Training Doctors to Be Active Citizens, Focused on Equity – Dr. Paula Termuhlen, Dean of Western Michigan University Homer Stryker M.D. School of Medicine

Michael Carrese: Hi everybody, I'm Michael Carrese, and today I'm happy to welcome Dr. Paula Termuhlen to Raise the Line. She's the dean of Western Michigan University Homer Stryker M.D. School of Medicine in Kalamazoo, one of the nation's newer medical schools. Prior to assuming that role in May of 2021, Dr. Termuhlen was the regional dean for the Duluth Campus at the University of Minnesota Medical School, which has a partial focus of training physicians for rural and Native American communities.

Earlier in her career, she was on the faculty of the University of Nebraska Medical Center, Wright State University Boonshoft School of Medicine, and the Medical College of Wisconsin. Dr. Termuhlen is widely published in surgical oncology and surgical education, and has served in a variety of roles for the American College of Surgeons, the Association of American Medical Colleges, and other national organizations. Thanks so much for making time for us today.

Dr. Paula Termuhlen: Thanks, Michael.

Michael Carrese: We like to start with learning more about our guests. What got you first interested in medicine, and particularly in becoming a surgeon?

Dr. Paula Termuhlen: I have friends that tell me that they remember me talking about being a physician, or being a doctor, when I was in kindergarten.

Michael Carrese: Oh, my goodness.

Dr. Paula Termuhlen: I'm a first-generation college student, so that was perhaps a bit surprising. But my father was quite ill when I was a child. He died when I was 12. We spent a lot of time going back and forth to the hospital. My brother was born prematurely back in the 60s, so I was surrounded by medical... stuff if you will. I used to play doctor with my Barbies, and I probably had surgery on the horizon because when my Barbie camper would have car accidents, I would take the Barbies to the hospital and fix them.

Michael Carrese: Oh, my. That is foreshadowing.

Dr. Paula Termuhlen: Yeah.

Michael Carrese: And why oncology?

Dr. Paula Termuhlen: Well, I chose to be a surgeon, or figured that out, during my third year of medical school. My husband of thirty-seven years -- he and I got married right before I started medical school -- he's not a physician, but he was a biomedical engineer working with the ventricular assist device program at St. Louis University, where I went to medical school. I used to wake up in the middle of the night when his pager would go off to go help with a patient. I'd be like, "Who wants to do that?" This was early in my medical school days.

I purposefully put my surgery rotation first, because I thought, “I'll just get it out of the way.” Needless to say, I fell in love with it. Prior to that though, I really saw myself as being a primary care physician, and how this all comes together in the realm of surgical oncology is that there's a significant component of longitudinal patient care that goes with that discipline. You spend a lot of years seeing your patients and getting them through some very difficult times, and I found that incredibly rewarding, in addition to the surgical component of the discipline.

Michael Carrese: Yeah. I can see how that would be the case. In terms of leadership, was that something you envisioned for yourself earlier in your career, or was it something that developed unexpectedly?

Dr. Paula Termuhlen: Well, once again, back to my childhood. I was on the safety patrol as a kid, and I think I actually met my husband through an American Red Cross program of leadership development. I attended as a high schooler, but then I was a facilitator where I met my husband when I was in college. 

I think I had some natural leanings towards being in leadership. Having said that, as a medical student, I was heavily influenced by one of my professors, Dr. Ray Slavin, with whom I did laboratory research between my first and second year of medical school.

I'd never really been exposed to that kind of laboratory research. He's a retired allergy immunologist that had a research effort, and I also saw that he was able to go outside of St. Louis University and really share that information with others in the way that we do in academic medicine: giving talks, teaching other people, etc. I really hold him up as a role model.

Then along the way, I had really wonderful mentors: Charles Balch, John Potts, a number of individuals who really helped me sort of see and understand what being a leader could be. By the time I was in my professional life as a fully-fledged, fully-minted associate professor, I was already getting asked to participate in different types of programming to help develop my leadership skills. 

It's a skill set. You have to really invest the additional time and energy. It's not something back in the day that we thought to include in the medical school curriculum, for example, even though we lead teams all the time. Over the years, I really found a lot of satisfaction in being able to help make a difference. That's a personal motto of mine. 

