The Challenge of Career Selection

When are Medical Students ready to decide?

Medical students begin their studies believing they have decided upon and achieved their career path, and can now devote their energies and attention to advancing that goal.  They soon learn that even greater and more complex decisions lay ahead.  The process of career selection has become a major cause of concern and stress for both medical students and curricular leaders at our Canadian medical schools.  Students must, by the end of medical school, select from among over 30 postgraduate training program options, which will further differentiate into over 70 approved medical specialty certifications.  Are students ready?  A recent, informal survey was carried out among the first and second year classes at our medical school.  Students were asked to state their agreement with one of three statements:

  1. I have a single, clear career interest.
  2. I have narrowed my focus to between 2 and 5 options
  3. I have no idea


So it would appear only a minority of our students have established a choice by these early years, although it’s unclear how durable these choices will prove to be.  It also seems that some further clarity emerges even by second year, but the majority of students remain uncertain.  Studies from the British medical educational system would suggest that about a quarter of doctors change their career choice after qualification (Goldacre MJ, Lambert TW, Medical Education 2000:34:700-707).  A review of Canadian graduates reports that 83% of graduates felt somewhat or very well prepared to make career decisions, but that leaves a full 17% who described themselves as “not at all sure” by graduation (Columbia B. Can Med Assoc J 1997;156:1248)

To illustrate how much the medical landscape has evolved, it might be useful to consider a “Tale of Three Classes”.

1870This photograph provided by Queen’s Archives illustrates one of our earliest graduating classes, circa 1870.  Students of that era received a common 3-4 years of instruction and clinical training, after which they were fully qualified practitioners.  Their scope of practice throughout their careers was virtually identical, determined only by the needs of the communities they served.







Let’s move forward about a hundred years.  The second photo was taken at the 25th reunion of my class, Meds ‘81.  My classmates and I also undertook a common four year curriculum.  With one further year of training, in virtually any “internship”, we were all deemed fully qualified as “General Practitioners”.  About half the class remained in General Practice, eventually becoming qualified by the College of Family Physicians when that body and its qualifying examinations came into being.  The remainder went on to additional training in one of the limited number of specialty programs and certification examinations offered by the Royal College of Physicians and Surgeons.  Importantly, I doubt any of my contemporaries regretted their general training, and even those eventually engaging very specialized disciplines would say that their clinical proficiency and effectiveness was enhanced by that background.

2009Contrast all this to the graduates of Meds 2009.  About a quarter of these students undertook training in Family Medicine.  Many will, by now, have completed the minimum two year training program and will have begun practice, having passed qualifying examinations and achieved full certification through the College of Family Physicians.  The remainder are still in training, having undertaken further training through the CFP or entered a variety of Royal College programs, all with their own entry requirements, training program and qualification examinations.  Although their undergraduate experience would have differed in many ways from that of their predecessors, it was based on a structurally similar four year model, common to all students regardless of career direction.

The routes to practice are, in fact, becoming increasingly tortuous, complex and longer.  In order to better understand this, I’ve consulted with my colleagues in our postrgraduate education office.  Jordan Sinnett, PG Program Manager, provided me with the accompanying table that outlines the various paths to the current available postgraduate programs.   The reasoning by which some programs are direct entry from undergrad whereas others diverge after core training, and the length of time of various programs is all rather opaque, but appears to reside with the individual program committees.

It’s important, in considering all this change, to recognize that the major driver is the increase in medical knowledge, available technologies and vast expansion of valuable service the profession is able to provide to our patients.  Our society requires (and demands) physicians who have the highly specialized knowledge and training that’s required to diagnose and manage our ever-expanding array of conditions and provide technologically complex treatments.  This is obviously all good.  However, as training needs have increased, we have simply added more time and qualifications to those previously available rather than to consider new educational paradigms.  At this point, a few questions must be posed:

  • Is this a problem?  Stated another way, are there unintended consequences of this evolutionary change that should be addressed?
  • What, if anything, is being done?
  • How will all this affect our learners, and can they be expected to engage career selection in a different way?

