The Troublesome Ethics of Entrepreneurship in Medical School Admissions
Medical school applications are becoming big business, and a rather troubling expression of supply and demand economics.
The “demand” side consists of the many thousands of young people in North America engaged in the highly competitive process of applying to the limited number of seats available at publicly subsidized Canadian and American schools. Rebecca Jozsa, our intrepid Admissions Officer and I recently explored the “supply” side by carrying out a simple Google search of options available to the assist the aspiring medical school applicant.
For MCAT preparation, we found no fewer than 22 available courses (probably an underestimate). The “MCAT Ultimate LiveOnline 123-hour” experience is offered multiple times per year for $2,199US. For those who prefer more intense and more personal preparations, the “MCAT Summer Immersion” experience can be had for $9,499US, not counting, of course transportation and accommodation. The “Most Comprehensive Prep Course in Canada” runs over 10 weeks, costs $2,195, comes with testimonials from satisfied customers and features both instruction by successful students and “unlimited free repeat policy”. There are many other choices, a veritable smorgasbord of choices.
One can also opt for more comprehensive guidance through the entire application process. One group provides the following offering: “With our flagship service, we offer unparalleled quality that will make your application to medical school stand out”. In addition to “MCAT prep”, clients can opt for any or all of “Online Diagnostic”, “Comprehensive Application Planning”, “Application Review”, “CASPer prep”, “Interview Crash Course”, “Interview Preparation”, and “MMI prep”. Costs, understandably, vary based on individual preference and perceived need, but appear to range from a few hundred dollars for individual components to more comprehensive packages such as the Platinum bundle which goes for $3500US. It’s hard to get all the details as to what’s available without engaging one of the friendly “consultants” for a “personalized needs analysis” (which we declined) but the sky appears to be the limit in terms of costs. Some arrangements even come with money-back guarantees!
It’s clear from the advertising that many of these programs employ, or are even operated by, medical students or recent grads. Who, after all, would be in a better position to provide the “inside information” so essential to success?
So, is all this a problem?
On the one hand, all this is perfectly legal free enterprise. It’s addressing a perceived need, clients are fully informed and fully competent, no one is forced to engage these processes unwillingly. It could be argued that these programs allow very worthy and genuinely motivated young people to pursue their dreams and overcome many of the unintentional barriers that we all would acknowledge are inherent in the admissions system. One could argue that medical schools themselves have given rise to these business opportunities by making the MCAT such an integral component of the admission process, while at the same time dropping basic science prerequisites.
On the other hand, one must also acknowledge a number of potential concerns:
- The widespread availability of these services may force students to participate to simply not be disadvantaged relative to other applicants. It’s no understatement to say that candidates feel desperate for any advantage in the process. That desperation, it could be argued, is being exploited.
- This intensive preparation and rehearsing for the various application processes may result in candidates portraying themselves in an unrealistic fashion, thus subverting a process fundamentally intended to ensure applicants are appropriately suited to a career in medicine. Such “mismatches” can be disservice to all, including the applicant themselves.
- These services are obviously expensive, adding a further socioeconomic barrier to medical education, a problem widely acknowledged in both Canada and the United States.
- The involvement of medical students, as paid consultants or instructors is troubling. Their recent experience with the details of application processes, including the structured interviews (for which most schools require them to sign a non-disclosure agreement) makes them attractive for this role, but also sets up an ethical dilemma: Can they undertake to help applicants navigate their interviews without sharing information or insights they have acquired as a result of their own experience? Even if specifics are not explicitly divulged, it’s hard to imagine that their recent intimate involvement in the process won’t find its way into their “counseling”.
All this provides lessons and demands reflection on a number of levels.
For the aspiring applicant, perhaps a word of caution. The principle of “caveat emptor” (let the buyer beware) very much applies. There is no accreditation or credentialing process for these offerings. Applicants may not be getting valid advice. I’ve heard anecdotally from students who have been advised to avoid expressing any personal opinions and instead memorize and regurgitate the prepared responses to anticipated questions. Admission committees and interviewers, searching for sincerity and deep commitment to a career in medicine, are astute assessors and have become very attuned to the “coached” candidate. They will become even more vigilant. The sincerity and true commitment they’re looking for tends to stand out, and is very difficult to artificially manufacture.
This entrepreneurial phenomenon should also cause medical admissions committees to reflect on their processes. One has to question the validity of the MCAT as an assessment of scientific aptitude if an “immersion experience” is truly effective in influencing test results. Do we believe a background or interest in basic science is an important applicant characteristic? If so, do we feel successfully undertaking an MCAT prep course meets that criterion?
For medical students, entering a profession that is self-regulatory and rightfully expects high levels of personal integrity and accountability, opportunities to become involved in these programs pose perhaps their first personal ethical dilemma. Clearly, what makes them attractive to these agencies is not their personal counseling or teaching skills, but rather their status as successful medical school applicants, which brings considerable cachet and intimate knowledge which is of high value. They will find (as they will as practicing physicians) that their professional identity can’t be easily separated from their personal lives, and therefore puts them in an ethically ambiguous position.
In our society, it seems supply will always be found when demand exists and sufficient resources are made available. That this has extended to the medical school admission process should come as no surprise. However, it does raise some unintended, but nonetheless concerning consequences. As always, your views on this issue are most welcome.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Year in Review? Why wait until then?
When I worked as a journalist (about a million years ago), an annual task was writing “Year in Review” articles. These were summary or “round up” stories with the highlights of the previous year.
The stated intent was historical record, reminders and reminiscing; marking highs and lows, significant events and momentous occasions. On a more practical level, these stories could be compiled fairly easily, mostly in advance, and take up copious column inches in our weekly paper in the week between Christmas and New Year’s when nobody was reading anyway and the editorial staff wanted to take extra time off from covering newer news. Closely tied to these were “Resolutions You Should Make Now!” advice columns.
