Featured – AM Rounds http://academicmedicineblog.org Beyond the pages of Academic Medicine, journal of the AAMC Tue, 19 Sep 2017 13:54:51 +0000 en-US hourly 1 https://wordpress.org/?v=4.8.2 72453062 Encountering the Other: Providing Excellent Care Despite Differences Between Patients & Physicians http://academicmedicineblog.org/encountering-the-other-providing-excellent-care-despite-differences-between-patients-physicians/ http://academicmedicineblog.org/encountering-the-other-providing-excellent-care-despite-differences-between-patients-physicians/#respond Tue, 19 Sep 2017 13:54:51 +0000 http://academicmedicineblog.org/?p=3534 A new episode of our podcast is now available through iTunes. Listen today.

Discussing how to provide excellent patient care in spite of differences between patients and physicians are editor-in-chief David Sklar and authors Emily Whitgob, Raya Kheirbek, and Paul Gordon.

This conversation complements articles by the participants in several recent issues, including:

Emily E. Whitgob, MD, MEd, fellow in the Department of Pediatrics at Stanford School of Medicine
The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees

Raya Kheirbek, MD, associate professor of medicine at the George Washington University School of Medicine and geriatrician and palliative care physician at the Washington DC VA Medical Center
Behind the Veil
Whispers

Paul R. Gordon, MD, MPH, professor in the Department of Family and Community Medicine at the University of Arizona
How Can Physicians Educate Patients About Health Care Policy Issues?
Opposition to Obamacare: A Closer Look

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Author Reading: Learning From Loss: What I Learned From the Death of My Grandfather http://academicmedicineblog.org/author-reading-learning-from-loss-what-i-learned-from-the-death-of-my-grandfather/ http://academicmedicineblog.org/author-reading-learning-from-loss-what-i-learned-from-the-death-of-my-grandfather/#respond Thu, 14 Sep 2017 20:02:09 +0000 http://academicmedicineblog.org/?p=3530 A new episode of our podcast is now available through iTunes. Listen today.

Medical student Maulin Shah recounts the lessons he learned from his grandfather, even in his death. His essay was published in the Teaching and Learning Moments column in the September issue of Academic Medicine.

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Deans Need Progressive Responsibility Too http://academicmedicineblog.org/deans-need-progressive-responsibility-too/ http://academicmedicineblog.org/deans-need-progressive-responsibility-too/#respond Tue, 12 Sep 2017 13:04:27 +0000 http://academicmedicineblog.org/?p=3525 Antman.blog post.AHA Gala

Dr. Antman and her family at the 2016 American Heart Association Boston Heart & Stroke Gala

Editor’s Note: This blog post complements the recently published study “The Decanal Divide: Women in Decanal Roles at U.S. Medical Schools.” Read the full study on academicmedicine.org.

By: Karen Antman, MD

Dr. Antman is dean, Boston University School of Medicine, provost, Boston University Medical Campus, and chair, AAMC Council of Deans

Why aren’t more medical school deans women? Medical school faculty don’t normally wake up thinking, “I want to be dean.” How then does one end up there? I was asked to tell my story.

First, my parents didn’t burden me with the standard expectations for girls at the time. My father expected me to be able to change the tire on the car before I was allowed to drive. My mother worked full time and actually returned to school for a masters degree when I was in high school. Thus, I was probably less conflicted about working full time when our children were young than other women whose mothers had not worked outside the home.

During a college study abroad program in Czechoslovakia during the Prague Spring of 1967, I studied politics and economics, contrasting capitalism and communism, and explored Hungary, Romania, and Yugoslavia where half of physicians were women. Clearly women were not fundamentally unsuited for medicine. Also Czech students knew more about American literature and theater than I did. After returning to the US, I took more music, arts, and literature courses, which contributed substantially to a broader education. Playing college basketball taught me not only teamwork but more importantly that losing is not the end of the world. Risks are OK. In my senior year, I was elected the first woman student council president of the college, which had only recently begun accepting women. I learned that politics matter.

