How to Maintain Passion in Teaching and Learning - Dr. Linda Costanzo, Professor Emerita at Virginia Commonwealth University School of Medicine

Michael Carrese: Hi, everybody. I'm Michael Carrese, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. 

We're marking a couple of firsts on today's episode. In over 420 podcasts, we've never interviewed a goddess before, and we've never had a guest who has won seventy-five teaching awards. But that is the happy situation we face today in welcoming Dr. Linda Costanzo to the show. 

Dr. Costanzo has been on the faculty of Virginia Commonwealth University School of Medicine for forty-three years, where she is currently Professor Emerita of Physiology and Biophysics. She earned the nickname “physiology goddess” for her trio of books -- including Costanzo Physiology 7th Edition, published by Elsevier -- that have been translated into thirteen languages. Altogether, there are more than one million of her books in print. 

In addition to her work in the classroom, she's held several administrative roles at VCU, including longtime course director of medical physiology, Associate Dean for Preclinical Medical Education, and Special Assistant to the Dean of Medicine. 

We're very happy to have you today. Thanks very much for coming. 

Dr. Linda Costanzo: Oh, thank you so much for the invitation. 

Michael: So we always like to start with learning more about our guests and what drove their career choices. Your PhD is in pharmacology, and you did postdoctoral work in physiology so what drew you to those fields?

Dr. Costanzo: Good luck, random chance. I was a chemistry major in college, worked in a lab at the medical school. I was at Duke as an undergrad, and I got a summer job working for someone named Leon Lack, who happened to be a pharmacologist. I didn't know much about pharmacology at that point, but he worked in the field of bile salts and intestinal transport of bile salts. In fact, he discovered that bile salts are recirculated in the ilium. I didn't have much of a context for how important that was at the time, but he said, you know, the second summer I was there, “What are you going to do with your life?” And I knew I wasn't going to be a chemist at that point, and I said, “Oh, I think I'll just maybe I'll stay at Duke and get a degree in biochemistry” and he said -- as these great, like old school mentors do -- “No. Don't do that, go to Syracuse and work with the smartest person I know. He's just become chair of pharmacology. So I'll buy you an airline ticket to go up and meet him.” 

Michael: No kidding. 

Dr. Costanzo: And sort of this life changing thing...I went up and decided to go there and work with this, at the time, the youngest chair of a medical school department of pharmacology in the country, just a real superstar. He was really a physiologist. Ike Weiner was my mentor, and he was a chair of pharmacology, but really, his research was kind of physiologic, and from there, in doing renal physiology with him, I knew I wanted to do single nephron techniques in physiology and that meant going from my postdoc to one of the big labs. I ended up at Cornell that was doing single nephron work and learning those techniques, and that happened to be a department of physiology. So, I just stayed in physiology. It's kind of a just an ordinary story in a way, serendipity, an amazing mentor who did sort of a life changing airline ticket, you know. 

Michael: Why do you think he knew that that would be a good fit for you?

Dr. Costanzo: Oh, I don't know....good question. I should have asked him. I did write back and thank him. 

Michael: Well, we hear so much in these interviews about the importance of mentors and then sort of paying it back. Have you done that in your career? 

Dr. Costanzo: That's such a great question and I think about that a lot. I was one of the luckiest

people. When I said luck, I really meant it because I was one of the luckiest people in terms of my mentors. I mean, Leon Lack was one kind of mentor at a very early stage, primitive stage for me. Ike Weiner was a brilliant graduate advisor. As a graduate student, I had to wait in line to get into his office.

Michael: Wow. 

Dr. Costanzo: Because everyone in the medical school wanted a piece of his time to talk about their projects. He actually became dean of that medical school and then dean of another medical school. And then I went to Cornell and worked with Erich Windhager, who was a totally different kind of mentor -- much sterner -- but underneath that sternness was a very, very kind person.

So, I had three great mentors. Answering your question, I think that kind of sets the stage for kind of modeling the mentor that I hoped I could become and a big part of my work is just working with students one-on-one. 

Michael: Yeah, you're certainly in position to do that. So, you find yourself in a research lab and at some point down the road, you have to make a choice about getting into medical education at VCU. You describe that in an essay called Am I Bored Yet? -- which is a great title...you sort of have to read that. So, take us through that decision and why you ended up making the choice you did.

