Marrying the Basic Sciences to Clinical Medicine

From the 6/12/2020 newsletter


Marrying the Basic Sciences to Clinical Medicine



Amy J. Prunuske, PhD and Jacob Prunuske, MD, MSPH - Faculty members at UW-Central Wisconsin



We recently celebrated our twentieth wedding anniversary. Spring 2000 was a busy time. Jake graduated from medical school. We had our wedding in Milwaukee, a honeymoon in Peru, and a move to Utah where Jake began a family medicine residency and Amy started graduate school in molecular biology. The next twenty years involved both conflict and resolution as we learned to balance individual and shared goals. They also gave us plenty of opportunities to discuss the relationship between clinical medicine and the basic sciences.


We met in a laboratory studying a mouse model of familial adenomatous polyposis that, like most basic science research, attempted to understand the causal relationships that contribute to health and disease. These basic science relationships form the foundation of medicine, lending insights into how health problems manifest, generating the rationale for new treatments, and creating new diagnostic tools.


Amy’s PhD thesis in Oncological Sciences involved studying the zinc finger domain of the nuclear pore protein Nup153 for five years. She patented an inhibitor to this domain that would block cell division, but like many discoveries, it has yet to be translated into clinical practice.


At the same time, Jake was progressing through his residency realizing that patients were complex and had multiple concerns that did not come with neat labels. He needed to integrate biomedical, psychosocial, clinical, and community knowledge to make appropriate diagnoses and develop care plans that were meaningful for his patients. Classes of drugs and new immunizations continued to emerge, and Jake used his Handspring personal digital assistant to look-up dosing, side effects, or immunization recommendations.


As we progressed in our careers, we realized we needed additional training to better apply medical knowledge in a multi-faceted world. Jake completed a Master of Science in Public Health and Amy broadened her expertise into other disciplines and in systems thinking. It became clear that diseases like tuberculosis were as positively impacted by better nutrition and the minimum real wage as Koch’s discovery of the causative bacilus.


Over the years, medical school curricula have had to absorb even more new scientific and clinical discoveries. The volume of material has made it difficult for students to see connections. The time and space for students to reflect and apply knowledge to clinical practice in a productivity-based world is limited. This is all happening at a time when we and people at other institutions are pursuing accelerated graduation options aimed at expanding our primary care workforce.


Our training in education allowed us the opportunity to reflect on how current instructional environments prepare medical students for residency. Based on our own backgrounds, we focused on finding better, more meaningful ways to integrate the basic and clinical sciences.


Merging the basic and clinical sciences requires attention to content, teaching methods, learning experiences, and evaluation; it cannot be accomplished solely within a single course or clerkship. Integration must occur longitudinally and within the mind of the learner. Integration also requires inclusion; you can put both the clinician and the basic scientist in the same room, but if both don’t feel welcomed and valued, a shared model will not emerge. Learning will suffer.


To address this need, MCW created courses like “Bench to Bedside” and “Symptoms” to create environments where the basic and clinical sciences are integrated. More case studies were incorporated into basic science courses. At the same time, the USMLE Step1 exam included questions that require students to apply basic science knowledge in a clinical context.


Contextualized learning moved beyond rote memorization and these approaches fostered inclusion and true integration. Students benefited from exploring many variations of disease and illness. Likewise, students absorbed core basic science knowledge and concepts when they saw the relevance of applying those concepts in a variety of clinical situations.


Here’s an example. Students may be able to list the classic presenting features of angina and describe the presentation and findings of a pneumothorax, yet still struggle to put together a differential diagnosis for chest pain. This is not a trivial problem since, in a family doctor’s office, chest pain may be cardiac (angina, pericarditis) pulmonary (pneumothorax, pulmonary embolism, pneumonia, pleurisy), GI (dyspepsia, GERD, PUD, esophageal stricture), musculoskeletal (intercostal muscle strain, referred pain) or mental health related (anxiety, psychosomatic). “Concept mapping” helps students link patient symptoms, clinical signs, and critical biomedical sciences concepts. Effective teaching allows for students to apply knowledge obtained from multiple sources to their diagnostic reasoning ability and the health of their patients.

Students working on a concept map

By creating maps and tying concepts together, students learn to be skeptical and to evaluate how the knowledge was acquired in the first place. They consider in what situations the knowledge does – and does not – apply. These critical analyses can be facilitated by both PhD scientists and clinicians through journal clubs and mentorship.


Novice learners rely heavily on contextual information but may lack understanding the underlying concepts. Given the time and space, students are naturally curious and connect classroom content with clinical experiences. Tools like concept maps can promote cognitive integration, helping learners understand the complex relationships between basic science knowledge, patient symptoms, clinical signs, clinical management, and decision making.


There are challenges to creating a truly integrated curriculum. Transformation requires cooperation and willingness to remove and alter course content, which can be especially difficult when people have built careers around the existing materials. Clinicians and basic scientists need to be open to collaborating and rethinking their approaches.


