Discussing the Grandkids: If RBG and Antonin Scalia can Find Common Ground, Then so can We

From the 1/22/2021 newsletter 

Director’s Corner

 

 

Discussing the Grandkids: If RBG and Antonin Scalia can Find Common Ground, Then so can We 

 

 

By Adina Kalet, MD MPH and Kathlyn Fletcher, MD MA

 

 

This week Drs. Fletcher and Kalet team up to argue that there are ways in which nurturing a patient-physician relationship resembles the healing our society needs today …

 

 

As clinicians, we learn to build rapport quickly. Most of the time this is easy. After all, people come to physicians and other health professionals seeking help or advice and are predisposed to trust us. Under most circumstances, we use our verbal and nonverbal skills to put the individual at ease and make an opening invitation, something along the lines of, “Tell me, what is going on?” or, “How can I help?” to get the patient telling their story. Evidence suggests that establishing a narrative thread, by encouraging the patient to speak uninterrupted and actively listenining  is the most efficient way to get to the “heart of the matter.” It provides information  for clinical reasoning and also establishes the therapeutic alliance needed to ensure shared decision making and a workable plan to address the issues that need tending to. And it usually takes under two minutes for the patient to come to the end of their story.  

 

Most of the time, this process works as it should, but occasionally, even seasoned clinicians find themselves struggling to make an initial connection with someone. When that happens, I (KF) pivot to something that I suspect we can connect about.  Given that I practice at the Veterans Affairs Medical Center and that many of my patients are older, my go-to is the grandchildren.  I have found that  when interactions aren’t going well, asking about grandchildren brings a mellowness that descends like magic.  Most people can’t help but smile.  Pretty soon the pictures are out, and we are connecting on a new level, with tenderness, talking about hopes for a better future.  

 

 

Recent events reverberate 

 

We can’t stop thinking about what happened at the US Capitol Building Wednesday, January 6, 2021.  In the days since, we have talked to many colleagues, friends and learners.  We have heard the same words time and again: shock, fear, shame, anger. 

 

Obsessively watching the news and checking newspaper websites has proven unproductive (not surprisingly), although it has been really hard to avoid.  As more details become available, the terrible implications of that day seem to increase, as do our anxiety and sadness.  Talking about the events does not lead to sense-making or understanding, and only reinforces negativity.  As we faced our colleagues and programs, we asked ourselves, How can we move from despondency and anger to action? How can we stop the feeling that we are banging our heads against the wall? 

 

Independent of one’s political views, we suspect that the thought of engaging the “other side” in dialog about the issues seems exhausting and futile.  But what other way is there?  

 

I (KF) found inspiration in an unlikely place, my email inbox! A message from Chad Kessler, National Director for VA Emergency Medicine, provided important advice about talking with  skeptical VA patients reluctant about receiving the COVID-19 vaccine.  He reminded us that, in some cases, providing facts – particularly when so much is still unknown – is not helpful.  For people fearful of the vaccine, trust in their doctors is more important than explaining the results of the randomized controlled clinical trials that led to emergency authorization. So, his advice was to focus on building the trusting relationship rather than trying to convert patients into vaccine believers. Asking about their health beliefs, listening to the answers, letting them know you care about them and their health, understanding their fears and concerns and, well, maybe asking about the grandkids, is time well spent.  

 

Perhaps the way forward isn’t to convince other Americans that they are wrong and that we are right.  Perhaps the way forward is simply expressing caring in different ways, finding ways to hold different views without fracturing relationships, and sharing a commitment to our common future, as embodied in our children and grandchildren. 

 

 

Reaching across

 

The New York Times reported on a nonpartisan project that brought 526 strangers from across the US and  the political spectrum together for a four-day retreat where they talked in small groups  about a wide range of issues that affected their lives.  The description of the project was inspiring.  Participants reported gaining perspective on how political and social policies affect other people’s lives.  It sounds so civil!  What is to stop of us from doing something similar in our own spheres of influence? 

 

 

An unlikely friendship as a beacon of hope

 

On the surface, the famous friendship between Justices Ruth Bader Ginsburg and Antonin Scalia defies comprehension.  And yet, it grew over decades across their tenures at the US Circuit Court of Appeals to the Supreme Court.  These two storied judges certainly did not agree in their work. Scalia regularly attacked the ideas expressed by RBG, but he never attacked her. She regularly and vehemently disagreed with his legal philosophy but had a deep and abiding respect for his, “captivating brilliance, high spirits, and quick wit.” They had a deep, respectful, and caring relationship with each other based on shared loves of  opera, theater and, of course, grandkids, sharing many meals and social outings.   These beautiful relationships which occur despite polarizing differences in politics seem exceedingly rare and precious these days.    

 

 

As physicians, we have the privilege of trustworthiness and the skills needed to find common ground. We routinely must navigate differences in belief systems toward solving a shared common goal. Perhaps we should expand our influence on civic discourse as well.   Asking about the grandkids, actual or only imagined, can focus us on our shared futures.  

 

 

 

 

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

 

Kathlyn E. Fletcher, MD MA is a Professor and Residency Program Director in the Department of Medicine at the Medical College of Wisconsin. She is the co-Director of the Graduate Medical Education Pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.

