A “Sermon” for Medical Students about Civic Character

 Guest Director’s Corner

A “Sermon” for Medical Students about Civic Character

Mark D. Schwartz, MD

If individual character is what we do when no one is looking, civic character is what we do when everyone is looking!
-Eric Liu “Citizen University”

I remember the excitement and fear of drinking from the fire hose as a medical student in the 1980s. I was aware of, but could not fully understand, how the AIDS epidemic was shaping and honing my professional identity, just as the current pandemic is shaping yours.

In this moment when the country is sick and suffering – when our health, our economy, and democracy are threatened and when science itself is being undermined – we need to impact the world beyond our next exam, our next rotation, our next patient, or our next scientific hypothesis.

Given the situation we are in, let’s talk about what it means to be civically- engaged physicians and scientists in this new world. Here are some simple but profound questions I have been living in, wrestling with, and trying to answer:

• Given our positions, capabilities, and resources, what are our responsibilities? And for whom are we responsible?
• What are our roles as a civic physicians, civic scientists, and civic healers?
• How can we use our professional roles and power to strengthen democracy?

I can’t tell you what your answer should be, but I do know that we need to think bigger.

Physicians have privilege and tremendous, untapped power. Power is misunderstood and mistrusted, yet there is no greater mechanism for positive change than through the harnessing of power and creating civic action. Power calls physicians to be positive agents of change in our communities.

Where and how do we begin?

I can guess what you are thinking. Listen – I get it. I am a doctor, a professor, a researcher, and a leader. I would put my “To-Do” list up against anyone’s! I know how unthinkable it is to add one more task. It is overwhelming enough to develop into the best doctor or scientist you can be.

Besides being incredibly busy, I hear other reasons why physicians and scientists are hesitant to engage in strengthening our democracy. Here are three of them:

Who can fight big money?

Science and politics don’t mix!
It’s not my job

Let me unpack these with you.

Myth #1: We shouldn’t engage in strengthening democracy because Who can Fight Big Money?

Undoubtedly, our democracy is driven by money and power. How can the rest of us ever have a voice? How can we not throw up our hands in cynicism and despair when we see how big oil, big banks, and big medicine turn policies, laws, and regulations in their favor? Here are two reasons why I am optimistic about your chance to make changes.

The first is that you have more power than you think. As voters we exercise a vital act of civic power, and forming, joining, and aligning forces supercharges your civic power. Organizations like the American Medical Association, American Hospital Association, or the Association of American Medical Colleges are out there every day, shaping how we educate, train, and practice medicine and science. When you align with your school’s advocacy agenda, national student organizations, and professional societies, your voice is amplified. Take advantage. As Samuel Adams, who incited the Boston Tea Party, famously said: “It does not take a majority to prevail... but rather an irate, tireless minority, keen on setting brushfires of freedom in the minds of men.”


The second reason why I am optimistic about your chances is that culture eats policy for lunch every day. Although policy includes the levers of public laws and regulations, culture – our norms, civic ideals, beliefs, habits, and practices – shapes our society’s norms, values, and the spirit of democracy. Culture is tied to our “civic character.” If individual character is what we do when no one is looking, civic character is what we do when everyone is looking! Civic character and behavior are contagious. If you doubt this, look around the country and notice how different regions of the U.S. have responded differently to the pandemic and our emerging social conversations.

We mimic what we see – what we do grows and becomes social norms. We are not stuck in traffic – we are traffic. We are part of the ecosystem we create. Democracy is not a machine, but a garden that needs active tending – like a garden, it needs water, sunlight, planning, understanding and respect of cycles, weeding, and adaptation.

So, what can you do in your daily life to promote civic character and to close the gap between our ideals and our practice in this American democracy
project? What does it mean to live like a citizen? John Wesley, the founder of Methodism in the 1700s, said, “Do all the good you can, By all the means you can, In all the ways you can, In all the places you can, At all the times you can, To all the people you can, As long as ever you can.”

