Rituals Stir our Memories and Push us toward Transformation

 From the 5/28/2021 - Memorial Day - newsletter

Director’s Corner

Rituals Stir our Memories and Push us toward Transformation 

Adina Kalet, MD MPH

In this week’s Director’s Corner, Dr. Kalet asks us to both attend to our need for commemoration of the very difficult time with rest and reconnection while we also work to sustain hard won transformative gains …

Memorial Day weekend is especially poignant this year. As a nation, we are exhausted. We have collectively experienced fourteen months of a frightening, isolating, unpredictable pandemic, an eye-opening year since the murder of George Floyd, widespread calls for social justice, and a nail-biting presidential election. We have been irrevocably changed and are emerging - in fits and starts - into a new post pandemic reality. Now that many of us have been vaccinated against SARS-CoV-2, we are eager for the summer season to kick off.

In many ways, the past months have forced us to innovate, create, and find new ways to conduct our lives. It is not yet clear which of these changes are good or sustainable, but we are different now than we were then.

Rituals and gratitude are important as we honor those who have served

In this Transformational Times issue, Capt. Tej Ishaan Mehta MD, who is an Internal Medicine resident at MCW, movingly recounts how Memorial Day came to be after the Civil War, when our deeply divided nation emerged from that awful, bloody conflict. He writes, “Across the North and the South, the fallen from both sides of the war were honored, respected, and remembered, continuing their service even in death by helping to reunite the country.”  He reminds us that ritual and symbolism have the power to bridge our gaping chasms and heal our festering wounds. 

This issue also features a fascinating excerpt from Richard N. Katchske’s new book, Knowledge Changing Life: A History of the Medical College of Wisconsin, 1893-2019. Mr. Katschke, MCW’s Chief Historian, describes our medical school’s mobilization during World War II.  Our faculty and students served the nation by embracing a dramatically accelerated curriculum to ensure a supply of physicians prepared to go to war. And go to war they did. Many served with great distinction, and one made the ultimate sacrifice. I plan to read Katschke’s entire book (I will share some highlights) and recommit to a favorite pastime of studying the class portraits that line the hallways on the main floor of the medical school building. I will inspect the faces and uniforms, knowing that many served overseas or at home in a war effort. How many were impacted by WWI, WWII, Korea, Vietnam, Iraq, and Afghanistan? Who went on to have careers touched by the influenza pandemic of 1918, by HIV/AIDS, or by other national challenges?  I will wonder. 

On this day, we honor the individual soldiers who made the ultimate sacrifice to protect and defend our many precious freedoms.  It is important to commemorate them, and we must support their grieving families and the loved ones who were left behind. It is a somber but awesome opportunity to take time to honor their losses, recognize their sacrifices, consider what they have taught us, and pledge to make a difference in the world they shaped. 

An evening ritual in New York and beyond

The response to COVID-19 inspired its own rituals. Starting mid-March 2020, at 7:00 p.m., everyone on my block in Brooklyn, NY came out on their stoops to make “noise” (some had musical instruments) for a good twenty minutes to celebrate the health care and essential workers who went to work every day at the hospital around the corner. This nightly ritual, which was occurring at 7:00 p.m. all over the globe, continued daily for many months, and evolved into a means for neighbors to check in with each other and socialize. It was so joyous and silly, that I found that I missed it when it petered out. 

Although not a part of our national Memorial Day commemoration, those of us in health care, and those whose families have been touched, also remember relatives and friends who died from COVID-19. The rituals to honor front line health care workers and first responders remind us that, as a society, we must address the unconscionable health disparities and social ills that put so many, particularly our Black and Brown citizens, at outsized risk.  As of yesterday, an estimated 3,511,748 worldwide have died of COVID-19, and it isn’t over yet. In many parts of the world, hospitals resources are overwhelmed, oxygen is not available, and vaccine supplies and infrastructure are inadequate. Despite the circumstances and at enormous personal risk, our international health care colleagues face the pandemic and do their duty with character and compassion. Heroes are everywhere. Perhaps someday soon, there will be a COVID-19 Remembrance Day.

