Varun Phadke, MD is Director of the microbiology thread in the preclinical phase of the MD curriculum, Director of the internal medicine clerkship in the third year of the MD curriculum, Associate Program Director of the Infectious Diseases Fellowship Program, and Assistant Vice Chair of Education for Clinical Reasoning in the Department of Medicine, Emory University School of medicine. In this episode Varun talks about how he's been passionate about education since grade school, but it was only when he went into his fellowship program that he was shown various pathways to make pursue education within medicine. Varun's words of wisdom for aspiring educators and education leaders include "you're not alone. Find colleagues, mentors, sponsors, collaborators to help you further the impact of your ideas." "I think your learners know more than you think they do. And your job is not to make them know more. Your job is to help them think through what they already know." and "when you have no clear defined role, that means many people are going to think that you are tasked with helping them, which may or may not be true, even if it's exciting for you."

Resources

• The Moth | Podcast
• Learn Serve Lead: The AAMC Annual Meeting
• Home - AAIM (Alliance for Academic Internal Medicine)
• Society to Improve Diagnosis in Medicine

Hello, listeners. Welcome to Educational Landscapes, lessons from leaders. On today's episode, we're going to learn from Varun Phadke. Welcome to the show, Varun.

Thanks, Ulemu. It's great to be here. I'm very excited and honored to be part of the group of people you've chatted with.

Wonderful, wonderful. We look forward to learning from you. To get us going, what is your educational leadership title or titles?

Great question. I am fortunate to have a lot of educational roles here at Emory involving work with a lot of different levels of learner. So in the medical school, I am the director of the microbiology thread in the preclinical phase of their curriculum. Then, I'm the director of the internal medicine clerkship in the third year of their curriculum. And then, in the GME space, I am the associate program director of the Infectious Diseases Fellowship Program. And then, most recently, I became the Assistant Vice Chair of Education for Clinical Reasoning in the Department of Medicine.

Congratulations. I love that it covers the whole spectrum, the continuum right there.

Yeah, no, it's a lot of fun.

Cool. So given the breadth of learners that you deal with, what do you do in these roles?

Great question. I think I do a lot of different things, ranging all the way from direct hands on teaching at the bedside or the classroom. And that can be a large group classroom like lectures or a small group classroom like workshops and small group activities. But a lot of it honestly is curriculum development, thinking about what content needs to be delivered over a certain amount of time, what competencies do my learners need to develop as a result of experiencing the curriculum that I'm in charge of. And then faculty development as well. I think the unifying thread of a lot of my clinical and educational activities is this clinical reasoning focus that I've developed over the last few years. And it's not a domain that many of us as faculty learned about explicitly in our training. And so developing faculty in that knowledge base is a big part of what I do.

I love it. Can you tell us a bit more about what drew you to clinical reasoning as the area of focus?

Yeah. Clinical reasoning has been an area of inquiry for a long time, for decades, understanding how clinicians think, but it's only more recently become recognized as a competency that we can and should explicitly develop in learners. And I came to it serendipitously because I didn't even know that I was teaching concepts that were aligned with current frameworks of clinical reasoning until I found them and saw, "Hey, I'm structuring my lectures and my chalk talks exactly like what this domain is all about. Maybe I should be even more intentional about following those frameworks and infusing them."

And I think what I love most about it is that it is very intuitive once you start to adopt the language. It is really how clinicians think all the time. We just are not really good at articulating it to each other, and therefore it often feels like a black box for trainees. And so when you're able to shed light on it and you get to see that moment where trainees realize, "Oh yeah, I really should be organizing my thinking like this," it brings together all of the medical knowledge that they already possess and just give them a way of organizing it and retrieving it more effectively.

I love that because I think it's so important to make things that are implicit, explicit, especially to junior learners who are like I don't know what you just did.

Absolutely.

So as you think about the work that you do, you're dealing with faculty, you're dealing with learners, teaching clinical reasoning, what skills do you use in your various roles?

