Author: Anthony Sanfilippo
Hope Amidst the Chaos of Charlottesville
Archbishop Desmond Tutu has defined hope as “being able to see that there is light despite all the darkness”.
It is difficult to find such light amid the darkness of the recent events in Charlottesville and their aftermath.
But such dark times are certainly not unprecedented in the history of our American neighbours.
Two hundred and fifty-five years ago, 56 rebellious colonists courageously broke their allegiance with a powerful monarch who they felt had been treating them unjustly. In what was an act of treason, they declared and justified their independence with the following words:
“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”
Fewer than ninety years later, the nation that emerged from that rebellion found itself engaged in a highly destructive civil war, caused largely by a failure to achieve those founding principles. In a brief but highly influential speech their leader at the time, Abraham Lincoln, justified the struggle and sacrifice by re-affirming those founding principles. He spoke of a nation “conceived in liberty and dedicated tothe proposition that all men are created equal”,and vowed that his nation would have “a new birth of freedom” ensuring that “government of the people, by the people, for the people, shall not perish from the earth.”
About a hundred years later, that same nation found itself again engaged in civil unrest arising from unresolved racial tensions and failed attempts to finally achieve its founding ideals. On a hot August day, standing at the base of a memorial dedicated to the very same President Lincoln, the Reverend Martin Luther King said:
“I have a dream that one day on the red hills of Georgia, the sons of former slaves and sons of former slave owners will be able to sit down together at the table of brotherhood”
In each case, the authors of these words were not expressing the realities of their times. Far from it. Rather they were giving eloquent expression to what they believed to be the values to which their nation, and any truly just society, should strive. They were expressing an aspiration, which faithful believers would contend, should remain in the collective consciousness, guiding decisions to continually approach the goal of full equality. Put simply, they were expressing hope.
This time, there is no soaring, inspirational eloquence recalling higher ideals and keeping hope alive. In fact, the actions and words of the current leadership evoke quite the opposite. Many, both within and without the borders of the United States, must be wondering whether the great American experiment in democracy and individual freedom has finally “perished from the earth”? Was the goal expressed in the original declaration (ironically penned by the most famous former citizen of Charlottesville) and re-affirmed so many times over the years, simply too much to expect of any group of mortal, flawed people. Where’s the hope?
For me, at least, hope was re-kindled in a single image captured by an amateur photographer with her cellphone, It depicts a Charlottesville police officer, himself African-American, standing guard at a barricade maintaining order despite the actions of those “protestors” whose overtly racist attitudes would bring harm to him and those closest to him.
Photo by Jill Mumie
The officer, Darius Nash, later wrote in response to his unexpected notoriety:
“I don’t feel like I’m a hero for it…I swore to protect my city and that’s what I was there to do. I don’t think it makes me a hero, just doing what I believe in.”1
At the same time that this police officer was doing what he believed in, his president and Commander-in-Chief was reluctant to condemn the actions of the other folks in this image and was finding fault in those who challenged them.
Who, of these two, is truly representative of today’s America? One would normally presume that the words and actions of the elected leader of a free people would represent the collective values of that nation. Hope for continuation of the American dream, it would seem, rests on whether the attitudes of this great people are best and most accurately expressed by its current president, or by the words and actions of a Charlottesville police officer.
I, for one, chose to believe, or hope, it’s the policeman. Like many Canadians, I follow American history and events closely. I know and count as friends (and even family members) many Americans. I have, for a time, lived among them. I have found that the vast majority of Americans are fair, decent and tolerant people. They are candid and pragmatic in addressing their social issues. They are proud of their nation and believe in its founding principles. They have been through remarkably difficult challenges and their political structures, although imperfect, have proven resilient under both internal and external threat. Ultimately, they are not a people to stand idly by and watch their values corrupted.
And we’re already seeing signs of that resolve.
Former presidents GHW Bush, GW Bush2 and Obama3 have all issued statements condemning bigotry and re-affirming the principles of equality – astounding gestures that attempt to fill the moral vacuum left by their successor.
Prominent business leaders, such as Merck CEO Kenneth Frazier, have resigned from influential presidential advisory panels4, risking loss of influence and the ire of the standing president.
Many athletes and celebrities have refused honours and invitations to the White House in protest5.
Most recently, more enlightened forces seem to be emerging in the White House itself, resulting in the firing of Steve Bannon, Chief strategist and former election campaign chair who was a driving force in this administration’s nationalistic, anti-globalization and anti-environmental agenda6. Mr. Bannon, one might recall, was formerly executive chairman of Breitbart News, which promoted the efforts and collaboration of “alt-right” groups such as neo-Nazis7.
So perhaps the tide is beginning to turn. Governments are like huge ocean-going vessels, built for the long voyage and therefore slow to adjust course.
In the words of Mr. Bannon, related to the Weekly Standard after his firing, “The Trump presidency that we fought for and won, is over”8.
Let’s hope that he’s at least right about that.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
- Globe and Mail, Aug 19, 2017
Life Lessons from an Unlikely Hero
Every sport, in fact every area of human endeavor, affords opportunities for heroes to emerge in dramatic fashion. In hockey, it’s the game winning overtime goal. In basketball, it’s the desperate long range shot with no time remaining that arches high over the court, seemingly suspended in space and time, before gracefully falling through the hoop.
In baseball, it’s the walk-off home run. This occurs when a batter, in the ninth inning, hits the ball out of the park assuring victory for his team. It’s called “walk-off” because it ends the game and all players depart – losers dejectedly, winners in joyous celebration. When there are runners on every base, it becomes a “grand slam” home run, adding further to the drama and celebration.
Among the more than 18,000 athletes who have played professional baseball since it’s inception in 1876, only two have hit multiple grand-slam walk-off home runs in a single season. That is, until a couple of weeks ago, when Steve Pearce of the Toronto Blue Jays did just that, during a single week of play.
When these moments happen to those who have already achieved prominence, it seems the natural extension of a pattern of excellence. But when it happens to someone previously unheralded in their field, it can be particularly sweet and revealing. Such is the case with Mr. Pearce. He is not a baseball superstar. He is not even a star. He has been described by those far more knowledgeable than I as a below average defensive player. He has, in fact, been characterized as a “journeyman” or “utility player”, which sounds like the sporting equivalent of a spare part that one might search for at the auto junkyard.
