Shared Change is a Rigorous Process

From the 4/2/2021 newsletter

Perspective/Opinion

Shared Change is a Rigorous Process

Jeffrey Amundson, PhD, Travis Webb, MD, MHPE, Amy J. Prunuske, PhD, and Adina Kalet, MD, MPH

The team describes the development of the curriculum transformation working groups, reports on their recent activities, and looks forward to the Human-Centered Design approach that will clarify and accelerate the curriculum redesign …

 

Change is hard.  However, when change is a shared experience, many of the stakeholder concerns and expectations can be attenuated by communicating and demonstrating conscientious and prudent planning.  The process of curriculum change is a large-scale change that requires thoughtful organization of various stakeholders into manageable and effective teams.  

MCW is currently transforming our traditional 2 + 2 curriculum into one that integrates foundational science with clinical knowledge and skills through case-based, inquiry focused, individualized learning with an emphasis on inclusion and wellness.  To achieve this transformation, various change management strategies have been used including Kotter’s 8 Step process of change and components of Implementation Science to create a rigorous process of communication and structuring with stakeholders. 

Envisioning and building the team 

A common starting point in most models of change management is to communicate a vision of the most important reasons for change. In Kotter’s 8 Step process and similar models (e.g., ADKAR), shared vision is the foundational concept for change. 

This first step at MCW began when all course directors, chairs, education deans from all campuses, Curriculum and Evaluation Committee (CEC) members, selected education staff, and student representatives from all campuses were invited to a Curriculum Exploration retreat held on October 2, 2019.  This involved approximately 100 stakeholders who began an iterative process that developed principles to provide a foundation for medical school curriculum redesign at MCW.

The next step was to create a team of representative stakeholders responsible for coordinating and guiding teams through effective communication and activities. The Curriculum Exploration Steering Committee became this coalition, and included basic science and clinical chairs, course directors, administrative leaders, and Curriculum and Evaluation Committee (CEC) representatives. These same individuals were dispersed throughout the subcommittees to promote contiguity for effective communication and activities. Please see the steering committee and subcommittee rosters at the end of this article. 

Exploring the five principles

After ratifying the new curriculum principles, the steering committee charged subcommittees of key stakeholders to consider how to implement these principles into a comprehensive curriculum considering the complexity of the three-campus institution. Subcommittee members were recruited via email, InfoScope postings, and verbal communication. The kick-off meetings of the “Principle Groups” occurred September 9th and 10th, 2020.

A Principle Group subcommittee took charge of each of the following: 

• Principle 1: Integration of foundational and clinical science learning throughout all years of curriculum.
• Principle 2: A systematic approach and focus on assessment that drives learning and assures that students achieve desired competencies.
• Principle 3: Individualized approaches to learning that are ultimately tailored to student interest and career goals.
• Principle 4: A student-centered, inclusive culture with a focus on wellness.
• Principle 5: An evidence-based instructional approach that is inquiry driven and utilizes active learning.

The subcommittees provided monthly progress reports starting in September 2020 which culminated in final reports on January 1, 2021 (a link to the five principle group reports is available here from an MCW computer or through InfoScope). Additionally, as Lindsey Bowman, Senior Administrative Assistant for Curriculum noted, the guiding coalition efforts were a standing CEC agenda item during the 2020-2021 academic year. These updates provided opportunities for discussion at seven curriculum meetings over the 2020-21 academic year. The coalition communicated monthly with the CEC, its M1-2 subcommittee, its M3-4 subcommittee, and the executive committee. In addition, there were also quarterly meetings with the Directors of Medical Student Education, the M1-2 Course Directors and Coordinators, the Advanced Clinical Experience Committee, and the Clerkship Directors.  It is important to emphasize most of this rigorous process was undertaken while adapting to the impact of the pandemic.  

