Preparing Medical Students to “Be the Difference”- Dr. William Cullinan, Dean of the College of Health Sciences at Marquette University

SHIV GAGLANI: Hi, I'm Shiv Gaglani. With the Omicron wave of COVID still in play and the possibility of more variants coming, questions remain about what can be safely done face-to-face. As Dean of the College of Health Sciences at Marquette University, Dr. Bill Cullinan continues to confront the challenge all academic leaders face of developing solutions that work best for students, faculty, staff, and the surrounding community. Dr. Cullinan is also a professor of Biomedical Sciences at Marquette and Director of the Integrative Neuroscience Research Center. His research focuses on understanding the neurobiology of stress and the link between stress and psychiatric illness. Dr. Cullinan, thank you so much for taking the time to be with us today. 

DR. BILL CULLINAN: It's my pleasure. 

GAGLANI: I'd like to start first with learning more about you, your background, and what got you interested in neuroscience. 

DR. CULLINAN: Well, that's interesting. I started off thinking I wanted to become a physical therapist. During that time, I realized I was really more excited about understanding the nervous system, and I guess, as they say, one thing led to another. Ultimately I wound up doing a postdoctoral fellowship at the University of Michigan, where we were studying something called the hypothalamic-pituitary-adrenal axis, which is a long way of describing a system that responds to stress and culminates in the release of a powerful hormone you've probably heard of called cortisol. There's a strong link between too much cortisol—which we call hypercortisolemia—and depressive illness. So for me, I guess that's where it all started. 

GAGLANI: Yes. There's no more relevant subject right now than stress and psychiatric illness, it seems, with the last two years of COVID. 

DR. CULLINAN: Yes. I think we've yet to realize the psychological debt we've incurred from the lockdowns and the lack of social interaction that the pandemic has precipitated. 

GAGLANI: Well, let's dive into that. How has your experience been over the past two years as a leader of a large health science school? How are you guys thinking about the next year ahead? 

DR. CULLINAN: Well, we've had challenges, of course, and we've gone through everything from de-densification, to social distancing, to masking, and we've been relatively fortunate. We have some on-campus clinics and we don't have a single documented case of transmission between, say, a client or patient and a therapist or provider in those clinics. You can never know for sure, of course, in that it's hard to prove a negative, but we haven't seen evidence of that. So that was encouraging. 

But life has been very different. I still spend some time in the classroom, so I interact even with undergraduate and professional students, and it's remarkable in the current climate, which is a little relaxed from where we were six months ago here in Wisconsin, just how excited students are to be with each other. It's palpable. 

GAGLANI: Yes, definitely. I know not just within the student communities, but in general, it feels like people are already booking travel plans and wanting to do that. So I'm curious, what are some of the changes Marquette did during COVID that you think are going to be still around in the next couple of years and outlive the pandemic or endemic, hopefully?

DR. CULLINAN: Like many schools, we went entirely remote, initially. What that forced us to do was learn how to deliver things remotely and in online and even hybrid formats. The faculty surprised themselves at how adept they were at picking up the technology, and have continued to use it in other ways going forward—partly out of necessity, but also partly to enrich courses. For example, initially, we were remote, but then we came back in a hybrid format. You'd always have some cluster of students cycling in and out of quarantine, so you'd have to create an online experience for them until they could be back in person with the rest of the group. We went through some creative applications of technology to make it kind of fair to the entire group. These are really competitive students, though. They're really reluctant to allow another group to get an advantage on them. But nevertheless, it seems to be working out. I think going forward, some of these technologies will be deployed as enrichment tools when things go back to a completely in-person experience for the most part. 

GAGLANI: Yes, that's consistent with some of the things we're hearing. You know, another trend that we're hearing about is just increased demand for positions and healthcare student enrollments. I'd love to hear any commentary you have maybe on both the intake at Marquette, like, have you guys been seeing increased demand?

DR. CULLINAN: Absolutely.

GAGLANI: As well as the outtake. 