With this cultural backdrop assigning retrospection to the turn of the year, it’s easy to become cynical about such things—and reduce thoughtful review to top-ten lists and cliché-ridden commentary. For educators, however, the importance of review should not be treated so lightly. Review and reflection are important. We expect our learners to do it. Educators should give it just as much attention.
Review and reflection are integral to effective teaching practice. January is a great time for this, but so is June, or September, or some other month. Right now, for some, a semester has recently ended, for others, it’s just beginning. There are benefits to both retroactive and proactive review – and in doing it more frequently than an annual check-mark on a to-do list.
So, instead of a ‘year in review’ summary, or even a list of new year’s resolutions for medical education, here’s a sample framework for incorporating review into your teaching practice. (Use it annually, or more often, as needed).
Theresa’s Five Step Review and Revise Process
Step 1: Review & Reflect
Whether you’re considering a whole course, a few teaching sessions, or a single seminar or other learning event the process is the same. Consider:
- What happened? What worked? What didn’t? (If you’re forecasting: What could be some pitfalls? What am I worried about?)
- For anything that didn’t go well, or didn’t accomplish what I planned: How can I fix it? (Forecasting: Do I have a back-up plan? Do I need one?)
- What’s a manageable change? Do I have the knowledge, skills and ability to do this? Where can I get support and/or resources? (Forecasting: Do I have the resources I need? What kind of feedback could be helpful to me on my teaching sessions?)
Step 2: Reconsider
Once you’ve reflected on what’s happened, or what you have planned, consider:
- Did I meet my objectives (or will my plan meet my objectives)?
- Are there things I did (or I’m planning) that are just out of habit?
- What should I change to make my course/session/seminar more engaging/relevant/appropriate?
Step 3: Find Resources
When you revise your teaching plans, you may also need additional resources. This could be in the form of your own skills, materials, input from colleagues. Consider:
- What support do I need to get to where I’d like to be?
- Do I have the abilities to do what I plan? If not, how could I acquire the necessary skills?
- Are there existing materials that could help me? Do I need to develop new materials? Who could help with that?
- Who could I call on for support or assistance?
- What sort of time frame do I have?
Step 4: Refine your plan
Sometimes, what we’d like to do just isn’t in the cards this year—there can be a lot of constraints on our teaching in time, materials, scheduling. It’s important to refine revisions into things that are manageable and realistic. Sometimes you are in a position to make large-scale changes to how you deliver your learning events, other times, not. Avoid the “all-or-nothing” plan: Incremental changes are better than no changes. It’s better to be good, than to be perfect. Consider:
- How realistic is my plan?
- Are there things I consider “must haves” and things that are “nice to haves”?
- If I could only make one change in my teaching right now, what would it be?
Step 5: Reflect & Review
At the end (or the beginning) – take another look. Good teaching really is an iterative process with the cycle of review, revision, redeliver.
Sometimes the best way to review and reflect (and plan) is to talk it out with a colleague. Bouncing around ideas can bring new perspectives and inspire you and others to add to your teaching toolbox. If you’d like to chat about your teaching any time, get in touch with the Education Team.
Socrates, “pimping” and teaching in medical education
Recently, one of the words in the title of an article in Academic Medicine really caught my eye: “Socrates Was Not a Pimp: Changing the Paradigm of Questioning” by Dr. Amanda Kost and Dr. Frederick M. Chen. (Kost & Chen, 2015)
Of course, the word that caught my eye was “Socrates,” he of sitting with students under an olive tree fame
Much of the scant information we have about Socrates is from his students, Plato and Xenophan. Plato portrayed Socrates as an excellent teacher and questioner, in the Dialogues, where a series of questions is asked not only to draw out individual answers, but also to encourage fundamental insight into the issue at hand.
Can it be, Ischomachus, that asking questions is teaching? I am just beginning to see what is behind all your questions. You lead me on by means of things I know, point to things that resemble them, and persuade me that I know things that I thought I had no knowledge of.
Of course, I can’t deny that another word caught my eye in the title: It’s not always that you see the word “pimp” in a medical education journal.
However, it’s a common term in medical education, since 1989 at least, where Brancati used it to refer to a questioning method that is supposedly Socratic but is defined as “whenever an attending poses a series of very difficult questions to an intern or a student.” (Brancanti, 1989) He suggests questions “should come in rapid succession and be essentially unanswerable.” There are other definitions, and the “not a pimp” authors Drs. Kost and Chen, write that in these definitions the purpose of the practice is to reinforce the power hierarchy of the team and, more specifically, the attending physician’s place at the top. (Kost and Chen, p. 21)
In a 2005 study, by Wear et al. fourth year medical students were questioned about the practice of this form of questioning:
Students divided pimping into “good” and “malignant” categories. “Good pimping” actions included questioning that advanced or enhanced the learning process and also encouraged students to be proactive about their learning…“Malignant pimping” frequently employed techniques designed to humiliate the learner. All students in this study identified humiliation as an outcome of any type of pimping—even good pimping had a component of shame because of the public embarrassment of not knowing the answer. (Wear, et al, 2005 cited in Kost & Chen)
I’d like to discuss “pimping” both from a syntactical and a pedagogical perspective.
I was trained as a language educator to acknowledge that language has a very pronounced impact on constructs in our thinking. I have to admit that I don’t get the use of the term. The other definition of pimp: a person, especially a man, who solicits customers for a prostitute or a brothel, usually in return for a share of the earnings; pander; procurer (Online Dictionary and Merriam-Webster Dictionary) seems to have very little to do with questioning, whether benign, or malignant.
