The Emotional Toll of Being a Health Care Provider During a Global Pandemic

 From the 10/16/2020 newsletter

Kern Grand Rounds Preview

The Emotional Toll of Being a Health Care Provider During a Global Pandemic

Paul A. Bergl, MD - Pulmonary, Critical Care, and Sleep Medicine

Dr. Bergl will be part of a Grand Rounds panel discussion sponsored by the Kern Institute during MCW’s Professionalism Week. The presentation will be held virtually on Thursday, October 22nd from 9:00 - 10:00am CT. To register, click here.

When I was asked to contribute a written reflection on the emotional toll that COVID-19 has had on healthcare workers, my first reaction was - and still is - genuine fear. Fear that any public emoting would come off as disingenuous or hyperbolized for rhetorical effect. Fear that I would come off as whiny, as weak, as lacking resilience. Fear that I had little to offer and nothing particularly novel to say about a pandemic that has been covered from every last angle. Most importantly, fear that, as a gainfully employed and financially comfortable white man, I might leave others wondering, “He thinks he has a reason to feel burned out?”

In this loosely chronological reflection, I do not assume that I have captured the sentiments of many of my colleagues; instead, I only offer my own. And I hope that I have made evident my sincere sympathy for those suffering greatly from the fallout of COVID-19 and my perpetual gratitude for those working even harder than I.

The "early" days

February. I remember my first reaction to COVID-19 was blithe naivete. Skeptical of media hysteria, I encouraged friends and families to keep on with their daily lives. “You are far more likely to die from a bolt of lightning than a novel virus spreading overseas.”

After coming to my senses as SARS-CoV-2 spread among our neighbors, I next experienced exhilaration. Here was my moment to fulfill the great dreams I had as a twenty-something applying to medical school... To save lives! To be part of living history! To serve on the frontlines of a crisis! Rapidly elevated to hero status, I dutifully reported to my clinical roles and spent most waking hours helping my colleagues prepare for Armageddon. We developed protocols; we debated how we would allocate scarce resources. We strategized about how to save our medical students’ education. Despite long hours in the ICU and countless email exchanges and Zoom meetings outside of my clinical work, I was indefatigable.

The pandemic continues

Of course, incredible sorrow interspersed these periods of elation. I witnessed patients succumbing to COVID-19 in an airtight room, devoid of any symbol that they indeed were a person. No family. No photos of loved ones. No spiritual guides. No favorite sweatshirt. Who wouldn’t cry after holding the phone to a dying octogenarian’s ear while her family pleaded with an unyielding fate?

Soon, guilt settled in. Guilt that I had regular opportunities to see real actual live people while millions of lonely people huddle indoors, comforted at best by faces on LCD screens and at worst, discomforted by total solitude. I reported dutifully to a job in which solidarity was high... A shared sense of purpose in a fight against a new enemy. Why should I have any sense of grief when so many collected unemployment? Or experienced the exasperation of witnessing racial injustices on two fronts? Or suffered through the grief of losing a loved one to a crisis partly of our own making?

Then came a rising and ultimately unmitigated anger. My fellow citizens began flouting social distancing. My leaders began politicizing every part of the fight. Millions assumed that because most cases were mild that the entire thing had been blown out of proportion. These attitudes depreciated not only the work my colleagues and I were doing in the ICU every day, but also the efforts of our greater scientific, medical, and public health communities. Yes, I am still pretty pissed off.

My own experience as a COVID-19 patient

In August, I suffered the profound malaise of two weeks of a so-called “mild case” of COVID-19 that sapped not only my energy and sense of smell but my optimism that we were turning the corner on a crisis. To add insult to injury, I believe I contracted the virus while performing a bedside procedure that conflicted with my own values... but a procedure that I was ethically obligated to provide nonetheless, at least within the framework of how we provide healthcare in America.

Where we are now

Now, as cases surge to their highest levels, I can see the lassitude that heralds burnout on my own face and those around me. I try to remind myself every day that I am privileged. And I am. I try to ignore the outside noise when I am at the bedside. “Remember Paul, your obligations are to this patient, this human being, and you need to be the best damn doctor you can be right now.” Sadly, there are few outlets to recharge from exhaustion these days. And after all, depersonalization is probably adaptive, right?

