The Truth About Trust

 From the 10/2/2020 newsletter

Director's Corner

The Truth About Trust

Adina Kalet, MD, MPH

In this Director’s Corner, Dr. Kalet considers the importance and complexity of trust in medical education and encourages us to hone our judgement and have courage …

Anyone who doesn’t take truth seriously in small matters cannot be trusted with large ones either.

-Albert Einstein

The first presidential debate this week has me thinking about the consequences of not being able to trust someone on whom you depend. We rely on our elected officials, like our physicians, to listen, have empathy, engage in respectful - even if sometimes - heated disagreements, make good judgements in very complex situations, have control over intense emotions and, most importantly, consistently tell the truth. To “trust someone” implies that we have confidence in that person, and believe that the individual will be capable, adaptable, and competent now and in the future – even when faced with novel, rapidly evolving circumstances, emotional and physical stressors, and unpredictable challenges.

While always in the background, trust (“entrustment” and “trustworthiness”) has moved to the forefront in the medical education. How we make these trust judgements in medical education – and in life – is worth a hard look.

How do we measure trustworthiness in trainees?

Hodges and Lingard point out that the discourse about what makes a “good” physician – a core responsibility of our work as medical educators – has moved through a series of distinct and overlapping eras over the past seventy years. In the Psychometric Era, we valorized measurable, highly standardized knowledge tests (e.g. MCAT, USMLE Board Exams). The next phase brought great enthusiasm for demonstrable, directly observable, and behaviorally measurable core clinical skills (e.g. oral exams, mini-CEXs, OSCEs). Next, and to the frustration of many program directors, organizations introduced comprehensive, nuanced competency frameworks designed to capture and document each learner’s developmental progress via new standards and milestones.

These changes reflect our evolving grasp of “quality” in medical education. As our understanding improves, we will uncover how to develop rich portfolios of assessment data for each of our trainees. But in the end, data do not make high stakes decisions. We do. And these decisions require making trust judgements and having the courage to act on those judgements.

Trust judgement barriers and opportunities

Unfortunately, clinical faculty are not very good at assigning objective measures of competence. My colleagues and I spent years trying to get experienced clinicians to make reliable (reproducible) measurements of medical student clinical competence. Even with lots of fancy, performance dimension, frame-of- reference, and behavioral observation training, experienced professionals are eccentric and resist standardization. This, I believe, is because there is no single “truth” about clinical competence.

Trust judgments are highly context-dependent and idiosyncratic. We tend to be internally consistent and we know a trustworthy resident when we see one. An experienced professional possesses a highly-honed identity and a strong sense of what a trainee must demonstrate to be trusted to care for “our” patients. Unfortunately, we disagree with our colleagues on when individual trainees can be entrusted to “fly solo” and more independently care for patients. Gingerich has challenged us to embrace this disagreement and see it as a strength rather than a weakness.

Furthermore, experts are also context-dependent! As we collect and collate more-and-more data from larger, diverse pools of experts, we must ensure that trust judgements are appropriately interpreted to protect students from the vagaries of any individual’s bias. This is what van der Vleuten and others call a Program of Assessment for Learning. Ultimately, trained competence“judges” will be charged with making final high stakes assessments regarding decisions such as advancement and graduation. These judges will determine if, based on solid evidence, we can trust a learner to consistently “do the right thing, at the right time, for the right person, and for the right reason” in their next phase of training.

Moving from theory to action

Social and cognitive psychology researchers suggest that competency judges need to both understand the value and limits of the objective data (e.g., exam scores don’t predict clinical skills competence, but they do predict future exam scores) and should explore and develop their judgement “sense.” This sense of who to trust is highly dependent on an individual’s characteristics, experiences and biases. Knowing thyself, in particular understanding one’s biases, is crucialbecause if we are cognizant of them and have integrity, we can make adjustments – “forcing” ourselves to slow down our thinking, toggle to a more analytical rather than intuitive deliberative strategy, when we are in danger of making an error. This takes work, discipline, and practice with feedback.

There is much interesting work to be done to ensure we have trustworthy physicians. Fundamentally, most of us make our trust judgements based not on what students know or can do (we can always teach that stuff), but on who they are as people. Do they always tell the truth even when it leaves them in a “bad light?” Do they admit when they missed a physical exam finding or forgot to check a lab or failed to follow up on something? Do they take the time to listen, attend to details, interact with empathy and kindness, even when stressed emotionally? Do they strive to improve rather than rest on their laurels or test scores? Do they seek to understand the perspectives of others? How do they handle being wrong or making a mistake? Can they sincerely apologize?