He was chosen in the 45th round of the 2003 major league baseball draft, meaning approximately 1200 players were chosen ahead of him. This is like being the last kid standing when your playmates are choosing sides for a game – “OK, we’ll take him, but you have to give us somebody good too”. He actually re-entered the draft twice, finally signing with the Pirates in 2005. Over his career he has played for no fewer than 8 teams. He didn’t start a season in the majors until 2011. In 2012, he played for three different teams. In his best year, 2014, he had 21 home runs, 49 RBIs and a .293 batting average playing for Baltimore. Respectable figures, to be sure, but far from spectacular. He is described by sports writer Cathal Kelly (Globe and Mail, July 30, 2017) as someone possessed of an “intense averageness”, with “no veteran swagger”. He is, by all accounts, unpretentious and well liked by his teammates – a hard worker and team oriented contributor who appreciates the opportunities he’s had to make a living in his chosen occupation. His response to his recent accomplishment and celebrity was, to say the least, modestly measured and understated. His teammates seemed genuinely pleased about his unexpected notoriety, evoking a sense of justice for the common man.
But Mr. Pearce hasn’t always been a common man. Growing up in Florida and attending the University of South Carolina, he was an outstanding athlete, excelling in multiple sports, but particularly baseball where he led his teams, set performance records, and won multiple and significant personal recognitions for his accomplishments. In fact, it wasn’t until he entered the major leagues that his “averageness” became apparent.
Despite all this, Mr. Pearce has survived in a highly competitive occupation, has earned (according to baseball_reference.com) almost $17 million in total salary, is highly respected by his peers and, this past week, injected joy into what has otherwise been a decidedly joyless season for followers of Toronto baseball.
So, you’re wondering, how does this story find its way into a blog about the education of doctors?
In about three weeks, we will be welcoming a new class to our medical school. Those young people have been accepted based on very impressive personal academic and non-academic accomplishments. They have known much success and have experienced much external approval. In that sense, they are not unlike Mr. Pearce as he began his professional career. They will find, as do all successful professionals, that their natural abilities are essential but not sufficient to achieve career success and personal satisfaction. They will need to define for themselves their concepts of success and worth. They will need to find their place within their new community of peers and teachers, and their way to make contributions within their chosen profession. They will need to find ways to engage and overcome adversities that will invariably come their way. They will, no doubt, have “grand slam home run” days, but must be equally content with the days of unheralded, honest effort.
These are life lessons, and the exclusive domain of no particular group. They will not be found in any formal curriculum. The term “hidden curriculum” has taken on very negative connotations, but it can also be a very positive force, providing that informal but vital exchange that occurs between students and their teachers that models and promotes professional development.
I don’t imagine Mr. Pearce thinks of himself as a teacher of aspiring physicians, but his perseverance and equanimity in the face of both adversity and success are an example to us all.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Chill out, Zio
The sign on the door clearly said the store should have reopened at three. According to my watch, and confirmed by my cellphone, it was now 3:12. I’d been waiting a full 3 minutes.
The place where I was waiting wouldn’t really qualify as a “store” as we would understand the term. It was really a ground level room of a three-storey home on the main street of the small Sicilian village I was visiting for my niece’s wedding. It was attached to rows of similar buildings that lined the narrow main street where most of the other ground level
rooms had been similarly converted to a variety of businesses – grocery stores, flower shops, bakeries, espresso bars, and other purposes I couldn’t discern based on outward appearances.
This particular “store”, I was assured, was the only place I might obtain a media card, the object that was apparently preventing my cellphone from being able to store more pictures. Fabrizio, who operated the store, would know what to do.
Looking through the glass, I became dubious that I’d find any solutions among the apparently random collection of items in the small, cluttered space. It seemed more like a workshop than a place of business. In fact, I wasn’t sure how more than one person would even fit inside.
I turned to my niece who had come along to help me find the store. As the central figure in the aforementioned wedding, which promised to be the social event of the season, she certainly had better things to do. But here she was, remarkably calm despite the circumstances and lateness.
“Where is he?” I asked, with righteous agitation.
With an expression one might reserve for calming a hyperactive child, she turned her big brown eyes to me and said with barely disguised condescension:
“But Zio, he lives upstairs. He’s having lunch with his family”.
And there it was. Crystallized in those few words, expressed by this young and vibrant woman, all the differences between her world and mine came into sharp focus.
In her world, people were simply not ruled by any clock or regulation.
In her world, people choose to spend their time doing what is valuable to them, and are unapologetic in doing so.
In her world, people not only take time for lunch, but truly value that time despite what we might regard as greater priorities.
In her world, the choice to value private time over work is not simply tolerated, but understood and respected.
Her world has trust and comfort in its way of life, and regards our work-obsession with a combination of amusement and pity. It’s a world that says, without rancor, but in no uncertain terms, “you’re here now – chill out, because we’re not changing.”
This is not a new realization for me. The contrast between the lifestyles of my ancestral and birth homes becomes apparent whenever I visit, but my understanding has changed, perhaps matured, over the years. What I previously regarded as a quaint, anachronistic way of life out of keeping with the modern world, I now see as an explicit and insightful choice, particularly when made by bright young people like my niece and her fiancé (now husband) who are choosing to remain and begin their lives there.
There is, of course, a price to be paid for this less-than-compulsive approach to productivity. The Italian economy is a continual source of concern to both its leadership and the international community.
Despite this glum outlook, Italian health indices, life expectancy, quality of life and “happiness index” rank among the highest in the world. There appears to be a dichotomy between the collective economic health of the nation, and individual contentment of its people.
Surely there are lessons there. Our two worlds, it would seem, have much to learn from each other. On a personal level, I love being Canadian and am grateful for the choice my father made to immigrate to this country, as was he. I also recognize that the Italian diaspora resulted a certain natural selection process whereby the ambitious and driven were more likely to leave their familiar surroundings, and so these differences are not surprising. Nonetheless, I very much appreciate the values and family focus of my ancestral home and have come to realize that occasional inoculations of “la dolce vita” provide much needed perspective.
