If You had a Blank Slate, How Would You Integrate Narrative into Medical Education?

From the 6/18/2021 newsletter

Three Questions for Dr. Deepthiman Gowda

If You had a Blank Slate, How Would You Integrate Narrative into Medical Education?

Deepthiman Gowda, MD MPH MS, is a nationally recognized expert on Narrative Medicine and the founding Assistant Dean for Medical Education at the newly opened Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena CA. He spoke to Transformational Times editor, Bruce Campbell …

Transformational Times: In what ways is narrative integrated into the curriculum at the Kaiser Permanente Bernard J. Tyson School of Medicine? 

Dr. Gowda: The School of Medicine's curriculum was intentionally built on the three co-equal pillars of the Biomedical, Clinical, and Health Systems Sciences. By emphasizing the value of deep dives into health systems along with the other disciplines, students discover that organ dysfunction, illness, and suffering always occur within social and societal contexts, and that nuanced and effective “doctor-patient relationships” require students to understand and address often obscure, external forces. Through our “spiral” model of learning, students revisit these key areas and concepts repeatedly and with increasing sophistication throughout the four years. 

In addition, we identified core values we consider essential for meaningful participation in high-functioning healthcare and turned these into four reappearing curricular “threads.” These are: 

• Equity, Inclusion, and Diversity
• Health Promotion
• Interprofessional Collaboration 
• Advocacy and Leadership

Narrative Medicine and its pedagogical cousins fit nicely within this curricular approach.  For example, patients are often powerfully affected by the social determinants of health and experience their illnesses and healthcare interactions within larger narrative frameworks. These moments provide wonderful opportunities for our students to explore and respond to stories. On a personal level, providers benefit when they have guided, protected time to investigate their own narratives. Finally, interprofessional teams and interpersonal relationships function better when people understand each other’s stories. 

To enable these moments, we built many opportunities for narrative into our curriculum. We worked with the foundational scientists and clinicians to provide narrative opportunities at “moments of attention,” such as with cadaver dissection, pelvic and breast exam sessions, and challenging experiences. Over the four years, each student participates in regular REACH sessions (Reflection, Education, Assessment, Coaching, Health and Well-Being), that occur in one-week blocks, four times each in Years One and Two and three time each in Years Three and Four. REACH incorporates dedicated time to explore health, well-being, and resilience skills. Students participate in close reading, writing-to-a-prompt, and conversation, facilitated by trained faculty mentors who remain with the same groups of six students throughout the four years. The sessions also include goal setting, professional identity formation activities, and the creation of critical reflective essays. 

Transformational Times: How have the students taken to this emphasis on narrative in the curriculum? 

Dr. Gowda: Students these days expect curricula to address health systems issues in ways that were not explored in the past. There was great local and national engagement around the Black Lives Matter movement and how implicit bias is manifest in medicine. Our school is small, only about fifty students per class, but the learners are enthusiastic about narrative opportunities. About one-quarter are part of our Medical Humanities Interest Group, for example. The M2s will soon head to one of the local art museums. 

Student-led initiatives have been key. For example, the students organized StoryTime, a monthly storytelling event that is much like The Moth. Each event includes volunteer student, staff, and faculty storytellers and is built around a theme, such as Solidarity, Community, or Mental Health. These events provide a glue for our community. 

Transformational Times: What barriers are there to incorporating narrative meaningfully into the curriculum?

Dr. Gowda: Well, first of all, it is relatively simple to bring narrative to topics such as well-being, professional identity formation, and diversity & inclusion. Students understand the inherent value of reflecting on - and learning from - their own experiences and struggles. For these types of narrative experiences, they engage easily. 

Other areas of study can be more challenging. Employing narrative techniques to unwrap broader issues within health systems science are also valuable but can be difficult, particularly when trying to make sense of large, amorphous structures and bureaucracies. Finding ways to integrate narrative into foundational sciences can be the most difficult, requiring commitment and engagement by both faculty and students. But it can be done. 