Dr. Costanzo: After the postdoc in New York, which took five years, I was married and had two kids at that point. My husband is also an academic so we were looking for two jobs in one place, preferably a medical school. So, we got to the two positions at VCU in Richmond. I was a full-time researcher doing single nephron work. Everybody who did research taught at some level, that was the culture and that was the way it was in 1979-80, when I started there. I started with graduate students and then medical students, and then, you know, one thing led to another and I really love the teaching and I love the balance that it brought to my professional life, because the lab can be a pretty isolating place. The results are long, long term with lots and lots of failures, and that's the research life, which I loved also, but teaching brought that immediate proximity to students, the one-on-one. The opportunity presented itself to move into a leadership role. I was already kind of running the medical physiology course and the dean asked me to take this big job and I thought, well, what to do? I got advice but in the end it's the decision only you can make for yourself because it would mean leaving research. That’s not a door that would reopen. 

Michael: Ah. 

Dr. Costanzo: It wasn't really a default kind of thing, but rather really kind of an active decision that I said, I’ve got to own this decision if I make the choice. So, I decided to take the deanly job. I got a lot of cheerleaders among my colleagues, but there was this one person in the department -- kind of the department naysayer...every group has somebody that's grousing around -- and he took me aside and said, “I want to tell you something. Everybody that teaches eventually gets bored.” Like, oh dear, I’ve just taken this job, what have I done? 

I tell the story about then starting to observe all the faculty in the preclinical medical education, trying to learn everything I could about everybody. And I sat in on his lecture, this naysayer’s lecture, the next day after hearing this and, you know, it was a pretty grim. He was a bored teacher who had gone on way too long. I sort of decided that, you know, as much as I wanted to dismiss him and his naysaying, I just couldn't put it out of my mind and I kind of saw his example and I said, “Oh my gosh, is this going to be me?” 

So, I started these boredom check ins... are you bored yet? That's the title of the article. Initially I set low, low hanging fruit kind of thing. And I was like, oh, oh, okay. Not bored yet. Not bored yet. And I tell a few stories in the piece about different scenarios. Then I sort of recognized that, oh, you are making this way too easy on yourself and you need to go dig deeper. And where I dug was in areas where I just felt very comfortable. You know, I was like, oh, this is teaching has become very comfortable now. It used to be very hard and I used to worry about it, but now I'm not so worried about teaching some of these topics. And when I dug there, that's where I feel like I’ve found it. I said, oh, you know, comfort...that's where complacency lives also. And complacency is the next step right before you start thinking, oh, good enough, good enough. That'll do. It wasn't everything, of course. It was just a few things where I was like, eh, it's such a dry topic. It's good enough. 

So, I decided if I was going to have a long career in medical education, which it looked like I was going to, I better do something about this. I sort of concocted as a scheme that was just for me just to get that edge back -- that fear of falling short, I would call it -- where I would challenge myself in ways that had nothing to do with anything I did directly in the classroom. I just did it to keep myself really humble. Like, take this really hard case, you can dissect it and figure it out. And so that was kind of the story. 

Michael: You sort of created some discomfort for yourself, I think is the way you put it. 

Dr. Costanzo: Yeah, to create the discomfort, which had been there in the early years. I suspect that any career, you know, especially a long career, this is something that we're all kind of potentially susceptible to is to just be at that point where comfort becomes complacency, and even boredom, and then you're not bringing the joy to the students that is so part of your whole teaching philosophy. 

Michael: Well, on that for a second -- because I do want to ask you about additional essays --  but you really seem to have a knack for teaching. I was reading some of the examples you were giving: you seem to be creative, you really seem to connect with the students. Where did all of that come from? Was that just kind of a gift or, how did you learn how to teach? 

Dr. Costanzo: You know, it wasn't from teaching workshops at the beginning. They have their place and they're handy, you know, little technique oriented kind of things. I think from seeing my mentors and seeing other examples. They would not be the kind of examples you would necessarily pick up on or talk about, but they’re things I've always remembered. I remember a faculty member when I was back in graduate school...we’d come in for a medical school pharmacology class and we find out that he had been called in the middle of the night to pinch hit. I actually remember the topic he was teaching: opioids, pain medications. He had been called in the middle of the night to pinch hit for someone who had become ill. We learned that he got up at two o'clock in the morning -- you know, the students learn these things -- and came in and gave the most brilliant lecture. That kind of memory is so connected with me and it sort of sets the whole philosophy of our obligation to the students, the obligation to excellence, the no whining, a whole bunch of things. That's what I thought of.