“Pimping” then… you know, that’s the last time I’m going to use the word! I dislike the relationship it implies that could so easily settle into the hindbrains of all us who have been using it. With your permission, I’m going to try “hounding” instead. Drs. Kost and Chen agree with me: “This word may evoke a negative affective response, and we would also argue that the use of such a derogatory term to describe an experience in medical education is unprofessional.”
Because, you see, questioning is one thing, and is an excellent and powerful educational tool. However, when does questioning move into “hounding”? It happens when the questioner is pursuing a different goal than a pedagogical one: perhaps humiliation(“She needs to know this stuff”), or going way beyond the knowledge of the level of the learner (“Shouldn’t clerks know this, or is it residents? Fellows?”) or venting frustration and anger (“You guys think you’re so smart? Well, let’s see…). They include the well-known “Read my mind” type of question, and the question that is so obscure that very few know the answer (except perhaps the questioner?).
In the Wear study, students felt questioning “was useful to “promote learning, logical thinking, defending one’s decisions, quick recall, self-assessment, and communicating well with one’s peers.” They didn’t like the hounding part of it, and wanted to use volunteering answers as an alternate to centering someone out and hounding them. (I know, I know…this can be an important part of questioning…I hear you and I’ll come back to this.)
So, let’s get back to Socrates. The Socratic questioning method is used often today, tho’ it appears it can be misunderstood. In a recent vehement and lively DR-ED listserve discussion, the Socratic method was linked heavily with “hounding” by one participant.
Socrates used the dialectic method of teaching, whereby he assumed the role of someone who knew nothing about a topic, and drew the students’ ideas out, through a series of questions, each one probing more in depth or looking at different options. (Fun fact: Did you know that the word “education” comes from the Latin ex ducere (to lead or draw out?)
Since Socrates was mainly concerned with students uncovering their own beliefs, and the validity of those beliefs, the correction of misconceptions and reliable knowledge construction all around large concepts such as truth and justice, modern teachers have created a sort of system for modern Socratic questioning of all types of learning. Here are some of the characteristics:
1. Students are questioned in a group, and in modern times, others in the group can collaborate with each other to find answers. But not always…Socrates challenged his listeners and students. And he picked them out, as well as had them volunteer. But learners could help each other. You’ll see in this sculpture, Socrates teaching in the Agora, by Henry Bates, below how avidly everyone listens to each other.
2. Socrates believed questioning would motivate learners and help them to the joy of learning. Thus, questioners should create a safe and comfortable context for questioning, where wrong answers are simply a signpost to heading down another path of learning. In other words, they wouldn’t mind being centred out because they were enjoying learning.
3. Use of by “why”, “what if” “how”, “then, if…” or open-ended questions vs. closed ended questions such as “What is this object?” “What is 1+1?” (Perhaps we can start with close-ended questions especially for novice learners, but they shouldn’t be the end goal of the questions.)
3. Socratic questions must be: 1) Interesting, 2) Incremental, 3) Logical (moving from the student’s prior knowledge towards a goal), and 4) Designed to illuminate particular points.
4. Questions should be well-planned with a goal of benefiting the student at his/her learning level in mind. Sometimes you have to start factually, but there should be progression toward critical thinking.
Let’s summarize, and then I’m going to prepare for you to write in to tell me what you think about “hounding” and questioning:
1. Let’s not use that word again…it’s really ugly semantically.
2. Hounding is not questioning. Hounding is hounding and it’s not supported pedagogically. Questioning is an excellent way to teach. It doesn’t have to be sweet, nor does it have to be easy. It has to be respectful and with the appropriate underlying purposes.
3. If we’re going to claim that “hounding” is Socratic, or even our questioning strategies are Socratic, let’s start using Socrates’ methods more. Let’s aim for critical thinking questions, one of Socrates’ key purposes in questioning.
4. Let’s focus on our learners and tailor questions to their learning level.
5. Let’s create a climate where questioning is accepted and even welcomed. Let’s give our learners appropriate language to acknowledge they haven’t prepared, or are at the limits of their abilities thus far and need assistance.
In my next column (look for it in January 2016), I’ll provide more suggestions—based on Socratic principles—for keeping Questioning productive.
So, what do you think? Are you a Socratic questioner? Do you think hounding has a purpose? Are there aspects of your teaching and questioning that can be enhanced through Socrates?
Looking forward to hearing from you about this.
And it’s not a smooth segue, but while I’m here with you, I’d like to take this opportunity to wish you all the best of the season!
And here’s to great teaching in 2016!
Brancati FL. (1989). The art of pimping. JAMA. 262:89–90.
Dictionary.com http://dictionary.reference.com/browse/pimp and Merriam-Webster Dictionary http://www.merriam-webster.com/dictionary/pimp
Kost, A.& Chen, F.E. (2015). Socrates was not a pimp: Changing the paradigm of questioning in medical education. Academic Medicine, 90: 1.
Wear D, Kokinova M, Keck-McNulty C, Aultman J. (2005). Pimping: perspectives of 4th year medical students. Teach Learn Med. 17:184–191.
It’s time to re-invent the Clinical Clerkship
The need to provide supervised learning within the clinical setting has always been regarded as essential to the development of future physicians. Indeed, early versions of medical education consisted entirely of what could only be termed apprenticeships under the direction of a fully- qualified physician who was engaged by the student as the tutor, mentor and assessor. It was largely as a result of Abraham Flexner’s (pictured) transformational 1911 review of medical education in North America that medical schools were required to provide formal instruction in the basic and medical sciences. However, Flexner continued to emphasize the critical role of learning with the clinical setting. This became consolidated into the discrete role that came to be known as the Clinical Clerkship.