We are accountable to society to make defensible promotion and graduation decisions based on each learner’s competence and trustworthiness. These are difficult-to-measure, shifting concepts. We pledge to engage in the ongoing discourses and learn how best to make difficult, discerning judgements.

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. 

ThriveOn, a Community-Centered Collaboration, has Broad-Reaching Focus Areas

 

From the 9/25/2020 newsletter

ThriveOn: A Community-Centered Collaboration has Broad-Reaching Focus Areas

The community-centered collaboration led by the Medical College of Wisconsin (MCW), the Greater Milwaukee Foundation (GMF), and Royal Capital Group has chosen the name of the ThriveOn Collaboration as the organizations continue deep resident and stakeholder engagement together to inform priorities and investments for supporting a thriving King Drive corridor and its connected neighborhoods.

The ThriveOn Collaboration champions a vision for a Milwaukee that is equitable, healthy and thriving for all. Achieving this vision will require durable partnerships with the community, focus on places where investment has been scarce, and supporting people of color, especially African Americans, who are disproportionately affected by health and economic disparities.

The ThriveOn Collaboration is built on the fundamental understanding that where a person lives has a tremendous impact on their health and wellbeing because housing, education, jobs, health resources and social connections are the underpinnings of healthy lives and communities. Consequently, a key component of the ThriveOn Collaboration is a place-based investment in the redevelopment of 2153 N. Martin Luther King Jr. Dr. into a community hub with neighborhood amenities, and offices for key MCW centers, institutes and programs and the Foundation’s new headquarters.

Extensive dialogue with residents, deep analysis of local and national data, and years of expertise in their respective sectors has shaped the collaborators’ approach to identifying priorities and developing thoughtful contributions that will add value to the community. The ThriveOn Collaboration’s corresponding strategies are designed to counter systemic racism and disinvestment that has negatively impacted black and brown communities in Milwaukee for generations.

The ThriveOn Collaboration has identified five priority areas. Many of the priorities directly relate to MCW’s 2025 goal of “Health of Our Community.” The long-term goals under this overarching goal includes ensuring all subsets of our community thrive, enabling the greatest positive engagement with our community to faculty, students and staff and demonstrating improved health of vulnerable populations and overall health of our community by leveraging MCW’s strengths.

The priority areas of the ThriveOn Collaboration are informed by the social determinants of health, factors that contribute significantly to health such as where people live, access to healthy foods and affordable housing, and social support networks. 

• Housing – invest in the availability of safe, quality and affordable housing for area residents. The long-term goal is to increase the number of residents leasing, purchasing, and maintaining homes with a focus on keeping long-time residents in the neighborhood.
• Early Childhood Education – invest in the quality, access and sustainability of early childhood education in the city. The long-term goal is to improve education outcomes for youth.
• Health & Wellness – investing in access to health and wellness facilities, healthy food options and preventive health services in the area. The long- term goal is to reduce rates of chronic disease and increase quality and length of life.
• Social Cohesion – support the community in building positive social and business relationships, celebrating diversity and promoting a sense of belonging among neighbors. The long-term goal is to increase resources for resident-led events and organizations.
• Economic Opportunity – support small business and enhance equitable economic opportunities for entrepreneurs and the local workforce. The long-term goal is to increase the stability of the small business community and increase access to quality jobs.

“Health of our community and moving toward health equity is more important than ever before, as demonstrated during the global pandemic of COVID-19,” said Greg Wesley, Senior Vice President of Strategic Alliances and Business Development for MCW. “By building upon MCW priorities, honoring this community's history, culture and people, and by listening and collaborating every step of the way, we are moving forward with GMF and Royal Capital Group to inspire change and action.”

The ThriveOn Collaboration reflects the values of the community shared through continuous dialogue and participation among residents, the collaborating organizations and other community leaders. The feedback helped shape the collaboration’s goals and how the work moves forward. Community engagement for the ThriveOn Collaboration remains active. Staff members currently are holding virtual office hours, and the team is establishing a Community Advisory Council (CAC). The goal of the CAC is to further integrate community perspective and participation by ensuring residents have additional decision-making power within the collaboration. The role of the CAC is to include a community voice in grantmaking and program initiatives that promote an equitable, healthy and thriving community with a focus on the Harambee, Halyard Park and Brewers Hill neighborhoods.