We need to think bigger!

Myth #2: We shouldn’t engage in strengthening democracy because Science and Politics Don’t Mix!

I teach a course on research methods each summer. Physicians and scientists venerate evidence. It is the ground on which we stand to do our work.

Were you as concerned as I was when it appeared that we were being pulled into an evidence-free world? Where truth becomes truthiness? Where each of us has our own dictionaries, our own encyclopedias, our own fragmented sources of evidence? Where national, scientific experts are pushed aside, data disappears, and evidence is ignored by our leaders?

I’ve got data, you’ve got data, we all have data. The power that you have, given your position, is to bring these data to life – with real, lived stories about how all these data play out in the world and affect real people. With cameras on computers and phones, I have been inside the lives, families, and homes of many people suffering or worried about COVID-19. Yes, I have graphs of rising and falling cases and deaths, but I also have stories of loss, fear, hope, and how families and communities are coming together to help us heal, cope, and mourn. We are in a unique position to link data to stories. People will listen.

As citizen physicians and scientists, we have the responsibility to tell these stories, to bring the data and evidence to life. Each of us can strengthen our democracy by telling these stories to provide compelling, living context for our science, our data, and our evidence.

We need to think bigger!

Myth #3: We shouldn’t engage in strengthening democracy because It’s Not My Job to Fix the Country

As a physician, my job is to help one person at a time when they come to see me.
Of course, only about 20% of health is affected by what doctors and scientists do in the office, the hospital, the lab. The other 80% is explained by our genes, our individual and civic behaviors, and the social determinants of health – where we grew up, learned, lived, worked, and played. These social determinants, with their history and the ways in which they are baked into society’s institutions and structures, all drive the disparities that the twin pandemics of coronavirus and of racially-targeted violence and injustice have made undeniable.

Each day, we look into the eyes of the patient in front of us, to plumb the depths of a scientific problem, and stare into the computer to do the work we are preparing to do. That is difficult, valid, valiant, and vital work, but it is not enough. If we want to have a larger, more enduring impact, we must lift our eyes from the patient, problem, and computer and embrace the context and culture of our populations and communities.

We need to think bigger.

I teach a course on health policy, and so I get to watch students learn the language, the anatomy, and the physiology of how health policy is made. Their brows furrow and their faces get heavy as they grasp our crazy-complex policy machinery. They discern how policy is shaped by money and by self-interest.

But I have also seen their faces brighten after they pick a policy issue about which they are passionate, prepare and practice their advocacy pitch, and visit their representatives in Congress. They are surprised how easy and how important it is to engage as citizens and to leverage their power as future physicians and scientists. Participating in acts that engage our civic character strengthens our democracy and repairs the world, given our position, our capabilities, our resources, and our power.

A central tenet in Judaism is the responsibility we each have of Tikkun Olam, that is, to repair the world. We can’t do the entire work, but we are called to do what is in our reach to knit together the broken ends and to partner in the work.

So, I leave you with the questions with which I began:

• Given our positions, capabilities, and resources, what are our responsibilities? And for whom are we responsible?
• What are our roles as a civic physicians, civic scientists, and civic healer?
• How can we use our professional roles and power to strengthen democracy?

As a leading rabbinic scholar, Rabbi Tarfon, taught 2000 years ago, "It is not your responsibility to finish the work [of perfecting the world], but you are not free to desist from it either.” My charge to you is to wrestle with these questions, connect with one another to engage the world where you can, and spend your careers searching for the answers. By developing and sharing your civic character, your work can lead to lasting change.

Thank you.

Dr. Schwartz is a Professor of Medicine and Population Health, Vice Chair for Education and Faculty Affairs, Department of Population Health, New York University Grossman School of Medicine. In 2010, as a Robert Woods Johnson Health Policy Fellow he “staffed” the Ways and Means Committee in the U.S. House of Representatives while they wrote the Affordable Care Act. He leads pre- and post-doctoral fellowship programs in population health and health policy.