DR. CULLINAN: Well we're a private school, and so price points are a sensitive topic. I think increasingly, students, or their parents, or both are looking at the return on investment, and the fact that we have an aging demographic and many projected increases in the need for healthcare providers has caused a large increase in the number of applications. To give you just one example, we have a very strong Physician Assistant Studies program here at Marquette University in our college. We have 75 seats in a class, and we receive over 2,000 applications for those 75 seats. The average grade point average of an applicant is 3.8 to 3.9. So, this is clearly, in the past, medical school territory. But these students don't want to be physicians; what they want is to be physician assistants or perhaps they'll be called physician associates one day. But essentially, they're looking for the flexibility of the career, the shorter time to get to be credentialed, the lower debt load, and the ability to change specialties multiple times over the course of a career—something a physician can't do without going back and doing a multi-year residency all over again, which is almost never done. 

GAGLANI: Yes, that's a really good observation. I think for four or five years in a row, according to the U.S. Bureau of Labor Statistics, the PA field has been in the top ten fastest-growing specialties.

DR. CULLINAN: U.S. News & World Report called it the number one profession in America sometime in the last three to six months. 

GAGLANI: Wow, I've got to go check that out. So that's the supply side; a lot of people are going into the programs. Clearly, 75 spots for 2,000 applicants is indicative of how competitive things have become to get into these programs, and your program. On the flip side, we're hearing constantly about burnout among physicians and nurses. I haven't heard as much about PA's, but I assume it's similar—maybe you have some knowledge about that. Has that been discouraging at all to faculty or students in the program? Because we don't want to be filling up a leaky bucket. 

DR. CULLINAN: I can't speak to the whole profession, and I would be shocked if it didn't affect the PA profession in some way, but we haven't seen it expressed as dramatically as in the nursing and medical fields involving medical doctors, at least so far. But I think for all frontline healthcare workers, the pandemic has created new sets of stressors and all kinds of complexities, as you could imagine, but it hasn't deterred admissions, or matriculation into programs, or demand. We're grateful for that but you know, we're vigilant about it. 

GAGLANI: Absolutely. You talked about some of the lasting changes, potentially, that will happen in the modality of teaching, like more virtual options. What about the content? Are there things that you've changed with the curriculum or plans to change with the curriculum? For example, value-based medicine, public health, any of those that are happening?

DR. CULLINAN: All of that. That's been evolving even pre-pandemic. We're at a very mission-centric university, and our tagline is “be the difference.” We want our students to live that. Part of getting to that place, or preparing them to change the world, is for them to understand the inequities in healthcare delivery. To get them to understand some of the larger social and cultural phenomena that are going on all around us, and will definitely affect their scope of practice in the years to come. We want to produce a caring, competent clinician who really has a heart to serve the most vulnerable amongst us. 

GAGLANI: Yes, absolutely. Glad to hear that, because we're hearing a lot more in recent years—partially because of the pandemic, but a lot because of other things that have happened during the pandemic around diversity equity and inclusion: serving rural areas, serving urban centers, making sure that the physician, PA, and health professional workforce looks like our general societal structure as well.

DR. CULLINAN: Yes, sure. And in fact, a lot of this comes very organically from the student. So I'll just give two quick examples. Some 40% of our own—since we're talking about PA, but this applies to all of the other professions we train in as well—40% choose positions or jobs in serving underserved populations. I think that's a testament to the extent that what they're getting in the program is making a difference when they leave us and it's sticking. The other thing is, the students themselves are very keen to raise awareness and funds for scholarships for classmates who are from exactly these diverse backgrounds, with the whole notion of diversity, equity and inclusion. They're actually driving the effort, in some cases, to make this happen. It's something that most folks want to get behind. 

GAGLANI: That's awesome; it's really great to see that. Just last week, we released our Raise the Line scholarships. We've been running this program for several years, and we are able to give six health professionals students about $10,000 in scholarships. That's another systemic change I'm hoping to see. I'm curious, given your position and involvement in training so many healthcare professionals, I wonder if, because of the pandemic, there will be more governmental support and more universities will be able to offer lower tuition or free tuition. 

We work with NYU and Kaiser Permanente, as two examples, and their med student classes are tuition-free at this point because of generous private donations. I wonder if society will not just call healthcare professionals healthcare heroes, but in fact, help make sure that they aren't graduating with hundreds of thousands of dollars of debt. 

DR. CULLINAN: Yes, the debt can be crushing. It's something we're all sensitive to, especially for medical doctors because of the length of training and the cost. But I guess it remains to be seen how successful we'll be in finding private partners, but kudos to you and Kaiser for supporting NYU, because that's as good as it gets, free tuition for medical school. It's virtually unparalleled. 

