Trying to Remember 9/11

 From the 9/11/2020 newsletter

 

 
Trying to Remember 9/11
 
 
Bruce H Campbell, MD FACS – Editor, The Kern Transformational Times
 
 
 Dr. Campbell shares his experience of being in the operating room the morning of 9/11 and what has happened in the years that followed …
 

My colleague burst through the door of my operating room.

“A plane! A plane just crashed into the World Trade Center.”
 
I looked up from where I was standing next to the operating table. My resident and I were removing a malignant mass from my patient’s neck. The surgery had just started but the scars from another surgeon’s biopsy made the initial steps of the dissection tricky.
 
“What?”
 
“A plane. I was in the OR lounge and the news switched to New York. A plane just crashed into the World Trade Center.”
 
I stared at him. I re-checked the surgical field and put pressure on the wound.
 
“So, what are they saying? What’s going on?”
 
“They don’t know. My God. It’s awful.”
 
He left and we went back to work. The resident and I teased out the anatomy, peeling the skin from the underlying muscles, finding the jugular vein and preserving the nerves to the tongue and the shoulder. We dissected the lymph nodes away from the surrounding tissues deep in the wound.
 
The door opened. “Another plane. This one crashed into the other tower.”
 
“What?”
 
“They’re replaying the videos over-and-over. The first tower is on fire. Then there’s the other plane.”
 
He ran out again.
 
We lifted out some of the nodes, clearing them from the carotid artery. By placing my fingers lightly on the carotid, I could feel the patient’s blood flowing from his heart to his brain.
 
The door opened. “Bush was just on TV. He says it’s terrorists.”
 
I closed my eyes. “Please stop. Please don’t come in with any more news reports.”
 
He paused. “Okay, sure.” Then he left.
 
We wrapped up the surgery, tying off a few small blood vessels and closing the wound. It was deadly quiet. None of us in the room had any idea what was going on, but we sensed it was bad. I lingered as the patient woke up. We wheeled him to the recovery room. 
 
Someone stopped me in the hallway. “The first tower collapsed.”
 
I went to the lounge to watch with the others, then walked down to the family center to talk to my patient’s wife. She was watching the news along with everyone else. We stepped into a private consultation room so I could review her husband’s surgery. We returned to the waiting area where I stared at the television with her for a few minutes. The scenes of smoke billowing from the towers and the slow-motion impact of the second plane were playing over-and-over. 
 
Everyone in the hospital looked dazed. News reports flashed about a plane crashing into the Pentagon. Another plane had reportedly crashed in Pennsylvania. 

 

I wondered: Were any of my New York friends killed? Would New York and Washington, DC hospitals be overwhelmed? Many of my partners were at a meeting in Denver. Were they okay? The airports are closed. How will they get home? Were more attacks imminent? Were we all in danger?
 
I walked back to the recovery room where my patient was waking up. I told him that the surgery had gone well. He smiled and dozed off. He had gone to sleep in one world and awakened in another. 
 
 
Despite humankind’s overwhelming capacity for kindness and compassion, we also seem bent on senseless, self-inflicted tragedy. The numbers of people killed during wars and atrocities are incomprehensible. 450,000 died in the American Civil War. Approximately 85,000,000 died over the course of WWII, including the single-day death tolls of 1,177 at Pearl Harbor, 145,000 in Dresden, and 60,000 at Hiroshima. Millions have died in wars about which we never studied in school. The death tolls from slavery, racism, and brutality cannot be measured. 
 
Survivors beg us to remember the stories, but their voices soon fade. Nineteenth Century Americans were exhorted to, “Remember the Alamo!” and reminded to “Remember the Maine!” as the country waged wars with Mexico and Spain. The survivors of those cataclysmic events - and many others - are long gone. Their appeals fail to stir us. After each moment of outrage, our collective and personal sense of innocence and the illusion of normalcy returns. Our hands return to our daily tasks. We turn away and forget. 

 
Still, I was shaken hard that morning. I will never understand why 3000 people were killed that day in New York, at the Pentagon, and in a farm field in Shanksville, Pennsylvania. I mourn the hundreds of first responders and clean-up workers who were sickened or died. I despair at the subsequent thousands of dead civilians and soldiers and the millions of refugees. The gnawing emptiness in my gut during the weeks that followed mirrored the emptiness of the skies devoid of planes. Yet, the aftershocks faded. Soon, even when I tried, I could no longer evoke the depths of despair that were once so real.  

 
 
For several years, the patient on whom I operated the morning the towers fell continued to come for follow-up visits. I was happy to see him. I would examine his neck and make certain his cancer had been controlled. We always spent part of the appointment reliving our shared, indelible experience. 
 
