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Three Wishes

Sklar, David P. MD

doi: 10.1097/ACM.0000000000002964
From the Editor
Free

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

As I near the end of my tenure as editor-in-chief of Academic Medicine, I have mixed emotions—a sense of relief that, after this editorial, the pressures of writing a monthly editorial will be lifted; a sense of loss that I will no longer have the regular opportunity to interact with the leaders of medical education and academic health centers; and a sense of gratitude for the privilege of leading the most-cited health professions education journal in the United States. As editor-in-chief, the editorials I have written have often led to invitations to speak at national and international conferences, and I have benefited from those visits in many ways. I have met some of the most creative and eloquent health education leaders in the world and developed friendships that have stimulated my thinking, enriched my life and work, and hopefully will continue beyond my time as editor-in-chief of the journal.

The travel associated with my visits and presentations has come with its own set of surprises and memories. During a plane trip after speaking at a medical school graduation, I responded to a call for emergency care. The flight was from Hawaii to Los Angeles, and the emergency occurred over open water with no options for landing for 3 hours. The stress of caring for a dying passenger without adequate knowledge of the nature of the problem was probably not unlike what a medical student or intern experiences on a regular basis, and I was reminded of how important our role as educators is. Opening the airline’s emergency medical box surrounded by the curious eyes of the flight attendants and passengers, I felt like I was on a stage not unlike the stage I had spoken from as graduation speaker. But the stakes were much higher, and my preparation was less organized. I realized, as I unpacked the intravenous fluids, that I was unfamiliar with the specific placement of connectors and types of catheters that were enclosed. Fortunately, a paramedic was there on the plane to help me and make me look good as they always do, and our patient responded well to our treatment. A few years ago, I wrote about that experience of high-altitude emergency care to begin one of my editorials1 because I have found that integrating stories of actual events into my editorials makes them more memorable, nuanced, and real.

On other flights, there have been less serious disruptions of my intent to retreat into a book or solve the problems of the world. I remember being seated next to a teenaged Mormon missionary, about to go overseas on a mission, who decided to turn his religious zeal on me for the next 5 hours. I pretended to read, closed my eyes, and even held my head—all to no avail. You can’t really shut the door on a missionary when he is sitting next to you, and so I looked him in the eye and we began a serious exploration of God and salvation. Nor could I ignore the cute 6-year-old girl who was flying for the first time and accompanied by a teenaged au pair. The 6-year-old was seated next to me on her way from Europe to Arizona to visit her parents. Five minutes after takeoff, her cheeks ballooned, she looked up at me, and then she vomited all over my shirt and pants. There was also a flight with a 300-pound woman from Detroit sitting next to me on a small plane who could not fit into her aisle seat and plastered me against the window as she filled half of my seat.

While each of these surprises elicited an initial groan, they led to unexpected outcomes. The teenaged missionary became interested in medicine as I diverted the conversation away from God to a night in the emergency room, and he actually wanted to hear my stories rather than tell me his. The little girl got over her vomiting quickly and slept for most of the trip, while the au pair helped me clean my clothes and entertained me with stories of her life as a traveling babysitter. And the woman from Detroit apologized profusely about taking up part of my seat, and we turned out to have a common public health research interest and planned a joint research study during the trip. My point here is that I have learned not to judge a situation or person based on first impressions, and if I can do that, my eyes can be opened to worlds I had not known existed and possibilities I had not considered. This has also been true of the thousands of articles submitted to the journal that I read during my tenure as editor-in-chief; they made me aware of creative ideas and innovative projects that I had never imagined. That has indeed been a blessing.

When people ask me why I would leave my editor-in-chief job—a job that is stimulating and influential and that I clearly love—I think of the visits I have made and articles I have read and realize that the job is a double-edged sword, with one edge being the excitement of new adventures and the chance to be of service and the other edge being the toll of time and energy the job can take. Eventually, we can all get worn down, even by jobs we love.

