Medical Students as Researchers

Should Medical Schools require, encourage, or support active research by students?

As I was recently completing Medical Student Performance Reviews (aka “Dean’s Letters”) for our fourth year class I was, once again, struck by the scope and quality of research undertaken by our students. Our curriculum provides instruction in research methodology, statistical analysis and critical appraisal. It also features active participation in the generation of research hypotheses and development of methodologic approaches to test those hypotheses. However, our students are not required to complete a project to the point of publication during medical school. Nevertheless, many do just that. With the help of members of our Undergraduate Office staff, I compiled the following summary information:

  • 69% of the class were authors of a published article during their medical school career
  • those students contributed to a total of 242 publications
  • in 137 of those publications, our student was the first author

Lest you think these are simple topics of minor interest, let me provide a few examples of publications first authored by one of our students, chosen to highlight the variety and scope of work undertaken. (For the entire list of first author publications go here).

Chang J, Munir S, Salahudeen S, Baranchuk A, Morris C, O’Reilly M, Pal R.  Atrial thrombi detection prior to pulmonary vein isolation: Cardiac computer tomography versus transesophageal echocardiography.  J American College of Cardiology (2013)

Cho CK, Drabovich AP, Batruck I, Diamandis EP.  Verification of a biomarker discovery approach for detection of Down syndrome in amniotic fluid via a multiplex selected reaction monitoring assay.  Journal of Proteomics (2011)

Cusimano M, Pudwell J, Roddy M, Cho CK, Smith GN.  The maternal health clinic: An initiative for cardiovascular risk identification in women with pregnancy-related complication.  American Journal of Obstetrics and Gynecology (2013)

Dossa F, Gao FQ, Scott CJM, Black SE.  Relationship between white matter hyperintensities and hippocampal atrophy in Alzheimer’s Disease.  Canadian Journal of Geriatrics (2009)

Eid L Helm K, Doucette S, McCloskey S, Duffy A, Grof P.  Bipolar disorder and socioeconomic status: What is the nature of this relationship?  International Journal of Bipolar Disorders (2013)

Fernando SM, Szulewski A, Baylis JB, Howes DW.  Motion artifact reduction of ECG signal allows for greater chest compression fraction during CPR.  Canadian Journal of Emergency Medicine (2013).

Ferrara S, Bradi A, Pokrupa R.  Decreasing neurologic consequences in patients with spinal infection: the testing of a novel diagnostic guideline.  Canadian Journal of Surgery (2012)

Fitzpatrick AM, Gao LL, Smith BL, Cetrulo CL, Cowell AS, Winograd JM, Yaaremchuk MJ, Austen WG, Liao EC.  Cost and outcome analysis of breast reconstruction.  Annals of Plastic Surgery (2013)

Gray AB et al.  The effect of a coronoid prosthesis on restoring stability to the coronoid-deficient elbow: A biomechanical study.  The Journal of Hand Surgery (2013)

Joundi RA et al.  Persistent suppression of subthalamic beta-band activity during rhythmic finger tapping in Parkinson Disease.  Clinical Neurophysiology (2013)

Kokorovic A, Cheung GW, Breen DM, Chari M, Lam CK, Lam TK.  Duodenal mucosal protein kinase regulates glucose production in rats.  Gastroenterology (2011)

Koppikar S, Baranchuk A, Guzman JC, Morillo C.  Stroke and ventricular arrhythmias>  International Journal of Cardiology (2013)

Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG.  Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation.  Applied Physiology, Nutrition and Metabolism (2011)

Lun G, Atenafu EG, Knox JJ, Sridhar SS, Tannock IF, Joshua AM.  Use of a clinical assistant to screen patients with genitourinary cancer to encourage entry into clinical trials and use of supportive medication: A pilot project at a Canadian cancer centre.  Clinical Genitourinary Cancer (2013)

Osumek JE, Revesz A, Morton JS, Davidge ST, Hardy DB.  Enhanced trimethylation of histone H3 mediates impaired expression of hepatic glucose-6-phosphatase expression in offspring from rat dams exposed to hypoxia during pregnancy.  Reproductive Sciences (2013)

Rogers E, Wang BX, Zhu C, Rowley DR, Ressler SJ, Vyakarnam A, Fish EN.  A host factor that influences the neutrophil response to murine hepatitis virus infection.  Anitviral Research (2012)

Tohidi M, Robinson L, Graham T, Smith G.  Effect of caffeine ingestion on fetal heart rate activity.  J Obstetrics and Gynecology (2013)

Wang M, Reid D.  Virtual reality in pediatric neurorehabilitation: Attention deficit hyperactivity disorder, autism and cerebral palsy.  Neuroepidemiology (2010)

So all this begs two key questions:

How does this happen?

Should it happen? Put another way: Should active participation in research be encouraged or intentionally embedded into medical school curricula?

Let’s start with the easier, first question. Research participation of this breadth and quality comes about, in my view, as a result of three key and mutually interdependent factors.

blog-clarke1. Faculty leadership. We have been fortunate at Queen’s to have the strong support of our current and previous Deans (Richard Reznick and David Walker respectively) to the fostering of research at our centre. Undergraduate education has benefitted from this commitment in many ways, both directly and indirectly. blog-murrayImportantly, our student research efforts have been guided by the dedication and tenacity of two key undergraduate program leaders. Albert Clarke, now Emeritus Professor of Biochemistry, guided a Critical Enquiry course which was, for many years, a distinctive feature of our curriculum and engaged every student at Queen’s in an active research project. More recently, Heather Murray, Associate Professor in the Department of Emergency Medicine, has taken on leadership of the Scholar Competency in our revised curricular structure. In doing so, she has incorporated the spirit of Albert’s Critical Enquiry and embedded it into our curriculum such that every student participates in a discipline specific research group with the goal of developing a hypothesis generating proposal and appropriate research methodology.