Being a “Clerk” was to have a job or role within a hospital’s complex system of service delivery. The role consisted of “clerking” patients (carrying out admission histories and physicals), following the progress of patients through their hospital stay, arranging and following up on investigations, and coordinating discharge and post hospitalization follow-up. In addition, Clerks had unofficial but widely accepted service delivery roles of their own within hospitals, including phlebotomy, administering intravenous medications, performing simple procedures such as Foley catheter insertion, cast removal, simple suturing and recording electrocardiograms. Appropriately supervised and monitored, this role provided opportunities to engage patient care in all its complexity in a transitional fashion, leading eventually to more independent practice after graduation. The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today. Importantly, the role of the Clerk varied very little between services, specialties and differing patient populations, the goal being to develop strong foundational skills in patient assessment and management, which were felt to be consistent and “learnable” within any patient care context.
In short, being a Clinical Clerk was a job. Clerks had a widely understood and (dare we say) useful role within the hospital. As a Clinical Clerk, a medical student felt part of the service delivery because they were making a tangible contribution. They therefore felt, and were, valued.
Many factors have combined to, gradually and without deliberate intention, dramatically alter the role:
- The service components came to be recognized as excessive and non-educational, to the point of diminishing true educational opportunities. Accreditation standards confirm and reinforce this perspective.
- Our hospitals have become much more focused on efficient, focused, therapeutic management of patients with complex and critical diseases. Diagnostic processes, so important to the Clerkship learning experience, have largely shifted to the outpatient setting.
- Career selection and the CaRMS application process have become a major focus for our students, making multiple, shorter service assignments preferable to the longer, continuing assignments that allowed the Clerk to develop a clear role within service teams.
- Hospitals are much more regulated environments that require clear definitions of roles and scope of practice for all providing care.
Although these issues are all valid, one must now ask what price we’ve paid for this evolution. A few questions come quickly to mind, and are being asked by our students, faculty and hospital personnel on a daily basis :
- What aspects of patient charting are Clerks expected to provide?
- To what extent are Clerks empowered to write patient orders?
- What diagnostic tests are Clerks empowered to order?
- Is a Clerk permitted to submit a consultation request or requisition for an invasive investigation?
- What medications can a Clerk prescribe, if any?
- What procedures are Clerks expected to provide?
- Can a Clerk obtain informed consent for procedures? If so, what procedures?
- To what extent should a Clerk be expected to provide care for a patient in an emergency (arrest) situation?
- In all these issues, what degree of supervision is required, and by whom?
Clearly, the application of all these aspects of service provision will vary between clinical assignments, but their fundamental nature (or, to use hospital terminology “scope of practice”) should be consistent throughout. It should not be necessary to re-define the Clerk role for every rotation.
Our Hospital Liaison Committee, capably chaired by Christopher Gillies with representation from all teaching hospitals, faculty, administration and students, has recently been considering solutions to the Learning Environment concerns described in previous articles (meds.queensu.ca/blog/undergraduate/?p=2026). They recognized that many of these concerns may have their roots in this lack of clarity regarding the Clerk role and have therefore advocated a redefinition of the role. To this end, our Clerkship Committee (Chaired by Andrea Winthrop and consisting of all Clerkship Course Directors) met this past week to re-define the role or “job” of the Clinical Clerk, recognizing our current educational requirements and current reality of the hospital based learning environment. They have already made excellent progress in addressing the various issues listed above.
To short, our senior medical students (Clinical Clerks) are able to make valuable contributions to patient care in the hospital environment. It is in doing so that they truly grow as physicians. That can only happen with a clearly articulated and widely accepted role description, appropriate to the modern hospital environment, developed jointly by medical education and hospital leadership.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Students compete in 7th Annual Health Care Team Challenge
Three interprofessional teams of students faced off on Monday, November 16 in the 7th Annual Queen’s Health Care Team Challenge.
The teams tackled a case developed by the Health Service Centre team at Canadian Forces Base Kingston. Each team had students from Nursing, Medicine, Occupational Therapy, Physical Therapy and Psychology.
The five-member judging panel included two local clinicians who developed the case, along with faculty, student and patient representatives.
The teams had been preparing for the competition since October 16.
The winners were “Team Three”, which included: Ahyoung Cho, Nursing; Wilson Lam, Medicine; Heather Shepherd, Occupational Therapy; Kayla Hertendy, Physical Therapy; Stephanie Gauvin, Psychology; Additional Team member: Elishea Mardling, Occupational Therapy; Back-up member: Verdah Bismah, Medicine; Faculty mentor: Lynne Harwood-Lunn, MN, RN, School of Nursing.
The two other teams were: Team One: Kyrinne Lockhart, Nursing; Alex Trajkovski, Medicine; Allie Rogers, Occupational Therapy; Heather Greene, Physical Therapy; Melissa Milanovic, Psychology; Additional Team member: Richa Kukkar, Physical Therapy; Back-up member: Shikha Kuthiala, Medicine; Faculty mentor: Brent Wolfrom, MD, School of Medicine. And Team Two: Charlotte Wilson, Nursing; Stephanie Piper, Medicine; Joshua Lee, Occupational Therapy; Erin Makins, Physical Therapy; Robyn Jackowich, Psychology; Additional Team member: Claudia Romkey, Nursing; Back-up member: Greg Smith, Physical Therapy; Faculty mentor: Heidi Cramm, PhD, OT, School of Rehabilitation Therapy.
Co-moderator Anne O’Riordan noted that all three teams’ presentations were exceptional, each presenting the case in a unique way which made for an educational evening for all. Co-moderator Ralph Yeung was a member of the very first Queen’s team in 2009.
