Radical Candor in Medical Education

From the August 4, 2023 issue of the Transformational Times

Radical Candor in Medical Education 

 

Kathlyn E. Fletcher, MD MA – Program Director, Internal Medicine Residency 

 

 
Dr. Fletcher highlights a Kern offering to new interns to prepare them for their role as educators. These sessions took place during orientation and combined a workshop on how to show learners that they matter with a workshop on how to give effective feedback.  These are the building blocks of medical education radical candor ...

 

My introduction to radical candor 

 

I first heard the concept of radical candor from my sister Julia, who is a retired Navy intelligence officer. I must have been talking with her about how hard I thought it was to give feedback, when she got out a piece of paper. She drew a 2 x 2 table that is the central figure in a book about how to be a great supervisor. She explained that to give impactful feedback, you must 1) care about the person you are talking to and 2) be honest.  

 

I proceeded in my usual path to change -- somewhat slowly. I bought the book Julia was referring to called Radical Candor by Kim Scott and started reading it. I got about halfway through before I dropped it in the bathtub and decided that I had read enough to “get” it.

 

A few concepts in the book specifically resonated with me.  

 

First, the quadrant in which we care about the person, and we are honest is called “radical candor.”  The quadrant in which we care about the person, and we are NOT honest is called “ruinous empathy.”  

Ruinous empathy struck a chord because I thought about all the times that I had convinced myself I didn’t need to be completely honest in my feedback. Phrases went through my brain like, “I’m sure she will get better; it is so hard being a July intern.” Or “It’s impossible to know everything as a third year medical student; I am sure he will fill in that knowledge eventually.”  I spent SO MUCH time in ruinous empathy.   

 

As I began trying out radical candor, I came to see that if I believed in someone’s ability to improve, then I had to be honest about how they could do so. I started framing my feedback by saying “I wouldn’t suggest this to you if I didn’t think you were capable of it.” I think many learners were grateful for the careful attention to how they could improve. 

 

Developing medical education radical candor skills in the residents 

 

For the second year in a row, the Kern Institute has sponsored half-day workshops for incoming residents to allow them time to focus on their skills as teachers. In 2022, interns from five residency programs participated. In 2023, thirteen programs participated.  

 

These workshops focused on two skills: how to make learners feel like they matter and how to give effective feedback. Medical education radical candor skills!  

 

The two sessions on “mattering” this year were run by Karen Marcdante/Rachel Ashworth and Andrea Maxwell/Caitlin Patten. 

 

When the facilitators asked participants to describe times on clinical teams when they felt like they didn’t matter, the interns shared poignant moments that have stayed with them for years. The interns also described times that they knew they mattered. 

 

As I sat through these sessions, I noticed how small things made a big difference toward making someone feel that they mattered: calling them by name, giving them meaningful work to do, asking them about their life. Importantly, it doesn’t take long to establish that you care. You can set the stage in less than a minute, which means you can give honest feedback without waiting days or weeks to assure yourself that learners know you care about them.  

 

After the mattering sessions, interns learned how to give effective feedback. Himanshu Agrawal ran one workshop on feedback this year, and Seth Bodden ran the other. Their frameworks for how to give effective feedback included being timely, actionable, and (of course) honest. As with mattering, the intern participants could recall both helpful and not helpful feedback (“read more,” “good job”). Making time and finding space to give personalized feedback is itself an act of caring. 

 

The concept of radical candor reminds us to show learners that we care and that we must be honest in our feedback.  

 

I would take it one step further and say that giving honest, effective feedback is an extension of our caring and demonstrates our belief in the learner’s potential for flourishing in medicine. 

 

It was so freeing for me to realize that if I cared, then I had to be honest. No more ruinous empathy. Bring on the radical candor.  

