“To boldly go where no (Doctor) has gone before”
Those as nerdy as I will recognize the title of this article as paraphrased from the introduction to the original Star Trek television series. That program, set in a technologically advanced future, was about a long journey of discovery. Perhaps the most peculiar aspect of that journey is that it had no particular destination. The voyagers were simply wandering aimlessly, hoping to run into something interesting. Consequently, they often found themselves woefully unprepared for the challenges they faced – an excellent means to provide dramatic tension to a fictional story, but a dubious strategy for real life.
A medical school curriculum is basically a journey. For our students, it’s a journey that will take them into an unknown future. Like any real journey (and in contrast to the intrepid Star Trek crew), establishing a destination is the first, critical step. A long journey may consist of many stages and stops along the way that demand our immediate attention, but those stages are only meaningful if they move the traveler toward some ultimate goal. That goal, of course, is to become effective, fulfilled providers of medical care to members of our society.
The students currently in medical school will be practicing into the mid 21st century. If we’re to provide them an education that will best prepare them to make meaningful contributions, we need to give some thought what that world will look like, and what it will require of them as physicians and professional leaders.
This was the topic of a presentation and subsequent discussion at our semi-annual Curricular Retreat this past week. In preparing some remarks to begin that discussion, I attempted to draw on changes that have occurred in the course of my career and use those observations to extrapolate into the future. I came up with five that I think are particularly relevant. This is, by no means, a complete list, but perhaps sets the tone and the challenge.
In no particular order:
- The role of physicians as purveyors of medical knowledge.
Knowledge is the fundamental fuel of medical practice, and the commodity that gives legitimacy to those providing care. A generation ago, medical knowledge was elusive. It had to be searched out, a process that was paper based and time consuming. Physicians were the primary source and conveyors of medical knowledge. People who wished to become physicians went to medical schools largely to seek out the knowledge and skills that were embodied in the practicing physicians who taught there.
That has all changed. Medical knowledge is now available, almost instantly, who anyone who wishes to find it. Physicians are no longer the primary source of that knowledge. They no longer hold any monopoly on knowledge.
- The expanding applications of Artificial Intelligence and robotic technology.
We were all impressed when Watson defeated chess masters and Jeopardy champions. In my field of cardiology, I think many dismissed automated interpretations of electrocardiograms as simple algorithm-driven time savers that would always require physician verification. The same is happening with respect to interpretation of diagnostic imaging such as chest x-rays and CT scans.
But AI is moving far beyond these applications that are based simply on prodigious memory storage and processing capacity. Applications are becoming much more sophisticated and are developing the ability to learn and adapt to dynamic situations. Diagnostic algorithms are available that will provide reasonable differential diagnoses for patient presentations, and computer interfaces are under development that are frighteningly life like in their ability to interpret individual patient speech and even facial expressions.
Robotic applications in the operating rooms and procedure suites hold the promise of increasing technical expertise and consistency while reducing infection rates. They also allow for interventions in locations where the human hands are simply incapable of performing.
Extrapolating forward, it’s not at all hard to imagine a world where most diagnostic imaging and many therapeutic interventions will require much less, or perhaps no human intervention.
- Our fundamental understanding of human disease.
For generations, physicians have understood and characterized disease states based on what they could observe clinically. “Consumption”, “Whooping Cough” and “Scarlet Fever” are examples of conditions described solely on symptoms and visual inspection. As the ability to image patients and do laboratory analyses improved, patients with Consumption were found to have pulmonary damage caused by Tuberculosis, Whooping Cough became Pertussis and Scarlet Fever became associated with streptococcus infection.
I have lectured students for over 20 years on the classification, diagnosis and management of cardiomyopathies based on morphologic distinctions (Dilated, Hypertrophic, Restrictive) established by clinical examination and imaging appearances. My teaching is now changing, based on new classification schemes based not on morphology, but on the genetic mutations that result in abnormal development of cardiac muscle cells and channels.
This is not only highly appropriate, but promises to bring genetically based therapeutics that promise to alter the natural history of these conditions in ways currently not available. It also represents an entirely new science, involving genomics and an understanding of sub-cellular processes that practitioners of the future will need to understand and develop comfort with if they’re to provide optimal care.
- Standardized approaches to disease management.
Physician order sheets used to be blank and on paper. They have not only become electronically integrated into patient management systems of various designs, but have also become prepopulated with standard orders for many, even most, clinical conditions. Often, all that’s required are patient specific data such as body size and renal function, and a physician’s signature (real or virtual) at the bottom of the page.
This is good in the sense that it promotes consistent and evidence based approaches to these conditions, and reduces transcription errors. However, it can also diminish the educational experience of medical students, and may not fully account for the needs of patients with multiple medical problems or individual characteristics that require an individualized approach.
- Expanding role of non-physicians in health care delivery.
The widespread availability of medical knowledge in general and guideline based management strategies specifically has allowed for other health care providers, such as nurse practitioners, pharmacists and physician assistants, to participate more fully many situations. Another example from my field would be the expanding role of nurse practitioners in heart failure clinics. NPs are fully capable of managing the introduction and maintenance of standard therapies in this population of patients who often require close and continuing surveillance. They do so very effectively, and their participation has been shown to improve patient functional status and reduce hospital admissions.
And so, what to do…
It’s important to state from the outset that this is all good. These five changes will make health care more effective and efficient. Like any development they have potential pitfalls, but, appropriately managed, they will bring significant advantages to our patients. It’s also important to recognize that they are not going away. Technologic progress does not wait for us, or any group, to be ready.
And so, we must engage some very difficult and disturbing questions, summarized in this slide I presented at our recent retreat:
Obviously, there are no definitive answers, but I provide a few thoughts that emerged from recent discussions.