These individuals have done an outstanding job through the first steps and generated numerous short-term wins (another common component of “models of change”), including formulating a set of design principles from the final Principle Group reports (i.e., Core Content, Instructional Approaches, Assessment, and Faculty and Student Support).  These principles served as the next piece of the process to create a larger team of volunteers.  Additionally, as in many models of change, the next steps will include establishing reasonable targets and, in MCW’s case, using competencies, learning objectives, and suitable governance frameworks to reduce barriers for stakeholders to work across silos.  

The next steps

The next stakeholder teams will clarify medical school learning objectives around: 

• Patient Care and the Health Care System
• Knowledge for Practice
• Communication 
• Personal and Professional Identity 

In models of change, this represents the transition from preparation to initiation of change.  

Importantly, these proposed changes rely heavily on stakeholder input so stakeholders can learn from mistakes and adjust the process as it moves from planning to implementation (as well as adjusting during implementation).  

MCW, with help from the Kern Institute’s Human Centered Design Lab, will capitalize on this input in the next steps.  Human-Centered Design is a team-based approach to problem-solving that uses empathy to develop a deep understanding of any problem.  This allows the problem to be clearly articulated, paving the way for the brainstorming of solutions, followed by prototyping the solution that is most impactful.  This will lead to a process of continuous and intentional short-cycle iterative improvement to the solutions design. 

Much work is yet to be done, and we hope that all faculty, staff, residents, fellows, and students will engage in this exciting process to achieve sustained acceleration (a very important component of change). Given the efforts put forth so far and with a continued rigorous process, the shared experience of change can achieve a fruitful transformation.

Jeffrey Amundson, PhD is a Postdoctoral Fellow in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. Travis Webb, MD, MHPE is a Professor in the Department of Surgery and Associate Dean for Curriculum at MCW. Amy J. Prunuske, PhD is an Associate Professor at MCW-Central Wisconsin. 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.

COMMITTEE AND SUBCOMMITTEE ROSTERS

Curriculum Exploration Steering Committee:  

Amy Prunuske, Travis Webb, José Franco, John Hayes, Alexandra Harrington, Malika Siker, Jonathan Marchant, Bill Hueston, Matthew Hunsaker, Lisa Dodson, Adina Kalet, Jon Lehrmann, Marty Muntz, Melinda Dwinell

Subcommittee Members (Faculty and Staff):

Jennifer Hinrichs, Joe Budovec, Marty Muntz, Mindy Dwinell, Jonathan Marchant, Craig Hanke  Sandra Pfister, Lisa Cirillo, Joe Brand, Hershel Raff, Steve Hargarten, Bipin Thapa, Beth Krippendorf, Marika Wroszek, Teresa Patitucci, Allen Last, Craig Young, Jeff Fritz, Maria Hintzke, Megan Waelti, Terra Pearson, Kathlyn Fletcher, Karen Marcdante, Brian Lewis, Lisa Dodson, John Meurer, Monica Shukla, Kerry J. Grosse, Catherine Thuruthumaly, Ankur Segon, Alan Bloom, Ellen Schuman, Karin Swartz, Carley Sauter, Leslie Ruffalo, Robert Treat, Erin Green, Mary Ann Gilligan, Tavinder Ark, José Franco, John Hayes, Paul Knudson, Elizabeth Hopp, Bill Hueston, Jules Blank, Roy Long, David Brousseau, Pat Foy, Kathleen Beckmann, Brian Law, Jordan Cannon, Johnny Neist, Dan Stein, Jon Lehrman, Malika Siker, Cassie Ferguson, Himanshu Agrawal, Theresa Maatman, Kurt Pfeifer, Kristina Kaljo, Linda Meurer, Anita Bublik-Anderson, Becky Bernstein, Jean Mallett, Adrienne German, Nicholas Yunez, Travis Webb, Ali Harrington, Ashley Cunningham, Amy Prunuske, Patrick McCarthy, Adina Kalet, Ellen Sayed, Ashley Zeidler, Art Derse, Jacob Prunuske, Erica Chou, Megan Schultz, Jay Patel, Joe Barbieri, Curt Sigmund, Matt Hodges

Subcommittee Members (Students):

Kelli Cole, Mario Castellanos, Marko Ivancich, Chase LaRue, Taylor Brockman, Haley Pysick, Gopika SenthilKumar, Alec McCann, Colton Brown, Emily Nordin, Jess Sachs, Connor McCarthy; Syndey Newt, Emily Schaefer, Phil Hartfield  

Recruitment Season 2021: It’ll all be Worth it!

