It was the end of the night and the first time she, one of two experienced health care leaders in the room, spoke during the 90-minute discussion that unfolded in the Beyond Illness Roundtable. We, the students, facilitated, directed and guided the conversation around what it means to be a good doctor, to bring presence and undivided attention to patient care, and to contribute to innovation in value-based medicine. It felt unfamiliar to us. Because it is.
Most medical school classes related to social justice, medical leadership, and innovation occur in the confines of a classroom. Faculty preceptors and course syllabi have little choice but to carefully steer the dialogue to mirror learning objectives that define the boundaries of the conversation. The result is an often apathetic blend of buzzwords like “social determinants of health,” “health care disparities,” “empathy” and “compassion” that tap dance on the surface of deep-rooted issues in medicine and public health. Students contribute to get participation points and keep a close watch on the preceptor’s response. When we sense our contributions meet the desired standards of “professionalism” or “leadership,” we let out a subtle sigh thinking, “I’m good, now. I got my points.”
Within each small group, one or two students have the desire to reach beyond “good enough,” seeking answers to the questions that burn inside them like “what’s next? What can we do about this?” or, taking it a step further, “how can we change the structures that have created the problems we’re discussing? The structures that house many of our current or future professional endeavors?”
In a traditional education setting, these students hear in response the lament that,“That’s an interesting perspective, but it is outside the scope of the discussion we are trying to have.” Many faculty members wilt as they feel the lack of curricular flexibility stifle their potential to help students turn ideas into action.
We don’t blame medical schools for this reality. It’s not their fault.
Our school feels full of clinicians and educators committed to changing health care and medical training. Yet, the national, overly standardized, bureaucratic structure of medical education handcuffs innovators, makers and game changers. Too often, individual institutions abandon their attempts at progress and new training modalities because they are unsustainable underneath the rigid guidelines set forth by educational organizations. Schools without heavily funded innovation institutes cannot afford the risk of pilot programs failing. Instead they end up choosing to simply check the boxes necessary to maintain their accreditation and the all important ivory tower stamp of approval.
The Beyond Illness Roundtable helped unlock the handcuffs. At least for a few hours. It eliminated many of the rigid boundaries that dilute discussions around how a good doctor acts and what obstacles we face in moving towards that goal. Ideas, insights, and vulnerabilities flowed out of a finally unfiltered conversation. Without concern for grades or professors’ perceptions, students’ authenticity broke through as they laid out their version of an ideal physician and improved healthcare culture.
“I don’t want to end up adding to the lack of teamwork so rampant in health care, but I see that succeeding in medical school can mean choosing yourself over a colleague. I fundamentally disagree with the zero-sum mentality, but see it as a game I sometimes have to play.”
“I don’t want to walk into an exam room and see patients as problems, not people, but the fear of getting questions wrong on rounds makes me focus more on the pathology and less on the humanity within a patient visit.”
“When are we going to admit that we’re not just part of the problem, sometimes, we are the problem?”
“I want to bring together different groups within a community to figure out how to build a different health care experience for patients. To pull health care out of its comfortable silo within the walls of doctor’s offices and hospital wards and be a part of the movement where practitioners step into communities, talk less and listen more, and focus less on being the hero and more on being the connector.”
Reflections like this are real, and sometimes dangerous, when evaluating eyes sit at the table. These realizations may pain faculty members who lead these sessions. The apprehension is a byproduct of an educational structure that over-emphasizes grades. This environment grows from and is fertilized by the high-achieving, score-oriented culture of medical education.
From our experience, it appears students do not feel as alone when engaging in this discussion. Removing the hierarchy removes the need to prop up straw walls of emotional strength we use to cope with the trying times of medical school. The pressure, combined with the culture that silently encourages stoicism impedes efficient, collaborative development of empathy and compassion. As students struggle to find avenues for expression and opportunities for mutual support, their ability to care for themselves, and ultimately for their patients, suffers. We hope that, with the Beyond Illness Roundtable, we contribute to building a new area for community and camaraderie.
Medicine has seen a reflexive transition from a paternalistic fraternity that benefited from and, at times, took advantage of patients’ unquestioning trust, to a modern day system full of red tape, bureaucracy, and endless documentation. As the Lown Institute explains, the necessary next phase is a third era that focuses on the value-based, personal side of medicine — the one touches the hearts and souls of patients and clinicians — and draws inspiration from the dialogues that the Beyond Illness Roundtables can start.
As technology, society and culture have progressed, so too have the needs of patients and communities. However, the tactics and ideas that educate future physicians still stem from this excessively hierarchical approach in which superiors know best and those lower on the totem pole — residents, students, nurses and even patients — are expected to listen and follow suit.
These Roundtable discussions create a space for a new dynamic to emerge, in which the stakeholders of health, wellness and medical care work together on a truly equal level to concoct unique pockets that catalyze progress. As we continue dive into deeper, sometimes more difficult conversations, and turn them into meaningful action, these pockets can grow to connect with one another. The fringe becomes the norm, and the new clinician of the third era emerges — one who helps create the intersection of what patients and communities need, and the leadership, science, and connection that health care can bring.
That evening, with only students participating, we bore witness to the power of open dialogues. Going forward, we are working on putting together another Roundtable that brings in physicians, patients and community organizations to continue this collaboration. It feels a lot more efficient and enjoyable compared to waiting with hopeful, potentially futile, optimism for bureaucratic progress to make this the norm.
While our motivation is tangible, we remain unsure of our ability to strike up. We fight the reflexive urge to listen to and act upon the traditional push to please and appease our way to the top of the medical hierarchy. That strategy got us into medical school, and many use it in varying degrees to get into and through residency. However, within each roundtable participant burned a skepticism of that strategy’s ability to help us create a world in which we can best care for our patients.
Perhaps, with time, the dynamic in more areas of a traditional education setting will shift to mirror that of the Beyond Illness Roundtable. Until then, we know we don’t need permission to have these discussions and contribute to the momentum of change. With the help of Shannon and Dr. Saini, the Right Care Alliance, and everyone at the Lown Institute, we remind ourselves of Margaret Mead’s timeless advice: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”