Paul A. Bergl, MD, is an Assistant Professor of Medicine in Pulmonary, Critical Care, and Sleep Medicine at the Medical College of Wisconsin. He will be part of a Grand Rounds panel discussion sponsored by the Kern Institute on Thursday, October 22, 2020 from 9:00 – 10:00am CT. To register, click here.

The Failure Effect: Why we should share our "failure stories" in medical education

Director’s Corner
 
 
The Failure Effect: Why We Should Share our "Failure Stories" in Medical Education
 
 
By Olivia Davies and Adina Kalet, MD MPH 
 
 

For this week’s Directors Corner Dr. Kalet invited Olivia Davies (MCW-Milwaukee Class of 2021) to co-write this piece on the critical importance of failure to learning and introduce The MCW Kern Fail Forward Initiative …
 

As you read this, I (Olivia) am sitting in a testing center taking my USMLE Step 2 board exam – one of the many hoops through which students are asked to jump gracefully. But the truth is, we don’t always make it through the hoops first time, sometimes not even the second. It feels like a long time has passed since I received the score from my first MCAT exam (a 27 by the old metric), and yet it’s also so personally recent. That application year, I was not accepted to medical school. In fact, it would be another three years before I received a solitary acceptance at the Medical College. I tell you this because I was certain I was the only person who ever had to retake the MCAT or who ever had to reapply to medical school, when the truth is, I’m not. 

 
In medical school, success is expected. Medical students, when they struggle — as all do at some point — experience failure in isolation. Classmates seemingly face no setbacks; struggles are stifled, shameful even. 
 
Educational theorists emphasize the importance of working in groups to enhance learning, yet medical students who “fail” often struggle alone. This façade perpetuated and upheld by our culture of perfectionism creates a deafening silence for those who trip and stumble. 
 
This culture of silence is not only harmful, but it fails to celebrate the many failures that shape our individual stories. Perhaps more importantly, it diminishes the potential flourishing that occurs when individuals who have faced failure nurture those acutely experiencing it.  
 
Melanie Stefan, PhD, a lecturer at Edinburgh Medical School, recently called on all academics to publish their own “failure résumés,” listing programs they didn’t get into, missed opportunities, critical feedback, and other rejections.¹ This idea has taken hold and captured the imagination of many faculty in medical schools and other highly competitive and academic fields. 
 
This past May, the MCW graduating class of 2020 was surveyed for “failure stories” with the promise that these stories would be their legacy for years to come. The goal of this project was to create a platform where current students could visit to not only view the number of students before them who faced similar failures, but read their predecessor’s stories of failure and, in them, find a sense of solidarity, optimism, resilience, and growth. Indeed, the pathway to success in healthcare is paved with failure, and the creation of a culture the lifts individuals up in both failure and success is essential in the fight for resilience and against burnout. 
 
 

My own (Adina) failure resume includes; the year I submitted sixteen grants and received three small ones that all added together did not allow me to continue the work I have poured myself into for years; the papers rejected multiple times, with harsh, often personal critiques; and the numerous leadership positions I sought unsuccessfully. And those are just the professional failures. My husband has shared his “failure resume” with his fellow leaders in a large department in a medical school and routinely shares it with his trainees. We are both tenured professors of medicine - successful professionals, by all accounts. We have both learned that sharing our failures – especially with junior colleagues – is a great way to identify, analyze, and articulate how to fail productively and strengthen those skills. 

 
Failure is critical to learning. But this is true only if the individual who fails doesn’t give up or walk away from continued effort. Of course, all failure necessitates a recovery period, a time to lick one’s wounds, but soon, too, comes the re-envisioning. Deliberate struggle, working until you fail, analyzing and learning from the failure and trying again is at the core of deep learning. 
 
Although the concept has yet to be widely embraced, allowing or even encouraging failure should be an important role for medical school faculty.² Psychologist Anders Ericsson, describes the importance of planful and deliberate practice to the acquisition and maintenance of expertise. There are now many streams of thought about concepts such as “productive failure” or “desirable difficulty” that all lead to one conclusion: failure is transformative. 
 
Here’s why. Becoming a physician, like other optimal performance fields (e.g., competitive athletics, world class chess) requires grappling at the “learning edge.” The idea of a “Zone of Proximal Development” — a term introduced by psychologist Lev Vygotsky in the early 1930’s — identifies that an educator’s roles include the creation of an environment in which learners identify the absolute edge of their knowledge or skills and then the provision of scaffolding and coaching toward aspirational learning. As the student explores the limits of their skills and understanding, failure is inevitable. 
 
