The Experience That Changed My Perspective on Everything

From the 6/11/2021 newsletter

Perspective/Opinion

The Experience That Changed My Perspective on Everything

Kaitlin Kirkpatrick, MD

Dr. Kirkpatrick writes movingly on how experiencing her own illness had a profound influence on how she sees others who suffer...

Four years of medical school, 2.5 years of residency under my belt, I entered spring of my 3rd year of residency as a confident and competent senior resident. I knew how to manage my inpatient team: which tests and procedures we needed to order right away, how to triage pages from nurses, and how much time we could allot to each patient we rounded - the essentials that kept us efficient and on top of our workload. Then one day I got sick, and everything changed.

Catching a variety of illnesses in residency seems to just come as part of the job, especially when you spend time in the pediatric emergency room. I remember when norovirus wiped out my team intern year, and I’ve had so many mild URIs over the years that I’ve lost count. That’s why when I started feeling ill one weekend, I felt guilty calling in the jeopardy resident but figured it would be quick. What I didn’t expect was to be barely conscious in the Moorland Reserve emergency room with blood pressures in the 70s/40s and the ER staff arguing about whether to start pressors now or let the ambulance take me straight to Froedtert’s surgical ICU.

The following days were a blur of overwhelming exhaustion, confusion, and fear, especially for my husband hearing words like “portal venous gas” and “likely sepsis” with little explanation of what it all meant. My memories come more in flashes. I recall crying when they told me they wanted to get an arterial blood gas. I remembered patients complaining of how much they hurt, but that had never stopped me from ordering them in the past. I've ordered so many nasogastric (NG) tubes during residency, that when they warned me that they were placing one on me, I assumed, “Okay, this can’t be that bad.” I was wrong. I was so tangled up in wires from my central line, a separate peripheral IV, telemetry wires, and a Foley. All of that was tolerable. 

The NG tube was not.

I suddenly became the patient that I used to dread. The surgical nurse practitioner came by and told me that we’d probably be able to take the NG tube out that day, but she had to run it past the attending first (a line I’ve used many times with my patients). Waiting for the attending doesn’t feel as easy when you’re the patient. Finally after telling the nurse I’d pull it out myself, she helped me remove it. For the first time that admission, I started to feel like things might be getting better. It was still another couple of days in the ICU consisting of sleep, echocardiograms, CT scans, more sleep, antibiotics/antifungals, the occasional pathetic walk around the unit, and more sleep before I finally got to transfer to the acute care floor. A few days after that I was able to discharge home, but it wasn’t until we picked up my 9-month-old son from his grandparents and made it back to the safety of our own home that I finally cried and began to process everything I endured. 

I still know the tests and procedures to order on my own patients, but now I’ve started to ask a little more often, “How badly do I need this test?” When my patient has something like an NG tube, I am much more conscientious about when it can come out. Will poking this patient for a lab really change what I’m doing or am I just ordering these tests out of routine? If the nurse is paging me, I try to be quicker to respond unless I truly am in the middle of an emergency. I understand now more how much they really are trying to advocate for their patients. Even now, I spend just a little more time at a patient’s bedside talking to them, to their family, trying to make a little bit of their hospitalization better, because I remember what it was like to be on the other side. 

I’m not the same physician I was prior to this experience, but I’d like to think that I am better than I was before. I do more critical thinking about testing and procedures, I try to be a more involved team player with my support staff. And most importantly, I’m more empathetic towards my patients and their families. I also try to make more time to take care of myself. Sometimes the mental healing takes longer than the physical. I’m lucky my husband and my residency program always supported me in finding the psychological support I needed to recover. I can’t say I’m thankful for having gone through it all, but I am grateful for the doctor it helped me become - the doctor I will continue to be as I graduate from residency this year and begin the next phase of my career. 

Kaitlin Kirkpatrick, MD, is a PGY4 Internal Medicine-Pediatrics resident.

Welcoming the Kern Institute’s Inaugural Medical Education Transformation Collaboratories!

 From the 6/4/2021 newsletter

Director's Corner

Welcoming the Kern Institute’s Inaugural Medical Education Transformation Collaboratories! 

