Can students achieve excellence without stress or competition?

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Striving for a Culture of Competency

A few days ago walking through the hospital I ran into a very excited third year medical student who was anxious to tell me about a recent clinical experience.  Apparently she’d admitted a patient with a complex array of medical problems and, after considering the differential diagnosis, ordered a test that confirmed the presence of fairly rare condition that led to a very effective therapeutic approach.  The patient was much improved and our student, for the first time in her experience, felt that she had personally made a significant contribution to a patient’s care.  Importantly, she wasn’t telling me this to boast or claim personal credit.  She was simply very excited in the moment and wanted to share.

Our student experienced what could be referred to as the “magic moment”.  This is a term for that point in a physician’s development when they realize, for the first time, that they have acquired the ability to positively influence a patient’s life.  For some it comes in the form of a procedure well carried out, for others it’s a diagnostic success, for some the realization that they’ve brought resolution or comfort to a personal crisis in a patient’s life.  Whatever the form, the central element is the realization that their long and arduous learning process has borne fruit, and finally, rather unexpectedly, makes sense.  Their learning has transformed from an abstract, theoretical exercise to a pragmatic and practical application of knowledge and skills.  The “competency-based” construction of our curriculum suddenly seems sensible and, importantly, much less threatening.  I’ve also noted that when our students come to this point, the “stress” of medical school changes in a favourable way.  They realize that if they allow their learning to truly focus on their competency- based learning objectives, the rest will basically take care of itself.  With this realization comes confidence.  They come to regard exams as necessary inconveniences rather than fearsome high stakes threats.  They no longer require their teachers to validate their learning.  They have become, dare I say it, competent life-long learners.

Many medical schools have, over the past several years, adopted a competency-based framework to structure their curricula and assessment processes.  Here at Queen’s, we adopted this as the basis of our curricular reform which began 6 years ago.  It has provided a logical and comprehensive framework around which to establish objectives, courses, learning events, and all their associated assessment tools.  Unfortunately, I think we have to recognize that we have not yet adopted a competency culture.  Our students continue to have difficulty evolving from the consciousness that short-term knowledge assimilation and examination marks are the sole components of success.  Many continue to see medical school as a series of “hoops” through which they must pass, discarding now “unnecessary” information at each step in order to move on to the next challenge.  Experiences intended to build “softer” skills, such as reflective exercises and portfolio assignments, are often given short shrift, or at least secondary effort, because their relevance may be less apparent and “they’re hard to fail”.  To a novice mountain climber, the ability to effectively and efficiently tie knots seems a tedious and pedantic exercise, until one is perched on a ledge and relying on that skill to negotiate a climb.

This difficulty is, in many ways, completely understandable and we, as medical school faculty, are partially to blame.

  • Our admission processes are heavily reliant on academic success as a criterion.  Our students are therefore pre-selected and “hard-wired” to excel in relative terms (relative to other students), rather than against pre-determined competency goals.
  • We continue to use very traditional assessment processes to evaluate success.  While it’s true that our major purpose in setting assessments is to inform rather than select or stratify, our students can’t help but have a very fundamental and visceral response to the examination experience.  If you breed thoroughbreds to race, it seems, they will run when the gate opens.
  • We continue to award academic “standing” through a multitude of awards that our schools have administered for generations, the very purpose of which is becoming increasingly irrelevant in our current curricular structures, and may be unintentionally promoting many behaviours we now recognize as counter to our competency goals.
  • Perhaps most troubling of all, shortly after admission to medical school, we thrust our students into another increasingly competitive process to select and engage postgraduate training positions.

The environment, intentionally or not, is highly competitive.  Is this productive?  Does it drive desirable qualities?  Does it result in better (more competent) physicians?  Many would argue that competition for personal success is inevitable, drives learning and selects for qualities that will serve our students well in their careers and personal life.  The counter argument is that it drives the wrong (short term) approach to learning and requires students to make strategic decisions regarding their learning that are unaligned with the needs of their future patients.  The inconsistency between internal competition and the “collaborator” and interprofessional competencies we strive to achieve is obvious, as is the potential to disrupt peer-to-peer education that we recognize is so valuable.  Many schools, including our own, have taken baby steps to address this issue by moving to “pass-fail” assessments, but even this has been met with considerable internal controversy.