After 84 editorials, I feel that I have covered most of the important topics in medical education at least once and in some cases multiple times. I am sure that our new editor-in-chief, Dr. Laura Roberts, will provide a fresh perspective on our perennial topics and identify new ones. I also did not want to burn out Al Bradford, whom I think of as my personal editor, who worked with me on all 84 editorials and kept me out of trouble politically while helping me communicate my ideas. Al has the perfect, delicate touch to improve my writing while protecting my ego. “What you are doing is not wrong,” he would say as he corrected a phrase that I had written, “it’s just not right.” If you have enjoyed my editorials, it is in large part due to Al’s efforts to make them clear and precise, and I thank him for his steadfast support.

Another reason I felt the time had come to leave my editor role was that one of the unique perspectives that I have been able to contribute to the medical education community has become less relevant. That perspective has been my integration of clinical care, health policy, and medical education based on my ongoing practice as an emergency physician supervising residents and students, where I hear their stories and those of our patients. While other editors might talk more expertly about educational theory, I could often provide a practical perspective of how new educational theories and programs could actually be used by clinician–educators to improve clinical care and medical education. I have long believed that the goals of our educational programs and our clinical care delivery system should be the same and should focus on improvements in clinical care, stewardship of our financial resources, access to all for preventive care, and a focus on health as well as disease.

Yet as my clinical experience has diminished over time, I have begun to feel increasingly concerned about the changes in the clinical learning environment and the experiences of patients that drive our purpose in medical education. Technology is steadily replacing the personal connection to patients, and meaningful relationships between learners and faculty are becoming more difficult to prioritize in an environment of shrinking educational resources. I have always believed that the personal relationships between teachers and students are the most important contribution we can make to the educational experiences of our students. But as podcasts, online resources, and short minilectures replace less-structured small-group interactive learning experiences, I find my old-school approach less relevant to the clinical learning environment. This is not to criticize some of the current educational innovations but to explain the evolution of my thinking about my approach.

In addition, when I started as editor-in-chief, I had recently completed a Robert Wood Johnson Health Policy Fellowship in Washington, DC. I was able to solicit articles from leading health policy experts due to my personal experiences with them on committees and at conferences, where I could see how their policy work connected with medical education goals. I had worked in the Senate Finance Committee, where many of the ideas that went into the Affordable Care Act originated. I also had the opportunity to help develop alternatives to the unpopular sustainable growth rate formula used to determine physician payment and limit health care spending. As the political landscape has changed, I have found myself increasingly out of the information flow on new health initiatives and regulatory changes and out of touch with the philosophical foundations of our current administration. I am no longer close enough to the action to be able to identify current experts who could inform our community about how health policy changes will affect medical education and what opportunities health professions educators have to influence the debates about future policy decisions.

With the broad scope of academic medicine encompassing diverse fields and methodologies such as those in the social sciences, education, humanities, biological science, and care delivery sciences, it is unlikely that any one person could master all the areas with which the journal concerns itself. It is clear to me that if I were to continue as editor-in-chief, I would need even more time for serious study of those fields and methodologies, even with the invaluable assistance of the various other journal editors, the editorial board, and the journal staff. That is time that I am no longer willing to take from the other areas of my life, particularly my family, that are also important to me.

I have also come to believe, as I have read articles about the lack of diversity within our own community of leaders, that we all have a responsibility to provide leadership opportunities for others, not only through mentorship, sponsorship, and coaching but also by eventually stepping aside and making way for the next generation of leaders. This is never easy, as there are many reasons we can use to justify a few more years in a position, and as we become comfortable in our role and have established a network of support, it can be difficult to allow promising leaders to displace us. But I think that there is a sweet spot of longevity in a position that varies depending on the position, and one of the ways we should judge the performance of our leaders should be their transition from leadership and what happens when they leave their leadership role. How well did they prepare their replacements? How well did the organization continue to function after the leader left? That is the legacy of leadership, and we should encourage our leaders and organizations to value transitions. It is something I am committed to doing as well as I can.

As a parting message to our community I would like to leave you with 3 wishes that have grown out of my observations and experiences as editor-in-chief over the past 7 years.