Medical Education will continue to transform 

How will we remember these pandemic times? Will they change our work when things return to something resembling “normal”? I suspect that there will be many tell-tale signs stamped on our educational practices. We have new levels of savvy with technology-enabled education, admissions processes, international conferences, and performance-based assessments. We have narrowed the “digital divide” between us and our applicants and students to address issues of equitable access. Even if a significant proportion of medical education remains remote, we will be better at enhancing face-to-face sessions with meaningful, integrative faculty-led small group experiences. While fancy equipment and simulators might be irreplaceable for some types of teaching, expanded use of low-cost virtual reality devices and mobile apps offer areas of untapped potential. As we harness new educational practices, what we discover will become endlessly scalable. 

Emerging from the pandemic will also help us re-commit to preparing our trainees to practice in, and influence, health care systems. How do we help our students and trainees see the “big picture” of medicine in society? How do we enable our trainees to provide outstanding, equitable health care to the marginalized? How do we prepare for future pandemic and health crises? Can we embrace technology, yet keep medicine humane? We will need to integrate the transformational goals of the Kern Institute into a constantly evolving medical education landscape.

Wars and pandemics have lead to unspeakable, senseless horror. Both, however, have also resulted in opportunities for innovation. Battlefield medicine during WWII led to life-saving civilian improvements in trauma care, limb salvage, reconstruction, and antibiotic use. The pandemic offers opportunities, as well and, as we commemorate the many losses of the past year, we will fiercely embrace the future. 

Too many have died both in battle and from preventable, treatable disease. We insist that they did not die in vain, and pledge to learn something good and important in their honor. 

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.

Stand Up for What You Believe In

From the 5/28/2021 - Memorial Day - newsletter

Perspective/Opinion

Stand Up for What You Believe In

Chad Kessler, MD

Dr. Kessler is the National Program Director, Emergency Medicine, Department of Veterans Affairs.  He is also a professor at Duke University and a staff physician at the Durham VAMC. He is the epitome of charismatic and inspiring VA leadership.  Here is an essay that he generously let us share from one of his twice weekly newsletters ...

So, I was sweating through my Thomas Pink button down shirt this late Friday afternoon and eon or two ago.  I was still in the hospital at 6:00 that day, stewing in this tiny, windowless room…not only because of the jungle like temperature, but the unfamiliar and frankly unnerving environment. As a young chief, this was all very new to me, and having to sit with these top leaders was terrifying, and only intensified by the news I had to share. We were short on coverage, I felt that we were teetering on unsafe care in our Emergency Department, and I needed to advocate for staff in a miserable budget year.  That word…I didn’t realize how much power was in that single word.  I literally remember the second when the Boss stopped the meeting in mid-sentence, and said, “Kessler, did you say we have an ‘unsafe’ environment?” Like I had uttered a profanity in Temple or put ketchup on a hot dog.  I looked around, realized everyone was staring at me, and said prophetically, in my best Homer Simpson voice, “uh…yes.”  I’ll be honest, I don’t remember much after that, except feeling like I said or did something wrong (even though I knew I wasn’t wrong), that people were mad at me, and that I truly may get fired…but I got home, gave my wife a hug, the kiddos jumped into my arms, grabbed myself a two liter chai and thought in my head, I did the right thing, right?     

 

Here’s the moral of my tale…Stand up for what you believe in, even if you’re standing alone! It may be pressure from your boss to not open your mouth, it may be your team telling you everything is fine or it may be that little voice (you know, the easier wrong voice) whispering to you how much you really like your job...and don’t really feel like updating your CV.  But whatever it is, make sure you’re doing what is right in your mind.  It’s your name on that memo, on that patient chart, it’s your voice they will hear, and it’s your conscious you will live with for years to come.  So, make sure you do the right thing, take the harder right, and stand up for what you believe in…even if you’re standing alone.

 

Just for closure sake, we did end up getting that additional coverage for the ED, and I did not get fired.  In fact, I specifically remember one of the senior leaders coming up to me later that week, telling me how brave that was…and was indeed the right thing for patient care. If only he was standing with me during that meeting…but nonetheless, alone or together, we need to stand strong for what we believe in.

Dr. Kessler curates an amazing series called “C20” or Covid in 20, which currently has over 100 informative episodes on a variety of topics from “COVID and the law (Episode 63) to COVID and delirium (Episode 28).  Some are VA specific, but many are not.  Click here to check them out. 

