Three Questions for Jose Franco, MD: Perspectives on the Transformation of Medical Education

From the 4/30/2021 newsletter

Three Questions for Jose Franco, MD

Perspectives on the Transformation of Medical Education

The Kern Institute celebrates the appointment of our colleague, Jose Franco, MD to his new role as MCW’s Interim Senior Associate Dean for Academic Affairs. Dr. Franco has been part of the Kern Institute since its inception and has held major leadership roles. As he assumes his new position, he is stepping away from his Kern responsibilities. In this interview, he describes his journey with Kern and his hopes as MCW enters a time of curriculum redesign … 

Transformational Times: Tell us about your journey with the Kern Institute. 

Dr. Franco: Dr. Cheryl Maurana, the institute’s inaugural director, asked me to be the associate director of the Kern Institute at its inception after MCW received the Kern Foundation grant in 2017. During the first year, we were busy with planning and defining the role of the institute. When the four “pillars” were created (students, faculty, curriculum, culture), we developed the “cross-pillar” team that would focus on areas that were important but which none of the pillars owned; areas like wellness, character, and caring. Under Ryan Spellecy’s leadership, for example, we ran focus groups and developed scholarship around “character” in medical education.

When Dr. Adina Kalet became the institute director in 2019, she saw a need to connect more intentionally within the institution and with our urban community, so the cross-pillar activities evolved into community and institutional engagement roles in ways that focused on education. I took on a more active role with event planning, recruiting speakers and panelists, and hosting Grand Rounds, Kern Connection Cafes, and Journal Clubs. It has all been a virtual-reality challenge over the past year.

While this has been going on, I have retained my clinical identity in hepatology and continued to engage with students at all levels. I still look forward to my days in clinic working with our entire group of physicians, students, trainees, PAs, and NPs. They are a great team! I enjoy teaching M1 gastrointestinal physiology, hepatology in the M2 GI nutrition unit and clinical hepatology to the M3 students rotating on internal medicine. I often work with M4 students on electives. I spend time on the wards and in clinic with internal medicine and general surgery residents and fellows. I am fortunate to work with medical students and trainees along every point of the training spectrum. I enjoy that.

Transformational Times: What do you see as your most urgent tasks as you move into your new role as Senior Associate Dean?

Dr. Franco: First of all, we have to define who constitutes our customers in Academic Affairs. Our customers are the students and the faculty. 

For students:

Academic Affairs focuses on curriculum. We must ask ourselves: Is our curriculum really preparing the students for the next phase of their careers? We do a great job covering the basic and clinical sciences but could do a better job with the social sciences. For example, students must leave MCW with a robust understanding and engagement with issues surrounding social determinants of health, and the wellbeing of marginalized populations. Those educational and experiential areas need attention. 

As an educational institution, we must do a better job fostering an inclusive, diverse environment. We are fortunate to have students who identify as being from underrepresented in medicine groups. We must ensure that they feel welcome, included, and empowered. There are, of course, great people at MCW doing this already and I hope Academic Affairs will enhance these efforts. Diversity makes us all better. 

Focusing our efforts on student wellness and wellbeing will be critical. The gaps here constitute a national crisis. When students and young physicians are in crisis, they will “fall out of love” with medicine. Too often, physicians end up seeing medicine as a “job” and not a “calling.” We must explore how we can prepare students and residents to be fully engaged and resilient for their entire careers. I would love to play a part helping students optimize their physical, mental, and spiritual health as human beings. 

For faculty:

I sense that faculty often see the Office of Academic Affairs as a “black hole.” I believe that the Kern Institute has worked to inform the faculty what it does through regular engagement and communication. In much the same way, Academic Affairs needs to let the faculty know what it does. 

The office has many resources that can help the faculty perform their roles as teachers and mentors. We have expertise in instructional design and educational technology, for example. We need to let the faculty know what is available, who to talk to, and how they can be the best educators possible. 

Transformational Times: How do you see the current status of the curriculum redesign?

Dr. Franco: The answer to that changes from week-to-week. MCW’s faculty are well aware that there is no perfect curriculum and that there is always room to make improvements. That said, we have been through change before and, even though we know there is a need to make adjustments, these processes always cause anxiety. The process will always feel like a curveball.

First of all, I am certain that we will be given the resources to do the curriculum redesign correctly. Senior leadership is onboard, responsive, and wants this to succeed.