Unintended Consequences

1.  Increasing focus of attention and stress for medical students.  The expansion of career options and requirement to choose from so many postgraduate training tracks is becoming an increasing focus (some would say obsession) of our students during medical school.  Observerships, interest groups, electives and even summer voluntary placements are all seen, and used, as opportunities to explore career options and advance one’s suitability for the increasingly competitive application process.  Although all of value, these pursuits compete with ever increasing educational demands expected of our students.

2.  Unhealthy competition among students.  Many postgraduate programs are over- subscribed relative to available training positions.  This results in a competitive environment at the very time medical schools are working hard to “undo” the pre-medical focus on superficial academic success and advance principles of patient-centred learning, collaboration and cooperation among colleagues.

3.  Subversion of medical education.  Medical school curricula are increasingly directed toward career exploration, to the extent that both core content and Electives (18 to 20 weeks at most schools) are essentially devoted to this purpose.  Career exploration is, in essence, subverting the educational priority.

4.  Increased time required to achieve practice readiness.  With the expansion of postgraduate programs and numerous emerging competency tracks, the duration of training is getting progressively longer.  Becoming a qualified interventional cardiologist, for example, requires 15 years from university entry (4 year undergraduate degree + 4 years of medical school + 3 years General Internal Medicine + 3 years Cardiology + at least 1 year Interventional fellowship).  Given that much of that time is spent in educational pursuits not directly relevant to the eventual practice requirements, the need for such a long training period is, at the very least, debatable, and given the increasing resource limitations of our health care system, will come under increasing scrutiny.

What’s happening that will affect all this?

The Future of Medical Education Postgraduate recommendations included the following:

Screen Shot 2013-12-09 at 4.17.16 PM

To implement this recommendation, the Association of Faculties of Medicine of Canada has established three committees with mandates to explore methods to refine processes within undergraduate programs, the transition from undergraduate to postgraduate education, and the transition to practice.  Those groups have been encouraged to think beyond current models.  Those revisions may involve more “streaming” or specialty-specific teaching during medical school, a more gradual transition from foundational to specialty-specific learning, and effective career counseling processes.

However (and this is a big “however”), any such change in the three or four-year common curriculum paradigm will necessarily require our students to make even earlier career choice decisions.  Is this a reasonable expectation?  The information I provided above would suggest they certainly are far from optimally prepared at this time.  So, what would be required to allow our students to make valid, durable career decisions earlier in their training?

The following would seem at least a reasonable place to start:

Clear and easily accessible information about the various career choices available to them.  Students need to understand the scope of specialty options and the essential differences, not only in clinical content, but also credible information about the “life” that goes with each.  They’re particularly interested in issues such as call expectations, mobility, and the availability of opportunities to integrate academic interests with their clinical obligations.

An understanding of their own preferences and aptitudes.  Students require direction and help in thoughtfully and honestly considering a number of personal issues relevant to career selection, such as:

  • Their willingness to engage patients with undifferentiated presentations
  • Their comfort with critically ill patients
  • Their comfort with continuing care versus issue-specific consultancy
  • Their comfort with surgery and procedural work
  • Their comfort with certain patient populations, such as children, the elderly, the terminally ill
  • Their comfort with various practice settings, such as hospital wards, emergency rooms, ICUs,  clinics, and offices
  • The degree of flexibility with respect to practice settings and mobility they wish to have

Although it can be very difficult for students, a full and candid consideration of issues such as these will allow them to reduce their reasonable options to a more manageable number.

Knowledge about availability of training and career opportunities.  Students have expressed very clearly their desire to know about long-term career availability.  Both shared experiences and recent studies (Frechette D et al, have suggested that many highly-qualified graduates of postgraduate programs have difficulty finding practice opportunities in certain specialties.  Students wish to have such information.  In this regard, they are allied with our provincial governments who seek to ensure our production of various medical specialists matches societal needs.  Unfortunately, accurate information is very hard to come by, particularly for students whose entry into the workforce is several years in the future.