I think what I've come to realize in having these roles is the most important thing in developing clinical reasoning skills and exploring other people's clinical reasoning is just being able to ask good questions. And I have really tried to be intentional about developing my question asking skills. It might seem really basic, but I think, in the microbiology thread or in the medicine clerkship or as a clinical educator and teacher on the wards with my fellows, a lot of the time we're not transmitting knowledge or our goal should not be to transmit knowledge because there's better resources than me to learn information and facts.

And so what people really want is an organizing tool. And you can actually talk people through the organization by just asking questions, but that means asking questions in a way that keeps the learning climate approachable for learners, that doesn't make learners feel unsafe, that allows them to share their uncertainty, that acknowledges that there were a lot of intermediate steps from where they were to where I am or where their other clinical teachers are. That, I think, recognition and appreciation is what has fed into my question asking ability and I think is one of the most important skills that I use in all of my educational roles.

That art of questioning. Given you're covering the continuum, I am very curious, what was your journey that led to these current roles?

I think like many of your previous guests, it was not linear, and I honestly didn't even realize that I could pursue this passion for education when I began my medical training. I always enjoyed teaching all the way back to grade school. I did a lot of tutoring in undergrad and was a TA for organic chemistry for two years. And actually, I should have realized and only in retrospect, I realize now that that experience was very formative because our organic chemistry professor had a completely non-lecture-based organic chemistry curriculum. And it was entirely small groups working through problems that he had created to incrementally teach the knowledge and skills. And as a TA, it was very cool because you would just circulate among the groups and see how learners were struggling and offer your wisdom. And I didn't realize the in innovativeness of that curriculum at the time, but in retrospect, it's like all I want to do now.

So then I got to medical school and residency, and I think, like many other people, during those phases of my development, I was very focused on, okay, what clinical specialty am I going to become an expert in and try to master and be passionate about. And enjoyed teaching, enjoyed teaching learners that I had when I was on teams as a resident and as a fellow too. And I think it wasn't until fellowship that my mentors during fellowship recognized my passion for teaching and showed me paths that I could pursue to apply that to larger groups of learners, and really gave me opportunities to teach in a large group setting or a small group setting by inviting me to give lectures or workshops and so on. And then I was lucky enough to be brought on as faculty with a couple of educational roles, including the associate program director role in the fellowship program, and then the director of the microbiology thread in the medical school. That started just a few months after I began as a faculty member.

And both of those roles were very formative for me in opening my eyes to the bigger world of medical education and the regulatory frameworks in which we function as educators. And then I got the opportunity to become involved in the clerkship as associate clerkship director. I did that for four-ish years before I became the clerkship director. And through all of those different things, I realized that they were coalescing around clinical reasoning. And I then was able to create an elective about clinical problem solving for medical students during COVID when the medical school had asked people to create electives at the last minute because they were pulled off the wards. And I created this problem solving elective, which really crystallized my interest and forced me to become very facile with the literature because I was now teaching it. And I think that then naturally morphed into this role that I now have.

That is amazing. And I love, as you said, that there was, in hindsight, a common thread throughout. What do you wish you knew before stepping into these roles?

I think... One thing I just mentioned was this idea of the frameworks in which our educational institutions exist. And I don't think we as medical learners appreciate that and the historical perspective about it, about why education is the way it is and what's been tried before and what assumptions have shaped what we do now and whether those assumptions are still correct. I think we as medical students maybe have a vague understanding of what LCME is, primarily because our stake in it is I want my institution to remain accredited if I'm going to graduate from it. And then, as residents, I think we interact with the ACGME to a greater degree because of milestones and things like that.

But I would venture to guess that most trainees don't have a more robust understanding of how that process works about accreditation and assessment and all the stakeholders involved. And I think just clinicians benefit from understanding the healthcare system in which they function and its limitations and potential, I think, as an educator, it would be, or it has been very helpful to immerse myself in that and learn about it so that I know, okay, if I want to change this, here are all of the other things that that might impact and who I need to get on board in order to make those changes.

Right. We are not silos in these spaces.