2. Faculty support. These efforts, of course, could not have taken place without the active participation of many faculty whose commitment to medical education and research drives them to contribute their time and creative energy. In fact, no fewer than 60 of our full time clinical and basic science faculty members are involved in the support and mentoring of our students in the Critical Enquiry program. The effort they provide, I can assure you, is far beyond the compensation or recognition they receive. They do this, quite simply, because they “buy in” to the value of research in general, and its development in medical school in particular.

blog-students-13. Student engagement. As mentioned earlier, our students are not required to complete or publish their research proposals. At our annual Research Showcase, most of our student body and many faculty turn out to review and celebrate the student research accomplishments of the previous year. A casual stroll through the many posters, conversation with the authors and review of the works selected for oral presentation are sufficient to convince that the dedication of our students to the themes they have engaged is original, genuine and highly insightful. It also speaks to many of the qualities that we should be seeking in medical school applicants and fostering in medical school. All this would suggest we must be doing something right in both domains, and should certainly encourage our ever-evolving admissions processes and curricular design.blog-students-2

The second question I’ve posed is perhaps more complex and controversial. There is increasing competition for time within MD programs as curricular objectives and accreditation requirements become more expansive. Curriculum Committees are called upon to make judgments between equally meritorious proposals for “real estate” and for the attention of students. In doing so, they must address a variety of forces and influences from disparate sources. The relevant accreditation standard from the joint Canadian/American agencies reads as follows:

IS-14. An institution that offers a medical education program should make available sufficient opportunities for medical students to participate in research and other scholarly activities of its faculty and encourage and support medical student participation.

Medical schools would seem to be required to provide opportunities but not ensure all students participate actively. The implied meaning would seem to be that research participation is desirable but not mandatory component of physician training.

The Future of Medical Education in Canada initiative, now in implementation phase, has two key recommendations that would seem to speak to this issue, but perhaps with somewhat divergent messages.

Recommendation III: Build on the Scientific Basis of Medicine

Given that medicine is rooted in fundamental scientific principles, both human and biological sciences must be learned in relevant and immediate clinical contexts throughout the MD education experience. In addition, as scientific inquiry provides the basis for advancing health care, research interests and skills must be developed to foster a new generation of health researchers.

The final sentence of this recommendation would certainly seem to support an active research agenda. On the other hand another FMEC recommendation would seem to suggest medical education should take on a broader, less discipline-focused approach…

Recommendation VII: Value Generalism

Recognizing that generalism is foundational for all physicians, MD education must focus on broadly based generalist content, including comprehensive family medicine. Moreover, family physicians and other generalists must be integral participants in all stages of MD education.

While the call for medical schools to emphasize generalism is certainly not intrinsically inconsistent with a strong research interest, and recognizing that many family medicine specialists make valuable research contributions, it is equally true that the highly focused and largely university-centred approach of those interested in research careers seldom overlaps with the generalist approach. These two recommendations therefore provide a considerable challenge to medical schools and those developing admission criteria and designing curricula.

Another obstacle to the establishment of individual research within a medical school relates simply to the demands on faculty. Effective research requires one-on-one mentoring and supervision. That faculty-student interaction, to be effective, must be intensive and continuing.

So given all these challenges, why bother? There are probably many reasons we could cite, but I’ll provide my top three:

  • The ability to critically assess new information is an essential physician skill, and will be even more important in future years as the volume and pace of new information increases. There is perhaps no better way to acquire that skill than to have engaged personally in the process of hypothesis generation, study design, data collection, analysis, presentation, and finally defending that work through the peer review process.
  • The research process requires mastery of many of the physician competencies we value and aspire to develop in our students, specifically medical expertise, communication, management, scholarship and collaboration.
  • The possibility of sparking, in even a few of our students, an interest in a particular topic or simply an awareness of the power of research process itself is enticing and potentially far reaching. It’s hard to imagine that the minds that developed or contributed to the works listed above won’t be positively influenced and perhaps inspired as a result of the experience.

Unfortunately, we can’t look into any crystal ball to know how many of the young researchers in our graduating class will carry that interest into their careers, or what influence their work will have. However, I think we can take some satisfaction that we have collectively done our best to provide opportunities that will enrich and inform those careers.

Many thanks to Katie Jones, Amanda Consack, Jane Gordon and Jacqueline Schutt of the Undergraduate Office for their assistance in the compilation of information for this article.

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Understanding Competency Based Education
Lessons from an unlikely source

I was recently asked to speak at a conference on the topic of Competency Based Education.  My assignment was to provide definitions of that topic and to discuss the advantages and challenges associated with developing such an approach in an undergraduate medical program.

graph-nov12My search for a universally accepted definition of CBE began with a call to Theresa Suart, Educational Developer, who promptly alerted me to the reality that no such thing exists and, in fact, I had stumbled into an area of considerable controversy.  She directed me to helpful references, including a 2010 paper by Jason Frank and colleagues (Medical Teacher 32; 631-637) that is actually a systematic review of published definitions!  They reviewed a total of no fewer than 173 published definitions and, as illustrated in this table from their paper, the topic has been attracting increasing interest in recent years.  All this leads me to doubt the practical utility or relevance of a topic that so many bright people have difficulty even defining.  However, one becomes accustomed to such dilemmas when venturing into the world of medical education, and begins to view such uncertainties as opportunities to re-examine basic principles and search for patterns or examples of prior success that may be applicable.

Screen Shot 2013-11-11 at 2.36.58 PMThe principle I always find useful in assessing educational change is the fundamental triad of associations between Objectives, Learning and Assessment.  One of my first practical lessons in curricular design (and accreditation standards) is that these three components must be closely linked if any medical curriculum is to be effective.  Objectives must drive instruction and learning, and assessment must be linked to the teaching provided and the stated objectives.

 

With this in mind, I searched for a simple example that might help advance our understanding of Competency Based Education.  A conversation with one of my nieces who’d recently completed her Driver’s Education course provided that example.  The granting of a Driver’s License is, in fact, recognition of a competence for which there exists an easily understood and widely accepted global objective, specifically the ability to safely operate an automobile.  That global objective requires a body of knowledge, skills and personal CanDriveattributes which, with apologies to the Royal College and with tongue firmly in cheek, could be expressed as the CanDRIVE competency domains, which centre around a body of knowledge and understanding (the Driving Expert) but require additional attributes, such as (we might conjecture) Judgement, fundamental Literacy, physical Coordination, Social Accountability, Alertness (no cell phones) and Sobriety.  The knowledge component is completely and clearly articulated by the Ministry of Transportation in the Driver’s Manual, and the assessment of competencies is demonstrated in three parts, a written examination with questions taken directly from the manual, a cursory visual assessment involving recognition of traffic signs, and a performance based driving test during which the candidate must demonstrate the global objective (drive the car) while exhibiting the component competency domains (show up sober, pay attention, etc…).