 

 

Reimagine: It’s Easy if You Try

From the 1/15/2021 issue of the Transformational Times

Reimagine: It’s Easy if You Try




Balaraman Kalyanaraman, PhD – Professor, MCW Department of Biophysics






Dr. Kalyanaraman takes a spirited look at the process of how we can reimagine many aspects of our lives, as well as our research (including the inspiring story of a COVID-19 researcher to whom we all owe a debt of gratitude), our relationships, and our health …

“Anything you do I can do better, but only if you do it first. That’s because I have no imagination, only a re-imagination.”
–Andrew Keith Walker

Right now, I bet you are telling someone, or have been asked, to reimagine some aspect of your work or life. Or perhaps you are reading about or watching an advertisement focused on reimagining. But what does reimagine mean? According to Merriam-Webster, the first use of the word was in 1825, and it is now among the top 1% of words that are looked up. I don’t know about you, but the word “imagine” makes me happy; hearing it frees up space in my brain. Conversely, the word “reimagine” makes me feel tense and anxious; it sounds task oriented and somewhat contrived! Well, the more I’ve pondered the word “reimagine,” the more I’ve realized I do not have to feel this way!

While trying to understand “reimagine,” I came across this anecdote about imagination from the book The Element: How Finding Your Passion Changes Everything by Ken Robinson, PhD:

An elementary school teacher was giving a drawing class to a group of six-year-old children. At the back of the classroom sat a little girl who normally didn’t pay much attention in school. In the drawing class she did. For more than twenty minutes, the girl sat with her arms curled around her paper, totally absorbed in what she was doing. The teacher found this fascinating. Eventually, she asked the girl what she was drawing. Without looking up, the girl said, “I’m drawing a picture of God.”  

Surprised, the teacher said, “But nobody knows what God looks like.”

The girl said, “They will in a minute.”

The girl was making an image of something she could not feel with her senses but could feel in her heart!

Try to reimagine “Imagine” written by John Lennon and inspired by Yoko Ono:

Imagine there’s no heaven

It’s easy if you try

No hell below us

Above us, only sky

Imagine all the people

Living for today

Hmm, the song is not the same when reimagined, right?

Clearly, reimagination requires a lot more imagination with a lot more passion!
In business, people “think outside the box” and reimagine everything from A to Z! (Do you have a novel idea? Sorry! Amazon already claimed it.) I considered synonyms for reimagine: reconceptualize, re-envision, reinvent, rethink, refine, re-create, reevaluate, or reinterpret imaginatively. It seems that “reimagine” is a word meant to inspire us; it captures the essence of what we need to do together or in collaboration that builds upon our strength.

Below, I’ve given my thoughts on reimagining a few aspects of research and life that are personal to me, but I know there are plenty more that you can reimagine. Some of these also could be applicable to other areas, such as workplaces, social systems, communication, teaching, childcare, sports, and recreation.


Reimagining ideas in research

How does one reimagine research ideas? Here are some ways to get started:

• To find one good idea, you ought to begin with several ideas. It’s important, though, to work on only one idea at a time.
• Become obsessed with your idea. Believe in yourself but be prepared to modify your idea.
• Always be ready to talk about your research ideas passionately at different levels depending upon your audience.
• Don’t be afraid to talk to your colleagues about the grant that was not scored or did not score well enough to be funded, even if they are not in your field!
• Rejection happens to everyone, no matter your reputation in your field. Even Nobel laureates experience it. Ideas, new and old, are rejected all the time. What matters is how you respond to criticism and reshape your ideas!
• Even though you may have the most cutting-edge idea, your proposal may lack widespread approval in the study section and require tweaking. Sometimes you have not exactly read between the lines in the summary statement, and you keep resubmitting the same idea while expecting different results. This is when you really need to get out of your comfort zone and reimagine—consider a chemist/biochemist collaborating with an immunologist, a vaccine researcher (perhaps, an extreme example)!

A great example of reimagining - Katalin Karikó, PhD

Katalin Karikó, PhD, a Hungarian-born biochemist, first laid the foundation for the messenger RNA (mRNA) therapeutics that have been used to develop the COVID-19 vaccine. Messenger RNA transfers the information from DNA to ribosomes to make specific proteins in cells. Karikó hypothesized that if a genetically coded synthetic mRNA was injected into mice, the cells in the body would make the specific protein instructed by the synthetic mRNA. In the 1990s, when she was faculty at the University of Pennsylvania, Karikó submitted several grant proposals on this idea. The proposals were repeatedly rejected, as the reviewers’ thought this concept would not work because of the potential degradation of the synthetic mRNA in the body and the potentially dangerous inflammatory immune reaction.

Despite professional setbacks, Karikó believed in her idea and continued the work with little money. Karikó began collaborating with immunologist/mRNA vaccine researcher Drew Weissman, MD; together they came up with the idea to modify the structure of uridine, one of the four nucleosides of the building blocks of RNA. As they predicted, the modified mRNA encapsulated in a lipid nanoparticle was taken up by cells; Karikó and Weissman then extended this technology to deliver the synthetic mRNA in mice.

