| Recognizing and Eliminating Shame Culture in Health Professions Education No abstract available |
| Applying to Medical School as a DACA Recipient
When I was 15 years old, I left home to enter a prep school in New Hampshire, and quickly went from being a top student at my inner-city public school to someone struggling to reach the middle of the class. My parents were convinced that my attending this school was an opportunity that would open doors to a world I could barely glimpse at home. But during those initial weeks all I could think about was how hopelessly behind my classmates I was, in class after class, and how long I would last before failing and being sent home. I felt out of place and different from the other students, many of whom had attended private schools all of their lives. My classmates made fun of my lower-class Boston accent, the clothes I wore, my short stature, my Jewish religion, and my lack of athletic skills. I felt totally unfit academically, culturally, and physically—but it was about to get worse.
During my second week at school I was told to report to a large auditorium with my other classmates. I waited nervously until my name was called, wondering what new challenge awaited me. I was ushered into a small room with five other boys. A photographer told us to take off all of our clothes. I can remember the shock and disbelief of watching as my classmates disrobed. The blinding lights of the photographer’s camera flashed as he gave directions to each boy to turn and stand on a line and look at a dot. I remember that no one smiled as the photos were snapped.
As I watched, awaiting my turn, I wondered what the purpose of these photographs could be. Who would look at them? When my time came, I took off my shirt and then my shoes, socks, and pants. But when it came to my underwear, I froze. I just couldn’t do it. It felt so wrong, so shameful, not just the nudity but the idea of my naked body being on view on a wall somewhere. The photographer yelled at me to strip off my underwear. He would not tolerate any resistance or delays. If I did not comply, I would have to go to the dean’s office, and I imagined immediate dismissal. Finally, I did as he asked. I stood looking into the bright lights, naked and trembling, as I was photographed from front, back, and side views.
Later I learned that the photographs were related to a study of body type and personality using a theory known as somatotyping developed by William Sheldon,1 a physician. He had photographed hundreds of young men and published a book with a picture of each one, his somatotype, and a description of the personality associated with it. Somatotyping was related to eugenics theories popular at the time that classified people either as having characteristics to be encouraged for future generations or as having characteristics, such as low intelligence, to be discouraged and even eliminated through sterilization. The classification of body types using somatotyping provided a pseudoscientific measurement meant to identify those most fit for leadership.
Many years later when I attended my 50th class reunion, my former classmates were still talking about those photographs. Some laughed about them and made jokes about their potential use as blackmail to get us to give donations to the school. Others discussed the humiliation and shame of being photographed and how that seemed to be connected to other experiences of bullying, racial and cultural bias, belittling, and in some cases sexual abuse that they had endured at the school. My way of dealing with the abuse was to write a novel, Atlas of Men,2 that explored some of the issues raised by the photographs and research theory, and in which shame and the assault on the identity of the students figured prominently. My hope was that the book would promote conversations about shame and abuse and help prevent them in the future.
The association of shame and humiliation with nudity has a long history going back to biblical times when Adam and Eve went from a state of innocence (“Adam and his wife were both naked and they felt no shame,” Genesis 2:25) to experience the shame of nudity after they ate the forbidden fruit (“Then the eyes of both of them were opened and they realized they were naked; so they sewed fig leaves together and made coverings for themselves,” Genesis 3:7). The inducement of shame and other elements of psychological distress associated with forced nudity is so strong that it has been used as a component of torture in various wars and conflicts. Leach3 notes,
Stripping a person of his or her clothes begins the process of stripping them of their identity and their personality, a process that saw its complete expression in the Nazi concentration camps.
Shame in the Medical Encounter
While forced nudity provides an example of how induced shame can lead to threats to identity, there are many other common experiences that can also create shame and threaten identity, some of which occur in the health care environment. Lazare4 described shame that occurs during the medical encounter. He defined shame as “distress concerning the state of the self that the person describes as no good, not good enough, or defective.” Lazare noted,
Once in the examining room, patients must reveal personal information, often about their weaknesses, expose their bodies, place themselves in undignified postures, and accept handling of their bodies, including intrusions into orifices.