So, what’s to be done?  Can we do better?  I would respectfully offer a few suggestions for consideration and discussion.

1. Frank discussion early in medical school.  We need to engage the issue early on, clarifying for our student the reality that their learning objectives have fundamentally changed.  Essentially, their objective needs to shift from personal achievement to the needs of their future patients.
2. The concept of “relevance” is best learned through patient contact.  More contacts, in more “real life” venues, earlier in the medical school experience will be key.  Observerships, the First Patient Program and Week in the Country are great examples, but need to be contextualized in a way that allow the student to recognize the importance of competency acquisition.

3. More clarity regarding our learning objectives.  I think we have to acknowledge that the competency domains as defined by our professional colleges are insufficient unless buttressed by concrete applications.  Being a good Manager, for example, means very little.  However, when broken down into more practical applications, students not only see the purpose, but can navigate the learning much more efficiently.  For example:

  • Managing personal time
  • Managing a medical practice
  • Managing diagnostic testing for your patient
  • Managing your finances

This now become more than knot-tying for the sake of knot-tying.  Fortunately, there is considerable activity currently underway that will help.  The Royal College is in the process of revising and refreshing the CanMEDS framework.  A joint AAMC/AFMC committee is in the process of developing a set of competencies required of the medical student about to enter residency training, and documents such as “The Scottish Doctor” represent thoughtful and comprehensive attempts to catalogue practical physician competencies.

4. Testimonies from near peers and role models.  The experiences of senior colleagues who have recently and successfully navigated the challenges our students are facing can provide powerful motivation and validation.  It can also provide critical perspective to reduce unnecessary stress.

5. Assessment review.  There has been movement in recent years toward competency-based assessments, such as Objective Structured Clinical Examinations (OSCEs), both by the Medical Council of Canada and most medical schools.  However, these are very difficult to design, complicated to administer and very resource intensive.  We need to develop more practical approaches that will allow our students to demonstrate their achievement of the various competencies in an open, objective way.

6. Reconsideration of our awards.  Recognizing excellence and personal achievement is undeniably of value, but do our awards recognize the qualities and achievements we strive to develop?

7. Rethink and refine the process of transition to postgraduate training.  This has been identified as a concern by the Future of Medical Education in Canada initiative of the Association of Faculties of Medicine of Canada (AFMC), and is under active discussion at this time.  Models for more graduated transition are being considered, and will come under increasing discussion in coming months and years.

In summary, some degree of competitive tension will likely always be present within our medical training processes, and some degree of stress is not only inevitable, but may have a useful role in preparing students for the pressures of clinical practice.  However, are we doing our best to use both intentionally and intelligently?  Can we ensure they all experience their “magic moment” early in their training?  I think we could do better.  What do you think?


8 Responses to Can students achieve excellence without stress or competition?

  1. Nice blog Tony. The pursuit of excellence at its highest level does involve competition and one has to have competitive drive to achieve change. This is usually difficult, sometimes intellectually difficult, sometimes just difficult to implement in the “real world”. The competition for Medical change agents is often not with an individual (i.e. it is not anti collegial). Rather the compeitiotn is about ideas and it is for the hearts and minds of colleagues and the public. it is with the inertia that invests all disciplines, medical or scientific. The profession needs young physicians of all types, but in addition to producing practitioners who can follow practice guidelines or are good at working in teams, we do need some percentage of our graduates who will see the flaws in the status quo (whether it is our research, our educational systems or our medical practice) and have the courage and persistence to effect change. Their competition will be with our conservative medical culture and their competency will be in being visionary change agents. This competency is hard to select for when we are choosing medical students and the individuals that possess this skill set are not always comfortable fits in hospitals and medical school. However, I hope the future of Medical training at Queens has a few spots for the boat rockers who will espouse very high standards, lack patience with the current state of Medicine and will display competency in in transforming the system. Incidentally, these people likely will not be selected by their MCAT scores or by MMI performance. Huxley had a nice quote that all geniuses first being hailed by society as mad men. We don’t want a medical school full of hyper competitive madmen BUT I do want to see ambitious people entering Queens Medicine. People who have an appetite to master Medicine and then transform it into whatever the next great thing may happen to be. Keep up the blogging!