An understanding of the application process.  Students need to understand the process by which they will apply and compete for postgraduate positions.  This requires clarity and transparency about both the matching and selection processes.  The former is carried out by the Canadian Residency Matching Service (CARMS), and is open, transparent and effectively provided.  The latter, which is in the hands of each specific postgraduate program, is considerably less transparent and subject to considerable rumour and “urban myth” among students.

Is there hope on the horizon?

All this requires a fresh, early and much more comprehensive approach to career exploration and counseling than medical schools have provided to date.   This week, those directing career counseling curricula and services at the six Ontario medical schools are assembling at the request of the Council of Ontario Faculty of Medicine Undergraduate committee to compare approaches, discuss challenges, and begin to develop more cooperative and effective approaches for our students.

The AFMC and ministry are jointly interested in providing more reliable definition of societal needs for all our specialties.  Such information will certainly be informative for our students.

The FMEC sub-committees mentioned above have, as a component of their collective mandate, consideration of improved student counseling and application processes.

These initiatives provide some optimism that students will be better prepared for their career decisions, and for the systematic changes likely to develop within our medical education programs in the coming years.  All these discussions and initiatives will be more effective if informed by those involved in (and effected by) the processes under discussion.  It’s in that spirit that this article is provided and your feedback is welcome. 

Many thanks to Jordan Sinett (Postgraduate Program Manager), Sarah Wickett (Health Informatics Librarian, Bracken Library), Jonathan Cluett (Meds 17 Class President), Sean Henderson (Meds 16 Class President), Jennifer Siu (Meds 16) and, as always, Lynel Jackson, for their assistance in the compilation of information for this article.

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UGME (and PG) go to the AAMC: Here’s what we learned

On Nov. 6, a band of intrepid medical educators from Queen’s travelled to Philadelphia to attend the Association of American Medical Colleges’ annual meeting.

Attending sessions from Nov. 6 to 10, Dr. Renee Fitzpatrick, Dr. John Drover, Dr. Laura McEwen, (Assessment Specialist in Post Grad), Ulemu Luhanga (a doctoral candidate working as a research assistant with Laura), Eleni Katsoulas (our UG Assessment and Evaluation Consultant) and I learned a great deal from our American counterparts.

But I would venture to say that they learned some from us too.  For example Laura and Ulemu presented their poster Queen’s Multisource Feedback Rubrics: Operationalizing Frames of Reference for Raters and Residents, and judging from the crowd around them during the whole session, their ideas were well-received.

I attended a great morning with the Directors of Clinical Skills group, where milestones were the topic of discussion and I’ve been invited to share our work on the clinical skills milestones we’re developing.  I’ll write more about milestones and the work from the AAMC in a later blog.

And Eleni went to hear the speakers of a great article, Jim Crossley and Brian Jolly, who wrote Making sense of work‐based assessment: Ask the right questions, in the right way, about the right things, of the right people.

Here she writes about their presentation and their article.  Please feel free to share your thoughts

Multiple Perspectives: finding relevance in idiosyncrasies


owl or coffee cups 2

What do you see in the picture above?

Do you see an owl? Or coffee beans and two cups of coffee? Some of you might say you see both things! Each piece is only part of the whole. This illustrates how different people can look at the same thing and see different things. Any one of these perspectives might be useful depending on the context!

How are  subjectivity and reliability related?

Does every context provide equally valid and reliable data for every domain? Crossley & Jolly (2012) argue that not every context provides good data for accessing every domain! So when might standing back and considering the whole performance give you a better picture than the sum of its parts? Or when are other perspectives just as useful?

The literature demonstrates that those who “have the competence to judge an aspect of performance, and have had the opportunity to observe it, appear to provide more reliable ratings” (Crossley & Jolly,p.35). Since clinical competence is so broad, isn’t it rational to say that multiple perspectives might be equally valid in certain contexts?

What does this mean for those of us teaching and assessing in medical education?
The authors argue that while historically, assessments have often
measured the measurable now we are concerned with measuring the important.  Workplace based assessments are often based on subjective judgements.  Sometimes the assessors develop an ” instrumental impressionism” whereby he or she makes a judgement that is global but, nevertheless, is vitally dependent on an overall, somewhat merged,
perception of the details (Crossley & Jolly, p. 33) and this is an equally valid if not more valid perspective.

