Anthony Sanfilippo

Lessons from Medical Variety Night

Last November’s Medical Variety Night provided an impressive peek into the musical and comedic talents of our students.  Andrea Winthrop, Steve Archer and I were asked to serve as a “Judges Panel” to determine the best class skit.  We were all amazed at the poise and creativity on display.

The evening also provided a few lessons for both faculty and students as to how well intentioned humour and satire can appear quite different before a mixed audience not familiar with the contexts employed.  A number of conversations have ensued which I believe have been illuminating and instructive for both students and faculty.  As in the patient care context, “near misses” are opportunities to learn and avert more serious problems in the future, and I believe we have, as a school, availed ourselves of the opportunities this year’s production provided.

A theme that I and others in attendance found particularly troubling related to a number of references to Family Medicine as a less-than-appealing career option.  This perception is hard to fathom given that we a have superb and award winning faculty teaching Family Medicine.  Our Family Medicine training program is widely recognized as one of the best and most sought after programs in the country.  In addition, Family Medicine is, arguably, the most demanding of specialties.  In open and frank discussions with a number of students on this issue, a few underlying causes came to light which I found illuminating and felt would be useful to share with faculty.  They provide superb examples of the “Hidden Curriculum”, a term used to describe unintended influences that affect student learning, and are known to be very powerful shapers of student attitude and behavior.  So, in no particular order:

  1. Engaging Uncertainty.  Students find Family Physicians they encounter to more commonly express uncertainly in their ability to resolve patient presentations.  This is in contrast to other specialists who they find characteristically more definitive in their approach.  Family Physicians more commonly use statements like “we’ll have to look it up”, or “don’t be afraid to say you don’t know”.   With respect to other specialists, the expression “seldom wrong but never uncertain” comes to mind (my quote, not theirs).  Importantly, students do not see this difference as inappropriate or as reflecting any lack of competence, nor are they so naive as to believe other specialists always have the answer.  In fact, the students I met uniformly expressed admiration and respect for Family Physicians they encountered, and their ability to manage a diversity of patient populations and presentations.  However, it’s clear that our students are accustomed to success, and many are not yet comfortable facing uncertainty in their lives, or in their future practices.
  2. Technical/procedural expertise.  Many of our students are technically very savvy and excited by the prospect of being on the “leading edge” of innovation and application of emerging technologies and procedural approaches to various conditions.  Simply stated, they like the “toys” of modern medicine and they’re excited about applying evolving procedures.  They perceive that these exciting new approaches as the exclusive domain of sub-specialists.
  3. Prestige”.  Hospital in-patient services remain at the core of clinical training for our students.  Properly run and supervised, they are superb environments in which the learning of pre-clerkship can be applied to real patients, with appropriate overlays of scholarship, professionalism, advocacy, collaboration and all the intrinsic competencies we have adopted within our curriculum.  Although formal teaching remains valuable during these rotations, we all recognize that the major component of learning occurs through active participation as part of the team, and by observation of “real life medicine”.  With respect to Family Medicine, these rotations are problematic in two important ways.  Firstly, virtually no Family Physicians are involved or even visible during these rotations.  Secondly, and most disturbingly, they often see instances where primary care and primary care providers are disparaged.  A casual reference suggesting that a patient was inadequately cared for prior to admission, or a concern that appropriate care will not be continued after discharge can, in a stroke, undo all prior teaching.  These observations in the clinical setting trump teaching in the pre-clerkship.  Our actions, it would seem, speak more loudly than our words.
  4. Money.  I have become convinced that the single most powerful expression of Hidden Curriculum in our society is the OHIP Fee Schedule.  Students are very aware of the differential reimbursement of physician groups, and the high premium paid for procedural work relative to patient assessments.  This of course, results in two hugely damaging consequences, the equation of financial with professional “value” or “prestige”, and the enticing allure of higher income to students facing increasing debt loads by graduation.

So what can be done?  A few suggestions, humbly submitted for consideration:

  1. Awareness of these influences, and of the Hidden Curriculum in general.  Hopefully this article is a start.  I hope it will generate some discussion, particularly at department meetings.  Dr. Leslie Flynn is chairing a group of which I’m a member to study and address Hidden Curriculum issues, and I think this may provide some focus for those discussions.  This awareness must extend to physicians of all disciplines who teach and supervise our students, particularly in the practice setting.  Those who attend on these services are, in my experience, largely unaware of the serious impact of casual commentary, and almost never intend to disparage any other specialty.
  2. Within our curriculum, developing strategies to address the “uncertainty principle” in a more open fashion.  This is both an academic and student wellness issue.  Our students require means to cope with the uncertainty that will inevitably develop in their professional and personal lives.
  3. Serious consideration of the troubling question:  To what extent do our admission processes pre-determine career choice?  Medical school admission remains a highly competitive process (applicant to admission ratio 38:1 at our school), and is likely to become even more competitive in the near future.  This environment favours the goal oriented, determined self-starter who is able to engage this single goal with appropriate compromises and sacrifices along the way.  It can be argued that such “survivors” will be naturally attracted to practice environments that provide definitive resolution of problems, technical mastery and perceived prestige.  There is a recognition, even embedded in the Future of Medical Education in Canada initiative, that admission processes should favour resiliency, personal maturity and problem solving, qualities valuable to any physician and not necessarily reflected by academic success.  Our admissions committee has, in fact, been inoculating these considerations into their procedures for the past few years.  However, as for all schools, academic success remains a key component of the application process.  Perhaps it’s time to consider more radical approaches.
  4. Increasing Family Physician presence in the hospital.  Our students perceive that in-hospital care, and the acuity, complexity and technologic innovation that goes with it, is the exclusive domain of sub-specialists, and fail to appreciate the role of Family Physicians in the continuum of care.  They also get little exposure to the in-patient care provided by Family Physicians in smaller communities.  Our Integrated Clerkship and “Week in the Country” programs address this to some extent, but we need to develop and engage initiatives to integrate Family Physicians effectively into the care of our in-patients.
  5. Advice regarding financial planning and practice management.  Although we can’t influence the fee schedule, we can certainly provide our students with sound financial advice to lessen any economic drivers of career choice.

I would like to end this article by thanking the many students who were willing to speak to me candidly about this issue.  I welcome their further commentary and impressions of faculty.  Open discussion is always the first and perhaps most necessary step to improvement.