What is our goal? Let’s start by saying that our goal is to work together to deliver a quality product. We could, of course, put out something tomorrow, but would it be quality? 

I sense that there are two major faculty concerns as the process moves forward:

The first major area of concern revolves around faculty development and preparation for the redesign. 

MCW’s preclinical curriculum has often relied heavily on the traditional fifty-minute lecture format with few interactive opportunities. If we plan to institute a flipped-classroom, case-based teaching approach, we must have a fully engaged and prepared faculty. We must better understand how long it will take to bring everyone up to speed. 

We need to engage the clinicians who will be expected to take on new teaching responsibilities. Clinicians will be increasingly integrated into the process and the proposals will require different approaches that will expand their teaching approaches and challenge their skill sets. 

The second major area of concern is the timeline. 

Is the timeline for deploying the newly redesigned curriculum in August 2022 realistic and optimal? Although it is over a year away, we have a much shorter time to make a decision, since we will begin interviewing the entering class of students late this summer. They are the “customers,” as it were, of the new curriculum. They are the ones who will have to decide if they want to come and experience what we will be offering. We need to be clear with them as to what the curriculum will look like. 

I know that many of the faculty have expressed strong opinions. We must work together and make certain we are all ready and onboard. 

The curriculum belongs to the faculty and the Curriculum and Evaluation Committee (CEC) has the critical role here. I had the good fortune to be chair of the CEC when the pilot integrated curriculum was approved. A few years later, I brought proposals for curricular change to the CEC. I have been on both sides of the table. As a result, I hope I will be in a good position to listen to peoples’ concerns. What excites them? What worries them?

I am excited to take on this role at this important time for our students and our faculty. 

Jose Franco, MD is the Interim Senior Associate Dean for Academic Affairs. He is a Professor in the Department of Medicine (Gastroenterology and Hepatology) at MCW. He previously held leadership roles in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

The Kern Institute Hosts a Conference - A Year Late but a Lot More Wise

 From the 4/30/2021 newsletter

Director’s Corner

 

The Kern Institute Hosts a Conference - A Year Late but a Lot More Wise

 

Adina Kalet, MD MPH

 

Today, the Kern Institute hosts the “Understanding Medical Professional Identity and Character Formation,” a conference originally scheduled for April 16, 2020 but postponed by the pandemic. Dr. Kalet reflects on how the havoc wreaked by COVID-19 has sharpened our focus on what matters and provides both challenges and opportunities for the work at hand …

 

 

In the run-up to April 2020, attendees and speakers were readying to fly into Milwaukee from across the country and around the world for a two-day conference on medical professional identity and character formation. The plenary was to be given by Dr. Muriel Bebeau, a moral psychologist and a scholar of professional identity formation. Workshops and poster presentations were firming up. Hotel rooms were booked. Conference rooms were reserved, food had been ordered, and Institute staff were finalizing details like an army prepares for tactical maneuvers. We planned an evening symposium where, over a fine dinner in the Alumni Center, attendees would discuss what they had learned and ponder how this field of study and practice could transform medical education. I was stoked. This was going to be fabulous! 

Planning such an event has much in common with preparing for a wedding or bar mitzvah - both of which I have some experience with and for which I claim no special skills - but without the music and ceremonial component. Working to remain calm, I attended to many details. This would be the Institute’s first large conference and the first of many to come.

 

That was, as we say now, in the “before times.”

 

Then COVID-19 started spreading. Asian and European attendees cancelled their trips as borders closed. Not wanting Dr. Bebeau to fly (after all, she is a “senior” statewoman), colleagues planned to drive her from Minneapolis to Milwaukee.

As the full force of COVID-19 bore down, our excitement turned to dread and then to resignation. After resisting as long as we could, we canceled. Soon, the nation hunkered down, and we learned what it meant to “stay at home.” When it appeared that interstate travel would soon be banned, and with all of the Kern Institute staff working virtually, I boarded a sparsely occupied early morning flight from Mitchell to LaGuardia to shelter at home with my family.

A year later, our conference will finally happen in a virtual space. Since Dr. Bebeau prefers not to talk to her computer screen (how can we blame her?), I will deliver the plenary talk in honor of her contributions to the field.