Correct. Yeah. I think because we often, as educators, get super passionate about our little pet project, we're like, oh, I made this amazing curriculum or lecture or workshop. And it's great to deploy it and learners may really enjoy it, but to make it sustainable, to make it disseminable, really understanding where it fits into the bigger scheme is very helpful.

Indeed, indeed. So thinking about that clinical reasoning and then the other skills that you're using, what continuing professional development do you do to keep up with the needs of your roles?

Yeah, I think that's really important. I do a lot of different things. Number one, attend a lot of conferences related to medical education and clinical reasoning to understand what curricula are out there, how are other people teaching the same material, how does it interface with other aspects of clinical medicine that I am not super familiar with, like medical decision making, high value care, things like that. In the process of attending these meetings, either in person or virtually, I've developed a network of colleagues, mentors, across the country who I interact with with some regularity to make sure that my ideas are being bounced off others who have expertise in the field. So that's another way.

I think just keeping up with the literature in medical education specifically as it relates to clinical reasoning has been very helpful for me, similar to what we do for our clinical practice and seeing how, as one of my mentors says, the basic science of reasoning, the cognitive psychology studies that go into dissecting people's thought processes to the implementation science of clinical reasoning, which is how do you incorporate it into a curriculum in a way that is meaningful and that you can measure its impact. So that's another way. So conferences, mentorship, networking, literature. I think those are the main ways that I've tried to keep my myself and the content that I create current.

Nice. Any conferences that you would suggest others attend that you've been to?

Yeah. If people are interested in clinical reasoning specifically, I think there's a lot of different places to go. There's a society called the Society to Improve Diagnosis in Medicine, or SIDM. They have an annual conference, which is named just SIDM. And I haven't actually been able to go in person because it often overlaps immediately with our National Infectious Diseases meeting, but I have gone virtually. Thankfully, because of COVID, they've made it a more hybrid type meeting. It's a small meeting, but I think the people who go are thought leaders in the intersection of clinical medicine, diagnostic error, clinical reasoning education. A lot of my mentors and so on that I described attend that meeting. I learn a lot from the posters and workshops that are presented there. So that's a fantastic meeting. I think a lot of clinical reasoning education gets presented at more general educational type conferences. AAIM, the Alliance for Academic Internal Medicine, has a lot of content-related to clinical reasoning and then other educational conferences too, like AAMC and so on, which I haven't yet attended, but I think those are high yield conferences to attend to expand your worldview.

Thank you. Thank you. What other advice would you give to someone interested in doing the same type of leadership roles that you have?

That's a good question. I think it really depends on, I guess, which of my leadership roles I think about to answer that question. I think it's probably easier for me to answer that question when it comes to some of the leadership roles that are more traditional, like the clerkship director role or the microbiology thread director role, the associate program director role. And so I'll touch on those and then I'll get back to the assistant vice chair role because that's a relatively unique role, I think, in our institution and among other institutions around the country. So I wanted to reflect on that a little bit more separately.

But with regards to the other roles which are more traditional, I think things that are helpful are, number one, immersing yourself in the literature about those roles. I think many of us, when we come to an educational activity, whether that's as something as small as a single lecture or workshop or small group activity, all the way to an entire curriculum or role, a lot has been done and studied and tried already. And it is vital to recognize that and understand that so that you inform all of your educational work with evidence, just like we do in clinical practice.

There's a lot of educational bodies that exist that have published curricula and guidance about assessment and things like that that are immediately applicable to a curriculum. So sometimes it might feel like you're applying your efforts in a silo, as you said, but recognizing that there's a larger network of people out there who have already created material that you can just adapt to your setting. Networking I think is super important. We often remain very institution-focused in medical education and think, okay, well, this is the way it's been done here. This is the way that it's going to keep being done. This is the way that I'm going to keep doing it. And it's not until you talk to a clerkship director or a program director at another institution when you realize, oh my gosh, there's a totally different way of doing it that is also really effective, and I could try that here. So I think those are basic pearls that I have come to recognize over the last few years in these more traditional roles.