I arrived at Columbia College of Physicians and Surgeons in 1970, in a freshman class of 160 students, 16 of whom were women. I met Elliott Antman, a classmate and my husband-to-be, in the lobby of the medical student residence the day before we started classes.

Columbia provided me a great medical education. In a large urban tertiary care hospital, I learned the importance of hands-on clinical experiences and responsibility. Medical students were expected to bring journal articles to rounds and present cases concisely without notes—a priceless skill. I also was introduced to the expectation of “moving the field.” Learning current medicine and being the best possible clinician weren’t enough. We also needed to address gaps in medical knowledge. To this end, many students spent significant elective time doing research, as I did.

Our daughter was born just before Elliott and I moved to Boston to start our fellowships in cardiology at Brigham and Women’s Hospital and oncology at Dana Farber Cancer Institute (DFCI), respectively.

During my fellowship, again the expectation was to move the field. Elliott and I now had two children, and three years of laboratory research provided a break from night and weekend call. I was worried about our kids though, until our son wrote in an essay for his English class that “My mom develops cures for cancer patients.”

I had no plans to be an academic but I did have skilled and, probably more importantly, patient mentors who taught me manuscript and grant writing. Junior faculty at DFCI were hired then as instructors with no office, tech, or secretary. The chair of Biostatistics gave me a cubby in the biostatistics space (and schooled me in biostatistical methods). As an assistant to the chair of a large cooperative cancer research group, I met the best cancer clinical investigators nationwide and learned to design effective clinical trials. I also developed my own research programs; experience on NIH study sections honed these skills. Eventually I organized multiphysician teams with research nurses and administrators with laboratory and clinical collaborations in sarcomas, mesotheliomas, and marrow transplantation research. Each team member was a first author on her or his own project and somewhere in the middle of the author list on other projects, leading to promotions for all.

I asked senior leadership how often I should accept invitations for talks and was advised that I “needed a national and international reputation to get promoted” so I should do it until I “couldn’t stand it anymore.” So Elliott and I took the kids to medical and research meetings in Europe, Japan, and China. Both children have subsequently become physicians and married medical school classmates.

Active roles on professional association committees led to expertise in medical and research policy and more management experience, with opportunities to testify before congressional appropriations committees. After service on these boards, I became the president or chair of several societies.

Being able to move was key to accepting new positions. A stint as deputy director for translational science at the National Cancer Institute gave me a close up view not only of the NIH’s grants process but also of their equally important power to convene university and industry researchers to launch new initiatives and develop policy.

When I became dean, an experienced dean emphasized the importance of being, and appearing to be, fair. Faculty will generally accept some decisions they don’t like if leadership listened to their points of view and decisions were fair. From the management school faculty, I learned that execution is as important as vision, maybe more so.

Along the way, was I discriminated against as a woman? Yes, I could tell you some pretty remarkable examples, best handled with clear disbelief and humor. But I also was protected by other leaders who provided opportunities for women to succeed.

Over my career, I had progressive administrative responsibility, sequentially managing larger teams with bigger budgets. (Skipping a step in this progressive process results in critical gaps in management experience.) Given that selection committees for chairs and deans highly value academic excellence and prior supervisory and management experience, women who aspire to leadership positions should be looking for such opportunities.

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What’s New and In the Queue for Academic Medicine http://academicmedicineblog.org/whats-new-and-in-the-queue-for-academic-medicine-27/ http://academicmedicineblog.org/whats-new-and-in-the-queue-for-academic-medicine-27/#respond Tue, 05 Sep 2017 18:25:00 +0000 http://academicmedicineblog.org/?p=3520 Journal revised

What’s New: A Preview of the September Issue

The September issue of Academic Medicine is now available! Read the entire issue online at academicmedicine.org. Highlights from the issue include:

Let’s Get Real About Health Care Reform
Karpf argues for an approach to health care policy that understands and accounts for the interdependence between choice, cost, and coverage in a competitive and functional market-based system.