Therefore, failure is critical to becoming a great physician. And yet our students are often left to fail alone, to feel shame and a sense of being an imposter. While these feelings may be part of what motivates us to work harder, overcome adversity, persist with what Angela Duckworth has called “grit,” these feelings are also likely part of what contributes to unhealthy stress, a sense of depersonalization-a component of work related “burnout”. 
 
So, what can we do to maximize the growth-promoting value of failure? We can talk about it. We can create respectful and thoughtful ways to routinely share failures. We can recognize and cultivate the strength of character it takes to “fail well.”
 
In his lovely essay³, Benjamin R. Doolittle, MD, MDiv uses lessons from JK Rowling, Oprah Winfrey, and the movie, The Best Exotic Marigold Hotel, to muse on why, in medicine, we do not “fail well.” We often hide mistakes, errors, and failures despite the growing realization that failure is important to developing true expertise. When we fail, we do not truly believe that we are worthy of redemption. “Accepting our faults requires courage and moral strength.” 
 
 
Over 130 students from the MCW Class of 2020 shared their failures in an effort to breakdown walls for future classes – are you ready to share yours? Contact us if you are.
 
 
 
The Fail Forward Initiative is in the process of being finalized. Anonymous student stories and data aggregates will be accessible to those with MCW credentials. If you’re interested in submitting your own failure story to share privately to those with MCW credentials or publicly on the forward facing failure site, reach out to odavies@mcw.edu or akalet@mcw.edu.
 
 
 

1. Stefan M. A CV of failures. Nature. 2010;468(7322):467-467.
2. Klasen JM, Lingard LA. Allowing failure for educational purposes in postgraduate clinical training: A narrative review. Med Teach. 2019;41(11):1263-1269.
3. Doolittle BR. Failure in Residency Education: Lessons Learned From Harry Potter, Oprah Winfrey, and the Marigold Hotel. J Grad Med Educ. 2019;11(2):233-234.

 
 
Adina Kalet, MD MPH is the Director of the Robert D. and Patrica 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
 
Olivia Davies is a fourth-year medical student at MCW-Milwaukee who is in the midst of applying for her dermatology residency. She is an associate editor of the Transformational Times. Follow her at @oliviamtdavies.
 
 

Every Virus Needs a Host and the Answer Lies Within Each of Us

From the 10/9/2020 newsletter

Perspective

Every Virus Needs a Host and the Answer Lies Within Each of Us

By Balaraman Kalyanaraman, PhD – Chair, Department of Biophysics

I don’t know about you, but the terms “social distancing,” “self-quarantining,” “asymptomatic,” and “flattening the curve” were all new to me until just a few months ago! You are not alone if you’re suffering from COVID-19 news fatigue and can’t wait to have your “old and boring” life back ASAP.

It took me a while to figure out that social distancing is not the same as anti- social, and that self-quarantining is not a punishment. Apparently, social distancing existed in medieval times and was used to fight the bubonic plague. Here is some historical “viral” news that may interest you.

Sir Isaac Newton (1643–1727)

Sir Isaac Newton (1643–1727), a transformative scholar, inventor, and writer, made all his discoveries in the fields of calculus, astronomy, optics, and gravitation, while in isolation. In case you are new to social distancing history, here is my take.

Twenty-three-year-old Newton was studying at University of Cambridge in England in 1665, when London was hit with the Great Plague. The university temporarily closed, and Newton went to his family home in the countryside. Even then, the rate of infection was recognized to be much higher in densely populated cities than in the rural areas. He used his time off wisely and started to think boldly in isolation. No emails from or videoconferencing with professors! No social media! Newton spent a lot of time musing under an apple tree in the backyard, and legend has it that one afternoon he was bonked on the head by a falling apple. Rather than being miffed about it, he wondered why

the apple fell straight rather than swerving, going up, or going sideways! Well, there you have it—the discovery of gravitational force. Newton also postulated the three laws of motion:

1. Everybody remains in a state of rest or uniform motion unless acted upon by a net external force. How true! I saw it in a health club. Good motivational messaging! Now that I stopped going to the health club, I try to social distance with the refrigerator.

