Valentine’s Day: I am Not (but, Thank Goodness, My Husband is) a Romantic

From the 2/12/2021 newsletter

Director’s Corner

Valentine’s Day: I am Not (but, Thank Goodness, My Husband is) a Romantic

By Adina Kalet, MD MPH

In this week’s Director’s Corner, Dr. Kalet talks about the links between love at home and high quality, world-changing science at work. She highlights the importance of strong, egalitarian partnerships in creating a life of meaning, purpose, and flourishing …

COVID-19 has highlighted the importance of having clinician investigators “on the ground” to care for both patients and populations. This group is the most likely to detect emerging disease variants, run innovative therapeutic trials, and move new discoveries to the bedside and into the community. Translational scientists save lives. We need to nurture these clinician investigators as they fulfill their vital scientific and societal roles and provide them with the resources they need to stay healthy and train the next generation of physician scientists. 

Despite their importance, though, over 40% of well-trained physician scientists leave academic medicine, causing a serious shortage of physician researchers and a resulting in a huge loss to the health science workforce. Given how exciting and important their work is, why do so many step off the track? 

I believe they leave because of the constant and recurring challenges these individuals face trying to balance their own lives while attempting to pursue meaningful clinical and research careers. Without solid, deep, and meaningful support both at home and at work, the challenging lives of clinician scientists can become overwhelming. 

What does this have to do with Valentine’s Day? 

In our recent paper entitled “Challenges, Joys, and Career Satisfaction of Women Graduates of the Robert Wood Johnson Clinical Scholars Program 1973–2011,” our group, including Dr. Kathlyn Fletcher, reported on a long-term study of the women graduates of this highly successful fellowship aimed at training change agents in the transformation of American healthcare quality. Among many findings, we identified that - of all these remarkably successful and influential women - the most satisfied were likely to describe their work as “…deeply meaningful and have egalitarian spousal relationships.” The views of these well-trained women clinician scientists offer important lessons to those interested in repairing the leaky pipeline of clinical researchers.

Most of the program graduates in our study were in committed, dual career, personal partnerships. What did “egalitarian spousal relationships” mean to them? It was very complex. We asked the women, some younger and some close to retirement, to reflect on the course of their working lives. On one hand, successful respondents noted that culturally determined and structurally maintained “traditional” gender social roles became flexible and negotiated over time as the needs of the couple changed. A small number of the women in our study reported that, during the child rearing stage of their lives, their partners were the primary parents while they were the sole employed spouse. Most women, though, were constantly juggling home and work. While some respondents reported satisfying lives of “serial monogamy,” divorce was uniformly reported as disruptive to careers and life satisfaction. 

Even as they support early career clinical investigators and scientists, funders such as the National Institutes of Health, the Robert Wood Johnson Foundation, and the Doris Duke Charitable Foundation, have not explicitly and formally addresses how to create, maintain, and sustain “egalitarian spousal relationships” that might be associated with a thriving, impactful, and flourishing life in medicine and science. This might be an area for future study.

What would a relationship curriculum for clinician scientists (and others) cover? 

Love relationships, although universally seen as positive and important are, typically, firmly in the personal and private domain. Most of us learn how to make a life from our own families, our particular cultural groups, or our close peers. Career-focused women in my generation, facing lives very different from that of our parents, had to be creative. We talked “offline” with our peers, scanned our mentors’ offices for evidence of outside lives (e.g., family photos, children’s artwork, dry cleaning, grocery lists), and asked directly when it seemed safe: “How do you do it all?” “Who does the laundry?” “When the kids are sick, who stays home?” “When do the grants get written?” “How do you decide if it is right to relocate?” 

When I was raising my own children, I loved gently interrogating medical students and residents who had “working mothers.” I asked about their experiences and views, hoping to learn anything that would improve my chance of being a good mother. Since then, there has been an accumulation of material to read and discuss. Role models are more common. We can now think about what a structured curriculum might include. 

There is much to learn about finding love, building healthy relationships, and negotiating lives of meaning while not driving each other crazy! When I was starting out, it would have been great to have access to “paired” autobiographies, such as Michele Obama’s Becoming and Barak Obama’s A Promised Land, to gain insight from each partner’s point of view into how hard, but inspiring, it is to maintain a loving relationship under the pressures of “dueling” careers. We can learn from others as they cope with the types of accumulated, complex life experiences that author Nikos Kazantzakis had his protagonist, Zorba the Greek, lament when he said, “I'm a man, so I'm married. Wife, children, house--everything. The full catastrophe."