And so, two parts of the educational triad are provided.  The true brilliance of the Ministry of Transportation however, is in how they handle the teaching/learning component.  Fundamentally, they don’t.  Learning is the responsibility of the applicant.  That learning is guided, to be sure, by both implied and explicit expectations, but the candidate is expected to seek out their own education, at their own expense, carried out at their own schedule.  There is absolute clarity, however, of the ultimate goals and no mystery about the eventual summative evaluation (answer the questions, read the eye chart, drive the car).

Screen Shot 2013-11-11 at 9.39.27 AMThus, the Ministry of Transportation has (whether intentionally or not) developed a masterful model of Competency Based Education that:

  • Is based on objectives that are clearly understood by learners and assessors alike.
  • Built on a knowledge base that is discrete, well-described and accessible by all.
  • Requires a set of personal attributes that are understood by all and accepted as relevant to mastery of the competency
  • Does not attempt to assess those attributes individually, but rather evaluates the overall competency in a blended, performance based method, the format (and content) of which is completely understood and open to everyone involved.
  • is truly Learner centred

But, you’ll note, there’s obviously a world of difference between driving a car and practicing Medicine.  Indeed there is.  However, the ability to assess and manage a patient presenting with a particular clinical presentation is, like driving a car, a competency set that requires a combination of knowledge, skills, personal attributes (a set of objectives), that must be learned and must be reliably evaluated.  What can we learn from our simple example that’s relevant to any attempt to develop a Competency Based Medical Education program?

  1. The learning objectives must be developed and expressed in meaningful, pragmatic terms.  Competency to do what?  What specific things should the “competent” learner be able to do?  In this regard, the emerging development of Entrustable Professional Activities will no doubt play a major role.
  2. The assessment should be performance-based and relate clearly and directly to those objectives.  There should be no mystery as to what will be expected, and the method of evaluation must be pre-defined and understood by all.
  3. Learning is primarily driven by the learner, not an inflexible curriculum, nor should it be based on any particular schedule.
  4. The responsibility of the program (or institution) should be to provide clarity regarding learning goals, an environment in which learning can occur, and support for the learning process.

Finally, I provide the reader with the best definition of CBE that I’ve encountered to date, which emerged from the previously mentioned article by Frank and colleagues.  It not only expresses these principles succinctly, but does so in a manner applicable to either driving a car or caring for a trauma patient, perhaps the best test of any definition attempting to capture such a complex combination of knowledge, skills and personal attributes.

 Screen Shot 2013-11-11 at 2.40.05 PM

Thanks to Theresa Suart (Educational Developer) and Lynel Jackson (master graphic designer) for their assistance in the development of this article. 

Posted on

Understanding Competency Based Education Lessons from an unlikely source

I was recently asked to speak at a conference on the topic of Competency Based Education.  My assignment was to provide definitions of that topic and to discuss the advantages and challenges associated with developing such an approach in an undergraduate medical program.

graph-nov12My search for a universally accepted definition of CBE began with a call to Theresa Suart, Educational Developer, who promptly alerted me to the reality that no such thing exists and, in fact, I had stumbled into an area of considerable controversy.  She directed me to helpful references, including a 2010 paper by Jason Frank and colleagues (Medical Teacher 32; 631-637) that is actually a systematic review of published definitions!  They reviewed a total of no fewer than 173 published definitions and, as illustrated in this table from their paper, the topic has been attracting increasing interest in recent years.  All this leads me to doubt the practical utility or relevance of a topic that so many bright people have difficulty even defining.  However, one becomes accustomed to such dilemmas when venturing into the world of medical education, and begins to view such uncertainties as opportunities to re-examine basic principles and search for patterns or examples of prior success that may be applicable.

Screen Shot 2013-11-11 at 2.36.58 PMThe principle I always find useful in assessing educational change is the fundamental triad of associations between Objectives, Learning and Assessment.  One of my first practical lessons in curricular design (and accreditation standards) is that these three components must be closely linked if any medical curriculum is to be effective.  Objectives must drive instruction and learning, and assessment must be linked to the teaching provided and the stated objectives.

 

With this in mind, I searched for a simple example that might help advance our understanding of Competency Based Education.  A conversation with one of my nieces who’d recently completed her Driver’s Education course provided that example.  The granting of a Driver’s License is, in fact, recognition of a competence for which there exists an easily understood and widely accepted global objective, specifically the ability to safely operate an automobile.  That global objective requires a body of knowledge, skills and personal CanDriveattributes which, with apologies to the Royal College and with tongue firmly in cheek, could be expressed as the CanDRIVE competency domains, which centre around a body of knowledge and understanding (the Driving Expert) but require additional attributes, such as (we might conjecture) Judgement, fundamental Literacy, physical Coordination, Social Accountability, Alertness (no cell phones) and Sobriety.  The knowledge component is completely and clearly articulated by the Ministry of Transportation in the Driver’s Manual, and the assessment of competencies is demonstrated in three parts, a written examination with questions taken directly from the manual, a cursory visual assessment involving recognition of traffic signs, and a performance based driving test during which the candidate must demonstrate the global objective (drive the car) while exhibiting the component competency domains (show up sober, pay attention, etc…).

And so, two parts of the educational triad are provided.  The true brilliance of the Ministry of Transportation however, is in how they handle the teaching/learning component.  Fundamentally, they don’t.  Learning is the responsibility of the applicant.  That learning is guided, to be sure, by both implied and explicit expectations, but the candidate is expected to seek out their own education, at their own expense, carried out at their own schedule.  There is absolute clarity, however, of the ultimate goals and no mystery about the eventual summative evaluation (answer the questions, read the eye chart, drive the car).

Screen Shot 2013-11-11 at 9.39.27 AMThus, the Ministry of Transportation has (whether intentionally or not) developed a masterful model of Competency Based Education that:

  • Is based on objectives that are clearly understood by learners and assessors alike.
  • Built on a knowledge base that is discrete, well-described and accessible by all.
  • Requires a set of personal attributes that are understood by all and accepted as relevant to mastery of the competency
  • Does not attempt to assess those attributes individually, but rather evaluates the overall competency in a blended, performance based method, the format (and content) of which is completely understood and open to everyone involved.
  • is truly Learner centred

But, you’ll note, there’s obviously a world of difference between driving a car and practicing Medicine.  Indeed there is.  However, the ability to assess and manage a patient presenting with a particular clinical presentation is, like driving a car, a competency set that requires a combination of knowledge, skills, personal attributes (a set of objectives), that must be learned and must be reliably evaluated.  What can we learn from our simple example that’s relevant to any attempt to develop a Competency Based Medical Education program?