 

 

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

 

 

 

 

 

 

 

 

Building a Culture of Health in Health Care and our Community

From the August 4, 2023 issue of the Transformational Times

 

Building a Culture of Health in Health Care and our Community 

Kajua Lor, PharmD, BCACP 

 

We as healthcare professionals and leaders need to recognize that to build a culture of health, we must take off our white coats and meet the community… The neighborhoods we live in, the places we work and play, impact the health of our community…

George Floyd. A Black man who died on May 25, 2020, as a white police officer in Minneapolis knelt on his neck for nearly nine minutes. A name that goes does down in history as a flashpoint of inequities faced by people of color and vulnerable communities. A death captured by a bystander on a video that went viral and sparked one of the largest protest movements in U.S. history, as well as a movement within health care.   

Together, George Floyd and the COVID-19 pandemic revealed the true colors of our broken healthcare systems and the inequities faced by people of color and people disadvantaged by the system.   

 

 

My experience as a Hmong American refugee 

 

As a Hmong American refugee growing up here in Wisconsin, I was oftentimes the only person of color in the room, the only woman in the room, the only pharmacist in the room. I struggled with my identities and many times would feel like I was “lucky,” and I was the “underdog” in many of the spaces that I was in personally and professionally. 

 

Being the “first” and or the “only” person made me question if I could be my own authentic self in the spaces that I was in. Early on in my professional career, I would hide myself and my identities as I felt that showing any vulnerability would mean that I may not be good enough.  

 

Since the COVID-19 pandemic, I’ve learned that life is so precious, that there are so many things to be grateful for, that I can show up as my own authentic self and that I need to know my allies, people who support and are able to create positive influences around me.    

 

When I saw the video of George Floyd’s death, I was shocked, angry and, then, sad. I felt disappointed in humanity. How can I influence change? Where is the love for humankind? What can I do to make things better where I live, work, and play? 

 

I remember a white coworker who said to me, “I don’t understand why those Black people are so angry.” And I thought about my own privilege as an Asian American. Why did they feel comfortable speaking with me? Was it because I was Asian American?

 

I remember being part of a virtual listening circle to create safe spaces to hear from others from the MCW community after the death of George Floyd. I volunteered to participate as a note taker for the circle. I appreciated being a part of this circle as I learned from others in the room about their stories. As the only person of color, I realized that this was a safe space with many allies, raised my “virtual” hand, and said, “As an Asian American woman and leader, I experience microaggressions almost every day at MCW. There hasn’t been one week that I have not had a microaggression.”  

 

Microaggressions happen and are real. Psychologist Derald Wing Sue, who has written two books on microaggressions, defines the term: "The everyday slights, indignities, put-downs, and insults that people of color, women, LGBT populations, or those who are marginalized experience in their day-to-day interactions with people.” 

 

Research has shown that microaggressions, although seemingly small and sometimes innocent offenses, can take a real psychological toll on the mental health of their recipients. This toll can lead to anger and depression and can even lower work productivity and problem-solving abilities. 

 

Some microaggressions I have experienced:  

 

• Patients asking me “Where are you from?”  
• Direct reports seeking recognition from male leadership as my recognition as a woman leader was not “good enough.” 
• After returning from maternity leave, a coworker stated, “hope you had a nice vacation.” 
• A staff member referring to Asian Americans as “Oriental.”  
• After sharing that I was attending a blessing ceremony over the weekend, a colleague saying, “Oooooo! Spooky”  
• A staff member’s written comment about a candidate that they “didn’t speak English good enough.” 

 

Mountain or mole hill? I’ve learned to pick my battles. Will I be working with them in the long term? Is it worth it to say anything?  

 

I learned that one of the officers in the video who was a bystander, watching the death of George Floyd, was Hmong. I remember the hatred toward the Hmong community for letting George Floyd’s death happen. Many Hmong were targeted with death threats. It seemed that there was a perception the inaction by one member of the Hmong community reflected the entire Hmong community. 

 

How do we create change with people who “don’t see color?” How do we change when there are differences in opinion on the approach to building inclusion and belonging? How do we learn from one another and embrace our differences? How can we move forward when we remain behind in the work that we do? 