When Fabrizio arrived and opened, I found that the door actually rolled up so that the store completely opened to the street. It became an open-air kiosk where he did his business on the sidewalk. In fact, all the stores were similar so that the street became sort of an open- air market where proprietors, passers-by, street residents and, occasionally, customers like myself, mingled as business was conducted. It was crowded, noisy, confusing, but welcoming and very engaging. There was none of the structure and process we associate with the consumer experience but things seemed to get done. Fabrizio, once we finished introductions and after he had enquired about every detail of the upcoming wedding, was able to find exactly what I needed from among the debris that was his workplace and install it in my cellphone. He had to stop a couple of times as his children wandered down to the store with some domestic issue that always, immediately, took precedence.
The wedding, by the way, was wonderful but started a half hour after the scheduled time due to the bride’s late arrival. No one seemed surprised. No one minded – least of all me.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Is every Canadian medical school graduate entitled to become a practicing physician?
If you’re reading beyond the title of this article, it is likely that you either believe this is already the case, or have a fairly strong opinion on the subject. In fact, I’ve come to learn that many Canadians, including medical school applicants and their families, believe that entry to medical school is the final major barrier to a career in medicine.
In the interest of ensuring a common starting point to this discussion, let’s clarify that a medical school degree does not entitle anyone to practice medicine in Canada. Graduates must also undertake and successfully complete a residency program. There are about 30 such programs available to graduates, all considered postgraduate programs within the same universities that house our medical schools, and all leading to qualification by either the Canadian College of Family Physicians or Royal College of Physicians and Surgeons.
Resident physicians, unlike medical students, are salaried during their training, which can last up to 7 years. The funding is provided by provincial governments, that therefore control the number and specialty distribution of postgraduate residency positions. In doing so, the number of medical school graduates is certainly known and considered, but the perceived societal need for physicians, both in terms of absolute numbers and specialty mix, is also a major determinant. The various ministries utilize complex but intrinsically imprecise methods to estimate those needs.
Each year, about 2900 students graduate from our 17 Canadian medical schools. There are a total of about 3300 postgraduate training positions available across Canada in all entry disciplines. In theory, there should be space available for all graduates. However, the specialty distribution of those positions does not match the career interests of the graduates. In fact, far from it. Some disciplines have many more applicants than available positions and are therefore highly competitive. Others that often fail to fill their positions. In addition, about 700 postgraduate positions are in exclusively French language environments and therefore not practically available to all graduates. Finally, each year about 2500 Canadian citizens or landed immigrants who graduated from schools outside Canada also apply for residency training positions. Although the number of positions for which they are eligible is restricted and controlled, they further reduce the availability of positions for Canadian medical school grads.
The net result of all this is that a steadily increasing number of Canadian med school grads are failing to find residency positions each year. This year, that number was 68, up from 46 in 2016 and 39 in 2015.
Depending on your particular perspective on this issue, those numbers may seem either insignificant or a major concern.
It is certainly true that the vast majority (over 97%) of Canadian graduates find residencies although not necessarily in specialties or locations of their choice. That is far more than occurs in virtually any other area of study or any other professional school, and may be seen as a reasonable concession in order to balance personal preferences against the societal need to have the right number of the right type of physicians in the right places, at least as assessed by those elected or appointed to protect the public interest. Medical education, after all, is not a right but a privilege, and a lucrative privilege at that. It is highly subsidized through the public purse, to the tune of an estimated half million dollars per physician in public funding. This is beyond the costs incurred by students themselves. It could also be rationally argued that an undergraduate medical education could serve as an excellent preparation for a variety of alternate careers, such as research, health system administration or medical technology.
Whatever your personal perspective, there are a number of consequences of this increasing phenomenon of “unmatched” graduates that must be considered.
- The sizable societal investment in medical education noted above is clearly intended to result in a productive physician engaging the health concerns of citizens. Anything else is a misappropriation of resources.
- The increasingly competitive environment for postgraduate positions is, understandably, becoming an increasing focus of attention to students. This influences how they engage all aspects of their curriculum and compromises what should be a time devoted only to learning and skill development. It also threatens the sense of collegiality and collaboration so important to a physician’s professional development and wellness.
- Undergraduate medical education is designed and structured with the intention of producing practicing physicians. It is seen as a continuum of training that leads seamlessly to practice readiness. The academic and professional expectations of students are based on this assumption. If significant numbers of students do not progress in their training, that concept and educational approach will no longer be justified. Can or should such high standards be maintained if significant numbers of students are expected to consider alternative careers?
- Students undertake considerable personal debt in supporting their medical education. The average debt in Canada is approaching $100,000, but ranges to over $250,000. This debt is supported largely by bank loans, provided on the assumption that the student will engage a career that will allow them to repay. Failure to engage postgraduate training can therefore trigger a need to repay a large loan with no means to do so. Failure to find residency training can therefore be a financial as well as personal disaster for these promising young people as they attempt to begin their careers.
- If the ability to obtain loans become more constrained, the already acknowledged socioeconomic barriers to medical education and careers may increase, affecting already underrepresented populations.
Finally, there is a huge personal cost to bear for those who go unmatched. These young people, who entered the study of medicine with understandably high hopes and aspirations, are forced to face rather bitter disappointment and self-doubt, often for circumstances that neither they nor those who advise them fully understand. That reality has been evident to those of us involved in medical education for many years. Recently, this situation has taken on a public face, thanks to the willingness of the family of Robert Chu to share their personal loss.
The following is quoted from a letter Robert addressed to Ontario Health Minister Eric Hoskins April 18, 2016:
“Without a residency position, my degree…is effectively useless. My diligent studies of medical texts, careful practice of interview and examination skills with my patients and my student debt in excess of $100,000 on this pursuit have all been for naught.”
Robert took his own life in September of 2016, after two unsuccessful attempts to obtain a residency position.
We cannot presume Robert’s motives for his actions, nor can this tragedy be laid at the feet of any individual or institution. However, it would be equally wrong to dismiss Robert as an inevitable casualty of a flawed system. At the very least, he personalizes and therefore crystallizes this issue for us and we should not dismiss the opportunity he and his family provide to engage this issue.
And so, we return to the initial question posed in the title of this article. Are we willing to make a commitment to our students and ensure that they have the opportunity to complete the medical training they have begun, at considerable personal sacrifice? If so, then major structural changes in the postgraduate entry process will be required, involving either expansion or sequestering of entry positions for unmatched students. Such changes are far beyond what undergraduate medical programs can achieve on their own.