  1. The learning objectives must be developed and expressed in meaningful, pragmatic terms.  Competency to do what?  What specific things should the “competent” learner be able to do?  In this regard, the emerging development of Entrustable Professional Activities will no doubt play a major role.
  2. The assessment should be performance-based and relate clearly and directly to those objectives.  There should be no mystery as to what will be expected, and the method of evaluation must be pre-defined and understood by all.
  3. Learning is primarily driven by the learner, not an inflexible curriculum, nor should it be based on any particular schedule.
  4. The responsibility of the program (or institution) should be to provide clarity regarding learning goals, an environment in which learning can occur, and support for the learning process.

Finally, I provide the reader with the best definition of CBE that I’ve encountered to date, which emerged from the previously mentioned article by Frank and colleagues.  It not only expresses these principles succinctly, but does so in a manner applicable to either driving a car or caring for a trauma patient, perhaps the best test of any definition attempting to capture such a complex combination of knowledge, skills and personal attributes.

 Screen Shot 2013-11-11 at 2.40.05 PM

Thanks to Theresa Suart (Educational Developer) and Lynel Jackson (master graphic designer) for their assistance in the development of this article. 

Posted on

Goalies, Poets and Medical Students Fallibility and “the highway to success”

Jonathan Quick made a mistake.

Jonathan Quick
© http://wpmedia.o.canada.com/2013/10/quick.jpg?w=660&h=330&crop=1[i]

For those of you not familiar, Jonathan Quick is a professional hockey player.  Moreover, he is a goaltender.  Moreover still, he is one of the best goaltenders in the world.  Yes, I said world.   Last year, playing for the Los Angeles Kings, he amassed an impressive numbers of wins and statistics in all things relevant to goaltending, and was the most valuable player on a team that competed deep into the playoffs.  His accomplishments have been acknowledged in numerous ways, including being recognized recently by Sports Illustrated as one of the best four goalies in the National Hockey League and, perhaps most significantly, with a 10 year contract with Los Angeles said to be worth 58 million dollars.

Last Monday evening Jonathan was tending goal early in the third period of a home game against the New York Rangers.  His team was down 2-1 but on the power play, pressuring the Rangers for the tying goal.  One of the Rangers managed to nab the puck and send it into the Kings’ end of the rink.  Jonathan, alone in that half of the rink, came out of his net to play the puck, presumably to pass it up to one of his players to continue the power play.  In a manner later described as “comical” by a sports writer, he dropped his stick, misplayed the puck, attempted to recover with his blocker, but instead sent the puck slowly but inexorably into his own net, forced to watch it helplessly, along with the 20,000 or so folks in the arena, as well as most of the sporting world who would relive the moment repeatedly in broadcasts the next morning.  Perhaps most painful of all was Jonathan’s body language after this mishap – arms in the air, head down, clearly devastated.

Significant in all this was the reaction of his teammates and even opposing players.  Their manner at the time and in commentary afterward was in no way condemning, but rather sympathetic and supportive.  “Tough break”…”It could happen to any of us”.  Even the opposing goaltender, Hendrik Lundqvist, himself a stellar player, was quoted as saying “I feel for him”.

The message was clear.  Jonathan Quick is still one of the best goaltenders in the world.  What happened to him is regarded by those who labour in the same business as an occupational hazard in a profession that has no tolerance for error and very high public scrutiny.   To his lasting credit, Jonathan met with the press afterward and took responsibility for what had happened.  Regret, but no excuses.

One can’t help but draw a parallel to the medical profession, where adverse outcomes are regarded as “errors” and draw understandable scrutiny.  Doctors have always recognized the value of reviewing and studying cases where outcomes are anything less than optimal.  Those reviews must necessarily involve all aspects of the care delivery, from simple administrative process, through equipment performance to decision-making and technical provision of procedures.  Perfection, although never attainable in any human endeavour, must always be the goal.  Every adverse outcome provides a lesson and learning opportunity that makes the overall process safer and approaches that perfection.  Like poor Jonathan, alone, sprawled on the ice, physicians feel isolated and very responsible when events go badly, and struggle to interpret these in broader, depersonalized contexts, a necessary struggle if they are to learn and go on to provide care to their next patient.  The open acknowledgement and reporting of errors is a fundamental ethic, and legal responsibility of both the physician and profession.

Medical students begin this struggle very early.  Entering medical school with stellar and usually unblemished records of academic accomplishment, many students have great difficulty dealing with even minor “failures” in their course work or professional behaviour.  The ability to accept and even welcome feedback is a necessary professional competency and one of the most difficult to both teach and learn.  We are accustomed to success and the praise that comes with it.  Anything short of this is seen as a personal “failure” and something to be avoided and even contested.

My colleague Dr. Michelle Gibson likes to quote a particularly revealing study in which a group of medical students were randomized to receive feedback that was either laudatory but non-specific, or very specific and critical of their ability to perform a technical task, in this case tying surgical knots.  When asked to evaluate the value of their feedback, those who received laudatory feedback rated their feedback as much more valuable than those who’d been critically reviewed.  However, when assessed objectively with respect to their ability to tie knots at a follow-up test, the critically appraised students performed significantly better.  The tough medicine, it would appear, is more effective.

Teaching faculty struggle with providing feedback.  It’s much easier to praise and non-specifically encourage than to critique.  Finding ways to provide that critical feedback is equally challenging.  It’s not much help to simply say, “your knots aren’t very good, you should work on that”.  Pointing out the specific issue and even demonstrating correct technique takes time and patience, but will ultimately lead to real improvement.