Lazare also recognized shame that can occur in physicians who made errors in diagnosis or treatment of a patient, and he questioned why it is so difficult to talk about shame, concluding that to talk about it is also shameful. I believe that the shame of discussing shameful events may partially explain the paucity of literature related to shame in the medical literature. Fortunately, there has been recent renewed interest in shame and why it needs to be discussed openly in health professions education.
Shame Associated With Medical Error
Davidoff5 described the connection between shame and resistance to improvement in health care, and suggested that moving from a focus of shame of individuals involved in a medical error to a recognition of the contribution of systems in the occurrence of medical error could lead to a more open and comprehensive improvement approach. He encouraged transformation from a culture of blame to a culture of safety. Through the open sharing of information about errors there could be less shame in being involved in an error and greater chances to identify ways to reduce them in the future.
Bynum and Goodie6 further explored the effects of shame associated with errors upon the wellness of learners. They described differences between shame and guilt in the health care learning environment and the importance of recognizing these emotions and their potential for occurring in association with a learner’s error. They explained that shame involves a negative reaction to the worth of the self, while guilt involves negative reactions to an action or behavior without implicating the value of the self. If learners and their teachers could focus on a behavior leading to a medical error, such as misreading an X-ray, rather than automatically assuming that the learners are defective, learners could concentrate on how to improve their performance and avoid future errors rather than dwelling on why they were such bad and inadequate persons.
I believe that scholarship on shame associated with errors can help create healthier environments for quality improvement and learning as we begin to dissect the contributions of individuals and systems to the patient and population outcomes related to health care. All of us will make mistakes during our learning and as we practice, and we need to do our best to see that those errors do not create shame or harm our patients. Open discussion of our errors and a supportive learning environment can be part of the process of improvement of care and the development of resilient health professionals.
Shame Reactions
Bynum et al7 described various shame events and their effects through a qualitative study of 12 medical residents who experienced shame in medical training. They described the events as intense and damaging. One resident felt “like I was swimming in my own body.” Another felt “like the wind was taken out of you.” Another described the desire to escape: “I just want to go home. I don’t want to see anybody. I want to go to bed.” Bynum et al suggested that shame reactions are
sentinel emotional events for many learners … unexpected jarring experiences that can have significant physical and psychological effects on medical learners.
They concluded by urging open discussion about shame in the health professions education environment so that it could be recognized and its harmful effects prevented.
In an Invited Commentary in this issue, Hoskison and Beasley8 describe their own shame and humiliation as medical students 30 years ago and how those experiences have inspired them to provide a better, more supportive educational environment for students. They conclude with a call to action:
We call on our colleagues—those who round with and educate our students, residents, and fellows—to join us in our pledge to end humiliation as a learning tool, to monitor ourselves and our partners for unprofessionalism, and to learn about and employ the cutting-edge science brought to us by our medical education research colleagues.
In this issue, Bynum et al9 offer an example of the type of medical education research advocated by Hoskison and Beasley, describing a seminar for medical students that provides a venue to share some of what was learned in their study of residents and to help develop resilience to shame. LaDonna et al,10 in a qualitative study of practicing physicians, also provide some insight about how practicing physicians address failures and shaming events and how their strategies may be of value to medical students and residents. “We’re not very good at doing it [admitting mistakes], which is one of the reasons we’re not very good at learning from them.” Learning from failure also seemed to rely on participants’ ability to rebound from an error without becoming paralyzed by fear, guilt, or shame. Sometimes this meant reassuring themselves that “I may not have done the best possible job, but as far as I knew, I was doing the best job that I could do, and that was enough for me.”
Shame and Personal Identity
In addition to shame associated with errors, shame can also involve humiliation based on our personal characteristics—how we talk, our social class, or what we look like (as exemplified by the nude photographs and the categorization of body types described earlier). We can receive messages about whether we have “the right stuff” to be successful in our future aspirations. Biases, both implicit and explicit, can create messages about our fitness based on race, gender, culture, physical or mental health, and body type. These biases can affect our judgments about ourselves and others, and others’ judgments about us. Williams and Rohrbaugh11 in this issue describe an incident of a patient’s explicit racist behavior and discuss how residents, units, and institutions should respond to these types of events. Such incidents can be seen as sentinel events, as described by Bynum et al,7 requiring an institutional reaction similar to that which follows a serious medical error.