To not make such a commitment is a de facto acceptance of the status quo, since it is clear that the current circumstances will continue and the number of unmatched students will therefore increase. In that event, we should, at a minimum, be fully honest and transparent with our students and applicants, clarifying that admission to medical school provides no assurance of eventual entry to medical practice. We should also alter our curricular objectives and content to ensure students are prepared for alternative careers. With no clear linkage to residency and eventual practice, clinical and professional components of undergraduate education will eventually be de-emphasized and deferred to postgraduate years, likely prolonging overall training.
And so, it must be asked: When does professional training for medicine begin? At present, the presumption is that it begins at entry to an MD program. A growing number of unmatched students changes that paradigm and, with it, the pedagogical basis on which those programs are established. The consequences extend beyond the interests of the students themselves, although they would be reason enough.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
How would you like to have been young Albert Einstein’s teacher? Walter Isaacson’s excellent biography, “Einstein. His Life and Universe” provides some intriguing glimpses of the great physicist’s early education that should be of interest to anyone involved in teaching gifted and naturally curious young people.
Popular myth holds that Albert Einstein was a poor student in early life. Apparently not so, but it appears he was certainly an uninspired and disengaged student. In fact, he failed to gain entrance to the Zurich Polytechnic on first attempt, failing to pass the general section of the entrance examination, which included sections on literature, French, zoology, botany and politics (as might be expected, he did well in the science and math sections).
As is the often the case, this apparent setback turned out to be a blessing in disguise, because it caused him to decide to prepare for the entrance subjects by enrolling in a school in the village of Aarau, located in northern Switzerland. This school, as it turned out, embraced a very different educational approach based on the philosophy of Johann Heinrich Pestalozzi (1746-1827), a Swiss educational reformer who believed strongly in individual discovery and in encouraging students to use visual imagery in their learning process. He pioneered a number of approaches that might sound familiar to us because
they’ve strongly influenced pedagogy, particularly early childhood education, over the years. For example:
- He stressed that instruction should be progressive, moving from the familiar to new concepts
- He believed in making allowance for individual differences
- He felt learning should be rooted in performance and lived experiences, thus emphasizing participatory activities such as drawing, writing, projects and field trips.
- He advocated (shockingly at the time and perhaps still for medical schools today) formal teacher training in education
It appears young Einstein found himself much better suited to the approach at Aarau. Isaacson quotes Einstein’s sister Anna’s observations:
“Pupils were treated individually…more emphasis was placed on independent thought and punditry, and young people saw the teacher not as a figure of authority but, alongside the student, a man of distinct personality”
Einstein himself is quoted as remarking:
“it made me clearly realize how much superior an education based on free action and personal responsibility is to one relying on outward authority.”
The use of visual imagery in the learning process seemed to particularly resonate with Einstein. It was at Aarau that he first utilized visualized thought as a means of conceptualizing and actually trialing this theories. “In Aarau I made my first rather childish experiments in thinking that had a direct bearing on the Special Theory.”
As he went on to carry out the “thought experiments” that eventually led to the development of his most significant scientific contributions, he actually avoided the
conventional academic university environment, which he found too restrictive and inflexible. Instead, he chose to take a fairly undemanding job in a patent office, largely because it provided him time alone each day to think and document his evolving theories. In a remarkable few months in 1905, while employed in that way, he developed no fewer than five remarkable papers that literally changed how we perceive the physical universe, including early works on quantum theory and special relativity. His doctorate was granted based on that work, as was his Nobel Prize.
Einstein, one might argue, is unique and it’s not reasonable to consider educational approaches for the masses based on such an example. It’s also very reasonable to observe that education, particularly at professional schools, must necessarily involve the learning of factual information and skills. Medical schools, in particular, have an obligation to ensure their graduates possess critical knowledge and can competently perform certain tasks. Consequently, a certain degree of pedantic delivery and directed instruction may be unavoidable.
Valid points, to be sure, but I would raise two further considerations. Although Einstein was clearly a remarkable exception in many ways, the drivers of his educational process were qualities that are not unique but, in fact, common in our students – curiosity, imagination and a pervasive desire to understand the world around them.
Secondly, it’s entirely possible to deliver factual information and have high performance expectations without stifling those critical personal drivers. Einstein’s teachers at Aarau obviously succeeded, not by diminishing the standards expected of him, but by additionally providing the latitude and encouragement to explore personal interests and learning. This required, on their part, a certain degree of open mindedness to novel and unconventional ideas, a willingness to engage the student as an individual with valid and fresh thoughts, and the humility to concede that their approaches may require individual modification.
In medical education, we face these educational challenges on a regular basis. Our students, without question, need to acquire considerable factual information and technical skills. They understand and accept that responsibility. As their teachers, we share with them the responsibility to ensure they meet certain minimal standards of competence. However, they are multi-dimensional, highly-motivated and thoughtful young people who develop interests and ambitions beyond these minimal standards, and we need to support them in those pursuits as vigorously as we support the core curriculum.
In educational parlance, this is termed “Independent Student Learning”, but if expressed simply as provision of unscheduled time students are free to use as they wish, the essence and potential of the concept is poorly served. It requires openness to new and innovative approaches to learning, even if outside standard curricular objectives. It requires institutional support and even encouragement for what might be termed “personalized” learning. It requires a (sometimes uncomfortable) engagement of what might be considered “destructive” innovation.
At Queen’s we have a number of examples of student initiated learning that illustrate nicely the potential advantages that can arise from such innovations for both students and the school. The Barry Smith Symposium, now in its third year, was conceived by two students (now graduates), Drs. Adam Chruscicki and Steven Hanna. Dr. Alyssa Lip, also a recent grad, was instrumental in the development of our wellness curriculum and Wellness Week, which has been embraced by other schools. The Queen’s annual Global Health conference which has been running now for many years by successive classes arose from student interest, supported by engaged faculty. This past week, Maggie Hulbert and Ashna Asim of the first year class have come forward with an idea to develop an event to explore the role of the humanities in medical education that we’ll be jointly exploring, likely as a new symposium event available next academic cycle.
For their part, students must accept the reality that medical education will require them to learn considerable material and demonstrate they have done so effectively. As faculty, we should support them in doing so, but also welcome support broader pursuits that both stimulate their genuine interests and can bring benefit to our school.