The ThriveOn Collaboration has been working to implement its vision and priorities. Its commitments in community have included:

• Helping to prevent resident displacement through partnership in the MKE United Anti-Displacement Fund. Housed at the Foundation, which contributed seed funding, the Fund so far has provided about $37,000 in property tax relief to 114 homeowners in the Harambee, Halyard Park,Brewers Hill and Walker’s Point neighborhoods, the majority of whom were over 60 years old.
• Approving approximately $100 million for joint investment in building improvement and development, including streetscaping and exterior art and green design.
• Providing more than $13.2 million in grants through the Foundation and in support of COVID- 19 relief, response, and recovery related to food, shelter, health, education, economic stabilization and more.

When redeveloped, the collaboration’s corresponding Milwaukee location on King Drive and, adjacent to Dr. Vel Phillips Avenue, will support health and growth, and be a destination where Halyard Park, Harambee and Brewers Hill neighbors can interact, learn and share.

MCW feels this is a return to its roots. For 34 years, from 1898 to 1932, MCW’s predecessor institutions (Wisconsin College of Physicians and Surgeons, which became the Marquette University School of Medicine) were located in Halyard Park in a building located on the southeast corner of Fourth Street and Reservoir Avenue. Next to the medical school was its dispensary (now called outpatient clinics) where medical students observed faculty physicians treated indigent patients. Across the street from the medical school was St. Joseph’s Hospital, the medical school’s primary teaching hospital.

For more information or to get involved with the ThriveOn Collaboration, please visit our website atthriveoncollaboration.org.

Kevin Newell from the Royal Capital Group, Ken Robertson and Ellen Gilligan from the Greater Milwaukee Foundation, and Dr. John Raymond from MCW were instrumental leaders for this initiative.

RBG and Dad

From the 9/25/2020 newsletter

Director’s Corner
 

RBG and Dad

 
Adina Kalet, MD MPH
 
 

In this Director’s Corner, Adina Kalet tries to reconcile the awesome vulnerability of being a patient, the potential transformative power of our profession, and the lessons learned from the life of an American hero.
 
 
This week, the death of Justice Ruth Bader Ginsberg has been on my mind and, as I considered what to share in my column, I realized how important she has been to us. I have benefited from, and been moved by, her critical and prophetic message that, “Women belong in all places where decisions are being made.” For women of my generation, this was not the norm and it is still far from a guarantee. Thanks to the work of RBG and a handful of others, some of us now find ourselves “at the table,” making decisions and expanding our spheres of influence as we attempt to make the world a better place. Her work led directly to transformative change. Many of us who would have otherwise been sidelined are now heard in ways that would never have been possible without her. 
 
Ruth Bader Ginsberg was an American hero and transformational leader, par excellence. People on all points of the political spectrum have noted her uncanny ability to listen, her impact on society, her brilliance and courage, her prophetic legal mind, her ability to see things as they should be for all people, and her perseverance. I have medical colleagues who take on the challenges inherent in medicine the same way.
 
 
This week, the chance to be heard became personal.
 
 
I am writing this column while sitting in a hospital waiting room, the daughter of someone suddenly thrust into the medical system. In my new unwelcome role, I feel vulnerable and less assured of the value of my personal “power and influence.” I had planned to write about RBG’s life and legacy. Instead, I find myself searching for parallels between how she leveraged her knowledge of the legal system for change and my need to exercise my familiarity with the medical system to make certain my father stays safe. Like her, I remain vigilant, paying attention to everything that is happening around us, and advocating on my father’s behalf. It can be exhausting.
 
My dad is a remarkably fit 84-year-old retired engineer who presented this past Tuesday to his internist with classic symptoms of exertional angina in a crescendo pattern. Dad’s EKG had developed non-specific T-waves that suggested something amiss. He was walked down the hall to the cardiologist who then called the interventional cardiologist who scheduled a cardiac catheterization. He was admitted to the ER for monitoring. His first troponin levels (an indicator of heart muscle cell damage) were equivocal, suggesting heart muscle cells were spilling their contents but he didn’t appear to be having a full-blown heart attack. 
 
For context, my dad sees a doctor in the large academic medical center where I did my residency training and spent the first thirty years of my career. I know this place and these people – warts, glory, and all. Even though I had confidence in his care team, I was terrified. I knew too much. I never left his side because, over the years, I have seen all of the things that can go wrong even when everyone is well meaning and highly qualified. 
 
From the patient’s (and the daughter’s) perspective, hospital care separates individuals from everything familiar. There are endless streams of humans with uncertain duties, repeated handoffs between nurses, physicians, and other staff, long (ten hour!) waits in the ER until a “clean bed” becomes available, no proffered food, malfunctioning cardiac monitors for a patient with a heart problem, a mix of disturbingly poor and remarkably skillful communications, and moments of caring and compassion juxtaposed with moments of “ghosting.” Even as someone who knows medicine and trained in the hospital where we now sat, the experience was dehumanizing.  
 
