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ISSUE 1 2013 QUARTERLY

The Rossi MED ICAL ED UCA TI ON NEW S, RESEAR CH RE VIEW S, TEAC HIN G T IP S ,

CON VER SA TI ON S W ITH ED UCA TIO N LEA DER S

Dani Dumitriu

Interview with Dr. Yasmin Meah Leader in Medical Education and Community Service

Dr. Yasmin Meah, MD is the faculty

founder of the East Harlem Health

Outreach Program, a student-run free-

clinic based at Icahn School of

Medicine at Mount Sinai, and director

of the InterAct Clerkship, a longitudi-

nal Ambulatory Care Clerkship. For

her work with the free clinic, she was

recognized by the 2007 Humanism in

Medicine Award given by

the Association of Medical Colleges—

Dr. Meah is the youngest person to

ever receive this honor.

The Rossi writer Dani Dumitriu was

pleased to discuss with Dr. Meah the

road to that led to her passion towards

teaching and service, including

influence from her immigrant parents.

Dr. Meah also discusses the balance of

her life between her patients, students,

family and passion towards the arts.

� MEDICAL EDUCATION RESEARCH CORNER: CRITICAL ASSESSMENT OF RECENT LITERATURE ... 8

� INTERVIEW WITH DR. YASMIN MEAH (CON’T)

............................... 2

� NYC CULTURAL CONSULTS: A STUDENT-RUN PROGRAM

............................... 6

THE ROSSI GOES LIVE ONLINE The Rossi articles are featured on blog.mountsinai.org Read articles online and join in on the conversation today.

Dr. Yasmin Meah, internist and founder of free clinic at Icahn School of Medicine

Icahn School of Medicine at Mount Sinai

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You wear a lot of hats at Icahn School of

Medicine at Mount Sinai. Can you give an

overview of them?

To go back to the beginning, I did residency here, I did chief resident year here, and got pregnant during my chief year. I had my first child, and then I took a year off. During that year off, I got involved with NYU’s free clinic. Then I came back to Sinai in the Department of Medi-cal Education. At the time, I thought I was going to go into fellowship, and I just decided after chief year and after having my first kid that I wasn’t going to go through any more training.

What fellowship were you planning?

Infectious diseases. And I was going to do it here but I decided to end that relationship very quickly, because I knew that ultimately I wanted to be very much in control of my own schedule. And so I was one of the first of several chief women who had their first kid during chief year and decided not to pursue fellowship after that. When I got recruited back, I actually came back to the Department of Medical Educa-tion. I had had a strong interest in Med Ed for years. I was actually primarily interested in stu-dents with academic issues and how to remediate

them. When I came back, I did a project called Resident-Teacher program where I developed a teacher program for residents who were interest-ed in teaching. I also at that time started the board review course, in 2003. That year as well, I joined the Visiting Doctors Program.

Was your appointment all one package, or

were you hired by Med Ed and then it

spawned from there? It just spawned from there. I was hired by Med Ed and the leadership at the time was actually my former program director. So every-body that I knew in the Department of Medicine was slowly moving over to the Medical School. My former program director at the hospital in internal medicine was Larry Smith, who eventu-ally became the Dean of Med Ed. And then slow-ly David Muller moved over. He was at the time

my associate program director. I got hired by the Department of Med Ed, and then I rejoined the Department of Medicine as part of the Visiting Doctors Program. I was the first part-time physi-cian in the Department of Medicine. At the time, being a part-time physician was not in vogue. It was not something that was encouraged. But it was strongly what I wanted to do. I joined with the idea that I would split my panel with a Nurse Practitioner.

To finish off in terms of your hats – you are

also involved with EHHOP.

Yes. At the time that I came back, my burgeoning interest was actually developing a free clinic here. I brought over the model from NYU. I worked with a group of students here who were very motivated in developing a free clinic. After a year of a lot of work, we got it off the ground in 2004. I run the clinic and oversee all of the clinical care, chronic disease manage-ment, acute care management, research projects, budget, grant writing. David Thomas is my medical director and he is sort of the face to the administration. I don’t know the who’s who in administration and he really helps navigate that. He’s savvy, incredi-bly intelligent, very well connected. He’s just

incredibly committed to service. And he was my mentor, so it’s great to work with David. Of course, my biggest support is actually the senior and junior students – they run the show. I play much more of a supervisory role to them. There is a lot of active teaching that happens, but it’s so much fun. It’s so much richer than most other experiences I have had. Even with the residents. Which is why I left the residency completely and I devote all of my attention to the medical school.

And then I am also the clerkship direc-tor for the InterAct Clerkship, which is the longi-tudinal Ambulatory Care Clerkship that I co-founded with Valerie Parkas and Rainier So-riano. Allison Gault, a pediatrician, and I run the program together. We received a Macy grant to pilot the program in its first 3 years and we are in year 3 right now.

“Of course, my biggest support [at the free

clinic] is actually the senior and junior students

– they run the show... There is a lot of active

teaching that happens, but it’s so much fun.”

THE ROSSI STAFF

EDITOR –IN-CHIEF K. H. VINCENT LAU ASSOCIATE EDITOR LENARD BABUS EDITOR-AT-LARGE DR. ERICA FRIEDMAN EDITORS ALEXA MIESES ALISON THALER ANN WANG WEB EDITOR MIGUEL YAPORT WRITERS DEMETRI BLANAS GRACE CHARLES DANI DUMITRIU H. CINDY KO LOHEETHA RAGUPATHI JOHN ROZEHNAL DIPAL SAVLA SUSAN YIN

“The most essential part of a student's instruction is obtained...not in the lecture-room, but at the bedside. Nothing seen there is lost; the rhythms of disease are learned by frequent repetition; its unforeseen occurences stamp themselves indelibly in the memory.”

- Oliver Wendell Holmes, M.D.

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What is the Macy grant?

It’s an educational grant that was developed by the Macy Foundation for educators. Josiah Macy Foundation funds educational projects within medical schools, nursing schools, anything that is health care related. Their primary motiva-tion is to develop physicians who have a strong interest in primary care as well as a strong interest in service and advocacy. They fund a number of projects across the country. In particular they have a strong interest in integrated clerkships. They funded several models for integrated third year medical school clerkships: the Harvard Medical School Cambridge Integrated Clerkship, University of California, San Francisco’s integrated clerkship and they’re currently funding our program. It was an important grant and it was co-authored by myself, Rainier Soriano, Valerie Parkas, and Allison Gault.

