Embracing Self-Honesty and Vulnerability in Medical School Education

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, the Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an Education Institute podcast exploring self-honesty as it relates to student wellness at Cleveland Clinic's Lerner College of Medicine of Case Western Reserve University. I'm your host, Dr. Tony Tizzano, director of student and Lerner health here at Cleveland Clinic in Cleveland, Ohio. Today I'm very pleased to have Dr. Stacey Jolly, associate professor of medicine and director of career advising at the clinic's Lerner College of Medicine here to join us. Stacey, welcome to the podcast.

Dr. Stacey Jolly:

Thank you, Tony.

Dr. Tony Tizzano:

To get started, could you tell us a little bit about yourself, your educational background, what brought you to Cleveland and your role here at Cleveland Clinic?

Dr. Stacey Jolly:

Yeah. So my name, again, is Stacey Jolly. I'm an internal medicine physician. I did my training at Stanford University and also residency at UCSF and then came to Cleveland about 15 years ago. My husband got a job at Case Western and we've been here ever since. I've been on faculty here at the Lerner College of Medicine since 2009.

Dr. Tony Tizzano:

And loving every minute of it, I know. We hear all about you. So in today's segment we hope to focus on the importance of work-life balance in the final piece of a three-part series exploring the topic of student wellness for medical students here at the Lerner College. So if you could help us frame this concept of self-honesty, as it relates to student wellness.

Dr. Stacey Jolly:

So I think this concept is something that students and faculty are aware of, but maybe not thinking exactly in that term of self-honesty. And part of kind of reviewing for this a lot that came up was it's around, you know, holding ourselves to a high ethical standard, thinking and reflecting on our own way we interact with our peers and patients, and being mindful of our behaviors, but also being mindful of our own authenticity and self-growth.

Dr. Tony Tizzano:

Yeah. And, you know, in our professional formation as students, I, I can see where there's some work to be done there. And I can also see where this is kind of a foundation of responsible scholarship and professionalism. I think anyone listening would agree that we want people who follow the precepts you've mentioned. So what's being done to actually build this into the curriculum and developing professionalism at the Cleveland Clinic Lerner College of Medicine?

Dr. Stacey Jolly:

I think this is something that from day one our students are learning about and growing throughout their time with us. One of the cores of self-honesty is being vulnerable and reflection. The vulnerability part is, again, we have our students working in clinic early on in their first year. We have our students working in small groups of eight in this problem-based learning environment where they need to rely on peers and their peers, you know, also need to share when they are very firm in that knowledge of a... say a topic or not. And it's important for us to share when we know something and don't 'cause we're relying on each other to learn. And then that reflection around where can we go and learn more and be able to share that back and be honest about it? I think that's important part of self-honesty that our students get throughout, again, in clinic, in their PBL, and as you touched on, the Art and Practice of Medicine in our medical humanities program, which is quite strong.

Dr. Tony Tizzano:

So the PBL is the problem-based learning that-

Dr. Stacey Jolly:

Yes.

Dr. Tony Tizzano:

... that is so a part of what we do here at the clinic. You know, I look at the emphasis on the humanities. I'm so impressed when I first became associated with Lerner and thinking, "Wow. The..." You know... And it's... A lot of it's writing and other things, but there's also history and so forth. And, you know, those precepts are kinda the backbone of medical thinking. And, uh, that along with targeted areas for improvement, it's kind of getting you accustomed to, to not knowing because you can't know everything. And I feel that they're doing a good job of that, what do you think?

Dr. Stacey Jolly:

Absolutely, right? It's kind of knowing what we maybe thought about in the past. So as you said, the history of medicine and how we've evolved as well as that reflection in the art, be it our own writing. We have a medical student journal, Stethos, that I'm always impressed with between not only writing, poetry, art, photography, music, dance, right? So many of our students participate in the Doc Opera as well. And then that reflective writing piece which comes out in their portfolio, their taffies, and then in what they are doing in their day-to-day curricular work.