The Health Care Team ChallengeTM is an interprofessional education event, originally developed at the University of British Columbia in the 1980s. Students volunteer to participate in order to enhance and practice their collaborative team skills. Each student interprofessional (IP) team is provided with the same case to work on for a period of three weeks, with the goal of developing a collaborative, interprofessional person-centered plan of care. A faculty mentor is matched with each team for consultation and advice.
The Queen’s Health Care Team Challenge is jointly sponsored by the Faculty of Health Sciences’ Office of Interprofessional Education and Practice (OIPEP) and the Queen’s Health Interprofessionals Student Society (QHIP).
Team Three (soon to be renamed the Queen’s Team) will compete in the National Health Care Team Challenge™ in March 2016, hosted this year by Dalhousie University.
“Major Marlene Lefebvre was instrumental in connecting the health services team at the base with OIPEP, after initial email connections made by Alice Aiken,” O’Riordan said. “It really took a ‘health care community’ to do develop, organize, and implement this event and the learning was apparent for everyone.”
Here’s the beginning of the case the teams had to address:
You are a medical officer (MO, i.e. a military physician) in the health care team in Care Delivery Unit (CDU) 2 at 33 CFH Svcs C in Kingston, Ontario. The Base Surgeon (BSurg) informed the team yesterday the she was talking to the task force surgeon in Afghanistan and that an injured female service member would be arriving at the clinic this morning for an assessment. It will be sometime mid-morning before she arrives, hot off a CC-117 Globemaster transport aircraft landing in CFB Trenton at around 0730.
You don’t know much about the case other than that she is a 25 y.o. captain logistics officer who was injured two days previously in Cyprus, where she was undergoing a decompression stop after finishing her tour in theatre in Afghanistan. You note that she is a member of the Canadian Forces Joint Operations Support Group (CFJOSG) based at Canadian Forces Base (CFB) Kingston, and you remember that members of the unit were attached to a provincial reconstruction team (PRT). She is ambulatory as far as you know…
Credit where it’s due:
It takes a lot of effort from a great many people to pull an event like this together. In addition to the teams, here are the folks who made it happen:
Health Services, Canadian Forces Base Kingston
CFB Kingston Liaison:
Major Marlene Lefebvre
Anne O’Riordan, OIPEP Clinical Educator, QHIP Advisor (OT)
Ralph Yeung, HCTC winner, 2009; IP Award of Leadership, 2013 (X-Ray Tech)
Welcoming Keynote Address:
Dr. Alice Aiken, Director, Canadian Institute for Military and Veteran Health Research, Queen’s University, Royal Military College, Kingston. (PT)
Dr. Lucie Pelland (SRT) – Faculty Representative (PT)
L.Cdr. Bradley Stewart, Clinical Rep. (Medicine)
Capt. Dwayne Rennick, Clinical Rep. (Social Work)
Amanda Shamblaw, Student Rep., QHIP Exec., Past HCTC participant (Psychology)
Dr. Peter Dunnett, Community/Patient Rep. (Economics Professor, ret., RMC)
Chloe Hudson, QHIP Executive Member, Past HCTC winner (Psych)
Presentation of Team Certificates & Team Photos:
OIPEP & QHIP
Presentation to Winning Team:
Dr. Rosemary Brander, OIPEP Director (PT)
Why I can’t build an addition and the fall filing cabinet
This fall, I’ve been cleaning out closets and filing cabinets and purging, as they say on Houzz. I didn’t want to—I hoard my teaching materials as if they were gold. But, my husband said, “If you don’t get rid of some of this stuff, we’ll have to build an addition onto the house.”
I don’t quite know why that’s a bad thing…:) Teachers are packrats—you never know when you’re going to need something again to help students and other teachers.
However, apparently we can’t build an addition just for more filing cabinets. So, I’ve started cleaning out my notes on teaching from…well… I started teaching in 1980…
I’ve rediscovered some wonderful things, and I thought I’d share some with you. Here are a few from my filing cabinets:
- First of all for our students (and anyone else who reads): I found this poem by the late great poet Maya Angelou which actually a student drew to my attention years ago (a shout-out to Jessica Chiu formerly at OCA!). It’s about reading, and if there’s anything I know about UG medicine, it’s about the amount of reading you have to do. I hope you find lots of ideas sticking to your mind.
Popcorn leaps, popping from the floor
of a hot black skillet
and into my mouth.
Black words leap,
snapping from the white
page. Rushing into my eyes. Sliding
into my brain which gobbles them
the way my tongue and teeth
chomp the buttered popcorn.
When I have stopped reading,
ideas from the words stay stuck
in my mind, like the sweet
smell of butter perfuming my
fingers long after the popcorn
I love the book and the look of words
the weight of ideas that popped into my mind.
I love the tracks
of new thinking in my mind.
- More for students…and teachers using small group learning: Roles to Assist in Group Learning
Many medical students have told me about their horror stories of group work, either in high school or university. And it’s true…sometimes teachers throw students into groups without advice or support to work things out. Sometimes one student dominates the group; others are couch potatoes and hitch-hikers. Some block consensus, some goof around and still others withdraw. Bearing in mind our adult learners in medical school, and also the concept of self-directed learning, here are 20 (!) roles which students can adopt in groups. So even if a student is an introvert (see the book Quiet: The Power of Introverts in a World That Can’t Stop Talking), he or she will find some useful roles below. Teachers, you can encourage students by helping them see these roles in their work. (Thanks to my old bosses, Gray Cavenaugh and Ken Styles at the Ontario Ministry of Education. I’d forgotten how good you were!)
Students, practice putting yourself in each of these roles, think of others in the group, and begin developing your group leadership strengths. Teachers, when I used these with students in the past, I asked them to read them over and put a star beside the ones they do, and an exclamation point for a few they’d like to try.
Teachers, do you recall hearing that students learn best with this saying: Tell me; show me; let me try?