That’s a lot of hats. Any others? I think that’s basically it. I continue to do a lot of advising for students who are interested in primary care or integrating service into their practice. But in terms of an official hat in Student Affairs, I have now completely moved away from that.

With all those hats – you started out

talking about how you had hoped to do

more part-time stuff so that you can

balance home and work, and yet here

you are with a myriad of different hats –

how is that balance working out?

You know, it’s something that is constantly evolving. I wouldn’t say it’s perfect. I describe the work-life balance as a constant pendulum. It’s something that is constantly moving and sometimes it swings too far to home, and sometimes it swings too far to work. I am very conscious of it. I think that what helps a lot

is that I have an incredibly supportive husband [Peter Gliatto, Associate Dean of Undergraduate Medical Education and Student Affairs at Icahn School of Medicine]. I don’t think I always give him a lot of credit. The two of us couples-matched here in residency, were chief resi-dents here, and we basically followed a similar but not the same path. I think our interests have always overlapped. We went

to college together, so we’ve known each other for a very long time and we’ve grown up together in the very formative years of adulthood, so a lot of our interests have been shaped by each other. We’ve always had this dream to belong to a practice where we could cover for each other and be able to cover for things at home too and that’s in fact what happened. We understand that there is always going to be this tension between work and home, and we sort of have a schedule worked out pretty well. There are several nights a week where I don’t come

home until very late and he has the kids. And then there is always a day off that I have during the week. My Thursdays – that’s a sacred day. I don’t answer any patient calls or anything work-related on Thursdays. I really stay away from my Blackberry. I stay away from the computer. I hang out with my youngest.

How old are your three kids? They are three, eight and ten. So I hang out with my youngest, I do a lot for their school, I am on the board of the charter school for my kids. It’s really fun. I love it. It’s actually great to use the same skills as here. Managing personalities, very difficult and complex ethical issues – it’s very similar to what I do here in both EHHOP and Visiting Docs.

Do you ever feel guilty about not having

more time with your children?

I have an amazing group of colleagues and I have an amazing mentor in David Muller. He knows I’ll work incredibly hard and that I have dreams and ideals and I can get there. So having that, I’ve been allowed to protect my time a little bit. Most Mondays I’m actually working from home. I can pick up my kids from school, do homework with them and then go back to work at 6 pm from home. I do have a lot of flexibility. There’s just 3 to 4 days where I’m fully here. And that’s

"The successful teacher is no longer on a height, pumping knowledge at high pressure into passive receptacles...He is a senior student anxious to help his juniors." - Sir William Osler

“I describe the work-life balance as a

constant pendulum. It’s something that is

constantly moving. I am very conscious of it.”

Dr. Meah at a home visit, as part of the Visiting Doctors program

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fine. Everybody knows that, including my husband. There are times that I feel really guilty – guilty in both ways; where I am ignoring a patient because I have a child issue, or vice versa. I think every physician who is a parent, or has a significant other, or a parent who is ill, feels this tension.

Do you think both males and females

feel that tension?

I think women feel it more, definitely. I think we are wired differently. We form more community connections. We feel like we owe more to our community. The drive to do well and commit extends beyond work for women. There have actually been studies on this as well. It’s pretty well known that men strive to do incredibly well at work, whereas women strive to do incredible well across all fields.

Can you talk about how your parents

shaped you? I think that it would be silly not to say that my parents in a strong way had an influence on me. They actually had very different influences on me. I grew up in North Jersey, in the suburbs. My dad is from Bangladesh, my mom is from Paki-stan, which is interesting because they married the same year their countries went to war with each other. My dad was an OB-GYN physician. So he was sort of the academic side of my growth. Well, I should say – he got his education in England and Canada and came to Jersey, and actually trained initially as an anesthesiologist, then moved to OB-GYN. He practiced in Patterson, which is a very, very low income area in New Jersey. There were a lot of Bangladeshi immigrating to Patterson and he would often donate his services to the uninsured there. Service was actually at the core of his practice, which is strange because I never saw that until later. He works exclu-

sively with the poor. It was something that my mom – who worked with him as his office manager – really pointed out to us, that you should always service the poor. This should be your community.

I know in Bangladeshi culture parents

try to push their children into medicine.

Did you grow up thinking you wanted to

be a doctor because you saw your dad

being one, or because you were told you

have to be a physician?

Both. I think that as I was grow-ing up I tried really hard to react against that compulsion to become a doctor. My

mom is from Pakistan and very much in their culture as well, at least one child should become a physician. I mean, this is Asian culture. I have two younger sisters and it’s interesting because all three of us had a strong interest in the arts, in fine arts in particular.

How did your parents react to that?

My mom was very supportive. My dad felt conflicted about it. I think now if you ask him, he’s very proud of it, particularly because my middle sister is the head exhibition artist at the Museum of Natural History. My dad is very proud of that. So art was a very strong passion of mine and when I went to college I thought that art was going to still be a strong piece of me. And it was. But I was also interest-ed in academics. I became an art history major at Hopkins and my art teacher wrote my letter of recommendation for medical school. It was actually the one letter that every medical school would highlight.

It was interesting because he said I wasn’t vain enough to become an artist. He was a strong influence on my reasons for why I eventually went into medicine. He felt I was too compassionate to give up a life in medicine.

Thank you so much for the interview.

My pleasure.

“[My father] would often donate his

services to the uninsured there. Service was

actually at the core of his practice, which is

strange because I never saw that until

later... It was something that my mom…

really pointed out to us, that you should

always service the poor. This should be your

community.”