None of this, of course, is surprising.  It’s the critical analysis and setbacks that help us improve and learn.  That lesson, however, is much more evident and easy to accept in mid or late career than it is to a novice learner.  Medical educators are in full agreement that the ability of a student to accept and assimilate criticism is a marker of both academic and career success.  The converse is equally true – that an inability to accept and grow from critical feedback is a marker of poor performance and poor behaviour in future years.  Humility, it would seem, is truly the beginning of wisdom, but it’s hard to be humble if you’ve never experienced or acknowledged failure.

The romantic poet John Keats (1795-1821) only lived to be 26 years of age, but in that time wrote the following: poet

“Don’t be discouraged by a failure. It can be a positive experience. Failure is, in a sense, the highway to success, inasmuch as every discovery of what is false leads us to seek earnestly after what is true, and every fresh experience points out some form of error which we shall afterwards carefully avoid.”

It may seem quite a stretch to connect a twenty-something English romantic poet of the early 19th century with 21st century hockey players and medical students of the same age, but the wisdom transcends both time and culture.

Jonathan Quick made a mistake.
Jonathan Quick is a great goaltender.
Last week, he got even better.

 

Image from:

[i] http://o.canada.com/sports/los-angeles-kings-jonathan-quick-deflects-puck-into-his-own-net/

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Not your Father’s (or Mother’s) Clinical Clerkship

Meds 2015 students get their white coats and begin the contemporary Clinical Clerkship 

This week, the students of Meds 2015 begin the phase of medical education still referred to as the Clinical Clerkship.  Last Friday afternoon, family and friends joined them to celebrate the White Coat Ceremony, a longstanding tradition that marks this important transition.  It was a pleasure to meet many family members, some of whom were physicians who remarked on the changes between their own educational experiences and those of their offspring.

white-coats

The need to provide supervised learning within the clinical setting has always been regarded as essential to the development of future physicians.  Indeed, early versions of medical education consisted entirely of what could only be termed apprenticeships under the direction of a fully qualified physician who was engaged by the student as their tutor, mentor and assessor.  It was largely as a result of Abraham Flexner’s (pictured) transformational 1911 review of medical education in North America that medical schools were required to provide formal instruction in the basic and medical sciences.  However, Flexner continued to emphasize the critical role of education within the context of clinical service.  flexnerThe role of medical students within service delivery, largely in hospital settings, became consolidated into the discrete role that came to be known as the Clinical Clerkship.  Being a “Clerk” was to have a job or role within the hospital’s complex service delivery.  The role consisted of “clerking” patients (carrying out admission histories and physicals), following the progress of patients through their hospital stay, arranging and following up on investigations, and coordinating discharge and post hospitalization follow-up.  In addition, Clerks had unofficial but widely accepted service delivery roles of their own within hospitals, including phlebotomy, administering intravenous medications, performing simple procedures such as Foley catheter insertion and cast removal, simple suturing and recording electrocardiograms.  Appropriately supervised and monitored, this role provided opportunities to engage patient care in all its complexity in a transitional fashion, leading eventually to the ability to engage patient care independently after graduation.  The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today.  Interestingly, the role of the Clerk varied very little between services, specialties and differing patient populations, the goal being to develop strong foundational skills in patient assessment and management, which were felt to be consistent and “learnable” within any patient care context.

As the “service” component of the clerkship grew and hospital care became more procedurally driven, understandable concerns were raised regarding the balance between service delivery and education.  Medical educators, buttressed by increasingly specific and prescriptive accreditation standards, developed standards and objectives for the medical student role, coupled with a need for more structured and objective assessment.  At the same time, our students were developing an increasing need to use clerkship experiences to explore career options in an increasingly complex and competitive postgraduate training environment.

Today’s clinical clerkship has evolved considerably from the model experienced by most mid or late career practitioners.  Now usually consisting of the final 2 years of medical school, it is intended to provide clinical exposures that vary not only in focus but also in setting, recognizing the reality that our students have a critical need to explore career options and to encounter patients in a variety of settings that will reflect their own career paths.  The rotations are enhanced with formal educational experiences, formalized feedback on all curricular objectives, and structured assessments of various types.  To illustrate the modern clerkship, the following example profile is provided to illustrate the journey of one medical student through a clerkship:

  • A six week General Surgery rotation on an in-hospital unit at either Kingston General Hospital or our affiliated teaching hospital in Oshawa.
  • A six week Peri-operative Medicine rotation rotating through a series of experiences with surgical subspecialties (such as Plastics, Orthopedics, Urology), Anaesthesia and Emergency Medicine.
  • Six weeks on Core Internal Medicine spent as part of the care team assigned to a Clinical Teaching Unit in Kingston, Oshawa or Peterborough.
  • A further six weeks on Specialty Medicine spent undertaking consultation or out-patient clinics within three medical sub-specialties.
  • Six weeks of Psychiatry in Kingston, Oshawa or Markham, generally office or consultation- based.
  • Six weeks of Family Medicine working with a community family physician or Family Health Team.
  • Six weeks of Pediatrics, provided in either a hospital ward or community practice.
  • Six weeks of Obstetrics and Gynecology, consisting of shifts in Labour and Delivery, gynecology ward, or outpatient clinics.
  • Sixteen weeks of electives, during which the students a series of 2 week experiences in specialty services and locations across Canada designed to broaden their clinical experience and exposure to career options.
  • Three 4 week “Core Curriculum” rotations placed at the beginning, within and at the end of the clinical rotations, intended to provide common instruction and assessment in advanced topics and practice related instruction.

All these rotations feature, in addition to the clinical experiences, structured teaching, all guided by objectives linked to the overall Curricular Goals and Competency Based Objectives document which was developed and is regularly reviewed by our Clerkship Committee and approved by the Curriculum Committee. 

In addition, students can elect to undertake our Integrated Community Clerkship, consisting of an 18 week placement within a smaller community working with community tutors and Family Health Teams, intended to provide longitudinal experiences in Family Medicine, Pediatrics and Psychiatry.

Students can also apply for an increasing number of International exchanges which allow them to undertake a core rotation at universities in another country.

All rotations feature content relevant to the various Professional Competencies (Professionalism, Advocacy, Collaboration, Management) and their achievement in these domains is a component of rotation assessments.

All students continually log their clinical experiences and technical procedures in order to ensure all learning objectives are being met.  They also undertake comprehensive structured clinical examinations (OSCEs) in order to ensure core clinical skills are mastered and maintained.