By doing so, we’ll hopefully avoid driving imaginative and motivated young people to the Patent Office.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Recognizing Outstanding Contributions to the MD Program
At the end of each academic year, the graduating medical class selects faculty it wishes to recognize for outstanding contributions to their educational experience. This is always a difficult task for them, given the number and quality of the teaching faculty they encounter during the four-year curriculum.
The most prestigious such recognitions are the Connell Awards. Named in honour of two former heads of Medicine and outstanding teacher/role models, these awards recognize three individuals who have, in the view of the graduating class, made outstanding contributions in classroom teaching, clinical teaching and mentorship. This year, I know the class had particular difficulty coming to final decisions, but I’m very pleased to announce that the awards went to three very deserving individuals who are all relatively early in their careers, already making tremendous contributions to our program.
The 2017 Connell Award for Classroom Teaching: Dr. Gordon Boyd
Born and raised in Thunder Bay, Ontario, Dr. Boyd received his undergraduate degree in Psychology from Lakehead University and his PhD in Neuroscience from the University of Alberta, where he studied the role of growth factors in peripheral nerve regeneration. In 2001 he moved to Kingston to do a post-doctoral fellowship in the Queen’s Department of Anatomy and Cell biology, examining the potential of glial cell transplantation to treat spinal cord injury. He stayed in Kingston to do his undergraduate degree in Medicine, which was followed by his residency in Neurology and fellowship in Adult Critical Care. He has been on Faculty at Queen’s University since 2013 as a clinician-scientist. His research interests are focussed on the neurological consequences of critical illness, cardiac surgery, and kidney disease. He also teaches at all levels of graduate and post-graduate medical education, on topics ranging from neuroanatomy to organ donation and has developed a well-earned reputation as a gifted teacher and mentor to students, both in the clinical and research settings.
The 2017 Connell Award for Mentorship: Dr. Jason Franklin
Dr. Franklin is also a Queen’s MD program grad (1998) having previously graduated with high distinction from the U of T HBSc program as an Immunology Specialist. He undertook his residency in Otolaryngology at Western University and went on to do a fellowship in head and neck oncology and microvascular reconstruction at U of T. He returned to Queen’s in 2013 to take on a lead role in head and neck surgical oncology. He and his wife, Kristina Polsinelli have three children, Nicolas (8), Alexander (7) and Talia (3) who Jason describes as his “claim to fame”. He describes his role as a Wellness Advisor in the undergrad program as his “most gratifying work”. Jason took on the role with great dedication and commitment. He has been a terrific advocate for our students individually, and participated effectively in our evolving Wellness curriculum.
The 2017 Connell Award for Clinical Teaching: Dr. Laura Milne
Dr. Milne is an Assistant Professor of Medicine at Queen’s University. She is originally from Durham, a small farming and industrial town in Southern Ontario. Prior to admission to medical school, she completed three years of undergraduate studies in physiology at the University of Toronto.
She studied undergraduate medicine at Queen’s University graduating in the class of 2008. She went on to pursue post-graduate medical studies in Internal Medicine at Queen’s University and graduated with a Fellowship in General Internal Medicine in 2012. Immediately after graduating, Dr. Milne worked as a general Internist in the community at Belleville General Hospital. She returned to Kingston General Hospital in early 2013 as a fulltime GFT faculty member in the Department of Medicine.
Since returning to Queen’s she has pursued her clinical interests in General Internal Medicine, Resistant Hypertension, and Stroke Prevention. She enjoys her work in the Undergraduate Medicine Program initially as a tutor for the Term IV Clinical Skills Course and, subsequently, as course director. She is currently course director for the Core Internal Medicine Clerkship Course. She also organizes the Internal Medicine yearly OSCE exam for the Postgraduate Medicine Program.
Dr. Milne brings that quality of “common sense competence” to her clinical, teaching and administrative roles. In a short period of time, she has earned tremendous credibility among the students and respect of the curricular leadership.
The Inaugural D. Laurence Wilson Award: Dr. Christopher Smith
I’d also like to introduce a new recognition being awarded for the first time this year. The D. Laurence Wilson Award was conceived and developed by the class of Meds ’66 on the fiftieth anniversary of their graduation. The award is named in honour of a distinguished clinician, teacher, role model and leader in the university and broader medical community who they feel exemplified the qualities of medical professionalism. To quote from the terms of reference of the award:
“Professionalism is the cornerstone of doctors who provide health care. The award with be provided annually to a faculty physician who best exemplifies the attributes of the profession that graduating class members aspire to emulate.”
Dr. Smith graduated from medical school at the University of London in 1990 and worked in the UK for several years before moving to the United States. He completed a 3-year residency in internal medicine at the University of Illinois at Chicago and completed a Chief Resident year before transferring to Cook County Hospital / Rush University for a fellowship in general internal medicine. He was an Attending Physician at Cook County Hospital for over 10 years and was intimately involved in the residency training program as an Associate Program Director. He was recruited to Queen’s in 2008 as the Program Director for the Core Internal Medicine program. He recently accepted a position as Head of the Division of General Internal Medicine. He performs most of his clinical duties on the clinical teaching units (CTU’s) and on the GIM consult service. His main interests are in medical education, evidence based medicine and clinical skills. He is widely regarded for his teaching, patient advocacy and mentorship to students.
Please join me in congratulating these four outstanding medical educators.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
“Why do you like baseball?”
I get asked this question a lot, mostly by those much younger than I – students, my children, nieces, nephews. It’s usually accompanied by an expression of pity that one would normally reserve for viewing the fossilized remains of extinct species. What they’re really wondering is “How could anybody in their right mind like baseball?”, or “Are you really that boring?”
I’ve often wondered myself, and have come to realize that, like most relationships, it’s complex and ever evolving. My grandfather got me started. He had two great passions beyond his family – opera and baseball. I remember visiting his sanctum – a small, dark, wood-paneled den filled with swirling pipe smoke where, settled in his overstuffed leather throne, he would watch a baseball game with the sound turned off while simultaneously listening to a recording of Pagliacci. I was never sure if the occasional tear in his eye related to the game or lyrics.