Ah, yes. The “full catastrophe.” 

A curriculum on creating egalitarian relationships might include exercises on how to determine if each partner shares values and a common view of the future. Children: yes or no? Bedroom window: open or closed? How important it is to “fight” fairly and forgive often? But in the end, it is not those issues alone that make a relationship work for the long haul. 

What might men in egalitarian relationships report? I suspect it would be very provocative but reassuring. To understand how best to create lives full of meaning, we must think deeply about how both people contribute to nurturing, sustained, and flexible loving partnerships. 

Let me tell you about my Valentine … 

My husband has received many “kudos” for playing nontraditional roles, yet when we both switched to four-day work weeks after the birth of our first child, colleagues were supportive of my choice but warned that it would “ruin his career.” (Today we are both tenured full professors.) When we share that he does most of the cooking, he gets showered with praise yet my years of boiling the water for pasta or broiling the fish still go unacknowledged. Thus, as my experience exemplifies, egalitarian relationships are better for both partners but still require different sorts of internal and external negotiations for men. Attention to this, with a reliable evidence base could lead to greater flourishing for all of us. 

Here comes my Valentine’s Day theme. I have had the benefit of such an “egalitarian” loving partnership, and it has made all the difference. I met Mark in July 1984 when we were the interns on the 16 East medical team at Bellevue Hospital. Needless to say, we became very interdependent that summer, meeting regularly in the ICU to replace central lines or draw blood cultures, writing progress notes side-by-side well into the wee hours. I suspect there are few ways to get to better know a person’s character than sharing a 2:00 a.m. cup of cold “food truck” coffee. That summer, well before we became a couple, we were partners.  

Mark recalls that time with much more “romance” than do I.  He has always been the cornier one. I am the “realist,” skeptical that romantic love even exists. I have been free with my feminist critique of all that life has thrown at us. He is the one who still believes in magic. 

Over thirty-three years of marriage, there has been lots of tension and compromise.  There were certainly many ways it could have - and almost did - go wrong. We have challenged assumptions, gained self-awareness, believed in and pushed each other, experimented, and occasionally jumped off the deep end.  We never seem to get it exactly right, but we have gotten better at getting it close enough. We have made a home, raised children, and had our share of adventures. Our egalitarian relationship is a perpetual work in progress, more of a constant juggle than a harmonious balance. We are both better people because of it and, I might add, we have both found rewarding roles as clinician scientists and administrators.

So, is this just good luck? Maybe. I certainly feel lucky. I know many of our junior colleagues think of us as a “dynamic duo.” My response when I hear this is “Forget the Marvel Comics version and come to dinner, see our messy but warm home, meet our kids and the cats, and watch us work it out.”    

For further reading:

Kalet, A, Lusk, P, Rockfeld, J, Schwartz, K, Fletcher, KE, Deng, R, & Bickell, NA (2020). The Challenges, Joys, and Career Satisfaction of Women Graduates of the Robert Wood Johnson Clinical Scholars Program 1973–2011. Journal of General internal Medicine, 35, 2258–2265.

Kalet, AL, Fletcher, KE, Ferdman, DJ, & Bickell, NA (2006). Defining, navigating, and negotiating success. Journal of General Internal Medicine, 21(9), 920-925.

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 about Growth Mindset from our Students

From the 2/5/2021 newsletter

Learning about Growth Mindset from our Students

Marty Muntz, MD

Dr. Muntz shares how to recognize trainees with fixed mindset and shares how small group coaching exercises can be game changers …

How often have you heard someone say, “I believe my intelligence, personality, or character is inherent and static. Locked-down or fixed. My potential is determined at birth and doesn’t change”? Rarely, if ever, hopefully. But have you worked with a learner or colleague who hides failures, desires to look smart, sticks to what they know, avoids challenging tasks, seems threatened by the success of others, is intensely self-critical, or seems resistant to feedback? These behaviors, which may signify a fixed mindset that can limit achievement and ongoing improvement, are not uncommonly observed in our clinical learning environments. 

To address this phenomenon, coaches in the 4C (Coaching for Character, Caring, and Competence) Program are trained to foster a growth mindset in their students. In her book Mindset, Dr. Carol Dweck suggests that learners with a growth mindset are likely to confront uncertainties, embrace challenges, learn from failures, and find lessons and inspiration in the success of others. A growth mindset helps one realize that feedback is a statement about current skills – and an opportunity to improve – rather than a personal attack.  