Adina Kalet, MD, MPH 

The word “collaboratory,” a mash-up between “collaboration” and “laboratory,” was originally coined in the 1980’s with the ascendence of the internet and emergence of collaboration software (think Google docs). Cogburn (2003) who states that “a collaboratory … is a new networked organizational form that also includes social processes; collaboration techniques; formal and informal communication; and agreement on norms, principles, values, and rules.” It has come to describe an open space, creative process where a group of people work together - in real-time, often virtually - to generate solutions to complex problems. And there is no doubt that transforming medical education is one such “thorny problem” deserving this kind of focused attention …

The Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education at the Medical College of Wisconsin is proud to announce our first cohort of Medical Education Transformation Collaboratories. These seven groups listed below represent cross-institutional, multi- and inter-disciplinary, multiple stakeholder communities of practice that will work together in a sustained effort around a shared project to transform medical education by engaging in both innovation and scholarship. Each of the funded collaboratories was selected after a highly competitive merit review process (See below for the list of reviewers). This group includes forty-five individuals from an array of academic disciplines plus a community representative, affiliated with twenty-two health professions education institutions, including medical and nursing schools in many regions of the United States and Canada. Four of the seven include an MCW partner! Members of these collaboratories will meet together in July 2021 and Winter 2022, as well as having regular subgroups meet throughout the year to share progress and resources, address challenges, plan for knowledge dissemination, and learn together. We will implement a process to determine eligibility for a second year of funding. They will update their progress regularly in the Transformational Times.

I learned early on that true collaboration is very challenging and worth doing

In 2005, I found myself co-principal investigator on a medical education research project funded by the National Science Foundation. By this time, I had already participated in a number of large scale multi-institutional collaborations among (only) medical educators, and I thought I knew what it meant to effectively collaborate. Boy, was I was wrong! My co-PIs on the WISE MD project, included a world class computer scientist (CS) from West Germany, an educational psychologist who led a lab exploring the use of technology in K-12 STEM education who was born in East Germany. Our project was focused on building a distributed network information system (with technology originally designed for the pornography “industry”) which would enable both delivering and studying the impact of a rich multimedia core surgery clerkship curriculum. Our team included CS and education graduate students from Korea, Turkey, and Israel, a MD/PhD in Medical Education from Canada, two fine artists (one Russian and one from New Jersey with a culture all its own), a British qualitative informatician (yes, that is a thing), a mostly US-based team of videographers and multimedia editors, surgery clerkship directors from seven medical schools from across the country, and advisory groups from the American College of Surgeons and the Association of Surgical Educators. 

Leading this project required that I danced as fast as I could. Although we were all fluent in English (at least the non-US born members were!), when we began, our team did not share a common scientific language (e.g., clinical surgery, medical education, computer science, learning science, technology, fine art, video production) or a common set of assumptions about what constituted education, learning, or successful research. We had widely divergent approaches to knowledge management (e.g., What do we name and where do we keep our shared documents? What are those funny formulas and code snippets? How the heck do we write about our work together?), or what it meant to do research and disseminate it (e.g., Do we meet in person? Teleconference? Email? IM? Use Slack? Write blogs, proceedings, or papers?). Oh, and we didn’t all sit in the same location. Some of us were one mile apart (which in Manhattan, could mean an hour commute), or across the country or overseas.

It was a remote Tower of Babel for the first year. It was also endlessly fascinating - interpersonally, culturally, politically, intellectually. Technology helped, but it was our commitment to spending the time to get to know each other as people, to have the patience to listen to all points of view before making decisions, define terms, write glossaries, and to tryand-fail, try-and-fail, and try-and-fail, that made this the most impactful project any of us have ever worked on. 

Despite going well down many blind alleys and surviving a good number of tense culture clashes, we figured it out. We had to, because we were accountable to our funders and each other to do innovative and creative work. In the end and as a team, we successfully garnered R01 funding from the NIH to conduct a randomized controlled trial to study WISE MD outcomes (WISE Trial). And consequently, the WISE MD program was one of the first rigorously studied, widely distributed digital medical education curricula in the world. This sparked building of many such curricula in wide use today. Whew! As they say, what doesn’t kill you makes you stronger. 