Northeastern Group on Educational Affairs (NEGEA) Annual Meeting

April 12-13, 2013 in New York, NY https://www.aamc.org/members/gea/regions/negea/meetings/

Accreditation Council for Graduate Medical Education Annual Educational Conference February 28 - March 3, 2013 in

Orlando, Florida http://acgme.org/acgmeweb/tabid/408/

MeetingsandConferences/AnnualEducationConference/

52nd Annual Conference on Research in Medical Education (RIME) in conjunction with the 124th Annual Meeting of the

Association of American Medical Colleges (AAMC) November 1-6, 2013 in Philadelphia

(Paper and abstract submissions due Feb 8), 2013

https://www.aamc.org/members/gea/gea_sections/322066/2013researchinmedicaleducationrimeconfer

ence.html

UPCOMING MEDICAL EDUCATION MEETINGS

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Icahn School of Medicine at Mount Sinai is known for innovation within the realms of patient care, research, and medical education. Training future physicians requires a commitment to progress, and the newest addition to the medical school’s curriculum is no exception: In the spring of 2013, handheld ultrasound will be introduced to enhance students’ and trainees’ clinical skills and generation of a differential diagnosis by reinforcing anatomic and physiologic principles.

Unlike traditional ultrasound, bedside ultrasound is performed at the point of care, not in an imaging suite. Handheld ultrasound - an even more recent technology - is small enough to fit in the palm of a hand, with a screen roughly the size of a smart phone. Compared to traditional ultrasound, these devices are more portable and less expensive, although the quality of image may be compromised.

Dr. Bret Nelson, an Emergency Medicine physician and Director of the Emergency Ultrasound Division at Mount Sinai, compares the use of various ultrasound machines to the use of various computer devices. “Your smart phone can be a passable computer in many circum-stances,” he says, “but more elaborate work requires a laptop, and when you need high-end processing power you use a workstation. Similarly, handheld ultra-sound devices can image structures quite well and can hugely benefit medical decision-making in real time. For added options in high-end imaging, more robust documentation, image archiving and other options, generally cart-based machines have more features. And top-of-the-line imaging systems generally used in imag-ing suites (and not at the bedside) will have the most comprehensive imaging tools.”

Icahn School of Medicine is one of few medical schools across the country to include handheld ultrasound devices in its training curriculum. Previously, ultra-sound has been used in the Gross Anatomy course directed by Dr. Jeffrey Laitman, for example to explore the chambers and blood vessels of the heart. Medical students appreciated the experience, but many wished they had more time to learn how to use the technology. “I thought it

was interesting,” one student said, “but I spent most of my time trying to orient my-self.”

Handheld ultrasound is now also used in the Art and Science of Medicine I course, in order to provide additional information about the physical examina-tion of the heart. The course is directed by Dr. Joanne Hojsak, M.D. a pediatric critical care specialist and Director of the Pediatric Intensive Care Unit at Mount Sinai. She says: “When first approached about incorporating ultrasound into the ASM I physical examination component, I was skeptical. How do you introduce tech-nology when many students have yet to understand how to wear a stethoscope? However, with some thought I realized

that ultrasound examination of the very areas the students will palpate and auscultate reinforces what they feel and hear, often for the very first time.”

Because medical students will again encounter both traditional and handheld ultrasound during clinical rotations, Dr. Nelson – the director of the ultrasound course-complement - says that students will be “more prepared to use this rapidly-growing technology… The ability to visualize anatomy greatly enhances our understanding of normal and pathologic states as we encounter them…Central line placement, peripheral IV access, lumbar

puncture, bladder catheterization, joint aspiration, nerve blocks, and a host of oth-er procedures can be enhanced by visualizing target anatomy and needle placement.”

General Electric provided the VScan model ultrasound devices to Icahn School of Medicine. The $1 million gift is entirely due to the work of Dr. Jagut Nar-ula, cardiologist and Director of Cardio-vascular Imaging. Ultimately, Dr. Narula would like medical students to receive their handheld ultrasound devices at the White Coat Ceremony at the beginning of medical school. Each device currently costs approximately $8,000. However, many companies will release individual versions

of the device in 2013, and the price is expected to drop substantially. As a result, these ultrasound devices will become more accessible, with the potential to be useful in public community clinics as well as large medical institutions.

Dr. Narula also credits Dr. Bret

Nelson, Dr. Reena Karani, Dr. David

Muller, and Dean Dennis Charney with

their willingness to accept what she calls

her “radical idea” – an idea for which,

speaking for my entire class as a current

first year medical student, we are

incredibly grateful.

Ultraportable Ultrasound Introduced to Medical Education Alexa Mieses

The VScan device made available to Icahn School of Medicine students and trainees

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What do Damian Woetzel, former principal dancer of the New York City Ballet and current Director of Arts Programs at the Aspen Institute, and Dr. Meredith Grossman, Mount Sinai pediatrician, have in common? First, both participated in an engaging round table discussion during one evening last January as distinguished guests of the NYC cultural consults. Second – something that became clear to everyone in the room as the dialogue progressed – both are, in different ways, performers. In a conversation over hors d’oeuvres with about thirty Icahn School of Medicine at Mount Sinai medical students, Mr. Woetzel and Dr. Grossman explored the surprising commonalities between medicine and dance.

These types of eye-opening discussions between medical students, faculty, and cultural leaders and innovators are precisely what Sar Medoff and Adam Philips, current third year Icahn School of Medicine medical students, had envisioned when they founded NYC Cultural Consults in 2011 under the mentorship of Dr. Erica Friedman, Associate Dean for Education Assessment and Scholarship. The group is

now led by second year medical students Alex Peters and Evan Pulvers, who met with The Rossi to discuss the group’s role in medical education at Icahn School of Medicine and the future directions of the organization.

Medoff initially conceived of the group after reflecting on his experiences as an undergraduate at Princeton University.

At Princeton's undergraduate dining halls and at certain eating clubs, professors from various fields were frequently invited to speak with students over informal dinners in a small group setting. Medoff enjoyed this opportunity to interact with leaders in diverse fields and sought to institute a simi-lar program at his medical school. Located

in the heart of New York City, widely rec-ognized as the cultural capital of the United States, the school affords itself great opportunities to attract experts, leaders, and innovators to sit down and speak with its intellectually curious medical students.