Ellen Arndt and Katherine Lumetta, MCW-Milwaukee medical students and near-peer coaches in the 4C program, recently developed and taught an interactive faculty development session for our coaches and created the lesson plan for the small group coaching sessions. After learning about this concept, both students and coaches brainstormed barriers to employing a growth mindset during different phases of medical school training and their careers. Unfortunately yet unsurprisingly, the list is long and includes grades, awards, the hierarchical structure of our teams, competition for research and other opportunities, and the residency match. 

In their coaching groups, students were asked to compare and contrast challenging life experiences they approached with both fixed and growth mindsets – and consider how the outcomes may have changed with reversing their approach. The coaching groups also discussed student behaviors that might signal to teachers and teammates that learners are fully invested in their personal and professional development despite barriers. Our near-peer coaches shared how their perspectives have changed during clerkship and other clinical rotations, providing concrete examples from their experiences. 

We are confident that small group sessions like these with trusted peers and faculty coaching starting early in medical school will help our students enter clerkships with the confidence and skills to set and achieve lofty goals. This, coupled with faculty development in programs like KINETIC-3 and 4C to encourage growth mindset, can help transform our learning environments to more fully support our students in their individual journeys to identify and achieve their goals.  

Martin Muntz, MD is a Professor of Medicine (General Internal Medicine) at MCW. He is Director of the Curriculum Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

Providing Space to Shed Tears may be Key to a Better Post-COVID Future

 From the 2/5/2021 newsletter

Director’s Corner

 

 

Providing Space to Shed Tears may be Key to a Better Post-COVID Future   

 

 

By Adina Kalet, MD MPH

 

 

COVID-19 is wreaking havoc in the lives of working women. In this Director’s Corner, Dr. Kalet shares some learnings from Dr. Ellinas’s work in the Center for the Advancement of Women in Science and Medicine (AWSM) and talks about what to do when someone cries …

 

 

Over the past couple of weeks, I have witnessed more tears among my colleagues and mentees than I normally see in a year. Even though I care deeply, I am not particularly worried about those who have cried. I find it reassuring that they reached out, seeking support and a reliable pep talk. I know that while shedding tears in someone else’s presence makes one vulnerable, it is also a sign of strength, resilience, and self-care. These individuals are bending under the prolonged pressures of the COVID pandemic but are unlikely to break. 

 

 

On January 21, 2021, Libby Ellinas, MD, Director of the MCW Center for the Advancement of Women in Science and Medicine (AWSM), Associate Dean for Women's Leadership, and Professor of Anesthesiology at MCW, gave Kern Institute Grand Rounds on Women in COVID. Her talk was a tour de force of cautionary tales and sobering data. She reminded us that the majority of people on the front lines of healthcare and education – and nearly half of our medical school faculty – are women. Data from multiple sources are consistent: women as a group are under special pressures during this pandemic. This poses a threat to both our medical education and health care systems. 

 

The ways in which COVID-19 has disproportionately affected women

 

Dr. Ellinas shared survey data from the USC Dornsife Center for Economic and Social Research confirming that the mental load – including concerns about the health of their families, themselves, and financial strain – is significantly higher among women compared with men. And while married men with children have the lowest mental distress, women with children have, by far, the highest. This is not news.  Sociologists have shown over-and-over that being married with children is associated with better health and more happiness for men while, for women, being married/partnered with children is associated with relatively high levels of stress and distress. Women do measurably more emotional work than men, both in families and at work. While often this work is energizing, it is a mental load that can overwhelm. 

 

Among MCW faculty members, Dr. Ellinas demonstrated that the social isolation necessitated by the pandemic is wreaking havoc for working women. With schools inconsistently in session, direct childcare hours have increased for both men and women, but the number of additional hours per week has been greater for women. Data from an MCW AWSM COVID survey show that while nearly 60% of male faculty have spouses employed part-time or not at all, this is true for only 21% of female faculty. Thus, MCW working women with families are much less likely to have robust support systems than their male counterparts.

 

There is also heterogeneity in how COVID-19 increases stress. Some find value in working from home, but many do not. Clearly, working from home – for those privileged to be able to do so – allows more flexibility and autonomy, reduces time spent commuting, and decreases costs associated with working away from home. It might even provide unexpected “quality time” with family. However, especially for working women with school-aged children, working from home is associated with less sleep and decreased self-care. Adding to this, the intersectionality of race and gender can weigh even more heavily on Black and Brown women. 