- Students no longer need to undertake medical education in order to locate knowledge – they are quite capable of doing that on their own. They do, however, require guidance as to what will be relevant to their careers, and an ability to interpret and evaluate the merits of the tsunami of information that will come their way.
- AI has the potential to dramatically improve the delivery of care, but can be highly threatening, partly because applications can develop out of context and without clear applications. Physicians of the future need to be more than consumers of AI, they need to involved in the development of applications, the purpose of which should always be to advance care. To do so, they will need fundamental education that develops familiarity with the technology and its potential.
- Medical education has always been rooted in science, but the nature of that science is changing rapidly. Fundamental knowledge about normal human structure and function will always be required, but will need to extend beyond the superficially observable to penetrate the genetic and subcellular levels of normal and abnormal human function.
- As Physicians are needed less and less to interpret test results or manage standard, well-defined clinical issues, their role will extend to ensuring patients enter the care system appropriately, and managing situations where the complexity or multiplicity of issues goes beyond standard management. This will require them to be even more acute assessors of patients at the primary presentation, develop high levels of sensitivity to patient outcomes that deviate from optimal, and have a depth of understanding of the scientific underpinnings of disease and system management that will allow them to step in and provide “customized” management when required. Indeed, “personalized medicine” may become the primary focus of the physician of the future.
All this, and no doubt much more, will require a vastly different approach to medical education, one that we need to begin to consider today. The future is closing in very rapidly. I’ll end with a quote regarding the future role of physicians from someone who was always technologically ahead of his time and not shy about expressing disruptive views:
“The doctor of the future will give no medicine, but will instruct his patient in care of the human frame, in diet, and in the cause and prevention of disease.”
Thomas Alva Edison (1847-1931)
Edison may have been somewhat overly optimistic about the “give no medicine” prediction, but was certainly perceptive in predicting fundamental change in approach. Over the next few months, we’re going to engage a series of dialogues about the doctor, and medical school, of the future, beginning with our recent retreat and this article. Please feel free to participate with your thoughts as we “boldly go” about charting a course into the next few decades of medical practice and education.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Facebook thinks I’m a doctor…
And other unusual things that happen when you’re an educational developer at a medical school
It’s a unique and interesting thing being one of the non-medically-trained employees who work (mostly behind the scenes) to help run the undergraduate medical education program at Queen’s. On the one hand, friends and family can sometimes think I’ve magically completed medical school in the types of questions they ask me. (I only work there, I say). On the other, through day-to-day interactions, I have absorbed terminology and “insider” information.
Having quietly marked my five-year anniversary working in medical education at the end of September, it was time for a little reflection. Here are five of the more unusual things that likely wouldn’t have happened to me before I worked at Queen’s School of Medicine:
- A new resident was surprised when, during a follow-up visit, I referred to my condition by name (gastroesophageal reflux disease), rather than calling it heartburn. “Most people don’t call it that,” she observed with surprise. I’d just done a curricular search for where and when we teach it – and at the earlier visit, that’s the term they used, so I paid attention.
- I can find my way around most of HDH and most of KGH most of the time. And I know there are THREE hospitals in Kingston, not two. (I just haven’t figured out the new Providence Care layout yet.) I’ve learned the “logic” of the multiple wings, the naming conventions, and – when all else fails – where to find the volunteer desk to ask directions.
- I now know that what you think something is might not be what it actually is. Case in point: My colleague’s son was diagnosed with OCD – but he’s not the least bit obsessive, so how does he have obsessive compulsive disorder? There’s another OCD, diagnosed by orthopedic specialists: Osteochondritis Dissecans of the knee. (It also stands for Ontario College Diploma, but that’s another story).
- Facebook thinks I’m a doctor. No, really, I get ads for MD Financial Management services, and medical conference. It’s based on analytics harvested from my Google searches (because everything is frighteningly linked these days). I search for things to assist with curriculum development, and voila! Facebook has changed my profession.
- I actually use those ubiquitous hand sanitizer dispensers while entering and leaving the hospitals. Every single time.
Because, as an educator, I just can’t help it: here are educational take-away lessons and considerations from these musings:
- When you’re “inside” you can forget what it’s like to be “outside”: how can remembering this influence communication, for example, in explaining acronyms, procedures, or what happens next? There’s power in language and understanding.
- When we’re familiar with buildings and facilities, it’s easy to forget what it’s like to be in an unfamiliar place and worried about getting around. How can we make instructions and directions as clear as possible?
- Don’t assume. If you’re not sure: ask. For example, we’re talking a lot about EPAs lately in undergraduate medicine. We don’t mean the US Environmental Protection Agency, but Entrustable Professional Activities. Even if we’re trying hard to adhere to my suggestion #1, we might slip up. Speak up and ask for clarification.
- Facebook still thinks I’m a doctor now and again, but more recently it’s promoting space-saving storage ideas and junk removal services. (I’m still adjusting to our downsized townhouse, 15-months in). The lesson here: We leave digital footprints everywhere we go. Intentionally (e.g. through public Twitter posts) or unintentionally through Google searches, nothing we do online is private. How should this influence what we do and how we do it?
Paper cuts and hangnails do not like hand sanitizer. At all. Ever. Be careful.
Here’s to the next five years.
Teaching, Learning and Integration Committee Summer Update
By Lindsay Davidson, Director of Teaching, Learning, and Integration
As classes (at least in years 1 and 2) have now ended, and teachers are perhaps thinking about courses that will resume in the fall, I wanted to provide you with an update of items from the TLIC. Some of these may already be familiar to you, but perhaps some are “new”. If you need any further information, please feel free to contact me directly or one of our Educational Developers (Theresa Suart from Years 1 and 2 and Sheila Pinchin for Clerkship and the “C” courses).