 

So much has changed

The topic for today’s conference has become much more poignant and important and less simply “academic” as a consequence of the pandemic. The understanding of character and professional development of health professionals has evolved while the public watched physicians and all healthcare workers rush to the front lines. Although data on the public’s level of trust in our profession had been declining up until last year, they have soared as it became clear that we perform our duty, show up, and care in the face of unknowable risks. Health professionals are seen as people who possess talent, energy, resolve, and character. As medical educators, our work is to help students be, not only exquisitely competent, but also brimming with extraordinary sensitivity and humanity.

Many of our exhausted students, residents, and frontline faculty have been through rapid-fire, anguishing, morally ambiguous experiences over the past several months. They have put their own lives - and their families’ lives - at risk. They have witnessed people dying separated from their loved ones. They have seen how social determinants of health impact real people with real names. They have dealt with their own crazy uncles and social media acquaintances who doubt the data. And the pandemic is far from over.

 

The pandemic has changed how we view identity and character formation

Later today, I will speak about how we might ensure that our trainees and faculty possess mature, internalized professional identities, because solidity of identity prepares each of us to hone the character, conscientiousness, courage, and wisdom needed to act in accordance with our principles under highly complex circumstances. While nothing can replace the experiential learning at the bedside and in the clinic, most of the preparation for character development must happen in the classroom. Interactive discussions, reflection, theoretical analyses, and rehearsals best prepare us and our students for unpredictable future events.

This is work we must do, because the alternative is to allow everyone to learn only through experience which means many will simply “react” to situations, without exercising the habits required to make principled decisions under stress. Expecting our trainees to make good choices without helping them develop the tools to act with moral agency is unacceptable. We must try to educate and measure professional identity and character.

 

Hopefully, there will be many chances to talk with the over 120 conference attendees about how to best support the development of practical wisdom in physicians, nurses, respiratory therapists, and others when, for instance, they are deciding how long to stay at the bedside with a terrified spouse or convincing someone they need a vaccine even though they have every reason not to trust the medical establishment.

I am hoping to talk about how we - teachers and students together - determine when a trainee can be “entrusted” to care for patients with less and less supervision. You see, we can measure a student’s competence to do the basic skills of doctoring, but we can’t be absolutely certain that an individual student - when faced with a real-life circumstance - will actually perform competently. As we try to determine whether our students have what it takes to do the right thing every time and when it matters, we make educated guesses buoyed by our experience but, too often, we depend simply on our subjective judgement of their character. I hope to provide a framework for thinking about these “trust judgments” as a matter of both character and competence of both the learner and the teacher.

It is interesting - and worrisome - that our “educated guesses” are very idiosyncratic; we rarely agree on what it means to be a competent physician. Yet, with experience and benchmarked performance metrics in the context of good relationships with our learners, we can make accurate judgments about who will be a trustworthy physician. Identifying trustworthiness and good judgement in a student is a harbinger of their future character, courage, and caring.

 

Challenges and opportunities

While far from over in the US, the pandemic is currently having a devastating impact in India and parts of Africa. Our sister and brother health care professionals in those countries are struggling to do the work they were trained to do under very difficult circumstances. In addition to concrete support, we send them our respect for their courage and professionalism.

I am grateful for the opportunity to host this conference at this inflection point in our understanding of character development and professional identity formation. The pandemic has given us both challenges and opportunities. Winston Churchill once said, “Never let a good crisis go to waste.” I hope that his sentiment will guide our work.

 

 

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.

Remembering H. Jack Geiger, a Role Model and Troublemaker I wish I Had Known

From the 4/23/2021 newsletter

Director’s Corner

Remembering H. Jack Geiger, a Role Model and Troublemaker I wish I Had Known  

This week, Dr. Kalet struggles with her regret at not humanizing her “heroes” when she had the chance ... 

It was with deep regret that I read his obituary because I never had the courage to get to know H. Jack Geiger as a person. Despite having him as a role model for decades, I missed the opportunity to have him as a mentor or friend, and I am poorer for it.  

Geiger, a graduate of UW-Madison, Case Western Reserve, and Harvard, was a physician, civil rights and antiwar activist, journalist, founder of social medicine in the US. He made lots of “good trouble” in his life. He believed that physicians must use their full capacities, their knowledge and skills, and the moral authority that comes with the profession, to improve the social and geopolitical conditions that threatened health. 

