Thursday, January 5, 2023

Finally Flourishing: A Long Journey to Living the Life She Was Meant to Live


 
Finally Flourishing: A Long Journey to Living the Life She Was Meant to Live   



By Adina Kalet, MD, MPH 

 
 


This week Dr. Kalet shares (with permission) what she has learned from witnessing the life journey of a longtime colleague, a physician leader, and a transgender woman ... 
 
 


“Like so many trans people I don’t remember a time that I didn’t feel I was the wrong gender,” Joanne said recently, recalling growing up in the 1950s as a quiet, withdrawn, ‘super-confused’ boy. Until one day in sixth grade,” she continued, “I went to the library and found a few books about transexual people.” The image of a prepubescent boy laying on the concrete library floor reading a book flashed in my “mind’s eye.” I could imagine the deep relief she must have felt to put words to the feelings, learning, for the first time that there were others like her out there.   
 
She described her high school-aged self as a “super-introverted, mute, ashamed,” and very lonely teenager.   
 

Joanne first told me she was a woman in 1990 when she looked very much like the man she had been for the first forty years of her life. She was still the bearded and balding man I had known as my favorite fellowship officemate and partner in a research project on physician-patient risk communication. I was initially shocked by the matter-of-fact admission and graphic description of gender dysphoria. At that point in time, I had no experience talking openly with someone who was transgender. But because of our friendship, I quelled my confused panic and listened carefully. The story, hard to hear, shot through with sadness, depression, loneliness, awkward relationships and periods of self-hatred broke my heart. At the same time, I was struck by the absolute certainty of my friend's femaleness. “I am a woman. I have been all my life.”  
 
Those next few years were a low point. While still living as a man, raising young children, and married for a second time, Joanne and her wife worked hard to hold it together. They both completed their medical training, found meaningful clinical work, and raised their family. However, after being hospitalized for suicidal depression, they knew that moving forward would require Joanne living openly and honestly as a woman.   
 
 
A familiar voice  
 
Almost twenty-five years later, I stared up at the television set in the patient lounge, drawn by the familiar voice I had not heard in a long while.  It was October 24th, 2014, and I watched the all-too-common national news coverage of a mass shooting. The local Chief Medical Officer stood at the podium describing the teenagers in the ICU, who had suffered bullet wounds to the head delivered by a 14-year-old classmate who opened fire in the cafeteria at Marysville Pilchuck High School in a suburb north of Seattle. After describing the gruesome situation as tactfully, clinically, and calmly as possible, Dr. Joanne Roberts said, "Our community is going to mourn this for years." She went on, "I can tell you that we will all go home tonight and cry."  
 
I emailed her immediately. “I saw you. That was you, right?” (I had not seen her for years), “You were so beautiful. What a great communicator, leader, and public physician,” I continued to gush. She politely confirmed this was her and thanked me for the compliments. I realized too late that my comments on her physical beauty and poise could have seemed rather sexist given that she was clearly doing her job expertly as a senior, physician leader. But to be honest, my clumsiness resulted from the powerful relief I felt to see her looking so confident and relaxed in her own personal and professional identity and, truthfully, I was thankful that she was alive.   
 
 
The gift of being “Trans” 
 
Joanne is retired now, living a peaceful life as a single woman surrounded by many close friends. There were hard times after her transition. She and her wife divorced. She remains close with her children who have struggled from time to time with their “dad’s” gender transition but have moved on as she has. 
 
Her three careers, first as a journalist, then a practicing palliative care physician and, finally, her six years as Chief Medical Officer at a hospital in Washington State, have given her many opportunities to consider issues related to gender and work. Reflection, reading, and talking with others have made her wise.  
 
“In my career, it was a gift to be trans, to have been socialized as a boy, and to live as a woman was a gift,” she shared during a recent conversation.  “… after the shooting, for instance… leading as a woman but having the male socialization, allowed me to act with confidence (real or false), …and be strong with the press, families, and law enforcement.” She reflected on how the complex alchemy of her gender as well as her professional journey enabled her to serve the community, helping them face the horrific moment, “…having been a journalist, …. I trust the media; they want to get the news out to the community. It was easy for me to do.”  
 