And so, in the spring of 2011, the NYC Cultural Consults student group was founded. The group invites three or four

speakers per semester for an evening roundtable discussion with up to thirty students and a faculty member at Icahn School of Medicine at Mount Sinai. Topics of conversation range from the impact of public transit on public health to the im-portance of movement to a dancer. Cheng-Cheng Zheng, a fourth year medical student who has attended an NYC cultural consults event, describes the event as "an amazing and rare opportunity for me to participate in an intellectual conversation outside of medicine with a giant in his field". She says, "the discussion not only allowed us to discuss some of the greatest issues both nationally and internationally, but also reminded us of how we fit into that dis-course as future physicians. I think events like this can be especially important at a medical school that is not attached to a larg-er university.” Indeed, the current trends in medical education highlight the importance of the social milieu of the patients, and the NYC Cultural Consults provides an excel-lent opportunity to engage in direct dia-logue with a diverse group of its leaders.

The group is funded primarily by the student council, with occasional donations from faculty members. The speakers are leaders in their respective fields. In addition to their faculty advisor

Dr. Friedman, the faculty in the medical education office have also been instrumental in identifying and contacting potential speakers.

Evan Pulvers (left) and Alex Peters (right), the current leaders of the NYC Cultural Consults

Expanding our horizons with the NYC Cultural Consults: An interview with Alex Peters and Evan Pulvers

Loheetha Ragupathi

“The discussion not only allowed us to discuss

some of the greatest issues both nationally and

internationally, but also reminded us of how we

fit into that discourse as future physicians.”

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The NYC Cultural Consults events, typically an hour and a half long, involve a short interview followed by a more informal discussion led by one student and one faculty moderator. The speakers generally talk about their careers as well as how medicine intersects their careers. All speakers participate on a volunteer basis, which according to Pulvers, has not deterred anyone. On the contrary, they have been very enthusiastic to share their stories with an engaged and bright group of medical students.

The list of past speakers (see Table 1) is an impressive one, composed of leaders in a wide range of fields, including the performing arts, business, and transportation. Lauren Feld, a third year medical student, was among the stu-dents who attended the event featuring Dan Rather, former CBS news anchor.

"Learning about the world of journalism from Dan Rather was an incredible opportunity, and he connected medicine and journalism with advice that authenticity is the key to success in both fields," she says. She shared a bit of advice gleaned from Mr. Rather: "As you move up, you're not likely to be the smartest person in the room. So get to work early, leave late, and work the hardest you can while you're there."

Speaking of that particular event, Pulvers tells that they had requests to attend from 60 to 70 students more than they could accommodate, citing the space

limitation for only 25 students. But space is not the only reason to limit attendance. As Peters explains, "the magic of [the events] is in the small group setting ... there's something about being in that round

table". Because of this, expanding the attendance limit for these events is not on the agenda for the program's future.

In fact, there is very little that Peters and Pulvers are looking to change, and with good reason. The pair of current leaders conducted a survey of attendees from their first ten events, and found that of the five faculty and twenty-six students who responded, 96.8% felt the overall quality of the events was either “above average” or "superior.” Interestingly, however, 80% of faculty but only 30.8% of students felt that these events should be integrated into the Icahn School of Medi-cine at Mount Sinai. Although formaliza-tion of these events into an elective curric-ulum is not their goal, the leaders will keep this idea in mind as the program continues to develop.

Former CBS News anchor Dan Rather (right), with moderators Dr. David Reich (left), Chair

of Anesthesiology, and Jamie Zimmerman (center), currently a fourth year medical student.

March 2011 Robert Friedman, President of Media and Entertainment

April 2011 John McArthur, CEO of Millennium Promise

November 2011 Cesar Bocanegra, COO Donorschoose.org

January 2012 Damien Woetzel, Former Principle Dancer, NYC Ballet

March 2012 Steve Daniels, IBM Watson Team Researcher

April 2012 Projjal Dutta, NYC MTA Director of Sustainability

May 2012 David Zaslav, President and CEO of Discovery Communications

Sept. 2012 Dan Rather, Former Anchor, CBS Evening News

Sept. 2012 Emily Senay, MD, MPH, Preventive Medicine Physician, Health News Journalist

October 2012 Jacques D’Amboise, Former Principal Dancer for the New York City Ballet

“The magic of [the events] is in the small

group setting ... there's something about being

in that round table".

Table 1 - Past events of the NYC Cultural Consults

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Due to the popularity of the Cultural Consults, the group is hoping to increase the frequency of these events in order to accommodate as many students as possible. Another goal is to increase the number of women speakers, as only one of the ten speakers so far has been female. Although there are currently no plans to open the events to medical students from other institutions, the group hopes to assess the value of this program to other New York medical schools. To showcase this novel program, they recently submitted an abstract to the Northeastern

Group on Educational Affairs Conference, which will take place at the Weill Cornell Medical College in April of 2013.

In the meantime, Peters and Pulvers continue to work on recruiting for their spring events and already have two accomplished guests confirmed. The first, Lucy Reed, who previously worked at the Hague, served as a Commissioner of the Ethiopia-Eritrea Claims Commission (an international humanitarian law tribunal created by international agreement) and currently serves as a member of the Council on Foreign Affairs, will

undoubtedly be a great draw for students interested in human rights initiatives. The second guest, Danny Meyers, is the CEO of the Union Square Hospitality Group, which includes award-winning restaurants such as Shake Shack, The Modern, and The Union Square café.

The Rossi is pleased to commend the strong student leadership behind a program that enhances the cultural experience for Icahn School of Medicine medical students.

Students participating in the round table conversation with Dan Rather

MedEd Research Corner Critical Assessment of Recent Literature John Rozehnal and Dipal Savla

ABSTRACT OF STUDY #1:

Competency is not enough: integrating identity formation into

the medical education discourse.

Jarvis-Selinger S, Pratt DD, Regehr G. Acad Med. 2012 Sep;87

(9):1185-90.

Despite the widespread implementation of competency-based

medical education, there are growing concerns that generally

focus on the translation of physician roles into "measurable

competencies." By breaking medical training into small, discrete,

measurable tasks, it is argued, the medical education community

may have emphasized too heavily questions of assessment,

thereby missing the underlying meaning and interconnectedness

of how physician roles shape future physicians. To address these

concerns, the authors argue that an expanded approach be taken

that includes a focus on professional identity development. The

authors provide a conceptual analysis of the issues and language

related to a broader focus on understanding the relationship

between the development of competency and the formation of

identities during medical training. Including identity alongside com-

petency allows a reframing of approaches to medical education

away from an exclusive focus on "doing the work of a physician"

toward a broader focus that also includes "being a physician." The

authors consider the salient literature on identity that can inform

this expanded perspective about medical education and training.