- Resources attached to learning events – these include lecture notes, classroom slides, required pre-class readings and optional post-class readings/resources. MEdTech is enabling a new feature for the upcoming academic year. Teachers will be required to review and “publish” each resource every year – with the option of adding in delayed release if appropriate. The goal of this is to provide students with an up-to-date, curated set of resources, deleting old files. Please direct any questions about this to Dr. Lindsay Davidson.
- Remember: “less is more”: Students report that when there are an excessive number of files, they often read few/none of them in advance.
- Clearly designate what is MANDATORY to review PRE-CLASS by indicating this in the “Preparation” field on the learning event, and checking the appropriate boxes on the menu when you review the resources.
- AVOID using dates on your slides/slide file names – students are sometimes disappointed to see that the file dates from 2009 or prior.
- The Curriculum Committee has approved a new learning event type – “Games” – reflecting several sessions already existing in the curriculum. This is defined as “Individual or group games that have cognitive, social, behavioral, and/or emotional, etc., dimensions which are related to educational objectives”. This type of activity might include classroom Jeopardy or other similar activities designed to allow students to review previously taught knowledge (content delivered either independently or in the classroom) and to provide them with formative feedback on their understanding. The instructional methods approved by the Curriculum Committee include:
Please direct any questions about this to Theresa Suart.
- Workforce – The Workforce Committee has recently adopted some changes including the following:
- Addition of credit for teachers who grade short answer questions or team worksheets
- Doubling of credit for teachers who develop new (or significantly renovate) teaching session
- Limit of one named teacher per DIL event
- Limit of one teacher per SGL event (gets additional credit to reflect session design, learning event completion, submission exam questions); additional teachers credited as tutors (credit for time in the classroom) – the Course Director may be asked to clarify who is the “teacher” and who is/are the “tutors”
- Reduction of credit for large classroom sessions (that are not new/newly renovated and/or do not involve grading)
Please direct any questions about this to Dr. Sanfilippo.
- Tagging of Intrinsic Role objectives. The TLIC and the Intrinsic Role leads recently held a retreat. One of the items that was identified was “overtagging” of sessional objectives with intrinsic role objectives such as communicator, collaborator, professional etc. by well meaning teachers. We are undertaking a comprehensive review of how these Intrinsic Roles are taught/assessed in the curriculum and would ask teachers/course directors NOT to tag sessions with these unless there has been a direct communication with the relevant Intrinsic Role lead.
- Communicator: Dr. Cherie Jones: email@example.com
- Collaborator: Dr. Lindsay Davidson: firstname.lastname@example.org
- Leader: Dr. Tony Sanfilippo: email@example.com
- Advocate: Dr. Jenn Carpenter firstname.lastname@example.org
- Professional: Dr. Rachel Rooney rooneyr@KGH.KARI.NET
- Scholar: Dr. Heather Murray email@example.com
Please direct any questions about this to Dr. Lindsay Davidson.
- DIL feedback from students. Over the past year, we have received useful feedback from students regarding the content and structure of Directed Independent Learning (DIL) sessions in Years 1 and 2. This will be collated and communicated to Course Directors shortly. Theresa Suart will be in contact with teachers/Course Directors should any sessions be identified for review/revision.
- Online modules. We have developed a process to facilitate the development of high quality online modules, often used as resources in DIL session. These are highly appreciated by students and are used for review in clerkship as well as pre-MCC exam. The current list of modules is available here: https://meds.queensu.ca/central/community/ugme_ecurriculum If you would like to create (or revise) a module for your course, please complete the linked intake form: https://healthsci.queensu.ca/technology/services/elearning/online_learning_modules/get_help
- New wording of learning event notices. You may have noticed this over the past year. The wording of the 3 email notices received by teachers has been revised. In particular, it has been streamlined and customized to provide specific, focused reminders prior to the scheduled teaching. We would appreciate any feedback or suggestions that you have about this change.
- Video capture In 2016-17, lecture sessions were video captured in select year 1 and 2 classes. We will be analyzing how these videos were used by students over the summer and will likely be continuing this into the fall. Please provide any feedback or comments that you have about this pilot to Theresa Suart.
Feel free to get in touch:
- Dr. Lindsay Davidson – firstname.lastname@example.org
- Sheila Pinchin – email@example.com
- Theresa Suart – firstname.lastname@example.org
Discover, Examine, Commit: A New Way of Looking at Group Work
I’m back with another perspective on collaborative learning. This time, I’m indebted to Jim Sibley at UBC for giving me permission to use Framework for TBL Application Activity Reporting Facilitation by Loretta Whitehorne, Larry Michaelsen, and Jim Sibley, reproduced here:
Our own Dr. Lindsay Davidson brought this home from the Team Based Learning (TBL) Collaborative’s Meeting this year.
or click on this:
This framework is designed to help us facilitate reporting on activities in our TBLs (SGL’s for Queen’s)…The 3 stages of an activity’s progression, Discovery, Examination and Commitment are great terms for ways of looking at key steps in any activity—in other words: get information, look carefully at the information and do stuff with it, and create a product. Specific tasks within each stage are extremely helpful advice for students and faculty to give reports on how they are doing in an activity. They’re also very helpful prompts for actual tasks!
(Actually, for the physicians and medical students out there, you can also see the 3 stages of arriving at a diagnosis: Gather information, Examine the information carefully and relate to experience, patterns, etc. and finally Commit to a diagnosis.)
However, these days I am focused on collaborative learning, and trying to go beyond the Norming, Storming, Reforming approach which many have often been taught. I often hear from students, “I’m not sure what to do in the group, except report back.”