First- and Second- Year Medical Students’ Responses to Remote Learning

From the 10/2/2020 newsletter

First- and Second- Year Medical Students’ Responses to Remote Learning

by Eileen Peterson and Anna Visser

MCW Students Eileen Peterson and Anna Visser organized a student survey to better understand how their colleagues adjusted to the remote learning environment, and lessons learned moving forward that can connect to well- being efforts ...

While online degree programs have existed for decades, they made up a small minority of degree programs in the United States until 2020, when remote learning became the norm, forcing students and faculty members to adapt to its benefits and challenges.

The Medical College of Wisconsin was just one of the many institutions affected once the threat of disease spread materialized during the spring semester of this past academic year. In-person lectures for first- and second-year medical students (M1s and M2s, respectively) stopped for the rest of the spring semester, and third- and fourth-year medical students were pulled from the clinics and hospitals during their rotations. As we all learned more about COVID-19 and how to safely bring students back to campus, things have slowly shifted to a “new normal.” The third- and fourth-year students were allowed back at their rotations. However, the path to this “new normal” has been a bit rockier for first- and second-year medical students.

As the first- and second-year medical school curriculum is largely lecture- based, many changes have had to occur to transition to mostly-virtual learning.

During the spring semester, virtual learning for first- and second-year medical students consisted of watching lectures that had been recorded the previous year. This fall, we have transitioned back to live lectures that are given on campus by masked faculty members and clinicians behind Plexiglass. Attendance is capped at 50 students, and everyone must sit 6 feet apart with their masks on. This is certainly not the same pre-COVID experience of cramming into Kerrigan with friends. We are not able to roll our chairs closer together to discuss which lunch talk might have the best food that day. We no longer make the trek to anatomy lab with all 200 fellow first-year medical students. We understand that it would not be safe for things to be like they were pre-COVID. Even with all the terms that fall under this “new normal,” being able to watch live lectures again, from home or at school, has been a great improvement from this past spring.

We wanted to know: How has this transition affected students? We sought out answers from first- and second-year medical students at MCW through a voluntary survey distributed at the beginning of September. Within mere days, we garnered 53 responses. Selected data are presented below, along with free responses published anonymously with permission.

Ease of Transition

The transition to mostly-remote learning this semester has been easy for me:

There was a wide variety in thoughts about the ease of transition to online learning. We postulate that this variety may be based on class year; since current M2s experienced remote learning last spring, they may have already formulated schedules and study habits that work well for them, whereas remote learning may be new to current M1s. Here are a couple free responses related to the ease of transition:

“The hardest part is not being able to separate school and studying from home and relaxing. There is no barrier between my desk and my bed, so work and life have meshed into one thing.”

“The transition was relatively easy as I had already been watching lecture and studying from home 99% of the time. I suppose the most difficult aspect has been not seeing many people. As introverted and painfully shy as I am, humans are largely social creatures. Not being able to seefamiliar faces after a while began to take its toll.”

Has mostly-virtual learning and/or COVID-19 affected how/where you are living this year?

For the majority of students who responded to our survey, their living arrangements were not impacted by the transition to mostly-remote learning or COVID-19. For those whose living arrangements have been impacted, there are many reasons why this could be the case. At the start of the pandemic, in the spring, many students chose to go back home for some time. There was also much uncertainty about how we would be coming back to school in the fall. 

Some students weighed in on their experiences:

“As an M1, I waited as long as possible to sign a lease because I was unsure of whether or not I would have any in-person classes this semester. As a result, I’m now living alone and have little to no interaction with my classmates. It’s made the transition significantly more difficult...”

“I had been planning to live at home with my parents this year. Both of my parents are older, and I was worried that somehow, I would be bringing COVID home by going back to school and clinic. I quickly found and moved into a new apartment so that I wouldn’t be putting my parents at increased risk.”