The Marquette University School of Medicine Aids America in the Time of War

From the 5/28/2021 newsletter

Medical School History 

 

The Marquette University School of Medicine Aids America in the Time of War

 

Richard Katschke, MA

 

In this excerpt from his book, Knowledge Changing Life: A History of the Medical College of Wisconsin, 1893-2019, MCW Chief Historian Richard N. Katschke explains how MCW’s predecessor institution, the Marquette University School of Medicine, responded to the national call to action during World War II …

 

As Europe was embroiled in conflict in the late 1930s, the possibility of the United States’ participation in the war effort impacted the Marquette University School of Medicine and other medical schools nationwide. Beginning in 1940, the Marquette medical school responded to a request from U.S. Surgeon General James C. Magee to sponsor an army surgical hospital. Eben J. Carey, MD, PhD, dean of the medical school, appointed twenty Marquette medical school faculty and staff members to provide administrative and technical assistance to Surgical Hospital #42, based at Fort Campbell, Kentucky. Also, in 1940, Marquette University – including the medical school – was one of twelve colleges nationwide selected to sponsor a Naval Reserve Officer Training Corps.

Following the attack at Pearl Harbor, the United States declared war against Japan on December 8, 1941. Four days later, Germany and the United States went to war. The world conflict triggered significant changes at the medical school. Beginning in July 1942, all teaching activities at the Marquette medical school were accelerated so that medical students could become physicians more quickly and provide medical care on the front lines. Vacations were shortened or suspended. Courses were abbreviated, and electives were dropped. Walter Zeit, PhD, ’39, recalled, “There were several instances where one academic year ended on a Friday and the next one started the following Monday.” Graduation ceremonies were conducted in May and November. Because of the demand for physicians during wartime, the medical school – unlike many other academic programs at Marquette – maintained a strong enrollment.

Norman Engbring, MD, ’51, noted in his book An Anchor forthe Future that the accelerated wartime curriculum placed an additional financial stress on the medical students. In 1942, the W.K. Kellogg Foundation provided $15,000 to the medical school to create a student loan fund. The Kellogg Foundation awarded similar grants to other medical schools nationwide.

Another change that occurred in September 1942 was that the fifth year of medical school - the internship year - was abolished. The requirement had been in place since 1920. Dr. Engbring explained that the fifth year was dropped so that junior medical students could qualify for federal loans that placed a four-year limit on the number of years a student could remain in school. By the end of 1942, only nine of the nation’s sixty-seven medical schools still required the completion of an internship year before medical school graduation. The Army and Navy gave medical students provisional commissions which enabled the students to avoid the draft and stay in school. For example, the Army Student Training Corps and the Navy’s V-12 program were organized, and medical student recruits received a base pay of $50 per month from the military.

“Khaki is now in evidence in the Schools of Medicine and Dentistry as 320 members of the Army Enlisted Reserve Corps in these schools were recently called to active duty by the order of the War Department,” reported the Marquette Tribune on July 15, 1943. “Within the last weeks these Meds and Dents were sent to Camp Grant, Illinois, where they were inducted, issued uniforms, and immediately ordered back to Marquette to continue their education. Roll call at 7:45 am either on the parade grounds or for senior medics, at the hospital, begins the day of the trainees.” Anthony Pisciotta, MD, ’44, recalled that the Army students were organized into the 3665^th service corps under the command of Major Joseph Plodowski, who was based at the medical school. The medical student soldiers became known as “Plodowski’s Raiders” and the “Fighting 3665^th.”

The Marquette Tribune reported that of the 334 male students enrolled in the medical school, 176 were commissioned as 2^nd lieutenants in the army, 104 received navy commissions, thirty-six had applications pending, and eighteen were ineligible for commissions because they were either non-citizens or had a medical disability. Earl Thayer wrote in Seeking to Serve: A History of the Medical Society of Milwaukee County, that nearly fifty faculty members saw active service, as well as a large percentage of alumni.