He immigrated from Italy in the 1920’s and settled initially with his wife and five daughters in Chicago. The opera he brought with him; the baseball he acquired as part of his new life. He loved to tell, with equal enthusiasm, of hearing Enrico Caruso perform and attending ball games at Wrigley. By the time he moved and settled in Huntsville, Ontario he had nine daughters (yes, NINE but that’s another story). I’ve often thought there was poetic symmetry in the number of daughters, the number of players on a baseball team and the number of innings in a baseball game, but he never claimed credit for the coincidence.
The daughters never intruded into the den while he was watching games but I was allowed to join him. At that time, I never really understood either interest. The grainy black and white images on the television screen didn’t hold much interest for me and seemed monotonous and slow compared to hockey games. The old phonograph recordings were scratchy and the lyrics didn’t make sense. The pipe smoke made my eyes water although I liked and can still vividly recall the smell of the tobacco. It was being with him that made it all worthwhile.
I was a reluctant recruit to both interests but, over the years have found myself, without deliberate intention, drawn to them. The opera might be considered a genetic inevitability. The baseball is acquired and harder to understand. On the surface, the young people have a point. Compared to other big league team sports, it’s slow and stuttering – monotony occasionally interrupted by moments of activity. Detractors love to note that during a complete baseball game, the actual active play only comprises about 10 minutes, but I’ve come to find that you have to scratch deeper to discover the charm and true depth of the game. It doesn’t give up its personality easily but, to the persistent observer, it reveals a character quite different than that of other so-called “major” sports. For instance:
There’s no clock. Baseball refuses to be governed by time. It’s over when it’s over, regardless of the hour. It eschews the concept of “clock management”, thank you very much.
It’s nerd friendly. No sport embraces statistics and relentless documentation of each and every event like baseball. There is an accounting and assigned acronym for every action and nuance in the game. True aficionados love to wallow in the numbers. And these statistics are not without meaning. “Moneyball: The art of winning an unfair game” by Michael Lewis is a fascinating account of how statistical analysis is being used effectively to change how players are selected and teams constructed. What all this means is that even those of us who aren’t gifted enough to play the game can understand what’s happening and comment with some validity. It brings together the athlete and the nerd and puts them on a more-or-less equal footing.
Personalities matter. In no game are individuals so much on display. Whether they’re pitching, batting, fielding or managing, there are moments in the game where attention is entirely focused on the actions of a single player, and there the outcomes are entirely dichotomous – success or failure. What becomes interesting is not whether they succeed or fail at whatever they’re doing, but how they respond to the moment. They become people with quirks and human reactions, not unlike those watching. And there’s the bound. Performer and spectator are brought together in this singularly human moment.
It’s quirky. The best nicknames: bar none. Consider: Catfish, Dizzy, Satchel, Pops, Smokey, Hammer, Sparky, Oil Can, Whitey, Yogi, Campy, Crabs, Eck, Gibby, Goose, Bambino, Mr. October, The Georgia Peach, The Say-Hey Kid, The Kentucky Colonel, The Splendid Splinter. And that’s just Hall of Famers. And the ballparks refuse to engage conformity. The Green Monster. The ivy at Wrigley. The brewery walls in the background of many outfields. Compare that to the obsessive conformity of football fields or hockey rinks. It all translates to personality and thumbing a nose at convention.
You don’t have to listen to it and watch it; either will do just fine, as my grandfather taught me so long ago. It’s also ideally suited to radio. In fact, it’s almost better.
It’s the most democratic of sports. Virtually anybody can play, and the game can be adapted and modified to fit the skills and energies of the participants.
It ain’t over ‘til it’s over. Hope springs eternal in baseball. Until the final batter makes the final out, there is always the potential for a team to come back from a deficit and snatch victory from defeat. In most other sports, points of hopelessness can develop where play becomes meaningless, but players are nonetheless required to go through the actions. An abomination.
It overcomes adversity. More than any other team sport, professional baseball has had its share of tragedies and miseries, all played out under public scrutiny. Segregation, corruption, betting scandals, the performance enhancing drugs debacle, have all tarnished its reputation and challenged the assumption of inherent innocence. In every case, the game has been the vehicle by which deep societal flaws have found expression and come to attention. As such, perhaps the game has served a purpose, reaffirming that the innocent are not immune from evil, but need not be defeated by it. Incredibly, improbably, it endures, scared but not broken, and arguably better for the experience. A metaphor for us all.
In the end, there’s a beguiling charm about a game that’s so quirky, unpretentious and stubbornly enduring. It survives despite the changes the world tries to impose. So, in answer to my young inquisitors, that’s why I like baseball. That, and memories of tobacco smoke, and Pagliacci.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Unintended casualties of Medical Assistance in Dying
There shouldn’t be much more to say about this subject. The highly contentious and divisive issue of medical assistance in dying (MAID) has been widely and publicly discussed. From a legal perspective, the issue has been settled in Canada. Citizens can now opt to have their lives ended given they fulfill certain criteria. The medical profession and our hospitals have an obligation to support patients who qualify. Individual physicians who chose to actively end the lives of these patients will be legally protected in doing so. Those who conscientiously object are not required to provide MAID but are professionally and ethically required to support their patients in making the decision and seeking the service, which is now being provided, both in and out of our hospitals. There would seem to be no need for further debate or discussion.
However, little has been written about the impact on those involved in the care of patients opting for MAID.
I’ve recently been hearing from medical students who, in the course of clerkship rotations, became involved with patients who elected for medically assisted death. They have found the experience, to say the least, highly unsettling.
For those readers not familiar, senior medical students, in the course of their clinical placements, will become part of medical teams caring for groups of hospital in-patients. The medical student is the most junior member of that team, consisting of graduate physicians training in particular specialties and supervised by a fully qualified Attending Physician. The student is assigned a small number of patients who they are expected to assess and follow throughout their hospital stay. They report regularly on their patients to senior residents and the Attending Physician who review the patient with them and must approve all investigations, treatments and major decisions.
In the course of these rotations, medical students get to know their patients quite well. In fact, they may become the member of the team most familiar with all aspects of the patient’s history and current care, most familiar with the patient as an individual, often even meeting their family, and may become a source of support and information to the patient and family. In short, they “bond” with their patients. Because these are the first such experiences for medical students, these relationships can be quite significant for them, and very memorable. Most practicing physicians can recall with considerable detail and deep feeling patients they encountered as medical students.