And finally, she attributes being calm in a crisis, seeing opportunity in bad times, and listening more than talking, to her unique experience of being socialized as a boy and living as a woman. While she readily describes blatant discrimination, she finds ways to empathize with all perspectives and points of view.  
 
Her leadership skills were honed by the many surprises of her gender journey. “One of the biggest shocks of my transition was that my biggest supporters were my conservative friends,” she says, noting the irony. It turned out that the people with whom she had already had a relationship found it much easier to accept her as Joanne. “It is so easy to hate groups and hard to hate individuals,” she notes, “…knowing this has made me a much better leader…you inspire, one conversation at a time.”  
 
 
The depression is cured 
 
Joanne had always wanted to become a physician. In the 1980s, though, despite having finally found a therapist and physician willing to help with the transition using gender-affirming hormone therapy, and even though planning to fully transition surgically and live as a feminine woman, Joanne stopped the transition because many medical schools considered transsexuality a mental illness incompatible with being a physician. This was a fraught, nearly unbearable tradeoff.  
 
Eventually, she was able to transition. “The sadness is gone, it never gets dark, I haven’t had an episode of depression since transition.” The emotionality she gained being able to live as a woman, attributed both to female hormones and the experience of being treated by others as a woman, greatly enhanced her capacity to practice palliative care medicine. Although Joanne is not a highly vocal advocate for the “queer community,” she does supportive work through one-on-one mentoring. “I just want to fit in as a woman doctor. No need for advocacy…” Toward the end of her administrative career, there was no explicit discussion with her bosses about transition. “A lot of people know, and a lot don’t,” she reflected with a verbal shrug. This is what acceptance sounds like.  
 
 
We have work to do…  
 
Less than 1% of physicians and matriculating medical students identify as Transgender or Non-Binary (TGNB). Most practicing physicians have persistent gaps in their knowledge about even the most mundane routine care for TGNB patients despite the increasing number of patients requiring that care.  
 
The public has become more accepting of gender diversity. A GLAAD—the world's largest Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) advocacy organization—survey from 2016 showed that nearly 12% of millennials identified as TGNB. Despite the increase in visibility and acceptance, those who identify as TGNB continue to be marginalized in their communities and vulnerable to high rates of depression, self-harm, homelessness, substance abuse, and sexually transmitted infections. Many healthcare settings continue to perpetuate intolerance by denying TGNB patients access to a clinician knowledgeable about gender-affirming care or treating sexual minorities with disrespect.  
 
As medical schools, we have a role to play in diversifying the physician workforce and ensuring that the workforce meets the needs of the communities we serve. We do this by becoming actively inclusive. We recruit students from gender minority groups, make efforts to feature TGNB students and physicians in public messaging, and encourage our current students, staff, and physicians to see themselves in the curriculum, the work, research, community engagement, and social events. We offer clinical care tailored for the LGBTQ+ community.  
 
While Joanne is delighted and envious that the world has become a much safer place for young people to explore their many identities, she hopes that this will lead to more character and caring. She worries that we are not socializing our young doctors “to have integrity, to develop wisdom.” She challenges us to remain clear about why we do this work. “I found in my leadership career when I was younger, I focused on the doctors, when I got older, I focused on patients again…we come to work to serve them…” That is what matters most.  
 


 
For further reading: 
 
https://www.aamc.org/news-insights/we-need-more-transgender-and-gender-nonbinary-doctors  
 
Westafer LM, Freiermuth CE, Lall MD, Muder SJ, Ragone EL, Jarman AF. Experiences of Transgender and Gender Expansive Physicians. JAMA New Open. 2022;5(6):e2219791. doi:10.1001/jamanetworkopen.2022.19791  
 
https://www.aamc.org/media/9641/download?attachment 
 
https://www.aafp.org/news/practice-professional-issues/20181214transgendercare.html 
 
https://www.glaad.org/publications/accelerating-acceptance-2016 
 
 

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. 
 