They published a paper in 2005 and obtained NIH funding, and this new technology was patented by the University of Pennsylvania. BioNTech, a German company known for developing vaccines, licensed this technology, as did Moderna, a biotech company in Boston.

Karikó is now the senior vice president of BioNTech RNA Pharmaceuticals. The Pfizer-BioNTech partnership developed an mRNA vaccine designed to induce neutralizing antibodies against a portion of the SARS-CoV-2 “spike” protein that the virus uses to gain access into human cells. The antibodies against the “spike” protein recognize and neutralize SARS-CoV-2, thus preventing the infection.

Although Karikó encountered early setbacks in her research, she never gave up and always “imagined how the synthetic mRNA approach could treat so many diseases.”


Reimagining a work-life balance

Ideally, having a good work-life balance would give one satisfaction, fulfillment, a sense of purpose, and empathy.

During this pandemic, a barrier to optimal work-life balance exists for parents (more often mothers), particularly single parents, as they juggle work with childcare and home schooling.

People in the workforce are on different trajectories. Some just starting, some climbing up and trying to reach cruising altitude, some pushing the “reset” button, and some pushing the “rest” button. All too often, people (myself included) are too carried away in their work and give little attention to their life outside of work. Organizations conduct workshops to teach us ways to restructure our lives, which may not seem like rocket science, but it may be nearly as difficult. In what ways can we strike a good work-life balance?

I leave this to the experts to ponder. If we take the time to pause and contemplate it, we will be off to a great start.



Reimagining relationships

Professional advice on improving relationships is available everywhere, in workshops, talk shows, magazine articles. This is all well and good and may work for some people, but often we just need to reimagine the little things that are forgotten. Yes, I understand, “Physician, heal thyself,” and I think it goes well with “better late than never.” In his article, 10 Ways To Reimagine Your Relationship, Barton Goldsmith, PhD, says “doing new things together, and old things in new ways, makes your love stronger.” He proposes a number of ideas to reimagine relationships:

• Let go of the past. Learn to forgive and forget, and focus on the positives. Be grateful for each other and treat each day as a blessing. Write down at least one thing (daily or weekly) that you appreciate about your partner.
• Create your fantasy vacation. Daydreaming about your ideal vacation can be fun! During the pandemic, this may be hard to fathom, but things will get back to normal. And when you are able to take a vacation, you will be ready.
• Take a class together. Or do other activities with your partner: Take a virtual cooking class, learn CPR, learn a new language, take a walk through the park.
• Have lunch together once a week. This will help break the monotony.
• Ask your partner 20 questions. Show curiosity in your partner’s interests. What are some things you’ve always wanted to know about your partner but never took the time to ask?

To this list, I’ll add: Never be afraid to poke fun of yourself. Self-deprecating humor can ease those tense moments.

I am sure you can find many more fun things to add to this list.

Reimagining stress reduction through mindfulness

Emerging science convincingly shows that routine exercise, yoga, meditation, and mindful meditation can alleviate stress, anxiety, and depression. Herbert Benson, MD (Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital) pioneered the beneficial effects of meditation (e.g., lowering blood pressure and heart rate, and increasing brain activity). Functional MRI studies support the beneficial aspects of meditation to combat depression and anxiety.

Suzanne Westbrook, MD, a retired doctor of internal medicine, says, “our mind wanders all the time, either reviewing the past or planning for the future.” Mindfulness teaches the skill of paying attention to the present, and that life is in the moment. Mindfulness is not about trying to empty the mind; rather, it is about remaining present. It is a practice designed to improve brain health. Taking a slow deep breath through the nostrils (i.e., inhaling) and then slowly breathing out through the mouth (i.e., exhaling) will help you relax, reenergize, and reconnect. Repeat this inhalation/exhalation technique about 10 times. Use it as a “balance break” as needed during tense times (e.g., grant preparation). Mindfulness will improve your focus on the task at hand and face challenges with a healthy attitude, reduced stress, and increased energy. Mindfulness could be incorporated into many things—eating, conversation, listening. Some people practice 20–30 minutes of meditation that involves “mindful body scan,” during which one notices the sensations one is feeling without judgement. Indeed, mindfulness is presently at the top of the wellness universe as a stress reduction technique!


Let us imagine and then reimagine 2021! But not without first learning from 2020. Yes, hindsight is 20/20.



Balaraman Kalyanaraman, PhD, is Professor and former Chair of the Department of Biophysics at MCW.

Corrected link for this week's newsletter

Here is the corrected link for this week's newsletter.

Editor's Corner: Narrative Medicine, Reflection, and Patient Care

From the 12/30/2020 newsletter

Editor’s Corner

 

 

Narrative Medicine, Reflection, and Patient Care

 

 

Bruce H. Campbell, MD FACS – Editor-in-Chief of the Transformational Times

 

 

Dr. Campbell, who has a background in Narrative Medicine, shares how the basics of Close Reading (Attention, Representation, and Affiliation) serve us well, both in medicine and in life ...