It’s actually the first thing I heard about (that I remember) when I hit Teacher’s College all those years ago. Here’s how I translate it into Medical Education:
|What it means||In medical school|
|Tell me: lecture or telling—even assigning reading especially with guides. Learners say, Get me oriented, motivated and let me absorb facts and concepts.||Provide students with facts, characteristics, vocabulary, symptoms, etc. through (mini-) lectures, or readings with questions attached, about medical conditions, systems, and approaches. Our RATs, or quizzes help students process what they’ve been told.|
|Show me: Learners say, Demonstrate how this works so I can see it in action. Give me examples of how it works!||Show students through written or verbal examples–cases you have encountered on how to recognize patterns, how to differentiate among diverse conditions, etc. Video clips and demonstrations are also really useful! A summary of your key findings and learning and the strategy of Think-Aloud (just what it sounds like) from the cases is useful for students to follow your thought processes. Don’t forget to tell them what you ruled in, and what you ruled out and why.|
|Let me try. Learners say, Give me a chance to apply the learning to see if I can do it myself, or if make it work in different situations.||· Provide students with written or verbal cases through which to work, often with a partner or in a group, so that they can learn how to apply the facts and examples you have given them.
· Change up the circumstances: paediatric or geriatric patient; chronic conditions vs. acute conditions, co-morbidities, different presentations or similar presentations with different associated conditions, different points in the illness journey.
· Put students in a simulated learning environment—such as with standardized patients.
· In clerkship, under supervision, allow clerks to apply their learning to patient care.
Key here is to find out if the students have learned through their application (mid-terms, graded team assignments, individual assignments) and observe them in practice (MiniPEx, MiniCEx, field notes, etc.).
So three tips from the files. I found a few more 🙂 Stay tuned…
Have a great fall! I’m looking forward to continuing the dialogue about teaching and learning.
We write these blog articles with ideas, thoughts and strategies, usually for teachers, but often for students too.
We’re always interested in your thoughts, so please feel free to respond.
What’s in your filing cabinet?
Using Copyrighted Images in an Educational Setting: A Primer
By Mark Swartz, Copyright Specialist
Understanding a few of the basic concepts behind Copyright law can help explain why some images can be used in certain situations and others cannot. The most useful concept to consider when thinking about how images can be used is balance.
A Balancing Act
In the landmark Supreme Court case Théberge v Galerie d’Art du Petit Champlain Inc, Justice Ian Binnie characterizes Copyright Law with the following statement:
The Copyright Act is usually presented as a balance between promoting the public interest in the encouragement and dissemination of works of the arts and intellect and obtaining a just reward for the creator.
When you create a work, whether it is a book or an article, a photograph, a painting or any of the other types of expression covered by copyright (Copyright Act, RSC 1985, c C-42, s 5 retrieved on 2015-10-16), you automatically get a bundle of exclusive rights to that work. These rights include the right to copy, to distribute, and to assign your rights to others. The full sets of rights that you get are listed in the Act (Copyright Act, RSC 1985, c C-42, s 3 retrieved on 2015-10-16). And, while these rights are exclusive, they are limited in both time and scope. The balance between exclusive rights and limitations ensures that creators are fairly compensated for their work, while still allowing for some permission-free uses in ways that contribute to the public good.
Limitations to the exclusive rights of copyright holders include the following:
- Copyright protection does not last forever. In Canada, the general rule is that Copyright lasts for 50 years after the death of the copyright holder. After that point, the work will fall into the public domain and can be used for any purpose.
- The Copyright Act lists a number of situations where Copyrighted works can be used with permission from Copyright holders. These situations are called exceptions. The most well-known exception is called the fair dealing exception, which allows for some use of copyrighted material, as long as the use falls under one of the purposes listed in the Act, and if the dealing is fair (Copyright Act, RSC 1985, c C-42, s 29.1 retrieved on 2015-10-16).
If you have determined that you are using a copyright protected image, you need to get permission from the copyright holder or you must ensure that your use falls under one of the exceptions in the Copyright Act.
So what does this mean if I want to use images in my class?
There are a wide variety of exceptions that apply to the use of copyrighted images in a closed, educational setting like a classroom or a Learning Management System. In the classroom, there is an exception that permits the reproduction of copyrighted images for use in PowerPoint presentations on campus (Copyright Act, RSC 1985, c C-42, s 29.4 retrieved on 2015-10-16). Additionally, fair dealing and the publically available materials exception will allow for the inclusion of many images in PowerPoint slides uploaded to Learning Management Systems like MEdtech. For more information, please see the In the Classroom and the On the Internet sections of the copyright and teaching section of my website.
As for images used in student assignments and presentations, most of the images used by students are likely to fall under the fair dealing exception. I do, however, always recommend that students do their best to find copyright free (or suitably licensed) images, so that when students leave the university and are asked to use images in the workplace, they know how to find images that can be easily used without having to get permission. Suggestions for finding these types of images are available on the Resources page of the copyright and teaching section of my website.
What about using images in materials that I post to the open web? What about images in conference presentations, posters and in research projects?
When you move from a closed environment like a Learning Management System to an open environment, it becomes more difficult to rely on exceptions like fair dealing, particularly if you intend to use your work for commercial purposes at any point.
In these situations, I would avoid using copyright protected images without permission and instead rely on finding works that are either licensed through the Creative Commons or that are in the public domain. The “resources” link I included in the section above provides some resources for finding these types of images. Images used in conference presentations and posters are much more likely to be fair than those on the open web, but I would be careful posting these presentations and posters on conference websites.
Finally, most images used in research projects and theses are likely to be fair dealing. One complication is that if you are going to publish in a traditional journal or publication, it is likely that the publisher will require that you get permission for everything. Fair dealing is often perceived to be too much of a risk for these publishers, so, if you are going to go that route, make sure you find materials where permission can be granted easily or is not required.
