Meaningful Careers in the VA

 From the 11/13/2020 newsletter

Perspective
 
 
Meaningful Careers in the VA
 
 
Kayt Havens, MD
 
 
Dr. Havens describes the myriad, rewarding career opportunities the VA has to offer …
 
 

Twelve years ago, I received a call from Dr. Ann Nattinger asking if I would accept a position at the Zablocki VAMC as Director of the Women's Clinic.  I am grateful every day that I said, “Yes.”  My work there powerfully influenced my identity as an educator-physician and design learner. When I told colleagues and friends that I worked at the VA, their faces often registered disbelief. Little did they know that the VA has the history of being the most innovative health care system in this country. 
 
Last week we celebrated Veterans Day. I am taking this opportunity to also honor the physicians and care teams who have committed some or all of their lives to the improvement of health care for veterans. I've asked some of our MCW Zablocki VAMC faculty why they chose to work in the VA. I'm including some of their comments below.
 
Dr. Jerome VanRuiswyk says, “I do consider it a privilege to care for all types of veterans. Many veterans paid the ultimate price for freedom and didn't return; the rest were willing to pay that price and, you and I have the privilege to serve them. Other things that have drawn me to a career at the VA is the fact that the vast majority of veterans are truly grateful for the care they receive. The system focuses on caring for these unique patients no matter their socioeconomic status including their wide range of comorbidities, some which resulted from their service.  Veterans are best served by the VA's multidisciplinary care teams who have a biopsychosocial approach to care.”
 
 Dr. Jeffrey Whittle, who has spent most of his career working throughout VA hospitals wrote, “I think that working in the VA has been a privilege because so many of the employees are mission driven. They truly view the opportunity to serve veterans as an important reason to come to work.”  As patients receive care regardless of their ability to pay has “allowed me to get to know people from across the socioeconomic spectrum on a personal level and has helped me recognize the nobility that is present.” Dr. Whittle also states that “history means more to me now.” He has worked with and taken care of the “ordinary people who have made that history,” having seen prisoners of war, a member of the Tuskegee Airmen, veterans of Pearl Harbor, the Omaha Beach landing on D-Day, and the Battle of the Bulge in his practice.  These veterans and those of the Vietnam War and current conflicts have added to his sense of commitment.
 
Dr. Amy Farkas joined our VA two years ago after completing a women’s health fellowship at the Pittsburg VA.  “Caring for veterans is one of the many things I find rewarding.”  There are a host of professional reasons that make a VA career appealing to her. “I’m lucky enough to be involved locally and nationally with the VA.” As faculty, I spend 1/3 of my time developing Women's Health education programming for the national VA where there is this amazing network of women health leaders.  This has been a huge benefit for my career. “The VA also provides great resources for medical education and scholarship including research projects. I have access to immense amounts of data and powerful tools for utilizing it.” 
 
Dr.  Margaret Holmes adds another dimension to her work at the VA. Her grandfather served in the trenches during World War I. Her beloved stepfather was a veteran of World War II, Korea, and Vietnam and her great-great-grandfather fought in the battle of Shiloh during the Civil War. Therefore, her work at the VA has a personal meaning as well.  She notes that she cares for a much sicker, poorer population. She has the “addition of terrific teams including a nurse, LPN and MSA who are all smart and capable.” A dietitian, social worker and pharmacist are also housed in her clinic. She experiences  fewer barriers to care  as “social workers slay the psychosocial dragons enabling us to see the patients more easily and get them access to services which are part of living a healthful life … I never have to say your insurance doesn't cover that and medications are cheap or free for everyone.” Dr. Holmes loves that she has time to do her job properly as there are no RVU’s, she has thirty minutes with each returning patient, sixty minutes for a new patient, and “no one fusses if it takes longer to complete a visit.”  Her collaboration with specialists is easy, and they're attentive to the needs of her patients.
 
For myself, my last five years at the VA included national work with the VA Innovators Network. As such, I traveled to thirty-two VA sites across the country and witnessed firsthand the commitment and dedication of frontline workers including nurses, occupational therapists, physical therapists, etc. through this network. Over $3,000,000 a year was awarded to frontline employees who identified and solved problems encountered by veterans using human centered design as part of understanding the problem.  3D printing programs were established across these thirty-two hospitals to create everything from a personalized spoon for a stroke victim, to improving a poor prosthesis fit.  A young woman whose leg was blown off in Afghanistan requested a prosthetic so she could wear a high heel for her wedding which was proudly presented to her.  The Minneapolis VA critically created a wheelchair which a user could crank up to a standing position; imagine being able to roll yourself down an airplane aisle. One multidisciplinary team of occupational therapists, designer and engineers created a hamburger helper device for two veterans allowing them to eat a full hamburger at Red Robin.  Previously the “claw” would destroy the burger half eaten. These projects were designed with veterans for veterans. I stand proudly with the veterans that my colleagues and I have served and those who have served me. 
 