 
 
 
 

Monday, January 2, 2023

So, You Want to Publish Your Medical Education Paper in Academic Medicine - The @AcadMedJournal Editors Share Their Tips



So, You Want to Publish Your Medical Education Paper in Academic Medicine - The @AcadMedJournal Editors Share Their Tips


By Bruce H. Campbell, MD FACS


Dr. Campbell, who curates the blog, shares highlights of a recent podcast moderated by Toni Gallo, the Academic Medicine staff editor, with practical tips that will smooth your way into publishing in the journal ...


Happy New Year! Maybe one of your resolutions this year is to publish a MedEd article in a top-tier journal. You can do it!

To make it more likely, the editors of Academic Medicine created an Academic Medicine Podcast (12/19/2022) where the people who help decide what will get into print offer a peak behind the curtain. The episode is entitled “Writing Effectively and Navigating the Publication Process."


First of all, here are links to online medical writing resources: 



Below are tips and suggestions that each editor offers. As you prepare your manuscript, remember that folks like these editors will eventually be reading it. 


Colin West, MD, PhD (Deputy Editor, Professor of Medicine, Medical Education, and Biostatistics, Mayo Clinic) 

Three things to think about when preparing a manuscript:
  • Be clear on how a practical application of your work bridges the gap from theory to practice without overstating your findings
  • Be clear about the paper’s place in the field of study
  • Be honest and thoughtful about the paper’s limitations


Jonathan Michael Amiel, MD (Assistant Editor, Professor of Psychiatry and Senior Associate Dean for Innovation in Health Professions Education, Columbia University)

Things he hopes to see when reviewing a submission:
  • A clear demonstration of how the work helps make medical education better
  • The paper doesn’t overreach; rather it takes a “small bite” and rigorously addresses the problem


Laura E. Hirschfield, PhD (Assistant Editor, Associate Professor of Medical Education and Sociology, University of Illinois-Chicago) 

Things she looks for when reviewing a submission:
  • A clear demonstration that the authors have engaged with the foundational papers and authors in relevant fields, even if outside the traditional MedEd disciplines. 
  • A well-demonstrated link between the research question or topic and the research design 

Gustavo Patino, MD, PhD (Assistant Editor, Associate Professor of Neuroscience, Oakland University William Beaumont School of Medicine) 

Questions he asks as a reviewer:
  • Do the authors clearly articulate the research question?
  • Have they described the knowledge gap? 
  • What was the genesis of the idea? 
  • Why is it important that this question be answered? 
  • Are the research methods and study design appropriate to answer the question? 
  • In the Discussion, are the claims and takeaway points consistent with the Methods and Results? 


Dan Schumacher, MD, PhD, Med (Assistant Editor, Associate Professor, University of Cincinnati)

His advice to authors:
  • Pay attention to Lorelei Lingard’s idea of “It’s a Story, Not a Study.” Tell the reader why it’s important, what you found, and why what you found is important.
  • Rely on well-crafted research questions and matching methodologies. 
  • Write with clarity.


John H. Coverdale, MD (Associate Editor, Professor of Psychiatry and Behavioral Sciences, Baylor College of Medicine)

His advice to authors:
  • For both qualitative and quantitative research, make the Methods section crystal clear.  Explain how the design relates to the research question or hypothesis, including how it is appropriate to the question.


Mary Beth DeVilbiss (Managing editor)

What she likes to see in the visuals:
  • Exhibits, tables, figures, charts should have a clear purpose and add value.
  • Visuals that enhance and illuminate the text, but never repeat it. 


Teresa Chan, MD, MHPE (Associate editor)

How she describes the Academic Medicine "Innovation Reports": 
  • They are a first stab at a new way of doing things that builds on previous literature but then tweaks it in a novel way. Outline the problem, outline the approach, and always provide a reflective component.


Bridget O’Brien, PhD (Deputy editor, Adjunct Professor of Medicine, UCSF)

Things she suggests to authors before they submit a manuscript
  • Read through the manuscript three times before submitting. 
    • Read as an author. Make certain arguments flow and that essential details are covered. 
    • Read as a reviewer. Try to apply the manuscript review criteria you use to your own work. 
    • Read as a reader. Is it interesting? Do you skip sections? Does it make sense?
  • Then ask others to read your manuscript from these perspectives, as well. 