It is Time to Cancel Medicine’s Social Contract Metaphor
Harris contends that removing medicine’s narrow, overworked social contract metaphor would open the door to a more complex, fruitful consideration of medical professionalism and medicine’s relationship with society.

Opposition to Obamacare: A Closer Look
Gordon and colleagues describe in detail their observations from a cross-country cycling trip during which they talked with locals about their opinions of the Affordable Care Act.

Interprofessional Medical–Legal Education of Medical Students: Assessing the Benefits for Addressing Social Determinants of Health
Pettignano and colleagues find that incorporating an interprofessional medical–legal curriculum may result in increased likelihood to screen patients for social determinants of health issues and to refer patients with legal needs to legal resources. A blog post related to this article is available.

Changes in Primary Care Graduate Medical Education Are Not Correlated with Indicators of Need: Are States Missing an Opportunity to Strengthen Their Primary Care Workforce?
Coutinho and colleagues argue that states should create explicit linkages between medical education and population need; strategically allocate Medicaid GME funds; and monitor the impact of workforce policies and training institution outputs.

What’s In the Queue: A Sneak Peek

Here’s a preview of an upcoming innovation report by Joanna M. Cain, MD, Marianne E. Felice, MD, Judith K. Ockene, PhD, Med, MA, Robert J. Milner, PhD, John L. Congdon, Stephen Tosi, MD, and Luanne E. Thorndyke, MD.

Meeting the Late-Career Needs of Faculty Transitioning Through Retirement: One Institution’s Approach

Abstract

Problem

Medical school faculty are aging, but few academic health centers are adequately prepared with policies, programs, and resources (PPR) to assist late-career faculty. The authors sought to examine cultural barriers to successful retirement and create alignment between individual and institutional needs and tasks through PPR that embrace the contributions of senior faculty while enabling retirement transitions at the University of Massachusetts Medical School, 2013–2017.

Approach

Faculty 50 or older were surveyed, programs at other institutions and from the literature (multiple fields) were reviewed, and senior faculty and leaders, including retired faculty, were engaged to develop and implement PPR. Cultural barriers were found to be significant, and a multipronged, multiyear strategy to address these barriers, which sequentially added PPR to support faculty, was put in place. A comprehensive framework of sequenced PPR was developed to address the needs and tasks of late-career transitions within three distinct phases: pre-retirement, retirement, and post-retirement.

Outcomes

This sequential introduction approach has led to important outcomes for all three of the retirement phases, including reduction of cultural barriers, a policy that has been useful in assessing viability of proposed phased retirement plans, transparent and realistic discussions about financial issues, and consideration of roles that retired faculty can provide.

Next Steps

The authors are tracking the issues mentioned in consultations and efficacy of succession planning, and will be resurveying faculty to further refine their work. This framework approach could serve as a template for other academic health centers to address late-career faculty development.

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The Many Facets of Career Flexibility in Academic Medicine: What Does It Mean to You? http://academicmedicineblog.org/the-many-facets-of-career-flexibility-in-academic-medicine-what-does-it-mean-to-you/ http://academicmedicineblog.org/the-many-facets-of-career-flexibility-in-academic-medicine-what-does-it-mean-to-you/#respond Tue, 29 Aug 2017 11:00:42 +0000 http://academicmedicineblog.org/?p=3514 work life balance

By: Lydia Pleotis Howell, MD, professor and chair, Department of Pathology and Laboratory Medicine, University of California, Davis Health, Sacramento, California.

What does “career flexibility” and “work-life balance” or “work-life integration” mean to you? When I bring these up to department chairs or academic health leaders at my (or other) school(s), I often get openly unenthusiastic responses such as “Don’t you know that we can’t afford to have faculty working less? We need more productivity than ever before!” This is despite the majority of medical schools—including those ranked in U.S. News and World Report’s top ten—all having adopted career flexibility policies to improve recruitment and retention by helping faculty better meet their work and family/personal responsibilities.1

But career flexibility does not mean working less. Flexibility, as defined by the Sloan Center for Work and Aging at Boston College, involves “making changes to when, where and how a person will work to better meet individual and business needs…. Flexibility should be mutually beneficial to both the employer and employee and result in superior outcomes [italics added].”2 Shared responsibility and accountability are therefore requirements—in other words, no entitlement.