Students who want to know more can sign up for the Military Academic Enrichment Elective that will be offered in January 2021. Michael Nagy, PharmD and his team of medical and pharmacy students worked with students, faculty and veterans. This will be the third year this class is offered to medical students and represents innovative curriculum development.
Chase LaRue, an MCW-Milwaukee Class of 2023 medical student and member of the US Naval Reserves, shares the following information about the elective: 
 

The military academic enrichment elective provides students a unique opportunity to learn specifically about veteran health care issues and considerations unique to this population. They explore the health care providers role in adapting their care to better suit the needs of those who served. The course consists of a weekly didactic given by lecturers experienced in advocating for veteran wellbeing combined with a portion of the class that allows for group discussion. Topics span a variety of subjects from experiences veteran populations may have faced during service to techniques that medical and pharmacy students may use to better connect with veteran patients. This class helps students develop a strong sense of trust with veterans. 
 
Due to the COVID-19 pandemic, the course will only involve medical students in 2021, but we look forward to continuing more programs in the future. The logistics regarding this year's virtual sign up will be available as we approach January. Given that virtually all MCW Milwaukee medical students will spend at least some portion of their rotations at the Zablocki VA Medical Center, taking the time to understand this perspective and diversity of issues surrounding these patients is important to help us serve there better and maximize the quality of care we are able to provide.
 

 
 
Kathryn (Kayt) Havens, MD is an Associate Professor of Medicine (General Internal Medicine) at MCW. She is a member of the Culture and Systems Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education, bringing expertise in human-centered design methodology.
 
 

What a week for Democracy! Great time for Kern to build community through a new funding opportunity

 From the 11/13/2020 newsletter
Director’s Corner
 
 
What a week for Democracy! Great time for Kern to build community through a new funding opportunity 
 
 
Adina Kalet, MD MPH
 
 

Dr. Kalet reflects on the past week’s events including the launch of the Kern Institute’s Medical Education Transformation Request for Proposals (RFP) and describes the RFP’s intention to stimulate collaboration, cooperation and communication as a way forward… 
 
 
What a week it has been! As expected, the presidential election results took four long days to reach a conclusion. Although frustrating, there was a beauty to watching our electoral system work at human speed, votes counted one at a time all over the country. When our new President-Elect and Vice President-Elect were finally able to make victory speeches on Saturday evening, the reality and symbolism of seeing a woman of color give the acceptance speech moved me to tears. 
 
Nearly half our fellow Americans are disappointed with the election’s outcome. It has never been more important for us to navigate forward gently but courageously, with respect and compassion. 
 
There is no doubt that we face a dramatic next two months. We can anticipate being schooled in the technical intricacies of our government. We will learn what guidance our constitution does and does not provide. In my house, we will read and listen to podcasts, watch news, documentaries and movies, and endlessly discuss the historical precedents for this moment. This will go on, all while we face what could be the worst of the COVID-19 pandemic here in Wisconsin. I do not have any answers, but I do want to consider the questions, together in community. 
 
 
Kern will fund “Collaboratories” that will transform medical education 
 
Into this context, on November 1, 2020, the Kern Institute launched our Medical Education Transformation Collaboratories Request for Proposals (RFP). The explicit purpose of the RFP is to incentivize groups of medical educators and scholars to seek each other out across disciplines, institutions, and other boundaries, to propose policy papers and projects that can contribute to transforming medical education. Letters of Intent are due before our winter holiday season. We have suggested some areas of interest: 

• Best Practices in Medical Education
• Data Science in Education
• Linking Medical Education and Patient Health 
• New Models for Structuring and Funding Medical Education 

 
We will give funding priority to members of the Kern National Network, groups that include patients as partners, and projects that have an explicit focus on evidence-based integration of character and caring in medical education. That said, we are open to all ideas. 
 
Proposals will describe in equal measure, a meaty problem or gap, an audacious idea, and a plan for assembling a small diverse group of partners in the work. We will require a clear and compelling description of the “problem to solve” as well as strong and convincing evidence that the group will work together effectively. This includes showing how the team will organize, communicate, plan, define roles and criteria for accountability and share credit generously.  These are some of the key features of strong “Collaboratories.”  
 
 
What is a Collaboratory?
 