When a patient assigned and followed by a medical student dies, it can therefore be quite an emotional experience for the student. They can experience a sense of very personal loss. They grieve. When that death occurs as a consequence of the medical illness under treatment, that loss and associated grief are difficult but valuable components of the learning experience. They understand that this is something that every physician must learn to deal with. Doing so is a part of professional development that must be experienced. In the learning context, senior members of the team can support them by sharing the sense of loss and their own experiences. Within the medical school environment, they can also seek help from knowledgeable and experienced advisors and counselors.
Medically assisted death brings new dynamics and challenges to physicians involved in the care of the patients.
Although always prepared intellectually for the eventuality of death as a consequence of illness, students (and qualified physicians) are not prepared either intellectually or emotionally for the concept of deliberately ending a patient’s life, even if they’re not directly involved in the final act. Coming to grips with this in the abstract is one thing, but encountering it in a person one has engaged as a patient and has gotten to know personally is quite another. No one engages medicine as a career with this purpose in mind.
We teach and practice that medical care should continue throughout a patient’s life, and that compassionate attention and care to a patient’s needs and comfort should not stop when cure is no longer possible. Participation in MAID seems, for many, very difficult to reconcile with that approach, even when carried out at the request of the patient.
Medical students on clinical rotations who have been involved with MAID situations, I’ve come to learn, are particularly vulnerable. There are a number of reasons for this. They may be reluctant to express and undertake “conscientious objection” out of fear of being seen as weak or inadequately trained. They may not be aware of that option. They may not yet be clear about their own perspectives on the issue or reactions to these situations. They are young, and for many these may be their first experiences with professional or personal loss. The playing field, therefore, is far from even.
Moreover, supervising physicians and residents who are themselves engaging MAID for the first time may be coming to grips with their own involvement and therefore uncomfortable and unprepared to counsel students involved in these situations.
For all these reasons, we need to give some consideration as to how we can best support students as they (and we) come to grips with MAID. This will involve ensuring:
- They understand the legislated rights of patients
- They understand the ethical/professional obligations of physicians
- They understand the procedures in place to provide MAID in their hospitals and communities
- They learn of the needs and how to best support patients with chronic pain and other end-of-life challenges
- They understand that when patients under their care die, they will experience a personal reaction they won’t be able to fully anticipate until it happens.
- That they know how to seek help to deal with these situations.
We also need to ensure our residents and faculty are aware and prepared to respond.
There is a danger that raising such concerns may be regarded as callous to the suffering of patients with terminal diseases, or opposition to their right to choose an option that is legally available to them. That is not the intention. The right to assisted death has been legally provided and should be honoured. However, the well-intentioned efforts to provide MAID has placed new and impactful demands on physicians and learners which were either unanticipated or ignored. We must consider these consequences as we come to grips with how this legislated right is to be provided.
In the end, there is something profoundly dissonant about expecting that those who have dedicated their lives to preserving life will also participate willingly in ending it, and without personal consequence. There is a price to be paid, and that toll may be falling on the most vulnerable among us.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
The Creative Spirit in Doctors: Medicine’s Two-edged Sword.
Over two full and very busy weekends in March, about 600 young people from across Canada are invited to Queen’s to apply for admission to our medical school. As they do so, they are welcomed, guided and encouraged by our first year class. Part of their welcome to our school is a video they screen for the applicants and their families, intended to entertain, but also to give some sense of our values and identity as a school and community. That video, essentially a fairly sophisticated mini-musical, is written, performed and produced entirely by members of the first year class. In fact, almost every member of the first year class is involved in some way in the production process.
Later this week (April 7th and 8th – get your tickets), our students will be putting on the latest version of Medical Variety Night “The Phantom of the Operation”. Anyone who has attended one of these productions in recent years will realize it has become much more than satirical commentary and slapstick humour (although both are still very much in evidence). MVN has become a showcase for the considerable musical and creative talents of our students, from sophisticated dance to rather impressive musicianship. In fact, as you get to know our students, you will find that a surprising number of them have deep interest and maintain active involvement in artistic pursuits. In many cases, there’s almost a reluctance to admit to such interests, perhaps fearing it may suggest a lack of focus or dedication to their burgeoning medical career.
This deep-seated interest in the arts extends to our faculty, for whom it may be submerged or “put on hold” but never fully suppressed. In the Department of Medicine, several members
have combined their musical talents to form “Old Docs, New Tricks” which, it seems, brings as much satisfaction to the performers as those they entertain. I happen to know a certain department head and accomplished career scientist who is a remarkably gifted classical guitarist. A cardiovascular surgeon acquaintance of mine “moonlights” as an operatic tenor. Even if not actual performers, many of the great physicians I’ve encountered and gotten to know well over the years have deep appreciation for literature, music and the arts.
This shouldn’t come as any surprise.
Albert Einstein, who had a lifelong and active interest in the violin said:
“If I were not a physicist, I would probably be a musician. I often think in music. I live my daydreams in music. I see my life in terms of music.”
Largely self taught, he also observed “love is a better teacher than a sense of duty.”
Winston Churchill possessed a remarkable creative energy that found expression in multiple ways. He was a prolific amateur painter, and also enjoyed bricklaying fences, gardening and breeding butterflies at Chartwell. His two great literary contributions The Second World War and A History of the English Speaking Peoples read not as dry historical accounts, but as personal memoirs written in a highly engaging narrative.
Scratch the surface of greatness, it seems, and an artistic temperament usually emerges.
So is all this just coincidental? Do bright people just naturally engage multiple interests, or is there a connection between career success and a creative, artistic personality? Are there particular lessons here for the medical profession, and for medical education? I’m sure there are many, but I would highlight three:
Creativity is creativity.
Whether it is conveyed in music, words, or scientific innovation, the expression of new ideas, or interpretation of existing ideas in fresh and unexpected ways, is the essence of the creative process. This does not apply only to research. Because every patient and every clinical situation presents unique challenges, the effective physician is required to continually develop creative approaches. Our best administrative minds are able to “think outside the box”. Algorithms, practice guidelines and standard approaches can only take us so far.
It broadens our appreciation of the human experience.
Creative art, in any form, is fundamentally an attempt to express some aspect of the human experience, and hold it up for all to see, consider and learn from. David Skorton, a cardiologist (and jazz flautist) who is currently head of the Smithsonian Institution perhaps expressed this best in an impassioned keynote address at the recent annual meeting of the American College of Cardiology entitled “Medicine Needs Art to Flourish”.