Dr. Tony Tizzano:

Yeah. In the Art and Practice of Medicine course, of which I have the privilege of spending time with a small group of students, I'm always looking forward to, to seeing their reflections. And I actually spend some time with those because many of them are really fairly well-thought-out and that vulnerability though that you speak of, you know, I like to think that I'm better at that now than I was at the outset. And that's a tough thing, how is that made to be okay?

Dr. Stacey Jolly:

You know, that is a great point. And, and, again, my own personal reflection thinking about this, I did think about that, I, I had the experience of 10 years ago needing to renew my boards. And reflecting on when I was first finishing residency and in a board review course and we did actually have audience response. We were at a very nice, fancy hotel in said Bay Area City and they would put up the audience response. And my colleagues and I, we were nailing it. We were getting them all right and there were clearly a small portion that were not. And we couldn't understand why, right? In our mind that it was clearly the right answer. Then fast-forward 10 years (laughs) and I'm now studying for boards again going, "Oh my gosh. I probably could be some of that small percentage not getting it right, you know?" There are just things that I needed to refresh on and get better at. And 10 years earlier I thought like I was at this peak of knowing it all. And I think to your point, the wisdom now, I'm now 20 years from taking those original boards and doing this longitudinal assessment, is that it's okay to, to not know it. And I think that's where I appreciate working with the student and freely sharing, you know, "I'm not sure, let's, let's look this up together." Or they're telling me, you know, they're helping me.

Dr. Tony Tizzano:

Yeah. The more time I spend, the more easily I'm humbled. And retiring for a short period and coming back, I'm relying on the new staff, even the students to, you know, keep me on point. And I say to them, you know, "When I pick a physician I'm not so concerned about how much they know, so long as they know what they don't know and not go skating out onto thin ice with me." That's a tough one. And I think, you know, you and I as, as the years go on we get better at that. So along comes this pandemic and it has implications related to self-honesty and so forth. Reporting of symptoms and what have you, especially early on when we had no idea what it meant. And, you know, we revise the medical school into a, a hospital and so on and so forth. What part do you think that played in focusing attention on this very concept?

Dr. Stacey Jolly:

I think it, again, caused students... I remember in the very brink of the pandemic really wanting to, to do all they could to help, but at the same time also, you know, as a school and as a profession, we had to reflect on where's best for students to be able to help and also to protect students as well. And so what I saw come out of that was an amazing project around, you know, students reaching out to olders in our community. Quite a few of my patients benefited from that where, again, students could reach out, listen to individuals on how they were feeling, if they were concerned about possibly having contracted the COVID-19 virus. Like where to go for testing, how to get testing. I think it was a testament to the humanity of our students.

Dr. Tony Tizzano:

Yeah. I would agree. And, you know, the interesting piece of that as well is, this was new for everybody.

Dr. Stacey Jolly:

Yes.

Dr. Tony Tizzano:

You know? Unless you were an infectious disease doc, I mean, we were all learning. And so the students knew just as much as most of us. And so their ability to come forward with good information for patients was probably equal to what I had to offer without really studying it. And that's one of the reasons I came back is... in the student health arena was because of COVID. So this whole notion of high standards of academic honesty and, you know, how does that fit into the picture, being truthful with patients and, and feeling comfortable with admitting that, you know, "I, I'm gonna need help"?

Dr. Stacey Jolly:

Yeah. I think this is one where it's really great that our students early on get in and work with general internal medicine physicians and family physicians, where the breadth of what we see is enormous, we can't know it all. And so for students to be able to see how their faculty practice that kind of out loud thinking of, "I think this may be going on, not quite sure. We're gonna try and investigate a little further. Or let's, you know, look together and see, maybe have others seen this before?" Again, for myself, working at the main campus in an academic setting, I don't feel alone, I have a lot of people that I can go and ask have they seen this or heard about this before? And I think that's important for our students to see.

Dr. Tony Tizzano:

Yeah. I, I'm sure you remember in your training, developing a differential. You weren't expected to just all of a sudden pull it out of a hat and be spot on. And, you know, here this whole idea of teamwork, which is virtually one of our pillars of thinking, is really refreshing. And when, when our organization, the Wooster Clinic, joined Cleveland Clinic one of the things we immediately felt is these department heads would come down and introduce themselves, is we had a backup system we could go to. And, you know, the lexicon of medical education or medical information is exploding. I think the doubling time is like 36 days. It's impossible to be on top of it all. Talk about the self-honesty and these targeted areas for improvements, we call them taffies. I, I know you do it in the interview process, you know, where does that fit in? Why is that important?