For the assistant vice chair role... I mentioned that it's a unique role, and I think that's probably only a handful of analogous roles around the country, and I think that's because clinical reasoning has only more recently become recognized as a competency that we need to intentionally develop. And so, to my knowledge, there's only two or three other people around the country who have a similar GME-focused role on clinical reasoning. There are clinical reasoning roles in UME, for sure, at a variety of institutions, including our own because I think it is more straightforward to embed clinical reasoning education into a undergraduate medical education curriculum. So because my role was unique or is unique and was new, it's newly created, no one had this role before me, that allowed me a lot of freedom to essentially define what I was going to do in that role. And I think that has pros and cons.

So advice to people more generally when you're creating a new role and then filling it yourself is deciding for yourself what your metrics are going to be because that's going to allow you to show the value of your role to the people who created it for you. It's going to narrow the scope of your work and allow you to remain focused on a certain limited number of tasks because when you have no clear defined role, that means many people are going to think that you are tasked with helping them, which may or may not be true, even if it's exciting for you. So I think those are two immediate pieces of advice I would give. Defining metrics for yourself, and then narrowing your scope.

For the people who are interested in clinical reasoning specifically and want more leadership roles in it, I think faculty development is key, and that can be personal development, so immersing yourself in the world of podcasts and literature and conferences, as I mentioned, about clinical reasoning. There's a whole language of clinical reasoning that you just need to know to understand what's happening. And it's not until you have that fluency that you can start to build credibility and then take on a position like mine where you can then define curricula for others, you can define assessment tools that are based on evidence and so on.

Thank you. I really appreciate you highlighting the things that you need to think about when you step into a new role because there is a lot of excitement for when something is, oh, nope, that scope creep is really quick. So I love, as you said, thinking about metrics because I don't think a lot of people think about that when they take on roles. If you ask probably a clerkship director, what are the metrics that are used in order to tell you that you're doing well? They'll probably sit there and go, "Oh, that's a nice question."

Yeah. And I mean, honestly, I wasn't even fully aware when I stepped into the role as associate clerkship director or clerkship director the metrics that are being used to measure us as clerkship directors from the medical school. And it was only until I started receiving information like, oh, there are these surveys that students complete at the end of every graduating year. There are surveys that they're completing regularly about the faculty that they encounter on the clerkship. There's a whole committee that reviews your clerkship at the end of every couple of years that you report to. When I became aware of those things, I realized, oh, okay, there is a structure in which I function and I need to be cognizant of that before I start to make changes and so on.

Right, absolutely. Thank you. Thank you, thank you. How do you support or expand education in your profession or through your roles?

That's a great question. I think two ways. One, I've alluded to previously, which is faculty development. So I spend a lot of time thinking about how to transmit my clinical reasoning expertise, passion, to others because a lot of other people have it and they just don't have the language to describe it. I think anyone who is passionate about clinical medicine and making diagnoses and making them efficiently would love to be able to say, "Here is what I do differently than others that makes me more efficient or more accurate. Here are the skills or activities that I engage in that make me stay current and stimulated," and they just don't have the language. And so creating workshops for the institution. There's a FEED conference. There's Medical Education Day. There are noon sessions, educational sessions for various divisions within the Department of Medicine that I have participated in. There's the core faculty for the internal Medicine Residency program. I think all of those are venues that I have explored to try to convey this passion for reasoning and develop that same skill level in others. So faculty development is number one.

I think number two is mentorship, which I think is one of the most enjoyable parts of my roles because a lot of my role is not direct teaching anymore. As a program director, I'm not running the curriculum for our fellows. As a clerkship director, I'm not even necessarily the one doing any direct teaching in the clerkship anymore. But the role that I do play for the learners in all those settings is a mentor and a sponsor. And learners coming to me and the other leaders of the team, coming to us with anxieties or queries about career development, anxieties about their clinical skills. That interaction, that relationship is really a big part of the joy of my work. And I think one way that I try to transmit my values in education to the next generation so that they can see how I got to where I am and how I can pay it forward, and hopefully they do the same for their trainees in the future. So I think mentorship is another very core aspect of my work as an educator that I think helps me further my educational mission.