Further, I could see the contrast between the technical, sophisticated wonders of modern medicine – cardiac catheterization suites with cutting-edge technology and physicians with impeccable expertise – and the troubling implications of the corporate commodification of healing in healthcare systems. Some patients in the city are offered luxurious private rooms with gourmet meals and spectacular views of the river while others – in the public hospital down the street – are offered no amenities. The public hospital’s professional expertise is, fortunately, comparable, but is also distinguished by the staff’s ability to offer excellent care despite their lack of resources. 
 
What’s the bigger picture here? How might we make healthcare more equitable? RBG had a wider vision of society, and she pushed the legal system to treat everyone equally no matter their gender or status. In the same way, visionaries in medicine envision a future where every person is entitled to safe, high quality, compassionate, cost-effective healthcare. We must include the most vulnerable patients, even as she fiercely advocated for all members of society. We will face challenges along the way, just as she experienced blatant interpersonal and institutional sexism during her career. 
 
She demonstrated that to be transformational, we need to be persistent. There was a moment, early in her time at Harvard, when RGB and the small group of women classmates were challenged by the law school dean to defend why she “took” a man’s spot in law school. They demonstrated their value with their actions and dedication. They showedthat they belonged. Later, despite graduating at the top of her class and being part of the law review, she could not get a clerkship or even a job with a law firm. She chose an alternative path, doing comparative international law research, joining a law school faculty, and creating her own way forward. She ended up changing the world. 
 
To achieve transformation, we will need to engage – like RBG did – in necessary, nuanced, and difficult conversations. She had a clear moral compass. She was able to change her mind, to be influenced by others, and to learn deep and abiding truths about human dignity from those whom she loved and especially from those she didn’t know. With these character traits, it is possible to engage in respectful, caring, civically responsible, and sometimes fierce dialogues on contentious issues, including the inequities in health care and society. “You can disagree without being disagreeable,”she said. “Fight for the things that you care about but do it in a way that will lead others to join you.” Although being patient enough to work through issues can be a huge challenge, her long view of history allowed her to dissent while remaining part of rich, mutually respectful, humble relationships with those with whom she fundamentally disagreed. Her ability to persuade without fracturing human connections is one of her most important legacies and lessons. 
 
 
I accompanied my dad on his journey this week. Happily, he had the best possible care and had a wonderful outcome despite the frightening situation. I advocated for him, speaking up and influencing the system when it faltered. But mostly, we realized that the outcome was a result of the fundamental commitment of his medical professionals to care for someone in need. 
 
RBG, too, depended largely on the goodness of people working in the legal system, although she did not allow that faith to keep her from being a vigilant advocate when she felt it was needed. She believed in the goodness of others, but also that she had the responsibility to drive the change. She persisted and the world is a better place because of it. May we all be inspired by her courage and passion. 
 
 
 
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.
 
 
 
 

The Unsolvable Tension Behind Good Intentions: Confronting Sincerity and its Shadow

From the 9/18/2020 newsletter
 
Student Perspective/Personal opinion 
 
 
The Unsolvable Tension Behind Good Intentions: Confronting Sincerity and its Shadow 
 
 

Jess Sachs, M3, explores the complex relationship between intentions and actions as she seeks to understand anti-racism and navigate her way toward being a consistent, effective ally. 
 
 
Like many, I have become increasingly motivated to step up and advocate for justice and equity. Also, like many, I struggle to determine where I am most needed and how to strike the delicate balance between white savior and white ally. So, when advocating for Black lives became “trendy” again in May after the death of George Floyd, I decided to do what plenty of other people started doing, which is committing to learning about social justice and anti-racism work and then...posting about it online. Otherwise known as “performative allyship,” or “slacktivism” in colloquial terms, this trend is something that white people like myself have an embarrassing history of participating in—that is, temporarily caring, and engaging in the work of reading, listening to, and advocating for Black people until our own lives become too “important” to continue pursuing meaningful activism. Nevertheless, I was drawn into this engagement, but this time I committed to doing it “right.” This would not be another time loop, another performance of the same pieties we have played out time and time again. What I ultimately intended to learn about was the death of Breonna Taylor. 
 
If you haven’t heard about Breonna Taylor, hers is the story of a Black woman losing her life to police brutality, a tragically common occurrence. Breonna was an EMT who was fatally shot by police officers attempting to serve a no-knock warrant on her home on March 13, 2020. (Brown & Duvall, 2020). The chronicle of her death is senseless, tragic, and heartbreaking. Why I became particularly attached to this specific tragedy, I am unsure. Perhaps it was because of the similarities between Breonna and me. We are the same age and working in the same professional field. Perhaps it was also because the case continues to evolve as new information leaks out - information that is often contradictory and confusing. 
 