For us, a few things emerge:  Some of our finely grained assessments are asking too much of assessors to provide meaningful assessment, especially in cases of concepts that are hard if not impossible to observe in the assessment setting.  Our assessors should be those with experience and knowledge in the specific areas of assessment, and their judgements as opposed to objective observations can and should play a large role in assessment. And finally, we should ask the right questions, in the right way, about the right things, of the right people.


Crossley, J. & Jolly, B. (2012). Making sense of work-based assessment: ask the right questions, in the right way, about the right things, of the right people. Medical Education, 46, p-28-37.

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History of Medicine 2013: Queen’s Medicine Takes Boston

Thanks to Hollis Roth, Meds 2016, who is our guest writer for today’s blog article, and to  Stefania Spano (Meds 2016) and Dr. Jacalyn Duffin for their photos.

This fall marked the 16th annual Queen’s History of Medicine trip; what began as a trip planned by Dr. Duffin in 1996 to the National Gallery in Ottawa has quickly became an annual tradition fondly remembered by many classes of Queen’s Medicine graduates. This year marked the fourth History of Medicine trip to Boston and spots were highly coveted, with a wait-list maintained until the very day of departure.

After classes ended on Friday, students eagerly piled on the coach bus and settled in for the long trip to Boston. While the 9-hour ride proved longer than anticipated, students passed the time in a variety of ways. Some diligently studied, others caught up with classmates and on sleep, and an unfortunate few spent the majority of the trip suffering from motion sickness. Arriving in Boston close to midnight, a cluster of students set off to explore the city, while others decided to wait until morning.

After gathering for a group photo on the steps of Massachusetts General Hospital, students spent the rest of the day exploring Boston. With only 36 hours to explore the city, students made the most of their time. Popular sites included the campuses of the Massachusetts Institute of Technology and Harvard University, as well as Fenway Park, the Boston Central Public Library, and sampling a wide variety of local delicacies. It was a lovely (albeit windy) fall day to wander the city amongst colleagues and friends while briefly escaping the rigorous demands of medical school.


Queen’s medical students explore the Harvard campus.  Photo credit: Stefania Spano (Class of 2016)

We began bright and early Saturday morning with a visit to the third oldest hospital in the United States, Massachusetts General Hospital. Massachusetts General is richly steeped in history and houses the Ether Dome, which served as a surgical theatre from 1821-1868 and is a National Historic Site. On October 16 1848, the Ether Dome was the location of the first public demonstration of the surgical use of ether anesthetic by William T.G. Morton. Under the guidance of Professor David S. Jones (MD PhD and the A. Bernard Ackerman Professor of the Culture of Medicine), and Dr. Sukumar P. Desai (Anesthesia, Brigham and Women’s Hospital), students learned how the use of anesthesia drastically redefined surgery.


Queen’s medical students at the Ether Dome.  Photo credit: Dr. Duffin

Our final stop on Sunday was Harvard Medical School, where we were privileged to have the Francis A. Countway Library of Medicine opened solely for our use.

Harvard Med School

Harvard Medical School  Photo credit: Stefania Spano (Class of 2016)

The Countway Library is one of the largest medical libraries in the world, serving Harvard Medical School and the Harvard School of Public Health, and contains the Warren Anatomical Museum. Led by Dr. Scott Podolsky (MD and Director of the Center for the History of Medicine), Mr. Dominic Hall (Curator of the Warren Anatomical Museum), and Ms. Joan Thomas (Cataloger, Rare Books), students received guided tours.

Countway Medical Library

Zeyu Li (Class of 2016) with Mr. Dominic Hall, Ms. Joan Thomas, and Dr. Scott Podolsky at the Countway Medical Library.  Photo credit: Dr. Duffin

Highlights of our visit included viewing first editions of Andreas Vesalius’ De humani corporis fabrica (1543) and Charles Darwin’s On the Origin of Species (1859) in the Rare Book Library, and viewing the skull of Phineas Gage in the Warren Anatomical Museum.