 From the 3/19/2021 newsletter

Perspective/Opinion

Recruitment Season 2021: It’ll all be Worth it!

Camille B. Garrison MD

Dr. Garrison describes how the Ascension Columbia St. Mary’s Family Medicine residency program adapted to the need for virtual interviews as they recruited their next cohort of residents, relying on social media, entertaining videos, and human interaction …

I had all the right people in place. From the perfect faculty leading the recruitment committee, the most enthusiastic residents set to attend our much-anticipated summer and fall recruitment fairs, the administrative team set with our new interview schedule, and an opportunity to pilot our new ranking system. I remember the heavy feeling of desperation that came over us when we heard that recruitment season and interviews would be transitioning to all things virtual. But once we got over the initial shock of what this would mean for our program, our team became energized and got to work. 

It was refreshing to have residents, faculty and administrative staff who were undaunted by the unknown, as COVID-19 likely prepared us for this moment too. We only had four months to prepare as our first recruitment event would take place in July, so we started to brainstorm which issues to tackle first: website edits, videos, social media and interviewing platforms, recruitment fair participation, visiting students, audition rotations, and finances. Looking back, this was a pretty significant list of issues, but all of the planning and effort that went into each of these areas has truly proven fruitful even without knowing the results of this year’s Match and, for that, I’m grateful.

As Program Director, I know that we have awesome faculty who teach Family Medicine excellently. I also know that we serve an amazing, underserved community and that we meet the community’s needs through clinical care and resident education. We also have a strong reputation of providing high quality care to our patients and their families. I felt like those qualities would not be that hard to convey to potential applicants in virtual format, even after all that the pandemic had brought to us. But the one thing that I was worried about not being able to convey adequately was the sense of family that people feel when they are at our program. 

When I was a medical student, I decided on Family Medicine after I rotated with our program in my fourth year. I remember sitting in rounds one day thinking, I could work with these people! It was the people who helped me see my calling in Family Medicine. It was the people who served as perfect role models for the type of physician I wanted to be. For me, the people included residents, faculty, clinic staff, administrative staff and the patients;  they are “the thing” that makes the program what it is and I wanted to let applicants know this before the interview day. Our goal was to effectively get people to sense “that thing” that I felt when I first came into contact with our program years ago. 

So, we decided to do what we did best, which was to be ourselves as we introduced people to our family. From the quirky, “80s-inspired public service announcement style” clinic tour to the Instagram page created and maintained by select residents, highlighting our team members and their favorite things. Our social media platforms helped us introduce people to our patient population and frequently displayed our commitment to social justice in light of current events. I, along with several residents, spent a lot of time talking with potential applicants during recruitment fairs and scheduled WebX meetings thereafter. We worked closely with our sponsoring institution ensuring that we would have a more professional video to introduce applicants to our hospital wards and clinical faculty, and that our website would be attractive and more appealing than our competition. We worked hard! We banded together as good families do. We were innovative problem solvers and had fun doing it. 

I truly believe that, this year, we interviewed more candidates who were genuinely interested in our program and our offerings and who had already done their research on us. Many of them spoke of how much they appreciated the details we put into our website and were able to vocalize those key details about us during their interviews. It was also great to hear that many of them loved that quirky, 80s-inspired video. Many applicants visited our social media platforms and were able to see the diversity within our program and surrounding community. I believe that the type of candidates we interviewed really seemed to have similar passions and interests which aligned well with our mission and commitment to Family Medicine. 

Overall, my goal is to always recruit individuals who have “that thing” that I was first attracted to when I was a student rotating at our program so I look forward to seeing who will join our team this year. This truly was an exciting recruitment season and I can’t wait until Match Day!

