7th Annual QHIP Speaker Series underway

The 7th Annual Queen’s Health Interprofessionals (QHIP) Speaker Series launched last week, but there’s still time for students to register for the remaining workshops.

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Each workshop takes place on Mondays from 6:30 – 8 p.m in Room 132 at the Medical Building. The series is free, but you need to register to attend. (Here’s the form: http://goo.gl/forms/xgH2k2ao2U). Those who attend at least four workshops are eligible to receive and Interprofessional Education Certificate.

While some of these topics are covered in uni-professional classrooms, this is an opportunity to address these complex issues as an interprofessional group of students.

For more information on QHIP, check out their page on Facebook: https://www.facebook.com/QHIPSociety/

 

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Is “Apprenticeship” Dead? The case for clinical service in medical education

An “apprentice” is someone who works for a fully qualified individual for the purpose of learning a trade. Although the term has taken on a somewhat negative connotation of semi-indentured servitude, the word itself, interestingly, shares entomologic roots with French verb apprendre (to learn), and the Latin apprehendere (to “grasp” or understand). It would seem then that apprenticeships are intended to be primarily educational endeavors.

Apprenticeships served admirably as the original model of medical education. Eager and bright young people who wished to become doctors would enter the service of an established practitioner, in the same way that aspiring masons or carpenters would engage training from masters of those trades. The apprenticeship provided, in addition to instruction in fundamental knowledge and skills, on-the-job, supervised practice training. Presumably, the level of responsibility and independence of the learner increased progressively over the period of training but, in fact, the contractual arrangements, terms of service and educational program were entirely at the whim of the “master” without consistent standards or regulation. At the end of the agreed-to term of service, the learner would receive the endorsement of the teacher and, after submitting to whatever regulatory process might exist, enter independent practice.

Our Clinical Clerkships and Residency programs are modern day vestiges of the apprenticeship model, the major points of departure being the organizational (school-based) rather than individual focus, and considerably expanded, highly defined and rigorously regulated educational expectations. However, the delicate interlacing of the two fundamental components-education and supervised clinical practice-remains the core, defining characteristic. As those two elements combine (as illustrated in the diagram below),three domains of activity are defined.

3domainsofactivityThe purely educational activities consist of scheduled rounds, conferences, academic days, assessments and various other structured events. Learners are either expected or required to attend. Together, these events provide an established “protected” learning curriculum. These events are deliberately, completely separated from clinical service in order to ensure opportunities exist for the requisite learning.

There are also activities where clinical service and education overlap and occur simultaneously. These consist of clinical activities where learners and teaching faculty work together in the delivery of care, such as clinics, operating rooms, procedural suites and emergency departments. In these settings, the learner is directly supervised, is involved in care delivery to the extent their training and acquired skills allows, and receives instruction ‘on the fly’. The “curriculum” is defined not by a pre-determined schedule, but by the issues presented by the patients receiving care.

This leaves a third component of clinical service that can be considered either indirectly supervised, or independently provided. This consists of activities appropriate to the learner’s qualification and can be considered the “scope of practice” at that point in his or her training. Examples vary considerably, but could consist of ordering basic investigations, prescribing, charting, minor procedures, and patient assessments. As learners progress in training, their “scope of practice” escalates accordingly. This more distinctly service role is recognized officially in the residents’ hospital or practice privileges, provision of payment for service, and development of professional organizations such as PARO which recognize residents as service providers and work to protect that role.

To extend the illustration above, the spheres progressively diverge until, at the end of training, they separate completely as the learner assumes independent practice and, with it, complete responsibility for both their clinical and educational activities. The latter is, in fact, an expression of professional identity.prof-practice

The balance between these two domains and three spheres of activity within medical training has been, and remains, contentious and a point of competitive tension. The need to vigorously protect the educational components of residency training has been very appropriately promoted through the development and protection of core curriculum within training programs and mandated by accreditation standards. The need to put limits on the clinical role has also been recognized and effectively enforced through accreditation and professional organizations that advocate for their members by, historically, promoting protection of purely educational endeavours above purely clinical service activities. The move to more competency-based models of residency education brings many potential advantages, but by formalizing and emphasizing educational processes, may further sideline the clinical service role.

It could certainly be argued that we’ve passed a tipping point where our emphasis on protection of educational activities has diminished the value of clinical service and portrayed to our learner the impression that avoidance is somehow virtuous. This would be appropriate if clinical service had no educational value and was simply a distraction from “pure” learning experiences. But is this the case? Is there an educational price to be paid for reduced clinical service experiences during training? Is it reasonable to consider residency as a “job” in and of itself with expectations of service independent of direct educational context? Expressing the issue another way: is there, in fact, educational value in the provision of clinical service? Some compelling arguments can be made:

The practice of medicine is much greater than the sum of the educational components. It is a complex interplay of scientific knowledge, specific technical skills, and an ability to understand and relate to the individual human situations in all their variety and complexity. There is something about engaging these situations individually that is far beyond what can be attained in any classroom or even directly supervised situation. The ability to do so in a nonetheless safe setting, with understood limits and readily available help is the core educational value of clinical service delivery.

Personal growth and development of professional identity. People in any human endeavour learn by engaging personal challenges and confronting adversity. This is certainly true of developing physicians. In medical school, it begins with the first time a student has a one-on-one encounter with a patient. It progresses steadily through training, but whether it is performing a minor procedure, an assessment in clinic or attending to a distressed patient with an urgent problem, these are all opportunities to grow as providers in a protected and supervised setting where optimal patient care is not only assured, but likely enhanced. This provides training physicians the opportunity to not only learn clinical medicine, but also about their own individual strengths and weaknesses in a way that can’t be reproduced in any artificial educational setting. That self-awareness is essential to professional development and critical to career decisions. Strong personal preferences or deficiencies should be identified and addressed during training, not after graduation to independent practice.

Our patients are our best teachers. Great physicians learn from every patient encounter, no matter how apparently straightforward or routine. This is the basis of lifelong learning. If the practice of valuing and learning from every patient encounter is not engaged and refined progressively during training, will it be developed in independent practice?

Valuing clinical service as a privilege, not a chore. The core mission of Medicine, and of physicians, is the provision of clinical service to our patients. To them, there is no “scut work”. If we don’t value clinical service as an educational community, what message are we sending to our learners? Are they graduating to a career of uninspiring and boring chores? In an educational sense, the development of clinical competence and increasing independence should be recognized, highly valued and accompanied by increasing status and prestige.

Pragmatically, there already exists a contractual definition of residency as a “job” with compensation and obligations. Rather than live in denial of this reality, we might be better advised to engage the balance between those obligations and educational development in a thoughtful way ensuring the optimal expression and value of both aspects.

Finally, we must recognize that this is no longer a theoretical discussion or abstract educational concept. Clinical care is becoming more, not less, demanding within our schools, outpatient clinical settings and academic teaching hospitals. Education and clinical service delivery are on a collision course that can only be averted by recognizing that these two aspects of medical education are individually necessary and mutually interdependent. Both must be preserved. We must recognize this essential duality, particularly as we go about developing newer models for both undergraduate and postgraduate education.