The framework that Whitehorne, Michaelsen, Sibley have developed immediately gave me ideas about roles a student could take on in a group. In looking at the framework, I’ve grouped the 5 main roles and given them an attribute. So following are several behaviours that students can adopt; ideally the same person could adopt all 5 roles in one activity, depending on the group’s need. In fact, if a person remains in one role too long, it may make the group less productive. The idea is to recognize what is needed and move into that role to help move the group task along:
1. Sensor (Listens, shares, looks for consensus, is aware of others’ ideas)
2. Converger or Focuser (Focuses on specifics, probes, builds on others’ ideas, examines in depth)
3. Generalizer (Takes specifics to generalizations, expands, relates to frameworks or theory)
4. Summarizer and Synthesizer: (Puts it all together, supports and asks, “What if?”)
5. Maverick: (Looks for the different, the alternative, the unconventional, etc. Dare’s to differ instead of follow the crowd if it’s going “down the rabbit hole.”) Checks on things.
If you look at the Framework’s matrix, you’ll see that the Sensor’s role stays quite true throughout the different stages of an activity, as does the Summarizer-Synthesizer, etc..
Then there are great descriptions of behaviours a group member can adopt to move the group work forward based on the framework.
For example, looking at the framework, under the Discovery stage,
a Sensor can respect and listen actively to all contributions. H/she can also be a person who moderates or facilitates so everyone gets their turn. A Sensor can also unpack or explain in detail how a team arrived at a decision.
A person who is the Generalizer might restate the aggregated ideas of previous speakers, or link or combine, or put ideas together. S/he may articulate links between ideas or incorporate multiple sources into a single idea.
If your activity has progressed to Examining stage, the Sensor might compare or contrast by examining rationales to articulate similarities and differences. The Maverick might redirect or park by gently guiding conversation away from non-productive directions, and refocusing to direct attention to other thematic elements.
Under the Commitment stage (and I like this term, because it symbolizes positive and concrete final steps), the person who is a Converger-Focuser may generate specific examples by applying concepts and incorporating personal experience. The Generalizer may create general rules by drawing out the general principles and developing tentative “rules of thumb”. The Summarizer– Synthesizer may make predictions by considering what might happen as a result of particular idea in particular scenario. What is the role of a Maverick at this late stage? Even as the group pulls together a product or a choice, or an answer, the Maverick considers to what degree the choice or answer fits into the context or the applicability.
All in all, I got very excited when I saw this framework—not only because it focuses on ways to extend tasks and activities for group work but because it adds to my thoughts on collaborative learning. I also have to compliment the artist behind the figures in this framework (Angela Cunningham?)—they are extremely helpful when you work at grasping what the behaviours are!
So happy collaborative learning with a few more tips and strategies for our students working in groups and teams.
P.S. I’m also writing this on July 1…and so want to celebrate our country’s 150th with you by wishing you a Happy Canada Day!
Canada Day South Huron 2017
Five things to do this summer: a Med Ed to-do list
This first year I worked in a post-secondary setting, I was somewhat bemused when students asked me how I was going to spend my summer – they were heading out on a three or four month “break” and assumed I was doing the same. Some had work plans, some travel, some both. Regardless, they would be away from campus and recharging their batteries, and, perhaps, expanding their perspectives in a variety of ways. I, however, would be at my desk.
Two decades and three universities later, I’m still working through much of the summer months as are many of my administration, staff, and faculty colleagues as we stagger vacations with other colleagues and other family members’ schedules.
For those of us at the School of Medicine (including our 2018 clerks!) who don’t have two or three months off this season but maybe a couple of weeks and the odd day here or there to make a long weekend – here’s my list of five things to do that are (loosely) related to medical education. (This list is best perused—and perhaps amended or augmented—while sitting on a patio with your favourite libation).
Read something not related to your discipline
In the crush of academic terms, it’s easy to fall into the trap of reading for work, not for recreation. There’s always just one more journal article to be read, one more new text to review. One more thing to stay on top of. Vow to read at least one novel (or collection of short stories, or poetry) this summer. Regardless of genre, you’ll learn something of the human condition (which is at the heart of medicine and medical education) and it will refresh you, too. So, move it to the top of your To Be Read pile. Among my picks: a toss-up between finally reading at least one of the Harry Potter books, or Abraham Verghese’s Cutting for Stone. Maybe both. The Art of Adapting by Cassandra Dunn is also in the running.
Binge watch a cooking show on the Food Network
Whether it’s TiVo’ed or Netflix, the ability to skip the ads is a godsend for a rainy Saturday’s binge-watching. Opt for something where you might pick up a recipe or tip or two, but pay attention to how the host explains what they’re doing. Is it conversational? Directive? Do you stay engaged? Or pick one of the competition shows (Chopped is my guilty pleasure) and check out how different judges give feedback. Some are brutal; some overly-kind without much substance. Some have thoughtful suggestions. Many adapt their critique delivery, based on the experience and competence levels of the chefs competing. How can this inform how you deliver feedback?
Enlist some pals and build a sandcastle at the beach
Sandcastles are hands-on and best accomplished as a team effort. Building one requires both attention to details and a flexibility to accommodate the sand, water, and tide schedule. The plan is rarely ever 100% completed without modifications along the way. Plus, everybody gets dirty. And, at the end of the day, there’s nothing except pictures as the tide washes it away. So, a fresh slate the next day. And, we can take the lessons learned on to the next one.