“Do you remember?” we would ask each other.  
 
“Yes, I do,” we would respond.
 
Eventually, though, there was no need for him to return. No more annual visits. “Let me know if things change,” I said. 
 
He shook my hand. “I won’t forget that day,” he said.
 
“Me, either,” I replied. Yet, I know now, I had already begun the process of forgetting. 
 
 
The fading passion, I am certain, protects us from being locked into permanent states of grief and anger. 9/11 – as well as all the shocking events that have rocked our recent national history – arouse outrage and grief. They evoke powerful emotions and calls to action. New leaders rise and inspire us to be part of the change. The events and names remain alive if we amplify the stories. We pledge to stay engaged.
 
Although nineteen years have passed, 9/11 remains one of my communal “Where were you?” moments. Most of the medical students with whom I work were in grade school the day that the attacks occurred. The act of telling this story again is my way of keeping a memory of that day – and the passions it engendered in me – alive. 

 
 
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. A previous version of this essay appeared several years ago in Dr. Campbell’s blog, “Reflections in a Head Mirror.”
 
 

Student and Resident Behavioral Health at MCW: A Personal Perspective

From the 9/4/2020 newsletter

Perspective 

 
Student and Resident Behavioral Health at MCW:  A Personal Perspective
 

David Cipriano, PhD – Director of Student and Resident Behavioral Health
 

Dr. Cipriano describes the challenges and rewards of running the Student and Resident Behavioral Health program at MCW. Sign up here to hear him describe the state of our program at an upcoming Kern Connection Café …
 

I became Director of Student and Resident Behavioral Health about four years ago and I’ve always had a knack for being in the right place at the right time.  At that time, the institution as a whole was really beginning to sit up and take notice of learner mental health and well-being in a comprehensive way.  Now, MCW has always taken care of its students and residents with mental health services and available wellness activities.  But, four years ago, MCW tackled the issues in a really planful and big picture way – looking at curriculum, community, and culture.  Since then, I have been riding a wave of enthusiasm and support for this mission – the mission to increase protective factors for our learners – such as access to care and a supportive community – and to decrease risk factors such as stigma and shame and isolation.  I’ve never had a job where I had so many people coming to offer ideas, suggestions, and resources.  

 
 
Results of the 2017 survey
 
Being a data guy, I wanted to “take the pulse” of our students’ behavioral health (if you haven’t been able to tell already, I am using “mental health” and “behavioral health” interchangeably).  In 2017, we conducted our first Mental Health Climate Survey of our medical students (shame on me for not including our graduate students at the time – and I’m a product of graduate school!).  We found high levels of depressive symptoms among our students (higher than the general population, but actually a little lower than estimates of medical students nationally).  We also found a certain number of our students dealing with suicidal thoughts daily or weekly; not out of line with general prevalence numbers, but still frightening.  Almost 20% of our respondents said that they didn’t know if they had a mental health diagnosis, telling me that I needed to work on mental health literacy with this group.  Finally, it turned out that despite high visibility of our services, a large proportion of students who said they needed help did not seek it.  Barriers to getting help included time, cost, and fear of stigma or – worse – negative implications for licensure.  
 
 
What we did next
 
Since then, we’ve worked hard to break down stigma by having faculty and students share stories of their own struggles.  We’ve tried to address the time issue by setting up special student clinics on Thursday afternoons when they have the most flexibility and a resident clinic on Tuesday evenings.  We’re giving students and residents more opportunities to self-assess, trying to increase that self-awareness and literacy piece.  A new online, self-help, cognitive behavioral therapy program called SilverCloud was brought onboard last year – talk about accessibility – it’s available 24/7!  We re-booted our website (www.mcw.edu/thrive) and rolled out support groups that are drop-in and usually include lunch (when we’re all back together!).  And, new this year we have added a student assistance program with a range of services, including an expanded network of providers (of course our learners can still choose our own MCW providers).  And, perhaps most importantly, the school expanded the benefit for students to ten no-cost sessions per academic year.  
 
Personally, I have never felt so energized and rewarded by a position.  Our learners are an at-risk population.  Healthcare trainees, including those in pharmacy, health sciences, and medicine, have higher levels of depression, anxiety and burnout than their age- and education-matched peers.  With an already stressed healthcare workforce, it benefits us all to see that we turn out the next generation of healthcare workers and scientists primed to be resilient and healthy.  
 
We re-did the Mental Health Climate Survey in early 2020 (actually before COVID-19 struck) and I’ll be sharing the results of that at the upcoming Kern Connection Café on September 17^th.  We’ve seen some improvements and some stubborn findings that simply tell us that we have to keep working at it.  I hope you’ll join us to share in the discussion.
 