One alumnus, Lt. William Henry Millmann, MD, ’43, was killed on February 21, 1945, while caring for war casualties in Italy. The Millmann Award, the Medical College of Wisconsin’s highest honor for graduating medical students, was named in his memory. The first recipient of this award was Marjorie E. Tweedt Brown in 1948. John Erbes, MD, who joined the medical school’s surgical faculty in the late 1940s, was the most highly decorated U.S. physician in World War II. As a battalion surgeon, he saw front-line duty in Morocco, Tunisia, Sicily, Normandy, Belgium, and Germany.

 _____

Excerpted from Knowledge Changing Life: A History of the Medical College of Wisconsin, 1893-2019, by MCW Chief Historian Richard N. Katschke, MA. The book is available for online purchase here.

 

 

Richard N. Katschke, MA is the Chief Historian of the Medical College of Wisconsin. He joined MCW as Director of Public Affairs in 1985 and served as the Senior Associate Vice President for Communications. He received MCW’s Distinguished Service Award in 2015 and was awarded an honorary Doctor of Humane Letters degree by MCW at the 2021 commencement ceremony.

The Hogwarts Model: Putting it all Together in Learning Communities is Foundational to the New Medical School Curriculum

From the 5/21/2021 newsletter

Director’s Corner

The Hogwarts Model: Putting it all Together in Learning Communities is Foundational to the New Medical School Curriculum  

Adina Kalet, MD MPH

Dr. Kalet discusses how MCW’s Learning Community (LC) model has the potential to benefit students and faculty members, addressing our desire to build character and caring, while strengthening both academic and social opportunities for our learners …

Last spring, in anticipation of a rough, rapidly evolving, and socially isolating year, the MCW School of Medicine built a learning community (LC) structure for the entering M1 class to ensure social cohesion and engagement. We wanted students to weather the pandemic with regularly scheduled and academically meaningful structured connections with their peers and between students and faculty members. We accomplished this by weaving together the required REACH (Recognize, Empathize, Allow, Care, Hold Each Other Up) Curriculum and the voluntary 4C Academic Coaching Program. We wanted the students to experience a sense of continuity and have sufficient time to establish true collegiality and strong bonds through “cyberspace.” 

A targeted, sophisticated faculty development process was devised and implemented to train over seventy MCW faculty and staff and twenty-seven students to be leaders. Now, a year later, we are in the process of analyzing the data and can report that the experiment was a success. Preliminary student feedback is inspiring. Similar to experiences at other schools with LCs, the participants report that they gained a great deal. The LC has become a central component of the evolving proposal for the new MCW medical school curriculum. 

This issue of the Transformational Times describes the process and amplifies the voices of both students and faculty participants. I hope you will read the descriptions and enjoy the personal stories they share.   

"It matters not what someone in born, but what they grow to be." 

– Professor Albus Dumbledore

The most well-known learning community model is Hogwarts School of Witchcraft and Wizardry, that secondary boarding school administered by the British Ministry of Magic in an unlocatable spot in the Scottish Highlands.  Upon arrival at Hogwarts, new students are assigned by the sorting hat - based on a magical mash up of personality, character traits, and a bit of “destiny” – to one of the four houses, Ravenclaw, and Gryffindor, Hufflepuff, or Slytherin, named for their founders. Just in case you are one of the few people alive who doesn’t know what I am talking about, read the seven volume Harry Potter series by JK Rowling for more details (or watch the movies). You will learn that once assigned to a house, students are pretty much set for years of mostly healthy academic and athletic competition and a great deal of intrigue. At Hogwarts, as in many idealized academic settings, students develop lifelong bonds with housemates by studying, eating, living, and having innumerable terrifying adventures together. 

This identity setting framework is very important to individuals and to the whole Wizarding community. Increasingly, medical schools - as well as many other higher education environments – are embracing this rather “ancient” model to redress the persistent concerns about lack of academic continuity and  inconsistent mentoring, and to provide the healthy social connections that enhance lifelong resilience. 

What are Learning Communities? 

Learning communities are not “extracurricular,” but fully integrated foundational components of the curriculum. Each LC is a group of people who share common academic goals and attitudes and meet regularly to collaborate on learning activities. While it has all of the “student life” benefits in common with advisory colleges, “eating clubs,” dorms organized by affiliations, sororities, or fraternities, an LC goes well beyond simply providing a rich social structure. They are best thought of as an advanced pedagogical design. Medical schools around the world are adopting this model, the highest profile among the early adopters have been Harvard and Johns Hopkins. 