Whatever I do is to make a difference, and as most leaders will tell you, you move through a process of helping, as a physician, that patient in front of you. If you're an educator in academic medicine, you're helping people with your research, or helping people with your community, or helping people with your students. And then when you move into these higher roles, like being the dean of a medical school, my whole goal right now is to help our organization make the biggest difference it possibly can for the people of Southwest Michigan and beyond.

Michael Carrese: Why don't we back up for a second. Can you just give us an overview of WMed, and highlight what you think some of its strengths are?

Dr. Paula Termuhlen: WMed is the shortened version of our name because it is quite long. It was created here in Kalamazoo as a way of serving this population, but we're a private school. We serve the nation, quite frankly. We have students from all over the country and occasionally a student or two that comes in from Canada because we are in the Northern Tier. We've just recently completed a new mission and vision process. Part of that was, it being a young medical school, I was hired at a phase where the school was hungry for an identity.

All of its energy had been focused on putting the bricks-and-mortar in place and all of the appropriate components to create a fully-accredited medical school. The founding dean, Dr. Hal Jenson, did really an incredible job with that. When I arrived, it was well, “Help us create an identity.”

Our identity now is one of service to the idea of health equity, and really doing that with the population that we serve here in Southwest Michigan…recognizing that we will help train people from all over the country and send them forward, but in the meantime, we're here to help our community.

Michael Carrese: How does that manifest itself -- the health equity mission?

Dr. Paula Termuhlen: It manifests itself among all of the four missions of any medical school. In our education space, our students have what we call active citizenship. For example, they helped teach some of our underrepresented populations, particularly the black community. They were able to help do immunizations and education at some of the black churches that we have here in Kalamazoo. They also do a variety of work with some of our refugee programs that are in the area here.

They also go out and serve our unhoused population in Kalamazoo -- we call it street medicine -- which was an initiative started by one of the then-residents of our family medicine program in Kalamazoo in partnership with a number of our medical students. That's been an exciting part on the education side. 

On the research side, we have a deep commitment to helping understand and create interventions to reduce infant mortality. In this area, we recognize that that's a community-wide partnership with the YWCA, with Western Michigan University, with our hospital partners Bronson Health and Ascension Borgess here in Kalamazoo, and many others that contribute to that effort. So that's on the research, and I would say community engagement side as well. 

And then clinically, we serve in many respects the underserved. We're a bit of a safety net in terms of our ambulatory care practices, and we provide service to our local Federally Qualified Health Center as well.

Michael Carrese: A connected issue is increasing diversity in the physician workforce -- that's obviously a topic that's challenging a lot of medical schools. Talk about how WMed is approaching that.

Dr. Paula Termuhlen: First you have to frame it in ways that people understand. We talk a lot here about creating a physician workforce that looks like or reflects and understands the populations that we serve in order to racially diversify, and also including other elements of diversity, such as the LGBTQ community, as well as those that have lower socioeconomic status. I mentioned I was a first-generation college student and things like student indebtedness and all of that are front and center for us. I paid off my student loans the first month I became the dean of a medical school, so you have to kind of pause and think about that.

Michael Carrese: Yeah, wow.

Dr. Paula Termuhlen: I don't want that to happen to anyone else. What we really need to do though, is get a lot of different voices at the table so we understand each other better, and we can really then relate to the patients that we provide care for. 

That can happen in a number of different ways, and you have to be very intentional about it. We've come to recognize that you really have to reach down into elementary school to inspire young people to continue their education.

We know that the programs that we have -- the pathway programs that have been created -- are not programs that will bring every one of those young people into medical school, and we're fine with that. If they consider other health professions, we think that's very important in a differentiated healthcare workforce environment. But we know some of them will go to medical school, and we'd love to be the place that they want to come to. If not us, then someplace else that will treat them well and also help them provide the care that we need them to for the patients.

Michael Carrese: I mentioned at the beginning you're one of the newer medical schools, and I'm sure I'm not the only one who's curious to find out, how does that happen? And why does that happen? Are there any particular challenges or advantages to the newness?