 
David J. Cipriano, Ph.D. is an Associate Professor in the MCW Department of  Psychiatry and Behavioral Health and Director of Student and Resident Behavioral Health. He is a member of the Community Engagement Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

The Moral Imperative to Promote Well-Being in our Learners

 From the 9/3/2020 newsletter

Guest Director’s Corner

The Moral Imperative to Promote Well-Being in our Learners

Cassie Ferguson, MD - Kern Institute Student Pillar Director

Dr. Ferguson shares her work exploring the gaps between what we know about well-being and our ability to reliably intervene with our learners …

Early in my career as a physician, I learned about the intimate connection between our own individual well-being and the quality and safety of care we provide to our patients. My interest developed out of my work in quality improvement and patient safety. Over the past ten years, this has led me to focus on the critical importance of promoting well-being among medical students, trainees, and physicians.

As I've learned about the depths of our un-wellness as a profession, my interests have shifted to advocacy; I now see the promotion of well-being and the support of those of us caring for others in the health profession as a moral issue.

Identifying the scope of the problem

It is unconscionable that nearly 40% of medical students are depressed. It is unfathomable that over 400 physicians die by suicide every year. And it is unjustifiable that we have neither centralized the efforts to improve well-being nor pushed them to the forefront of every leader’s strategic plan. As we attempt to understand and work toward solutions, we must begin by acknowledging that many of the drivers of unwellness exist at organizational and societal levels; when the canary dies in the coal mine, you don’t blame the canary’s lack of resilience.

Organizational and environmental factors – like productivity-driven staffing models, lack of diversity, cultures of blame, and workplace violence – absolutely drive our unwellness. Societal factors like systematic oppression and structural violence may impact us personally, particularly if we are a member of a marginalized community, and bear witness to this type of violence regularly.

When we think of interventions, however, we tend to dichotomize well-being into those aspects driven by systemic factors and those driven by individual factors. In reality, these cannot be separated. They are inextricably linked. What this means is that we cannot expect that the impacts of workload, inequitable compensation, or tolerance of institutional prejudice and microaggression will be mitigated by lunch hour meditation for students or yoga classes for clinicians. By the same token, it is just as important to understand that our individual well-being – our capacity for compassion and empathy for our colleagues, our ability to self-regulate, our recognition of the impact that our presence, our biases, our attitudes have on those around us – collectively contributes to the learning environment and workplace culture and thereby the well-being of the entire institution.

I do not define well-being by the absence of depression or suicidality, but rather by a more holistic vision that assumes that, as physicians and physicians-in-training, we might flourish; a vision that leads to encompassing physical, mental and emotional health, embracing joy, and finding meaning.

Recognizing the gaps in our understanding of wellness

To realize that vision, many have called for to shift the focus from what drives our unwellness to what may help keep us whole. To that end, the National Academy of Medicine (NAM) launched the Action Collaborative on Clinician Well-Being and Resilience in 2017; one of their goals is to “advance evidence- based, multidisciplinary solutions to improve patient care by caring for thecaregiver.” The ACGME has partnered with the AAMC and the NAM to co-chair this action collaborative to help “create a healthier, safer medical community.” Leading researchers in this realm continue to call for more robust research studies designed to evaluate interventions aimed at improving well-being.

Despite these efforts, there are still no multi-center, randomized, placebo- controlled studies that definitively point to interventions that, if implemented, will make us all well. Frankly, I do not believe that even the most perfectly designed study will ever reveal the value of such an intervention. In the studies we have done with medical students at MCW through the Kern Institute, it is quite clear that what works for one student may not work for another. And my three-year experience as the chair of the professional health committee atChildren’s Wisconsin has helped me to understand how local, even systemic, drivers act.

Understanding this, I propose that, in our quest to elucidate effective well- being interventions, we shift from asking, “what works?” to “what works for whom, under what circumstances, and why?”

To this end, our team has shifted to using Design Thinking tools, quality improvement methodology, and profile analysis in this work. Although we can efficiently summarize testing results from students on psychological, behavioral, or social measures into a “mean score,” it is fair to say that the mean often provides very limited information in helping students, because it masks differences that exist in student trajectories. That is, the mean can often hide the trajectories of students who have different patterns, needs, strengths, and weaknesses, hiding heterogeneity by homogenizing everyone to one value. As educators, the differences in trajectories is where our first lever of facilitating change lies.