Hit the movie theatre to see a summer blockbuster
Enjoy the a/c and see something outrageous. Popcorn optional. Take note of if the story drags anywhere: did you get the urge to check your smart-phone (pre-movie admonishments aside). What made your attention wander? Was it an extraneous info-dump? An overly-long car chase? Just too much of something? A gap in knowledge? If you’re working on online modules for next year, take note of where the show lost you. Adapt this insight to material you create for your students.
Watch some fireworks
Most of us know that fireworks were invented in China centuries ago. According to the “Fireworks University” website, this was an accident when a field kitchen cook happened to mix charcoal, sulphur and saltpeter. What a happy accident*.
There’s no great medical education insight to go with this watch fireworks suggestion: they’re just fun. And maybe that’s the insight right there.
* (I feel obliged to stress the importance of following all instructions for the at-home kind of fireworks and strongly urging you to show up for community fireworks shows instead. Avoid the unplanned side trip to the ER).
Sorry to interrupt but I just had this great idea: How learning about and adapting communication styles can help move group learning forward
When I last wrote to you in March, I asked if you were a constructive or destructive problem-solver in groups. We do a lot of small group (and larger group) learning in Queen’s UGME and I hoped to give a great framework to help prevent groups from imploding before or while constructive work could be done.
We looked at identifying the types of problem-solving that might occur in a group and some strategies that could help prevent destructive problem-solving. The ideas came from Team writing: A guide to working in groups by Joanna Wolfe. For this article, I wanted to share another set of ideas she has put forward in the same book, about Conversation Styles, and why they’re important to successful group functioning.
Why am I writing about challenges that small group learners can face? In the research project that was the foundation for Wolfe’s book, she noted that nearly half the teams [she] observed experienced major breakdowns and that instructors responsible for teams were rarely aware of the problems students were facing, mainly because students almost never notified instructors of the problems and instructors had no independent information that could help them anticipate and head off trouble. (Preface, p. v)
I’d like to offer another of Wolfe’s frameworks to help anticipate and head off trouble and prevent implosion in constructive group work.
This framework concerns assumptions we make about communication styles including how we should talk to one another, what constitutes productive behavior and rude behavior. Wolfe posits we need to understand others’ assumptions about “normal communication” behaviours and preferences in order to modify our own, and adapt to others’.
She provides a sampling of common communication norms (that are mostly extreme ends of a spectrum) and challenges us to self-assess, and also assess others in assumptions of appropriate and effective communication and teamwork. While Wolfe discusses 3 types of communication styles (Discussion Styles, Presentation Styles and Problem-Solving Styles), I’ll focus on Discussion Style here.
We start with self-assessment and recognition.
In a self-assessment tool about discussion style, Wolfe asks us to rate how well our behaviour is described in statements such as “When I get a good idea during a team meeting, I say it as soon as possible, even if I have to interrupt to do so.” Or “My teammates accuse me of not listening.” Or When a teammate expresses a new idea my first instinct is to point out the flaws” or “I think it is rude when my teammates never stop to ask me for my opinion,” or “If I need to express criticism, I am always careful to avoid hurting my teammates feelings.” (p. 84)
The outcome of the self-assessment is to place oneself on a spectrum of “norms”. For example, the “Competitive Norm” is defined as “conversation [which] is a miniature battle over ideas. Speakers tend to be passionate in supporting their ideas and interruptions are frequent.”
The “Highly Considerate Norm” features “speakers who acknowledge and support one another’s contributions, and disagreements are often indirect. Interruptions are rare and the conversation often pauses to allow new people to speak.” (p. 87)
There are pros and cons to each norm: in the former while this style leads to fast-paced conversation and the often exciting challenge of publicly defending ideas in the face of competition, the most aggressive speaker rather than the best idea often wins out and speakers are more concerned with defending their own ideas than carefully listening to their teammates. In the latter, while there is concern for others, a polite tone and equitable conversations, the conversations may be perceived as slow-moving and even unimportant, and this norm sometimes privileges feelings and emotions over constructive criticism of ideas. (p. 87)
The idea is to recognize that there are values and assumptions to each style first and in this recognition understand the others in the group. Then you have to learn to work with the others in the group.
So…if you identify yourself more with the “Competitive Norm”, what can you do to adopt a more considerate style? (Note, some of these strategies are from beyond Wolfe’s book.)
- Repeat back or restate ideas before disagreeing with them.
- Repair interruptions and other competitive behaviours with an apology (“Sorry, I didn’t mean to interrupt” or “I’m sorry—you were saying?”)
- Check in with the quieter speakers—often a job for a manager or chair of a group, but a person on the competitive norm spectrum could surprise everyone by doing this, asking, “Do you have any thoughts?”
- Pay attention to body language…pay attention to others.
- Listen. (LISTEN!) Write down good ideas. Affirm non-verbally.
- Write down questions or ideas you have, to save them for after the speaker has finished.
- Engage in uncritical brainstorming (all brainstorming is supposed to be non-judgemental but often people jump in with criticisms. Give a limited period for any ideas to be put forward with no judgement (say 10 minutes). Members can build on another’s ideas and ask questions but do no fault finding.
And if you identify with the “Considerate Norm, how can you adjust to a competitive conversation?
- Prevent or forestall interruptions by saying, “I’m not finished yet,” or “One minute please.”
- Speak within the first 5 minutes of a meeting, so people don’t ignore you or think you’re peripheral.
- Find gentle ways to interrupt in a competitive conversation. Humour, such as waving a hand wildly, or timing interruptions so they don’t seem rude may help. Say (when someone pauses for breath) “May I contribute here?” “Is now a good time to hear from others?”
- Ask the chair to institute a round robin (everyone goes around the circle and contributes a set amount of time) or raising of hands or perhaps using the Indigenous strategy of a Talking Stick.