All of us in the field struggle with metrics. In other words, how do we demonstrate the value of narrative in the curriculum? There are rubrics for scoring reflective activities, but we don’t always know if they are measuring what we think they are. We also worry that if students believe they are being “graded” on their reflections, that might suck the joy out of the process. Reflection fatigue is real, and students are smart enough to “write to the test,” even with reflective essays. 

We need to understand the students’ growth along the spectrum - as my colleague at Columbia University, Maura Spiegel, describes - between “thin” and “thick” narratives. In this sense, growth occurs when students demonstrate shifts from stories that focus on a single aspect of identity to stories that reflect multiple points of view and enriched contexts. The ability to create these “thickened narratives” might be important in understanding our learners’ narrative progress and competence. 

As they graduate, we need to make certain that our efforts have helped them become compassionate, team-based, and resilient physicians who possess narrative humility. We believe narrative is part of that, but we are still deciding how best to understand and measure progress in a competency-based system.

The transformation of medical education is a difficult but necessary challenge. I have been here at Kaiser Permanente for two years and have never worked harder in my career. It is a huge, exciting task and there is much left to do. 

 

Deepthiman Gowda, MD MPH MS, is the Assistant Dean for Medical Education and Associate Professor of Medicine at the Kaiser Permanente Bernard J. Tyson School of Medicine. He also serves at the Director of Clinical Practice of the Columbia University Irving Medical Center Division of Narrative Medicine. 

Painting: Dreaming of Home

 From the 6/11/2021 newsletter

Dreaming of Home

Kathleen Monahan, DO 

Kathleen Monahan, DO is a chief resident in the Department of Medicine at MCW.

Remember your residency family

 From the 6/11/2021 newsletter

Guest Director's Column

Remember your residency family

  

 Alicia Pilarski, DO

Kathlyn E. Fletcher, MD MA

 

 Doctors Alicia Pilarski and Kathlyn Fletcher share with today’s residents how their own experiences during residency led to lifelong, supportive, and important relationships.

  

From Dr. Fletcher:

 June is a time filled with so much nostalgia and excitement.  There are so many endings in June.  But of course, endings almost always make room for beginnings. This weekend, I (KF) had a Zoom call with members of the graduating class of 1996 from the University of Chicago’s Pritzker School of Medicine.  How can it have been twenty-five years since I graduated?  But that ending made way for the beginning of my residency which would ultimately become the most formative years of my professional life.  

I remember snippets of my own intern orientation week. In one particular memory, I was sitting on the 7^th floor of the hospital in the Internal Medicine residents’ respite area.  I was in the room that I would go to daily for three next years for morning report.  On that day, I looked around at my class of twenty-five interns, eight of whom had graduated from medical school with me and four of whom were my closest friends of the past four years.  We were doing an ice breaker meant to help us get to know each other, and I thought to myself, “Why am I doing this?  I already have plenty of friends in this program.”  Clearly, I had a lot to learn about the village needed to get me through residency.

Those four people remained close friends throughout residency and beyond; in fact, two of them were at my 50^th birthday party last year.  However, many of the others profoundly influenced me as well.  To call those who walk beside you through residency “friends” seems to be a gross underrepresentation of the role they play.  Co-residents are very much like siblings.  They are part of the daily rhythm of life.  They also bear witness to extraordinarily difficult moments, days, weeks.  My own co-residents ate ice cream with me when I needed it even when they didn’t (thanks Reggie!), patiently double checked my calculation of the rate of hypertonic saline for an obtunded hyponatremic patient in the ICU (thanks Jeff!), and cried with me for patient and other losses during those three years (thanks Erin!).  They debriefed, advised, bolstered, and encouraged.  They were my family.

 

From Dr. Pilarski:

 I (AP) had an incredibly similar experience to Dr. Fletcher during my time in residency. The highest highs and the lowest lows were shared with my seven other Emergency Medicine (EM) residents. Getting my first solo intubation during a code on the floor and celebrating with a margarita that night (thanks, Peter!), late nights in the Trauma ICU trying to keep our sickest patients alive (thanks, Troy!), and experiencing my first medical error and having my co-chief there to help support me through it (thank you, Josh!).