The payoff is worth it, though. Integrative approaches improve medical student attitudes towards the importance of the basic sciences, increase student retention of knowledge, and support success for students who are underrepresented in medicine. These experiences also model strong working relationships between basic scientists and clinicians for the students.


Similar to creating a thriving marriage, transforming education by integrating the basic and clinical sciences requires a willingness to try new approaches, an openness to considering the other person’s perspectives, and alignment of expectations. True partnership stems from a mutual respect for each other’s strengths, opportunities for both partners to achieve their goals, and room for disagreements. Only then, will we see growth.



Amy Prunuske, PhD is on the basic science faculty at MCW-Central Wisconsin. 

Jacob Prunuske, MD MSPH is the Assistant Dean for Clinical Learning at MCW- Central Wisconsin.

My White Privilege

From the 6/12/2020 newsletter


My White Privilege


by Megan L. Schultz, MD, MA


I am racist. As a white person born into a racist society where white people have all the power – and always have – I am racist. It is essential that white people say this out loud, believe this is true in our white privileged hearts, and work unendingly to fix this in ourselves. It is essential that white people understand that racism is our problem to solve – we are the perpetrators. It is essential that white people conduct a personal reckoning with the infinite ways we have sustained, promoted and profited from the racist structures that oppress Black people in our country. As a white person, I will start.

• I bought a home in a neighborhood that is overwhelmingly white.
• I send my children to schools where the students are overwhelmingly white.
• I have not surrounded my children with Black role models and leaders. 
• My social circle is so segregated that when my son was 3 years old, he saw a group of Black men standing at a bus stop and said to me, “Look, Mama, basketball players!” Even after his comment, I still have not directly spoken about racism with my children.
• I live in the most segregated city in America and I have never once called my representatives to demand affordable housing, school desegregation or better public transportation.
• I live in a city where a mentally ill Black man was shot fourteen times by police for sleeping on a park bench and I have never once called for police demilitarization, universal body cameras, or police de-escalation training. 
• I have asked for the presence of security guards in the Emergency Department where I work more often with Black patients than white patients.
• A Black medical student once told me she thought she was treated differently on a clinical rotation because of her skin color, and I did not immediately seek out and speak with the medical team members who made her feel inferior.
• I once heard a colleague say, “I don’t understand why we can’t joke about lynching,” and I did not directly engage her in conversation about the extreme lack of comedy in racial violence.
• I have never once challenged a supervisor or a board of directors about the lack of Black leadership in a department, conference or organization in which I am involved.
• I have never once asked a political candidate to end mass incarceration, end solitary confinement, decriminalize marijuana, end cash bail or divest from private prisons – all of which disproportionately affect Black people in our communities.
• I have never once donated to organizations that support Black people running for political office, such as Higher Heights or Collective PAC. 
• I have completely and thoroughly bought into the racist schema that the opioid epidemic, which largely affects white people, is tragic and the people affected are victims, while the heroin and crack cocaine epidemics, which largely affect Black people, are criminal and the people affected are guilty.
• I have scrolled past documentaries and movies like 13th and Selma and thought to myself, “Ugh, I don’t want to watch that, it’s too depressing.” Meanwhile, Black people in my community fear for their lives, and the lives of their children, every day, and do not have the privilege of not thinking about racism.
• I have never once thought about specifically supporting Black-owned businesses.
• I have perpetuated racist theories about “Black on Black crime” when most crime, due to the vast segregation in our country, occurs within the same racial group. 84% of white murder victims are killed by other white people, and I have never once described this as “white on white” crime.
• I have felt uncomfortable talking about reparation and affirmative action. Instead of educating myself and listening to Black voices about these topics, I have avoided them completely.
• I have not protested, I have not rioted, I have not raged in the streets about the inhumanities and injustices that Black people in my community endure every day.

I am racist. I hereby publicly vow to work on becoming anti-racist. Because Black Lives Matter.


Megan L Schultz, MD MA is an Assistant Professor of Pediatrics (Emergency Medicine) at MCW.

Microaggression

From the 6/12/2020 newsletter


Microaggression

Bruce H. Campbell, MD



I hand out a short story to the fifteen residents and students. They follow along as one of them reads aloud:

“One last blow, and, blind as Samson, the black man undulates, rolling in a splayfooted circle. But he does not go down. The police are upon him then, pinning him, cuffing his wrists, kneeing him toward the van. Through the back window of the wagon – a netted panther.”