What it will take to transform medical education

Despite knowing how very difficult it was, the WISE Trial experience is why I believe that the key to transforming medical education will require a large number of intentional, and savvy collaborations across diverse groups of stake holders. While it is much easier to work with a group of like-minded people with whom you share a culture, background, and values, these small-scale projects are less likely to produce sustained meaningful change. It is just true. When you step far outside your comfort zone the risks are higher but so are the potential benefits.

The specific outcomes of the WISE Trial (which was a negative randomized controlled trial, by the way) were diverse and unexpected. We demonstrated the importance of context (Ellaway) and the difficulty conducing intra-institutional work (Sarpel). In addition, there were many sustained research, innovation and business collaborations that resulted. But, most important to me, were the close, life-long, intellectually stimulating relationships across a wide range of academic disciplines, world views, and working styles that developed. These colleagues keep me honest and brave enough to question assumptions. I learned to keep trying and failing until something wonderful happens. 

Why we need to transform medical education now 

We must take advantage of the available pedagogical principles and educational research to move the training of physicians from a 20th century to a 21st century model. Technology is irrevocably altering the practice of medicine. Artificial intelligence and robotics are disruptive. It is essential that our trainees need to engage with the technology and know both how to think and what to think about. 

In the US, despite having the most expensive health care system in the world, our health outcomes are poor. There is an unconscionable maldistribution of physicians - both in specially and geography - such that a great many of our citizens do not have access to or are able to afford basic medical care. There are many problems to address that we are not well prepared to address at this moment. It is time to pivot. We need to do this together, in collaboration. 

Collaboratory Titles, Descriptions, and Members

Here are the seven newly launched collaboratories:

Laying a Strong Foundation: How Do Medical Schools with and without Learning Communities Promote Character, Caring and Professional Identity Formation During Students' Pre-Clerkship Years? 

Team Lead: David Hatem, University of Massachusetts Medical School

Description: 
This project will “develop a greater understanding of the phenomenon of PIF as experienced by medical students early in their medical education” by including the voice of medical students and the role that organizational frameworks play in promoting PIF. 

Collaborators: 
Jennifer Quaintance, University of Missouri Kansas City
Marjorie Dean Wenrich, University of Washington
William Agbor-Baiyee, Chicago Medical School at Rosalind Franklin University
Mrinalini Kulkarni-Date, University of Texas/ Austin-Dell Medical School
Megan A McVancel, University of Iowa/Carver College of Medicine
Alejandro Moreno, University of Texas/ Austin-Dell Medical School
Thuy Lam Ngo, Johns Hopkins School of Medicine
Kurt Pfeifer, Medical College of Wisconsin
Elizabeth Yakes, Vanderbilt University School of Medicine

The Data Science of Character 

Team Lead: Debra Klamen, Southern Illinois University School of Medicine

Description: 
This project will establish a multifaceted, multi-level definition of character, a corresponding collection of behavioral measures of character, and draft a set of recommendations for cultivating character at the at the individual and institutional level.

Collaborators: 
Anna Cianciolo, Southern Illinois University School of Medicine
Collin Hitt, Southern Illinois University School of Medicine
John Mellinger, Southern Illinois University School of Medicine
Bridget O'Brien, UCSF
Robert Treat, Medical College of Wisconsin
Crystal Wilson, Southern Illinois University School of Medicine

Educating Educators to Serve as Change Agents through Professional Identify Formation 

Team Lead: William T Branch, Jr, Emory University

Description:
This project will create, implement, and evaluate a new longitudinal curriculum for interprofessional healthcare leaders based on five content areas associated with higher-order professional development and education leadership among faculty participants.

Collaborators:
Corrine Abraham, Emory University
Richard M. Frankel, Indiana University School of Medicine
Debra K Litzelman, Indiana University School of Medicine
Calvin Chou, University of California, San Francisco
Elizabeth A Rider, Harvard Medical School

NYU-UCSF Collaboratory to Advance URiM Faculty in Academic Medicine 

Team Lead: Richard E. Greene, NYU Grossman School of Medicine

Description:
This project will examine the impact and outcomes of a Faculty Leadership Development Program (FLDP) designed for junior faculty who are underrepresented in medicine (URiM) developed using a novel theory-based framework.