I have more time to study or enjoy recreational activities now that my learning is largely remote:

When asked for their favorite part of remote learning, many students discussed their schedule’s increased flexibility, including getting more sleep, avoiding the commute to school, and being able to watch lectures at their own pace. A student explained,

“I enjoy not needing to drive to campus for class. Even though I live close, it saves at least 30 minutes every day and instead I can continue studying from my desk, watching lectures at my own pace, while still getting a quality education.”

However, not all students feel this way, especially those with families and other commitments at home. One student was frustrated with the increase in assignments given the remote nature of medical courses:

“It seems that we have more work to do now more than ever. It appears faculty are concerned we have a lot of free time, but we have the same amount of time, if not less, now that we are home. For instance, many people have children they now have to help out with school.”

Faculty and Staff

It is easy to reach out to faculty and staff remotely when I have questions or concerns:

Though our responses to this question were fairly neutral, the majority of responses were positive. Seventeen students chose Somewhat agree, Agree, or Strongly agree; while only ten students chose Disagree or Somewhat disagree. No students strongly disagreed with this statement. Though we have not been able to have as many face-to-face interactions with faculty as we were able to pre-COVID, it has still been fairly easy to reach out to faculty and staff with questions and concerns in this mostly-virtual age. However, there is certainly still room for improvement in the format of mostly-remote learning.

One student commented,

“I don't like the email barriers to asking questions - I'd much prefer to get real-time answers to questions. I don't like Panopto - it’s clumsy and lags.”

I feel supported by faculty and staff, even though my learning has been largely remote:

Based on our personal experiences and our survey responses, is clear that the faculty and staff are still here for students during this time. A large majority of students who answered our survey feel supported by MCW faculty and staff. In an effort to improve their medical school experience, several students offered suggestions for faculty, staff, and MCW as a whole:

“I would love if MCW offered more free virtual workout classes for us to stay mentally and physically healthy, especially if we aren’t comfortable using gyms or wearing masks when working out in more public spaces.”

“I wish that [student organizations] would be able to do outdoor activities/more online events... I'm disappointed by the lack of community especially having just moved here from far away.”

“Brightspace is very clunky - it takes 7-8 clicks to find one thing. I also wish there were more ARS questions instead of professors droning on. It feels very removed watching a lecturer in a mask behind a glass screen and the audio is not always good. I'd rather professors broadcast from home.”

“I really, really wish they could change the scratch paper rule during tests.”

“Send us something once in a while, a joke, a song, something to keep us connected.”

“Be supportive when we have illnesses or injuries. We are students, but we are patients too.”

“Be receptive to changes especially with the [Black Lives Matter] movement sweeping the nation. We finally feel open to talking about these hot topics. It may seem like an attack or uncomfortable but imagine decades of that for [people of color].”

Connectedness to Peers

I feel connected to my peers, even though my learning has been largely remote:

When asked about the hardest parts of their transition to mostly-virtual learning, many students discussed their feelings of disconnectedness from peers and challenges with social isolation. Compared to students from the Milwaukee area or those who knew each other from undergraduate experiences, these feelings of isolation are exacerbated in first-year students who moved here from out of town and may not have already developed those previous friendships with other medical students. One student expands upon this challenge:

“I just moved to a new city, I’m living by myself, and have little to no interaction with my classmates. I find virtual learning to be significantly more difficult because it requires way more self-discipline than if we were to be attending lectures in person. So.... it’s been not only a tremendous adjustment in terms of just finding my footing as a med student, but I also feel incredibly disconnected from my peers. I worry that I may somehow be missing the opportunities to meet people just because I’m out of the loop somehow.”

Adaptability and Growth

Whether their mostly-remote learning experience has been smooth or rocky, freeing or isolating, or otherwise, students have learned a lot about themselves. They discussed their resilience and adaptability: 

“I can overcome obstacles and still have a meaningful experience.”

“Being flexible and ready to adapt to new changes and plans is the key to success.”

“Nothing will stop me from reaching my goal, not even a pandemic.”