GAGLANI: Yes. That's where I made such big headlines when NYU and Kaiser did that. Switching gears a bit to the other hat you wear, being Director of the Integrative Neuroscience Research Center. Neuroscience is very close to my heart; that was my college thesis. I was considering going into the MD-PhD program in Neuroscience. My co-founder of Osmosis, Ryan Haynes, actually got a PhD in Neuroscience at Cambridge, looking at decision-making. I would love to hear more about your research, as well as what the center does, and maybe if there are any, initiatives or projects that dovetail with the health professional student education that you do, too.

DR. CULLINAN: Sure. I could talk for a long time about this, but the center essentially has the mission of bringing together collaborators from across our campus and beyond to share ideas and explore common interests. I think what we have been able to build, partly through the center, is an interesting cluster of neuroscientists that we can split out into what I would call three functional domains, which collectively form the underpinnings of understanding mental health and mental illness. 

Having some training and having done a thesis on this, you'll understand that it's well known that the brain has a reward circuitry, an emotive circuit. That's part of the area that we hired around initially, with a series of researchers interested in addiction. It's also the case that the limbic system or the emotional brain is a part of neuroscience that's coming into sharper focus. There's lots of interest and we hired a series of a half a dozen scientists who focus on that. 

More recently, we've been trying to cluster hire around the prefrontal cortex, the executive-decision-making area of the brain. The brain that is responsible for impulse, in addition. The part of the brain that's the last to fully developed through myelination, at age 26 or so—which, ironically, auto insurance companies have known for decades, because that's when your rates go down. We just didn't have the mechanism until more recently. 

Nevertheless, when you put those three domains together, it's clear to anybody with training in this area that they anatomically overlap. This creates a synergy across the group that's very distinctive if not unique. We've been able to hire folks away or, let's just say, young scientists who were considering some of the most elite institutions in the country out to this group, I think for each other more than anything else. That's because they know that as soon as they're ready and they get their research program launched and off the ground, they're going to have five or six instant collaborators right there within their own department next door. 

There's a great spirit among these scientists. They all have access to each other's labs, they share equipment in space, they write grants together, they co-publish. The best thing is, in addition to the positive effects it has for postdocs and graduate students, it also involves undergraduate research experiences that are considered perhaps the highest-impact things happening on college campuses. We're not talking about standing in the shadow of the professor senior year during a capstone project. We're talking about, maybe starting in the summer, in a ten-week paid summer research program, latching onto a lab, learning a skill that you contribute to the laboratory team over the next four to six semesters for credit or for pay, and winding up as a co-author on a manuscript and published paper, perhaps traveling to a national meeting to present original data. 

This is a really needed opportunity for some 50 undergraduate students that we
put through this program each year, and it's self-funded. That's a whole other story—we created a business, the profits of which completely fund this program. We also have a benefactor who supplements the stipends, but it's working on a lot of levels and we're really excited about it.

GAGLANI: I'm very happy to hear that, because actually before Osmosis, what got me interested in education in the first place...I used to do a lot of research in high school and in college, and a lot of it I mentioned is neuroscience. I went to the Society for Neuroscience and American Academy of Neurology conferences multiple times with my-

DR. CULLINAN: Talk about an overwhelming meeting, the Society for Neuroscience.

GAGLANI: SFN is, I feel like, the largest academic meeting. Things have come full circle, because the research—while I did not pursue a Ph.D., I instead pursued medical school and then business school, too, and then started Osmosis to do education—a lot of the skills you pick up as a student researcher are vastly applicable: writing skills, presenting skills, analytical thought, learning about whole new fields, and learning about R and Python if that's what you need for your research. Those skills are really translatable into the business world and many other fields. It's really good to hear that that's something that you guys have prioritized at Marquette, even at the undergraduate level, because not many schools seem to really care about undergraduate-level researchers. 

DR. CULLINAN: We're really serious about critical thinking skills and the analytical thinking, that you described, that comes with research. You know, it's a habit of mind and it changes the way you approach life, I believe, because you don't take things for granted, and you want to see evidence, and you want to challenge your own biases. These are things that science helps you to cultivate. 