Jamaica Kincaid’s short story, Girl, is a list of forty-eight instructions and life lessons that the narrator, a Caribbean mother, is passing along to her daughter. 

 

…when buying cotton to make yourself a nice blouse, be sure that it doesn’t have gum in it, because that way it won’t hold up well after a wash; soak salt fish overnight before you cook it; … always eat your food in such a way that it won’t turn someone else’s stomach; on Sundays try to walk like a lady …; this is how you sweep a yard; this is how you smile to someone you don’t like too much; this is how you smile to someone you don’t like at all; …

 

The list allows the reader glimpses into the spoken and unspoken cultural traditions from a place far away. 

 

 

Exploring fiction and the arts with students and residents 

 

During a December Zoom-based narrative workshop, I read “Girl” aloud with the entire third-year medical school class. The students had just completed their first six months of clinical rotations, and I knew that the short story would seem to be set a million miles away from their recent lives: 

 

…this is how you grow okra—far from the house, because okra tree harbors red ants; don’t sing benna in Sunday school; you mustn’t speak to wharf-rat boys, not even to give directions …

 

The students broke into small groups to talk about the story, its structure, the narrator, and outside allusions. I asked them to think about how they themselves might fit into the story, and if they felt any obligations having read the text. 

 

Now, it was time to make it relevant. “Having experienced this story,” I said, “we will write for five minutes in its shadow. Here is your prompt: Create instructions on how to be a medical student.” What they discovered from their writing was remarkable. They made their own lists. They wrote about experiences. They went back and spoke to their pre-medical school selves. The responses were varied and heartfelt. 

  

Earlier this fall, I taught a Narrative Medicine elective course for fourth-year medical students. We watched videos, looked at visual arts, listened to music, shared poetry, and read fiction by writers including Albert Camus, Rafael Campo, Flannery O’Connor, and Richard Selzer. On the surface, many of the pieces seemed entirely divorced from medicine yet, in every case, we found ways to respond to prompts in the shadow of the works, either in writing or other forms of creativity. 

 

 

This week, I watched Gabriel Osorio Vargas’ Oscar-winning video short, Bear Story, with our otolaryngology residents. The animated film, which is neither medical nor political, is a wordless story-within-a-story about things that are left unspoken. After a conversation about the history of the piece and our initial reactions, I asked the residents to write in its shadow about a time when things might have had more than one ending. As physicians, we could all relate. 

 

The relevance of Narrative Medicine

 

In each of experience, the students and the residents gamely read fiction or experienced other forms of creative expression. Although some likely viewed it merely as a pleasant distraction from lives that are constantly focused on science, clinical knowledge, and patient care, my goal was to get them to practice “close reading,” a narrative technique centered around the precepts of paying close attention, creating a representation of each story so it can be told to someone else, and being committed to an affiliation with the artist or storyteller. Narrative Medicine (as developed at Columbia University) teaches that enhancing the skills needed to “close read” a piece of literary fiction, a painting, or any other form of creativity, encourages clinicians to build the exact same skills that we exercise when we deeply engage with the stories our patients entrust to us. The more we practice, the better we get.  

 

When I work with students, I routinely ask them whether they value writing, reflective, and narrative exercises in their medical education. The majority believe that these activities are important, yet many believe that their peers view reflective exercises as a waste of time. In other words, “I think this is really great, but I doubt my classmates do.” Our data, as we found here and here, say they significantly overestimate their peers’ negative views. In reality, most can benefit from and appreciate this type of activity. 

 

 

As we work toward designing medical education for the future, we should find innovative, measurable ways to include narrative opportunities into the curriculum that build skills and encourage wellness. As one of the M3 participants wrote: 

 

At first, I was unsure how I would feel about spending my morning writing and reflecting with students, but I found this extremely useful … I wish we had more of this placed in our curriculum.

 

When given the opportunity, the students had no difficulty seeing the parallels between the girl in Jamaica Kincaid’s story and their own experiences running into medicine’s “hidden curriculum.” But, until the opportunity to reflect and write arose, the changes remained hidden. 

 

Next steps

At MCW, we have several narrative- and humanities-literate colleagues whose gifts remain hidden. There are unexplored community-based humanities partnerships and opportunities. It is time to explore how best to employ the medical humanities to foster character, enhance caring, expand patient care skills, and deeply enrich the lives of our students, trainees, staff, and faculty. 

 

 

Bruce H. Campbell, MD FACS is a Professor in the Department of Otolaryngology & Communication Sciences and in the Institute for Health and Equity (Bioethics & Medical Humanities). He is a member of the faculty pillar of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

 

 

On Joy and Sorrow in Our Long Winter

 From the 12/30/2020 newsletter

Perspective

 

 

On Joy and Sorrow in Our Long Winter

 

Ana Istrate, MD MS – Internal Medicine PGY-1 Resident

 

 

Dr. Istrate reflects on how her rotation through the COVID ICU as an intern is inextricably tied to the rest of her year …

 

 

 

Then a woman said, Speak to us of Joy and Sorrow.

  And he answered:

  Your joy is your sorrow unmasked.