Dr. Duffin made a very exciting discovery while exploring the Countway Library. Dr. Duffin has long searched for the origins of an image used as a bookplate for books purchased in the 1920s for our medical library, but even after consulting with colleagues across the world the source remained unknown. Happily, Dr. Duffin was astonished to stumble across the very same image in Hortus Sanitatis (1491) while touring a selection of rare books chosen for our viewing. It was an extremely fortuitous discovery – had this book not been selected for viewing or conveniently left open at the relevant page by the student who had previously viewed it, Dr. Duffin may not have made this connection. It can truly be said that this History of Medicine trip was an educational experience for all!

Hortus Sanitatis

The frontispiece of “Hortus Sanitatis” (1491) and the cause of Dr. Duffin’s jubilation.  Photo credit: Dr. Duffin

We would like to extend our deepest thanks to Dr. Jones, Dr. Desai, Dr. Podolsky, Mr. Hall, and Ms. Thomas for taking the time to share their passion in the History of Medicine with us (on a weekend, no less) and for making us feel so welcome in Boston. As always, a huge thank you is due to Dr. Duffin for her continued support of these annual History of Medicine trips, to Zeyu Li (Class of 2016) for organizing the trip, and to the Aesculapian Society for funding. While I will be deep into clerkship at this point next year, I look forward to hearing about next year’s trip!

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Educational Resources at your Fingertips: Faculty and Students

As teachers, you may want to find resources that assist you with teaching, or find out what the latest news from the Curriculum Committee is, or find out who to contact about what.  As students you may want help about people, places, policies and other “p’s” in the Undergraduate Medical Education program.

We have published two resources recently:

The first is the new Faculty Resources Community:

NOTE:  first log into MEdTech via the dashboard URL, then simply click on the community, which would be among those listed on the left side of each user’s dashboard page. All faculty members including community preceptors are members of the Faculty Resources Community, but to “see” it you’ll need to log in first.

The Faculty Resources Community was created to provide faculty members, Course Directors, Year Directors and Committee Chairs with advance notice of topics to be discussed at Curriculum Committee meetings as well as easy access to Curriculum Committee Highlights, links to faculty development on teaching and assessment and materials distributed at Course Directors’ Retreats. Other resources posted in the new community include the Future of Medical Education in Canada reports and the latest LCME accreditation standards. We welcome suggestions for additional resources.

The second resource is for students!  The Student Handbook, a brilliant idea from Associate Dean Sanfilippo, and edited by Alice Rush-Rhodes, is now published on MEdTech and is available in a printable pdf format thanks to Lynel Jackson from MEdTech.

To access the Student Handbook, please go to and to print a copy, scroll down to the bottom of the side menu.  The Student Handbook contains information on people to assist students (including peer mentors), advice on careers, CaRMS and the Dean’s Letter, lockers, MEdTech, the Curriculum, and Special Programs to name a few components.

Is there anything we should add to the Student Handbook?  Any other way you’d like to see faculty ideas?  Just respond to the blog and let us know, or email Sheila Pinchin at




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Medical Student Research Showcase: Meds student researchers take over the Medical Building

September 26th marked the 2nd annual Medical Student Research Showcase at the Queen’s School of Medicine. This yearly event was brought to us by Dr. Heather Murray (Emergency Medicine and Public Health Sciences), Melanie Walker (Public Health Sciences),  and Amanda Consack (UGME) as well as many other members of the UG staff.  It showcases research performed by our medical students, during their time in medical school, for other students and faculty. This year’s session had a collection of 54 posters in the David Walker atrium, and three students were selected to deliver their research findings in an oral plenary, moderated by Dean Reznick.  It was an inspiring display of innovation, effort and accomplishment.

A wide range of research topics were presented, and over the lunch hour the students were able to go over their work with a crowd of interested faculty and students. Many Queen’s faculty served as poster assessors and completed a structured feedback form so that presenting medical students could understand where their posters succeeded, and also how they might be improved. Additionally, the 10 QuARMS students were introduced to the event through an assignment evaluating the design and findings of 3 posters that appealed to them.