This is just a brief overview outlining some of the main image-related considerations that you might come across as an instructor or researcher. If you have any further questions about the use of images, please get in touch with me at extension 78510 or at firstname.lastname@example.org.
Théberge v. Galerie d’Art du Petit Champlain inc.,  2 SCR 336, 2002 SCC 34 (CanLII), <http://canlii.ca/t/51tn> retrieved on 2015-10-16.
Copyright Act, RSC 1985, c C-42, s 29.1 <http://canlii.ca/t/52hd7> retrieved on 2015-10-16.
Accreditation Success Stories…and lessons going forward.
Medical school accreditation has been described, with some justification, as the colonoscopy of medical education. The parallels are rather striking:
- Both require a long and distinctly uncomfortable period of preparation.
- Both require a public exposure of personal features most would prefer to keep modestly hidden.
- Both can get messy.
- Both carry high potential for embarrassment.
- In both cases, the procedure itself can be tortuous and painful.
- And finally, for the asymptomatic and fundamentally healthy, their value is highly debatable.
Also like colonoscopy, one emerges from a successful examination with a sense of great relief. That relief, in part, is simply related to having completed the process. Doing so with a successful report of findings adds immeasurably to that sense of relief.
At Queen’s, we are fortunate to have recently emerged from our own collective internal examination with that great relief, having achieved a full eight year approval, with no further invasive procedures required until 2023.
Reflecting now on a process that really started after our last review in 2007, it’s possible (and probably healthy in a preventive sense) to set aside for a moment the struggles and various deficiencies that required attention, and focus rather on the positives that have emerged. A few come particularly to mind and merit attention because they bear important messages we should carry into the future.
Firstly, our success was based on our ability to mount a common effort. Without question, the very real threats to our school imposed by the 2007 review galvanized our efforts and collective will in a way that made possible the changes that we needed to make.
Our Deans (both Drs. Walker and Reznick), engaged accreditation efforts with resolve and unconditional support. Our university leadership (particularly Principal Woolf whose first duty in his new role was to publicly defend a medical school he had just inherited), have been staunch supporters of the accreditation effort. Our Department Heads, to a person, have been nothing but supportive of the school. Our curricular leadership, undergraduate office, medical education team, medical technology unit, hospital partners and, critically, our students, all came together to meet the various challenges, and did so with methodical efficiency, driven by a shared desire to support (dare I say, defend) our school. One sees such common, focused effort only rarely, and usually only when necessitated by great and imminent peril. It is nonetheless rather inspiring to consider what our common efforts achieved and speculate on what might be possible if we could continue to work collaboratively without the need for external motivation.
Secondly, one must acknowledge that many significant and enduring changes emerged from these efforts. A robust and effective new curriculum, effective assessment methodologies, creative and updated approaches to teaching, a revised and much more effective governance structure, a refurbished framework of policies and procedures, our highly impressive and sought after MedTech curricular management system, and even our new School of Medicine Building itself were all, at least in part, motivated or accelerated in their development by our accreditation efforts.
The process brought welcome attention to a number of areas of strength within our school, often overlooked as we focus attention on problem areas. Refreshingly, and unexpectedly, the recent report made reference to our teaching, which it identified as an area of strength. To quote from our report:
As reported by students in the ISA [Independent Student Analysis] and by the survey team, the program benefits from many capable and dedicated teachers. For example, in the MEDS 125 [Blood and Coagulation] course, with 99% of students commenting on the course, no negative comments were made within the 9 pages of comments, and the survey report suggests that the Course Director and the faculty involved in this course are to be congratulated…. Another course that received similar accolades was MEDS 127 [Musculoskeletal], where the team reported: “Dr. L Davidson who continually monitors and enhances the course. This is a “poster child course” and Dr. Davidson deserves significant recognition for the evolution of this highly innovative and interactive course.”
In fact, we are truly blessed with many dedicated and talented teachers, knowledgeable and committed faculty leaders in all key portfolios, committed and hard working undergraduate administrative and educational support teams, and a receptive and engaged student body.
In the final analysis, the most enduring lesson we should take away from our eight-year struggle with the accreditation process must be that we never again require a “crisis” to spur us to collective action in order to ensure we are providing the very best educational experience for our students. Complacency is poison. The continual, collective pursuit of quality improvement and courageous innovation must be our continuing goals. These are the lessons of the day.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
When is an hour only 50 minutes?
This blog post is part of the series of periodic updates from UGME committees.
Have you looked at your teaching or learning schedule recently? You know those hour-long and two-hour long blocks? They’re a bit misleading.
We’ll admit it, we’re part of the problem since we routinely talk about hour-long and two-hour-long classes. The reality, however, is that our class blocks are really divided into 50 minutes for class and 10 minutes for a break. If you’re teaching a two-hour block, that first 10-minute break can be a little flexible about where it lands, but for finish times, it’s vital to stick to the end at 20 minutes past the hour rule.
What are those 10 minutes for? That’s actually time for the next instructor to get set up, so they’re ready to start on time. Time for folks to grab a coffee or hit the washroom – or check their Facebook or email. It’s also the 10 minute traveling time from room to room. This hasn’t always been much of an issue for our medical students, but it’s more important than ever as we cope with the classroom disruptions because of the flood in the Medical Building in August. Often, our students are now moving between farther-flung campus buildings for back-to-back classes – those 10 minutes are golden.