Michael: I understand you're going to write some more essays about medical education. Can you give us a preview of some of the topics you'll be covering and what inspired you to start writing these sorts of things?

Dr. Costanzo: Yeah. So I've actually published a few. Am I Bored Yet?  is the fourth one. And then I have some others that are cooking in various stages. And really, it kind of goes back to something we were talking about a bit earlier...developing that next cohort of new teachers. I see the need. People like me are not going to be around forever, and to really encourage and excite young faculty who wish to teach, have that love of the connection with the students to really support them in what is going to be their personal journey, but it's going to be a long process. It is a long process to really develop into the great teacher that they aspire to be.

And I thought, doing something in writing is so accessible at any time. These are personal essays, so they really take kind of a little vignette, a single memory, let's say, and really discuss the between the lines aspects of medical school teaching. Not the formulaic workshop -- here's how you do it -- but the kind of things that we all encounter in our personal journeys and common points of crisis where you might give it up.

The first one is This Will Never Do. That was published in the American Physiological Society Education Journal, and that is a profile of Erich Windhager. He was my mentor at Cornell who asked me to teach the medical students. It was the first lecture I ever gave and it's about the rehearsal that he demanded. I told you he was demanding. It's just me and him in the big lecture hall, me at the podium, with this lecture I had prepared and him in the back row. He held his head in his hands for two hours. I just kept going. And at the end of the two hours, he yelled from the back, “This will never do.”

Michael:  Wow. That must have been a tough moment.

Dr. Costanzo: Well, it was and then he said “Tomorrow.”  

Michael: So that meant you have to you have to redo…

Dr. Costanzo: A man of few words. Redo the whole thing. Yeah, we'll do this again tomorrow is what that meant, and it better be good enough for my medical students was the message. So that's the first essay I published. That's just about that first teaching attempt. I told the story in various venues and stuff and my colleagues are all like, “…and you taught again after that?” Everyone thought, you know, you just give it up.

I wrote another one, Acid, Base and Me, that was published in Medical Teacher about learning to teach a topic that you don't understand or that you're afraid of, and that's about common points of crisis. And then another one about new faculty development and faculty development workshops and getting asked to do that and not wanting to do it the way they wanted me to do it. And then I have some other ones cooking. So, it's really about supporting others, even medical students who think that they would love to have teaching as part of their careers.

Michael: I absolutely love to hear that. That's wonderful. You know, I've mentioned you've won 75 teaching awards -- I've never heard a number that high before. I guess the question is, you know, what is it that you think you do well? What are your strengths as a teacher and are those the strengths that are being picked out in the awards, or are they missing the boat? 

Dr. Costanzo: Yeah, I don't know. The awards... you’ve got to think of the time period. It's a long time period. Yes, it's wonderful and I've been really lucky. It’s the students who are, you know, the evaluators. Ultimately, they're the ones that say what's working for them and I pay attention to that and I guess there's something in my style that just clicks in that way. I'm very organized. I mean, I'm just like probably obsessively organized and that helps because I don't like to leave a lot to chance in terms of the overall plan for any teaching exercise and that allows me then to be kind of spontaneous as well, but not too spontaneous because I know what the overall structure is. I know what the goals are. I think that works well with most students. Most students like to see something that's clear. 

And then it really is so much about the personal connection with students, and just enjoying that, welcoming more of it. None of this happened overnight. It was a long process. It's sort of like coming in every day, being the best you can possibly be for that group of students, because it's not about last year's students or how successful you were. It's the people in front of you who deserve the best. 

I was driving into work, this was maybe a month ago, and I was going to be giving the last review of the M2 students renal course and they were going to have the exam the next day or something. I had NPR on and Bonnie North -- she has a wonderful voice -- she always says in her programs, I'm going to paraphrase it, “Delighted to have your company today.” And I thought, oh, I'll have to share that with the students today, because I felt that's how I feel about them. They came in for this review. They have a big exam coming in a very difficult subject matter and it's sort of like that company idea. Yeah, I like her choice of words, you know, to sort of do this together.

So, I think that’s really it. Kind of that philosophy of welcoming all students, regardless of where they are in their trajectory -- whether they're gifted in the sciences or whether they're always striving to keep up with the sciences -- but love people and that people part of medicine, that sort of inclusiveness, I think, is a big part of it, too. 