Regardless, her story has become a source of painful preoccupation. Much of my time is spent searching twitter and Instagram with the hashtags #Breonnataylor, #justiceforbreonnataylor, #breonnaslaw, in an effort to absorb and learn everything I can about her. I attend Zoom Call to Action meetings. I read stories written by her sister and her mother. I donate to the Louisiana Until Freedom organization. I aim to become an expert in her case, because for the sake of our humanity, I did not want this to be another example of futile action. I vowed that my involvement would be one of the many steps in the proper direction of acknowledging systemic racism and advocating for justice. 
 
Recently, however, I read an article exploring how Breonna Taylor’s trending name has gone from a call to action to an oversimplified meme. Zeba Blay, the author of the piece writes, “Turning Breonna Taylor into a meme, then, risks turning the conversation around what justice looks like for her into a temporary fad.” This was my biggest fear. By reading and posting everyday, perhaps her story and her name were ultimately losing meaning. I questioned if I was becoming desensitized to the true goal of this work and blindly following a fashionable fad that looked like, but had nothing to do with, justice. This was never my intention, I kept thinking. And herein lies the complexity and confusion with our intentions. Below the surface of our rational minds lies a traffic intersection of contradictions, within which we ask this question: Is what we do substantive or simply another manifestation of our hopeless hypocrisy? Were my efforts simply designed to temporarily absolve my own white guilt? Was this true allyship, and is that even the goal? 
 
The answer to these questions? I still don’t know. What I do know is that my intentional actions to dismantle white supremacy will never be enough. What I do know is that my unintentional actions have maintained a culture of oppression and racism. Our personal truth is always far amore complicated than it seems, and reflection is necessary as we confront these feelings of guilt, discomfort, and confusion. But we continue to commit to meaningful causes, even if our motivation remains imperfect and clumsily emerges from a welter of conflicting impulses. It is of little value to attempt to fully reconcile our own emotions and intent after 400 years of unreconcilable damage done to Black people. Writer Tre Johnson says it best when he comments, “The confusing, perhaps contradictory advice on what white people should do probably feels maddening. To be told to step up, no step back, read, no listen, protest, don’t protest, check on black friends, leave us alone, ask for help or do the work — it probably feels contradictory at times. And yet, you’ll figure it out. Black people have been similarly exhausted making the case for jobs, freedom, happiness, justice, equality and the like. It’s made us dizzy, but we’ve managed to find the means to walk straight.” My ncertainty regarding the best pathway to follow in the direction of social justice is of little importance when compared with the uncertainty of not knowing whether calling the police will end in your safety or in your murder. Thinking critically and listening to those who have been doing this work for decades and centuries is indeed necessary when it comes to broadening and deepening the conversation about how to best move our nation towards a more just and equitable society. 
 
I wouldn’t be my father’s daughter if I didn’t mention a Jewish tale that comes to mind as I write this. Once, a wealthy disciple came to the Alter Rabbi, R. Schneur Zalman of Liadi, and said that he had been contemplating opening an orphanage, but had since abandoned the idea. Having mulled over the project, he came to the conclusion that he was only doing it to gain more respect in his community. The Rabbi lifted his eyes and told him firmly to go ahead with the orphanage, reasoning that, “While perhaps you may not mean this sincerely, the poor young orphans who will eat hot meals and sleep in comfortable beds will certainly do so sincerely.” The Rabbi understands that his disciple’s motivations are not entirely “pure”, yet the Rabbi also understands that there is still value to motivations that have a higher purpose even if they are partially spurred by energy that is not entirely rooted in ethical rectitude. Moral aimmaculacy is not a pre-requisite for moral action. Good intentions will not solve the problems of systemic racism and police brutality. Regardless, we commit to action because our lives depend on it and because we must take on the issue of racism as our own. As I continue to reflect on my efforts to pursue this particular summons to action, one point has never shifted-- Breonna’s Taylor life mattered. While it might take more time for all the facts surrounding her death to be revealed, it is an honor to learn her story, and with every action that I take, be it right or wrong, intentional or unintentional, I refuse to let her name and her story be forgotten. 
 
 
References: 
Brown, M., & Duvall, T. (2020, June 30). Fact check: Louisville Police had a 'no-knock' warrant for Breonna Taylor's apartment. Retrieved September 16, 2020, from https://www.usatoday.com/story/news/factcheck/2020/06/30/fact-check-police-had-no- knock-warrant-breonna-taylor-apartment/3235029001/