 

Race was created as a social construct, not a biological construct. 

 

We as healthcare professionals and leaders need to recognize that to build a culture of health, we must take off our white coats and meet the community. 

 

According to the Robert Wood Johnson Foundation, “Building a Culture of Health means working together to dismantle structural racism and other barriers so that everyone has the chance to live the healthiest life possible.” 

 

The neighborhoods we live in, the places we work and play, impact the health of our community.  

 

I’ve learned over the years, working with community, that I can be my own authentic self in the spaces that I’m in and that I need to show up when times get tough as an ally for others. 

 

Each of us has a different story and a different walk of life. We need to embrace each other as humans to be able to “see” one another and develop a deeper understanding -- to learn from one another to be able to move forward.  

 

 

Take action: Practice inclusive leadership  

 

Has the needle moved? Progress has been made; however, the journey has just begun and will continue to be a long one. Many hospitals and healthcare systems have expanded positions and resources to support health equity efforts. Many organizations have provided more budgetary resources and infrastructure in efforts to build health equity.   

 

At MCW, the Office of Diversity and Inclusion developed the Inclusive Excellence Framework. This framework showcases how we all can create communities of safe spaces for others to ensure all feel they belong.   

 

We must develop inclusive leadership skills. Inclusive leadership is defined as “leadership that assures that all community members feel they are treated respectfully and fairly, are valued and sense that they belong, and are confident and inspired.” (“Workplace Inclusion Network – Reflections from our Virtual Roundtables ...”) 

 

Strategies to practice inclusive leadership:  

• Take time to make a personal connection with your team and your patients (if applicable). 
• Develop topic discussions with your team that incorporate inclusive leadership principles. 
• Describe resources for health and well-being. 
• Address fears – listen with empathy. 
• Cultivate compassion for yourself and others.  

 

Spend some time to reflect on equity, diversity, and inclusion:  

• What does diversity mean to me?  
• "When have I or someone else been treated equally, but should have been treated equitably?" (“Discussion Guide DEI: The Basics – Part 1”)  
• Think of a time when you felt excluded. What were your feelings? How did they impact you?  
• Think of a time when you felt included. What were your feelings? How did they impact you?  
• How can I help others to be/feel included? Valued? 

 

Take action:  

In the next month, what one action will I commit to that promotes diversity, equity, and/or inclusion? (i.e., “I will engage in a conversation with someone whose opinions differ from my own.”) (“Discussion Guide DEI: The Basics – Part 1”)  

 

For further exploration: 

 

• This Day in History: George Floyd is Killed by a Police Officer
• Robert Wood Johnson Foundation: Why Build a Culture of Health?

Resources from the MCW Office of Diversity and Inclusion: 

• MCW Office of Community Engagement Introduction and "Quick Links"
• Inclusive Excellence Resources
• Resources to Read and Watch
• MCW Anti-Racism, Equity, Diversity, & Inclusion Glossary

Videos: 

• Reggie Jackson: A History of Race 

Kajua Lor, PharmD, BCACP, is Founding Chair/Associate Professor in the Department of Clinical Sciences at MCW School of Pharmacy. She is a clinical pharmacist at Sixteenth Street Clinic, a federally qualified healthcare center serving Spanish-speaking communities one day per week. Dr. Lor was a fellow of the Robert Wood Johnson Foundation Clinical Scholars Program from 2017 – 2020, a leadership program to build healthier and equitable communities. She is a community-engaged researcher building a culture of health with Hmong refugees.  

 

 

 

 

 

A Reflection on the Impact of George Floyd at MCW

From the July 28, 2023 issue of the Transformational Times

Perspective/Opinion

Has Anything Changed? A Reflection on the Impact of George Floyd at MCW

Precious Anyanwu & Chiemerie Ogbonnaya, Class of 2026

Three years after the murder of George Floyd, medical students Anyanwu and Ogbonnaya offer their perspective on the shortcomings of the American healthcare system, and the racial and ethnic injustices that perpetuate them...