Dr. Geiger died this past December, after living for almost a century. While I knew some of his story, the obituaries - and there were many including a beautiful one in the New England Journal of Medicine - pointed out that he excelled at being an iconoclastic rabble rouser. They describe how he was, more than once, sanctioned by his medical institutions for speaking out to “raise the bar” for our profession, but he persistent none-the-less. 

He was not like most of us.  A preternaturally brilliant, child of immigrant German Jewish parents, who were a physician (dad), and a scientist (mom), he finished high school at fourteen and ran away from home (with his parents’ permission!), to live in Harlem among actors, musicians, and the celebrated authors of the time. He entered the University of Wisconsin as undergraduate and wrote for the Capital Times in Madison before he was eighteen years old. He never took any straight paths, following his instincts and his strong moral compass. 

Both Dr. Geiger and I began at the Sophie Davis School for Biomedical Education (now the City University of New York Medical School) in 1978. I was a college freshman, and he a remarkably accomplished physician, social activist and newly minted Arthur C. Logan Professor of Community Medicine. I wish I had invited him for a cup of coffee or a beer. I never considered it; it was too intimidating I was convinced he would be “too busy”. Later, I wish I had visited him at his home in Brooklyn during his last decades when he stopped traveling, became frail, and had failing vison. I certainly could have. I am now certain that he would have made time to talk with me. He might have even enjoyed meeting a former student. But I never called.  Instead, I took the easier route and had conversations and debates with him in my head. It is hard to learn anything that way!

The problem of being afraid of our role models is this: they remain on pedestals and exist mostly in our imaginations. We try to understand them and learn from their examples. We watch them and read about them, but we never know them in their full humanity, warts and all.  

Of course, this “hero at a distance” is often all that is available to us. Our role models may not be proximate. They may be long gone, or they may be entirely fictional. But I now believe that if opportunities arise to transform role models into mentors, one should take full advantage, even though there might be risks. To truly know a remarkable person is invaluable, and the privilege to be known by someone who has done heroic things is rare. 

When I was in college, we knew only vaguely of his many accomplishments to that point, (he had yet to win his two Nobel Prizes) and we were way too self-absorbed and naïve to truly appreciate how unusual a physician he was. Although we heard him lecture occasionally, we were largely unaware of what a character, in all the senses of that word, he was. Boy, did we miss out! 

In fact, he was redefining what it meant to be a physician just as we were working very hard to become one. His example was destabilizing to our nascent professional identity formation. The lessons he represented, the moral exemplar he was, were lost on most of us.  Admittedly, it might have been difficult for us to truly appreciate what he had to teach us early in our careers, but we should have tried. Missing that opportunity was a great loss. Had we taken the risk and made the effort, we would have been the richer for it. 

How might my medical school have taken better advantage of this giant walking amongst us? I think there are “curriculum” lessons in this. In addition to the occasional lectures from him and about his work, the book chapters and New York Times editorials he wrote (but which we weren’t obligated to read), there should have been a way to understand him beyond the “hero” stories. Had we found ways to engage with him meaningfully as a person, it would have humanized this intimidating, moral exemplar and, perhaps, provided us each with more detailed career maps. What a remarkable “leadership training” program it might have been to talk with him informally, to hear his personal stories, his journey, and his views on his own coming of age! Besides reading about his work and hearing him speak, we would have been able to bring our questions, comments, and fears to him. 

It is also possible we might have been disappointed. That’s okay. After all, no role model is perfect. Many are not even particularly gifted in interpersonal skills. There might have been confrontations and rebukes. He might have initiated intellectual debates that rose well over our college-educated heads. This was a man who talked with Langston Hughes as a 14-year-old! But, had we the courage to engage, we might have learned more of what he had to offer in ways that would have challenged us and given our own embryonic careers direction. 

It is also true that he might have been too overwhelmingly engaged in other activities to be part of such a curriculum. Although he was only in his mid 50s when he came to the Sophie Davis School, he had already traveled to South Africa where he had studied their community health centers. He then brought this approach to the Mississippi Delta, sparking a movement that is credited with bringing basic health care access to tens of millions of Americans. At the same time, he was co-founding two Nobel Prize winning organizations, Physicians for Human Rights and Physicians for Social Responsibility. Sometimes, role models must be just that and nothing more; they have work to do and we should watch from the sidelines and take notes.  