 

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

 

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“When the patient fainted, her eyes rolled around the room”: How to make medical charting clear and accurate.

Recently Dr. Maurice Bernstein from The Keck School of Medicine, at University of Southern California, wrote into the listserve DR ED with this intriguing question:

I find many first and second year medical students present their patient write-ups for their instructor’s review with errors both typographical but also errors in presentation that makes statements seriously ambiguous.  I tell my students to read what they have written and then re-read again as an individual who knows nothing about the patient.  In addition, I have presented them with a list of “comic” but presumably also realistic medical charting errors. 

Is there something more I can do to teach the students to be more attentive particularly later when what they write for the record has greater clinical significance for the patient than a first or second year student?

MEDICAL CHARTING ERRORS 

  • By the time he was admitted, his rapid heart had stopped, and he was feeling better.
  • Patient has chest pain if she lies on her left side for over a year.
  • On the second day the knee was better and on the third day it had completely disappeared.
  • She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.
  • The patient has been depressed ever since she began seeing me in 1986.
  • Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.
  • The patient is tearful and crying constantly. She also appears to be depressed.
  • Discharge status: Alive but without permission.
  • The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.
  • Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.
  • The patient refused an autopsy.
  • The patient has no past history of suicides.
  • The patient expired on the floor uneventfully.
  • Patient has left his white blood cells at another hospital.
  • The patient’s past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.help pile of records
  • She slipped on the ice and apparently her legs went in separate directions in early January.
  • The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.
  • The patient had waffles for breakfast and anorexia for lunch.
  • Between you and me, we ought to be able to get this lady pregnant.
  • The patient was in his usual state of good health until his airplane ran out of gas and crashed.
  • She is numb from her toes down.
  • While in the ER, she was examined, X-rated and sent home.
  • The skin was moist and dry.
  • Occasional, constant, infrequent headaches.
  • Coming from New York, this man has no children.
  • Patient was alert and unresponsive.
  • When she fainted, her eyes rolled around the room.

After I finished giggling, I started to think…this is a problem with an educational and literacy component. What does educational pedagogy teach us to assist with this issue?

So here are a few ideas from my experience as an educator —these could be potential teaching strategies.   BTW, don’t do all of these…:)  1-3 should make some impact.

  1.  Work with this list: Give students the charting errors list above—it will be a good teaching moment for them and help them see how awful some of their errors could be.  You could ask them in partners (to share the fun) to correct the errors as best they can, reading between the lines, or to create a set of questions that would help clarify some of them. In other words, put them in the role of the teacher.
  1. Think of busy times: Ask students to list the times they may be most busy in a clinical setting.  This list should be posted for them to remind them that these are the times they need to slow down and focus most, ironically, on their writing.

    Busy? Slow down.
    Busy? Slow down.
  1.  Writing and recall for purpose:
think of the patient
Think of the patient.

a. Ask students to generate a list of purposes for charting; writing for purpose is a strong strategy for improving writing. I’m hopeful some of the purposes will be:  pay respect to the patient’s illness and the patient (patient-centred care), safe care for handover and for others reading the chart, legal documents for liability, etc.

b. Then, ask students to keep these in mind as they chart.  Mindful exercises could include using a symbol to associate with each purpose—drawing it, literally, or drawing it clearly in their minds, using a key word to help them recall, or if they tend to associate sounds, or colours with concepts, they could do that.

handover
Here’s my image for handover, for example. Don’t drop the baton.

Ask students pause for exactly 3 seconds prior to charting to collect their mind, to steady their writing and to recall these purposes.  Actually 3 seconds is like taking a deep breath.

NOTE:  thinking about the target audience, as in “Who potentially is going to read this?” can also achieve a impact.

  1.  Simulated chart exercise: Give students a simulated case and a chart exercise and a very stringent time limit.  Ask them to work in pairs and edit each other’s notes after the exercise.  OR, use “Pass It On” strategy, where students affix a nickname, or number to their work (to preserve anonymity and dignity :)) and pass the chart along to the left, so that at least 4 people get to weigh in on it with feedback.  NOTE:  this is also a good exercise in how to give feedback—warn them against being sarcastic, or harsh—their time will come! Ask students to practice good feedback techniques:  being specific, offering suggestions, avoiding judgements of the person, focusing on the writing, etc.
  1. Read the chart entry aloud.  Ask students to practice this.  This takes approximately 6 seconds at most (depending on the chart).  Reading a piece of writing aloud is another recommended editing strategy practiced by writers.

    each-word
    Read it out loud.
  1. Be careful with the use of abbreviations and acronyms which are not commonly used or can be ambiguous in interpretation. For their patient write ups, except for absolutely classic clinical acronyms such as C for “centigrade” or BP for “blood pressure”, the words should be written out such as “myocardial infarction” and NOT “MI” since MI could also represent “mitral insufficiency”. You could teach students that if any obscure acronym is to be used later on in the text, in its first use, the full expression should be written then followed in parentheses with the acronym noted.  Unfortunately, also, many acronyms or abbreviations in medical use are not written in a standardized manner between one institution and another and this can also lead to errors if not recognized. Bottom line: avoid or be really careful. (Thanks to Dr. Maurice Bernstein for this tip.)
  1. Avoid General statements: I got this feedback to a student from a nursing blog article by Katie Morales called 17 Tips to Improve Your Nursing Documentation.

Teacher: For example, you wrote “Dr. Smith called.” Did you mean: you called and are waiting for a return phone call; physician called nurse; or nurse called and spoke to physician?”  A better option is “MD

EmergencyResidencyStudents
Work with a partner and correct.

paged, assessment findings discussed, and no additional orders at this time.” 

 

Similar to strategy 1, I would give the students general statements where they can figure out what’s going on, similar to Ms. Morales’ example.  I’d work through one or two on the screen with the students first.

 

  1.  Checklist of common charting errors:  Making a checklist of these for students is helpful and having it handy when they are charting is also helpful (make it pocket-sized).  Checklists are a helpful literacy tool—no reason they shouldn’t work with charting literacy:  Here are errors from a good module RN.com has: Professional Documentation:  Safe Effective Legal.  (Students could make it into an alpha list or an acronym list). Most of these would be applicable for physicians as well as nurses. (You might want to make them positive: e.g. “Record Pertinent Health or Drug Information.”)

3d small person makes a tick in cell. 3d image. White background.

Common charting mistakes to avoid include the following:

  1. Failing to record pertinent health or drug information
  2. Failing to record nursing actions
  3. Failing to record that medications have been given
  4. Recording in the wrong patient’s medical record
  5. Failing to document a discontinued medication
  6. Failing to record drug reactions or changes in the patient’s condition
  7. Transcribing orders improperly or transcribing improper orders
  8. Writing illegible or incomplete records
from:  Nurses Service Organization, 2008, pp. 4 – 5

From a medical standpoint: Take a look at: Top 10 documentation error pitfalls: from Wisconsin Medical Society: 2008.