That's wonderful. And I'm always curious, knowing how important mentoring is, when it comes to doing that, did you do any professional development to prepare yourself to be a mentor? Or was it one of those, I'm going to just wing it and learn as I go?

That's a fantastic question, and I wish one that was asked of all graduates of medical training who intend to remain involved in medical education. I have not honestly engaged in any formal professional development about mentorship. Have I attended workshops at national meetings? Absolutely. Have I tried to engage with literature about mentorship? Absolutely. Have I tried to extract wisdom in a very explicit way from my own mentors? Absolutely. But does that necessarily mean I've gone through a mentor development program? No. And honestly, a lot of what you come to realize as a mentee yourself is sometimes seeing things that your mentors do that you want to do differently. So I've tried to incorporate some of that into my own role as a mentor to others. But I do think that there is room for me to continue to develop that skill, especially since I'm now in these leadership roles where people are coming to me, including other faculty, for development in that skill.

Thank you. Thank you. I'm always curious with that because I know how important it is, and yet it is, it's tricky to really build out a mentorship development program that meets everybody's needs.

Absolutely.

All right. So continuing on, what contributed to your biggest successes thus far, or what has been one of your greatest successes thus far?

I'm going to blend those two questions and try to illustrate one of my successes through the lens of the opportunity I was given to succeed. I think the microbiology thread in the preclinical phase of the curriculum was really an amazing opportunity for me to explore my educational skills as I came out of training. Before that, I had given a handful of lectures to people about various topics in infectious diseases before, but I'd never really been tasked with designing a longitudinal curriculum. And so I was given that position pretty early on after graduating from fellowship, as I mentioned before. And I think what was a really amazing opportunity was the person and the people who handed it down to me, separated themself from the curriculum, and therefore gave me a lot of leeway about how to change it.

I think oftentimes in medical education, there is this natural challenge with completely handing something over, especially if you've been in charge of it for a long time and have seen a lot of changes happen that you may be proud of. But handing it over to someone else and seeing that that person might either undo what you did or change what you did, I think it's only natural to want to continue to have a hand in the development. But the people who gave me that opportunity and responsibility were very intentional about separating themself and saying, "Varun, this is yours now. Make it what you want it to be. We know that you have the ability to do so. We trust you to create a robust curriculum that will engage learners, develop the competencies that are necessary and be a resource for the medical school."

And that freedom then translated into me being able to revamp the curriculum significantly. And now I think it's our medical school's or medical students, one of their favorite parts of the curriculum, even though many of them won't go into infectious disease, sadly, I think many of them really enjoy that part of the preclinical curriculum. And I see that because I see them all come through the medicine clerkship in the third year, and they recognize me. And I think that's... I'm very proud of that because I didn't necessarily remember many of my preclinical teachers when I finished the preclinical phase of my curriculum. So I consider that the microbiology thread to be a success. And I think a lot of it has to do with being given that freedom and responsibility very early on.

That's amazing. And I really appreciate you bringing that up because it is one of the things that we say we're excited about change, but there is that, okay, can you let go so that the change can happen? And everyone's like, "But that's... I mean... yes."

So yeah, no, I think it takes a lot of trust to hand over something like that to another person, especially if you've invested a lot of time and energy in it yourself. And I feel like I'm going to struggle with that same dilemma whenever I hand over the microbiology curriculum too. But I hope that I can do the same that happened to me and allow the new person to enjoy that freedom.

Yeah, that's wonderful. Wonderful. So recognizing you've had successes, and I'm sure you'll have many more, what would you say are some of your biggest growth opportunities that are still in the works?

Yeah. I do a lot of different things as I've talked about in this discussion. With various levels of learner and have innovated in a lot of different spaces in the microbiology thread and the clerkship, in this assistant vice chair role. In full transparency, I have not effectively figured out a way to measure and disseminate the work that I'm doing. And I suspect that this is a common thread among many educators. And I think it is important to take what I have done and share it with others so that my impact is able to be felt outside of the institution, to make myself visible as a resource for more junior faculty at other institutions who are looking for mentors. And that network that I mentioned is so important because if I don't, I think that's like an opportunity lost. I think that is by far my biggest opportunity for growth and development as an educator, is figuring out and taking the initiative to disseminate the work that I'm doing.