-Kahlil Gibran, “On Joy and Sorrow”

 

 

At the beginning of this strange year, I took a solo trip to Washington DC, a city I had never seen before. Sunlight hit the Reflecting Pool like a knife, the air was uncommonly warm, and the National Mall was full of maskless strangers. It was impossible to find a quiet moment at the Lincoln Memorial. I met a family friend at the National Gallery of Art, where we made our way through currents of people, half in conversation with each other and half in conversation with the paintings and sculptures around us. I remember the contents of that conversation much less than I do the feeling of being in it, like floating on a raft through a luminous city, watching the threads of our childhood ripple in its wake.

 

It is curiously difficult to disentangle that more recent memory from all the memories of our lives that resurfaced then. Lately I find myself running through the locales of my past as if turning the pages of a photo album, aware that I am looking for a particular photo without knowing exactly which one. There is no living memory that seems best poised to clarify our present trial.

 

 

Rotating through the COVID ICU

 

Fragments of time in the COVID ICU remain more salient than what took place there: squinting through the glass doors of negative pressure rooms to see if oxygen requirements had shifted or ventilator settings had been recalibrated, noticing the unforgiving brown-red of facial pressure ulcers as we prepared to place another line, and catching a glimpse of our medical student’s eyes full of tears after our youngest patient had died. Equally vivid is the sensation of walking in each morning to be greeted by my co-residents’ familiar faces. It went unstated, as many important things in our lives somehow do, but they fueled my optimism.

 

I remember placing the phone back in its cradle at the end of one of my night shifts, having told a wife, whose halting, soft voice I don’t think I will ever forget, that her husband was not long for this world, to find one of my co-residents sitting next to me, prepared with morning eyes to receive the story of that night. It’s curious that we call these transitions of care “hand-offs.” At times, it seems we redistribute emotional loads too. (There is a certain generosity, I’ve also found, in the springing to action so specific to ICU care.)

 

Those of us who are interns have barely any point of reference for what being a physician was like before this pandemic, and we still spend much of our time taking care of non-COVID patients. We take it on good faith that the medical ICU was busier and more strained this winter than the last. For better or for worse, this profession and its members stand firm in their resolve to soldier on. And so, the mental and emotional burden on all those involved in patient care is nothing new under the sun, but perhaps more profound. I know I am not alone in the constant oscillation between hopefulness and seemingly impermeable disillusionment that this long season has brought us. There is a particular sting in the signs of indifference we encounter these days. It is present in the nonchalance of maskless strangers and the well-rehearsed backtracking of policymakers. Mercifully, we have little time to ruminate. That is the blessing of apprenticeship and its demands.

 

 

The thread unraveling behind us

 

And yet, that rushing in fragmented haste from one patient or idea to the next bewilders us into forgetting that there is a thread unraveling behind us. Grief, rather than being reserved for clearly demarcated losses, is less a discrete emotion and more a slow change of climate. At its most acute, it leaves us in tears. But mostly it is the inseverable string that links one loss to the next one in our lives. It becomes impossible to separate experiences, sleep deprivation notwithstanding. The death of my last patient in the ICU—a middle-aged, cadaverous man whose pancreatic disease marched him coldly into heart failure and whose death wish in his final hours left me heartbroken despite his ever hostile (wounded) demeanor—had nothing to do with COVID, and yet I cannot extricate his story from the pandemic playing out in the background.

 

So many of us take comfort in relegating this year to the corner of exception. We are keen to label this pandemic an anomaly. It is with a perverse kind of thrill, too, that the media delights in labeling this moment (and the next) as a historical turning point. And there is no doubt that, given everything that has happened, it will be. But how many of us can feel such cosmic shifts in our own inner worlds? It is frequently beyond the intimacy of human experience. Many of us have never confronted loss in so swift and raw a form, though we have been cognizant of it (I don’t only mean the loss of life but also the loss of dignity and patience and faith). I wonder if we can forgive ourselves when it all seems so muddled and even collides with the small joys we still discover in our lives.

The view from here

 

And lately, there is more cause to hope than there has been in the past year, though I follow the news from California and other overwhelmed regions of the world with a heavy heart. A collective joy surrounds these early vaccination efforts, which stems from a deep sense of relief. I couldn’t help but grin like a fool behind my mask as I felt the needle sink into my deltoid. (My vaccination card will be passed down through generations, I semi-jokingly tell my family and friends.) The winter solstice is behind us, and a new year is about to begin. In six months of residency, I have encountered more kindness than I ever expected. The waters of the Reflecting Pool greet me every time my cell phone wakens, and the Lincoln Memorial sits in the corner of that photograph like an afterthought. Life has not yet given me cause to change the backdrop, though the thread has unraveled so fast and far from there. Somehow, there’s no separating that afternoon from all the ones that followed.

 

 

 

Ana Istrate, MD MS received her MD from Case Western Reserve University. She is a PGY-1 in the Internal Medicine Residency Program at MCW.

 

The Patient Told Me “You cannot take care of me. You’re black and I don’t like black people.” How Do You Respond?

 From the 12/18/2020 newsletter

 

Perspective                       

 

 

The Patient Told Me “You cannot take care of me.  You’re black and I don’t like black people.” How Do You Respond?