  1.  Teach with examples.  Show students excellent examples of charting to give them the necessary language for their work.  Give them criteria that facilitate effective charting.  Look back at the RN.com for some great criteria! As well CMA (Canadian Medical Association) has a good module called Medical Records Management with 31 (!) criteria for effective charting.

NOTE:  I’ve never met anyone who can keep to a 31 point checklist, but the criteria cited are all really important, so…perhaps students can check off the ones they think they do well already, and star the ones they need to work on.  A sampling of their work in clerkship (observation and feedback—still necessary) will demonstrate their self-assessment skills as well as how well they record.

10.  For senior clerks and residents: The  nursing module, RN.com: Professional Documentation:  Safe Effective Legal, has a list of situations that are classified as high stakes documentation.  This would be critical information for senior clerks and residents. (You’ll see that I’m citing nursing education here a lot: Nurse Researchers and Nurse Educators do excellent work on health and education.)

charts patient safety handover
For Residents and Senior Clerks

In Ratnapalan et al, Charting Errors in a Teaching Hospital, these suggestions for residency are included:

  • Many training programs recognize that residents in their first month may have charting errors and have put in place orientation programs, increased supervision from senior residents and staff, and a more thorough review of the notes that are written by new residents.
  • The ED at the Hospital for Sick Children is the only dedicated pediatric emergency department in the city of Toronto, and 380 to 400 trainees rotate through the department annually. Currently, there are orientation packages, orientation sessions, and a Web-based orientation available for trainees to teach accurate charting of emergency records.
  • The orientation package is a large binder with complete instructions on goals and expectations, codes of conduct, medical record keeping, handling of specimens, procedures, and academic activities.

Glad to get feedback on these strategies, and add to the list! What do you suggest?

send us your suggestions

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The Troublesome Ethics of Entrepreneurship in Medical School Admissions

Medical school applications are becoming big business, and a rather troubling expression of supply and demand economics.

The “demand” side consists of the many thousands of young people in North America engaged in the highly competitive process of applying to the limited number of seats available at publicly subsidized Canadian and American schools. Rebecca Jozsa, our intrepid Admissions Officer and I recently explored the “supply” side by carrying out a simple Google search of options available to the assist the aspiring medical school applicant.

For MCAT preparation, we found no fewer than 22 available courses (probably an underestimate). The “MCAT Ultimate LiveOnline 123-hour” experience is offered multiple times per year for $2,199US. For those who prefer more intense and more personal preparations, the “MCAT Summer Immersion” experience can be had for $9,499US, not counting, of course transportation and accommodation. The “Most Comprehensive Prep Course in Canada” runs over 10 weeks, costs $2,195, comes with testimonials from satisfied customers and features both instruction by successful students and “unlimited free repeat policy”. There are many other choices, a veritable smorgasbord of choices.

One can also opt for more comprehensive guidance through the entire application process. One group provides the following offering: “With our flagship service, we offer unparalleled quality that will make your application to medical school stand out”. In addition to “MCAT prep”, clients can opt for any or all of “Online Diagnostic”, “Comprehensive Application Planning”, “Application Review”, “CASPer prep”, “Interview Crash Course”, “Interview Preparation”, and “MMI prep”. Costs, understandably, vary based on individual preference and perceived need, but appear to range from a few hundred dollars for individual components to more comprehensive packages such as the Platinum bundle which goes for $3500US. It’s hard to get all the details as to what’s available without engaging one of the friendly “consultants” for a “personalized needs analysis” (which we declined) but the sky appears to be the limit in terms of costs. Some arrangements even come with money-back guarantees!

It’s clear from the advertising that many of these programs employ, or are even operated by, medical students or recent grads. Who, after all, would be in a better position to provide the “inside information” so essential to success?

So, is all this a problem?

On the one hand, all this is perfectly legal free enterprise. It’s addressing a perceived need, clients are fully informed and fully competent, no one is forced to engage these processes unwillingly. It could be argued that these programs allow very worthy and genuinely motivated young people to pursue their dreams and overcome many of the unintentional barriers that we all would acknowledge are inherent in the admissions system. One could argue that medical schools themselves have given rise to these business opportunities by making the MCAT such an integral component of the admission process, while at the same time dropping basic science prerequisites.

On the other hand, one must also acknowledge a number of potential concerns:

  • The widespread availability of these services may force students to participate to simply not be disadvantaged relative to other applicants. It’s no understatement to say that candidates feel desperate for any advantage in the process. That desperation, it could be argued, is being exploited.
  • This intensive preparation and rehearsing for the various application processes may result in candidates portraying themselves in an unrealistic fashion, thus subverting a process fundamentally intended to ensure applicants are appropriately suited to a career in medicine. Such “mismatches” can be disservice to all, including the applicant themselves.
  • These services are obviously expensive, adding a further socioeconomic barrier to medical education, a problem widely acknowledged in both Canada and the United States.
  • The involvement of medical students, as paid consultants or instructors is troubling. Their recent experience with the details of application processes, including the structured interviews (for which most schools require them to sign a non-disclosure agreement) makes them attractive for this role, but also sets up an ethical dilemma: Can they undertake to help applicants navigate their interviews without sharing information or insights they have acquired as a result of their own experience? Even if specifics are not explicitly divulged, it’s hard to imagine that their recent intimate involvement in the process won’t find its way into their “counseling”.

All this provides lessons and demands reflection on a number of levels.

For the aspiring applicant, perhaps a word of caution. The principle of “caveat emptor” (let the buyer beware) very much applies. There is no accreditation or credentialing process for these offerings. Applicants may not be getting valid advice. I’ve heard anecdotally from students who have been advised to avoid expressing any personal opinions and instead memorize and regurgitate the prepared responses to anticipated questions. Admission committees and interviewers, searching for sincerity and deep commitment to a career in medicine, are astute assessors and have become very attuned to the “coached” candidate. They will become even more vigilant. The sincerity and true commitment they’re looking for tends to stand out, and is very difficult to artificially manufacture.

This entrepreneurial phenomenon should also cause medical admissions committees to reflect on their processes. One has to question the validity of the MCAT as an assessment of scientific aptitude if an “immersion experience” is truly effective in influencing test results. Do we believe a background or interest in basic science is an important applicant characteristic? If so, do we feel successfully undertaking an MCAT prep course meets that criterion?

For medical students, entering a profession that is self-regulatory and rightfully expects high levels of personal integrity and accountability, opportunities to become involved in these programs pose perhaps their first personal ethical dilemma. Clearly, what makes them attractive to these agencies is not their personal counseling or teaching skills, but rather their status as successful medical school applicants, which brings considerable cachet and intimate knowledge which is of high value. They will find (as they will as practicing physicians) that their professional identity can’t be easily separated from their personal lives, and therefore puts them in an ethically ambiguous position.

In our society, it seems supply will always be found when demand exists and sufficient resources are made available. That this has extended to the medical school admission process should come as no surprise. However, it does raise some unintended, but nonetheless concerning consequences. As always, your views on this issue are most welcome.