 

And, as if that wasn’t challenging enough, there are signs that the COVID-19 pandemic negatively impacts the academic productivity of early-career women more that it does men. The long-term impact of this is worrisome and may lead to the reversal of recent gains in women’s academic status on the whole. These are challenges for us all. 

Institutional solutions are critical and complex

What did Dr. Ellinas recommend? She offered a number of institutional recommendations that are consistent with AWSM’s inspiring and audacious vision that “MCW will be a destination for women leaders, cultivating an inclusive and vibrant culture that supports all genders to grow and thrive in the health sciences,” and mission “to advance the careers of women at MCW through data-informed strategic projects that enhance opportunity and improve workplace climate.

• Evaluating leadership structures to ensure women are well represented in decision making
• Valuing parenting through generous parental leave and creative childcare
• Supporting women to “step forward” rather than depending on “step back” policies
• Valuing the hard work of mentoring, equity, diversity, and inclusion 
• Valorizing women role models for us all

 

We need policies that can be individualized and flexible over time. Extraordinary caregiving responsibilities may be acute, due to an illness or urgent need, chronic, as in having a child with special needs or an aging relative with evolving needs, or both, as in this stuttering pandemic. Community resources are distributed unevenly. Some people do not have enough help while others have what they need, if not to excess. Institutions like ours can improve the quality of life for our employees and community by offering concrete services, such as low-cost, high-quality childcare, sick childcare, food preparation and delivery, and help with chores. 

 

To support women (and men) whose academic careers have been impacted by the pandemic, some institutions have found ways to provide assistance that enable researchers to continue collecting and analyzing data while they tend to a “special” personal need. One program, the Doris Duke Fund for the Retention of Clinical Scientists (see “For Further Reading” below), has funded such efforts. Many workplaces provide access to high quality food, recreation, and other wellness services. Much can be done. 

 

How do we, as an institution, come out of COVID-19 better and stronger? We need a flexible range of options going forward that includes working from home. Our men need to engage. We all need to honestly complete surveys to have quality data that inform best solutions.  Men who have the relative privilege of having more support at home and at work – as well as having disproportionately higher salaries – need to be allies and advocates for equity and flexibility. No one should assume that they, alone, know what will work; we need to ask women. Don’t insist on “fairness” or “equality” until you have a full-thickness view of the situation. 

  

Back to crying

 

I have always kept a box of tissues on my desk. When seeing patients, the box was discretely tucked just out of view, easily slid toward the patient at the first glisten in the eyes. As a colleague and mentor, the box would be brought forward when the face flushed, the head dropped, and the tears rolled. It has been my experience that, most of the time, a good cry in the presence of an empathic other is the most efficient way to clear the air and help the words and problem-solving flow. People cry for all sorts of reasons. Sometimes it is sadness and grief, but just as often people cry because they are overwhelmed, angry or frustrated. I have come to believe that an effective mentor, like the good physician, must learn to invite and sit with the tears of others without needing to fix anything; just listen, sit quietly, check in.  Fighting back tears takes energy, blocks thinking, and keeps others away. Letting tears fall clears the air and loosens the voice. 

 

Did I say that it is mostly women who shed tears in my office? Well, it is. But occasionally, the men cry as well.  Three times in the past three weeks, I have spoken with distraught educational leaders, people who are deeply respected by colleagues and beloved by trainees. They were emotionally and physically exhausted from the expanding and rapidly evolving needs of school-aged children and elderly parents. They had less help from their working spouse than they needed. Their jobs presented new and growing demands on themselves and their trainees (e.g., being “deployed” to care for critically ill COVID-19 patients). They feared a loss of income. They were at the brink. 

 

In each case, I pushed the virtual box of tissues. Why doesn’t Zoom design a “tissue box” emoji?

I hope my message is clear: It is okay to cry here. I am not afraid of your tears. I will hear you out and empathize. You are not crazy, this is hard. I know you will find your way through this. I will help if I can.  

 

These folks do not need to be fixed, they just need a shoulder to cry on, a good night’s rest, regular meals, and an occasional walk in the woods. I think we can get them that. 

 

 

 

For further reading:

Jagsi, R, Jones, RD, Griffith, KA, Brady, KT, Brown, AJ, Davis, RD, ... & Myers, ER (2018). An innovative program to support gender equity and success in academic medicine: Early experiences from the Doris Duke Charitable Foundation's Fund to Retain Clinical Scientists. Annals of Internal Medicine, 169(2), 128-130.