 

 

Victor Redmon, MD

 

 

Dr. Redmon, a resident in the Med/Peds Program, shares what he has learned about speaking up when experiencing or witnessing moments of injustice …

 

 

My name is Victor Redmon.  I am a fourth-year internal medicine and pediatrics resident here at the Medical College of Wisconsin Affiliate Hospitals (MCWAH).  I have served on the MCWAH Diversity and Inclusion (D/I) Committee since my intern year.  Given the current political landscape and the ever-present pandemic, we felt it necessary to put out a narrative centered around “accountability,” both for yourself and your colleagues around you. 

 

The year of 2020 has been one for the ages. I have been more cognizant of reading articles addressing intolerance, injustice, and micro-aggressions this year, more so than in years past.  A student of mine recently asked me particularly good questions about accountability and when to speak up for yourself and others, when either your colleagues or patients make insensitive remarks.  I do not know if I gave him the best answer at the time, partly because I do not know if there is one right answer give.  

 

 

A patient care story

 

In medical school, I was taking care of a woman during my third-year internal medicine clerkship.  She was Caucasian and in her 60s.  We were treating her for a pneumonia, UTI and encephalopathy.  She was admitted overnight and the next morning I decided to follow her as one of my primary patients.  I walked in the room alone and introduced myself along with my role on the team.  She took one look at me and said, “You cannot take care of me.  You’re black and I don’t like black people.” I paused and then she went ahead to ramble on about other things that didn’t make much sense.  I asked permission to examine her and she stopped talking and let me perform my examination.  Once I was done, I thanked her and told her I would see her later in the day.  She said “Okay, but I don’t like black people.”  As we continued to treat her infections, she became more coherent and "with it.”  

 

The next day when I went to see her, she greeted me with a “Good morning,” 

 

I replied back, “Good morning. It looks like you are feeling better today.” 

 

She said, “Yes, I am. Who are you?”  

 

I realized that she did not remember our first encounter, so I re-introduced myself.  She thanked me and the team for our treatments.  The rest of the encounter with her was very pleasant and we discharged her home eventually.   

 

I keep thinking about how and why I handled this encounter the way I did.  I knew the patient was delirious from her active infections and hospitalization.  Does that give her a pass for what she said to me?  How much truth was in her words?  I never told anyone on my team about what she said to me.  Not my fellow third-year student colleague, not my intern, not my senior resident and not my attending.  Why did I choose not to?   

 

 

Another patient care story

 

During my second year of residency, I was senior resident of one the medical ward teams at the VA.  We had a patient who was notorious for his abuse of the health system, bigotry, and sexism.   He was homeless, and every time he was admitted to the hospital, it was a saga to get him discharged.  If you worked at the VA long enough, you knew this guy by name alone.  You were either on his good side or his bad side.  I had taken care of him several times in the past, starting when I was still a medical student.  The patient and I had a good doctor-patient relationship, and he was never disrespectful to me.  I wish I could say that for others.   

 

My third day on the team, my intern following this particular patient came back to the room laughing.  I chuckled and asked him what was so funny.  “Oh Mr. So-and-So being Mr. So-and-So,” he replied, “he’s not so bad if you’re on his good side.”  The patient had been medically ready for discharge for weeks and we had been working with social work and case management to find him a place to stay since he required home oxygen therapy.   After rounds, my attending went to speak with the patient alone to basically tell him that he will be discharged the following day, and he could not stay in the hospital any longer.  My intern, who was of East Asian descent, was now very nervous about how this will affect his relationship with the patient.  I told him that the patient would be more likely to be mad at the attending, but I offered to be there for him if he needed me.  My intern declined and said, “I’ll just see how it goes.”  

 

The next day, my intern came in laughing again: “Mr. So-and-So being Mr. So-and-So.”  I took it as a positive sign and moved on.   During rounds, my attending asked how Mr. So-and-So was doing today.  My intern said “He’s fine, nothing has changed medically.  But he hates you,” referring to my attending.   My intern then said, “He says he never wants to see ‘that brown, Jihad *********** again’.”  

 

This statement is wrong on so many levels.  My intern then laughed it off.  My attending, of Indian descent, was silent for a moment, but then said, “Well unfortunately, he doesn’t have a choice.”  I looked around and the rest of the team (the other intern and two medical students) was dead silent.  As a team we moved on and finished rounds.   The patient was discharged without much drama.  

 

Internally, I was an emotional wreck.  I felt anger, remorse, shock and regret all at once.  I didn’t know how to respond in that moment.  I was with people I had not grown comfortable with yet, so I froze and didn’t respond at all.  

 

The following day was switch day for both the interns and the attending, so I had a whole new team.   Approaching the patient about what he said would have not been a battle worth fighting.  However, I never approached anyone else on the team about what was said, how they felt and how we could have done things differently.  I missed an opportunity to point out intolerance and injustice and to take a stance on a perpetuated culture that needs to end.  I feel like I failed my team.  I feel like I failed as a leader.  

 

 

What I have realized

 

I could continue to write about countless stories that are similar and worse than which I discussed above.  