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

 

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Socrates, questioning and you

Socrates, Questioning and You: Revisiting the question of questioning

Happy 2016 all! Are you thinking about some educational resolutions? How about reflecting on how you question medical students, especially in a clinical setting?

When we last spoke in December, the topic was Socrates, “pimping” and teaching in medical education (http://meds.queensu.ca/blog/undergraduate/?p=2575).

I ended by saying I’d be back to talk about Socrates and questioning.  Well, I’m back…

We often use the term “Socratic questioning” but what does it mean? Socrates used questions as a way to teach, in that he questioned his students so that they would uncover truths for themselves.

socrates-statue

Six Types of Socratic Questions: Here below, are R. W. Paul’s six types of Socratic questions as a modern day interpretation. (There are now 8 types! I’ve combined a few. ) These are from several sources listed below.

What I love is that they are grouped by purpose. You’ll note that none of the less desirable purposes (humiliation, venting, anger, etc.) are present. I’ve put a star beside some of my particular favourites—perhaps you could do the same? Because, as you’ll see next, planning your questions (and that starts with types and purpose) is part of being a Socratic questioner.  Can you see how you could use these in your questioning?

unlock

1. Questions for clarification:
  • What do you mean by?
  • How does this relate to x?
  • What is your main point?
  • Can you give me an example?*****!
  • What is the source of that idea or information?
  • Can you summarize what we discussed?
  • Jane, could you summarize what Wei just said? Wei, is that what you meant?*
  • Would you say more about___
2. Questions that probe purpose and assumptions:
  • What is the purpose of _______?
  • What are you assuming?*
  • How would you support your assumptions?
  • What could we assume instead?
  • How can you verify or disapprove that assumption?
3. Questions that probe reasons and evidence:
  • What did you observe?
  • What would be an example? ****
  • What evidence supports your hypothesis? What is it analogous to?
  • Is this good (or enough) evidence to believe this?
  • What is the cause?
  • How did you come to that conclusion?*
  • What do you think causes to happen…? Why?
  • Have you seen this pattern before?
4. Questions about Viewpoints and Perspectives:
  • What would be an alternative? *
  • How could you answer the objection that another group might make?*
  • What is another way to look at it? *
  • Would you explain why it is necessary or beneficial, and who benefits?
  • Why is the best?
  • What are the strengths and weaknesses of…?
  • How are…and …similar?
  • What is a counterargument for…?
5. Questions that probe implications and consequences, inferences and interpretations
  • What effect would that have?”
  • What generalizations can you make?
  • What are the consequences of that assumption? *
  • What does this remind you of?
  • What patterns have you seen?*
  • How are you interpreting her behaviour? Is there a more logical inference?
  • What have you left out?*
  • How did you reach that conclusion?
  • How does…affect…?
  • How does…tie in with what we learned before?
  • What do you predict will happen next?
6. Questions about the question: (especially if the students are struggling…)
  • How can we find out?
  • Is this the same issue as ___?
  • Can we break this question down?*
  • What was the point of this question?
  • Why do you think I asked this question?*
  • What does…mean? Was the question clear?
  • How does…apply to everyday life?
  • What does this question assume?
  • Why is this question important? *

TIP 1: Try to pose questions that are more meaningful than those a Weekly-Tips-Imagenovice of a given topic might develop on his or her own.

TIP 2: Start with key answers you hope students will give–in other words the key teaching points of the session.

TIP 3: Phrase 3 key questions.

TIP 4:  Use some of the above questions to fill out your Socratic roster.

Are you a “Socratic Teacher?” The teacher who uses the Socratic method is looking for “systematicity”, “depth”, and has a keen interest in assessing the truth or plausibility of things.Close-up-of-Socrates

Strategies:

  1. Model critical thinking
  2. Respects students’ viewpoints,
  3. Probe their understanding,
  4. Show genuine interest in their thinking.
  5. Helps students feel challenged, yet comfortable in answering questions honestly and fully in front of their peers.

Implementing Socratic Questioning in your clinical (or classroom or seminar) setting. Try some of these strategies to build a positive questioning climate bedside rounds

  1. Distinguish upfront between Socratic Questioning and “Hounding”. Ask students to bear with you while you ask keep asking questions as soon as they have answered and tell them why. Let them know this is your educational approach and that there are no ulterior purposes such as humiliation. In other words, set the climate for this kind of questioning by being explicit with students right from the start.
  2. Not all questions have a single “right” answer. Prepare students for the difficult position of having to determine which is most right…sorting through the grey areas, and being wrong, at least first time around.
  3. Set some ground rules: If a case coming up for rounds is an important case (and it’s helpful if you can identify important cases, as medical students may not be able to), it’s fair game, and students are expected to “read around” that case.
  4. You DO ask questions of individual students (but you don’t center out students): Let students know that you will be asking individual students questions as well as asking for volunteers. However, like Socrates did, it’s helpful to have the group help. It’s all in the way you phrase it: “I can see you’re stuck—you’ve done well to get us to this point. Is there someone who can take us to the next question?”
  5. Mature student responses for when they’re stuck: To create the “safe climate for questioning,” students should have mature answers for not knowing an answer that you are willing to accept:
  • Student A. “That’s as far as I can go from my reading, Dr. Z___.”
  • Student B. “In my reading, the ____was the most likely diagnosis. Can you help me with this?” (Don’t be fooled into giving an answer—Socrates would just keep asking questions to get at a deeper concept.)
  • Student C: “I think I do need to call a friend.”
  • Student D:“I didn’t do the reading, Dr. B___I apologize and I’ll pick up tonight.” (However, if this latter student keeps giving this answer, then it’s moved to scholar and professional competencies and you have to switch from Socrates to assessment, and they need to explain what’s going on.)

OR…explain to students what answers you will accept.

It’s important to teach students to acknowledge shortcomings and to motivate them to correct these. It’s also important to give them the language to respond to questions and to accept it.

6. If there is a problem: If the questioner is disturbed by a learner’s diff feedbackpreparation, attitude, or any other issue, humiliation in front of a peer group, or a near peer group is not recommended in any circumstance.  Rather, discussion, with feedback, follow-up and tracking with that student should be conducted separately, apart from the rest of the group. (I know…it’s time-consuming.  But it’s better for the learner and for the teacher.)

7. Forge a relationship on mutual respect, and allow the learner to question the questioner, and to ask for clarification and where to go to learn more.

scroll

Do you agree with these strategies? What do you like about the 6 types of questions? Will I ever stop asking questions? 🙂question upside down

Feel free to write back with your questions or answers about questions.

Sources

How to Use Socratic Questions: http://serc.carleton.edu/introgeo/socratic/fourth.html

Kost, A & Chen,F.M. (2015). Socrates Was Not a Pimp: Changing the Paradigm of Questioning in Medical Education. Acad Med. 2015; 90:20–24.

The role of Socratic Questioning in Thinking, Teaching and Learning
Socratic Questions: http://changingminds.org/techniques/questioning/socratic_questions.htm

The Six Types of Socratic Questions http://www.umich.edu/~elements/5e/probsolv/strategy/cthinking.htm

Schumacher DJ, Bria C, Frohna JG. The quest oward unsupervised practice: Promoting autonomy, not independence. JAMA. 2013; 310: 2613–2614.