Because of the various challenges associated with being a medical student during a pandemic, many students advocated for prioritizing mental health and other efforts to promote wellness:

“It has been further cemented into me that I alone am in charge of my wellness. With nearly all learning being remote, the days of the week blend together and a weekend is almost no different than a weekday. Taking the necessary time to unwind and take a break from studying needs to be an intentional act, and deciding when enough studying is enough on any given day is also important to prevent burning out. I’ve learned that spending time alone, whether it be reading a book or playing guitar, is a great and fulfilling alternative to hanging out in big groups when trying to enjoy some time away from school work, given the circumstances.”

“I’ve learned that I need to keep myself accountable for my work by keeping checklists and to do lists so I can do my school work, keep the house chores under control as well as think about eating right and staying social.”

Being a medical student is notoriously challenging, much less during a pandemic. From technological hiccups on Brightspace to feelings of isolation, students discussed struggles that are shared by many of their classmates. Amidst the difficulties, it has been inspiring to witness the resiliency, adaptability, and courage of learners, faculty, and staff as we navigate our “new normal.” Until handshakes, coffee shop meetings, and large-group gatherings return, we encourage you to continue promoting wellness for yourself and others, one small step at a time. 

If you or anyone you know is struggling, you are not alone. Below are some resources for students, shared via Dr. Cassie Ferguson and the REACH curriculum:

MCW Student and Resident Behavioral Health Services

- Referral Coordinator: Carolyn Bischel, MS, LPC

- (414) 955-8933

- Referral Hours: 8:00 am-4:30 pm, Monday-Friday

- After-hours Emergency Contact: (414) 805-6700

24/7 Suicide Helplines

- National Suicide Prevention Lifeline: 1-800-273-8255

- Crisis Textline: Text the word "Hopeline" to 741741

Columbia Suicide Severity Rating Scale (research-based screening tool for

assessing suicide risk in individuals)

- https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/cssrs-for-

communities-and-healthcare/#filter=.general-use.english

Milwaukee Health Department/Office of Violence Prevention

- Blueprint for Peace:

https://city.milwaukee.gov/ImageLibrary/Groups/healthAuthors/O

VP/Reports/20171117OVP-Report-MKEBlueprintforPeace-Low-

Res.pdf

Eileen Peterson and Anna Visser are students at the Medical College of Wisconsin with interests in Diversity and Inclusion, Medical Humanities and Student Wellness. They are both Associate Editors of the Kern Transformational Times newsletter. 

Justice Ruth Bader Ginsburg – Losing a Brilliant Voice for Equity

From the 10/2/2020 newsletter

Perspective / Opinion

Justice Ruth Bader Ginsburg – Losing a Brilliant Voice for Equity

Libby Ellinas, MD – Director of the MCW Center for the Advancement of Women in Science and Medicine (AWSM)

Dr. Ellinas shares her perspective on the loss of Supreme Court Justice Ruth Bader Ginsburg at precisely the time when our country needs her most of all ...

Supreme Court Justice Ruth Bader Ginsburg died on September 18, 2020. It felt like a punch in the gut. A wave of loss and a fear for our nation’s future. It brought again to mind a deep concern for the health, safety, and opportunities for women in the United States.

This week, the police officer who shot and killed Breonna Taylor was not indicted. That decision brought about a wave of loss and fear for the health, safety, and opportunities for women in the United States. In the faces of my colleagues, I could see that loss, that emotion.

Justice Ginsburg’s loss was personally devastating to me, not only because she was a superb intellect and a dauntingly hard worker (two traits I admire in anyone), but because she was clever – ingenious even – at helping colleagues and justices gain insight into their own views.

There are multiple examples of RBG’s cases that support her creativity and strategy to “Fight for the things that you care about, but do it in a way that will lead others to join you.” One of my favorites is Weinberger v. Wiesenfeld, a case she litigated (as Weisenfeld’s attorney) at the Supreme Court in 1975.