The University of California Davis has had career flexibility policies (such as childbearing and family leaves, active service-modified duties, and “stop the tenure clock”) since 1988, but in our NIH-funded survey, we found only 6.7% of women and 0.0% of men in the School of Medicine officially used these policies.3 Faculty appear to self-censor their use, as one-third under age 50 reported wanting to use the policies but choosing not to make the request.4 Highest among the many reported barriers to use was concern about burdening colleagues and others’ (including department chairs’ or division chiefs’) perceptions that the policy user was not committed to his/her career or team. These barriers are more frequently reported by women, but increased for both genders after an educational intervention, indicating that raising awareness of policies also raises concern about “flexibility stigma.”4,5

The qualitative analysis of written comments from our survey provides unique and valuable insights into institutional culture and norms that depress use of flexibility policies and inhibit growth of a culture of flexibility.6 We identified several themes, including misinformation and myths about using these policies and a perception of an unsupportive local culture, as faculty expressed concern that using the policies could be damaging to their career, despite all faculty generations and genders anticipating the need to use them in the future and considering them to be important for career growth, recruitment, and retention. Another theme we identified was a rigid, inflexible professional/academic culture, as faculty reported an inability to diminish their pace or take family-related leave due to fears of falling behind or limiting future opportunities.5 Many of the concerns identified in these themes reflect “face-time bias” (a form of unconscious bias related to physically seeing/not seeing colleagues in the workplace) and a culture of “over-work” creating conflict between professional and personal identities, which also reflects conflict with gender-specific roles since gender differences in the reported barriers and comments were observed.5,6

Having worked part-time for 16 years of my academic career while raising my children, I can personally confirm these concerns are significant and real. I made every effort to make my 80% faculty appointment “invisible” to others, so I wouldn’t be perceived as being on the “mommy track” and not serious about my career. I took on extra duties, including some considered onerous by others to minimize any bias to having a “part-timer” on the faculty. The upside is I was able to be flexible about my time, create a buffer in my life, and minimize the stress associated with being a working mother, while still rising through the ranks to professor and serving in leadership roles.

Keeping talented faculty in academic medicine and nurturing them so they can succeed and give back is exactly why career flexibility policies exist. How can we help more faculty overcome barriers and conflicts related to accessing career flexibility policies so more can achieve career success in academic medicine? Increasing awareness through published studies3–6 is an important and effective approach to culture change. Identifying and raising the visibility of successful faculty who have used flexibility policies or had alternative work schedules or places is also important to normalize flexible career approaches and paths. Finally, revealing faculty struggles and the consequences of an inflexible culture6 to school leaders is important to change the flexibility stigma and reshape the next generation of physicians and scientists into a happier, healthier, and more resilient workforce.

 

References

  1. Bristol MN, Abbuhl S, Cappola AR, Sonnad SS. Work-life policies for faculty at the top ten medical schools. J Womens Health (Larchmt). 2008;17:1311–1320.
  2. Sloan Center for Work and Aging at Boston College. What Is Workplace Flexibility? http://workplaceflexibility.bc.edu/workFlex. Accessed July 13, 2017.
  3. Villablanca AC, Beckett L, Nettiksimmons J, Howell LP. Attitudes, awareness and use of family-friendly policies for career flexibility: An NIH-OWHR funded study to enhance women’s careers in biomedical science. J Womens Health (Larchmt). 2011; 20:1485–1496.
  4. Howell LP, Beckett LA, Nettiksimmons J, Villablanca AC. Generational and gender perspectives on career flexibility: Ensuring the faculty workforce of the future. Am J Med. 2012;125:719–728.
  5. Howell LP, Beckett LA, Villablanca AC. Expectations of the ideal worker and its influence on professional identity in academic medicine: Perspectives from a career flexibility educational intervention [published online ahead of print June 15, 2017]. Am J Med. doi:10.1016/j.amjmed.2017.06.002.
  6. Shauman K, Howell LP, Paterniti DA, Beckett LA, Villablanca AC. Barriers to career flexibility in academic medicine: A qualitative analysis of reasons for the underutilization of family-friendly policies, and implications for institutional change and department chair leadership [published online ahead of print August 22, 2017]. Acad Med. doi:10.1097/ACM.0000000000001877.
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Author Reading: The Need for Developing a Cultural Understanding With Underserved Minority Patients in Medicine http://academicmedicineblog.org/author-reading-the-need-for-developing-a-cultural-understanding-with-underserved-minority-patients-in-medicine/ Tue, 22 Aug 2017 13:05:39 +0000 http://academicmedicineblog.org/?p=3511 A new episode of our podcast is now available through iTunes. Listen today.