The selection processes for both medical school and residency represent other opportunities to consider effects of bias and shame on applicants who look, speak, or act differently from the majority of applicants. In this issue, Mian et al12describe an admissions process to increase the matriculation of Indigenous students at their medical school through revaluing characteristics of Indigenous applicants to align with the school’s social accountability to the region’s population. Finally, in this issue, Derrick Paul,13 a medical student, discusses the continuous assault of current events and personal traumas on his and his classmates’ personal identities resulting from racial, anti-immigrant, and other hatreds. He concludes:
Buffeted from the outside, we can be hardened in our values of decency, truth, diversity, and equality. These ideals may be the necessary tools to approach the tasks before us that loom enormous but are made conquerable by the growing strength of our voices and our practice in the art of fighting for ourselves, our families, and our patients. Among the many lessons I have learned in the early years of medical school, one stands out: that justice for all people, health equity for all people, and the push for progress on our most difficult health epidemics are not areas of peripheral interest to a life in medicine; they are essential to it.
Addressing Shame
The study of shame in the health care learning and services environment can provide a window to the broader challenges that need to be addressed to provide health equity within our population and a healthy environment for our health professionals. In this issue, two special articles describe possible antidotes to a culture of shame by offering a focus on humanism and compassion. Thibault14 urges a focus on humanism to help health professionals resist bullying and other dehumanizing forces in the society around us as “we strive to make the health professions the model for humanism.” And Snyderman15 shares an extraordinary conversation with the Dalai Lama about the importance of compassion in health care, the role of mindfulness, and the need for dedicated time with patients for physicians to engage in compassionate care. If we were to encourage more humanism and compassion in medical care, I believe that shaming might diminish or even disappear from our training environments.
Addressing shame is as much about recognizing who we are and the differences we bring to the health care environment as it is about what we do and how we communicate safely and honestly with each other about our uncertainties and errors. Discussions of shaming can help us address power hierarchies and biases that get in the way of our service to our patients. Such discussions can help us to support each other, so that each day when we look in the mirror, we can take pride in the person staring back at us.
David P. Sklar, MD
References
1. Sheldon WH. Atlas of Men: A Guide for Somatotyping the Adult Male at All Ages. 1954.New York, NY: Harper.
2. Sklar DP. Atlas of Men. 2018.Phoenix, AZ: Volcano Cannon Press.
3. Leach J. Psychological factors in exceptional, extreme and torturous environments. Extrem Physiol Med. 2016;5:7.
4. Lazare A. Shame and humiliation in the medical encounter. Arch Intern Med. 1987;147:1653–1658.
5. Davidoff F. Shame: The elephant in the room. BMJ. 2002;324:623–624.
6. Bynum WE 4th, Goodie JL. Shame, guilt, and the medical learner: Ignored connections and why we should care. Med Educ. 2014;48:1045–1054.
7. Bynum WE 4th, Artino AR Jr, Uijtdehaage S, Webb AMB, Varpio L. Sentinel emotional events: The nature, triggers, and effects of shame experiences in medical residents. Acad Med. 2019;94:85–93.
8. Hoskison K, Beasley BW. A conversation about the role of humiliation in teaching: The ugly, the bad, and the good. Acad Med. 2019;94:1078–1080.
9. Bynum WE IV, Adams AV, Edelman CE, Uijtdehaage S, Artino AR Jr, Fox JW. Addressing the elephant in the room: A shame resilience seminar for medical students. Acad Med. 2019;94:1132–1136.
10. LaDonna KA, Ginsburg S, Watling C. Shifting and sharing: Academic physicians’ strategies for navigating underperformance and failure. Acad Med. 2018;93:1713–1718.
11. Williams JC, Rohrbaugh RM. Confronting racial violence: Resident, unit, and institutional responses. Acad Med. 2019;94:1084–1088.