Even beyond that, getting back to the education piece, we are trying to get our students to think clinically very early in their undergraduate careers, as early as sophomore year. We have a course here called Clinical Human Anatomy, which covers a lot of breadth. It's a lot; it's intense. It's compared to the intensity of organic chemistry. You know that wherever you go, organic chemistry is a beast, and that's probably why professional schools use it as a benchmark, because they figure, if you could do well in that while carrying a full academic load, well, you'll probably do okay in medical school. But the relevance of, say, an anatomy course versus an organic chemistry course to what you're going to do in your future as a physician couldn't be more different.

Our students then have the opportunity to dissect a human cadaver, like a first-year medical student would, as second-semester sophomores. You want to talk about an engaged group of students? They're just on fire. Then the curriculum, which is very medical—it's actually called Biomedical Sciences, just like the department—becomes progressively more cellular and molecular. So after anatomy, of course, physiology, biochemistry, cell biology, molecular genetics—a macro to micro progression. So that throughout, its students are never asking the question all educators hate to hear, which is, “What do we do to do this for?” t's abundantly clear what we need to know this for; we were just there and now we're taking it deeper and deeper and deeper. They can always connect it back to the human body. 

We're not asking them memorization questions. I teach the one of the anatomy courses, and I tell them, “Never will I show you a picture of an anatomical body part with an arrow pointing to something, saying, 'What do we call this?' We're going to assume you know that. What we want you to do is answer this question. A patient comes into your office. They can move this way, but not that, they can feel these sensations, but not those. Tell us where the problem is, and you can do it.” Or alternatively, “Here's a problem in the vascular tree. Predict the downstream consequences in terms of signs and symptoms.” They can do that, too. For students, that's fun, but there's an initial investment on the front end that takes a lot of time and effort. But once they can do it, they're on a whole other level of engagement, and are willing to work really hard. So that's been a lot of fun to be a part of, because if you're an educator, there's nothing better than an engaged class. 

GAGLANI: I love that example, because definitely I've had professors who were very much rote memorization: “What does a type-two alveolar cell do?” It's very easy to write those questions, but very hard, very useless table stakes. Versus the Circle of Willis, “You have a stroke here in the Circle of Willis, what are the downstream effects?”as you mentioned.

I think when we first started talking to you for getting on the podcast, we were an independent company. We just recently joined Elsevier, which makes Grey's Anatomy and Netter's Anatomy. Our colleagues at 3D4 Medical just came out with the first female body, 3D anatomy model. It's a very big anatomy education institution, and one of the reasons we're really excited is because they're starting to offer all these diverse and inclusive models. 

We talked about trying to train a more diverse workforce. Even a decade ago, when I started at Hopkins Med School, and I'm sure when you were training, too, most of the anatomical figures are white men, and now it's very much diverse genders, skin tones, ages, etcetera. It's kind of an interesting time in health education. 

DR. CULLINAN: Yes, it certainly is, and Elsevier, well, what can you say? They do great stuff. I'm actually part of the International Advisory Board for Netter's Atlas. 

GAGLANI: Oh, cool.

DR. CULLINAN: From the 7th edition and beyond. That's been a lot of fun, too.

GAGLANI: That's awesome. I should tell Marios Loukas, who's at St. George, Kathleen Reid at Elsevier, and Maddie Hyde, who I know well. I'll make that connection later. 

I have two more questions for you—well, actually, three. One is, since you're a neuroscientist, one thing I'm personally interested in is, I realized a decade ago when I was in neuroscience training, the ganglia—you know, basal ganglia, I learned about that several times, but other ganglia, too—I did spinal cord research in Miami, and there were a lot of dorsal root ganglia I was looking at. What's interesting is, it's literally my name. If you look at my last name, Gaglani, it's an anagram of ganglia.

DR. CULLINAN: Oh, wow.

GAGLANI: I'm trying to explain what a ganglia does to people who don't know medicine. How do you explain the basal ganglia? It does everything. It almost feels like that, not just movement, but also emotion and whatnot. How would you explain ganglia to someone? Not to quiz you, but... 