Tony Artino, PhD (Assistant Editor for Last Pages, Professor at the George Washington School of Medicine and Health Sciences)

Reactions he suggests you have if you are asked to “revise and resubmit”:
  • A revision request is a win, right? Don’t be discouraged! It is better to get it right before publication than after.
  • Revisions always result in a better paper. 
  • (Tongue-in-cheek) Editors and reviewers are always right. Realize that arguing only delays getting your manuscript into print. 
  • Remember that medical and health professions education is a very small world. Your work might end up in the hands of the same reviewers if you re-submit to another journal. So, be gracious.

That should get you started. Happy writing!


Bruce H. Campbell, MD, FACS, is a Professor in the Department of Otolaryngology and Communication Sciences and in the Institute for Health and Equity (Bioethics and Medical Humanities) at MCW. He is on the editorial board of the Transformational Times and a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He has published two Innovation Reports in Academic Medicine and still learned some stuff listening to and summarizing this podcast. 


Thursday, December 29, 2022

Diagnostic Reasoning – A Call for Faculty Engagement

From the August 12, 2022 issue of the Transformational Times newsletter




Diagnostic Reasoning – A Call for Faculty Engagement 


  


By Jayshil J. Patel, MD - Director of MCW's curriculum "Critical Thinking in Medicine" thread


  



Dr. Patel shares, in earnest, this call to interested clinical faculty to engage in the diagnostic reasoning curriculum.  In many ways, our patients and posterity depend on it ... 

 


As many of you know, threads will be woven into the new medical school curriculum.  The Critical Thinking in Medicine thread will be a synergistic marriage between diagnostic reasoning and evidence-based medicine which, I think, are the key constituents for deliberately practicing medicine in today’s clinical environments and setting learners on paths towards diagnostic expertise.  Over the past few years, components of the curriculum have been tried and tested in various venues throughout undergraduate and graduate medical education and many learners have embraced and incorporated the language of the diagnostic process into their medical lexicon. Some have left training equipped with skills to metacognate.   

I am thrilled the curriculum will become a staple of undergraduate medical education at the Medical College of Wisconsin, but the initial implementation and sustainability of any curriculum, let alone ours, relies on an acceptance and participation from learners and faculty.  Thus, faculty development will be crucial.    

If, at this point, you’re asking, “Well, how are you going to do that?” Don’t fret. I share your line of questioning.  My honest answer is that I don’t know.   Or rather, I haven’t figured it out yet.   

But before embarking on a journey to capacitate and train the trainers, I would like to share why I think clinical faculty members would benefit from engagement, including becoming fluent in the semantics, scientific underpinnings, and metacognitive strategies related to the diagnostic process.  Here, I outline the impact (and really benefit) for three key stakeholders. 


For the sake of patients: Reducing medical errors by teaching how to arrive at a correct diagnosis 

Clearly, the goal for many front-line specialties is to get an accurate and timely diagnosis.  Without it, management is ineffective, wasteful, and potentially harmful.  With an accurate diagnosis, management and prognosis are guided.   

A diagnostic error is defined as a “failure to develop an accurate explanation for a patient’s health problem and/or failure to communicate that explanation,” and studies of autopsies, secondary reviews, and voluntary reports suggest diagnostic errors occur in up to 15% of cases, culminating in adverse events in up to 90% of cases.  It turns out cognitive errors are by far the most common cause of diagnostic error. An analysis of 583 physician-reported diagnostic errors suggested a failure/delay in considering diagnosis, suboptimal weighing of information, or too much emphasis placed on competing diagnoses were the most common reasons for “what went wrong.”  

As a result, patients may be subject to unnecessary testing and incorrect therapies, which may subsequently lead to psychologic/physical harm, toxicity, prolonged hospitalization, financial distress, and even death. Therefore, if the primary goal during an initial undifferentiated patient encounter is to arrive at a diagnosis, shouldn’t medical education, for the sake of patient care, strive to teach learners how to arrive at a diagnosis by explicating the diagnostic process into discrete teachable components to be deliberately practiced? And in doing so, is it possible to reduce diagnostic errors?   