Collaborators:
Sarah Schaeffer, UCSF School of Medicine
Tiffany E. Cook, NYU Grossman School of Medicine
Joseph Ravenell, NYU Grossman School of Medicine
Walter Parrish, NYU Grossman School of Medicine
Sonille Liburd, NYU Grossman School of Medicine

Characterizing Cultures of Mattering in Health Care Education 

Team Lead: Julie Haizlip, UVA School of Nursing & Medicine

Description:
This project will learn how nursing and medical students matter, defined as adding value and feeling valued, in their learning environments. 

Collaborators: 
Natalie May, UVA School of Nursing & Medicine
Karen Marcdante, Medical College of Wisconsin
Caitlin Patten, Medical College of Wisconsin
Rana Higgins, Medical College of Wisconsin

Creating a Collaboratory to Map Medical Education’s Blind Spots 

Team Lead: Sean Tackett, Johns Hopkins Bayview Medical Center

Description:
This project will help the medical education community see its blind spots with clarity, identify structures and barriers that prevent progress, and define strategies to address blind spots.

Collaborators:
Scott Wright, Johns Hopkins Bayview Medical Center
Cynthia Whitehead, Wilson Centre
Yvonne Steinert, McGill
Darcy Reed, Mayo

A Model for Integration of Clinical Performance Measures into Residency Training Programs (Policy Paper) 

Team Lead: Abby Schuh, Medical College of Wisconsin

Description:
This project will address policy related to the challenges of linking educational innovations with clinical outcome measures through the use of meaningful clinical performance measures, harnessing the potential of the electronic health records to capture these data, as well as bridging the silos of medical education and health care quality improvement.

Collaborators:
Dan Schumacher, Cincinnati Children's Hospital Medical Center
Alina Smirnova, University of Calgary
Saad Chahine, Queens University

For further reading:

Ellaway, R. H., Pusic, M., Yavner, S., & Kalet, A. L. (2014). Context matters: emergent variability in an effectiveness trial of online teaching modules. Medical Education, 48(4), 386-396.

Sarpel, U., Hopkins, M., More, F., Yavner, S., Pusic, M., Nick, M., ... & Kalet, A. (2013). Medical students as human subjects in educational research. Medical Education Online, 18(1), 19524.

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.

The Healer’s Art Course: Preparing M1 Students for What Lies Ahead

From the 6/4/2021 newsletter

Perspective/Opinion

The Healer’s Art Course: Preparing M1 Students for What Lies Ahead

Julie Owen, MD

Dr. Owen, who co-directs MCW’s M1 Healer’s Art Course, describes the value of having students address wholeness, grief and loss, awe and mystery, and service as a way of life early in their medical school careers. She also talks about how important it was when an empathetic physician “bore witness” to grief and uncertainty in her own life …

“The core tasks… are helping the patient acknowledge, bear, and put into perspective feelings and painful life experiences.”

- Glen Gabbard, MD (Gabbard’s Treatments of Psychiatric Disorders, 2007) speaking about Elvin Semrad, MD, renowned psychiatrist at the Massachusetts Mental Health Center in Boston from 1956-1976, one of the nation’s oldest psychiatric hospitals

By the time I entered medical school, I had built an almost decade-long career as a professional actor, performing in regional musical theatre productions around the country after completing my undergraduate degrees. By the time I entered medical school, my professional identity had been firmly established as an “artist,” and transitioning to medicine precipitated a bit of an identity crisis. I happily discovered and immersed myself in the invaluable MCW Medical Humanities Program, recently described by Art Derse, MD, JD, in the Kern Institute’s Transformational Times. A prominent component of this program is the Healer’s Art elective course, introduced to MCW in 2007 by Dr. Derse and Julia Uihlein, MA.

The Healer’s Art curriculum was designed by Rachel Remen, MD, and the course was first taught at the University of California-San Francisco (UCSF) in 1992. Since 1992, it has been offered annually as a fifteen-hour elective, and its reach has expanded to over 100 medical schools across the country. It is currently offered at all three MCW campuses.

The Healer’s Art curriculum was designed as an antidote to physician (and medical student) burnout. As Bruce Campbell, MD, noted recently, a significant body of literature has demonstrated that empathy in medical students precipitously declines throughout the duration of their medical education. After medical school and training is complete, physicians not infrequently leave the practice of medicine, unable to maintain a sense of meaning, personal/professional satisfaction, and commitment to the profession. 