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Critique of Study #1

John Rozehnal

How can we better understand the long process of becoming a doctor? Is this transformation defined in terms of what we want a doctor to be able to do and who we want a doctor to be? How do we measure and evaluate these hallmarks? Medical training undoubtedly entails the accumula-tion of a large body of knowledge and a unique skill set. However, Sandra Jarvis-Selinger et al. argue that the process of medical education is chiefly the process of forming and acquiring the identity, rather than the skills, of a doctor.

Jarvis-Selinger et al. define iden-tity as the roles, habits, values and mastery of social contexts required to function as a good physician. Identities form, ossify, degenerate and reform dynamically, sometimes very suddenly. In contrast,

skills are competencies such as the under-standing of a metabolism cycle or the ability to take a history, which increase linearly and in a quantifiable way. Identity formation additionally requires establish-ment of intermediate identities: student;

clerk; intern; resident, each of which

brings its own set of challenges, roles and behaviors. The authors suggest that the focus on competency over identity-formation leads us to mistake what is measurable for what is meaningful. This misplaced emphasis may be a shortcoming of medical education.

Jarvis-Selinger builds on a conceptual framework that breaks identity formation down into three important

stages, Becoming, Being, and Integrating. In the first stage, the student acts the role without understanding what it really means, in order to acquire the skills. In the second, the student internalizes the behaviors and can effectively fulfill her role. In the third, the student understands and internalizes not only the behaviors but also the personal systems used to relate the behaviors to the system in which they function. The authors underscore the importance of this three-stage model be-cause the factors involved in each stage are different for each phase in a physician's development. At its core, the authors’ argument stresses that medical education based solely on competency ignores the important process of shaping multiple roles, and the cyclical formation and destruction of intermediate identities.

Focusing on competency produces an excellent rubric against which

to test students. However, the authors ar-gue this method is flawed in two important ways: first, by the "tendency to atomize" and hold constant a process that is in reali-ty fluid and dynamic; second, the establishment of qualitative metrics sets a baseline level of adequacy as the benchmark of readiness to practice. Incorporating identity formation into our rubric for medical education training and assessment focuses on how a doctor behaves instead of what he or she can do.

Assessing the Study

The authors foreground the idea that possessing a doctor's skill set is not equivalent to being a doctor, the ultimate

goal of medical education. Similar to the recent shift in focus towards teaching bedside manner, a skill set previously thought to be “unteachable”, the authors argue that the cultivation of a professional identity should be actively addressed in medical education. This identity is too important to be left to chance or institutional inertia. Additionally, Jarvis-Selinger et al. strongly argue that a single-minded focus on quantifiable measures of competence can lead to an excessively reductionist understanding of what it means to be a doctor.

The piece poses many thoughtful questions yet provides few answers. The authors argue that identity formation should be folded into current competency-based evaluations but stop short of describing how to merge the two in practice. The article comes closest to providing practical direction when describing the shifts in evaluations during the later stages of residency to accommodate identify formation: “As the resident progresses, assessment requires an evaluation of the integration of a host of competencies into something greater than the sum of those parts.” By failing to provide alternatives for incorporation, the authors do not fully advance the discussion on identify formation.

Assessing the Application

Nevertheless, the authors' core position is worth consideration. Medical students play many roles before becoming independent physicians. It would be overly simplistic to reduce students’ learning to one-dimensional, linear increases in competency. A supplementary perspective that incorporates the dynamic creation and deconstruction of roles, responsibilities and identities is more difficult to evaluate. However, this perspective is more likely to reflect a student’s ability to be a physician rather than his/her ability to merely act like one.

Incorporating identity formation into our rubric for

medical education training and assessment focuses on

how a doctor behaves instead of what he or she can do.

ABSTRACT FOR STUDY #2:

Perspective: the negativity bias, medical education, and

the culture of academic medicine: why culture change is hard.

Haizlip J, May N, Schorling J, Williams A, Plews-Ogan M. Acad

Med. 2012 Sep;87(9):1205-9.

Despite ongoing efforts to improve working conditions, address well-

being of faculty and students, and promote professionalism, many

still feel theculture of academic medicine is problematic. Depression

and burnout persist among physicians and trainees. The authors

propose that culturechange is so challenging in part because of an

evolutionary construct known as the negativity bias that is reinforced

serially in medical education. Thenegativity bias drives people to

attend to and be more greatly affected by the negative aspects of

experience. Some common teaching methods such as simulations,

pimping, and instruction in clinical reasoning inadvertently reinforce

the negativity bias and thereby enhance physicians' focus on the

negative. Here, the authors examine the concept of negativity bias in

the context of academic medicine, arguing that culture is affected by

serially emphasizing the inherent bias to recognize and remember

the negative. They explore the potential role of practices rooted in

positive psychology as powerful tools to counteract

the negativity bias and aid in achieving desired culture change.

10

Critique of Study #2 Dipal Savla

Academic physicians pride them-selves on the scholarly, innovative, and achievement-driven environment in which they practice. Yet dissatisfaction, burnout, and depression are commonplace among medical students and physicians in academia. To enhance physician satisfaction, medical schools and academic health centers have attempted to reform medical education and physician training by imposing work hour limitations and introducing wellness programs such as yoga and reflective writing in training curriculums. However, these programs have had limited success in changing the culture of academic medicine. The above study, suggests that the limitations of these programs stem from the widespread culture and perspective of negativity occurring throughout medical education and training, that instills a pessimistic attitude in physicians.

According to the theory of negativity bias, humans have evolved to be more drawn to and influenced by negative experiences than positive ones. Thus, it is not surprising that skepticism is prevalent in academic medicine and negative reinforcement is commonly used as an educational tool throughout medical training. For example, many instructors and attendings utilize “pimping,” a teaching strategy in which they ask train-ees medical questions designed to bring to light what the trainees do not know, using the shame of missing questions to motivate students to study. Additionally, in graduate medical education, residents are taught to consider and rule out the worst-case scenarios prior to the more benign ones. While both these practices reduce the like-lihood of physicians missing an important diagnosis, they cultivate a predisposition to pessimism.