I am working to integrate narrative into medical education. On this early morning, the ENT residents and a few medical students concentrate – heads down, brows furrowed – as they take turns reading aloud “Brute” by Richard Selzer, a riveting first-person short fictional story first published in 1982 and republished in 1996. An exhausted young surgeon must repair the gash on a prisoner’s forehead in the middle of the night. Both the surgeon’s frustration and his admiration of the patient escalate as the roaringly drunk black man “spits and curses and rolls his head.” After one last, unheeded demand to “Hold still!” the surgeon calmly sews the man’s ears to the cart, wipes the blood from the man’s eyes, and grins victoriously down into his face, a demeaning gesture the surgeon profoundly regrets many, many years later.


The reading ends and everyone's eyes widen. The trainees are well on their way to becoming surgeons, and I watched them squirm as they read the story from the surgeon’s point of view. “So,” I ask the group, “what are your reactions?” After a pause, the discussion flows. Residents nod knowingly, recalling difficult, late night encounters with uncooperative, ungrateful people. “God,” says a resident close to completing her five-year training, “those situations are really frustrating. I know exactly how he feels.” Some of the students – having never been in the ER with a drunk – wonder aloud, “But what do you actually do?” and “Do you think this is a real story? Did this really happen?” I break off the discussion at the end of the hour. Several thank me as they file out. We have all been given something to contemplate.


A couple of days later, one of the senior residents, Tristan, and I are in the operating room. “Dr. Campbell,” he says, “Melissa was upset by the story.”


“Really?” Although Melissa is a junior resident, she should have already had similar encounters. “About the way the surgeon reacted?”


“Talk to her.”


Later that day, I track her down. “Melissa,” I ask, “do you want to talk?”


“Dr. Campbell.” Her gaze is steady and she speaks very evenly. “I was really disturbed when the writer portrayed the black man as an animal. It was awful.”


Oh, my goodness. Melissa has a mixed-race heritage. She is a gifted writer and a gentle soul.


“Tell me more.”


“I hated how the writer described the victim. I was upset. I called my parents to talk about it and they said I should talk to you. I wasn’t going to. I didn’t want to talk.”


“Sorry,” I reply. “Tristan ratted you out.”


We spend time talking through the reading and her reaction. Where I had always viewed the story through the surgeon’s eyes, she had immediately identified with the patient. “I apologize,” I say. “I have always seen the victim’s race as a placeholder.”


“Not for me,” she says.


As we talk, I think back. I have used “Brute” in teaching sessions before but cannot recall if other residents and students of color participated. If they did, were they upset, as well?


Without recognizing the harm, I have perpetuated a racist act of prejudice – a “microaggression” – a misstep that I commit more often than I realize. Melissa has reminded me that I am a late-career, white male surgeon who grew up in a certain time and place and bring my own preconceptions to every experience. Even as I continue to teach residents and students, I must remain open to what my trainees teach me, as well.


“I’ll find a different story next time,” I tell her. “Or maybe you can help me teach it in the future.”


She smiles. “I’ll think about that,” she says as she checks her pager. “Excuse me. I’ve gotta go to the ER.”


-------
The names have been changed.


Bruce H. Campbell, MD FACS is a Professor of Otolaryngology & Communication Sciences and is on the faculty of the Center for Bioethics & Medical Humanities at MCW. He is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. He serves as editor of the Kern Transformational Times.

An Open Letter to my Colleagues

From the 6/12/2020 newsletter

An Open Letter to my Colleagues

Loren Nunley, MD, MBA - Infectious Diseases

I am a black man.

Ten days after my sixteenth birthday I caused a car accident (with minimal damage and no injuries). As I made a sharp turn in the pouring rain, I lost control hitting another vehicle stopped at a red light. Witnesses included two police officers. I was immediately ordered to step out of my vehicle. My white friend in the passenger seat was ordered to get out and stand across the street. Upon silently complying with the order, I was slammed against my own car. Moments later, still silent, I found my face, bloodied, on a curb with something heavy on the back of my neck. It was the knee of the police officer trapping my head against the curb as I struggled to breathe. I am fortunate. It wasn't for nine minutes. I was not murdered. But I will never forget the weight of that knee on my neck.

George Floyd isn't a stranger. You work with him. You know him.

I am George Floyd.

This does affect you. So how will you affect it?

There are many meaningful actions you can take and places you can contribute. I offer these links as a starting point, but you can also take it upon yourself to do further research on how you can help work towards positive change. 



• Comprehensive (and bilingual--Spanish/English) spreadsheet of places to donate, relevant articles, etc.
• Comprehensive spreadsheet of important legal services, places to donate by state, memorial funds, international info, etc. 
• Important article: "How to Check in on your Black Friends and Coworkers."
• Important article: "What You Can Do *Now*: A Black Veteran's Perspective on George Floyd."
• Historical context: "George Floyd’s Death Is a Failure of Generations of Leadership"
• Historical context: "The Double Standard of the American Riot"

From the floor of my heart, thank you for your kind consideration.

Be courageous,

Loren

Loren Nunley, MD MBA is a fellow in the Division of Infectious Diseases at MCW. This letter, originally shared with his colleagues, is reprinted here with his permission.