Stephen Wiesenfeld and Paula Polatschek were married in 1970. Paula, the primary breadwinner, worked as a math teacher. When she died in childbirth from an amniotic fluid embolism, Steven became the sole provider for their son, subsequently applying for social security benefits. At the time, a widow under identical circumstances would have been eligible for those benefits. Steven, a widower, was not. Wiesenfeld sued for benefits, and the case was appealed all

the way to the US Supreme Court against Caspar Weinberger, the Secretary of Health, Education, and Welfare.

During the case, Attorney Ginsburg argued that the Social Security Act discriminated against both Paula’s social security contributions (because she was not a man), and Steven survivors’ benefits (because he was not a woman). The 8-0 decision rendered by eight white male Supreme Court justices agreed that the purpose of social security benefits was to allow for the proper care ofchildren, and that “proper care” was not dependent upon the sex of the parent. Arguing not for women’s rights but men’s rights, this case demonstrates Ginsburg’s ability to work within the biases of her listeners, to bring about decisions that helped erode those same biases.

Bringing us to the connection between Breonna Taylor – the individual case – and the Supreme Court. Weinberger v. Wiesenfeld was not “Weinberger v. Gender Equity.” It was brought on behalf of Steven Wiesenfeld. Father. Widower. Individual. With Ginsburg’s death, a similar case brought on behalf of Breonna Taylor won’t have the same chance, the same advocate, the same writer ofbrilliant “dissents” that RBG was notorious for. Even the likelihood that the case would be brought to the court at all is lessened without Justice Ginsburg. And that is a terrible loss.

Ginsburg’s arguments were often for equal treatment, not equitable treatment, in part because many sexist decisions were ostensibly made to “protect” women. RBG is famous for saying, “I ask no favor for my sex. All I ask of our brethren is that they take their feet off our necks.” For too many black Americans, removing pressure from a neck represents a literal first step toward justice. For many women, freeing a figurative neck is still insufficient, because many women’s feet remain firmly fixed to the floor, hemmed in by structures of racism and sexism.

As we all work to move equity forward, I believe that Justice Ginsburg would have continued to advance her thinking as well. She was open to finding her own mistakes, to being told she was wrong, to being unprotected from the truth. She said, "Women belong in all places where decisions are being made. It shouldn't be that women are the exception." But not just “present” at decisions, she furthered:

"When I'm sometimes asked 'When will there be enough [women on the Supreme Court]?' and I say 'When there are nine,' people are shocked. But there'd been nine men, and nobody's ever raised a question about that."

Once again, RBG illuminates our biases, and helps us to see that a statement that seems at first shocking, may not be so shocking after all.

We have lost a brilliant voice for justice at precisely the time when injustice needs her more than ever. It’s up to us to raise our voices now.

Elizabeth (Libby) Ellinas, MD is a Professor in the Department of Anesthesiology, Director of the Center for the Advancement of Women in Science and Medicine, and the Associate Dean of Women's Leadership at MCW. She is a member of the Faculty Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medicine.

The Truth About Trust

 From the 10/2/2020 newsletter

Director's Corner

The Truth About Trust

Adina Kalet, MD, MPH

In this Director’s Corner, Dr. Kalet considers the importance and complexity of trust in medical education and encourages us to hone our judgement and have courage …

Anyone who doesn’t take truth seriously in small matters cannot be trusted with large ones either.

-Albert Einstein

The first presidential debate this week has me thinking about the consequences of not being able to trust someone on whom you depend. We rely on our elected officials, like our physicians, to listen, have empathy, engage in respectful - even if sometimes - heated disagreements, make good judgements in very complex situations, have control over intense emotions and, most importantly, consistently tell the truth. To “trust someone” implies that we have confidence in that person, and believe that the individual will be capable, adaptable, and competent now and in the future – even when faced with novel, rapidly evolving circumstances, emotional and physical stressors, and unpredictable challenges.

