Physical Medicine and Rehabilitation
Physical Medicine and Rehabilitation, also known as Physiatry, is the branch of medicine concerned with the comprehensive diagnosis, medical management and rehabilitation of people of all ages with neuromusculoskeletal disorders and associated disabilities. Physiatrists work in a diverse range of subspecialty areas to help patients with a variety of impairments related to conditions such as stroke acquired brain injuries, spinal cord injuries, amputation, and various musculoskeletal disorders. Physiatrists play a vital role in our health care system and as the Canadian population continues to age, the demand for their services will only continue to grow.
What does haemoglobin of 90 have to do with assessment in medical education?
When I am meeting with faculty members, new or ‘seasoned’, who are keen to teach medical students, many of them note that while they love working with students, they may feel uncomfortable with assessing students. On the one hand, this is not a surprise, since most of us were not taught this in medical school or residency, but, on the other hand, clinicians are well-equipped to assess medical students, because the principles of assessing students are often very similar to how we approach patient care.
If I approach a physician and ask, "Dr. X, I have a patient whose haemoglobin is 90. Should I give her a blood transfusion?", no competent doc would give me a yes or no answer without knowing a lot more about the patient. One would want know what symptoms the patient was having, her age, location of treatment and all about her past medical history. Any physician would ask for details about the relevant physical examination, and about other investigations that had been performed. Many physicians would engage in a discussion about the patient, discussing the pros and cons of transfusions in general, and in the context of this patient, and would explore other options – largely since, as is often in the case in medicine, there is no clear single answer that can be applied to all patients.
Many physicians would question if I was sure the haemoglobin was "valid" - i.e. did that measurement actually represent what was going on with the patient's blood or could there have been a measurement error? They likely would not want to make a reasonably high-stakes decision based only on one measurement. Doctors would want to know what the patient’s haemoglobin was yesterday and before, to help inform their answer. They might even want to know what it is in four hours, or tomorrow, before they draw any conclusions.
I always choose haemoglobin of 90 for this scenario. It is perfectly in the gray zone. It could be completely appropriate to transfuse, or not, depending on the circumstances of the patient. Also of importance in this scenario is that giving a patient a blood transfusion is a reasonably high stakes intervention, as opposed to some other interventions we could use. In other words, the decision made will have significant implications for the patient.
How does this relate to assessment in medical education? And in particular, how does this relate to the assessment principles we have adopted in the Undergraduate Medical Education (UGME) program?
1. We make decisions about student performance based on multiple points of assessment
Decisions about student performance should not be made only based on one test score. Just as we rely on a complete history from our patient, carry out an appropriate physical exam, review investigations, and maybe even order more tests for our patients, we must look over all the student’s work. We can then attempt to determine if circumstances might have affected that score, to help us to interpret what it means about that student’s performance. In UGME, we look collectively at a student’s work in a given course, term, or year when we make recommendations about course standing. We are then able to make informed recommendations about supports students might need to succeed. We ensure that there are multiple forms of assessment in each course, so we are using a variety of sources of information. In any given course, these methods are chosen to meet the needs of the assessment blueprint, demonstrating that that students’ learning of the course objectives and Medical Council of Canada presentations are assessed appropriately.
In addition to multiple points of assessment, we have systems in place where very high stakes decisions such as those that might require a student to undergo significant remediation, require that the student’s performance be reviewed by multiple individuals, first at an examiner’s meeting of faculty from the relevant component of the curriculum, and then at the Progress & Promotions Committee for an arms-length vetting. This approach may be used in clinical medicine for particularly challenging decisions, where we may use a case-conference approach, or a tumour board, bringing in the input and expertise of many.
Thus, all decisions about student performance are made based on rich data that is appropriately reviewed in a careful fashion – just as we would normally approach a clinical scenario.
2. We ensure we are using high quality assessments.
We have implemented processes to ensure that the tests we use are high quality assessments. Are they testing what we think they are testing? How can we minimize measurement error? Just as any one haemoglobin measurement might be inaccurate, even with carefully calibrated equipment, test scores can be misleading. If 50% of a class of medical students failed a midterm, it is likely there was a flaw in the construction of the midterm (since medical students always study!) In UGME, we have a process to have examinations and other high stakes assessments reviewed by a team of faculty members, assessment experts, and others as required. After the tests are administered, we undertake item analysis to determine if any of the questions could be of concern, and should be deleted. For other forms of assessment, we have looked to the literature for tools that could be adopted in our setting, and the Student Assessment Committee will vet novel assessment strategies for quality and provide feedback to course directors. Again, the results of these assessments are reviewed first by a course director, and then at an examiners’ meeting to ensure that the data is of good quality, and should be used to inform decision-making about student performance.