If you’re concerned about how to plan your lecture or SGL or other learning event with timing in mind, get in touch with the Educational Development team. We’re happy to help with plotting out sufficient flexibility so you can finish on time without missing out on essential instruction. (Email Theresa Suart at email@example.com)
The Curriculum Committee recently approved the TLIC proposal to map a series of “Integrated Threads” through the UGME curriculum. Integrated Threads represent important domains of learning for medical students that span multiple courses, terms and academic years. These may represent disciplines (e.g. genetics, geriatrics, imaging, pathology), competencies (e.g. communication, leadership) or other defined groupings (e.g. patient safety, diversity) which contribute to the attainment of the skillset of a graduating physician.
The aim in mapping Integrated Threads is to clearly articulate where particular topics occur and re-occur through our curriculum. It will help guide both learners and instructors in expectations and achieving learning objectives. Some integrated threads have an “anchor” unit within a course with other related material taught elsewhere throughout the curriculum (for example: Genetics). Others don’t have an identified unit, but are taught in relation to other material throughout the four-year UG program (for example: Imaging).
The inaugural Integrated Threads list – also approved by the Curriculum Committee – includes 28 distinct topics. Over the next academic year, TLIC will be working with faculty and the Education team to map existing curricula and identify opportunities for enhanced teaching of each topic. The Integrated Threads list will be reviewed on an annual basis.
The TLIC will keep you posted as the Threads are identified and mapped. Faculty who would like to suggest additions to the Integrated Threads list should contact the TLIC Chair, Dr. Lindsay Davidson (firstname.lastname@example.org) or the Educational Development team.
Tony’s Top Ten Tips for Success and Happiness in the Clinical Clerkship
This week, the class of Meds 2017 begins their Clinical Clerkship. This is a highly significant milestone in their medical education, representing not only the half-way point, but also a transition from a program dominated by knowledge and skills acquisition carried out in classrooms and simulation settings, to “real life” learning in a variety of clinical placements and elective experiences. Last Friday, this occasion was marked by a White Coat Ceremony, conducted by Drs. Armita Rahmani and Sue Moffatt, and featuring personal presentations and “pearls” from Drs. Heather Murray, Andrea Winthrop and Dean Reznick.
Top Ten lists have become ubiquitous, including those providing unsolicited advice for medical students. In fact, a quick Google search revealed no fewer than 76,200 such compilations, ranging from the authoritarian to the humourous. Undeterred, I offer my own list, all based on more than a few years of experience and observation as to what works and what sometimes goes wrong. So, here goes, in no particular order…
- Show up, and show up on time. It all starts with dependability. Even the most brilliant among us are useless if absent or unreliable. On the other hand, there will always be a welcome for the honest, steady contributor. If you are late, apologize, and do not show up with the coffee or snack that you picked up on the way.
- Repeat after me: “I don’t know”. Self-awareness is right up there with dependability. There will be things you don’t know. There will be things nobody knows. You will not get into trouble or lessen your reputation by admitting to a lack of knowledge or experience with a particular clinical situation or procedure. After all, you’re a medical student, you’re not supposed to know everything! You do need to know what you don’t know. You will have major problems if you compromise a patient’s care through your unwillingness to admit limitations.
- Make it your business to learn about things you didn’t know first time. In fact, become an expert in that issue and look for opportunities to apply your new knowledge. When you do, you’ll find it intoxicating, and will search out even more knowledge. Careers have been built on less. Regard every patient and fresh problem you encounter as your curriculum. Keep track. You’ll be amazed at what you’ll be learning, and how fast.
- Remember that no decision that’s made honestly and in the patient’s best interest can be wrong. Anything we recommend for our patients, even the simplest decision, test or therapeutic intervention must meet one of three (and only three) criteria – it must relieve symptoms, improve functional capacity or increase life expectancy. There is no other justification for any intervention. You can’t be wrong for trying honestly to achieve one of those goals.
- And yet, things can go wrong... Even the best and most obvious decision may not go the way we intend or hope for. When things do go wrong and patients suffer adverse outcomes, it must be openly acknowledged and understood to ensure everyone (including you) learns from that outcome and becomes a better provider. As a medical student, you will not be the responsible party, but are nonetheless in a position to learn. Don’t be afraid to engage such situations, and don’t hesitate to discuss your feelings and reactions with more experienced people.
- Ask questions. Not to impress or stand out, but because you really want to know, and are concerned about the impact on your patient. Ask respectfully, but don’t be afraid to challenge decisions. Good clinicians don’t mind being asked to explain what they’re doing. Really, they don’t.
- Get along. With everybody, not just those you think are important. Do this all the time. Everyone you encounter knows more about the practical aspects of health care delivery than you do. They all have something valuable to pass along if you’re attentive and receptive. I’m going to use a key word here: Humility. People can sense it and respond positively to it. The opposite is arrogance, which people can also sense but respond to quite differently.
- Eat, sleep, laugh. You’ll be busy, but not so busy that you won’t have opportunity to look after your own well-being. Use your down time wisely. Plan meals and recreation. Surround yourself with people who know you well and have the capacity to make you laugh. They will become increasingly precious to you. Talk to them.
- Be open to possibilities. If you think you’ve decided on career choice, don’t be shocked (or worse yet, disappointed) if something unexpected emerges. If you feel strongly conflicted, there’s probably a good reason. Talk it out with someone and remember it’s never really too late to change. If you can’t decide because everything seems great, that’s a good thing, but you might also need to talk it out. We’re available.
- And finally… look after each other. You know each other very well, and will know when someone is having difficulties, likely before they know it themselves. Don’t be afraid to reach out, or to seek advice or help. Our Student Affairs staff, headed by Dr. Fitzpatrick, Janet Roloson and myself are all available to you or your colleague. Remember QMed Help, the red button available on MedTech.
So there you have my list. Happy to receive revisions, additions or comments from readers. Final word to our students – enjoy. Clerkship is a great time to grow and learn.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education