I have been animated by the idea of Collaboratories since being introduced to the concept by a computer science colleague with whom I worked in the early 2000s. First described in the 1980s as a “laboratory without walls,” it was an idea which grew as technology enabled scientists living at great distances to work closely together, sharing techniques and equipment in real time. As we all have learned too well recently, nearly ubiquitous technology makes it is possible to be “socially networked,” yet the technology is necessary but not sufficient for success. Collaboratories are powerful when there is careful attention and lots of trial and error to establish “norms, principles, values, and rules” that enable both the things we have always done (teach, learn, meet, create) and to work together to generate solutions to complex new challenges. The future of medical education is a complex challenge and I believe Collaboratories is a good way forward. 
 
Hopefully, we will have at least a handful, if not a pile, of good proposals to review come January 2021. The money we have saved in Kern this past spring, when travel and sponsored events were cancelled one after another due to COVID-19, will now we put toward funding the Collaboratories. Those who receive funding will be expected to meet together regularly to discuss their work and, in this way, “cross-pollinate” other groups creating a densely intertwined medical education transformation community of practice. Even if can only fund some of the proposals we receive, the process of writing a letter of intent is, in my experience, never wasted. Good ideas, once articulated, are like genies released from their bottles. Magical things may happen. 
 
 
The collision of the COVID-19 spike, fatigue, and opportunity
The unseasonably balmy weather this past week has enabled many of us to manage the tension of the election by being active out-of-doors. In Wisconsin, especially, we could remain in denial, pushing off the inevitable few more months of sheltering at home as daily COVID-19 cases hit all-time highs. The situation with the pandemic is different from what it was in the spring. As our hospital census of COVID-19 patients ratchets up to unprecedented levels, we reap the benefit from what we have learned. We now know how to provide routine medical care safely. Scheduled procedures continue, telehealth has found its groove, our students and faculty are in a virtual routine. 
 
The downsides are also obvious. We are fatigued from mask wearing and yearn to be together physically without constant consciousness of the “social” distance. We will be working from home, forming “pods” with our close friends, and grieving family Thanksgiving dinners, winter vacation travel, and some outdoor sports. School-aged children’s schedules will change weekly, our college-aged children will be taking final exams remotely surrounded by family and not friends. We are exhausted from talking about testing, quarantining, and vaccine distribution plans, and from all the pivoting. An effective vaccine is likely to be implemented in a couple of months. For those of us who have lost loved ones, there is little comfort in this unprecedented scientific wonder. 
 
Now is the time to focus on building hardy communities. Now is the time to collaborate, cooperate and communicate as if our lives, work and future depends on it. At Kern, even as we live through upheaval, we look forward to being a catalyst for transforming medical education. 
 
 
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
 

Learning to Care for Those in Harm’s Way – Educational Innovations from The Uniformed Services University School of Medicine

From the 11/6/2020 newsletter

Guest Director’s Corner

Learning to Care for Those in Harm’s Way – Educational Innovations from The Uniformed Services University School of Medicine

by Louis Pangaro, MD, MACP

For this week’s special Veteran’s Day issue Director’s Corner, Dr. Kalet invited Dr. Louis Pangaro, interim dean of the Uniformed Services University School of Medicine and medical education scholar to describe “America’s medical school” and its lessons for us all …

 

It is my privilege to comment on the contributions of the Uniform Services University School of Medicine to advance in how we educate doctors. Our school is directly funded by the federal government to produce physicians who will serve the country in the United States Army, Navy, Air Force, or Public Health Service. This notion of service is implicit in our school’s motto, “Learning to care for those in harm’s way.”

A commitment to public service is made by students in all medical schools in the country, but our innovative model of service in return for education is even more specific. After completing graduate medical education training, all of our students have an obligation to remain in national service for at least another seven years. Scholarships to medical school are not uncommon, and it is worth noting that our students not only have no tuition but are paid as active-duty officers in one of our uniformed services. Thus, they have no financial burden to make up in the decade or two after medical school, and their careers choices are not based on debt. We hope that the USU model will be used by more and more medical schools.

This long-term commitment gives rise to another unique aspect of our school, in that our graduates will, with few exceptions, do their specialty training in graduate military medical education programs and, after this, they will have at least seven years of further commitment to remain in the Military Health System (MHS) or in the Public Health Service. At a minimum, our students are in our own system for fourteen years, and most stay longer. This gives USU an extraordinary laboratory for studying the outcomes of medical education over time, and we have our own dedicated program, the Long-Term Career Outcomes Study, designed to do just this. We now also have graduate degree programs (masters level and PhD) to provide the educational leadership needed to study the relationship between education and the care given to the nearly ten million beneficiaries in our large military health care system.