    • Thanks Steve, and very well said. The point is not to avoid competitive drive, but to ensure that drive is directed toward positive change. I can’t help but make a comparison to the Arts community and struggles of those engaged in literature, visual arts or music, with which I have some familiarity. Those folks undoubtedly face intense competition, but their goal is toward the personal perfection of their art, not a relative comparison to other practitioners. Fundamentally, it’s been my observation that accomplished artists aren’t satisfied with being better than others, they set their own standards and trust that will serve. I would certainly agree that complacency and comfortable mediocrity are toxic to our growth as a profession, and as a school. We need to continue to attract the free-thinking “boat shaker” that you describe.

      • Anonymous says:

        Agree we need that certain % of MDs who buck the status quo. But I sometimes fear the hidden curriculum beats this out of medical students. We’re often reminded we’re lower on the totem pole, and questioning authority (even respectfully) can bestow a reputation on a student as a “hell-raiser”/”troublemaker”. And…..who wants that kind of reputation pre-CaRMS?

        • It’s true Danica, that students are recipients of much subtle and not-so-subtle messaging about their “status” and feel vulnerable in our increasingly competitive placement processes. However, it’s been my experience that most faculty appreciate creativity and original thinking if it’s expressed in respectful terms and intended to bring about constructive change. In fact, most find the intellectual stimulation a major incentive for teaching.

  2. Fantastic post Dr. Sanfilippo. Two points specifically connected well with me:

    1) The comment on awards for top grades. As you noted, this is counter-productive to the goals of balance and competency-based learning. One idea just popped into my head – perhaps students could be nominated in each course for their contributions to the class learning (ie. running tutorial sessions, sharing notes, contributions during lecture and SGL)? Lecturers/Course Directors could then select an award winner based on written nominations submitted by students.

    2) As a new trainee, I can’t stress enough how valuable speaking with near peers and role models has been. Having lived with a few clerks for the past 7 months, I’ve frequently asked about their transition from the classroom to the wards. Time and time again, these role models have reflected on how competencies in areas such as collaborator and advocate have a large impact on their successes in clerkship (more-so than medical expert). My current understanding is that a skilled clerk can integrate themselves seamlessly into each new team, understand the workplace dynamic, seek out their specific role on the team and perform each day with a reliable, hard-working attitude. They stress that I shouldn’t worry about achieving a 95% in each course. Instead, I should practice living a balanced lifestyle and gaining as many clinical experiences as possible.

    As first-year students, we currently have our mentorship program to facilitate these connections (along with other sporadic events). However, I think we could be doing more. One idea – from the moment each first-year student arrives at Queen’s (or even before), they could be connected with a 3rd-year as they prepare to enter clerkship. This would ideally start a relationship where all first-year medical students have the opportunity to ask the same kinds of questions that I’ve had with my housemates.

    Would love to hear your thoughts on these. Your (and the rest of UGME) focus on student wellness continues to be appreciated.


    • Thanks Jonathan. Always great to get the student perspective on these issues. The Awards Committee, chaired by Dr. Belliveau, is in the process of reviewing our various awards to better align them with the current curricular goals competency based objectives. I’m optimistic that those changes will contribute to re-focusing the competitive energy in a more positive way. I also appreciate your comments about near-peer mentoring, which we will continue to promote wherever possible in our program. I like your idea about the Y1-Y3 matching. I think you and I should suggest it to our respective Mentor Program organizers.

  3. Richard Reznick says:

    Tony, what a wonderful and thoughtful blog. I enjoyed it tremendously and believe it identifies a very important tension that we have “learned to live with” but probably, as you suggest, should tackle head on.


    • Thank you Richard. After recent discussion with the students on this issue, we’re in the process of developing a joint student-faculty working group to discuss this very issue and develop recommendations for us to consider. I’m sure we’ll be hearing more from them soon.

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