Rather than considering the individual learner as the only relevant unit of instruction and performance assessment, these “communities of practice” explicitly acknowledge that education is a shared cultural activity with a significant communal component. This sociocultural approach is not a new idea, but it remains a challenge to implement effectively. At its best, the LC model provides a means to structure medical education in truly relationship-centered - as opposed to course-centered – ways.   

In our proposed LC model, academic coaching is fundamental. This inextricably links the cognitive and non-cognitive components of learning on the road to becoming a physician, and put relationships among members of the community at the center of that learning and professional identity formation. 

As part of the Kern Institute’s Understanding Medical Identity and Character Formation Symposium (see my Director’s Corner on April 30, 2021), a group of national leaders discussed “The Nature of Learning Communities and the Goals of Medical Education.” David Hatem, MD (University of Massachusetts), William Agbor-Baiyee, PhD (Rosalind Franklin University), Maya G. Sardesai, MD MEd (University of Washington), and our own Kurt Pfeifer MD, explored how their LC structures explicitly address students’ acculturation to both medical school and the profession of medicine. They reported how a healthy learning environment counters the noxious impacts of the “hidden curriculum,” while supporting students on their professional journeys during medical school, aiming to ensure that students are ready for, and will thrive in, a lifetime of practice as a physician.  

The panelists also shared the collective experience of the  forty-seven medical school members of the Learning Communities Institute (LCI), reviewing the essential characteristics LCs must possess to foster character, caring, and the development of a mature and hardy professional identity. These include:

• Committing dedicated medical school resources and time in curriculum 
• Assigning buildings or spaces that allow students to gather to form relationships (Johns Hopkins constructed a building dedicated to their learning communities) 
• Aligning espoused professional values with values that are practiced by promoting the skills of doctoring while intentionally countering the learning climate’s unsavory elements and its hidden curriculum  
• Promoting longitudinal relationships between mentors and students from beginning to end of medical school, thus enabling mentors to simultaneously support learners while holding them to high professional and academic standards
• Supporting character formation through peer mentoring programs and career decision making

With these guidelines to inspire us, and seeking the collaboration with and approval of the MCW’s Curriculum and Evaluation Committee and the Faculty Council, we intend to build LCs tailored to our institutional culture and strengths. For more, see the essay in this week’s newsletter entitled, “Learning Communities at MCW – A Vision for the Future.”  

The critical importance of continuity - Putting it all together

Throughout my career as a medical educator, I have been involved in efforts to structure close student-faculty engagement and mentoring through small group learning structures. This has included decades of teaching in small groups in an introduction to clinical medicine course for M1 and 2s and being an Internal Medicine “Firm Chief” responsible for successive cohorts of clinical clerks (M3s) while leading an Advisory College style program. These learning structures have often been profoundly satisfying for students, my colleagues, and for me as we provided meaningful educational experiences and mentoring. But none of these experiences provided students with truly longitudinal - admission to graduation - integrated coaching or mentoring. I always knew we could be doing better. I fully believe that the LC model promises a real opportunity for the continuity the current system lacks. 

There is benefit to the faculty, as well

There is no better way for faculty to develop wisdom as medical educators than by committing to a longitudinal process. I started my career focused on residency education and got to know wave after wave of trainees as individuals. These relationships showed me the common developmental trajectories and predictors of success or failure and, therefore, made me a more patient, accurate, and persistent coach. For example, I noticed that the first year residents who worked most slowly in clinic, staying later than peers to finish their patient care sessions, often grew into skillful and efficient clinicians, and were more likely to be eventually selected as chief residents. Knowing this made me more patient and kept me from “taking over” to get their patients “out the door.” I let the novices struggle a bit, confident that their patients were receiving better, more attentive care. It was personally rewarding to know that my patience helped to nurture some wonderful, future colleagues, but I only knew this because I had provided years of longitudinal mentorship. 

Medical school should be a guided experience toward a life in medicine. Learning communities offer a framework for “putting it all together,” providing solutions to many of our modern challenges in medical education while enabling the magical relationships with the student’s peers and faculty. Our goal is to create opportunities for discovery and growth because, as Professor McGonagall once noted, “We teachers are rather good at magic, you know.”

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.