As medical educators will understand, this give us a laboratory to study our graduates long term. As you would expect, we have always placed an emphasis on competence and the readiness of graduates to perform in graduate medical education in our own programs and, eventually, to serve in combat, natural disasters, and humanitarian missions around the globe to provide, as one might say, “good medicine in bad places.”

Why we developed the RIME Framework

One of our innovations in the 1990s to support this competency-based approach was to move away from using numerical rating scales for student progress in clinical rotations to a descriptive vocabulary of students’ progress, known as the “RIME framework” for “Reporter-Interpreter-Manager-Educator.” This framework supplemented the commonly used analytic frameworks (which divide competence into knowledge, skills and attitudes) into roles, which synthesize those domains. (More recently, Milestones and Entrustable Professional Activities (EPAs) have used such a synthetic approach.) RIME captures the basic rhythm of clinical work (history and physical – assessment – plan) and capitalizes on our clinical reasoning processes, which internalizes patterns of illness or, in this case, stages of professional competence. In other words, our teachers are not asked “to give a grade” for their students, but to “diagnose” or classify the levels of RIME proficiency in which the student has shown reliability. Studies of the RIME scheme from USU and other schools have shown it has a reliability and validity as good and perhaps better than commonly used alternatives.

The challenges of assuring educational quality across multiple sites and the importance of face-to-face sessions between clerkship directors and faculty members

One of the reasons it was important for USU to have an intuitive, performance, behaviorally- based evaluation framework was that we have for decades had core clinical clerkships far from our home base in Bethesda, Maryland. (We have clerkships in San Antonio, San Diego, Honolulu and other places across the country.) While all medical student schools struggle with consistency across their local regions, the LCME has held USU accountable for such inter-site consistency at great distances. Hence, we have made something of a science of this problem. The combination of the intuitive RIME scheme and face-to-face conversations with teachers has been a major component of our process.

At our institution, clerkship directors hold face-to-face conversations with faculty every few weeks to discuss their own students in a form of “case-based faculty development,” with their own students as the “cases.” These “formal evaluation sessions” were introduced at USU by my own mentor, Gordon Noel, three decades ago, and we believe that they remain the state-of-the-art in the assessment of students on clinical rotations. It may be obvious that teachers will tell you what they won’t write down, and our studies show that the process doubles the chance we will pick up cognitive or professional issues. Moreover, in a form of multi-source feedback, the clerkship director and the teachers agree on the next steps for the students, which will be looked at again at the next evaluation session. So, we have credible evaluation, we generate feedback and we calibrate the faculty all in the same session in what my colleague, Paul Hemmer, calls the “triple play.”

While the RIME scheme has been adopted in many medical schools across the country, the use of these regularly held evaluation sessions has been less popular, probably because of the time commitment for teachers and clerkship directors, approximately fifteen minutes for assessment and then fifteen minutes to generate feedback per student. With students dispersed in many hospitals, the work load is shared across on-site clerkship directors.

The Education Committee and its role in determining the need for remediation

The use of the RIME framework and then the calibration of faculty in using it are fostered by oversight of the process by an education committee review of all pass-fall grading decisions of students identified in the evaluation sessions. This innovation is at the top-level of the three-tiered system in which the clerkship directors who run these on-site evaluation sessions are themselves calibrated by a group of senior colleagues who meet on a regular basis, timed to the students’ schedule to review performance, and to make any determination of a failing grade or need for remediation. The departmental education committee has representatives at the clerkship level from the pre- clerkship clinical courses, from the sub internships, and from our graduate medical education program directors involved in the decision. (Such a process has recently been adopted as a national standard for GME in the form of competency committees.) The process separates not just the teacher, but also the clerkship director herself, from making a pass/ fail decision. While not relieving individual teachers from evaluating how successfully their own students are progressing, it does separate them from the “grading process” that many teachers find emotionally difficult.

Systems and simulation in military medical training

A systems approach has been inherent in how students and faculty understand their roles in the larger military healthcare system. From our first graduating classes in the 1980s, our students have learned how their own work in our academic health center tertiary hospitals is related to medical care at the site of injury in combat settings thousands of miles away, and how triage, stabilization and evacuation back to the United States is all part of their system. This innovation may not have been widely applicable in the first decades of the school, but now all medical schools are actively looking at health systems science.