2. The amount of acceleration of a body is proportional to the acting force and inversely proportional to the mass of the body; f = ma. I don’t know why your car is so f@#*king damaged when you hit a deer at 70 mph.

3. For every action, there is an equal but opposite reaction. Hmm, does this remind you of what is going on in Washington, D.C.?

Having worked out his theories on gravitation, calculus, and laws of motion, Newton returned to Cambridge after the plague subsided. He went from student to full professor in two years. By the way, the two years Newton spent in isolation and discovering new theories of nature are known as annus mirabilis or “remarkable years.” Who knows? Some of our graduate students may realize 2020 was their annus mirabilis!

Sir William Shakespeare (1564–1616)

Many artists completed their classic works during isolation from a pandemic. Sir William Shakespeare (1564–1616) was one of them. Shakespeare was an actor, shareholder, and playwright. After an outbreak of bubonic plague, London’s theatres were shut down and Shakespeare was out of a job! He decided to use his free time to write plays, including masterpieces like King Lear and Macbeth. However, Shakespeare’s most plague-inspired play was Romeo and Juliet, in which the plague and quarantine play a prominent role in the plot. Here are some Romeo and Juliet highlights and my thoughts on what Shakespeare can teach us all in the midst of COVID-19. Juliet and Romeo, from two feuding families in Verona, Italy, were in love but their families did not approve of their

relationship. So, they secretly arranged to elope. In the meantime, Juliet’s family decided she would marry someone else. Juliet’s mentor had a counterplan to put her to sleep with a clever drug that would make her appear dead. A letter describing this plan was arranged to be delivered to Romeo. Spoiler alert: Romeo did not get the message because the messenger was quarantined and could not leave Verona due to the plague. You know the rest of the story. So, what did Shakespeare teach us all that can be applied to COVID-19 and the upcoming presidential election? During a pandemic, mail delivery might be slowed down or even crippled, so people opting to vote absentee should do so in advance so their votes are delivered on time and uninterrupted. (If you haven’t already requested your absentee ballot, you can do so here.)

2020 and COVID-19

Seriously, folks, we have a lot to be proud of. How can we forget the incredible sacrifices made by all the doctors, nurses, health-care workers, scientists, firefighters, grocery store and delivery workers, IT professionals, and all the other essential workers that have kept us going? Recovered COVID-19 patients have given their plasma to COVID-19 ICU patients, saving their lives. Automobile workers have repurposed their skills to make lifesaving ventilators. The list goes on. Stories of ordinary people doing extraordinary things abound in the time of COVID-19: An Arizona woman on an Indian reservation raised millions of dollars through GoFundMe to help the elderly and struggling families living without electricity or running water. These are our real heroes.

COVID-19 vaccines are moving rapidly through the pipeline and are undergoing clinical trials in record time. Operation Warp Speed, a public–private partnership, was initiated to develop and distribute safe and effective vaccines. Several vaccine candidates attacking SARS-CoV-2 via different mechanistic pathways will become available. Thanks to all the scientists from National Institutes of Health, University of Oxford, AstraZeneca, the Serum Institute of India, Pfizer, Moderna, and Johnson & Johnson.

Years from now, 2020 will go down as our annus mirabilis.

Every virus needs a host, but we don’t have to be hospitable. At least part of the solution to keeping SARS-CoV-2 at bay is that we must continue doing the simple things to keep everyone safe—wearing masks, social distancing, washing our hands, sanitizing surfaces, and avoiding touching our faces. Let us remember our heroes and be grateful for all they have done for us. Together, we will get through this.

Thanks to The New Yorker, Gates Notes, The Atlantic, CNN Opinion, InsideHook, and Jimmy Kimmel Live! for news and inspiration.

Balaraman Kalyanaraman PhD is Professor and Chair of the Department of Biophysics at MCW.

The Congruence in My Quest

From the 10/9/2020 newsletter

Perspective/Opinion

The Congruence in My Quest

By Sherréa Jones, PhD – MCW Milwaukee Medical Student

What made you decide to actively pursue your career?

Traditionally, when this question is posed to the majority of people, their response involves seeing someone congruent to themselves in the profession they are seeking. For many Black individuals in this country, our answer to this question is, overwhelmingly, because we do not.