Dr. Stacey Jolly:

This is an important part for our students and really all of us in the profession. As you alluded to, the knowledge that is just exploding and the paradigms of how we might think about disease and illness now will change and so we have to have this growth set mindset. And so for our students I am really impressed with when they are in their clinic or in their PBL sessions or when they do their community service are highly reflective on things that they would wanna learn further, things that they didn't know about and appreciate that learning growth, and things where maybe their thoughts of, you know, perhaps how a certain disease process was was changed or shifted.

Dr. Tony Tizzano:

Okay. So again, it reinforces that idea that there's always an area for improvement, h- how can you focus? You're, you're not allowed to say, "I can't think of one." You gotta come up with one.

Dr. Stacey Jolly:

Absolutely.

Dr. Tony Tizzano:

So that's excellent. So when you look at the wellness consequences of things like academic dishonesty, maybe imposter phenomenon, that sorta thing, how does that, you know, fit into all of this and, and what sorts of measures are taken in the way that Lerner approaches evaluation, compared to the traditional grades and exams?

Dr. Stacey Jolly:

Yeah. I think with our college program students, they have an incredible amount of people that are really wanting to help them grow and learn. So they have their physician advisors who are going to be can there paramount around keeping them with that academic honesty, looking at their taffies, p- encouraging them to kind of continue to dig and, and push further. The research advisors around their area of research and inquiry and, you know, where could things go further and that critical analytical thinking. And then their advising that I do with career advising, again around that reflection of if you are enjoying this specialty then digging further as is it the people that you worked with, is it the subject, is it the area, in-patient, out-patient, you know? 30 years down the line can you still see yourself doing this, you know? Kind of a lot of those reflections on finding a career that's gonna work.

Dr. Tony Tizzano:

You know, we aim at developing clinical researchers. We have an additional year, which is really impressive about the program. And, you know, part of that is coming up with a research project and hypothesis. So, you know, maybe it's of your own, you know, design or maybe you're dovetailing into something that's already being done, but there's always that notion, you know, publish or perish, you gotta get it done, your hypothesis hopefully is correct. You think that we foster an environment where it's okay to say, "You know what? We were off track. It turned out..." And maybe just as importantly to find out the hypothesis wasn't correct. Is that a failure or is that tied to what we're talking about?

Dr. Stacey Jolly:

I believe it's tied to what we're talking about. Having done a lot of research early on in my career and being married to a scientist, it's often those failures that it's where we get the growth. Sometimes it's those what we think of failures is where 20 years later it's the solution to a problem that we didn't think about back then. But I do feel like that whole publish or perish can lead to the potential for dishonesty and plagiarism. I mean, we've seen and at the highest level. You know, my former alma mater at Stanford, the, uh, highest level president falling under that. Where, again, I think when there is so much explosion of literature and say sometimes up to 30 people on a manuscript and having that healthy reflection of, "Is everything in here accurate? Would I stand by it?" Is gonna be important.

Dr. Tony Tizzano:

Yeah. I couldn't agree more. And I think it gets tougher and tougher as time goes on. And now you've got AI and ChatGPT, artificial intelligence, and chatbots. How do you sift through... I mean, you can see the desire to wanna use that and maybe should, but where do you draw the line and how do you sift the important material from that which may be somewhat tainted? It's kinda tough.

Dr. Stacey Jolly:

Yeah. This is gonna be a huge area where I can foresee a lot of ethical reflection. It will impact our clinical practice, it already is, right? It's gonna impact how images are read. It's gonna hopefully help me in my patient care and getting notes written. We know there's been study where the AI response to MyChart messages, patients see them as being more empathetic and humanistic. And then, again, in preparation for this I was reflecting on there is a AI f- really for medical professionals, it's called OpenEvidence, it's out of Mayo Clinic. And it is revolutionizing. I learned about it from internal medicine residents and faculty, asking very directed questions that then links to clear medical literature to kinda, again, help. If we were to ask a medical question in ChatGPT, it's not gonna be as accurate as an OpenEvidence. And then, you know, going forward and how to maybe think about the patient that came in with X, Y, or Z. I think as a physician and then as a potential utilizer of healthcare, I think we're gonna have it, but I think we also have to be honest of when we use it, how we use.