So…a far cry from the service dominated Clinical Clerkship so familiar to most practicing physicians.  A key, and very reasonable question could be posed: Does it matter?  Are our students better prepared for the demands and rigours of residency and practice than their predecessors?  This intriguing question will be the subject of my next Blog.

 

 

 

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Visiting with Dr. Vincent Lam Making the case for Humanities in Medical Education

I have always loved reading novels.  I’m particularly drawn to those that feature complex and fully fleshed out characters battling various personal “demons”, confronting sundry human challenges in interesting contexts.  I must confess to having always regarded the reading of such books as something of a “guilty pleasure”, a self-indulgence taking time away from more immediate, directly relevant pursuits.

This week, vincent_lambthanks to the efforts and insight of the Aesculapian Society, particularly Michael Chaikoff and Soniya Sharma, many of us had the opportunity to hear from and meet with Dr. Vincent Lam, who was this year’s H.G. Kelly Memorial lecturer.  Dr. Lam is an Emergency Medicine physician and award-winning author of a number of works including “Bloodletting and Miraculous Cures” and “The Headmaster’s Wager”.  In his address, Dr. Lam made the case for the role of storytelling as a way of understanding and deepening communication between physicians and their patients, not only as a means of transferring important information, but he also spoke of how it can contextualize the relationship in more human and personally meaningful terms.  In conversation afterward, I asked him about the process of novel writing.  I had always naively assumed that the author begins the process with an outline of the completed story and goes about adding detail and context.  Apparently not so.  Most authors, including Dr. Lam, begin by imagining and developing their characters as fully formed people with all their individual traits and uniqueness.  They then go about studying and researching the context in which those characters will “live”.  Using characters and contexts with which the author is already somewhat familiar is obviously a good start, but considerable research and immersion is required in order to produce stories with depth, realism and relevance.  In researching for “The Headmaster’s Wager”, Dr. Lam made two trips to Vietnam in order to better appreciate the environment in which his story would evolve.  With character and setting in place, the author allows his characters to “live”.  Their actions and reactions become a natural consequence of the interaction of their personality with the times and situations in which they find themselves.

One can’t help but recognize parallels within the physician-patient relationship.  Our patients come to us as uniquely formed individuals who find themselves in a new, baffling and threatening context, specifically an illness or health challenge of some type.  Our role as physicians is to come to the encounter already prepared with understanding of the illness, or “setting” of that challenge.  Our “art” is to find within ourselves ways to efficiently and effectively engage the patient, understand the uniquely individual responses to the illness and guide the patient through the terrain.  In doing so, the physician must develop a broad appreciation of the human experience in all its fascinating complexity.  In this sense, the reading and appreciation of quality literature would seem at least as valuable as reading the latest thrombolysis trial.  Certainly the former is likely to be of more enduring significance.

At Queen’s, we have benefitted over the years from the efforts of numerous faculty who have steadfastly championed various components of the Humanities within and around our curriculum.  Dr. Jackie Duffin, herself an award-winning author, has been providing History of Medicine lectures integrated with various teaching blocks for many years, as well as student projects and excursions intended to deepen their appreciation of the history of their chosen profession.  Students have consistently found her teaching to be a highlight of their medical school experience, as evidenced by Dr. Duffin being a recipient of the Connell Teaching Award which the graduating class bestows annually on the faculty member considered to have had the greatest influence on their education at Queen’s.  Drs. Shayna Watson and Peter O’Neill have provided, largely on their own initiative, contributions to elective courses devoted to various themes related to literature, spirituality and the humanities.  We have maintained strong curricular content in Medicine and the Law (led by Patti Peppin of the Faculty of Law) and Medical Ethics (led by Drs. Cheryl Cline, Susan MacDonald and previously Ellen Tsai).  Many others have contributed in informal but highly meaningful ways.

The challenge, of course, is determining how best to integrate the Humanities and Social Sciences within a rather dense and highly scrutinized curriculum.  How does a Curriculum Committee, charged with meeting the various competencies and objectives established by professional bodies, accrediting agencies and well-intentioned interest groups, ensure these are achieved and balanced?  How does it weigh the value of medical literature or history against understanding the management of hemoptysis or causes of renal failure?

As a means of engaging this challenge, I recently asked Drs. Duffin, Cheryl Cline and Shayna Watson to develop a review and make recommendations on the teaching of Humanities within our school.  They involved three of our students, Alicia Nicke-Lingefelter (Meds ‘16), Amanda Lepp (Meds ‘15) and (now Dr.) Renee Pang (Meds ‘13).  That excellent report has already motivated changes in representation within our curricular committees and is leading to changes in how we “label” and integrate various teaching opportunities within our curriculum.  It has also raised a consciousness about the Humanities and Social Sciences that is always the first step to ensuring appropriate balance.  I’m arranging for the report to be posted on the UG Website and welcome feedback from all faculty and students.  It can be accessed at: https://meds.queensu.ca/central/community/curriculumcommittee:reference_material

I’m most grateful to the authors of this report and to all who have and continue to champion the Humanities within our school.  I’m also very grateful to Dr. Lam who has made me feel much better about my guilty pleasure.

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Introducing Queen’s Meds 2017

One of the special benefits of working in a university environment is the sense of renewal that comes each fall with the entry of new students.  This week we welcome members of Meds 2017, the 159th class to enter the study of Medicine at Queen’s since the school opened its doors in 1854.

meds 2017

A few facts about our new colleagues:

They were selected from the largest applicant pool in recent memory – 3818 highly qualified students submitted applications last spring.

Their average age is 23 with a range of 20 to 36 years.  Fifty-seven percent of the class are women.

They hail from no fewer than 49 communities across Canada, including Abbotsford, Ajax, Ancaster, Ariss, Barrie, Bedford, Brampton. Brockville, Burlington (3 students), Calgary (2), Coquitlam, Delta, Edmonton, Etobicoke, Hamilton, Inverary, Kamloops, Kingston (5), Kitchener, London (4), Maple, Markham (9), Mississauga (6), Montreal, North York (2), Ottawa (4), Owen Sound, Palgrave, Peterborough (2), Pickering, Puslinch, Richmond Hill (2), Scarborough, Stittsville, Thornhill (2), Tillsonburg, Toronto (19), Upper Island Cove, Shrewsbury, Vancouver (2), Vaughan, Waterloo, West Vancouver, Whitby (3), Windsor, Winnipeg, Woodbridge (2) and Yarmouth.