3. We support and promote assessment for learning, including the use of formative assessment and ongoing feedback for our students.
In UGME, assessment is ongoing and must exist to support student learning. In medicine, we would never transfuse our patient (or not transfuse our patient!) and then stop thinking about why they had a low level. Efforts would be made to address the underlying condition that led to the problem, and then to fix that problem. In UGME, we have embedded formative assessment and feedback into all of our courses allowing us to provide appropriate information back to students about their performance. Either they can address areas that require improvement; we can provide supports, or both. In clerkship, clinical skills, and other similar settings, this must involve direct observation of student performance, along with other assessment methods. In medicine, our goal should not be to simply ‘fix the number’, and this is the case in medical education as well. We want our patients and learners to thrive, and we should give them the information and supports they need to do this.
If we return to our patient- should she receive a transfusion? The answer is clearly “it depends.” We should be careful to be clear that our learners don’t have a disease – this is the main danger of this metaphor. However, the next time you are asked to assess one of your learners, it might help to think of what you are doing as being very similar to the clinical approach that you use on a daily basis. And, if you are one of our very valued faculty members who is not a clinician, your expertise in research and other related fields will stand you in good stead to assess our students in what you are teaching them… and maybe you can come up with the next great assessment metaphor!
At the leading edge of heart and stroke care
Advances in recent years have drastically changed the outlook for those suffering from cardiovascular disease. A host of new technologies, medications and procedures have increased survival rates and have smoothed out many of the bumps that were once a common part of the recovery process.
“Cardiovascular disease is no longer the number one cause of death in Canada,” says Dr. Chris Simpson, Chief of Cardiology at Queen’s. “All of the advances, both in technology and treatment, have improved the chances of survival and recovery.”
One of the areas where Dr. Simpson has been making strides is the utilization of new leadless pacemakers. The current generation of pacemakers are implanted surgically under the skin, with a long wire feeding from the pacemaker into the heart, delivering a pulse when necessary. The new generation have been miniaturized, compressing all of their hardware into a small, thin capsule which screws right into the heart.
They’re so small that the pacemakers can be implanted without major incisions, going through a vein in the groin and travelling up to the heart. The process creates no scars, requires no stitches and the pacemaker isn’t visible from outside the body.
“The Achilles heel of pacemaker insertion has always been infection, which will be drastically reduced with the new models,” says Dr. Simpson.
It’s just one of the many modern improvements to heart treatment happening at KGH-Queen’s.
Dr. Christine D’Arsigny (Respiratory and Critical Care Medicine) is treating arterial hypertension with new medications and has had very encouraging results.
“These new therapies we’re using have led to a dramatic impact on quality of life for those affected,” she says. “We’re continuing to learn more about the disease and perfecting our medication treatments.”
Pulmonary hypertension is an increase in blood pressure in the blood vessels within the lungs. Those afflicted are often struck by shortness of breath, dizziness, fainting and have a high death rate from the disease, if left untreated. Previously, treatment was limited to IV-therapy and organ transplantation, often not an option for people who were too sick to undergo surgery. This is also true for chronic thromboembolic pulmonary hypertension, another cause for pulmonary hypertension
The new drugs Dr. D’Arsigny is prescribing work to dilate the pulmonary vessels and change cell signalling, resulting in better blood flow through the lungs, a decrease in shortness of breath and alleviation of other symptoms. The end result is improved quality of life and improved survival.
“These oral medications have provided an excellent treatment option,” Dr. D’Arsigny says. “The improvements I’ve seen in some of my patients have been dramatic —I have had some patients go from barely walking without getting short of breath to thinking they can go skiing again.”
Solving the mystery of strokes
Promising new research has shed light on one of the longstanding mysteries of strokes. For nearly 30 per cent of stroke victims, the cause of the stroke is not readily apparent after medical examination. A new study, co-authored by Dr. Albert Jin (Neurology) and published in the New England Journal of Medicine, takes a big leap forward toward understanding the problem.