Medical student Ajay Kailas recounts two experiences that taught him how open discussion with patients is key to building trusting relationships. His essay was published in the Teaching and Learning Moments column in the August issue of Academic Medicine.

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Editorial Board Q&A: John Paul Sanchez, MD, MPH http://academicmedicineblog.org/editorial-board-qa-john-paul-sanchez-md-mph/ Thu, 17 Aug 2017 18:15:26 +0000 http://academicmedicineblog.org/?p=3493 JPREVISED3

John Paul Sanchez, MD, MPH, Assistant Dean, Diversity and Inclusion, Associate Professor, Emergency Medicine, Rutgers New Jersey Medical School, President, Building the Next Generation of Academic Physicians Inc.

Describe your current activities. 

My workweek is split between patient care in the emergency department, leading various diversity and inclusion efforts across the medical school (from high school students to faculty members), overseeing the Community-Engaged Service Learning elective, and research related to diversifying the academic medicine workforce.

What gaps do you see in the current academic medicine scholarship?

Gaps in the current academic medicine scholarship include best practices and evaluations of initiatives and programs to enhance diversity and inclusion in the physician workforce and the academic medicine workforce.

Name two to three seminal Academic Medicine articles that everyone in your field should read.

What issues will we be reading about in Academic Medicine in five years? 

I’m looking forward to reading more Academic Medicine articles on:

  1. Diverse pioneers of academic medicine, whether they represent education, service or research.
  2. The history and impact of medical organizations (for example, AAMC, NHMA, NMA, AMA, LMSA, SNMA, GLMA) in facilitating change at our academic health centers, especially in improving learner and patient outcomes.
  3. On-going and emerging health policy topics and how to become more effective health advocates.
  4. Strategies to promote diverse trainees interest and preparedness for academic medicine careers.

What book(s) are you reading right now? 

I enjoy taking my students and mentees to the summer Shakespearean performances in Central Park, NYC.  In preparation for the 2017 shows, I’ve been re-reading A Midsummer Night’s Dream and Julius Ceasar.

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Author Reading: Stupid Consult http://academicmedicineblog.org/author-reading-stupid-consult/ Mon, 14 Aug 2017 19:45:34 +0000 http://academicmedicineblog.org/?p=3491 A new episode of our podcast is now available through iTunes. Listen today.

In “Stupid Consult,” Jonathan Kersun remembers a patient who taught him about overcoming intolerance and strong emotions to connect with others. His essay was published in the Teaching and Learning Moments column in the August issue of Academic Medicine.