12. Mian O, Hogenbirk JC, Marsh DC, Prowse O, Cain M, Warry W. Tracking Indigenous applicants through the admissions process of a socially accountable medical school. Acad Med. 2019;94:1211–1219.
13. Paul DW Jr.. Medical training in the maelstrom: The call to physician advocacy and activism in turbulent times. Acad Med. 2019;94:1071–1073.
14. Thibault GE. Humanism in medicine: What does it mean and why is it more important than ever? Acad Med. 2019;94:1074–1077.
15. Snyderman R, Gyatso T; the 14th Dalai Lama. Compassion and health care: A discussion with the Dalai Lama. Acad Med. 2019;94:1068–1070.
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| Enhancing Formative Feedback in Robust Evaluation Systems: Time to Move Beyond Rating Scales?
We read with great interest the recent article by Warm and colleagues1 on their assessment system based on entrustment of observable practice activities. As fellow academic internists, we recognize the tremendous feat they have accomplished in creating a robust evaluation system at the University of Cincinnati College of Medicine’s internal medicine residency program that utilizes faculty incentives and training to generate what appears to be thousands of direct observation-based summative assessments. Furthermore, they appear to have trained their clinical competency committee (CCC) to be able to analyze narratives generated from those direct assessments to identify hidden problems, suggesting that their CCC members are comfortable and facile with qualitative analysis methodology.
Although the authors have demonstrated all the components of a mature assessment system, they note that residents scored the assessment system low on satisfaction with their feedback, and the assessors felt that the summative components dominated their assessment work. Considering these findings, the authors set out to clarify the aims and goals of the system to the assessors and residents.
We suggest that the next step may not be reeducation on assessment aims, reorganization of the rating instrument, or rebalancing of the equations that interpret it but, rather, doing away with the scale portion of the rating altogether—truly “embracing the subjective.”2 The work of Dr. Shute3 demonstrates that learner change in response to formative feedback can be completely blunted by providing simultaneous summative feedback, and medical educators have called for assessors to replace scales with narrative ratings.4 We believe the authors’ mature assessment system may be a uniquely ideal place to embrace subjectivity, and we welcome their thoughts on this.
Anthony Donato, MD, MHPE
Associate program director, Tower Health, Reading, Pennsylvania, and professor of medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; Anthony.donato@towerhealth.org; ORCID: http://orcid.org/0000-0002-8294-6769.
Susmita Paladugu, MD
Academic hospitalist, Tower Health, Reading, Pennsylvania; ORCID: http://orcid.org/0000-0001-7981-7862.
References
1. Warm EJ, Kinnear B, Kelleher M, Sall D, Holmboe E. Transforming resident assessment: An analysis using Deming’s system of profound knowledge. Acad Med. 2019;94:195–201.
2. Ten Cate O, Regehr G. The power of subjectivity in the assessment of medical trainees. Acad Med. 2019;94:333–337.
3. Shute VJ. Focus on formative feedback. Rev Educ Res. 2008;78:153–189.
4. Hanson JL, Rosenberg AA, Lane JL. Narrative descriptions should replace grades and numerical ratings for clinical performance in medical education in the United States. Front Psychol. 2013;4:668.
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| In Reply to Donato and Paladugu
We thank Donato and Paladugu for their letter. They suggest that our assessment rating scales may have led to poor learner satisfaction and erroneous faculty judgment and ask us to abandon scales in favor of purely narrative data (e.g., “truly embrace the subjective”). Although the learner satisfaction and faculty judgments in our system have improved over time, we feel that any issues have less to do with rating type than with how we use the data.
We agree that assessment and feedback are complex, and interventions meant to help can have the opposite effect.1,2However, we do not accept that values created by rating scales must be seen as summative and objective, and that narrative data must be seen as formative and subjective. Narrative assessments do not inherently remove risk, as they may contain sensitive or detailed feedback and be used in a summative manner—just like numbers. Numerical ratings are not inherently more objective than narrative comments, particularly in workplace-based assessments, as they represent a “code” based on a variety of inputs. The reality is that learners may perceive any type of assessment as subjective and high-risk when used improperly.