“There is a reason we hang art on our walls and venture out to hear live music and watch theatrical productions. There is a reason the words of Shakespeare or Angelou or Springsteen move us. There is a reason we gather in temples, cathedrals, libraries and museums. The reason is that we learn fundamental truths about ourselves.”
Those truths, I would argue, are critical to the practice of medicine.
It promotes wellness.
At the risk of being overly simplistic and offending those much more knowledgeable in such matters, let me simply say that I believe the creative process is good for us. There is something fundamentally and rather profoundly satisfying about producing something new and uniquely personal. Whether it’s music, performance, creative writing or whatever doesn’t seem to matter. It doesn’t even matter whether it is carried out privately or very publicly. Creative expression somehow connects us with ourselves and with the world in a way that is validating and allows us to better face all our various challenges. We need it. We crave it. It’s almost intoxicating. If you need convincing, watch the expressions and body language of students or physicians as they engage their various artistic interests. Consider how many immensely talented young people engage careers in the arts with little prospect of personal security, or even opportunities to indulge their passion. Again quoting Einstein, who knew a thing or two about the creative process, “I know that the most joy in my life has come to me from my violin.”
So the advantages seem obvious. A creative mind and artistic spirit provide an ideal starting point and are quite probably essential to learning and practicing medicine. It could even be considered quite natural that creative thinkers will be drawn to careers in medicine. But, as with most natural processes, there are counterpoints, or consequences to consider.
The artistic spirit follows its own path and naturally resists external control. Since the profession so often attracts these free and independent thinkers, developing consensus and unified approaches to controversial issues can be hugely challenging. This reality is in rather public and painful display in Ontario at present and, I’m sure, at any department or practice group meeting. Doctors will never be found marching lockstep for any cause, or at least not for long.
Leadership within the medical profession is therefore a considerable challenge for those who bravely take on such positions. To be effective, that form of leadership must be much less about exerting authoritarian control and much more about harnessing and nurturing the considerable creative and highly-motivated energy available. That harnessing and nurturing takes interpersonal skill, patience, energy and self-sacrifice, a rare but very valuable combination of attributes.
The other unfortunate consequence of an artistic spirit engaged in work that demands high level performance of repetitive tasks is restlessness. Creative minds require continual and changing challenges. Put simply, they get bored doing the same thing, even if that thing is critically important and demands perfection. Failure to recognize this, I would conjecture, leads to job dissatisfaction and what we might identify as “burn out”. On the other hand, recognition of this issue by both the individual and those in leadership positions can provide opportunities to harness that creative restlessness and use it to great advantage, salvaging careers while strengthening groups and institutions.
So the artistic temperament can truly be regarded as both a great advantage and potential liability for the profession. Like the metaphorical two-edged sword (or scalpel), it can be very effective, but must be grasped carefully and handled skillfully.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Embracing a Proactive, Preventive Approach to Student Wellness
Preventive medicine: Medical practices that are designed to avert and avoid disease. For example, screening for hypertension and treating it before it causes disease is good preventive medicine. Preventive medicine takes a proactive approach to patient care.
Clinical medicine and medical education often intersect in intriguing ways. The concept of Preventive Medicine, defined above, is well understood and accepted in medical practice. Fundamentally, the concept involves:
- Identification of modifiable conditions that promote development of a particular disease, called “risk factors”. (The term “modifiable” is key here, since many known risk factors, such as family history and age, are beyond our ability to influence).
- Detection of those who harbour the risk factor
- Development and implementation of strategies or treatments to prevent or neutralize the culprit risk factor
In my own field of cardiology, hypertension, hypercholesterolemia, and smoking are among the most well established risk factors, all known to contribute to the development of coronary and cerebral vascular disease. All are modifiable through lifestyle changes and appropriate application of medications.
The challenge of preventive medicine, of course, is that folks who have these risk factors are unaware and feel fine before they actually develop symptomatic manifestations of vascular disease. It’s therefore often difficult to detect them and, once detected, convince those at risk that they should change their lifestyle or accept the need to take a medication (with potential for unwelcome side effects). The challenge for physicians promoting and practicing Preventive Medicine is therefore considerable. It requires them to not only be aware of the science and evidence related to risk modification, but to develop personal and effective relationships with their patients. It requires much more than dogmatic pronouncements. “Do what I say because I know better” seldom works, or survives the first minor adverse effect. It requires, dare I say it, a relationship of trust. Patients accept preventive treatment not because of the diploma on the wall, but because of they trust the intentions and motivations of the person providing the advice. That trust, in turn, is rooted in a distinctly human and interpersonal perception that the physician truly cares for them and is making recommendations solely on that basis. Patients, I’ve come to believe, possess an almost instinctive ability to perceive authentic altruism in medical encounters.
Medical students are also an “at risk” population. As many studies have demonstrated, rates of “burn out”, mental disorders and even suicide, exceed rates expected in the general population. (http://jamanetwork.com/journals/jama/article-abstract/2589340)
Unfortunately, prevention of medical student risk remains an imprecise science, with much speculation but little objective evidence that would guide appropriate preventive interventions. Nonetheless, here at Queen’s and at medical schools across the country, curricular leaders are not content to simply respond to crises that emerge, but are developing approaches they hope will raise awareness and allow students to identify and modify risk in themselves and their classmates. They are, in essence, extending the principles of Preventive Medicine to the world of medical education.
At Queen’s, Dr. Renee Fitzpatrick and the Student Affairs team has developed a Wellness program that is not an “add on”, but rather embedded within our core curriculum. That approach embraces multiple components, including didactic content, embedded scenarios, easy and confidential access to help, and Wellness Retreats. The latter are half-day sessions planned in conjunction with the students themselves, to promote awareness and preventive interventions.
In addition, the recently revised School of Medicine strategic plan will, for the first time, identify Wellness as a strategic priority for all our programs.
The major challenge, as with any preventive strategy, will be to reach those who are at risk but unaware, and are therefore the most reluctant to engage the issue with necessary commitment. The reluctant include both students and faculty. In addressing this difficult but critical challenge we must recall the lessons of the clinical world, that effective intervention must be rooted in the development of trust, and that trust evolves naturally from truly caring about the welfare of those affected
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education