One of my fondest memory was when we created a calendar of photos that we gifted to our faculty and the ED nurses upon graduation. Clearly, we believed our faculty and nurses would always remember us as the “best” EM residency class, and so we felt it was our responsibility to remind them of that fact for at least the next year. We staged photos in various locations throughout the hospital and around town, many of which resulted in hysterical situations and additional photos that were deemed “too inappropriate” for the final product. At the end of the day, our faces hurt from smiling and laughing so hard. But then it became very real that our time together was ending, and in a few short days we would be spread out across the country in new emergency departments. I tried to manage the excitement about the next chapter in my career with the immense sadness I was feeling from being separated from my residency family that I had formed such a unique and special bond with over the past three years. I worried that the bond we had created would be lost to distance, new colleagues, busy schedules, or elapsed time. But I knew it was time to move on for all of us. 

We stayed in touch for the first year via text and then, slowly, our chats became less frequent. It was bound to happen, right? But then, COVID hit. And on March 16, 2020, our first group text in several years started that bond all over again: “Checking in with all of you. We are just starting to get hit with COVID. Thinking of all of you and hope you are all staying healthy.” What followed were numerous texts about our fears and anxieties, what each of our respective EDs and hospital systems were doing, what PPE we had, how we would decontaminate after a shift, how we planned to keep our families safe, and what we knew about this novel virus. And then we shared pictures of our kids, dogs, ourselves in N95s and CAPRs, and other funny pictures from when we were in residency (including some from that calendar we made!). And those texts continued through the year and into this year. They are now more focused on celebratory messages and pictures of things like vacations and group photos with friends.

We had gone through another immensely stressful, challenging, and formative phase of our lives again. What I came to realize was that distance, new jobs, busy lives and time did not break that bond. It was always there this whole time, and it was stronger than I could have ever imagined.

 

In this issue of the Transformational Times, we hear from three graduating residents who tell their stories of the formative experiences of residency, what they learned and what they hope to carry forward.  Like all of us who persevered through residency (or another professional equivalent), they had personal journeys marked by small and big moments.  We also hear from Dr. Ken Simons, who leads the GME enterprise at Medical College of Wisconsin Affiliated Hospitals.  He offers a poignant reflection on the last sixteen months and how that time has shaped the worldviews of all of us, especially the residents.  Finally, Dr. Eric Holmboe, from the Accreditation Council of Graduate Medical Education, offers additional insight into what to carry forward from residency.  There is even a piece of original artwork for you to contemplate.  We hope that you enjoy it!

To all the graduating residents across MCWAH, we are incredibly grateful for your work during residency.  You have healed patients, listened to families, taught students, comforted each other, and grown personally and professionally.  Whether you believe it or not, you are ready for this ending and the beginning that follows it.  Remember your residency family and lean on them when you need to.  Know that many people are proud of you and believe in you.  We can’t wait to see how you move our profession toward the ideal we all know is possible.   

 

Alicia Pilarski, DO is an Associate Professor of Emergency Medicine, Associate Chief Medical Officer of Froedtert Hospital, Co-Pillar Director for Kern Institute GME Pillar, Co-Medical Director for the F&MCW “Supporting our Staff” Peer Support Program.

 

Kathlyn E. Fletcher, MD MA is a Professor and residency program director in the Department of Medicine at MCW. She is the co-Director of the Graduate Medical Education Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

 

Words of gratitude, encouragement and strength from the Senior Associate Dean for Graduate Medical Education

 Freom the 6/11/2021 newsletter

Perspective/Opinion

 

Words of gratitude, encouragement and strength from the Senior Associate Dean for Graduate Medical Education

Kenneth B. Simons, MD

 

Dr. Simons, MCWAH Executive Director & DIO, MCW Senior Associate Dean for Graduate Medical Education and Accreditation, offers this message of congratulations and best wishes to all of the residency and fellowship graduates, reminding them that, while their knowledge and skills are important, it is their humanity, compassion, and caring that their patients and families will remember …

 

The journey of a thousand miles begins with one step.