Topics explored during the Healer’s Art 

The topics covered in depth by the Healer’s Art course include maintaining one’s wholeness, grief and loss, awe and mystery, and service as a way of life. Faculty physicians gather with M1 students in a “Discovery Model,” process-based curriculum, in which the mutual sharing of personal experiences and beliefs create a unique professional support system and a safe space of “harmlessness” to explore these fundamental principles of life and of healing. 

One of the core principles of the course is the concept of generous listening. Our medical education teaches us to listen analytically, to ask questions that will allow us to generate a differential diagnosis. Dr. Remen emphasizes that generous listening is practiced not to diagnose, evaluate, fix, or even to understand the speaker; rather, it is the practice of listening only to know what is true for another person and to bear witness to that moment. 

As a psychiatrist, this brings to mind Dr. Semrad’s characterization of our work with patients — to acknowledge, bear, and put into perspective the (often painful) experiences of our patients. When I hear medical students remark that they feel they have little to offer patients, especially in their most vulnerable moments, I hope educational experiences like the Healer’s Art illustrate and nurture the tremendous power we all have as healers, no matter our level of training or practice, simply when we are present with the patient.

My own family’s experience with an artful healer

My husband and I recently “celebrated” the five-year anniversary of his cancer diagnosis and treatment initiation. As an M3, he was diagnosed with a large right frontal lobe tumor, a grade II-III oligodendroglioma, after he had a grand mal seizure during the last day of his surgery clerkship rotation (he fondly recalls that day as “going out with a bang”). His neurologist called us into his office during the lunch hour the day after he had his MRI, the final piece of his outpatient seizure work-up. I remember walking into Froedtert Hospital from the parking garage thinking, “This is one of those life-changing days… and I will never feel this way (read: blissfully ignorant) again.” 

During one of the moments seared into my memory, I am sitting with my husband hearing the news we feared most, and his neurologist is sitting silently with us, tears in his eyes, as we took it all in. Bearing witness. Acknowledging our pain. That moment, more than any other from that whirlwind time period, is forever imprinted in my brain; this physician showed his compassion and his humanity merely by giving us the gift of his quiet. These are the superpowers of a true healer… ones we all possess, if we have the courage to use them.

Julie Owen, MD is an Assistant Professor in the Department of Psychiatry and Behavioral Medicine at MCW. She codirects the M1 Healer’s Art course. 

The MCW Healer’s Art course runs each year over five Wednesday evenings during January through March. Faculty who would like to discuss volunteering as facilitators can contact Dr. Owen through her MCW email address. 

“Proceduralists” Do Care!

From the 6/4/2021 newsletter

Perspective/Opinion

“Proceduralists” Do Care!

Harvey Woehlck, MD - Professor, Department of Anesthesiology

Dr. Woehlck reminds us that doctors whose main task is to perform procedures can break from their molds and have fulfilling roles as caring physicians, as well …

What does a caring academic proceduralist look like in today’s modern medical environment?  

We can imagine that the modern proceduralist descended from the surgeon of ancient times.  In the second century, the expression of “laudable pus” was a common procedure which, of course, required incision.  [Excuse the digression, but laudable pus was staph-related and often survivable with incision and drainage as the only treatment, as opposed to what we now call necrotizing fasciitis, which was uniformly fatal at the time.]  Amputations were described a century earlier, where lack of anesthetics required the proceduralist to be as fast as possible. 

in that era, caring may not have been a meaningful virtue; completing the amputation – and allowing the patient to survive – was meaningful.  Unfortunately, this may have selected for what we could today call a psychopathic trait in proceduralists of the preanesthetic era.  Just how could you have empathy when the goal was to amputate as quickly as possible?  

Nitrous oxide was synthesized in 1772, but was mostly used as a party curiosity, not for procedural pain relief.  Anesthetics like ether gradually increased in use from the 1840s to the present day, but “modern” pain relief is something we would recognize only in the twentieth century.  Prior to the era of anesthetics, lay literature, newspaper accounts, and battlefront stories from numerous wars and conflicts described eager but cruel doctors sliding down the slippery slope of brutality themselves, amputating, when possible, on the most minor of injuries as if to draw the biggest possible crowd as part of a spectacle. 