I grew up in the inner city of Milwaukee, WI. I graduated from a severely underperforming school system and I found myself, as a child, pregnant with my very own child. I was raised by a single Black woman in a family where I was surrounded by other single Black women, none of whom were in a career that aligned to the professional aspirations I was captivated by on Thursday night
television. Sure, every child wants to be a superhero growing up, and eventually those dreams become more realistic. In contrast to some other children, these fictional characters served as my only visual source of hope for a career in medicine.

During my first semester at UW-Madison, I found myself engulfed in feeling ridiculous for wanting to be a physician. Here I was, at a nationally recognized research institution, with 40,000 other students of which only 2% were Black. Five years later, I matriculated as the only Black student within the entire Department of Biological Sciences at Marquette University. I remained the only Black student for the duration of my tenure as a PhD candidate. As you might imagine, my scholastic unpreparedness resulted in grave academic struggles. I felt intimidated, shamed, defeated, embarrassed, and increasingly believed myself inferior in intellect compared to my white peers.  

When I was granted the opportunity to join the class of 2024 at the Medical College of Wisconsin, I decided I was going to own this experience. I made the conscious decision to be transparent about my personal and academic struggles, my feelings of ineptness and, most importantly, my intentionality about using my voice as a vehicle to speak for the disenfranchised. Moreover, I desired to utilize the uniqueness of my physical presence to be there for those seeking racial, socioeconomic and/or gender congruence in their aspirations. Being in the racially distinct faction, as a student, was no longer shocking to me, it was the anticipated norm. What I did find resounding was the glaring lack of visible support for Black students at one of the largest teaching hospitals in the state of Wisconsin. A campus with an ever-expanding and commanding presence directly adjacent to the city of Milwaukee, which is nationally referenced as one of the most segregated cities in the United States, and consistently leads the nation in having the largest race-based disparities in health, wealth, and incarceration rates. 

During my first year of medical school, I was introduced to a parade of PhDs and MDs who were facilitating my education, yet only one of them (Dr. Erica Arrington) looked like me. Prior to starting school, I read about well-established mentorship programs in place at numerous institutions that are targeted to help Black students thrive. There was, however, nothing in place here at MCW. Although I did not see a tangible support network for Black students at MCW - except for a small number of individuals (Dr. Jennifer McIntosh, Jean Mallett, Dr. Cassie Ferguson, Dr. Michael Levas, Dr. Greer Jordan, Dr. Marty Muntz and Dr. Malika Siker), I refused to believe there was no interest in its erection. Similarly, I refused to believe that, a hospital that cares for a largely impoverished and disadvantaged population, where many of its children were born, was a hospital that did not care to support the success of its future Black physicians in training. Furthermore, I refused to believe that, an institution that welcomes over 200 students each year (albeit only 4% are Black) did not have a proactive committee to offer resources and refuge to students who found themselves on academic probation - the frightening place I was in at the conclusion of my first semester at UW-Madison. I refused to believe that absolutely no one, within administration, faculty, or staff had a genuine concern about the mental health and well-being of Black students.

Despite the daunting data and the countless conversations with my Black student colleagues surrounding feelings of isolation, frustration, and powerlessness, I am glad I held on to my skepticism. Through our activism and advocacy, we have been introduced to a village of physicians, administrators, staff, and non-Black students who have tremendous concerns about the deficiency of a culture that ensures the support and success of Black students. Through my student leadership roles, I have discovered a team of individuals that have launched a collective effort on shifting the paradigm at MCW built around anti-racist directives. There is a community at MCW that works tirelessly, while facing insurmountable organizational hurdles, against the structural inequalities that are systemically designed to perpetuate the failure of Black students that choose to enroll at MCW based on the advertised supportive nature of the program.

In discovering this assemblage, I have begun a personal quest to bring awareness to this community. Although this quest feels strikingly reminiscent of the imaginary characters I held on to in an effort to catapult me to a realistic place of actively pursuing my dreams, I unequivocally embrace the intangible ideal that, one day, the members of this community will be unapologetically and unashamedly empowered to speak up for Black students, visibly support Black students, and enforce palpable change for the betterment of the Black student experience at MCW. 

It took over 400 years to structure the system that anticipates my failure. I am well aware that I cannot unravel it in four.

Sherrea Jones, Ph.D. is an M.D. Candidate in the MCW-Milwaukee Class of 2024. She serves as a liaison to the Student Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.