Absolutely. I am sure you will find ways, I'm sure. As you reflect on all the things that you've done thus far, what do you love most about your work and what you do?

This has come up several times during our conversation. I think one of the reasons I love clinical reasoning so much is it makes me a better clinician. And my two passions throughout my medical training, from when I was a student to a resident, to a fellow, priority number one, was always being clinically excellent; to deliver the highest quality patient care. And I always looked with admiration at senior clinicians who were brilliant diagnosticians, who made really thoughtful decisions about patient care. And I thought to myself, "When am I going to be that person? Do I need to wait until I'm that stage of my career before I can say, okay, now I can say I'm an excellent clinician?" And I realize that you can reach that level of excellence, or you can build a trajectory, I should say, to that level of excellence by being intentional about developing your clinical reasoning skills.

And so in teaching about clinical reasoning, I have found that I not only love the interaction with learners and the light bulbs that light up when I walk them through a framework to organize the knowledge they already possess, that then translates immediately into me becoming a better clinician about that problem, which then I feed back into curricula.

So as one of my mentors across the country in clinical reasoning told me... He's a expert clinician recognized globally for his diagnostic expertise, and he's a full professor of medicine. And during one of our conversations, I asked him, "You're so mature in your career and you still do so much clinical work," which is not that common in people who are that high up in their career. And I asked him, "Why do you do that?" And he said, "Well, because the wards and the clinic and the ER are my laboratory. That's where I practice what I teach. That's where I learn what I'm going to teach about." And that has really stuck with me because that close interaction between the practice of medicine and the teaching of reasoning for me is what really drives my educational activities in every domain. And so building those thinking skills is, I would say, the philosophy that imbues everything I do.

That is wonderful. That is amazing. I love that close interaction because I think sometimes people think, "Oh, there's that saying, those who can't, teach." And it's like, no, if you do, you learn really what you want to teach in order for people to-

Correct.

make that connection. Wonderful. I recognize you are more than what you are at work. So what are some things you do outside of work to help you maintain joy in life and practice?

Yeah. And I think that's become more and more important, and I think we've all become more and more aware of it over the last few years. So for me, number one, two, and three is spending time with my family, my wife, and my close-to-five-year-old son. And so we, I think, do a lot of fun activities together, hiking, biking, cooking, eating, playing with Legos, whatever it might be. I think that's really the centerpiece of my life outside of medicine. But when I do have some time for myself, I enjoy podcasts, nonmedical podcasts. I listen to The Moth, and I love the stories. And I think about how the storytelling as an art form and how that impacts me as a clinician and the way I tell stories to learners about how to learn from a case. I love reading. Detective fiction is my passion, as you might have guessed. And then, lastly, as evidenced by the fact that I was baking a cake just prior to this podcast, I really enjoy cooking. So I have developed a passion for that over the last 10 years or so since I was a fellow. And that's something I really love doing for my family. And now all of the gifts that I've gotten over the last many years are related to cooking. So that, I definitely think is a big part of my joy outside of my work.

I love that. And everyone's like, "Since you enjoy cooking, we will happily eat, and so we will do whatever it takes to keep you feeding us."

Exactly.

I love that. Well, thank you, Varun. Those were my core questions for you today. But before I let you go, are there any last words of advice for aspiring educators or education leaders that you'd like to share?

It's a great question. As I've mentioned a few times already, I mean, I think the most important lessons I've learned over the last few years and now in these roles is you're not alone. Find colleagues, mentors, sponsors, collaborators to help you further the impact of your ideas. I think we all operate sometimes in a silo in education, and that limits the potential for what we can accomplish. And I think your learners know more than you think they do. And your job is not to make them know more. Your job is to help them think through what they already know.

I love that wonderful words of wisdom to end on. So thank you again for your time, Varun.

Absolutely. Thank you, Ulemu.