Tredway, L. (1995). “Socratic Seminars: Engaging Students in Intellectual Discourse.” Educational Leadership. 53 (1).

 

 

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The Art and Science of Medicine – a critical but troubled marriage

“I always feel better after talking to the doctor.”

The first time I recall hearing this statement, it was many years ago, spoken by an elderly lady emerging from the inner office of our family physician. I also recall it leaving me me a little confused, and a little intrigued.

Dr. Mitchell practiced in Collingwood for many years and looked after any malady that might befall members of my family. I was waiting to get my biweekly “allergy shot” (another story). With Dr. Mitchell, you didn’t really have an appointment; you just showed up and read magazines until called. No one ever complained. There seemed to be acceptance that the order was based on some greater principle than “first come, first served”. As I was leafing through a New Yorker searching for the cartoons, I overheard the lady make that statement to her waiting husband as they got ready to leave. I wasn’t really eavesdropping; she seemed to intend the comment for everyone in the room. She’d been in there only a few minutes. She entered clearly worried and upset. She emerged looking considerably relieved and energized.

What, I wondered, had happened in there? Clearly, there had been no time for any treatment to have been administered, let alone take effect. All he could have done was talk to her. And yet, she was better. She was relieved. She was grateful. Whatever happened was effective and made a difference to her. Some talking! I was intrigued, and whatever process eventually led to my decision to consider a career in Medicine probably started, or was at least advanced, that day.

I’ve since heard variations of that statement many times. During medical school and residency I heard it applied by patients to many of the excellent physicians I had opportunity to train with over the years. I heard it applied to many of the highly skilled colleagues I’ve worked with. I consider it to be one of the simplest but also purest ways patients can acknowledge the effectiveness of their encounters with their physician. Simply put, they feel better afterward than they did before.

This ability is not the exclusive domain of physicians. People emerge everyday from their encounters with nurses, therapists, pharmacists with similar feelings of well being and renewed energy.

What’s going on?

To the skeptical, this could be dismissed as some sort of placebo effect, a psychological delusion or defense mechanism that those desperate for help construct for themselves in order to deal with their malady. After all, no concrete intervention has occurred. No pathophysiologic process has been medically or surgically influenced. It doesn’t really make logical sense.

On the other hand, it doesn’t always work, and we’re all aware that making the correct diagnoses and applying appropriate therapy can often be inexplicably ineffective. Patients tell us repeatedly how frustrated and abandoned they feel after encounters where they’re told “everything’s fine”, or “take this medication and you’ll be fine” but are unconvinced, and feel no better afterward. Moreover, sound recommendations may be completely ignored by patients, leaving their doctors baffled, or perhaps never even knowing and therefore content in the false knowledge of a job well done.

All this relates, of course, to the fundamental and critical duality of the physician role – what we’ve come to regard as the “art” and the “science” of Medicine. It’s been appreciated since ancient times that, in order to be effective, physicians must combine their knowledge of medical science with personal qualities and skills that provide and promote a human relationship, a personal link with their patients, and it’s in the context of that relationship (and only in that context) that scientific therapies are effectively applied.

The importance of these humanistic “healing arts” has been well described.

Hippocrates is credited with the aphorism “it is more important to know what sort of person has a disease than to know what sort of disease a person has.”

William Osler is famously quoted as proclaiming, “the good physician treats the disease, the great physician treats the patient who has the disease”.

Abraham Flexner, the non-physician educator who so profoundly transformed medical schools in the early 20th century is famous for championing the inclusion of fundamental science in medical education. He’s less well known for his views on what were termed the “empiric” aspects. The following is taken from his 1910 report:

“The practitioner deals with facts of two categories. Chemistry, physics, biology, enable him to apprehend one set; he needs a different…appreciative apparatus to deal with the other, more subtle elements. Specific preparation in this direction is more difficult; one must rely for the requisite insight and sympathy on a varied and enlarging cultural experience. Such enlargement of the physician’s horizon is otherwise important, for scientific process has greatly modified his ethical responsibility.”1

It’s interesting that 15 years later he tried to correct what he perceived to be an over-emphasis on his recommendations regarding science and technology. The following is taken from Medical Education: A Comparative Study (1925):

“In respect to the position I have thus far taken, a curious misapprehension not uncommonly arises. The careful scrutiny, reflection, and decision (which is the essence of the scientific method), the employment of every weapon by means of which the causation of disease may be ferreted out and health restored (which is the essence of the scientific procedure) – these are sometimes regarded as in conflict with the humanity which should characterize the physician in the presence of suffering. Assuredly, humanity and empiricism are not identical; with equal assurance, one may assert that humanity and science are not contradictory…It is equally important and equally possible for physicians of all types to be humane, and at the same time to employ the severest intellectual effort that they are severally capable of putting forth…The art of noble behaviour is thus not inconsistent with the practice of scientific method”2

The late Bernadine Healy, prominent American physician, academic leader and former head of the NIH, spoke eloquently on this subject and is perhaps more pragmatic: “the art of medicine transcends all else when an anxious individual confronting death or disability looks to the physician and asks, ‘What’s right for me?’” In an excellent article on the subject, she goes on to describe four key components: Mastery, Individuality, Humanity and Morality. Her description of Mastery seems particularly apt: “expertise, not just experience; wisdom more than knowledge; and a creative way of thinking, ever alert to the reality that sickness is not as obvious as it seems.”3

It would seem that the importance of maintaining the “art” as we engage the ever expanding “science” of medicine is critical and fundamental to effective practice. It is what elevates the profession beyond the simple application of remedies or technical interventions. It is, to be more pragmatic, what the public expects, and what it feels it is paying for. It is also what makes the teaching and learning of medicine so very challenging. Knowledge, these days, is easily within our grasp. Technical skill comes to the appropriately skilled with dedication and practice. The ability to understand patients as individuals, establish relationships of trust, and apply treatments with sage wisdom are all much more difficult to identify in applicants, to teach and to assess.

At this point in our history, it seems we’re at a critical juncture. Our dual roles appear to be heading in opposite trajectories. Medical science is in unprecedented ascendency. In virtually every discipline, new and highly effective therapies are available. Conditions previously untreatable are being cured or at least improved. People are living longer and better. All this is wonderful. At the same time, we have many indications that the “art”, the humanistic components of medicine, are under threat and in decline.

The threats are both multidimensional and unintentional.

Time pressure. I know no physician who doesn’t feel under over-extended and under pressure to do more in less time. The provision of “timely”, “efficient” and “cost effective” care has become the paramount objective. Although this may seem necessary and even noble, the result is that our clinics, emergency departments, hospital wards, procedural units, are all under intense pressure to deal with high volumes expeditiously. We fall back on corporate, business- based approaches to deal with these practical issues. It becomes easy to forget that those “high volumes” are individual people experiencing what they perceive to be a time of great personal crisis. They often do not feel the centre of care, but rather something more akin to components on an assembly line. It’s not all bad – necessary care is provided, conditions are treated and usually resolved. But patients too often emerge wondering what happened, and even who was treating them.