  • First, I wish good health for all of you. Those of us who care for patients recognize how suddenly an illness or injury can strike and how it can forever change lives. We often take our own health for granted, and my wish is for us not to do that but rather to take the steps to protect and nurture our health and that of our families, colleagues, and community. An extension of this wish is that we take the steps to create a more healthy work environment for our trainees and that we start with the most vulnerable group: pregnant residents. While I would wish for fewer duty hours for all our residents and students, the enormity of that change might paralyze our actions and prevent any change. But we could start by providing better support for our pregnant residents and students; we could and should do that now.
  • My second wish is for all of us to become engaged in the current dialogue about health policy and our future health care system. Our experience in health care must be shared and our voices heard as advocates for the health of our patients and communities. The upcoming election will provide guidance for the future role of government in health and health care.

There are many ways to become involved, ranging from discussions with patients about how various proposals might affect their access to health care to active support of candidates with particular health care platforms. In the summer of 2020, Dr. Paul Gordon and others will ride cross-country again, following up on the success of their 2016 Bike Listening Tour where they spoke with people about the Affordable Care Act.2,3 This time they’ll be talking with people about their thoughts on health care policy and how it might influence their vote in the upcoming presidential election. For those interested in this type of engagement and possibly joining him, he can be contacted through email at pgordon@u.arizona.edu. And there are many other ways to become involved in the health policy discussions related to the upcoming election. As medical educators, our ability to improve health will be limited if millions of Americans lose access to health care. We can’t let that happen. My wish here is that the voices of our community are heard and that our patients are able to provide informed decisions when they vote for candidates who will be deciding the future of our health care system.

  • My third wish is that we continue to work toward an integration of our goals of medical education with the goals of our health care delivery system. If we do that, we will broaden our curriculum so that we move beyond a bioscientific model of health care to a socioecological model that will address environmental, behavioral, cultural, policy, and financial influences on health. Our curriculum will move from an emphasis on disease and illness to one on health, and our assessment tools will reinforce this enlarged scope. A socioecological model can also integrate the stories of our patients with the many facets of health and help us to address health equity and disparities in care. We must understand the constraints on our patients, who attempt to navigate an increasingly complex and expensive health system requiring the coordination of many different specialists. We must understand and control the technology that provides new opportunities, new information, and new treatments. We must take the time to listen to our patients, understand their worlds, and help them make decisions about their illnesses that allow them to continue to lead meaningful lives.

I feel enormous gratitude to all of those who helped make my tenure at Academic Medicine successful, in particular the managing editor, Mary Beth DeVilbiss; her staff; the editorial board of the journal; the Journal Oversight Committee, which helps to reinforce the journal’s editorial independence; and our sponsor, the Association of American Medical Colleges (AAMC). The past president of the AAMC, Dr. Darrell Kirch, was always helpful to me, making connections with possible authors and opening the doors to the considerable resources available at the AAMC. My institutional colleagues at the University of New Mexico and Arizona State University provided support and much of the stimulus for my ideas through their questions and discussions. The students, residents, and patients at both institutions inspired many of the stories that created context for the ideas in my editorials.

Finally, I would like to thank the members of my family, who had to put up with my working on articles and reviews during family vacations and late into the night and on weekends so that I would not hold up feedback to our community of scholars about their articles. My wife, Dr. Deborah Helitzer, dean of the College of Health Solutions at Arizona State, gave me emotional support as well as technical advice about topics related to her own areas of expertise and scholarship. My children and siblings have been valuable sounding boards for my ideas and articles. And finally my parents—my dad, who passed away a few years ago and taught me about loyalty, service to our country, and humility, and my mother, with her indomitable spirit and curiosity about the world, who has always inspired me to do my best and to ask the question “Why?” when I look at a problem. That question has led me down numerous long, dark alleys that were often far more fascinating than my original quest and has taught me that you must enjoy the journey because that’s when the most important things in life happen.

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References

1. Sklar DP. The view from 30,000 feet. Acad Med. 2013;88:1589–1590.
2. Gordon PR. How can physicians educate patients about health care policy issues? Acad Med. 2016;91:1333–1336.
3. Gordon PR, Gray L, Hollingsworth A, Shapiro EC, Dalen JE. Opposition to Obamacare: A closer look. Acad Med. 2017;92:1241–1247.
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