And so in instances of using it, I'm at least sharing with patients of, "You know what? Again, we don't know, we've looked into this, this is what we're finding so far. We're gonna try and see." But again, having that also self-honesty of where are we getting the source of information from, I think, is gonna be important.

Dr. Tony Tizzano:

Yeah. I can't agree more. And just listening to you talk I get the sense that you're a, "I work for you, you don't work for me-"

Dr. Stacey Jolly:

(laughs) 

Dr. Tony Tizzano:

... relationship with your patients and are very open with them. And I think it's so important because at the root of it all is the trust.

Dr. Stacey Jolly:

Yeah.

Dr. Tony Tizzano:

And hoping that the information you get is accurate, to the best of your ability, and allow them to question too. Because they do come up with questions.

Dr. Stacey Jolly:

Yeah.

Dr. Tony Tizzano:

And, you know, they, they want to... they feel as though they're in harm's way. "How can I trust what is being said? And I know the clock is ticking and there's only two minutes left in this 30 minute appointment."

Dr. Stacey Jolly:

(laughs)

Dr. Tony Tizzano:

"And did we do enough?" And that's a tough one. So as you look at continuing to build this sort of thing, integrity, honesty, into the curriculum, what do you see on the horizon?

Dr. Stacey Jolly:

So I see that there's going to be more research in this area. So we will contribute to the explosion of the literature. But one of my colleagues, again with residents, recently published a paper in the American Journal of Preventative Medicine on the accuracy of online artificial intelligence models in the primary care setting, right? So we're gonna have this availability of AI out there, but we gonna need to research and study the accuracy, the utilization of it. And then the importance still of that professional identity for our students as they navigate, move through this profession. We have no idea yet what sort of new things will come from AI or, or what is the next AI. We, we don't even have a name for it yet, but I'm sure it will impact-

Dr. Tony Tizzano:

Oh.

Dr. Stacey Jolly:

... the humanism of medicine. And so having our students really be reflective on that and seeing their, you know, peers, faculty, and leaders nurture that self-honesty is very important.

Dr. Tony Tizzano:

So mentorship?

Dr. Stacey Jolly:

Yes.

Dr. Tony Tizzano:

Seeing the attending physician say, "Hey," scratch their head, "I'm not sure, but we're gonna have to think about this, come back, and regroup, Mrs. Jones. There's some things that have to be vetted-"

Dr. Stacey Jolly:

Absolutely.

Dr. Tony Tizzano:

... "before we can come up with something." That, that is so true. And that's another area, I think, that whole idea of mentorship that is rather rich in the college program. At least from my perspective and comparing it to what it was like when I was in medical school. So kudos there. So Stacey, are there any final thoughts or questions that I didn't pursue that you think would be important for our listeners to know?

Dr. Stacey Jolly:

I thought about this and last weekend we had the white coat ceremony recently. And two students presented this year's class' oath to the profession. And what struck me with that was that it was a group effort amongst 200-plus students who then had this executive team and ultimately selected the two students to present the final draft at the ceremony in front of their peers, faculty, family, and friends. And I was struck by the core values of professionalism, wellbeing, and integrity, all things that we have touched on on these podcasts, to the profession, that came through in their class oath. And so it did leave me feeling hopeful for the future of our profession.

Dr. Tony Tizzano:

Fabulous. And we- were these students that are actually just matriculating?

Dr. Stacey Jolly:

Correct. This was for our first year students'-

Dr. Tony Tizzano:

Excellent.

Dr. Stacey Jolly:

.... white coat ceremony.

Dr. Tony Tizzano:

Excellent. Well, thank you so much, Stacey, this has been an enlightening and thought-provoking episode of MedEd Thread. To our listeners, thank you very much for joining and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.