Ninety of our new students have completed an Undergraduate degree, and 27 have postgraduate degrees, including 4 PhDs.  The average grade point average achieved by these students in their pre-medical studies was 3.82.  Their undergraduate universities and degree programs are listed in the tables below:

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Undergraduate Degree Programs

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Postgraduate Degree Programs

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An eclectic and academically very qualified group, to be sure.  This week they will undertake a variety of orientation activities organized by both faculty and their upper year colleagues.  At their welcoming session they were called upon to demonstrate commitment to their studies, their profession and their patients.  They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers.  I invite you to join me in welcoming these new members of our school and medical community.

 

 

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Remembering three great mentors and teachers

Over the past few months, our faculty and medical school have lost three people who made tremendous contributions over the course of their careers.  Peter Munt, Robert Hudson, and Ed Yendt were all master clinicians, leaders in our medical community and contributors to our understanding of illness and disease.  They were also gifted teachers and mentors who were always willing and eager to pass on their wisdom.  As we approach the beginning of another academic year and are about to welcome a new class of medical students, it seems appropriate to reflect on the lessons and legacies that they’ve so ably provided.

Dr. Peter Munt was recruited to Queen’s after postgraduate training in Respiratory Medicine to head the newlymunt formed Division of Respirology and Critical Care Medicine.  He went on to head the Department of Medicine through a time of tremendous transition, and then became Chief of Staff at KGH.  As his medical resident many years ago, I recall caring for a patient with a pulmonary infection eventually traced to a rather novel organism.  Not content to simply identify and treat the infection, he encouraged me to identify the source and explore for any patients who may have suffered from similar infections.  By doing so and documenting the results of our search, we were able to contribute to the care of many more patients, and raise awareness among other physicians of a little appreciated source of infection.  Moreover, he taught me and my fellow residents the importance of pursuing root causes and the value of documentation and publication in disseminating knowledge.  His career, both as a physician and administrator, was characterized by this quality of uncompromising attention to all facets of an issue, and unwillingness to accept the expedient solution.

hudsonDr. Bob Hudson was head of our Division of Endocrinology for many years.  In addition to his clinical responsibilities, he maintained a very active research career making important contributions to the understanding of androgen function.  I’ll remember him for his dedication to physical examination and bedside teaching.  His ward rounds were highly valued by housestaff.  Not content with mere identification and demonstration of physical findings, Dr. Hudson challenged us to understand the underlying cause and pathogenesis.  “So I agree this patient has exophthalmos” he would concede, but always follow with something like “but why do patients with thyroid disease develop this finding? What’s the mechanism?”  His great skill was to help the learner work his or her own way through the problem without intimidation or belittlement.  In fact, you emerged from these sessions not simply knowing something about a particular finding, but with a mechanism that could be applied to a variety of findings and conditions.

yendtDr. Ed Yendt had already developed a reputation as a leading specialist in calcium disorders by the time he was recruited to Queen’s to head the Department of Medicine.  He led that department through a period of rapid growth, and development of many of the subspecialty divisions.  He continued to do basic research through his career, becoming an internationally recognized expert in osteoporosis.  Always a dedicated clinician, he continued to see patients long after usual retirement age and long after financial considerations provided any motivation.  He was the embodiment of what we would today refer to as “translational” or “bench to bedside” research.  I had opportunity to talk to him on numerous occasions in recent years, and was continually impressed at his knowledge of recent literature and eagerness to apply new findings to his patients.  He was intrigued by patients with unusual presentations or responses to therapy, and continually used those experiences to learn more and apply that knowledge.  He never lost his excitement for discovery or dedication to patient care.

Three great teachers, three different styles, but all sharing an insatiable curiosity, dedication to advancing the science of medicine, and to applying that science to their first concern – the care of their patients.  Their families might find some solace in the knowledge that those lessons are not lost and that their examples and teaching will continue to inspire our students and those currently charged with their learning.

 

 

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Mentoring – a “win-win-win” proposition

What do practicing physicians remember about their medical school experience?  What do they feel had the greatest impact on their development?  What do they retain?  My guess, based on many reunions and even more conversations with graduates, is that it’s not the classes, labs or examinations, but rather the faculty they encountered along the way.  Of course we all remember the “characters” and the “larger than life” personalities that populate every medical school, but it’s those faculty with whom we were fortunate enough to develop a personal, one-on-one relationship that have the most enduring and significant impact on our development as physicians, and on our personal lives.  We call such folk “Mentors”.

mentorThe derivation of the word “mentor” is interesting.  The origin is Greek and is traced to Homer’s Odyssey.  Mentes was a wise and valued friend of Odysseus to whom he entrusted the education of his son Telemachus when he set out on his epic voyage.  The elements of wisdom and trust are therefore intertwined in the term, qualities obviously central to the role as we understand it today.

The value of mentorship is well known in all facets of professional education.  It’s this realization that leads many schools and departments to deliberately develop programs designed to promote these mentoring relationships.  At Queen’s, we have developed a program that assigns a mixture of students from all years in groups led by two faculty members.  Like all such programs, much depends on the specific and usually unpredictable “chemistry” that develops among the group.  When it works (and it usually does) the relationships that emerge are highly rewarding.  Below I provide testimonials from two students and one faculty member regarding their mentorship experience that may provide some insights.

Eve Purdy
Eve Purdy, MEDS 2015

In a 1973 article “Indoctrination of the Medical Student” Dr. Vilter pointed out that turning a new, eager medical student into a competent, caring physician takes more than just training in science, more even than just training in science and clinical skills. The mentorship program at Queen’s has been a special part of my indoctrination to the profession. Our group’s main goal is to have fun in a relaxed way but I am always surprised at the impact of these casual interactions. Whether it be a night of bowling, an intense night of trivia or a simple evening over shared drinks and food, I always leave more energized and excited about what’s to come. 

When a clerk in your mentorship group gives you a tip for the wards next year, you don’t forget. When the fourth year students graduate, you celebrate with them and picture yourself walking across the stage in a few years’ time. When a mentorship group leader encourages you to dream big, you might just. 