Our school has been heavily invested in simulation for decades and the Val G. Hemming Simulation Center has been a world leader in development and application of medical simulation programs. Unusual is our Wide Area Virtual Environment (“WAVE”) where students practice resuscitating and stabilizing a patient for transfer in a setting in which the sounds of bullets flying and helicopters landing are all around them. Our final year students participate in the unique Operation Bushmaster, a combat-like exercise in which they are put into a remote, forest-like setting to practice teamwork, leadership and military medicine. Several students on a team will in this simulation be the operating surgeons, several others triage officers, several supply officers, and several will maintain the periphery against possible hostile action. (First year students play the moulaged casualties).

“A promise of duty and expertise”

We have for years used the idea of professionalism as a promise of duty and expertise introduced to our students by Dr. Edmund Pellegrino. Our educational innovations are intended to foster in our students the promise which they make to their patients and to our nation. For our faculty the promise is to foster progressive independence and to evaluate or students’ readiness for the next level of responsibility. We think of USU as “America’s medical school” with a unique role in our society and we hope that some of our innovations may be useful to other schools.

Thank you very much for the opportunity of sharing the system of which we are very proud. The innovations which I have mentioned are described in more detail in the annotated bibliography attached.

Link to Dr. Pangaro’s annotated bibliography. 

Link to Dr. Pangaro’s faculty page.

Louis N. Pangaro, MD MACP is the Interim Dean and Professor of Medicine at the Uniformed Services University (USU) F. Edward Hébert School of Medicine

The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense.

My Dad was a Veteran

From the 11/6/2020 newsletter

Editor’s Corner

 

 

My Dad was a Veteran

 

 

Bruce H. Campbell, MD FACS – Editor-in-Chief of the Transformational Times

 

 

In this Veteran’s Day issue of the Transformational Times, you will meet several people who have offered their time and talents in service of country. Some, in the earliest stages of their careers, share their motivations; others, who have retired, offer their reflections. All have taken the oath, just as my father once did, to “support and defend the Constitution of the United States against all enemies, foreign and domestic.” Like our newsletter contributors today, my father inspired me.

 

 

My dad was a veteran. He spent over three years on a light cruiser, the USS Santa Fe CL-60, during World War II. His ship earned thirteen battle stars, seeing action from the Aleutians to the Philippines. I have no idea what that experience was like.

 

Similar to many other citizen-soldiers of his era, Dad never planned to be in the military. He grew up on a Missouri farm during and after the Depression, knowing only that he wanted a different kind of life. He worked his way through college and graduate school by scraping together enough money to, as he said, “keep body and soul together.” Like everyone else, his life was upended on December 7, 1941. 

 

He enlisted in the Navy shortly after the attack on Pearl Harbor. His mother, back on the farm, bemoaned his choice. “Why didn’t you join the Army like your brother?” she cried. “Navy boys all drown like rats!” 

 

After ninety days of Officer’s Candidate School, newly commissioned Ensign Ray W. Campbell, USNR was on his way to the Pacific. He served in many capacities on the ship from gunnery officer to officer of the deck. He occasionally assisted the ship’s doctor (who had trained as a gynecologist) in surgery. He helped direct rescuers after the attack on the USS Franklin, and was nearly killed when a kamikaze plane barely missed the gun turret where he was standing. He played the ship’s small portable organ to accompany Catholic, Protestant, and Jewish services. He wrote letters to parents of sailors who died. His ship became part of the occupation fleet after the attacks on Hiroshima and Nagasaki ended the war. He returned home to a different world.

 

My dad was twenty-three when he enlisted and twenty-seven when the war ended in 1945. For perspective, I never lived more than a hundred miles from where I was born until I was thirty. Between twenty-three and twenty-seven, I was finishing medical school, starting residency, and trying to figure out what I wanted to do with my life. At the age when he was fulfilling his service as part of the Greatest Generation, I was exploring the depths of imposter syndrome. 

 

My dad spoke very little about his experiences. At home, we looked occasionally at a book he had helped compile about his ship’s campaigns. There were a few mementos around the house. He called a shipmate once in a while. He didn’t march in parades or join the VFW. I wish I had asked him why but, now, it is too late. 

 

Because my dad spent little time talking about his Navy service, I am encouraged that there are VA-based programs that help veterans to tell their stories. I count myself fortunate to have met many veterans throughout my career at the Zablocki VAMC. 

 

I have the utmost respect and admiration for the veterans for whom I have cared and for this week’s Transformational Times contributors. I hope you will pause and sit for a while with each of the essays. Please listen to their stories and then take time to honor the veterans in your life. 

 

 

 

Bruce H. Campbell, MD FACS is a Professor in the Department of Otolaryngology and Communication Sciences at MCW. He is on the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.