- I like these respectful but firm reminders to someone who is holding the floor too long from Sharing the Floor: Some Strategies for Effective Group Facilitation https://www.uua.org/re/adults/group-facilitation
- “Excuse me, Francois, but I’m concerned about the time.”
- “I’m going to stop you there, Laila, because I’m concerned that we are moving off our focus.”
- “Francois, can you summarize your point in 25 words or less, because we need to move on.”
- “Laila, is this an issue we can put on the Unfinished Business list? We can’t address it now.”
I would like to propose some steps from Wolfe’s discussion, to adapt our communication styles to the needs of a group and a group task:
- Self Assess: and be honest about your style
- Analyze: What’s positive about your style? How might your style be perceived negatively?
- Resolve: Decide what you can do to ameliorate some of the less constructive aspects of your style, while still retaining some of the positives.
- Enact: Practice in a group setting. Practice until it becomes habit.
- Seek feedback: Ask others: Am I helping the group along? Am I listening more? Am I contributing more?
Well! Speaking of communication styles, I apologize. I’ve talked for too long: It’s your turn now 🙂
Do you think that this discussion about communication styles may be helpful to students? Perhaps helpful to your meetings (communication styles feature heavily in business literature about meetings)?
Let me know if you decide to use these strategies and steps. I’d really like to see them in action and there are more wonderful ideas in Wolfe’s book!
Queen’s UGME well-represented at CCME
Queen’s UGME was well-represented in the oral and poster presentations at the recent Canadian Conference on Medical Education (CCME) held in Winnipeg, MB.
Four oral presentations showcased UG work with another oral highlighting a teaching innovation in the QuARMS Program while a dozen posters featured Queen’s UG research and innovations featuring work by faculty, students, and staff.
As explained on the CCME website, “the purpose of the CCME is to highlight, and allow participants to benefit from, developments in medical education and to promote academic medicine by establishing an annual forum for medical educators and their many partners to meet and exchange ideas.”
The Queen’s oral presentations included:
- The Next SSTEP: The Surgical Skills and Technology Elective Program decreases cognitive load during suturing tasks in 2nd year medical students by Henry Ajzenberg, Peter Wang, Adam Mosa, Frances Dang, Tyson Savage, Peter Thin Vo, Justin Wang, Stephen Mann, Andrea Winthrop
- The Newborn Book – An evaluation of an interactive eBook as course material by Lauren Friedman, Jonathan Cluett, Bob Connelly
- Altering the scoring of global rating scales on an Undergraduate OSCE: Does it affect the identification of candidates with borderline performance? By Michelle Gibson, Eleni Katsoulas, Stefan Merchant, Andrea Winthrop
- Sampling Patient Experience to Assess Communication (SPEAC): A Targeted Needs Assessment by Adam Mosa, Andrea Winthrop, Sachin Pasricha, Eleni Katsoulas
- Fireside chats – High Impact Informal Learning by Jennifer MacKenzie, McMaster University, Theresa Nowlan-Suart, Anthony Sanfilippo
Posters, presented both during facilitated poster sessions and the new, dedicated poster session, included:
- An Inter-professional, Cross-cultural Service Learning Project: Development of a Nutrition Education Program in Rural Tanzanian Schools by Jenn Carpenter, Queen’s University, Donna Clarke-McMullen, Renee Berquist, Saint Lawrence College
- Pathways to community service learning: The Queen’s Service-Learning Framework by Lindsay Davidson and Theresa Nowlan Suart
- Introducing Medical Students to Stories of Indigenous Patients by Lindsay Davidson, Melanie Walker, Steven Tresierra, Jennifer McCall, Michael Green, Laura Maracle,
- Predictors of medical student engagement in an e-Portfolio for intrinsic CanMEDS roles by Steven Bae, Danielle LaPointe-McEwan, Sheila Pinchin, Anthony Sanfilippo, John Freeman, Queen’s University Ulemu Luhanga, Emory University Jennifer MacKenzie, McMaster University
- Evaluating the effectiveness of the First Patient Program’s use of resources in achieving learning objectives for medical students by Stephanie Chan, Vincent Wu, Sheila Pinchin, Phillip Wattam, Leslie Flynn
- Evaluation of a multi-modality nutrition program for first year medical students by Andrea Guerin, Theresa Nowlan Suart, Shannon Willmott, Karen Kaur Grewal
- Assessing the Effect of the Eye Matching System on Clinical Competency with the Ophthalmoscope in Medical Students by Etienne Benard-Seguin, Jason Kwok, Walter Liao, Stephanie Baxter
- Curriculum to Cookbook by Moncia Mullin, Meghan Bhatia, Renee Fitzpatrick, Shelia Pinchin
- The CFMS National Wellness Challenge: evaluating a new initiative to promote development of healthy habits in medical professionals by Alyssa Lip, Renee Fitzpatrick
- Ontario Medical Students Association Wellness Retreat: A Program Evaluation by Shannon Chun, Renée Fitzpatrick, Queen’s University, Christine Prudhoe, University of Ottawa
- Evaluating Student’s Perspective of Team-Based Learning In Undergraduate Medical Education by Kate Trebuss, Vincent Wu, Jordan Goodridge, Gemma Cramarossa, Lindsay Davidson
- Preclerkship Interprofessional Observerships: What I Know Now by Shannon Willmott, Ameir Makar, Etienne Benard-Seguin, Sarah Edgerley, Lindsay Davidson
Next year’s conference is set for April 28 – May 1 in Halifax, NS. The abstract submission portal is already open. Find it here.