Camille B. Garrison MD is an Associate Professor in the Department of Family and Community Medicine at MCW and residency program director for the Ascension Columbia St. Mary’s Family Medicine Program.

Work and Career in that Order: Residency is Just the Next Step in the Life of a Physician

 From the 3/19/2021 newsletter

Director’s Corner

 

Work and Career in that Order: Residency is Just the Next Step in the Life of a Physician

 

By Adina Kalet, MD MPH

 

Dr.Kalet celebrates Match Day 2021 by exploring how residency, as difficult as it can be, offers opportunities for growth and a path to a rewarding career …

 

Later today, more than 48,000 medical students will find out where they will begin residency training in July.

While the numbers vary, about half of students matched to their top choice, and about two-thirds to one of their top three. About 5% of all applicants did not match and have spent the week working with deans and faculty to “scramble” into open slots. There will be disappointments and not everyone will be thrilled.

In normal times, MCW-Milwaukee would be hosting our 200 students, their families, and their friends in an Alumni Center celebration with balloons, short speeches, finger food, intense excitement, and identical “I MATCHED!!!” t-shirts. Even still, today’s celebration and energy will be shared on social media and over the internet when, at 12:00 noon EDT, students open the e-equivalent of an “envelope” and learn for the first time to which program they have matched.

Today is one of the most significant watershed moments in each of their lives. They will, finally, be able to glimpse more clearly the outlines of their future selves.

 

The importance of “place” in residency training

Where a physician trains does matters. Residency takes each young physician to a city or town where they are committed to stay for a while and, although it varies by specialty, over 50% of physicians end up practicing in the state where they complete training. The shared experience of residency builds profound and lifelong friendships forged during long nights-on-call and the intellectual, physical, and emotional challenges inherent with the transition from medical student to practicing physician. Clinical “habits” are formed and imprinted for a lifetime.

I am amazed how intense the experiences I had during my own residency remain. While I have not drawn blood cultures, done a lumbar puncture, or placed central intravenous line in the subclavian vein in three decades, I still recall the rhythm of each procedure, the proper aseptic techniques, the positioning of the patient, the feel of the cannulas and needles, and the proper documentation. My fingers remember the sensation of the needle overcoming resistance, piercing the skin, and finding the proper space. During my residency, I learned to rehearse “delivering bad news,” and still do so as I walk toward a difficult conversation. Facing an emergency, I still summon courage the same way I did when I was wearing the “code beeper” and running toward, rather than away from, the crisis. Always take the stairs. Never wait for the elevator. Hope the nurses are already there with the cart. Will the medical student by my side be ready to do chest compressions? I learned to be ready when I arrived. 

 

Looking for meaning during residency training

Some things have changed about the match since I was in medical school. While many of my classmates in the early 1980’s applied to only one type of residency, a sizable minority listed more than one type of program on their match lists, allowing the algorithm to determine whether they would end up as an internist, pediatrician, dermatologist, or orthopedist. I share this because I now know how this approach worked out. These peripatetic students understood something the rest of us did not, and here is the lesson: It is much more important to choose what kind of career you want to have, than which clinical discipline or “tribe” you seek to join. They understood that there are, for most of us, many paths to a satisfying life as a physician.

Here are some examples. One friend knew she wanted to spend her career in women’s health, so she applied to and ranked OB/Gyn, family medicine, and internal medicine programs. Another close colleague, hoping for a quiet, suburban, “Marcus Welby” type of practice, applied to both family medicine and internal medicine. They let the match decide their specialty, knowing that each path would lead to their goals. Other classmates were so committed to where they wanted to live that they applied to several different specialties in the same city, believing that the type of residency was secondary.

This type of flexibility seems very old fashioned now and there are reasons for this. Over the past decades, for example, the increase in medical school graduates has far outpaced the increase in first-year residency positions, placing an intense “What if I don’t match?” pressure on students that we never experienced. Today, certain clinical fields are so competitive that students feel the need to plan far ahead, take time off to complete specialty-focused research, concentrate on doing things that will make them more attractive for the few spots, and audition extensively. Back when each residency program had its own pen-and-paper application form, we applied to ten or so institutions and ranked five to eight. These days, the number of electronic applications submitted by each applicant continues to climb, and it is not unusual for a medical student to apply to over sixty programs hoping for a handful of interviews. Different times, for sure. But instructive. Life as a physician has always been a journey with many choices, and residency is just the next step after medical school.