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 “I Feel that I’m a Human Being There”: A Transgender Older Adult’s Experience With a Family Medicine Clinic http://academicmedicineblog.org/i-feel-that-im-a-human-being-there-a-transgender-older-adults-experience-with-a-family-medicine-clinic/ http://academicmedicineblog.org/i-feel-that-im-a-human-being-there-a-transgender-older-adults-experience-with-a-family-medicine-clinic/#comments Thu, 10 Aug 2017 11:00:24 +0000 http://academicmedicineblog.org/?p=3481 doctor holding heart

By: K. Abel Knochel, PhD, University of Minnesota Duluth, Duluth, Minnesota, and Dylan Flunker, MPP, Rainbow Health Initiative, Minneapolis, Minnesota

Melissa is a white, 63-year-old academic. She began identifying to others as female six years ago, although she has self-identified as female throughout her life. Melissa is in the process of transitioning and receives care through Smiley’s Family Medicine Clinic. She discussed her experiences in an interview with the Minnesota Transgender Aging Project (MTAP) in September 2016. MTAP is exploring the care that older transgender adults experience and expect in the Twin Cities Metro and Northland regions of Minnesota. The interview is excerpted below, with Melissa’s permission.

In her interview, Melissa emphasized the difference it makes for a patient to have their legal name accord with their gender by describing two minor experiences with misnaming and misgendering at Smiley’s, both of which occurred before her medical records used her preferred name.

Experience 1: [S]omebody was looking at my chart, and no one had written [my preferred name] on the top of it, which is what they typically do, and so called out my old name … I just sat there … I didn’t even say, “That’s not my name.” … So they gave up and went in and talked to somebody else and then came back out and just said my name. I got up and went, “Eh.”

Experience 2: I was going through some issues of dizziness and fainting that had to do with adjustment of meds related to hormone therapy and my high blood pressure …. It was a Friday late in the afternoon, they were about to close, so [they] said, “Better get in here because we won’t be open until Monday.” …. [T]he nurse that was involved was new to me. He … misgendered me, … but [it] wasn’t malicious, and I corrected him.

These types of experiences underscore the call from Hinrichs et al to ensure that medical staff throughout the clinic are trained to provide competent care to transgender patients.

Despite these experiences, Melissa described an overwhelmingly positive experience with receiving care through Smiley’s. She spoke of the ways the clinic staff has responded to her gender identity, honored her humanity, and partnered with her on medical care.

Smiley’s has been fabulous …. [W]hen you ask for an appointment you have to say why …. I said, “I need someone who’s knowledgeable about—or comfortable about—dealing with midlife or later trans women.” My medical insurance still had my birth name and … so I wrote in my preferred name. Within a few hours, I got a call saying, “May I please speak to [preferred name]?”

[T]he first day I got [to the clinic] … there [were] two people at the desk … I thought, “Oh. How are they going to feel about this?” I [went] up to the first one who was free and… she said, “Could you give me your name and show me your insurance card?” I said, “Well, they won’t be the same because I’m a transgender person.” She said, “Oh, thank you so much for telling me.” She was so … professional about it … pleasant about it … no big deal about it.

The very first day …. I was really prepped to make my case for hormone therapy, because I’d had this resistance, with [a previous doctor] saying no and [previous physician assistants] feeling at sea a little bit …. [My doctor] said something welcoming, and I said, “I guess I’m going to have to persuade—” She stopped me and put her hand on my knee … and said, “You don’t have to persuade me of anything.” I just started weeping …. [She] asked me right away, “Do you need a letter for surgery?” She’d actually read my little note [in the chart] and the whole clinic has clearly been trained. … [M]y current doctor … clearly feels I’m part of my own care team in way that I haven’t experienced …. That is to say … I have a huge role in the decision-making process.

… [T]he overall atmosphere is so positive. I feel that I’m a human being there. I’m not a freak, and that’s huge …. My experience makes me hopeful that I’ll be treated well [by medical providers in the future].

The care demonstrated in these interactions is consistent with the characteristics of trans-competent care that Hinrichs et al identified in their study.

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Author Reading: Whispers http://academicmedicineblog.org/author-reading-whispers/ Mon, 07 Aug 2017 20:35:26 +0000 http://academicmedicineblog.org/?p=3484 A new episode of our podcast is now available through iTunes. Listen today.

In “Whispers,” Raya Kheirbek remembers a patient who taught her to recognize the subtleties and differences in a seemingly shared language and culture. Her essay was published in the Teaching and Learning Moments column in the August issue of Academic Medicine.

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