While I can’t cite literature, and even if the answer is “no,” I opine, from a philosophical standpoint, that there’s intrinsic value, for doctoring and the doctor-patient relationship, in better understanding the diagnostic process.  


For the sake of learners: Giving them tools to build their diagnostic expertise 

It is not uncommon for novice learners to be “full of facts.”  However, they may have a difficult time “putting it all together.”  In fact, the diagnostic process is often considered a “black box” where learners can see what goes in (the data) and what comes out (the eventual diagnosis) but may not be able to articulate (in written or verbal communication) the intermediate steps.  And in some cases, the diagnoses are often drawn from a grab bag of differential diagnoses, which are verbalized using reflexive and biologically unlinked thinking.   

Instead of just creating competent graduates, what if we aim to set learners on a path towards diagnostic expertise?  After all, and as stated earlier, nothing good happens without an accurate diagnosis.  And so, what if the learner could: 

(a) Recognize how to appropriately utilize and toggle between different systems of thinking 

(b) Recognize when their cognitive load is high 

(c) Utilize different approaches to problems (e.g., hypothetical-deductive versus inductive approach) 

(d) Acquire a template for knowledge storage, expansion, and retrieval 

(e) Learn to conduct a cognitive autopsy and scan their environment for cognitive pitfalls 

(f) Learn to calibrate their thinking for future similar but not identical cases 


It is not a stretch of the imagination, and in fact, when we launched this curriculum in the internal medicine residency program, these components were exactly what learners desired out of their training.  For learners to grasp and deliberately practice these components, they’ll need their faculty counterparts to share their understanding of the diagnostic process (or at minimum, speak the same language). 


For the sake of faculty: Creating a culture where they can share their skills 

A few years ago, before delineating the components of a diagnostic reasoning curriculum, I began with the end in mind.  Assuming resources abound, I envisioned a Center for Diagnostic Reasoning (and Evidence-Based Medicine). It would be a place where educators would encourage learners to think aloud, deliberately dissect clinical cases into aliquots, and expound systematic approaches. They would approach problems embedded in a patient context and within a consciousness of the scientific underpinnings of decision-making and evidence-based medicine, all the while reflecting and calibrating their thinking.  The Center would be magnetic, attracting educators into the logos of diagnostic reasoning, creating sustainability.   

To me, that is aspirational and exciting.  Here’s why.  Sure, for young learners, the acquired skillsets are meant to promote lifelong learning and equip them to stay on the path towards diagnostic expertise.  But for clinical faculty, the acquired skillsets provide an opportunity to illuminate their thinking and provide a window (for learners) into their mind, within a culture of democratized rounds where both learners and faculty are encouraged to say, “I don’t know,” without the worry of perceived failure.   

Faculty might be overwhelmed and say, “I just don’t have time to do this.”  I will submit to you that you (faculty) are already, some in an extemporaneous manner, reasoning; however, the addition of semantic and scientific structure may provide greater clarity for learners (and yourself).   

Importantly, such a culture would enable the expression of virtues such as courage, prudence, empathy, grace, and humility.  For example, it takes courage and humility to say, “I don’t know.”  The manifestation of these virtues is central for the success of the hidden curriculum, which has far-reaching implications, perhaps more than the exposed curriculum.  And an explicated awareness of an individual’s thinking may be the key in accruing tacit knowledge.   

After all, it was Aristotle who said, Knowing yourself is the beginning of all wisdom. 


Jayshil J. Patel, MD, is an Associate Professor of Medicine in the Department of Medicine at MCW.  He is on the Learning Environment Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and the Critical Thinking in Medicine Thread Director at MCW. 

Monday, December 26, 2022

Medical Education Matters podcast


Medical Education Matters podcast


Join Kern Institute hosts Michael Braun, Anita Bublik-Anderson, Jeff Amundson, and Herodotos Ellinas as they explore MedEd topics with innovative and distinguished thought-leaders.



Listen on Boomplay, Amazon Music, Apple Podcasts, or wherever you find and stream your podcasts.