DR. CULLINAN: Well, I think the first thing that comes to mind is the classic definition of a collection of nerve cells in the peripheral nervous system as a ganglia, versus a nucleus, which would be the same thing in the central nervous system, although the basal ganglia, ironically, are nuclei in the central nervous system. So they've been misnamed all along. If you start looking at some of the more recent anatomy textbooks, they're calling them basal nuclei, but I'm convinced that the clinical literature will continue to call them basal ganglia for another hundred years because they're real stubborn about change. 

In the periphery, obviously ganglia serve of series of functions. They're critical in the sensory system, because they contain those pseudo unipolar cells that act as conduits for sensory signals to make it from the periphery to perception, typically on the opposite side of the brain in the sensory cortex. But the basal ganglia or basal nuclei in the forebrain, that's something that I'm very fascinated about as well, because in some of the teaching that I do, we cover motor systems, and you're right—there are multiple parallel channels through the basal ganglia that affect everything from emotion and affect to just classical movement.

I'm particularly fascinated with motor function and the fact that the basal ganglia and, also to an extent, the cerebellum, cooperate or collaborate to not only plan and program complex mode or function, like throwing a ball, and to keep it of high fidelity—to correct errors in almost real-time. If you think about the capacity of the motor areas of the brain to do that, they're just simply not big enough. There's not enough information processing capacity and precentral gyrus to do a complex motor act, because it's just such a complicated thing. 

What I'm what I'm fascinated with is the fact that if you look at the circuitry through the basal ganglia, this is massive cortical input that's funneled back to the motor areas of the brain. Presumably, it's in that loop, or so-called re-entrant pathway that motor planning and programming takes place. As we get better and better at perfecting the motor act, like say, free-throw shooting, which is another obsession of mine, their synaptic strengthening at all the nodes along the way, whether you're in the direct pathway, or the indirect pathway, and all the rest.

Think about this. This isn't always taught in neuroscience courses, but if you look at it, the first descending input to the striatum in the basal ganglia pathway comes from the entire cortical mantle, whereas what returns goes only to the motor areas of the brain—either the motor cortex or supplementary motor cortex—which to me says the entire brain, in a very real way, participates in motor actions of this type that are complex. 

So if you think about what takes place when you throw a ball, all of the different motions taking place. We'll just consider the upper extremity—the external rotation, abduction that has to be then reversed and turned into flexion, internal rotation—and then, of course, if you're extending your elbow, or putting a spin on your wrist, more. All of that involves very precisely-timed volleys of activity: leaving the motor cortex, crossing to the other side of the spinal cord, going to just the precisely correct levels of the spinal cord, to just the precisely correct motor neuron pools to leave through the precisely correct peripheral nerves, to go to the precisely correct muscles, in exactly the precisely correct sequence. It's nearly miraculous. I tell the students, “You're a walking, talking miracle. The fact that you can stand up and walk out of this room is, in neurological terms, amazing.” That resonates with people when they compare the anatomy to what I've just said. And that's just the basal ganglia's role. So that's a long answer to a short question. 

GAGLANI: I love that. I kind of want to go check out your next neuroscience class.

DR. CULLINAN: Well, we have fun.

GAGLANI: My last question is, what advice would you give? I'm sure you give your students advice all the time, but what advice would you give to our audience of over 2.3 million current and future healthcare professional students about approaching their careers in science and healthcare?

DR. CULLINAN: Well, I think when you embark on something that's long and arduous, it's easy to lose sight of the prize. You're going to be tested. You're going to be stressed. You're going to make sacrifices. You're going to make sacrifices in your social life during your training, because it takes time to do these things successfully. The punchline is—and this assumes that you're on the right track and you're properly motivated—it's all worth it. It's all completely worth the effort that you're going to put in. And if you have chosen wisely and you're on the right course, you're not really working a job like everyone else for the rest of your life. Think about what that's worth and keep your eye on that. 

GAGLANI: I love that; that's great parting wisdom. Empirically, I can say the same. I haven't felt I've been working on Osmosis whenever I've felt in flow because of what we're doing. So, Dr. Cullinan, this has been an absolute pleasure. I know we could've spoken for several hours more, but I appreciate you taking the time, and more importantly, the work that you do to the raise the line and train the next generation of health providers. 

DR. CULLINAN: It's been a privilege and a pleasure, and nice to meet you.

GAGLANI: Good to meet you, too. With that, thank you to our audience for checking out today show. Remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.