Lao Tzu

 

The journey of becoming a physician is a difficult one; quite understandable given the importance of what the responsibilities are. Thus, completion of the residency or fellowship training portion of this journey in “normal” times is a remarkable achievement. In extraordinary times such as this, it is a feat of incalculable proportions. You, the 2021 graduates of our 98 ACGME accredited programs along with our non-accredited GME programs have been tested like no other prior graduates. The COVID-19 pandemic was your crucible and pushed you in every possible way. Professionally, while your didactic education became virtual, your responsibilities to be physically present to care for patients never did, other than some telemedicine encounters. You wore your PPE as battle armor and you came to work every day to do what you were born to do; care for the sick who required your expertise and more importantly, use your compassion as you learned and practiced your craft under the supervision of faculty. Some of you in fulfilling your responsibilities to patients actually developed the disease, and we are all very grateful that you survived in contradistinction to the 597,000+ dead in the US and 3,730,000+ worldwide.  And to your great credit and remarkably, more than 95% of you received one of the vaccines, demonstrating to your patients and the world that science is real and that it matters.

 

Beyond having to deal with a viral pandemic, something that hadn’t happened in more than 100 years, you also had to deal with our country’s latest and critical reckoning with health care inequities and systemic racism. America’s shameful legacy of slavery and the institutionalization of racist behavior was placed on international display as a result of the murder of George Floyd which fortunately, was filmed by a brave 17 year old woman, assisted by others who watched and confronted the officers who forsook their oath to protect and serve, something you never have and would never do, given each of you took an oath to care for all who come to you in need of your expertise. Mr. Floyd was not the only black person who was killed or maimed this past year as a result of excessive force by police and racist thugs and it is incumbent upon us to remember all of them. In addition, you witnessed a rise in violence against our Pan-Asian community as a result of the pandemic and the hateful, ignorant rhetoric spewed by some “leaders.” Through it all, you did the right thing for patients, your communities and yourselves. You participated in peaceful demonstrations, you knelt for nearly nine minutes, you wore pins that said Black Lives Matter and others with rainbows, demonstrating to everyone that you cared about your fellow human beings in a committed, real way and that diversity, equity and inclusion aren’t just words in a mission statement, but words to be lived by in a visible, tangible way, each and every day.  As you leave here, it is incumbent on you to continue making society healthier for all, better for all and to eliminate racism in all its forms. 

 

The word doctor comes from the Latin docere and means “to teach.” Throughout your tenure here, you taught medical and other students, your peers, the staff and the faculty that actions do speak louder than words; all while reading about your patients and their conditions to enhance your knowledge for the benefit of your future patients. And as impressive as all of this is, you accomplished this while also caring for your own families and other loved ones, and as such, they clearly share this august accomplishment with you. In your heart you know better than anyone that without them and their support, this accomplishment would not be as sweet, nor would it have been possible. Their assistance, encouragement and unconditional love during this challenging time was critical to your achievement. They, along with your many teachers and mentors throughout the years, coupled with your own efforts, brought you to this moment and they will always be with you, either in spirit or in reality.

 

So, years from now when you look back on your time in training and reflect on what you did during one of the most difficult times in medical history and that of our country, remember that you stood tall and did far more than you probably thought was even possible. Your legacy in MCWAH is secure and represented by the following two stories: Two upper level housestaff volunteered to form a COVID-19 intubation team to “protect our older faculty and younger, less experienced colleagues” and by a mother, a first year resident, who said “while it will be a hardship to leave my young child for a month, it’s nice to go to a place where I will be needed and can make a difference.”

 

You, the graduating housestaff, are inspiring, and you are going to be amazing doctors to whom your patients will look for assistance during what can easily be considered some of the most trying times in their lives: when they are dealing with and overcoming illness. Always remember that while your knowledge and skills are important, it is your humanity, compassion and caring that your patients and their families will remember during those times. It is now time for you to practice independent of supervision and take the next steps on your journey. Godspeed and know that you are ready and we are with you always. Remember, “Your journey never ends. Life has a way of changing things in incredible ways.” Alexander Volkov

 

Best always,

 

 

Kenneth B. Simons, MD

 

Dr. Simons is the Executive Director & DIO, MCWAH, Inc. and the Senior Associate Dean for GME and Accreditation, MCW.  He is also Professor of Ophthalmology and Pathology (tenure) at MCW.