NOTE: Tear gas can be neutralized with about three tablespoons of baking soda mixed with eight ounces of water. It is important to have this mixture in hand before you arrive at a protest because when the gas hits, there will be no time to waste. Remember to carry enough to help wash the eyes of your peers. But most importantly, get out immediately.

This simple recipe has spread from crowds of protestors in Hong Kong to civil activists in Washington DC, all fighting for the preservation of their people.

In the wake of the unjust murder of George Floyd, protesters sought justice at the steps of our government. Instead, they were met with controlled violence in the form of tear gas and police batons. Even with the gas burning their throats, protesters continued to scream for justice. The pain they experienced in that moment was incomparable to the agony of watching yet another Black man lose his life to institutional injustice.

Long before the shocking event that transpired on May 25, 2020, the lives of persons in Black and Brown communities were undervalued and endangered in America. The death of George Floyd, combined with the simultaneous COVID-19 pandemic, amplified how deeply ethnic discrimination and racial inequities are rooted in key American structures. The pandemic disproportionately impacted marginalized communities because of longstanding, systemic inequalities.

Numerous studies have proven that the American healthcare system does not prioritize cultural understanding for ethnic communities. This neglect contributes to an overall decrease in the standard of care and a notable increase in poor health outcomes. Justified mistrust of the healthcare system by these communities is ingrained in history. America’s past is riddled with medical exploitations of racially marginalized communities; recall the Tuskegee experiments and Henrietta Lacks.

The cycle of medical abuse and healthcare avoidance perpetuates chronic illness and shortened lifespans in Black and Brown communities. If American institutions continue to discriminate against marginalized populations under the guise of extenuating circumstances, they will never restore faith in the system and America will remain tainted by its sordid history.

Change starts at the grassroots

Although we have a substantial amount of progress to make as a country, it is important to acknowledge that change starts at the grassroots. In response to George Floyd’s death, the Medical College of Wisconsin implemented several changes to its surgery department centered around prioritizing the principles of diversity, equity, and inclusion.

These changes brought the opinions of marginalized groups to the forefront, introducing pertinent cultural topics that may not have been considered otherwise.

With this seemingly minor adjustment, disadvantaged communities now have advocates speaking on their behalf in spaces that can implement true change. Some cities also chose to pursue action after George Floyd’s passing. For example, Minneapolis reallocated $8 million from its police department to expand mental health crisis response services and Boston chose to invest $12 million into expanding public and social health services.

White Coats for Black Lives

White Coats for Black Lives originated from the national outcry for justice in response to the murder of George Floyd. We aim to safeguard the well-being of our future patients by advocating for the elimination of racialized medicine.

Our ultimate goal is for government officials and civilians across the country to recognize the need for restructuring how America operates fundamentally.

Tangible action against racial inequities is needed. History cannot be rewritten, and the lives lost from injustice cannot be resurrected, but the future can be changed. 

For further reading: 

1. MCW’s Department of Surgery’s response to George Floyd’s death. https://www.mcw.edu/- /media/MCW/Departments/Surgery/DOS-Statement-Racism-Disparities-DSiversity-6-12- 2020.pdf

2. Vasquez Reyes M. The Disproportional Impact of COVID-19 on African Americans. Health Hum Rights. 2020 Dec;22(2):299-307. PMID: 33390715; PMCID: PMC7762908. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762908/

3. Eric C. Schneider et al., Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, Aug. 2021). https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror- 2021-reflecting- poorly#:~:text=The%20U.S.%20ranks%20last%20on,on%20measures%20of%20care%20process

Precious Anyanwu and Chiemerie Ogbonnaya are in their second year of medical school at the Medical College of Wisconsin. They are currently serving as Co-Presidents of the White Coats for Black Lives organization. Their work emphasizes the importance of outreach and intervention to provide a lifelong space for Black and Brown communities in healthcare.