The harsh reality is that the medical/technical aspects of care are more easily and more efficiently applied devoid of the need for interpersonal interaction. In our multidisciplinary and team based approach, compassion can come to be regarded as a delegated act.

The primacy of therapeutics over diagnostics. The practice of medicine has gradually and unceremoniously shifted over the past several decades from a largely diagnostic to therapeutic endeavor. This is a function of the greatly expanding therapeutic options, medical, interventional and surgical, now available for many conditions previously not treatable. In addition, many diagnostic tests and procedures are now available that can establish a diagnosis with a minimum of historical information. This is all obviously good, to the benefit of our patients and society at large. However, a consequence of this change is that the communication skills, personal contact and relationships required ferreting out a useful history and differential diagnosis is a less prominent, less essential physician skill, particularly in procedurally heavy specialties. Conditions previously diagnosed by historical and physical examination features alone are now established (even defined) on the basis of laboratory or imaging studies. This may have advantages in terms of time required and objectivity, but the “art” of establishing a diagnosis through insightful questioning and insight (still essential in all but completely straightforward situations) is gradually being eroded and, with it, the necessary human interaction.

Specialization. The dramatic expansion of knowledge and therapeutic options has required physicians to specialize in specific applications of medical service. Medical school graduates in Canada currently select between about 30 entry disciplines, many of which branch further resulting in well over a hundred very different practice options. This, again, is a function of our success and provides advanced, effective service to patients. However, a consequence of this specialization is that, for many physicians, their engagement of patients is exclusively in the context of a very specific, often predetermined, service. The need to establish that interpersonal connection may not be seen as necessary or welcome and, amazingly, may even be seen to be inappropriate to the encounter. This has important consequences. Patients are at risk of being deprived of individual consideration during these encounters. Perhaps more profoundly, the practice of medicine is finding a home for individuals who are unable, or unwilling, to engage the humanistic aspects. In essence, what was previously requisite is becoming optional.

Our award system. In terms of both prestige and monetary compensation, we clearly value situational, specialized technical or procedural expertise over primary patient contact and continuing care. We may value the art and science equally from a theoretical perspective, but our practical choice is very clear. Our learners and young physicians, both astute and aware, are faced with unbalanced choices.

Medical school admissions and curricula. Despite decisions and efforts to make medical education more broadly available to individuals with backgrounds and interests in the broader human experience, it remains largely the domain of those with scientific backgrounds. In fact, pre-medical courses in the humanities are seen as disadvantageous to potential admission since they generally provide much lower marks than science or math courses. Medical school curricula themselves are very much, and understandably, directed to knowledge and skill acquisition, and increasingly to career exploration. The “arts” are simply being squeezed.

These issues, although rather daunting, are nonetheless individually approachable and our profession lacks neither the imagination nor capacity to approach them. However, this brings us to the most significant issue of all. Do we see this as a problem? Is the gradual erosion of humanism within the practice of medicine a threat we must marshal our efforts to reverse, or do we see it as a natural evolutionary change, a natural consequence of how medicine and health care in general must adapt to a vastly expanding base of interest and the resource constraints we’re all only too familiar with? Are those who raise these concerns simply pining nostalgically for a bygone era?

In posing this question, I recognize that my contemporaries and I are not the ones who must provide the answer and necessary commitment to change. It is, in fact, our students and young colleagues who will face this choice and determine the direction of our profession. They will need to consider what’s left without the humanistic “art” of medicine, how it will be regarded by their patients, and how it will be valued by society. The choice is perhaps best summarized by Thomas Lewis, a former medical school Dean and frequent essayist and writer, who wrote:

“The uniquely subtle, personal relationship has roots that go back into the beginnings of medicine’s history and need preserving. To do it right has never been easy; it takes the best of doctors, the best of friends. Once lost, even for as short a time as one generation, it may be too difficult a task to bring it back again. If I were a medical student or intern, just getting ready to begin, I would be more worried about this aspect of my future than anything else. I would be apprehensive that my real job, caring for sick people, might soon be taken away, leaving me with the quite different occupation of looking after machines. I would be figuring out ways to keep this from happening.”4

So, does your patient feel better after seeing you?

 

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

  1. Medical Education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Abraham Flexner. Arno Press &The New York Times. New York. 1910. Page 26.
  2. Medical Education: A Comparative Study. Abraham Flexner. The MacMillan Company. New York. 1925. Page9-10:
  3. http://www.cbsnews.com/news/medicine-the-art/
  4. The Youngest Science: Notes of a Medicine Watcher. Thomas Lewis. Alfred P. Sloan Foundation Series.1983.

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MD Program Executive Committee Meeting Highlights – December 16, 2015

Faculty and staff interested in attending MD PEC meetings, should contact the Committee Secretary (Faye Orser, (orserf@KGH.KARI.NET)) for information relating to agenda items and meeting schedules.

School of Medicine Building – Flood Repairs

Dr. Sanfilippo was happy to announce that the repairs to the building are wrapping up and classes will resume in the lower lecture theatre as of January 4.  He would like to extend his appreciation to everyone for their patience and efforts to make this term successful despite the space challenges.  Thanks also to Kevin McKegney for his continuing efforts to ensure repairs progressed as expeditiously as possible.

Admissions

Dr. MacDonald reported that the Admissions Committee are looking at several areas which may impact the admission process in future years.  MD PEC was asked for input on topics such as the School’s diversity statement and policy, pipeline programs and whether the School defines itself has having a National or Regional perspective. These issues will be considered in upcoming meetings of MD PEC.

Transfer Student Policy

The Committee approved a newly developed policy relating to MD students from other education institutions requesting transfer into the Queen’s MD program.  This new policy formalizes existing practices and is not intended to alter or change the School’s current approach.

Audio and/or Video Recording of learning events in the UGME Policy

The Committee approved a newly developed policy allowing video recording of UGME lectures.   A pilot project is being established to test the effectiveness and viability of the capturing of lectures for student viewing.

All Undergraduate Medical Education policies and terms of reference are available on the UGME website:  http://meds.queensu.ca/undergraduate

 

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Socrates, “pimping” and teaching in medical education

Recently, one of the words in the title of an article in Academic Medicine really caught my eye: “Socrates Was Not a Pimp:  Changing the Paradigm of Questioning” by Dr. Amanda Kost and Dr. Frederick M. Chen. (Kost & Chen, 2015)

Of course, the word that caught my eye was “Socrates,” he of sitting with students under an olive tree fame

20120223-Socrates Greuter

and, of course,  from Bill and Ted’s Excellent Adventure. socrates with bill and ted

Much of the scant information we have about Socrates is from his students, Plato and Xenophan.  Plato portrayed Socrates as an excellent teacher and questioner, in the Dialogues, where a series of questions is asked not only to draw out individual answers, but also to encourage fundamental insight into the issue at hand.

Can it be, Ischomachus, that asking questions is teaching? I am just beginning to see what is behind all your questions. You lead me on by means of things I know, point to things that resemble them, and persuade me that I know things that I thought I had no knowledge of.

