The Kern Institute Learns to Blow our Shofar!

From the January 13, 2023 issue of the Transformational Times

The Kern Institute Learns to Blow our Shofar!  

By Adina Kalet, MD, MPH

In this week’s Director’s Corner, Dr. Kalet describes what she learned about transformational leadership while drinking coffee on a beach overlooking the Mediterranean Sea …

 

The beginning is the most important part of the work.

-Plato

In December 2018, I traveled to Israel to meet with palliative care physician and medical educator Dr. Dafna Meitar and educational psychologist and philosopher Dr. Daniel Marom. We talked about the Mandel Leadership Institute’s Leadership in Medical Education Program, a sophisticated, unique, year-long, philosophically-framed, intensive training they were creating in Jerusalem. We spent a whole day in a café in the coastal city of Herzliya, looking out over the Mediterranean, drinking coffee, eating pita, hummus, and diced salad, and discussing medical education. Ideas flew back and forth. We shared serious ideas, stories, and jokes. We gesticulated wildly. I got a tan and furiously took notes in multiple colors. 

When there was a lull in the conversation, I asked their advice about the job opportunity I was contemplating in Milwaukee. Daniel asked solemnly, “When you take this job, what will you mean by ‘transforming medical education’?” 

I talked unintelligently for a few minutes, reciting the laundry list of things I intended to do, but the look on their faces made it clear I hadn’t answered his question. “You must develop your shofar!” he said, cutting me off. “You must articulate the why of your work before  you will be ready to decide on the what.” He assumed that I would—although I had not yet decided to—take the job. 

Soon after that conversation, I accepted the offer. 

A shofar is an ancient musical instrument made from a ram’s horn. It was used like a modern bugle to call the community together for important announcements and discussion, to proclaim important calendar events, and to note solemn occasions. In modern times, the shofar is used during the Jewish High Holidays. In my community, the shofar can be—and is—blown by any member of the community with the proper embouchure. It is considered an honor and a source of pride to be able to “blow shofar.” 

I find the sound of the shofar stirring and meaningful. It accompanies those moments during the religious services when, in community, we are contemplating past errors, seeking forgiveness, and feeling humble. In awe, we formulate our resolutions for the future. I knew that by linking my career change to the shofar, Daniel was challenging me to think deeply and then “blast a horn” to get the attention of like-minded others so we could articulate a manifesto that would transform medical education. I had no clue what that would require, but I was reassured that Daniel and Dafna would be there to accompany me.

Once I joined the Kern Institute in fall 2019, I saw that our members were very busy. They had rolled up their sleeves and were solving problems. The KI had launched a robust faculty development program (KINETIC3), a well-being curriculum for students (REACH), and the Transformational Initiatives (TI2) program. However, I sensed that our members, our community within MCW, and the community beyond our walls did not clearly understand why we were doing what we were doing. I searched for ways to dedicate time to rest from all the doing and engage in some deep thinking. 

COVID-19 changed everything, and we wrote (and we wrote...)

As they say, be careful what you wish for! In March 2020, with the pandemic on our heels,  we launched the Transformational Times and have published weekly ever since. Once a collection of quality essays built over the first year-and-a-half, we published them in Character and Caring: A Pandemic Year in Medical Education at the end of 2021. 

Now, as we have continued our work and our writing, we present our new book, Character and Caring: Medical Education Emerge From the Pandemic, which was released on  January 2nd, 2023!  See Dr. Fletcher’s essay in this issue detailing the history of our work. 

Please consider purchasing the two volume Character and Caring  set (at a special price) for your favorite health professional. This is our shofar! It is a good read. Every member of the Kern Institute is expected to write regularly. The Transformational Times and the books call us all together for the deep conversations. In addition, we are publishing contributions from an enlarging group of local and national stakeholders and fellow travelers. 

Many have heard the “blast.” We receive emails from our readers and have regular literal and virtual hallway conversations stimulated by the essays. The responses are mostly expressions of appreciation for the opportunity to hear our why; the newsletter and books allow people to know us and know our work. Readers regularly share their own stories. There has been an occasional friendly debate and rarely a pointed disagreement. We welcome it all.  

Beyond the transactional to the transformational

We have a much more to learn from Drs. Marom and Meitar. Their deep and abiding respect for educators is intoxicating. They believe that educational leaders, through their work, define and design their professional community and, therefore, are responsible for giving expression to the values that comprise what medical sociologist, Eliot Freidson, PhD, called the "soul of their profession." Their approach to leadership development is guided by a clearly articulated framework they call a “typology” made up of five interrelated levels. The typology frames everything they do to facilitate—and provides a language for ensuring—that leaders understand why we are doing what we are doing. This, in turn, greatly enhances the likelihood that these motivated and committed individuals will have an impact that goes well beyond the transactional toward the transformational. 

All the work in the Leadership in Medical Education Program is done in peer groups and supported by coaching. Through discourse, readings, and reflective writing, senior medical educators wrestle first with core philosophical ideas surrounding human health and sickness (Level 1 of the typology) followed by questions surrounding the larger aims of the education of physicians (Level two). Then, and only then, are they allowed to dive into the implications of all this for educational theory (Level 3), implementation of new educational practice (Level 4) and, finally, evaluation of outcomes of that practice to measure success (Level 5). 

For most physicians who are very action-oriented, it takes discipline not to jump into the “doing” (Level 3) too soon. But, with practice and experience, most of Meitar and Marom’s participants internalize the discipline needed to seriously engage with the philosophical questions underpinning medical education before jumping into or designing and/or implementing programs. 