Flash forward to the present.  With a history like that, what does a caring academic proceduralist look like in today’s modern medical environment?  

High-tech procedural platforms require numerous people for support.  Housekeeping, instrument processing, lab services, anesthesia services, proceduralists and assistants, nurses, technicians, and more are part of the team.  Let’s not kid ourselves. All of these people and resources need to work together. They are expensive to operate and maintain.  We need to be mindful of RVUs created, payer mix, and the effect on dollars generated, turnaround times, expense units utilized (which includes choice of drugs and equipment). You wind up with a dizzying array of competing factors.  Add to that teaching of students, residents, fellows, and it’s amazing that we’re not reduced to robotic, unemotional, protocolized efficient machines in an environment devoid of empathy focusing on getting patients in and out faster and cheaper. Without efficiency, modern infrastructure could not exist.

And then, there’s caring and the patient’s best interests.  

Many people equate a caring physician with a good bedside manner. While that is important, some might argue that caring is secondary if the patient is asleep or sedated for the most critical part of one’s procedural interaction. As an anesthesiologist, the life-or-death part of most interactions with a patient occur when the patient is unaware. Stolid efficiency might be supportive of the infrastructure that allows us to provide an optimal level of care by today’s standards, but it doesn’t end there.  

The epitome of proceduralism transcends efficiency and a low complication rate. But it differs for patients receiving their definitive procedure versus those at the beginning of their diagnostic journey.  

What about the lost patient, trying to find the mountain pass to Erewhon?  I’d argue many nontraditional opportunities exist for caring, some of which could be hard to explain.  And notice that I used the word “argue” in there.  People who know me personally know that I am frequently contrary and argue a lot.  I pride myself on being one of those “competing factors.”  

Let me exemplify:

As a proceduralist – an anesthesiologist – I recently had a patient with a mundane problem having a common procedure, and I was part of the anesthesia team.  This is what Kikuko Tsumura might call an “easy job” for me.  Or what I imagine the late economic anthropologist David Graeber might have berated as a job where any interchangeable person with minimal competence sufficed.  

But I noticed the patient had multiple co-morbidities that didn’t substantially alter anesthetic care. Those anomalies happened to fit a pattern for a diagnosis that was neither listed nor treated by any of the dozen qualified healthcare providers he had seen in the prior six months. In addition to performing the dull, boring anesthetic, I took it upon myself to arrange some screening tests for this potential undiagnosed problem that would tie together the co-morbidities into a single diagnosis and change treatment 180 degrees.  

The test came back positive for what the textbooks call a “rare disease.”  After a referral and more procedures, the patient thanked me for figuring out, and finally solving, the underlying issue that caused years of suffering and, untreated, would have taken decades off of his life.

Why didn’t others find the problem?  Did we unknowingly allow ourselves to wear the mask of tunnel vision and be compartmentalized into that mechanical state of efficiency?  Was it production pressure?  Protocols?  A nebulous bureaucratic expectation that we maintain our defined roles?  

Many opportunities existed to look the other way and perform only up to minimum acceptable standards.  Breaking from this mold is what I call caring.  I am sure nobody would have noticed the difference had I only done the minimum.  For some, caring could mean providing emotional comfort, but for others, it may mean taking the extra time to solve a problem, even if it opens the uncomfortable door of crossing boundaries of specialties or roles, or advocating for the rare and unpopular.  

Tsumura might summarize this approach by arguing that caring encompasses the dignity of work.  Or becoming more invested and engaged as the job becomes increasingly routine or trivial, extracting from context nuances that defy description.

For me, in my procedural world of the unaware, caring transcends the routine and encompasses the intangible.

For further reading:

Kikuko Tsumura. There’s No Such Thing as an Easy Job. Bloomsburg Publishing, 2020.   ISBN: 9781526622242 To find the book, click this link.

David Graeber. Bullshit Jobs: A Theory. Simon & Schuster. 2018. ISBN: 9781501143342 To find the book, click this link. 

Harvey Woehlck, MD is a Professor of in the Department of Anesthesiology at MCW. In addition to multiple educational, clinical, and administrative responsibilities, Dr. Woehlck is an accomplished concert pianist.