 

“Careers are made in retrospect”

Most of us can look back and see the paths we took, the opportunities we seized, and the roads not taken. But discerning the path that still lies ahead of us is impossible. It is rare to meet someone who, in retrospect, knew where they were going from the very beginning. Nearly half of the students who match today are entering different fields than they had envisioned for themselves when they started medical school. As many as 20% of residents switch fields before the end of their training. Mid-career physicians often retrain into new clinical specialties, seek advanced education, or pursue mid-career fellowships in a wide range of areas.

My woman’s health friend, for example, ended up happily doing groundbreaking immigrant health research. “Marcus Welby” is now a professor and urban health services researcher. Even though they did not end up where they might have predicted, their training gave them the flexibility to build satisfying and meaningful careers.

This is really good news. It means we can each feel free to be fully in the present. With reflection, mentorship, and opportunity, we can redirect our work. As the ancient Greeks advised: Know Thyself. Then move in that direction.

The wonder of a career in medicine is its flexibility and ever emerging opportunities. So how do we make good choices?

 

Residency is a learning experience, but it is also a job. Some advice …

Find work that matters. Look for the aspects of your new careers that intrigue you and get you out of bed in the morning. As novice physicians, you will learn about yourselves and your patients as you engage with both the well and the chronically ill. You will learn to prioritize and lead teams as you work through the daily tasks and confront the patients who decompensate in front of you. You will perform procedures that require significant manual dexterity and employ advanced technology. You will engage with colleagues, team members, and communities. You will collect and analyze data, peer through microscopes, study the results of sophisticated analyzers, and seek the truth and beauty hidden in a radiologic image. You will deal with unimaginable ambiguity. Learn to think, to feel, and to engage at various paces and rhythms — optimally, for your entire professional lifetime.

Take time to reflect and grow. Listen to others as they help you discern how your work impacts you. Find ways to stay well even as you do the hardest work in your life.

 

Residency is only one step on the path to a career

Training is extremely hard, and it can become a life of one challenge after another. Yet, as residents touch the lives of patients, learners, colleagues, friends, family, and the community, opportunities for growth, character development, and changemaking present themselves. Some residents will avoid these occasions while others will seek them out. To some, the work of residency will drive them forward into rich careers, dictating their goals and what they work on. For others, the opportunities will fade into the background while they are “busy making other plans.”

This is what continues to astonish me. While residency is an overwhelming experience, there are those who take full advantage of its opportunities. They learn early that training is only one step toward a career that will take unexpected twists along the way. As faculty, we must recognize their sacrifices, yet help them stop and consider: What do you want to be able to say you have done? How will you know you have done it, influenced others, engaged in those conversations, made the world just a little better? How might I help?

 ___

The next group of residents will arrive soon. This week’s Transformational Times celebrates the agility, flexibility, and compromise inherent in recruiting the next cohort of residents during a pandemic. In this issue, you will read about how our MCW community of residency program directors, students, and residents have faced and embraced the special challenges this COVID-19 year. Airports, hotels, and long visit days filled with hospital tours and interviews were replaced with Zoom interviews, “1980’s style” videos, social media blitzes, all produced to give the potential residents a “feel” for the culture of the programs.

And there have been upsides! Programs saw the numbers of applicants increase. There was a more diverse applicant pool. Web pages were spiffy, social media campaigns were buffed, and all hands were on deck as residents showcased their program’s camaraderie and the wonders of living in Milwaukee. In some ways more exhausting (zoom fatigue) and in some ways more intimate, faculty and applicants got to see each other’s home offices and meet the family dog. No cheese curds, brats, and beer; instead, there were suit jackets, a clean shave, and a new house plant along with scrub pants and sneakers.