 

Whatever personal accounts or stories that my friends and colleagues have experienced, these types of encounters happen every single day.  Often, we are silent and decide not to say anything so we can keep the peace.  I no longer regret being timid in those moments. I felt I was doing what was necessary to “survive” and progress to where I want to be in life.  I imagine that others have taken similar stances for similar reasons.  

 

I do not think there one “right or wrong” way to handle these situations, but I do think it is a reflection on how little improvement we have made as a society in addressing these issues. 

 

I realize now that it is not about me or one person at a given time.  It’s about all of us as a society.  As a medical society, we have a significant impact on our communities, especially the marginalized communities.  It does not matter if you are a medical student, a physician, nurse practitioner, physician assistant, a nurse, a medical assistant, a physical therapist, or a speech therapist.  You have a voice.  You have a platform to use to speak out against injustice, intolerance, and micro-aggressions that we too often meet in our work environment.  

 

I am far from perfect and I do not pretend to be free of my own implicit biases.  I hope to further an inclusive culture.  I want to be called out if I am being insensitive or have a moment of intolerance -- because that’s how we grow as humans.  I hope that I can learn from my failures and successes.  At the same time, I hope others can learn from my experiences and their own experiences as well.  

 

 

A challenge to all of us

 

We can no longer stay silent about these issues.  There is a lot of work to be done, but small simple steps eventually lead to larger ones.  I intend to start speaking up for my colleagues; especially for my trainees and students, who are in a particularly vulnerable period in their life.  I hope I am not alone.  For MCWAH D/I, we hope that we are not alone. 

 

 

 

Victor Redmon, MD is a fourth-year resident in the MCW combined medicine and pediatrics (Med/Peds) residency program. 

 

 

Winter Equinox - Poem

From the 12/18/2020 newsletter


Winter Equinox

Tamera Amadei-Bourne 

The darkest day of the year
announces itself in a fortnight
heralding for us to 
pause – 
reflect – 
heal.

Winter slowly knocks
on the door,
grasping its icy, bone fingers
to the frame,

inching it open,
expanding the dark, crisp night.
failing to eliminate the pin prick of 
light.

Tress adorn with candles,
illuminating the familiar faces – 
Parents, child, spouse
as gifts are passed around.
Laughter defrosts the chill
enveloping us into an embrace,
eroding the darkness into a fine dust – 
freeing the light.

 This week’s poem is by Tamera Amadei-Bourne, a Research Program Assistant, whose passion is writing. She began writing when she was seven, and that love led to a degree in Mass Communications/English with an emphasis in Public Relations and Creative Writing. Poetry helped her heal through a personal tragedy, and she had the pleasure of seeing three of her poems published. This poem is inspired by the approaching Equinox and the turbulent times we are currently experiencing.

Can You Recommend a Good Primary Care Provider?

 Perspective/Opinion

Can You Recommend a Good Primary Care Provider?

by Andy Petroll, MD

Dr. Petroll, who conceived and founded the Froedtert & MCW Inclusion Health Clinic, describes the role that the clinic plays to enhance services to the LGBTQ+ community in Milwaukee and beyond...

Since I began my career in medicine nearly twenty years ago, and as a member of the LGBTQ+ community, I would hear this question frequently. Usually, the next sentence was the questioner expressing a preference for a provider who was, themself, a member of the LGBTQ+ community, but stating that they would be willing to settle for someone who wasn’t. At minimum, they wanted a provider who would make them feel comfortable and would easily understand them when they talked about their sex life, their gender identity, or their relationships with their partner and families, while also providing them with the care they needed. I’d always do my best to make a recommendation, but I knew that what they were looking for was hard to find, especially if their insurance required them to stay within one health system or if they wanted a provider in a certain part of town. A handful of large and mid-sized cities had LGBTQ- focused clinics, many of which had been well-established for decades, but here in Wisconsin, there were none.

Identifying concerns for LGBTQ+ patients

What would often follow this question was a story about a negative experience in healthcare. Sometimes, their provider had not understood or had not wanted to hear about the kind of sex they were having. Maybe they were asked which parent was “really the mother.” Maybe they were called out of the waiting room by their legal name, rather than the name they actually used and that reflected their gender identity and appearance, sending shockwaves of embarrassment, anger, or fear through their bodies immediately before entering the exam room. Maybe they had asked for medication for HIV prevention and their provider was unfamiliar with or unwilling to learn about it or, worse, chastised them for even asking. In some cases, they had subsequently acquired HIV. Maybe they had had a good experience with their provider, only to have a staff member ask them an inappropriate question, or, horrifyingly, try to convince them that their sexual orientation or gender identity was immoral. Maybe their provider was “nice enough,” but “seemed uncomfortable” discussing sexual health, or never offered appropriate screening for STIs or certain kinds of cancers.