And a few more interesting links that I have come across about mentorship in medicine: 

Trivia…or is it? – this is a link to a post on my blog about trivia night earlier this year

Being a Mentor for Undergraduate medical Students Enhances Personal and Professional Development

Mentoring Programs for Medical Students- a review of the literature

Informal Mentoring Between Faculty and Medical Students

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Graydon Simmons, MEDS 2016

The Queen’s Medicine Mentorship Program has provided me the opportunity to have informal interaction and communication with Queen’s faculty and residents that I wouldn’t be able to experience anywhere else. In the hospital or after a lecture, it is hard to just walk up to a physician to inquire about what they enjoy about their profession or how they balance their personal lives with their work. Through the mentorship program, I have been able to build relationships with faculty and residents in a more relaxed atmosphere that is conducive to conversations about one’s future directions in medicine. Additionally, the mentorship program has also increased that sense of Queen’s community for me. As a pre-clerkship medical student, it can be intimidating to enter the hospital during your first clinical experiences. With something like the mentorship program in place, you begin to see the quality of physicians we have here at Queen’s and the encouraging, open teaching environment that they create. Ultimately, this interaction and positive community that the mentorship program has created for me has contributed to my learning and career exploration as a Queen’s medical student.

Dr. Peter O’Neill
Dr. Peter O’Neill

It is About Mentorship

Being a mentor in the mentorship program has been one of the most exciting aspects of being on faculty at Queen’s. At my mentorship group’s last meeting, we had breakfast. For our group, breakfast was a good time to get everyone together without the distractions that can happen with an evening out.

One of the first year students asked if we should have an agenda for the meeting, but the senior students just laughed. The agenda is always the same. I ask the senior students: “what is cool in what you are doing right now”? They answer, in the usual spectrum of experiences, and the junior students say: “wow, how do I get to do that”! That is mentorship in action.

While I enjoy checking in with all the students to see what is cool or if they are struggling, I think the students would rather hear from their near peers. I see our relationships not so much as a vertical structure, but a horizontal one. The clerk explains how to get an elective to the second year student. The second year student describes the observership program as a kind of “back stage pass” to the first year student.

Our group has enjoyed the group events and while I couldn’t make the “Great Mentorship Race & BBQ” in the park this spring, our group was well represented. Over the years we have had fun with Guitar Hero, and had pot luck suppers (which means that everyone has some food that they can surely eat without looking into all the dietary restrictions).

At the Convocation in May, I enjoyed meeting the family of one of my mentees. He said: “Dad, this is Dr. O’Neill, I beat him at guitar hero the second month of medical school.  You couldn’t believe it when I told you we were playing guitar hero in his basement. I smoked him at guitar hero. In spite of that, three years later he taught me how to deliver a baby.”

In the years to come, memories of delivering a baby might fade in this future internist, but I will bet he will remember beating me at guitar hero. He may never know that I let him win.

win-win-winAnd so it seems mentoring is truly a “win-win-win” proposition, benefiting both parties involved, as well as our school, which is becoming known for the value we place on faculty-student interactions at many levels.  We’re always looking for more faculty willing to become involved in this program.  If you’re interested, or simply wish to learn more about it, feel free to contact myself, Peter O’Neill or Erin Meyer in the UG office who coordinates the program.  Erin can be reached at ugmelwc@queensu.ca.

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Student Directed Learning ”Everything old is new again”

My undergraduate education was enlivened by a number of professors who were fond of taking rather unconventional points of view, many of which would be considered “politically incorrect” in today’s parlance.  They were even fonder of defending those perspectives with spirited and colourful debate.  Perhaps travillthe leading proponent of this approach was Dr. Tony Travill, professor of Anatomy, who would spend more of his curricular time discussing points of professional practice and social foibles than the assigned topics of embryology or anatomy.  On the rare occasion that one of us mustered the temerity to point this out, he would make the rather emphatic point that “universities aren’t centres of teaching, they’re centres of learning”.  The message was clear – it wasn’t his business to teach so much as it was our responsibility to learn.  Our goal should be to learn for the benefit of our future patients, not simply to satisfy curricular goals.  I recognize in retrospect that his not-to-subtle shift of emphasis helped us to transition from being passive consumers of information to what today’s educational theorists would term “active learners”, although we had no idea this was happening at the time.

Turing our attention to the present, one of our 2015 students, Eve Purdy, spoke eloquently at the recent Celebration of Teaching Day of how she addressed her interest in the process of clinical decision-making.  She searched the internet and came upon a free web-based seminar series from the University of California (San Francisco) that she accessed over several weeks and found quite useful.  She shared the information with others, both students and faculty who also made use of this resource.  As teaching faculty, we should take considerable comfort in the fact that our students are, on their own, seeking opportunities to advance their learning, often going beyond the baseline requirements of our curriculum.

In fact, our students make use of a wide variety of unstructured learning opportunities in addition to standard curricular offerings such as Courses, Integrated Learning Streams, various types of Small Group Learning, clinical rotations and assigned projects.

Last academic year, about 20 Student Interest Groups were active, each developing a series of at least 8 learning sessions outside standard curricular time that were devoted to a particular discipline or theme.  Although supported by faculty on a voluntary basis, students developed the themes and content of these sessions.  The following is a list of some of the groups that were active this past academic year:

hidden

In addition, our students informally access the world of information available to them through the internet and social media.  A world of information is studentsliterally at their fingertips, and they make use of this almost continuously, both to search information and to dialogue with each other, with faculty (sometime during lectures), and people farther afield.  The challenge is not access, but rather discernment of relative value.

Perhaps the most powerful non-curricular learning experience our students engage is what’s been termed the Hidden Curriculum.  This term refers to all of the unintentional but incredibly powerful messaging that occurs in the context of their environment and clinical experiences.  Observing a respectful and effective interaction between an attending physiciansphysician and nursing staff provides a much more effective and durable lesson than hours of formal teaching on the topic of professionalism.

The challenge for teaching faculty in the midst of all this is to keep pace what’s happening around us, and to shift our focus from delivering content to guiding the learning process.  To borrow an old adage – we can’t control the wind, we can only set our sails.  In this environment, it becomes more important to set the objectives and provide direction than to attempt to rigidly control the process.

And so, as the song says “Everything old is new again” when it comes to student directed learning in medical education, although technical advances and connectivity expand the potential (and our challenge) tremendously.  I like to think Dr. Travill would be amused.

 

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

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