“We typically perform an electrocardiogram that runs for 24 hours, and it’s often not adequate” says Dr. Albert Jin.
He instead made use of a new cardiac monitoring method that tracked heart behaviour continuously for 30 days. This revealed that many of the strokes were caused by atrial fibrillation, an abnormal heart rhythm.
“Our detection rate increased sixfold, showing us that 18 per cent of people had atrial fibrillation," he says. "That translates to hundreds if not thousands of Ontarians each year that now have a recognized cause of stroke that we can treat.”
Another of the major causes of stroke is the formation of blood clots which restrict circulation to the brain. Dr. Jin is taking part in another new study that seeks to better treat these strokes. Current treatment focuses on medications which target and break up the blood clot; the new study supplements this treatment with ultrasound waves which help to further dissolve the clot.
By applying ultrasound waves to the brain, Dr. Jin is able to specifically target the clot, complementing the work of the medication. Though there are safety risks for ultrasound waves in lower frequencies (think of the booming bass of car stereo), the study makes use waves in a higher frequency.
“There’s been ample safety work done and it’s been demonstrated that ultrasound waves tuned to a higher frequency are safe,” Dr. Jin says.
Though the new study is only just beginning, work being done at KGH-Queen’s is making the prognosis for stroke victims brighter.
Treatment for strokes and heart-related health problems has long been hindered by a lack of information. When searching for the causes of a stroke, for example, technological limitations meant that doctors could only track a patient`s heart pattern for 24 hours at a time. They then had to project that information into the future, assuming the heart would function the same way for weeks at a time. That made heart monitoring a difficult process, says Dr. Adrian Baranchuk (Cardiology).
“The patient would have to reconnect to the monitor every day. It was inconvenient, it irritated the skin and people had to plan their lives around access to the heart monitor.”
That’s why Dr. Baranchuk has been eagerly putting into practice new technology that makes the whole process more reliable, safer and less invasive. He’s begun fitting his patients with a new monitor called the Reveal LINQ by Medtronic. At less than two inches in length, the monitor is so small that it removes the need for serious surgical insertion.
In a procedure that only takes about two minutes to conduct, Dr. Baranchuk makes a minor incision, inserts the monitor and bandages the patient up. The incision’s small size drastically reduces the risk of infection, removing the need for stitches and antibiotics and the monitor can function for three years, providing steady heart rhythm data.
“As a global approach, heart rhythm monitoring allows you to detect arrhythmias and decide whether someone needs medication, a pacemaker or other treatment,” says Dr. Baranchuk. “This is going to be future of heart monitoring.”
An overview of our UGME curriculum
Our curriculum and program have evolved over the past 7 years. Here’s how:
On the first day, the “Red Book” was written, and it was good. There was rejoicing throughout the land. Everybody liked the Red Book.
- Our Curriculum is designed on the basis of the Roles, Competencies, Program Objectives and Curricular Objectives defined in the “Red Book”, a.k.a. “Curricular Goals and Competency Based Objectives”. Translation: Everything we do flows from the Red Book. If it’s in the Red book, we do it. If it’s not in the Red Book, we don’t have to.
- We have defined 14 Competencies, based on the 7 key Physician Roles which derive from the CanMEDS and Family Medicine principles. These Competencies guide all aspects of curricular design, teaching and assessment.
- The Competencies are further refined into (total of 27) Program Objectives. These Program Objectives are the key components that allow for definition of our course structure and overall curricular design.
- Of critical importance is the fact that these Program Objectives define the domains in which student achievement must be documented in a course and over four years.
- For the purposes of clarifying teaching and learning objectives for both faculty and students, each Program Objective is further divided into a variable number of Curricular Objectives. We have defined a total of 91 Curricular Objectives. Specific learning objectives for a learning event may be described under these.
- The 4 Program Objectives that define the Medical Expert Role are further guided and delivered in the context of the Medical Council of Canada’s Clinical Presentations.
- NB: All the assigned Red Book program and curricular objectives and the MCC clinical presentations are entered into MEdTech for each course and form the basis for learning objectives in drop-down menus for each learning event.
Courses were built…
What is our course structure?
- Our curriculum uses a Course structure. For operational purposes, a course can be defined as a time and term limited sequence of learning and assessment experiences designed to ensure the appropriate teaching and assessment of a subset of Program Objectives and MCC Presentations.