–       Socrates (Quoted in Xenophon’s “Economics”) Portrait Herm of

Of course, I can’t deny that another word caught my eye in the title:  It’s not always that you see the word “pimp” in a medical education journal.

However, it’s a common term in medical education, since 1989 at least, where Brancati used it to refer to a questioning method that is supposedly Socratic but is defined as “whenever an attending poses a series of very difficult questions to an intern or a student.” (Brancanti, 1989) He suggests questions “should come in rapid succession and be essentially unanswerable.”  There are other definitions, and the “not a pimp” authors Drs. Kost and Chen, write that in these definitions the purpose of the practice is to reinforce the power hierarchy of the team and, more specifically, the attending physician’s place at the top. (Kost and Chen, p. 21)

In a 2005 study, by Wear et al. fourth year medical students were questioned about the practice of this form of questioning:

Students divided pimping into “good” and “malignant” categories. “Good pimping” actions included questioning that advanced or enhanced the learning process and also encouraged students to be proactive about their learning…“Malignant pimping” frequently employed techniques designed to humiliate the learner. All students in this study identified humiliation as an outcome of any type of pimping—even good pimping had a component of shame because of the public embarrassment of not knowing the answer.  (Wear, et al, 2005 cited in Kost & Chen)

I’d like to discuss “pimping” both from a syntactical and a pedagogical perspective.

I was trained as a language educator to acknowledge that language has a very pronounced impact on constructs in our thinking.  I have to admit that I don’t get the use of the term.  The other definition of pimp:  a person, especially a man, who solicits customers for a prostitute or a brothel, usually in return for a share of the earnings; pander; procurer (Online Dictionary and Merriam-Webster Dictionary) seems to have very little to do with questioning, whether benign, or malignant.

“Pimping” then… you know, that’s the last time I’m going to use the word! I dislike the relationship it implies that could so easily settle into the hindbrains of all us who have been using it.   With your permission, I’m going to try “hounding” instead.  Drs. Kost and Chen agree with me: “This word may evoke a negative affective response, and we would also argue that the use of such a derogatory term to describe an experience in medical education is unprofessional.”

Because, you see, questioning is one thing, and is an excellent and powerful educational tool.  However, when does questioning move into “hounding”? It happens when the questioner is pursuing a different goal than a pedagogical one:  perhaps humiliation(“She needs to know this stuff”), or going way beyond the knowledge of the level of the learner (“Shouldn’t clerks know this, or is it residents? Fellows?”) or venting frustration and anger (“You guys think you’re so smart? Well, let’s see…).  They include the well-known “Read my mind” type of question, and the question that is so obscure that very few know the answer (except perhaps the questioner?).

In the Wear study, students felt questioning  “was useful to “promote learning, logical thinking, defending one’s decisions, quick recall, self-assessment, and communicating well with one’s peers.”  They didn’t like the hounding part of it, and wanted to use volunteering answers as an alternate to centering someone out and hounding them. (I know, I know…this can be an important part of questioning…I hear you and I’ll come back to this.)

So, let’s get back to Socrates.  The Socratic questioning method is used often today, tho’ it appears it can be misunderstood.  In a recent vehement and lively DR-ED listserve discussion, the Socratic method was linked heavily with “hounding” by one participant.

Socrates used the dialectic method of teaching, whereby he assumed the role of someone who knew nothing about a topic, and drew the students’ ideas out, through a series of questions, each one probing more in depth or looking at different options. (Fun fact:  Did you know that the word “education” comes from the Latin ex ducere (to lead or draw out?)

The scientific method, which begins with a hypothesis and then proves or disproves the hypothesis is widely credited with having its roots in the Socratic method. just saying

Since Socrates was mainly concerned with students uncovering their own beliefs, and the validity of those beliefs, the correction of misconceptions and reliable knowledge construction all around large concepts such as truth and justice, modern teachers have created a sort of system for modern Socratic questioning of all types of learning.  Here are some of the characteristics:

1.    Students are questioned in a group, and in modern times, others in the group can collaborate with each other to find answers.  But not always…Socrates challenged his listeners and students.  And he picked them out, as well as had them volunteer.  But learners could help each other.  You’ll see in this sculpture, Socrates teaching in the Agora, by Henry Bates,  below how avidly everyone listens to each other.listening

2.    Socrates believed questioning would motivate learners and help them to the joy of learning. Thus, questioners should create a safe and comfortable context for questioning, where wrong answers are simply a signpost to heading down another path of learning.  In other words, they wouldn’t mind being centred out because they were enjoying learning.

3.  Use of by “why”, “what if” “how”, “then, if…” or open-ended questions vs. closed ended questions such as “What is this object?” “What is 1+1?” (Perhaps we can start with close-ended questions especially for novice learners, but they shouldn’t be the end goal of the questions.)

socrates and exams

3.  Socratic questions must be: 1) Interesting, 2) Incremental, 3) Logical (moving from the student’s prior knowledge towards a goal), and 4) Designed to illuminate particular points.

4.  Questions should be well-planned with a goal of benefiting the student at his/her learning level in mind.  Sometimes you have to start factually, but there should be progression toward critical thinking.

Let’s summarize, and then I’m going to prepare for you to write in to tell me what you think about “hounding” and questioning:

1.    Let’s not use that word again…it’s really ugly semantically.

2.    Hounding is not questioning.  Hounding is hounding and it’s not supported pedagogically. Questioning is an excellent way to teach.  It doesn’t have to be sweet, nor does it have to be easy.  It has to be respectful and with the appropriate underlying purposes.

3.    If we’re going to claim that “hounding” is Socratic, or even our questioning strategies are Socratic, let’s start using Socrates’ methods more.  Let’s aim for critical thinking questions, one of Socrates’ key purposes in questioning.i cannot make

4.    Let’s focus on our learners and tailor questions to their learning level.

5.    Let’s create a climate where questioning is accepted and even welcomed.  Let’s give our learners appropriate language to acknowledge they haven’t prepared, or are at the limits of their abilities thus far and need assistance.

In my next column (look for it in January 2016), I’ll provide more suggestions—based on Socratic principles—for keeping Questioning productive.

So, what do you think?  Are you a Socratic questioner?  Do you think hounding has a purpose?  Are there aspects of your teaching and questioning that can be enhanced through Socrates?

Looking forward to hearing from you about this.

And it’s not a smooth segue, but while I’m here with you, I’d like to take this opportunity to wish you all the best of the season!

seasons greetings

And here’s to great teaching in 2016!

 

 

References:

Brancati FL. (1989). The art of pimping. JAMA. 262:89–90.

Dictionary.com http://dictionary.reference.com/browse/pimp and Merriam-Webster Dictionary http://www.merriam-webster.com/dictionary/pimp

Kost, A.& Chen, F.E. (2015). Socrates was not a pimp:  Changing the paradigm of questioning in medical education. Academic Medicine, 90: 1.

Wear D, Kokinova M, Keck-McNulty C, Aultman J. (2005). Pimping: perspectives of 4th year medical students. Teach Learn Med. 17:184–191.