Creativity overflows. This is an important moment. Let’s take advantage of it.

 

 

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.

Interviewing for Fellowships - My 2020 Experience

 From the 3/19/2021 newsletter

Perspective/Opinion

Interviewing for Fellowships - My 2020 Experience

David A. Campbell, MD - Department of Otolaryngology and Communication Sciences

Dr. Campbell, who will complete his otolaryngology residency in June 2021, talks about some of the plusses and minuses of interviewing for fellowships during the COVID-19 pandemic … 

“Please tell me you’re not in Atlanta yet!” 

It was March 12, 2020, the day before my first fellowship interview. In the days preceding, interviews dropped off the calendar one by one as travel restrictions tightened and hospital campuses closed their doors to non-essential workers. Some programs switched directly to virtual interviews, while others were hopeful they could have applicants in person by May or June (a wildly optimistic prospect, in hindsight). The Atlanta program finally shut their campus down and the coordinator was frantically trying to stop applicants from getting on flights. After being through medical school and residency interviews, I knew this would be very different. However, as I worked through nineteen virtual interviews spanning five months, I did find some surprises along the way.  

The first thought was how disappointing it was to be unable to visit the cities and hospitals I’d potentially be spending a year at. A very close second thought (in reality, probably a simultaneous thought) was how much money I’d save. Already, credit card bills were piling up and vacation days were evaporating. It was becoming clear that physically getting to 19 interviews was likely going to be impossible. However, on the virtual interview trail, I could attend a morning interview in Florida, an afternoon interview in California, and an evening Zoom social event in New York, all without leaving my apartment or spending a dime. Some programs scattered interviews over several days, meaning I could duck into a hospital workroom for 15 minutes at a time, using no vacation days at all. I’ll admit I did several interviews between cases wearing a suit coat and scrub pants.

Some aspects of the virtual process weren’t immediately obvious. One significant drawback was not meeting the other applicants. Otolaryngology is a small enough specialty that during the residency interview trail, applicants tend to run into each other several times. In the process of comparing notes on past and future interviews at social events or making small talk on the 10th hospital tour, many of us formed connections that only grew as we found each other at conferences throughout residency and will continue to grow as we move through our careers. The graduating ENT class of 2021 got to meet each other during the interview trail of 2016. Now, as I was virtually interviewing to enter the even smaller community of Head and Neck Surgical Oncology, I realized I was missing out on the opportunity to meet my soon-to-be colleagues. 

There were also some unexpected advantages to virtual interviews. As interviews approached, there was concern if programs and applicants could get to know each other as well on the virtual platforms. Similar to the residency match, the 10-to-15 minute interviews themselves are incredibly important for both applicant and program. A single awkward interaction vs. a meaningful connection can have huge impacts on how applicants and programs rank each other. Of course, there were the expected technological hiccups with lots of “I can hear you. Can you hear me?” However, I had several interviews that felt easier because they were virtual. While many physicians interviewed from their offices, I spoke to several world-famous Head and Neck surgeons from their homes. One particularly well-known surgeon was arriving home from work as the interview started. He greeted and introduced me to his wife and showed off the view from his yard (“This could be the type of view you get if you move here!”). From the applicant side, rather than being led into an office at an unfamiliar hospital after sleeping in a hotel bed, I was often interviewing from my apartment with my cats napping on my bed that was just steps away. While some ability to connect was undoubtedly lost with interviews being virtual, my guess is that both parties being in a familiar setting facilitated easier connections in a different way that would not have been possible in-person.  

I’ve heard the sentiment over and over that virtual interviews could never replace in-person interviews. In many ways, I agree with this. However, it was refreshing see people finding new ways to connect with each other when the world was turned upside down.

David A. Campbell, MD is a PGY5 in the Department of Otolaryngology and Communication Sciences at MCW. He will spend the 2021-2022 academic year as the Head and Neck Oncology - Microvascular Reconstructive Surgery Fellow at the Icahn School of Medicine at Mt. Sinai in New York City, a town which he has never actually visited.