The Value of Medical History
By Sallya Aleboyeh, MEDS 2019
A group of passionate and curious medical students chose to venture to Ottawa on the Family Day weekend this past February. Instead of visiting their families, they dove into history, with a group of equally-passionate curators and assistant legislators to Elizabeth May who also gave up time to give us private tours of:
- The Preservation Centre in Gatineau, which houses vaults filled with paintings, media and lots of important archives
- The Museum of Science and Technology’s Storage Facility (which is apparently cooler than the museum itself)
This year was the final time Dr. Jacklyn Duffin, Hannah Professor in the History of Medicine, organized the history of medicine trip, making the fate of future trips uncertain. So instead of telling you how cool everything was (hopefully the photos can show that), I thought I’d share the value I see in keeping the tradition alive.
1. Cool Architecture: The Role of design, décor and architecture in medicine
Arriving at our first stop, the Gatineau Preservation Centre, what stood out most was the architecture. The vaults were inside a huge cement box that looked like the set of a parkour film; while the top floor, where restoration was done, resembled a Lego village complete with primary colour paints and street names for corridors. Whether you cared about the science behind restoring artifacts or not, the design was very hard to ignore.
On a day-to-day basis, physicians not only interact with patients, but with their environment as well. While it’s not practical or financially viable to have an architect design each hospital as a unique piece of art, the impact of space is large enough to warrant investing some thought. There are already lots of examples of environment helping with patient or doctor experiences:
- Having windows in the ICU rooms to help with delirium
- Having paintings/magazines in waiting rooms to make wait times seem shorter
- Having healing gardens to reduce stress for patients and health care workers
- Having cartoon characters on walls in children’s hospitals
- Having the nursing station in the middle of a room, visible to all patients, to reduce anxiety
- Decorating your office with pictures of family to make working there more enjoyable.
(for more evidence of the importance of environment in health- check out this NYT article here!)
Obviously, during an emergency, it won’t matter how aesthetically pleasing the sheets or walls are, but the vast majority of hospital interactions with patients and among health care workers aren’t immediately urgent. In these instances, a little interior design can work its subtle magic on people’s mood and their interactions because we all (I think) appreciate pretty things. It’s why chefs create garnishes and why companies invest in packaging. In the long run these small effects can add up to increase overall wellbeing and happiness.
2. Studying History is humbling and reminds you that your actions might outlive you
If you’ve ever been to a really old place, you’ll know that you get a strange surreal feeling, like you are experiencing something bigger than yourself (hopefully it’s not just me). When I was 16 and my mom took me to the ruins of Persepolis (wiki: “the ceremonial capital of the Achaemenid Empire”) and I felt it for the first time while trying to imagine what it looked like thousands of years ago before Alexander attacked it. It reminds you at once of how insignificant you are and how capable you are of creating something that can last for generations after you are gone.
The profession of medicine can be demanding: long hours, bad news, on call shifts, high stake decisions and emotional fatigue to name but a few. It’s in these moments when remembering that you’re working towards something bigger helps. One day when we’ve all left this planet, curators, historians and medical students may look through the ultrasound machines, pacemakers and lounge room coffee machines we used and try to uncover the story of our daily lives. We can’t predict which of the thousands of items we see and use in our lifetime will survive as artifacts, but we can choose what kind of story they tell.
3. History is full of lessons and wisdom
Finally, most important of all is that history is an endless resource of wisdom and lessons. We constantly look to our tutors, teachers and mentors for guidance for medicine because it’s easily accessible; but why stop there?
From history you can learn to be creative, and to draw inspiration from new places. Over the course of the weekend, we saw multiple examples of technology from other industries being adapted to medicine.
- The cloth used to make sails being used as a backing for fragile paintings
- Ultrasound machines being used to detect aircraft defects and in the navy before being applied to medicine
- The Fibroscan for the liver coming from cheese manufacturing (I technically learnt this in class after the trip but it helps prove the point)
History’s mistakes teach us to not just accept what we’ve been told but to dig deeper and ask questions because things may not be what they seem. During our visit to the Storage room, the curator’s personal research on artifacts in the storage revealed that Sir William Osler – a great Canadian medical teacher – may have used the remains of aboriginal bodies for research purposes. Another inquiry led the curator to discover that models of babies with syphilis were used to promote eugenics and not medical education as previously believed. If we remain passive in our learning and acceptance of new information, it’s often the patient who will pay the price.
(In conclusion) I hope there will be many more history of medicine trips to come because there is still a lot that history can teach us (and lots of cities to be seen) before we begin our practices.
A version of this blog post appeared previously on the Medicine and Literature blog. Find it here. Thanks to Sallya Aleboyeh for her permission to repost it here.
Are you a constructive problem-solver or a destructive problem-solver? Some strategies for working in groups
Here at Queen’s UGME, we use small group learning a great deal—from our prosections to PBL-based Facilitated Small Group Learning, to our TBL-based Small Group Learning.
One very important aspect of group learning is preparing students to work successfully in teams. We do this in our first sessions in Orientation Week and in our new course, Introduction to Physician Roles.
In my quest to support our faculty in promoting successful group learning, I recently came across a jewel and I thought I’d share it with you.
The jewel is actually a whole book: Team writing: A guide to working in groups by Joanna Wolfe (2010, Bedford/St. Martin’s). I started with my usual dipping into sections and found myself reading cover to cover because of the concise, sensible and evocative ideas.
The concept I wanted to talk to you about today is what Wolfe terms Constructive and Destructive Conflicts.
Our students have lots of experience negotiating in groups (Think of all those high school groups! And case work in Commerce and projects in Engineering! And Lab partners!) and in making sure their groups work well. But research tells us that conflict in groups is a very challenging part of arriving at a successful outcome. Teams that deal with conflict by competing or trying to avoid the conflict are likely to suffer. One main aspect of conflict is not to prematurely close a discussion because of conflict but to make sure it’s healthy.