 

 

 

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It’s time to re-invent the Clinical Clerkship

FlexnerThe 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 the 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 learning with the clinical setting. This became consolidated into the discrete role that came to be known as the Clinical Clerkship.

group72Being a “Clerk” was to have a job or role within a hospital’s complex system of 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, 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 more independent practice after graduation. The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today. Importantly, 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.

In short, being a Clinical Clerk was a job. Clerks had a widely understood and (dare we say) useful role within the hospital. As a Clinical Clerk, a medical student felt part of the service delivery because they were making a tangible contribution. They therefore felt, and were, valued.

Many factors have combined to, gradually and without deliberate intention, dramatically alter the role:

  1. The service components came to be recognized as excessive and non-educational, to the point of diminishing true educational opportunities. Accreditation standards confirm and reinforce this perspective.
  2. Our hospitals have become much more focused on efficient, focused, therapeutic management of patients with complex and critical diseases. Diagnostic processes, so important to the Clerkship learning experience, have largely shifted to the outpatient setting.
  3. Career selection and the CaRMS application process have become a major focus for our students, making multiple, shorter service assignments preferable to the longer, continuing assignments that allowed the Clerk to develop a clear role within service teams.
  4. Hospitals are much more regulated environments that require clear definitions of roles and scope of practice for all providing care.

Although these issues are all valid, one must now ask what price we’ve paid for this evolution. A few questions come quickly to mind, and are being asked by our students, faculty and hospital personnel on a daily basis :

  • What aspects of patient charting are Clerks expected to provide?
  • To what extent are Clerks empowered to write patient orders?
  • What diagnostic tests are Clerks empowered to order?
  • Is a Clerk permitted to submit a consultation request or requisition for an invasive investigation?
  • What medications can a Clerk prescribe, if any?
  • What procedures are Clerks expected to provide?
  • Can a Clerk obtain informed consent for procedures? If so, what procedures?
  • To what extent should a Clerk be expected to provide care for a patient in an emergency (arrest) situation?
  • In all these issues, what degree of supervision is required, and by whom?

Clearly, the application of all these aspects of service provision will vary between clinical assignments, but their fundamental nature (or, to use hospital terminology “scope of practice”) should be consistent throughout. It should not be necessary to re-define the Clerk role for every rotation.

Our Hospital Liaison Committee, capably chaired by Christopher Gillies with representation from all teaching hospitals, faculty, administration and students, has recently been considering solutions to the Learning Environment concerns described in previous articles (meds.queensu.ca/blog/undergraduate/?p=2026). They recognized that many of these concerns may have their roots in this lack of clarity regarding the Clerk role and have therefore advocated a redefinition of the role. To this end, our Clerkship Committee (Chaired by Andrea Winthrop and consisting of all Clerkship Course Directors) met this past week to re-define the role or “job” of the Clinical Clerk, recognizing our current educational requirements and current reality of the hospital based learning environment. They have already made excellent progress in addressing the various issues listed above.

To short, our senior medical students (Clinical Clerks) are able to make valuable contributions to patient care in the hospital environment. It is in doing so that they truly grow as physicians. That can only happen with a clearly articulated and widely accepted role description, appropriate to the modern hospital environment, developed jointly by medical education and hospital leadership.

 

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

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Accreditation Success Stories…and lessons going forward.

Medical school accreditation has been described, with some justification, as the colonoscopy of medical education. The parallels are rather striking:

  • Both require a long and distinctly uncomfortable period of preparation.
  • Both require a public exposure of personal features most would prefer to keep modestly hidden.
  • Both can get messy.
  • Both carry high potential for embarrassment.
  • In both cases, the procedure itself can be tortuous and painful.
  • And finally, for the asymptomatic and fundamentally healthy, their value is highly debatable.

Also like colonoscopy, one emerges from a successful examination with a sense of great relief. That relief, in part, is simply related to having completed the process. Doing so with a successful report of findings adds immeasurably to that sense of relief.

At Queen’s, we are fortunate to have recently emerged from our own collective internal examination with that great relief, having achieved a full eight year approval, with no further invasive procedures required until 2023.

Reflecting now on a process that really started after our last review in 2007, it’s possible (and probably healthy in a preventive sense) to set aside for a moment the struggles and various deficiencies that required attention, and focus rather on the positives that have emerged. A few come particularly to mind and merit attention because they bear important messages we should carry into the future.

Firstly, our success was based on our ability to mount a common effort. Without question, the very real threats to our school imposed by the 2007 review galvanized our efforts and collective will in a way that made possible the changes that we needed to make.

Our Deans (both Drs. Walker and Reznick), engaged accreditation efforts with resolve and unconditional support. Our university leadership (particularly Principal Woolf whose first duty in his new role was to publicly defend a medical school he had just inherited), have been staunch supporters of the accreditation effort. Our Department Heads, to a person, have been nothing but supportive of the school. Our curricular leadership, undergraduate office, medical education team, medical technology unit, hospital partners and, critically, our students, all came together to meet the various challenges, and did so with methodical efficiency, driven by a shared desire to support (dare I say, defend) our school. One sees such common, focused effort only rarely, and usually only when necessitated by great and imminent peril. It is nonetheless rather inspiring to consider what our common efforts achieved and speculate on what might be possible if we could continue to work collaboratively without the need for external motivation.

Secondly, one must acknowledge that many significant and enduring changes emerged from these efforts. A robust and effective new curriculum, effective assessment methodologies, creative and updated approaches to teaching, a revised and much more effective governance structure, a refurbished framework of policies and procedures, our highly impressive and sought after MedTech curricular management system, and even our new School of Medicine Building itself were all, at least in part, motivated or accelerated in their development by our accreditation efforts.

The process brought welcome attention to a number of areas of strength within our school, often overlooked as we focus attention on problem areas. Refreshingly, and unexpectedly, the recent report made reference to our teaching, which it identified as an area of strength. To quote from our report:

As reported by students in the ISA [Independent Student Analysis] and by the survey team, the program benefits from many capable and dedicated teachers. For example, in the MEDS 125 [Blood and Coagulation] course, with 99% of students commenting on the course, no negative comments were made within the 9 pages of comments, and the survey report suggests that the Course Director and the faculty involved in this course are to be congratulated…. Another course that received similar accolades was MEDS 127 [Musculoskeletal], where the team reported: “Dr. L Davidson who continually monitors and enhances the course. This is a “poster child course” and Dr. Davidson deserves significant recognition for the evolution of this highly innovative and interactive course.”

In fact, we are truly blessed with many dedicated and talented teachers, knowledgeable and committed faculty leaders in all key portfolios, committed and hard working undergraduate administrative and educational support teams, and a receptive and engaged student body.

In the final analysis, the most enduring lesson we should take away from our eight-year struggle with the accreditation process must be that we never again require a “crisis” to spur us to collective action in order to ensure we are providing the very best educational experience for our students. Complacency is poison. The continual, collective pursuit of quality improvement and courageous innovation must be our continuing goals. These are the lessons of the day.

 

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

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