Numerical and narrative assessments represent a polarity, and rather than abandoning one for the other, we suggest maximizing the value of both.3 Training programs should develop support systems, such as longitudinal coaching, to help learners interpret and integrate all types of data. Coaches should personalize assessment data with a goal-directed approach, using feedback as the scaffold.1 In turn, coaches should be removed from making summative judgments, and this should be made explicit to learners.4 Data used for formative purposes should truly be low stakes, with no data point representing a threat to the learner. High-stakes decisions should be based on all available data (numerical and narrative) and should not be a surprise to learners or programs.4 Learners should coproduce these programs of assessment with faculty members. Finally, all forms of assessment should be supported by validity evidence. Do the data help learners become better over time?
Why do we need words and numbers? Although it may be possible to judge improvement over time using narrative only, it is a difficult thing to do. Numbers tell the story quickly and imperfectly, and narratives do so more slowly, but also imperfectly. Together, they tell a better story than either one can alone. How we listen to and use both assessment methods matters most.
Eric J. Warm, MD
Professor of medicine and program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; @CincyIM; warmej@ucmail.uc.edu; ORCID: https://orcid.org/0000-0002-6088-2434.
Benjamin Kinnear, MD, MEd
Assistant professor of medicine and pediatrics and associate program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Matthew Kelleher, MD, MEd
Assistant professor of medicine and pediatrics and associate program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Dana Sall, MD, MEd
Assistant professor of medicine and associate program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Eric Holmboe, MD
Senior vice president, Milestones Development and Evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois, adjunct professor of medicine, Yale University, New Haven, Connecticut, and adjunct professor, Feinberg School of Medicine at Northwestern University, Chicago, Illinois.
References
1. Shute VJ. Focus on formative feedback. Rev Educ Res. 2008;78:153–189.
2. Watling CJ, Ginsburg S. Assessment, feedback and the alchemy of learning. Med Educ. 2019;53:76–85.
3. Johnson B. Polarity Management: Identifying and Managing Unsolvable Problems. 1992.Amherst, MA: Human Resource Development.
4. Van Der Vleuten CPM, Schuwirth LWT, Driessen EW, Govaerts MJB, Heeneman S. Twelve tips for programmatic assessment. Med Teach. 2015;37:641–646.
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| Medical Error, Cognitive Bias, and Debiasing: The Jury Is Still Out
In their Perspective, Norman and colleagues1 contest the relative contribution of cognitive bias to medical error, and they challenge the efficacy of debiasing strategies in mitigating such error. They argue that “knowledge deficits,” rather than cognitive biases, underlie medical error.1 I would like to address key elements of their argument.
What Norman and colleagues include under the rubric of “knowledge” is unclear. Is it factual knowledge, or does “knowledge” also include cognitive attributes acquired through years of experience? They insist that “more experience will lead to greater knowledge.”1 But knowledge gained through experience may be different than the factual knowledge that rectifies “knowledge deficits.” Physicians’ factual “knowledge” base is arguably greatest shortly after they complete their fellowship and board exams, whereas their clinical “experience” is limited at this early stage. If “knowledge deficits” underlie most medical errors, then the most knowledgeable physicians should make the fewest errors. Evidence for such a claim is scant.2 “Experience,” conversely, encompasses the gradual acquisition of complex skills and attributes, such as the capacity to monitor and regulate one’s thinking (metacognition), which can play a critical role in catching and preventing errors before they occur.
In an experimental investigation, Norman and colleagues used hypothetical case vignettes to contest the effectiveness of cognitive debiasing strategies.3 Many physicians would argue that experimental conditions of short duration do not adequately reflect the clinical environments in which complex decision making, leading to medical error, occurs. Debiasing strategies are, however, difficult to test reliably under general experimental conditions, as they may need to be customized to specific contexts and require multiple interventions and sustained maintenance to demonstrate effectiveness.2 Debiasing strategies that are generally underappreciated include metacognitive skills, reflection, feedback, mindful attention, and checklists.