The article argues that the high rates of depression and burnout among

academic physicians and trainees stem from the extensive use of negative reinforcement as a teaching mechanism throughout medical school and residency. Fixing these issues requires more than simply introducing regulations and programs promoting physician wellness;

rather, the culture of academic medicine must be reformed. As a first step, a deliberate effort to incorporate positivity in the classroom and on the wards can be an effective way to achieve change.

The article discusses several studies that support this notion. Specifically, researchers have found that simply keeping a journal of positive experiences has been correlated with a lower likelihood of developing depression. In another study based in a different field of education, high school teachers who used personal strength identification and other techniques to induce positivity in students found a significant increase in students’ engagement and love for learning. Given these findings, a recent

study attempted to investigate whether inducing positivity among third year medical students and internists impacts performance. The results were profound: simply praising the students and appreciat-ing the physicians not only induced a positive attitude in the students and physicians; it made them more efficient,

more likely to go beyond the task they were assigned, and more thorough in considering differential diagnoses. This suggests that making a concentrated effort to regularly express positive sentiments towards colleagues may diminish the high rates of depression among physicians, and trigger a change in the culture of academic medicine.

Assessing the Study The article describes many of the ways in which negativity is serially reinforced in medical school and teaching hospitals, as well as the profound impact of negative experiences on human memory

and effective learning. However, the impact of the resultant culture on physician depression is less clear. While work environment clearly influences job satisfaction, its impact on depression is more complex. Many factors that are not related to work can influence one’s suscep-tibility to the illness. The article could have further explored whether physicians tend to have a negative mindset even outside of the workplace. Additionally, the article concludes by recommending that physicians compliment and thank their colleagues and students more often. Presumably, this would induce positivity in physicians and trainees, increasing not only their job satis-faction but also work efficiency and quali-ty. However, the implementation of this strategy would require that compliments and expressions of gratitude be perceived as sincere; if not, they are completely dis-

missed. Thus, a hospital-wide initiative to encourage physicians to express their posi-tive feelings towards colleagues runs the risk of making all compliments feel delib-erate and artificial.

Assessing the Application Perhaps the most compelling con-clusion this article makes is that the mind-set through which physicians perceive and approach their work environment has a stronger impact on long-term job satisfac-tion, as compared to any specific programs or regulations implemented to promote wellness. Without a change in perspective, physicians continue to focus on the prob-lems that remain in their work environ-ment, focusing on the limitations of these interventions instead of appreciating their positive impact. Thus, the importance of

increasing positivity among physicians is

clear. This optimism can either be

externally or internally induced. Physicians

and students have a more positive attitude

when their colleagues compliment and

thank them more frequently, as well as

when they spend more time internally

reflecting on the positive aspects of their

day; however these compliments may

appear insincere and thus be ineffective.

Instead, teaching physicians and trainees to

cultivate an internal predisposition to

positivity may be a better way of reform-

ing the culture of academic medicine.

According to the theory of negativity bias, humans

have evolved to be more drawn to and influenced

by negative experiences than positive ones.

“I hear and I forget. I see and I remember. I do and I understand.” - Confucius

11

Simulator-based education, developed by the aviation industry in 1909, was initially designed to help pilots fly the Antoinette monoplane. Simulation programs aim to recreate real-life situa-tions. Given this goal, a simulation’s big-gest challenge is achieving fidelity: does the simulation facilitate learning that trans-lates into real-life settings? Simulation programs that do adequately portray their depicted scenarios provide many benefits. Programs are inexpensive in the long term, as they can be mass-produced and reused once constructed.

For medical schools, simulation-based education provides important oppor-tunities for students to experience rare cases and safely learn from incorrect actions or diagnoses. A simulator program in medical education may re-create patient encounters or feature critical care situations.

As a specific example, through-out training medical students are told a crescendo-decrescendo murmur that is loudest at the upper right sternal border, is louder on expiration, and radiates to the carotids is a physical finding of aortic ste-nosis. Despite constant repetition, this statement is often not truly understood until experienced in person, but unfortunately, this particular pathology is relatively uncommon. Today, educational simulations (in this case, recordings of the heart sound) make it possible for every medical student to become familiar with an otherwise rare finding.

During simulated patient encounters with a mannequin – a second example of simulation-based education - medical students make decisions for their mock patients under the watchful eye of an attending doctor. These sessions allow students to learn how to make rapid, im-portant decisions, and to experience the consequences of these choices without ever putting their patient in real danger. The attending physician’s main role is not to step in to intervene; failure is always an

option. In many real-life instances, these errors would lead to negative outcomes or death, results which highlight the powerful role of simulators as teaching tools.

Although simulator-based experi-ences are now commonly used in medical education, Mount Sinai’s Anesthesiology Program is known throughout the world

for its simulator center, known as The Mount Sinai HELPS Center, or simply the Sim Center. The Sim Center is open not only to anesthesiology residents but also to Icahn School of Medicine medical stu-dents as well as several other groups of providers from Sinai and other institutions.

It was in the Sim Center that Dr. Adam Levine, Dr. Samuel Demaria Jr, and Dr. Jason Epstein first developed a com-puterized preoperative patient interview simulation. According to Dr. DeMaria Jr, the idea evolved from the desire to aug-ment “our high-stakes simulation-based assessment for attending anesthesiolo-gists”. Mount Sinai’s Anesthesiology Department now employs this Sim Center as part of its re-certification program for

Anesthesiology attendings as well as for individual assessments for medico-legal reasons.

As a first step towards creation of this simulator for high-stakes assessment, Dr. DeMaria Jr, Director of Research of the Mount Sinai HELPS Center, partnered with LogicJunction, Inc to develop a screen-based virtual human simulator (known as an avatar) to train and evaluate Anesthesiology residents. This simulator was the first of its kind in anesthesiology. It can be set to mimic the preoperative environment, and its design allows “the full range of human emotions, facial expressions [and] body language…”. It is so realistic that Dr. DeMaria Jr believes it can even be used to “train physicians to interview difficult patients or patients with psychiatric disorders”.