Expanding the analyses of student wellness diversity

We need to go beyond the mean by focusing on analyses that will allow us to understand groups of students with similar patterns of responses across a variety of important behavioral, cognitive, and social dimensions. This is where analyses like latent profiles analysis (LPA) comes into play. LPA is a statistical analysis that helps researchers identify groups of individuals that have similar and different responses patterns on measures or tests. Combining LPA with trajectory analysis (time series/growth modeling) results in a very powerful way to look at students over time. These types of analyses help uncover sub- groups of students, map their trajectories over their medical school careers, and provide a way to understand what helped students improve, decline, feel joy, or struggle. Supplementing these analyses with student voices through open-ended questions, focus groups, and interviews creates a deeper understanding of our students. This information can help educators design and enhance curricula that support students with various needs, leaving no student behind on either end of the distribution, with a long-term focus on supporting their growth over time.

Ultimately in our well-being work at MCW, the goal is to combine LPA, growth trajectories and qualitative analyses to understand how a number of psychological (e.g., mindfulness), social (e.g., perceived social support) and behavioral measures (e.g., intrinsic/extrinsic motivation) relate to skills fundamental to the practice of medicine: how students’ communicate with patients and colleagues, how they work in teams, and how they navigate the complexities of being present for the suffering of other humans.

Acknowledgement: Thank you to Tavinder Ark, PhD of the Kern Institute for her contributions to this article and for her consistent and innovative work in the study of student well-being.

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.

Fabulous Failures

 From the 9/4/2020 newsletter

Being Human in Medicine

 
Fabulous Failures

 
Himanshu Agrawal, MD – Department of Psychiatry and Behavioral Medicine
 
 

To encourage his students who might be worrying about USMLE board scores and other life challenges, Dr. Himanshu shares the story of one of the darkest and best days in his life …
 
 
It's 2:00 a.m. and I am a junior medical student in India. I haven't eaten in two days and am worsening my heartburn – and my heartbreak – with black coffee and a cigarette. I can feel the sense of doom grip my fundus. A senior medical student whom I barely know staggers into the cafeteria, happy to have a brief respite from his overnight rotation. “Why the long face?” he asks out of genuine concern. The tears erupt, uninvited – “I did horrible in my USMLE Step 1 exam!” I tell him. I hardly know the guy, but I am in mourning, so shame be damned. “There, there! It can’t be that bad. How much did you score?” Envisioning my entire future evaporating in front of me, I manage to say the numbers: “197.”
 
The man takes a step back, and his hand instinctively rises to stroke his chin. It’s as if he has heard someone mutter a terminal diagnosis. “Hmm…That is bad! Well…with a score like that, you won’t be able to get into internal medicine…the only US residency you can get into is psychiatry…” 
 
Suddenly, he meets a reaction he did not expect – a wide grin appears on my tear-smudged face. “Really?! But that’s what I want to do! Psychiatry!!” He looks at me with surprise, then smiles. “Well then what are you crying for? Let’s celebrate! This cup of tea is on you, my friend!”
 
The year was 2000. Psychiatry was not nearly as competitive as it is now, and international medical graduates still got interviews in American programs. So much has changed in the last twenty years, but some things remain the exact same. You see, looking back, this random stranger had no idea what he was talking about – he was certainly no authority on USMLE scores, successes and failures – but, like so many others, he was a speculation-guru, a pundit of pontification. Unknowingly, his prophesizing was exactly the piece of straw I needed to stay afloat!
 
Hopelessness cast as large a shadow on my future back then as it has for several of my medical students. And sometimes, it is as quickly dispelled as mine was that fateful day by that clueless senior student (Sometimes it takes a bit longer).
 
I am writing today for all my students who have recently faced despair or who may one day meet with crippling news. This Distinguished Fellow of the American Psychiatric Association, this latest recipient of Edward J. Lennon Endowed Clinical Teaching Award, this boy from New Delhi who grew up without running water but who now swims in a 29,000 gallon swimming pool (feel free to insert your own yardstick of success) – I was once ready to walk away from it all. I was ready to throw in the towel. 
 
I am so glad I didn’t.
 
Remember two things- firstly, you are not as good as they say you are when you succeed, and you are never as bad as they say you are when you fail. 
 
Secondly, you will never cherish success more sweetly, than when you have had to swallow the bitterness of failure.
 
Do I wish you failure? Of course not. What I am saying is this – there is more to life, so much more, after failure.
 
Failure is not the same as defeat.
 
They say nothing succeeds like success.
 
They have not seen the daily grin on the face of this Fabulous Failure.
 
 
 
(Dedicated to Roda Sir)
 
 
Himanshu Agrawal, MD, DF-APA, is an Assistant Professor in the Department of Psychiatry and Behavioral Health at MCW and co-director of the psychiatry clerkship. He serves as a small group facilitator in the Kern REACH curriculum.