 Over the past few years, as I have worked with the five medical schools in Israel (more on that another time). I have had the honor of meeting many of the nearly fifty medical educators who have completed the Mandel Institute’s Leadership in Medical Education Program. After experiencing a very old-fashioned medical education themselves, most of them light up when discussing the pleasure in having the opportunity to engage with their peers intellectually and personally through this program. They are inspired to lead the change that is needed, even though it will be difficult, even though it will be resisted, and even though resources are very limited. Many of these graduates are now moving into positions of influence in their medical schools. 

Marom and Meitar are having an impact on the future of the whole country. I continue to take notes in multiple colors and have tried to bring these renderings into our work in the Kern Institute.  

Checking in again

After a couple of years in lockdown, I recently returned to a beach café in Israel to meet with Dafna and Daniel, both of whom are now affiliate faculty of the Kern Institute. They read our Transformational Times. They are still working to lift up medical education in their country as we are in ours. We discussed how the Kern Institute’s shofar is going and shared our successes and challenges. It is my hope to bring them to Milwaukee very soon (in the warm season) to teach us a thing or two about medical education leadership. I will take them—and as many of you as can join us—to the South Shore Terrace Kitchen & Beer Garden for a campfire, some s’mores, and a view of Lake Michigan. 

Looking out over the water, we will pick up our conversations from where we left off. 

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.

Love in the Time of Medical School

From the December 30, 2022 issue of the Transformational Times

Perspective/Opinion

Love in the Time of Medical School

Nicholas Visser – MCW Class of 2023

Once a staple of the American social scene, swing dancing is a vigorous form of dance which requires exquisite rhythm and grace. Alternatively - as for my teenage self - it is a time in which a man can speak to a woman, providing he can keep left foot one and left foot two from colliding for a few minutes. I would like to think that night at a church fundraiser it was my comedic chops that proved myself worthy of a second date, but I have been assured it was how convinced I was that I did not look like a fool dancing the night away. In either case, it would be easy to say that the rest is history; however, there’s more to this story.

Finding one’s spouse in college is a story that has been told a thousand times. The joy of discovering freedom and responsibility. The winter break trips to each hometown, anxiously seeking parental approval. On some occasions, a shared career interest can add to the connection. In my case, a shared goal of medical school tested and formed it.

Surely, it was only a few months into dating that Anna and I become aware that we both intended to become physicians, but this desire did not weigh so heavily on our relationship until Fall 2018. I had graduated and elected to take a gap year, in part for the opportunity to apply in the same cycle. Anna was enjoying a thrilling senior year. We both had worked tirelessly on primary and secondary applications. But as interview invites were released, the dream of having the chance to study together in medical school was evaporating. As fall turned to winter, we had only two shared interviews and no shared acceptances.

The reality of having to choose between starting our lives together and both pursuing this career had become such a real possibility. In those moments – sharing long evenings discussing our values and priorities – I believe that the groundwork for a strong marriage was formed: listening and being open to working through any challenge together. Less than one week after one particularly moving discussion, I bought an engagement ring. Less than one week after that, we shared an acceptance to the Medical College of Wisconsin.

It is hard to say where we would be now had our cards not turned up so serendipitously, but I know that being willing to bet on our relationship and let career aspirations follow has strengthened rather than weakened us as individuals and as students. Focusing first on loving and serving one another has developed a habit of caring and hard work that benefits our patients and colleagues. As medical school gives way to the match, residency, and attending life, I know the rhythm of life may get more complicated, but I am confident I will be able to keep the beat with my till-death-do-us-dance partner by my side.

Nicholas Visser is a medical student at MCW-Milwaukee.

Editor's note: This essay, which originally appeared in the Transformational Time's Valentine's Day issue (2/11/2022), was one of the most popular of the year. 

Temperature

From the January 6, 2023 issue of the Transformational Times

Temperature

By David Nelson, PhD, MS

Temperature
36 degrees Fahrenheit.
AM? PM?
Breathe that stands out.
Feet to stand on – cold.
Concrete to stand on – cold.
It rains, and the feet on the concrete – are cold.
Head, shoulders, arms, waist, legs, wet and cold.
You are out and in need of everything.
Gratitude for those that come along to support.
Holding a sign with shaking hands from the cold.
Breathe or fog – we do not know.
AM? PM?
36 degrees Fahrenheit.







Author’s Notes

This day was memorable for all the wrong reasons. There are days in the city that are just glorious. Bluebird days with blue skies and moderate temperatures and a shining sun. Then, there are days like this one. Gray clouds, frosty-just-short-of-freezing air and rain. I do not remember exactly if the forecast predicted a day of the weather, but having been out on the streets doing outreach for many years, I thought it could be just like this all day long. I snapped a picture with my phone of the digital thermometer in the truck while stopping for a coffee up a coffee and it stood out. Only the temperature showed on the digital thermometer. For some reason I thought it might be the same temperature all day long and it turned out to be so. It was going to be a crap weather day.

A recurrent theme of the streets are shoes. Community members walk a lot. It is not unusual to for someone to walk five or six miles on a given day. On outreach, I look at a person’s feet first. The shoes tell me a lot about the person. I can also know their size and if they have feet issues by seeing how they wear their shoes out. Worn heels signify one issue, toe sticking straight up or to the side another issue and so on. The size comes from changing a lot of shoes over the years – the benefit of working in a shoe store for a season.

David Nelson, PhD MS is an Associate Professor of Family and Community Medicine at MCW. He leads many of MCW’s community engagement efforts, partnering with public and private organizations to enhance learning, research, patient care and the health of the community. Much of this work involves leaving campus and going to the places where the people he wants to help live, work and play. He serves on the board of Friedens Community Ministries, a local network of food pantries working to end hunger in the community.

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

From the January 6, 2023 issue of the Transformational Times

 
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.