While always in the background, trust (“entrustment” and “trustworthiness”) has moved to the forefront in the medical education. How we make these trust judgements in medical education – and in life – is worth a hard look.

How do we measure trustworthiness in trainees?

Hodges and Lingard point out that the discourse about what makes a “good” physician – a core responsibility of our work as medical educators – has moved through a series of distinct and overlapping eras over the past seventy years. In the Psychometric Era, we valorized measurable, highly standardized knowledge tests (e.g. MCAT, USMLE Board Exams). The next phase brought great enthusiasm for demonstrable, directly observable, and behaviorally measurable core clinical skills (e.g. oral exams, mini-CEXs, OSCEs). Next, and to the frustration of many program directors, organizations introduced comprehensive, nuanced competency frameworks designed to capture and document each learner’s developmental progress via new standards and milestones.

These changes reflect our evolving grasp of “quality” in medical education. As our understanding improves, we will uncover how to develop rich portfolios of assessment data for each of our trainees. But in the end, data do not make high stakes decisions. We do. And these decisions require making trust judgements and having the courage to act on those judgements.

Trust judgement barriers and opportunities

Unfortunately, clinical faculty are not very good at assigning objective measures of competence. My colleagues and I spent years trying to get experienced clinicians to make reliable (reproducible) measurements of medical student clinical competence. Even with lots of fancy, performance dimension, frame-of- reference, and behavioral observation training, experienced professionals are eccentric and resist standardization. This, I believe, is because there is no single “truth” about clinical competence.

Trust judgments are highly context-dependent and idiosyncratic. We tend to be internally consistent and we know a trustworthy resident when we see one. An experienced professional possesses a highly-honed identity and a strong sense of what a trainee must demonstrate to be trusted to care for “our” patients. Unfortunately, we disagree with our colleagues on when individual trainees can be entrusted to “fly solo” and more independently care for patients. Gingerich has challenged us to embrace this disagreement and see it as a strength rather than a weakness.

Furthermore, experts are also context-dependent! As we collect and collate more-and-more data from larger, diverse pools of experts, we must ensure that trust judgements are appropriately interpreted to protect students from the vagaries of any individual’s bias. This is what van der Vleuten and others call a Program of Assessment for Learning. Ultimately, trained competence“judges” will be charged with making final high stakes assessments regarding decisions such as advancement and graduation. These judges will determine if, based on solid evidence, we can trust a learner to consistently “do the right thing, at the right time, for the right person, and for the right reason” in their next phase of training.

Moving from theory to action

Social and cognitive psychology researchers suggest that competency judges need to both understand the value and limits of the objective data (e.g., exam scores don’t predict clinical skills competence, but they do predict future exam scores) and should explore and develop their judgement “sense.” This sense of who to trust is highly dependent on an individual’s characteristics, experiences and biases. Knowing thyself, in particular understanding one’s biases, is crucialbecause if we are cognizant of them and have integrity, we can make adjustments – “forcing” ourselves to slow down our thinking, toggle to a more analytical rather than intuitive deliberative strategy, when we are in danger of making an error. This takes work, discipline, and practice with feedback.

There is much interesting work to be done to ensure we have trustworthy physicians. Fundamentally, most of us make our trust judgements based not on what students know or can do (we can always teach that stuff), but on who they are as people. Do they always tell the truth even when it leaves them in a “bad light?” Do they admit when they missed a physical exam finding or forgot to check a lab or failed to follow up on something? Do they take the time to listen, attend to details, interact with empathy and kindness, even when stressed emotionally? Do they strive to improve rather than rest on their laurels or test scores? Do they seek to understand the perspectives of others? How do they handle being wrong or making a mistake? Can they sincerely apologize?

We are accountable to society to make defensible promotion and graduation decisions based on each learner’s competence and trustworthiness. These are difficult-to-measure, shifting concepts. We pledge to engage in the ongoing discourses and learn how best to make difficult, discerning judgements.

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.