- These are the types of courses we have: Scientific Foundations, Clinical Foundations, Clinical and Communication Skills, Professional Foundations, Clerkship Core Academic and Clerkship Clinical course. We use the courses to scaffold (or build upon) student learning from Ideas to Connections to Extensions.
Curricular objectives were integrated…
How do the curricular objectives fit into the courses?
- Medical Expert Role and Competencies: Many of our courses are designed and sequenced to ensure the 4 Program Objectives associated with the Medical Expert role are taught and assessed appropriately. The Curriculum Committee assigns a subset of the 4 Medical Expert Program Objectives and MCC Clinical Presentations to most courses, with the expectation that they would align with, and inform teaching methods, content, and assessment. (The committee also assigns other competency objectives…see #2)
- Intrinsic Roles and Competencies: Achieving competency in the 23 Program Objectives that constitute the six so-called “non-medical expert” or “intrinsic” roles (Professional, Scholar, Communicator, Collaborator, Advocate, Manager) requires a combination of factual information, lived experiences, targeted assignments, reflection and feedback, integration with other courses and must be continuing and progressive throughout the curriculum. The Curriculum Committee, assigns these program objectives as well. The “curriculum” for these objectives will therefore require a combination of: courses dedicated to specific roles (CARL, Professional Foundations), integration within other courses, special events as part of courses, and longitudinal assignments and programs (First Patient Project, Observerships, Community Based Projects…)
Course Directors, Competency Leads and Directors were created…
Who looks after Courses?
- Each of the courses is managed by a Course Director, whose responsibility is to:
- Develop a teaching plan that ensure the assigned Program Objectives, Learning Objectives and MCC Presentations are taught
- Ensure a variety of teaching methodologies are employed so that integrated and applied learning as well as provision of information are accomplished
- Develop an assessment plan that ensures that students have met the assigned Program and Curricular Objectives and MCC Presentations.
- Provide a blueprint of the exams and of the course.
- Regularly review and revise the course structure based on a variety of feedback.
- Responsibility for oversight for each of the intrinsic roles is entrusted to a Competency Lead.
- Identification and integration of all curricular learning opportunities relevant to the defined Program and Curricular Objectives
- Identification of any gaps in the provision of learning and assessment opportunities relevant to the defined Program Objectives
- Development, as required, of new curricular content to address gaps.
- Ensuring a variety of teaching methodologies is employed so that integrative and applied learning as well as providing information is accomplished
- Development of an assessment plan that ensures the assigned Program Objectives have been mastered.
- Regular review and revision of the role “map” including relevant learning opportunities and programs, based on a variety of feedback.
- Provide continuity over years, guidance for changes, innovations, etc.
- A number of roles have been developed to provide oversight for large components of the Curriculum:
- Director, Year 1: Provides oversight for all Year 1 courses and support to those Course Directors
- Director, Year 2: Provides oversight for all Year 2 courses and support to those Course Directors
- Director, Clinical Skills: Directs all Clinical Skills courses
- Director, FSGL: Directs Facilitated Small Group Learning events throughout the curriculum, coordinating with Course Directors and Competency Leads.
- Director, Clinical Clerkship: Provides oversight for all Clerkship clinical rotations and support to those Course Directors
- Director, Clerkship Curriculum: Provides oversight of the three Clerkship Curriculum courses and support to those Course Directors
Communication channels were developed to ensure continuity…
Communication among Curricular Leads: Competency Leads and Course Directors undertake a regular dialogue that ensures appropriate integration and assessment. The Curriculum Committee assigns program and curricular objectives. The Year Directors, representatives from the Professional Foundations and Course Directors meet together at the Curriculum Committee, and share reports. Year Directors communicate and meet with the Course Directors in their year, and have an Examiners’ meeting twice annually to go over assessment for each course over each term.
Committees were created…
What committees provide curricular oversight?
- The Curriculum Committee has “Integrated institutional responsibility for the overall design, management and evaluation of a coherent and coordinated curriculum” (as per accreditation standard ED-33). It must therefore review, make recommendations and have final approval of all curricular content.
- The Professional Foundations Committee brings together all Competency Leads and other key faculty and administrative personnel to provide coordinated delivery and assessment of these objectives. The Professional Foundations Committee is a sub-committee of the Curriculum Committee and makes all recommendations for curricular revision through that committee.