Recently, the avatar’s ability to train and assess the performance of

residents was examined in a randomized study. Residents were assigned to inter-view either the avatar or a standardized patient. The study found that simulator-based training and assessment were statis-tically comparable to training and assess-ment using a standardized patient. Interest-ingly, residents were more likely to per-form a physical exam and check vitals on the avatar than on the standardized patient.

The avatar, says Dr. DeMaria Jr., has the potential to teach medical students both history and physical exam skills, as well as to help with practice for Step 2 CS. Similar to the online exams that medical students take at home, this avatar program can be accessed online. Additionally, Dr. DeMaria Jr. says the machine “can reliably

reproduce patients and pathophysiology” in contrast to standardized patient actors, who cannot reproduce medical phenomena such as heart murmurs.

However, Dr. DeMaria Jr does have a few words of warning. “When it comes to a mannequin simulated patient, human standardized patient or avatar, the primary goal is not care of the patient; it’s

sometimes training to the test.” In other words, although simulated patient encoun-ters offer tremendous value as an adjunct to medical education, they cannot replace treating and caring for real patients.

These simulator programs are gradually but powerfully transforming medical education. The Mount Sinai HELPS Center has long been at the fore-front of simulation technology and has become an important training tool. As Dr. DeMaria Jr. makes clear, however, its full potential is only just being realized.

Patient Simulator in Anesthesia at Icahn School of Medicine at Mount Sinai

Avatar Patient Interview Interface

Miguel Yaport

12

This fall, a new interprofessional course titled “Practical Analysis of Your Personal Genome” was introduced at Icahn School of Medicine at Mount Sinai. It was structured around having the twenty graduate students, medical students, resi-dents, genetic counseling students, and faculty sequence and analyze their own genomes.

According to Dr. Michael Linder-man, Ph.D., Assistant Professor of Genetics and Genomic Sciences at Mount Sinai and one of the course instructors, the course addresses “a gap not just in medical school education but in biomedical education generally, the need to understand and apply the wealth of genomic information now available, [and] to help provide tailored therapy to individ-ual patients to improve their treatment.”

The human genome contains a total of 46 chromosomes, six billion base pairs, and roughly 20,000 to 30,000 genes. The first complete sequence of the human genome was released in the year 2000. The project cost $3 billion to complete and was actually a composite of genomes from anonymous donors. Craig Ventor of the Human Genome Project published the complete sequence of his own genome in 2007. Since then, the cost of sequencing has drastically decreased. Currently, sequencing an entire human genome costs only several thousand dollars, and is expected to fall below $1000 in the near future. However, practical clinical applications for this wealth of genomic data have lagged behind the initial promise to personalize everything from drug prescriptions to disease treatments.

“We believe that precision medicine will never become routine until clinicians have access to whole genome sequencing data, as well as the training and skill set to interpret and analyze this novel data,” Dr. Linderman said.

Using hands-on techniques to enhance the training in medical genetics was one of the goals of the new course. “For the medical students, this course expands on material they saw in their se-cond-year Medical Genetics and Genomics course,” Dr. Linderman said. “This year, MD students were offered the opportunity to have genotyping done at four genes associated with metabolism of

medications…by engaging the students in this way, we will better prepare them to make use of genomics data in clinical practice - but at a much larger scale than what is possible or relevant in the second year course.”

Offering students a chance to analyze their genomes wasn’t without concern. The information revealed might have serious psychological implications for the students and their families. How is one impacted when finding out their risk of developing an incurable, unpreventable disease, for example Alzheimer’s, decades in the future? Two years ago, a program at the University of California, Berkeley that offered to test all incoming students for common variants in their DNA was shut down because the Department of Public Health considered it clinical testing.

The Sinai students spent the summer before the course began discussing many of these issues. In an in-terview with The GenomeWeb Intelli-gence Network, Andrew Kasarkis, Ph.D., Senior Faculty in Genetics and Genomics Sciences at Mount Sinai, said “Part of the

summer course was just to make sure that everyone had, based on discussions in a group setting, thought through all the issues about knowing your own personal genome sequence.” Students were given access to genetic counseling services and were allowed to analyze an anonymous sequence instead of their own. Students could also exclude certain regions of their genome from analysis (such as those for alleles associated with Huntington’s or

Alzheimer’s disease). Instructors gathered plenty of feedback from the students as well. The genomes were sequenced at Mount Sinai’s own Genomics Core Facility and took a month to complete. Throughout the duration of the course, the students used existing databases such as PharmGKB or HGMD to annotate their genomes for mutations, variations, and structural rearrangements.

Whole genome sequencing and whole genome analysis still have several obstacles, and students were made aware of them. “The annotation databases are relatively incomplete and poor, for instance,” Kasarkis said. Additionally, the implications of genetic variations seen among people are not completely understood. Common chronic diseases, such as diabetes, are caused by a confluence of environmental and genetic factors and cannot be completely predicted by one or even many genetic variations.

Nevertheless, the instructors plan to continue and expand upon the course in the future. A strong interest exists within the Sinai community. The school’s

Institute for Genomics and Multiscale Biology, headed by Eric Schadt, Ph.D., is rapidly expanding, with the recent addition of the Genomics Core Facility and newly hired researchers in computational biology.

Genomics will play a crucial role in medical research and clinical medicine in the coming years, and an early educa-tion on the topic will be invaluable to medical trainees.

Practical Analysis of Your Personal Genome: A new medical school course Ann Wang

“We believe that precision medicine will

never become routine until clinicians have

access to whole genome sequencing data,

as well as the training and skill set to

interpret and analyze this novel data.”

13

Family medicine physicians are trained to treat any patient who walks in the door regardless of their presenting complaint. These physicians, in a sense, are part of the oldest specialty in medicine. In urban settings today, family medicine doctors often focus on disease prevention and management of patients with chronic,

complex medical conditions, highlighting the key role these physicians play in the ever-changing health care environment. Striving to positively impact the health of its patients and improve upon the current health care model, Mount Sinai, in collaboration with the Institute for Family Health, opened the Department of Family Medicine and Community Health and the residency-training program in 2011. As the only major academic medical center in Manhattan with a family medicine residen-cy-training program, Mount Sinai is re-newing its effort to promote primary care education, as well as clinical services for the patients it serves. Mount Sinai is also the only major hospital in Manhattan to have been awarded federal designation as an Accountable Care Organization (ACO).