Dr. Paula Termuhlen: There's a whole lot I could tell you about that, but let me capture a couple of thoughts. We've recognized that in general, we believe there to be -- based on a lot of national information promoted often by the Association of American Medical Colleges -- a significant, looming physician workforce challenge. I think the pandemic has really uncovered, not just in the physician space, but particularly in the nursing space, where we were short-handed in so many different ways. People will say, “Yeah, we've got plenty of physicians” but we're missing certain types.

We recognize that we don't really have 100 percent of all the physicians that we need in the places that we need them. I think that's a place where you have to start. That then spurred a large number of medical schools to pop up on the horizon over the last ten to fifteen years. WMed is ten years old, and I could easily rattle off five or six other medical schools that are roughly the same age as we are because these were initiatives either taken on by states or communities to help support that workforce increase of physicians, if you will.

As an aside -- because I have experience with the regional campus model -- we've also seen a large growth in the numbers of schools that have decided to extend their classes by putting campuses in different locations that are all under the same accreditation of the same medical school. We hope to get there someday. We're not there yet at WMed, but I just came from a conference where people are really doing this all over the country as ways to serve their communities across their states and across their regions, and in that instance also across Canada.

The push was on to create and open the doors to pump more physicians into the workforce. Then the other piece of the question has to do with, what is it like to be at a new school? The first thing I'd say about that is startups can be messy, because there's a lot of energy…it's just a huge amount of work to really get a school launched. The school that I have the great privilege of being in charge of launched very well. We graduated our fifth class. We actually were able to hire back on our faculty one of our graduates from the very first class who completed training in internal medicine.

Michael Carrese: Oh, that's neat.

Dr. Paula Termuhlen: Yeah, it's totally coming full circle. It's been incredibly rewarding in that regard, but I can also tell you some of the challenges that we have. I don't have a real deep bench. For example, if someone retires or moves on or becomes ill, we don't have a lot of extra people that have been trained up to be able to take that role. That's a piece that I think is an ongoing challenge, and we're seeing that layered on top of what's been called the great resignation around the country, so that's one piece that we struggle with.

On the other hand, when you're a young school, and you're a relatively small school -- we have a class of 84 per year -- it gives students an opportunity to really engage with us and help drive and improve their circumstances. We listen. We really need them to help us do the job that they need us to do the help to educate them, and then also participate in things like our strategic planning that we had students and residents help us with.

Michael Carrese: Now, obviously, being dean of a medical school is a tricky enough job in and of itself. But you took over a year ago when the pandemic was well underway. I'm just wondering if you can give us some assessment of how you think WMed has managed the challenge of providing care and providing clinical education at the same time in the middle of a crisis?

Dr. Paula Termuhlen: I am very fortunate that while I was working at the University of Minnesota, we had incredible leadership. I came ready to understand and have a mindset around what is it that we need to do? I'm sure for the listeners, particularly those who are medical students, I know some of you are the individuals who have been deeply impacted by the experience of the pandemic. I mean, this is a professionally-defining moment for all of us in terms of how we reflect on the work that we do and the people we provide care for, and the disparities in healthcare that it has uncovered.

And then layering on top of that the practical components of do we have enough personal protective equipment? That's what was keeping students out of clinics and hospitals for a long time, including here in Kalamazoo. We have a wonderful community benefactor who has relationships in China and we were able to actually get some of that equipment early on to be able to provide and get our students back into clinics in hospitals as quickly as possible.

I think we learned some important lessons. What was definitely true in Minnesota has been very true here at WMed, which is leveraging the virtual experience in good ways. We know that no one has graduated a medical student and created a physician who has not touched a patient. I want to be very clear about that for the listeners who are just trying to understand medical education in general. No school has done that. But we've learned that we can actually prepare students to make their on-board, in-clinic, in-the-operating room experiences more effective by providing some virtual learning experiences in advance. 

Then in the classroom setting, finally, we started to think about, "Well, why do we have to have people sitting in the seats? Why can't we be thinking about how to do remote learning and be more creative about how we deliver that content?"

To me, that is the silver lining because we're a bit stodgy in the world of medicine when it comes to education. Because the stakes are so high, were reluctant to just go out there and do something wildly different. But on the other hand, it's something that we really need to do. And I think we've learned that we can leverage these tools now in ways that will enhance the educational process for our students.

