s learners. We start from a place of inquiry, asking participants to share their impressions of character education in medical education. We hear a gamut of responses at this point, ranging from endorsements (yes, we can all inspire to a better self!) to tentativeness (I'm not sure I’m buying this!) to disbelief (our character is fixed by the time we are adults). We then introduce the topic with a positive psychology focus, using tools from the Values in Action Institute on Character (viacharacter.org), specifically, the Science of Character video to inspire an interest in practical application of character strength development. We ask our participants to share their strengths and how they display those with their learners, families or co-workers. We ask them to consider Carol Dweck’s “growth mindset” as a premise upon which we can continue to develop our character strengths well into adulthood. Transitioning to character educational efforts for our learners, we present K-12 constructs and resources, including CASEL and character.org and advance to reflections on the relationship of character to existing constructs in medical education, such as professionalism and professional identity formation. We then conclude the workshop sharing Dr. Jeff Fritz’s reflective exercises in Anatomy as an example of a character development activity and have the faculty plan out their own character development activity for their learners.

Our KINETIC3 participants respond positively, uniformly, to the Character workshop. Some eagerly share their designed character activities. Others reflect after the session and share: “This is when I realized that I have multiple times to discuss/teach/implement character into every day, clinical teaching,” and “I realized how I've been really interested in character in medicine without actually thinking about it. It's something that I've been trying to learn how to teach, and this class immensely helped!” We try to integrate character development into other workshops in the program to varying success. And this year, we have launched even more character-focused curriculum, including inspiring creativity, growth mindset, culturally responsive teaching, the science of gratitude, role modeling, empathizing with your learners, supporting our students, learner and teacher well-being, psychological safety, and using reflection and narrative stories. Each workshop has the potential to develop one’s own character and influence that of his/her students.

Let us return to the topic of influencing culture. Character.org has published a guideline document, entitled “11 Principles of Character Guidebook,” which serves as a resource for cultivating a character culture within a K-12 school. These principles are equally relevant to our task of building a character culture in medical education at MCW and beyond.

Two of these principles deserve some discussion. The first, “core values are defined, implemented, and embedded into school culture,” asserts that all stakeholders, from staff to faculty to students, can describe the unique, shared values of the school, as these values are ubiquitously adopted, displayed, and practiced. The second is particularly relevant to this discussion on the importance of faculty engagement and development: “all staff share the responsibility for developing, implementing, and modeling ethical character.” This means that we need widespread faculty and staff buy-in and support for character development and that each of us, needs to “walk the walk.” How about we start by choosing to work on our own character?

But what does character education look like in medicine and in medical school? That is, of course, our charge. To create. To experiment. To iterate. We do not have all the answers, but we are working on bits of them. Personally, I think character development in medical education looks like multiple petals forming a beautiful bloom: professional identity formation, well-being, communication, leadership, social intelligence, empathy, professionalism, ethics, and advocacy. This is an oversimplification and may be insufficient for many; but it is practical and offers an outline through which we develop our character strengths for the purpose of becoming our best self, providing the best care for our patients, and contributing to a flourishing society.

I share my story of Tumor Board with you (yes to be vulnerable, Dr. Ferguson) and to provide an example of how each of us is still molding our best self. Building a character culture will take time. It will not be easy. But it starts with us.

“Start with the adults.”



Alexandra Harrington, MD, MT (ASCP) is a Professor of Pathology and Director of Hematopathology in the MCW Department of Pathology. She serves as Director of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.