Norman and colleagues’ studies ostensibly demonstrating that physicians are unable to correctly identify cognitive biases are indicative of the lack of awareness and education among physicians about bias, rather than disproving the existence of such biases.
Norman and colleagues are nonetheless right to criticize the assumption that “relatively simple and quick strategies directed at identifying and eliminating biases can reduce errors … [or] that a magic bullet will emerge to eliminate all errors.”1 But this has never been the assumption of Croskerry2 and others who believe cognitive bias is real and debiasing strategies feasible. The debate about cognitive bias has not been settled. It is counterproductive to discourage much-needed ongoing investigation on this critically important topic.
Quentin Eichbaum, MD, PhD, MPH, MFA, MMHC
Professor of pathology, microbiology, and immunology; professor of medical education and administration; director, Vanderbilt Pathology Education Research Group; director, Vanderbilt Pathology Program in Global Health; and clinical fellowship director, Vanderbilt University Medical Center, Nashville, Tennessee; quentin.eichbaum@vanderbilt.edu.
References
1. Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. The causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Acad Med. 2017;92:23–30.
2. Croskerry P. From mindless to mindful practice—Cognitive bias and clinical decision making. N Engl J Med. 2013;368:2445–2448.
3. Zwaan L, Monteiro S, Sherbino J, Ilgen J, Howey B, Norman G. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Qual Saf. 2017;26:104–110.
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| In Reply to Eichbaum No abstract available |
| Potential Solutions to Medical Student Burnout
Taking an interdis ciplinary angle to address the growing problem of burnout among medical students, Pathipati and Cassel1 provide three succinct, yet insightful approaches inspired by business school curricula—namely, (1) increasing learning opportu nities that foster innovation, creativity, and problem solving; (2) providing more resiliency training that explicitly introduces interpersonal communication and self-reflective methods for navigating high-stress work and learning environments; and (3) making available more thorough career counseling that critically analyzes the socioeconomic and personal implications of diverse career choices. I suggest adding a fourth approach, drawing upon a robust body of research in the field of cognitive psychology: teaching self-regulated learning strategies, which have shown to be negatively correlated with depression, and positively correlated with academic and clinical performance among medical students.2,3
For well-defined tasks across learning environments (e.g., reading, studying, test taking, clinical reasoning, clinical procedures), self-regulated learning can be integrated into medical education curricula through problem-based learning activities, academic coaching, peer mentoring, or faculty development programs. Specifically, the following key strategies most commonly used in the three-phase assessment-to-intervention method referred to as “self-regulated learning microanalysis” could serve as a framework for implementation4,5: goal setting and strategic planning (forethought phase—prior to task); metacognitive monitoring (performance phase—during task); and self-evaluation and causal attribution (self-reflection phase—after task). To facilitate their implementation, these strategies could be introduced in combination with strategies from the learning sciences such as retrieval practice, spaced repetition, interleaving, and elaboration.6
Resolving the burnout crisis in medical education requires a multidisciplinary approach that taps into theoretical frameworks and intervention strategies not traditionally located in the literature on student burnout. The learning sciences, being multidisciplinary in nature, offer a wealth of theoretical frameworks and methods that may serve as starting points for further exploration of the correlation between burnout and learners’ utilization of study strategies across learning environments.
Adrian K. Reynolds, PhD
Academic enhancement specialist and assistant professor of professional practice, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; a.reynolds1@miami.edu; ORCID: https://orcid.org/0000-0002-0130-794X.
References
1. Pathipati AS, Cassel CK. Addressing student burnout: What medical schools can learn from business schools. Acad Med. 2018;93:1607–1609.
2. Cho KK, Marjadi B, Langendyk V, Hu W. The self-regulated learning of medical students in the clinical environment—A scoping review. BMC Med Educ. 2017;17:112.
3. Van Nguyen H, Laohasiriwong W, Saengsuwan J, Thinkhamrop B, Wright P. The relationships between the use of self-regulated learning strategies and depression among medical students: An accelerated prospective cohort study. Psychol Health Med. 2015;20:59–70.