Michael: I imagine there are people listening that are finding this very valuable because they aspire to teach one day. And there also may be people listening who aspire to write a textbook someday. So, I do want to get you to talk about that. How do you even approach something as complicated as that? And what are the biggest challenges in writing a didactic style book? 

Dr. Costanzo: The textbook is the physiology textbook published with Elsevier and I actually chose Elsevier because of the long tradition of didactic textbooks that they have. I thought I wanted to be in that company. That was really the reason.

Michael: Forthe benefit of our audience, you're talking about Grey's Anatomy, Robbins...

Dr. Costanzo: Robbins Physiology. I had the great honor to meet Arthur Guyton a couple of times and he's a legend in physiology, Cecil's Medicine. I should have said the names. I read the history of W.B. Saunders before I made my decision. That's actually a great book. That's what I wanted to do was to write a didactic textbook for physiology because I saw that there was a need for that and students were craving that I had previously published the BRS review book and students were using that as a textbook, which they shouldn't have been doing. I mean, it's fine as an adjunct to their classes for review, but not for primary learning, I didn't think. And so I said, there's a need for this. So, the philosophy is it is written to students and for students. It is not written to impress my colleagues with any research-level physiologic knowledge.

I think the tension is between keeping that accessibility for students -- because that is who it's for -- and still maintaining the integrity of the science and riding that line. I think that probably is the greatest challenge. The other, I think, is just maintaining my philosophy and voice, which is to make it as accessible as possible, to make it as fun as possible. Fun is a big part of the whole teaching philosophy, 

Michael:  But it's also not a word that people associate with textbooks.

Dr. Costanzo: Yeah, but it should be, and I'm actually going to be starting the next edition and I'm going to even make it more fun because I just decided why not? I think it's fun already. I mean, it's really the best subject. How does everything work that's in the body? Keeping that voice, but also having my ear to the ground for feedback on what's working, what's not working in terms of student users and keeping that balance and tension as well.

Michael: And so this would be the eighth edition you're working on? 

Dr. Costanzo: Yeah. 

Michael: So that's pretty uncommon. What do you attribute the success of the book to? And are you surprised? I mean, as I said, you’re at a million copies in print of all of your books. That's an amazing achievement. 

Dr. Costanzo: I would never have had an idea of that scale. Except that I was pretty sure there was a need for a book like this, but whether I could be successful...I mean I didn't imagine it. It feels like it's somebody else. I just don't have that, that image of myself.

So anyway, I think why it's lasted -- because this is what I hear -- is that physiology is so difficult and the level at which medical students need to know physiology is so complex and there are difficult concepts. They need as much help as possible in making those connections and the stepwise kind of thinking. And that's really what I do with my teaching, is kind of this stepwise thinking approach, so I just brought that to a textbook. The challenge for me was to learn all the areas of physiology that I didn't know at that level yet. I had to teach myself, and as I taught myself, I sort of saw how I could teach others. I had certainly had the background to figure it out, but I mean I had to really tackle kind of almost everything that way. 

Michael: My goodness, what a ton of work. We only have a couple minutes left. We always like to have our guests provide some advice to the students and early career professionals in our audience about how to approach their careers. You're around students all the time. What's your go-to advice? 

Dr. Costanzo: Well, I think about my own students because they're my group, my people. Those are the people I know the best and whenever I have the chance, I always encourage them to stay curious, to not be afraid ,to be fascinated by what they're learning. Because I see, you know, the grueling preclinical education. It is a slog, and then there’s the reality of Step 1 and the incredible focus on all that and on surviving it and on passing Step 1. 

But what I would say to them when I have a chance is that is going to be behind you in the rear view mirror before you know it, and everything else lies head and that is going to be up to you, to your own drive and curiosity to keep learning. So, that is my true advice. 

Michael: And there's no shortage of things to learn in healthcare because it's changing every single day. 

Dr. Costanzo: Yeah. Yeah. 

Michael: Well, listen, Dr. Costanzo, this has really been a lot of fun -- I can say that because podcasts should be fun too -- and super interesting, and we really appreciate your time today. 

Dr. Costanzo: Well, thank you so much. I thoroughly enjoyed it. Have a wonderful day. 

Michael: You too. I'm Michael Carrese. Thanks for checking out today's show. And remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.