- The Teaching, Learning and Innovations Committee is a sub-committee of the Curriculum Committee. The mandate of the Teaching, Learning and Innovation Committee (TLIC) is to ensure the optimal use of instructional methodologies and technologies within the Undergraduate Medical Education Program, consistent with accreditation and current educational standards. It reports to and makes recommendations for change through the Curriculum Committee.
- The Student Assessment Committee is a sub-committee of the Curriculum Committee. It has responsibility for developing principles and processes for student assessment and for regular review of assessment methods provided in all components of the curriculum. It reports to and makes recommendations for change through the Curriculum Committee.
- The Course and Faculty Review Committee is a sub-committee of the Curriculum Committee. The Course and Faculty Review Committee, provides systematic and impartial course and faculty reviews and develops reporting processes ensuring compliance with relevant accreditation standards. It reports to and makes recommendations for change through the Curriculum Committee.
- The UGME Program Evaluation Committee is a sub-committee of the Curriculum Committee. The Program Evaluation Committee provides faculty and administration with timely feedback in order to refine and improve MD program. It collects quantitative and qualitative data on curriculum and supporting activities in order to inform decision making at all levels in the School.
How do the committees communicate with each other?
- The Teaching and Learning Committee, Student Assessment Committee, Course and Faculty Review Committee and Program Evaluation Committee regularly liaise with each other through reports to the Curriculum Committee. Each Chair sits on the Curriculum Committee. Minutes are available on MEdTech Communities as are Terms of Reference.
There was stability and peace in the land…
After 5 years of change, what does our curriculum map look like in 2015?
Chris Simpson's messge to Council of the Federation
Service-Learning at Queen’s UGME
Two key values of the Queen’s Undergraduate Medical Education (UGME) curriculum are learning and citizenship. Under learning, we affirm that “we foster an environment that optimizes learning in pre-clinical and clinical settings,” and under citizenship, we profess that “we believe our students should be active contributors and participants in the leadership of their communities, society and professional organizations.” (UGME Curricular Goals and Competency Based Objectives, p.7)
Combining these two values together results in innovations such as service-learning, a concept that is more than community service or volunteer work, yet not the equivalent of internship learning.
At Queen’s medicine, we regard service-learning as a three-part process which incorporates preparation, service, and reflection.
The core components of service-learning include:
- Formal, deliberate preparation, which includes consulting with the members of the community who will be served by a project and which may include classroom instruction or another form of mentorship/coaching. A plan, detailing both the intended service and learning outcomes is created.
The “service” and “learning” are completed:
- The learner reflects on the process, the service and the learning.
(This may occur throughout the project or period of service). The learner provides evidence of learning. (This could be provided in different ways, for example, through written reflections or an interview with a preceptor).
Through its Statement of Commitment to Service-Learning the School of Medicine has undertaken to:
- Provide students with information about available community service opportunities in Canada and internationally
- Acknowledge students’ participation in service learning
- Ensure students connect service-learning experiences to their educational goals
- Allocate funds to help support service-learning activities
- Offer faculty and staff mentorship for student-run workshops, conferences and other events related to service learning
Although there is no mandatory requirement that medical students participate in a service-learning experience, such activities have been made available and engaged by students with steadily increasing numbers over the past several years. Eighty-four students reported involvement that would meet the definition of service-learning in 2013-14. Those opportunities include MedExplore (left), Altitude, Queen’s Community Health Talks (below, right) and Global Health Service-Learning.
To continue and grow these service-learning projects, we have undertaken the creation of a Service-Learning Panel, with funding to allocate to support and promote service learning. This includes:
- Engage the curriculum about service learning with a definition, a Service Learning Lead and learning events.
- Facilitate student contact with service agencies in the community
- Support service-learning projects with funding, counseling, and communication strategies.
- Recognizing individual students’ service-learning activities in the Medical Student Performance Record.
- Providing opportunities for students to share their learning experiences with their peers through existing venues or a new event
Going forward, students are able to submit individual activities for inclusion which will be included if they meet our service learning criteria. Meds students were surveyed on their participation in community service activities. Of those who responded, 55.9% said that they had participated in community volunteer work over the past year.
Encouraging opportunities for service-learning should in no way suggest that other, equally-worthy, voluntary service is not valued by the School of Medicine, Queen’s or the wider Kingston community (and other communities in which our students find themselves). However, because of the integrated nature of service-learning, it has the potential to provide unique opportunities for our students and our communities.