4. Cleary TJ, Callan GL, Zimmerman BJ. 2012. Assessing self-regulation as a cyclical, context-specific phenomenon: Overview and analysis of SRL microanalytic protocols. Educ Res Int. 2012;2012:428639.
5. Cleary TJ, Durning SJ, Artino AR Jr.. Microanalytic assessment of self-regulated learning during clinical reasoning tasks: Recent developments and next steps. Acad Med. 2016;91:1516–1521.
6. Brown PC, Roediger HL III, McDaniel MA. Make It Stick: The Science of Successful Learning. 2014.Cambridge, MA: Belknap Press.
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| Potential Solutions to Medical Student Burnout No abstract available |
| Compassion and Health Care: A Discussion With the Dalai Lama The calling to be a physician has historically been driven by compassion—that is, the desire to relieve the suffering of others. However, the current health care delivery system in the United States has increasingly limited the ability of physicians to express compassion as they are afforded little time for meaningful interaction with their patients. One of the authors (R.S.) draws on his current focus on developing personalized, proactive, and patient-driven models of care to argue that patient engagement plays a critical role in achieving favorable outcomes. Believing that compassion is key for establishing the physician–patient relationship needed to foster patient engagement, R.S. sought the advice of one of the world’s most recognized thought leaders on this topic, His Holiness the 14th Dalai Lama. This Invited Commentary describes the meeting between the two authors, the Dalai Lama’s thoughts about compassion, and his challenge to bring attention to the importance of compassion in medical education, practice, and research. |
| Medical Training in the Maelstrom: The Call to Physician Advocacy and Activism in Turbulent Times In this Invited Commentary, the author probes current events overlapping with his early medical education for unwritten lessons. Today’s generation of trainees studies the careful application of science to suffering in the roiling context of resurgent white supremacy, anti-immigrant hatred, climate disasters, contentious public health epidemics, and attacks on the structures undergirding access to health care for millions. The author reflects on the connections between sociopolitical events and his own experiences, as well as those of his classmates, friends, and family members. These experiences, he argues, have galvanized his and his fellow medical students’ commitment to decency, truth, diversity, and equity. He concludes that, in the current climate, the practice of healing is inextricably tied to the social and political context, such that advocacy and activism have become essential to a career in medicine.
Like most of my peers, I was aware of the tedious and demanding pursuit of getting into medical school. Thus, I worked tirelessly to achieve competitive grades while juggling multiple jobs and extracurricular activities. I was taken aback, though, when it finally came time to apply. As a recipient of Deferred Action for Childhood Arrivals (DACA), I was surprised by the additional obstacles I confronted during the admissions process, unlike a traditional applicant. To my dismay, none of the medical schools in my home state allow DACA students to enroll in their MD or DO programs. Hence, I was compelled to apply to out-of-state medical schools.
As I did more research, I learned that most medical schools in the United States were not an option for me. Even the list of medical schools that would accept me was not as reassuring as it appeared to be. After finding little information about DACA students on most of these medical schools’ websites, I decided to call each one. I discovered that most of the schools still had restrictions, like having little-to-no financial support available for DACA recipients, accepting only DACA students with state residency, or prioritizing DACA students with state residency over out-of-state ones.
I stayed resilient in my approach and tried reaching out to multiple private loan companies to help me tackle my financial issues and, therefore, expand my choice of medical schools. Most of these companies required that I first have a cosigner who was either a U.S. citizen or permanent resident before applying for a loan. This was not an option for me. Consequently, I was forced to eliminate many schools from my already diminutive pool of options. My limited list of suitable medical schools consisted of only highly competitive schools, like private and Ivy League institutions.
Through it all, I remained optimistic and applied to the most competitive schools. I hope my experience of applying to medical school raises more awareness of the obstacles DACA students continue to face and their slim odds of getting admitted. DACA students have a lot to contribute to this country, but they need an equal opportunity to do so.
Raj Singh
Certified research specialist, Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; rsingh72116@gmail.com.
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Τετάρτη 31 Ιουλίου 2019
Academic Medicine
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