Of course, the stories I heard were a skewed sample. People who were satisfied with their care wouldn’t have reason to ask me for a recommendation or tell me their story. Nonetheless, after years of these conversations, I knew there was a demand for better healthcare for LGBTQ+ people. People wanted a combination of things:

• A physical space that made them feel like they belonged

• Clinic staff that would understand them without having to explain themselves

• A provider who would know what preventive tests they needed and who would comfortably listen to and competently answer questions about their sexual health

• A provider who could explain and prescribe medications that would affirm their gender

A provider who would know that it may have taken extraordinary courage for them to even come to the appointment.

Meeting an unmet need

The hope to meet these expectations formed the vision for the F&MCW Inclusion Health Clinic. The journey from conceptualization to inauguration was long. Along the way, when presenting this idea to senior leadership, I was met with enthusiastic support beyond my expectations. Appropriately, we were asked to formulate business plans similar to any new, proposed venture. After revising our plans, assembling MCW providers with significant expertise, training staff, decorating our clinic space, developing of a webpage, and doing outreach at community events, the plans for the clinic were approved. After more than three years of planning, we opened the F&MCW Inclusion Health Clinic in July 2018.

The goal is for the clinic to deliver comprehensive care within a clinical space that feels familiar and welcoming by providers who are experienced with and passionate about LGBTQ+ health. The clinic opened with six providers from several specialties (Internal Medicine, Infectious Diseases, Obstetrics/Gynecology, Psychiatry). The clinic population grew steadily, limited only by the number of new patient openings we had available. Over time, we delightedly welcomed additional enthusiastic providers from additional specialties (Endocrine, GI) into the clinic. Recently, we onboarded two new primary care providers to help meet the demand for our services including,notably, the clinic’s first transgender physician, bringing the number of providers to twelve.

The response

Reactions to the clinic have been more positive than I had even imagined. Often, patients start their first visit by expressing gratitude that the clinic was opened, even before we have provided them any care. Others express that their visit to the IHC was the first time they felt truly comfortable in a healthcare setting. Some are elated to begin their journey of gender affirmation easily and without barriers. Parents have been relieved to finally find a place where their adolescent children (we see patients age 15 and older) can get the care they need and have their questions answered. Community organizations and major corporations have invited us to speak about the clinic and a national conference requested that we present on the process of opening it. Patients travel from Milwaukee, throughout Wisconsin, and at least two neighboring states to see us. Our patients have been integral in providing feedback that has helped us improve. Some have pointed out the flaws in the multitude of systems and personnel that constitute their experience in our healthcare system. Some wish they didn’t have to wait so long to see us (thankfully, now, they don’t!). We are grateful for all types of feedback. We view this clinic as a community resource that should be continuously shaped and grown through input and feedback from the community we serve.

Do we really need a specialized LGBTQ+ clinic? Shouldn’t every provider be able to provide care to this population?

These are appropriately challenging questions that I heard several times during the journey to develop the IHC. In theory, the questioners are right. Ideally, all clinics and providers should be able to provide competent, comprehensive, and affirming care to LGBTQ+ patients. In reality though, without purposeful efforts in every clinic, staff members who create a welcoming environment, and providers who become culturally fluent and clinically competent delivering LGBTQ+ healthcare, patients will continue to have the kinds of negative experiences I described above.

Reaching beyond our walls

In addition to striving to be a center of excellence for LGBTQ+ healthcare, we also view the IHC as a catalyst for improving LGBTQ+ health in our region. We regularly provide clinical education on LGBTQ+ health to providers in our system and our state. This semester, our newly approved M4 elective in LGBTQ+ health began offering MCW students the chance to graduate with a more in-depth understanding of how to provide LGBTQ+ healthcare. We also regularly provide clinical experiences for MCW housestaff. I hope that with continued educational efforts, there will come a day when a clinic like the IHC is no longer needed. Until then, the IHC, and other clinics like it, are essential for the lives, health, and dignity of LGBTQ+ people.

It has been an honor to be able to bring the IHC into being. I couldn’t possibly name all the people whose support and hard work were essential in developing the clinic. Nonetheless, I am extremely grateful for their work and their encouragement. I am humbled by the passion and dedication of my colleagues in the clinic, both providers and staff members, and by the administrators from multiple departments who pour their hearts into supporting this multispecialty clinic.

Our work will continue. We see many ways to expand the size and scope of the clinic to better meet our patients’ needs and will continuously pursue these ideas. We will continue to solicit and react to our patients’ feedback with the goal of optimizing their care. We will continue to educate learners to populate the healthcare professions with competent and enthusiastic providers of LGBTQ+ healthcare. We will know we achieved our goal when every LGBTQ+ person can walk confidently, without fear or hesitation, into our clinic, and every medical clinic, and receive outstanding, complete care, with the dignity they deserve.

RESOURCES:

• If you want to learn more about the Inclusion Health Clinic, visit Froedtert.com/lgbtq

• If you are interested in having our group provide LGBTQ health training for your clinic or department, please email me.

  
  

If you are interested in self-directed learning on LGBTQ health, I recommend the National LGBTQIA+ Health Education Center (https://www.lgbtqiahealtheducation.org/) which has dozens of high- quality learning modules.

Andrew Petroll, MS, MD, is an Associate Professor in the Division of Infectious Diseases in the Department of Medicine at MCW. He is Medical Director of the Inclusion Health Clinic.