One of the leaders behind the institution’s recent engagement with family medicine is Neil Calman, MD, a family medicine doctor and chief operating officer of the Institute for Family Health (IFH). Designated as a network of federally qualified health cen-ters (FQHCs), the IFA operates and runs three residency training programs, including one at Mount Sinai. The Institute for Family Health was founded in 1981 as a single clinic out of a health center in Union Square. It has since grown to run 18 outpatient health centers with an operating budget of over 90 million dollars annually. The IFH mission is to serve any patient

who walks in the door and to focus partic-ularly on the underserved. Dr. Calman said, "For us, it was everything family medicine is about: keeping patients out of the hospital."

The Rossi recently had the opportunity to talk with Dr. Calman about his journey from a resident in family

medicine at Montefiore Hospital to COO of one of New York City’s largest FQHCs. Dr. Calman’s experience operat-ing community health centers began in his senior year of residency in 1977, when he and three other residents founded a federally qualified health center in the Bronx. Due to internal disagreements with the community board, this health center was closed after only a few years.

Dr. Calman then went on to become the medical director of a primary care practice on the Upper East Side, a position he eventually left to help Pedro Espada, a community leader in the Bronx, run a community health center. While there, he won a federal grant to run a residency training program based out of Jacoby Hospital; however, the community board

did not support this vision. Once again turning a setback into an opportunity, Dr. Calman founded his third community health center, the Institute for Family

Health, this time with lasting success. The institute’s first major step was to transform the ailing outpatient specialty-based private practice at Jacoby Hospital into a clinically and financially successful practice run by family medicine doctors. The Institute then won a contract with the Clothing and Textile Workers Union to provide primary care to its members, allowing the Institute to acquire the Sidney Helman Health Center, a six-story building at Union Square that serves as their current main office space. The Institute’s growth has since been exponen-tial. It has played a successful and central role in the rapidly transforming health care system in New York City, serves as one of the city’s leading providers of primary care, and provides a dynamic new partner in the effort to serve the community at Mount Sinai.

By partnering with Mount Sinai, Dr Calman hopes to build a strong foundation for the work of the IFH in research that will allow it to advance its

mission of providing excellent care to those most in need through evidence-based approaches. Mount Sinai will benefit from the partnership by gaining a leader in com-munity-based care that serves a large part of the population of New York City."

"The story of the Institute for Family Health is the story of lots of people who have been here for a really long time,” Dr. Calman says, “And we are still driven by the same vision that it started with."

Primary Care Emphasis at Mount Sinai Demetri Blanas and Kamini Doobay

"“The story of the Institute for Family Health is

the story of lots of people who have been here

for a really long time, and we are still driven by

the same vision that it started with."

“For us, it was everything family medicine is

about: keeping patients out of the hospital."

“There is no more difficult art to acquire than the art of observation, and for some men it is quite as

difficult to record an observation in brief and plain language.”

- Sir William Osler

14

Best Practices: Providing Effective Feedback Lenard Babus

Throughout professional development, from medical student to resident and beyond, feedback helps to define the extent of a trainee’s content mastery and skill acquisition. Apart from this role in assessment, feedback has been shown to increase satisfaction of learning encounters and, perhaps most importantly, to improve future clinical per-formances. However, the quality of feedback is variable among teachers. To better understand how to deliver effective feedback, The Rossi spoke with Dr. Brijen Shah, Assistant Professor of Medicine and Associate Director of Graduate Medical Education for Faculty Development. The following guide aims to highlight key concepts and techniques for delivering effective feedback.

Definition of Feedback “An informed, non-evaluative and objective appraisal of performance intended to improve clinical skills” (Ende J. Feedback in Clinical Medical Education. JAMA 1983;250-777-781). Whereas an evaluation is summative and based on predetermined goals, feedback is specific to improving future behavior.

Why is Feedback important? The goal of feedback is to produce a consistently high level of trainee performance. Feedback provides an opportunity for the instructor to reinforce model behaviors, identify gaps in clinical skills or knowledge, and recom-mend modifications for future encounters.

At the outset of a learning experience:

1. Describe the expectations and objectives to the students. With clearly defined goals, students and instructors can work in unison to obtain the desired skills and knowledge.

2. Students should expect feedback. If feedback is not provided, the student must be proactive. It may also be beneficial to set-up regularly scheduled feedback sessions. However, these sessions are not necessarily official meetings; a resident who provides specific, constructive ways to improve a student’s clinical skills is delivering important feedback.

During the feedback session: 1. Elicit student self-reflection on his/her performance. Self-reflection engages the instructor and student in

beneficial dialogue and allows the instructor to address the student’s concerns. 2. Provide responses in the context of the objectives and expectations. Trainees are able to measure their

progress in relation to these expectations and better able to close the gaps in their skills. 3. Identify 1-3 points for behavior-based improvement. These points should address items that lend

themselves to behavioral modification. Providing more than 3 points may overwhelm the student and be counterproductive.

4. Observe the emotional reaction of the student. A negative or even overly positive emotional response to feedback may lead to an ineffective session. Assess whether this reaction should be addressed. Be balanced with the feedback, pairing constructive comments with positive ones.

5. Apply suggestions to future encounters. Feedback is only effective when it elicits behavioral change. The instructor and trainee should address how to apply the feedback to improve future encounters. Additionally, the instructor may review how these suggestions correct specific behaviors from the initial encounter.

After the feedback session: 1. Record feedback and provide trainee with resources for further learning. These resources allow the

student to target the area in need of the most improvement. 2. Determine if feedback was applied. The instructor should observe future encounters and talk to the student

about his/her progress. If the feedback did not result in behavioral modification, it may be necessary to discuss additional methods for improvement and provide more specific instructions.

In additional to the above guidelines mainly targeted towards instructors, trainees also share the responsibility to

seek out meaningful and useful feedback: Effective feedback is a conversation, not a monologue.