 

Jones, RD, Miller, J, Vitous, CA, Krenz, C, Brady, KT, Brown, AJ, ... & Jagsi, R (2020). From Stigma to Validation: A Qualitative Assessment of a Novel National Program to Improve Retention of Physician-Scientists with Caregiving Responsibilities. Journal of Women's Health, 29(12), 1547-1558.

 

 

 

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.

 

 

Growth Mindset and Wellbeing: Getting off of the Roller Coaster

 From the 2/5/2021 newsletter

Perspective

 

Growth Mindset and Wellbeing: Getting off of the Roller Coaster

 

David J. Cipriano, Ph.D.

 

 

Dr. Cipriano shares that developing a “growth mindset” can help learners smooth the bumps along the way, viewing setbacks as opportunities rather than signs of failure …

 

 

“Tell a story about you at your best.”  

 

“Now, tell a story about you at your worst.” 

 

For many, there would be a sharp decline in mood with the second part of this exercise.  But not for people with a growth mindset – for them, both outcomes would be taken in stride.  Both scenarios would be followed with, “What did I learn from this?” and the worst scenario would be followed by, “What will I do differently next time?”  Growth mindset – the belief in our capacity to change and grow our abilities, not just our skills or effort, but our supposedly innate abilities – is a natural self-esteem preserver.

 

 

Growth mindset v. fixed mindset 

 

For folks with a fixed mindset – the opposite of a growth mindset – failure is a sign that they are not up to the task; that it’s time to pack it up and move on to something else.  For these people, failure, as a New York Times article points out, has been transformed from a verb (“I failed”) to a noun (“I am a failure”) and, indeed, an identity.  But there is an almost equally dangerous attribution for success among those with a fixed mindset – that this is proof of my God-given talent and validates my awesomeness!  Here’s the problem in Dr. Carol Dweck’s words: If you’re somebody when you’ve succeeded, what are you when you’re not successful?  

 

Dr. Dweck is the originator of this concept and she’s been at it for a while now.  Back in the 1970s, she began asking third graders why they thought they were struggling in math.  This research, firmly grounded in attribution theory led to the discovery that, depending on your belief about how changeable the outcome is, you would be more likely to persevere – and even come to enjoy – math.  People with a growth mindset attribute their failures mostly to effort, but even when they attribute to ability, they have the belief that this ability can grow.  People with a fixed mindset almost always attribute to ability, and without the added benefit of believing this can change.  So their destiny is set, there’s not much reason to consider how they might develop from this.

 

I’ve been steeped in this stuff nearly as long.  Back in the 1980s, my master’s thesis was based on attribution theory and my doctoral dissertation touched on it, as well.  I never thought I’d use these concepts in psychotherapy, though.  Back then, I was going to be a social psychologist and do research like Dr. Dweck.

 

Fast forward to the new century and I find myself working with medical, pharmacy, and graduate students, a high-octane group, to be sure!  When they’re succeeding, they’re great.  But, when they’ve failed, they don’t feel so great.  For people with a fixed mindset, failure can even lead to depression.  Now, failure stings for all of us, but it doesn’t have to define us. In psychotherapy with these folks, I examine the self-talk occurring, which is almost always self-recrimination and self-demeaning.  When I challenge this, I hear, “Being so hard on myself is how I’ve gotten where I am today!”  To which I say, “Your ‘self’ can only take so much of this beating, before it freezes and stops trying.”  

 

 

The fixed mindset leads to a “roller coaster” of self-esteem

 

Imagine the roller-coaster that their self-esteem is on.  If you have a fixed mindset, you’re more concerned about the judgment of others and more worried about making mistakes.  When you’re succeeding, it is confirmation that you are the superstar you’ve always been told that you are.  Feels great – especially if you don’t have to try – because having to try negates the notion of having a ‘gift.’  But, when you’ve had a setback or a failure, it is confirmation of your worst fears.

 

 

Getting from roller coaster to journey

 

A good therapeutic outcome with people stuck in this cycle is for them to separate out their identity from their performance – to rid them of that notion that “I am my grade,” or “My worth can be measured in my performance.”  

 

Imagine, instead of being stuck on a roller coaster, they are enjoying the journey.  Learning is savored, and not a threat.  Mood is stabilized in the knowledge that mistakes are to be expected and will make one even better.  Self-worth is preserved in the belief that there is value in getting knocked down and getting up and trying again.

 

 

For further reading:

Dweck, C.S. (2016). Mindset:  The New Psychology of Success.  Ballentine Books:  New York.

 

 

 

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.