I think Joanna Wolfe’s ideas would further help students solve problems themselves, by deciding if they are constructive or destructive in a conflict situation.
The term constructive conflict was coined to stress the productive role that healthy conflict can play in problem-solving. Constructive conflict occurs when two people share the same goal but hold different ideas about how to achieve that goal. (Wolfe p. 52)
This type of conflict is good especially when there is productive debate of merits and drawbacks of ideas in pursuit of the best solution to a problems. But not all conflict aids learning. Destructive conflict occurs when there is intransigence, mockery or ridicule, personal affronts, and emotional defensiveness. (Wolfe, p. 53)
Here are the differences between Constructive Conflict and Destructive Conflict as recorded by Wolfe. Can you see aspects of yourself in the Destructive Conflict? in Constructive Conflict?
If you find you are in destructive conflict mode, here are some strategies Wolfe recommends (italics mine):
- Clarify roles and responsibilities up front in a task schedule.
- Lay ground rules for conversation
- Set aside time for uncritical brainstorming
- Get input from everyone in the group including the introverts who may need more time
- Restate ideas (to help with listening)
- Don’t interrupt or if you do, apologize, write down your idea, listen, and wait
- Set time limits for discussion of certain items before moving to an action proposal
- Establish team priorities in a project plan or team charter
I found a few other helpful ideas from GOE, a group which has worked with NASA on simulation of small groups for space missions.
- When a team members offers a dissenting point of view, thank her/him for speaking up (to encourage others to speak up).
- Easiest way to kill psychological safety? Punish someone for voicing a dissenting opinion.
- When two team members have an interpersonal conflict, it should typically be handled in private perhaps with a neutral mediator.
- Conflicts sometimes emerge because small concerns go unchecked. Talk with your team to bring irritants to the surface before they become bigger problems.
- Be constructive when you disagree with a team member (to model how to disagree effectively).
- Admit your own concerns or mistakes (so other team members become comfortable voicing theirs).
And here’s one I use: Think of a role model who handles conflict well, and channel their behaviour or even their words.
I haven’t even touched on the communication styles Wolfe identifies (Competitive vs Highly Considerate, Self-promotional vs Self-deprecating, and Action-Oriented vs. Holistic problem-solving styles) in Chapter 7. But this will give you a good taste of self-analysis and strategies to assist in moving the team forward.
Stay tuned in a later blog article for Jewel 2 for small group learning: What are good roles a small group learner can adopt? A small group facilitator can adopt?
In the meantime, what do you feel can aid in preventing destructive conflict in a group? And enhance constructive conflict?
When your objective is to write learning objectives…
Several times over the last few weeks, I’ve had conversations with course directors and instructors about writing learning objectives.
Many people – from award-winning educators to rookies and everyone in between – find writing learning objectives a challenge. The typical advice of write out who will do what under what conditions is vague, so it’s often not very helpful.
“General” learning objectives – from our UGME Competency Framework, aka the Red Book* – are already assigned to your course, and possibly to your session by your course director.
The key task for instructors is to take these general objectives and annotate them with specific objectives for their sessions, including what level of learning, such as comprehension, application or analysis. (This is from something called “Bloom’s Taxonomy”, if you’re interested in the research behind this).
A natural starting point is: What do you want your learners to take away from your session?
Frequently the response is:
- “I want them to know….”
- “I want them to understand….”
- “I want them to be able to…”
Once you’ve wrestled something like this into sentences, I realize it’s disheartening to have someone like me come along and say, “Uh, no, that’s not up to scratch.”
What’s wrong with “know” and “understand”? Isn’t that exactly what we’d like our students to walk away with – knowledge, understanding, skills? Absolutely. The challenge with these so-called “bad objective verbs” is that we can’t measure them through assessment. How do we know they know?
That’s the starting point for writing a better learning objective. If you want to assess that students know something, how will you assess that?
For example, while we can’t readily assess if a learner “understands” a concept, we can assess whether they can “define”, “describe”, “analyze”, or “summarize” material.
Here’s my “secret” that I use all the time to write learning objectives – I can’t memorize anything to save my life, so I rely on what I informally call my Verb Cheat Sheet. The one I’ve used for many years was published by Washington Hospital Centre, Office of Continuing Medical Education. It list cognitive domains (levels) and suggests verbs for each one. There are many such lists available on the Internet if you search “learning objectives” (here’s another one that’s more colourful than my basic chart, below).
Well-written learning objectives can help learners focus on what material they need to learn and what level of mastery is expected. Well-written objectives can assist instructors in creating assessment questions by reminding you of the skills you want students to demonstrate.
Here’s my quick three step method to annotating your assigned objectives on your MEdTech Learning Event page with your learning-event specific objectives:
- Start with writing your know or understand statements: what do you want learners to know or understand after your session?
- Think about what level of understanding you want students to demonstrate and how you would measure that (scan the verb chart for ideas)
- Write a declarative sentence of your expectation of students’ abilities following your session. In your draft, start it off with “The learner will”. For example: The learner will identify the bones of the hand on a reference diagram. Your objective would be: “Identify the bones of the hand on a reference diagram.”
As a fourth step, feel free to email your draft objectives to me at email@example.com for review and assistance (if needed). I’m happy to help.
Table excerpted from Washington Hospital Center, Office of Continuing Medical Education’s “Behavioral Verbs for Writing Objectives in the Cognitive, Affective and Psychomotor Domains” (no date).
* The “Red Book” got its name because for the first edition (we’re now on the fourth), the card stock used for the cover was red. Over time, everyone started calling it the “Red Book”.