The “writing prescriptions for food” lecture 

Every year, we gathered for the same “Geiger Lecture,” where he told the story of his work in rural Mississippi. The most memorable section was when he described the political battle into which he was drawn when funders realized that the program was writing, and then the federally subsidized community health center pharmacy was filling, prescriptions for food.  Every year he delivered the same punch line, describing how he won the battle. “I told them,” he said, “the last time I checked my textbooks, the specific therapy for malnutrition was, in fact, food.” 

I am ashamed to say that my classmates and I rolled our eyes at this story, much like children sigh at the Thanksgiving table when Grandpa tells the same stories every year. But these stories are our legacy and, at the risk of boring the children, it is through the frequent retelling of these “hero stories” that communal values are transmitted. Of course, now I want to know more. Was he scared or anxious when he need to confront those with the authority to stop his important work? How had he prepared? What would he have done if they had pulled the funding? I would have wanted to hear about his failures and how he delt with those. But now I cannot. 

When my son was little, he was absolutely enthralled with superheroes (still is, I think). Batman and Superman costumes were festooned throughout our home, red capes and black masks everywhere. Through our many conversations about the thoughts and feelings of his role models, we landed on the conclusion that it was easier to know what the right thing to do was than to actually do it.  Our maxim became, “courage means being scared but doing the right thing anyway.”  It would have taken courage to reach out and insisted that H. Jack Geiger talk with me, but the privilege to have known him better would likely have been worth the effort.  

I will be reaching out more and connecting with my heroes. And the Kern Institute will do what it can to create proximity with the “s/heros” of our times, to the benefit of our students, our trainees, and ourselves.  

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.

Poetry by Rhea Martin - Dear America

From the 4/16/2021 newsletter

Poetry

Rhea Martin

Dear America

I wish I felt loved by you.
I wish I felt safe being with you.
I wish I could trust the promises of hope and progress you keep saying will come.

Like any love
It is not perfect 
There is beauty as well as sorrow 
To give unconditional love means to have trust
I wish I could trust you America
But I can’t 

and what’s worse 
Is that it breaks my heart to see that people are trying
beautiful, strong, devoted people fight for you
And maybe I’m not strong enough to give 
That trust

That doesn’t mean you are hopeless
Or less beautiful and vibrant and passionate 
Nor is anywhere else going to be perfect
I’m not naive to expect more than what can be given within the current climate 
But maybe we just don’t fit 
and that’s ok
I wish nothing but the best for you

To the man who almost ran me over today
Who didn’t stop
Who didn’t look back 
To the witnesses who walked away 
To the police that drove around my neighborhood pretending to look out for the community

How dare you have the audacity to put the words “Black Lives Matter” in your yards
and in your windows 
and bumper stickers on your cars

To the one POC who witnessed what happened and gave me a ride home and said
Thank you for doing the decent, human thing

“Thank god you had good reflexes”

I know it is not a crime to be 
A women
Queer
Or Black

But America

Stop gaslighting me 

America

Being with you it’s like being with an alcoholic
I don’t know whether to be pessimistic or optimistic that recovery is in your future
There are so many programs and so many resources
Your casual slurs and liveliness at parties used to be fun
And I know I can be easily accused of not being virtuous enough to see you through and see you get better
I feel like it is on my back to make it my responsibility for you to get better

You have made it so many people's responsibility to call you out on your history and your lack of transparency of your habits habits you keep and how you destroy communities
But you are like my family
I would not be who I am without you
To have criticism does not mean I don’t see you for who you are
More
So much more than a simple word 
A moment 
A feeling 
I get so mad when others treat me better
Because I want to feel that love and acceptance 
from you

Show me I can believe in you
I want to trust you 

I want to walk down the street and feel safe
As a queer
Black 
Women
I google, safest places to live In America
Then I remember 
Back space 
Safest places for black queer women to live in America
Because there is a difference

Am I the problem
And I the problem in this relationship?
You shrug your shoulders
And I guess it depends

What am I wearing 
Where are you from
Did I say what I said the right way
Do I care too much?
Are you on your period?
Are my standards a little bit too high

I don’t know
But I’ll keeping working on things that are in my control
I am still standing today
I know about us right now, let’s take a break

Rhea Martin is a Public Ally with Public Allies MKE and an Intern with the MCW Office of Diversity and Inclusion. Rhea reflects on their relationship with America as a queer person of color. This work was shared during the Spring 2021 MedMoth event at MCW.