It helps us provide care to patients via telehealth in ways that it took a pandemic to move us along that path. We've understood a little bit more about the efficiencies, and we've understood why it's important to then also have in-person experiences with colleagues and peers that allow us to really be with each other in a way that you just can't do in the two-dimensional space of a Zoom.

Michael Carrese: Absolutely. Well, speaking of educational tools, Osmosis, as you may know, is an education company. We love to fill knowledge gaps, and we love to ask our guests for some direction about what you think is a knowledge gap, a myth, a topic that is of particular concern to you that you'd say ‘Osmosis, if you guys made a video about that, that would really help.’

Dr. Paula Termuhlen: I'll tell you the thing that immediately comes to mind when you ask that question, which is how can we do a better job of educating our public and engaging them in the science work? I think there are some people thinking about this very deeply, but the challenges we have around increasing the vaccination rate in the United States is front of mind for me.

It's something that WMed has been personally involved with in terms of requiring it for employees and students because we see it as a core value of reflecting the science and then also respect and protection for the populations we serve. And yet, we recognize that there are individuals that don't have that same belief system.

I think as a country the pandemic caught us off guard a bit. We haven't learned how to communicate effectively about how important it is that we do this. I think one place Osmosis could spend some time is helping all of us understand how do we build the communication tools so that we can make these kinds of conversations more accessible to people, so we can get the hearts and minds going in the right direction, so we can protect the public health. We really don't have the trust of the public, and that's something we have to work very hard on and I think it does come down to communication.

Michael Carrese: Yeah, it echoes remarks that Dr. Ashish Jha made. He's obviously now at the White House. When he was talking to us on this show, he was still at Brown University, and he said he thinks it's really one of the greatest challenges of our time, this communication around science and medicine, and the trust factor that's been frayed during the pandemic.

Dr. Paula Termuhlen: Generationally, those of us that are in leadership positions today in American medicine, we come to the table with an inherent trust. Part of it is because it is our profession. But if you just look generationally, there's far more assumption that when your public health officials tell you something, you should listen. We are very fortunate at WMed. We have the medical director for the Public Health Department of Kalamazoo and Calhoun Counties on our faculty. He's fabulous, and he knows how to communicate very effectively to the public. We think about this a lot at our place, about how can we do a good job of this. 

Really, it caught us off guard because we weren't even seeing it. We weren't really hearing. We weren't identifying that those a generation or two younger than I am really don't have that trust. If you're a community of color in particular, these are individuals who have mistrust for all kinds of reasons, and we just really didn't see that coming as we've tried to communicate effectively during the pandemic.

Michael Carrese: Right. As we're wrapping up here, we like to ask our guests to provide our audience -- which again is a lot of medical students and early healthcare professionals -- with some advice about meeting the challenges of this moment and also looking ahead to their careers.

Dr. Paula Termuhlen: I said before that the pandemic has been really a defining moment for all of us. It's one of those few times in life, regardless of where you are in your profession – thirty years of practice like me, or someone who just put a hood on and graduated in early May -- we have all experienced this together. This was a tabletop exercise for me when I was in medical school, but this is a reality for you.

I think that you're going to help us not only solve some of the big issues that we have today around how we deliver our healthcare and how we provide care for our patients, but you also have sort of the creative mindset and the open-mindedness -- and now, this incredible experience of the pandemic -- to really galvanize us into action. 

I was incredibly heartened to see that medical school applications went up twenty percent in 2020. I was predicting -- again wrong -- I was predicting that we might actually have for the first time a dearth of applications. Instead, it increased by 20 percent, because that inspiration was there. 

I think we have a lot to learn from our younger listeners about how they want to tackle the problems today of medicine, and that they're committed, and have seen firsthand how important it is to have really bright minds and the real successes of when we work together to solve problems. I look forward to seeing what they have. I hope they'll be able to take care of me, because I know I'm going to need them.

Michael Carrese: That's one thing that is true of all of us. We're going to need help at some point.

Dr. Paula Termuhlen: Yeah.

Michael Carrese: Well, listen, that's a great note to end on. We thank you very much for your time, Dr. Termuhlen, and I wish you the best of luck in your important work there.

Dr. Paula Termuhlen: Thank you. It's been a pleasure.

Michael Carrese: I'm Michael Carrese. Thanks for checking out today's show, and remember to do your part to flatten the curve and raise the line. We're all in this together.