The Right to Breathe

From the July 28, 2023 issue of the Transformational Times

The Right to Breathe

Michael N. Levas, MD, MS

A pediatric emergency medicine physician advocates for comprehensive and compassionate care in the broader context that health is more than biology – that it encompasses people’s lived experience, their trials, their strengths. As a leader of several diversity, equity, and inclusion initiatives at Medical College of Wisconsin, he also reflects on recent shifts he has observed in institutional culture, and reminds health care providers to be mindful of the social pressures that burden patients and colleagues...

“I can’t breathe.”

These were some of George Floyd’s final words, captured in a bystander video. Through this video, we as a nation also witnessed a dying man call out for his mother.

I often see youth who are scared, and some who feel like they are dying, as a pediatric emergency medicine physician who practices at Children’s Wisconsin. They say, “I can’t breathe” and they ask for their mothers. Watching the video of George Floyd, I felt powerless. But in the emergency room, there are situations where I can do something — I can help their difficulty breathing, we can find their mothers and get them to their bedside.

The risk of becoming numb to social injustices is real. It can lead to harmful health outcomes, even death. The continued traumas our nation experiences are seemingly endless.

Mobilization and hope

There has been a movement within MCW to increase advocacy addressing diversity, equity, and inclusion, including the development of DEI councils within residency programs and clinical departments.

For the first time since I was a medical student at MCW (many moons ago), I feel that it is okay to talk about biases, microaggressions, social determinants of health, and health equity.

In fact, health equity has become a theme of many clinical, educational, research and community efforts at MCW. More grand rounds across campus focus on racism’s impact on healthcare outcomes. Trainees are demanding health equity be woven into curricula. There is more acknowledgement that

health is much more than biology – that health encompasses people’s lived experience, their trials, their strengths.

Within the Department of Pediatrics, over 500 faculty and staff have participated in Implicit Bias Training. Other departments have requested this training, including Psychiatry and Behavioral Medicine, Anesthesiology, Physical Medicine & Rehab, the Admissions Committee, the Joint Fellowship Council, among others.

The Comprehensive Injury Center and Department of Pediatrics recently adopted policies recognizing MLK and Juneteenth as holidays by not scheduling recruitment, training, or lectures during those days.

Barriers are real

But two things are clear: inertia is real, and not everyone is happy with such activism. For every stride we make fighting for equity in health outcomes and health education, a counter narrative is threatened by change.

While we are deliberating about what efforts to implement or back as institutions, youth are dying from firearms, families are losing their homes, and transgender youth are losing faith in the healthcare community.

Some changes that need to be made do not require repeated meetings or committees to implement. Unfortunately, our current healthcare environment has become accustomed to that approach, driven by fear of retribution rather than focus on doing what is right.

“The time is always right to do the right thing,” is my favorite quote from Dr. Martin Luther King Jr. We cannot become numb to the trials that our patients face. We cannot ignore the social pressures that burden our patients and colleagues.

Despite continued barriers and bureaucracy, as health care professionals we must continue to model comprehensive and compassionate care. We need to have the courage to use our privilege as health care providers to speak out against social injustices and our expertise to show the evidence-based approaches that lead to less disparities.

Every living human has the right to breathe.

We need to breathe to stay alive.

We need to breathe life into policies that strive for health equity.

We need to help others to pause and breathe before they are threatened by ideas that lean towards justice.

We need to breathe for those who no longer can.

Dr. Michael N. Levas, MD, MS, is a professor of Pediatric Emergency Medicine, Vice Chair of Diversity, Equity, and Inclusion for the Department of Pediatrics, Medical Director of Project Ujima, Associate Director of the Comprehensive Injury Center, Faculty Advisor for the Latino Medical Student Association, and MCW Faculty Advisor for White Coats for Black Lives.