This year, students who attended the poster session were encouraged to vote for their top 3 posters in a “People’s Choice” award competition. We had over 80 ballots cast, and in combination with the poster assessors feedback, a poster winner was selected: Osbert Zalay, with his poster “Foundations of the tricorder: Artificial intelligence solutions for biomedical classification problems.”

Later in the afternoon, the 3 students selected for the oral plenary session delivered their research in the main auditorium. These students were selected after submitting a 5-page summary of their work, each of which was reviewed 3 separate times by a panel of faculty judges: Dr. Albert Clark, Dr. Paula James, Dr. Anne Ellis, Dr. David Lillicrap, Dr. Will Pickett, Dr. Mike Brundage, Dr. Heather Murray, Dr. Tan Towheed and Dr. Rob Brison. Eighteen submissions of extremely high quality were reviewed, and the following students were selected:

Nathan Roth, MEDS 2015 “Inside the brain of an expert: Comparing medical decision making and cognitive processing demands between medical students and experienced medical resident learners.”
Faculty supervisor: Dr. Dan Howes

James Simpson,  MEDS 2015 “Patient evaluation of clinical interaction with medical students: A pilot study.”
Faculty Supervisor: Dr. Andrea Winthrop

Yan Xu, MEDS 2015 “Prescribing pattern of novel anticoagulants following regulatory approval for atrial fibrillation in Ontario, Canada.”
Faculty supervisors: Dr.Ana Johnson, Dr.Chris Simpson, Dr.Anne Holbrook (MacMaster) and Dr. Dar Dowlatshani (Ottawa)

These 3 students, and Osbert Zalay MEDS 2015 (“People’s Choice” Poster) have all been awarded the 2013 Albert Clark Award for Medical Student Research Excellence. This award was established in 2012, in honour of Dr.Clark’s longstanding contributions towards the critical enquiry program at Queen’s.

Students at the Queen’s School of Medicine are actively involved in a wide array of research enquiry with impressive results. Our students are asking questions, seeking answers, advancing care and inspiring change. Congratulations to all who presented, and to the faculty who have mentored them.

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Help for students reading challenging texts

Many students in medical education are not used to reading large amounts of dense materials, where, as one student put it, “every word is loaded and I end up looking up everything.” When experts read through a reading they have assigned to beginning medical students, they often underestimate the amount of time and effort that is needed.

In other posts, I’ve discussed how it’s important for teachers to preview their assigned reading materials, and to seek out the best material, through help from librarians and educational team members, that accomplishes their goals and is at an appropriate reading level for students.

For today, I’d like to introduce you to a reading method that may assist our students: it’s called SQ3R.
SQ3R stands for Survey, Question, Read, Recite and Review. It’s an approach to reading that can help students retain the information they have been asked to read. It promotes curiosity and a determination toward reading, that is based on the cognitive processes of successful learners. SQ3R is not a new technique–it’s been around since well before I was a university student–which is a long time! 🙂 Credit goes to Francis Pleasant Robinson who in 1946 first published about it in his book Effective study.

So how does it work?  NOTE:  readers, you may find that this looks like a long process.  While it’s longer than skimming, it can become habitual, OR you may want to take pieces of it for your own.  Please “read” on.
Survey: Basically, SQ3R asks readers to survey or look over a whole reading paying particular attention to:

  • The title, headings, and subheadings
  •  Captions under pictures, charts, graphs or maps
  •  Bold print, italics, numbered items, color coded passages, marginal notes, glossaries, outlines, questions, lists, charts, etc.–these are cues that the author regards these as key items
  • Review questions or teacher-made study guides
  • Introductory and concluding paragraphs
  • Summary

Question while you are surveying:

  • Turn the title, headings, and/or subheadings into questions
  • Read questions at the end of the chapters or after each subheading
  • Ask yourself,
    “What did my instructor say about this chapter or subject
    when it was assigned?”
  • Ask yourself,
    “What do I already know about this subject?”

Read, but read for a purpose:  look for answers

  • Look for answers to the questions you first raised
  • Answer questions at the beginning or end of chapters or study guides
  • Reread captions under pictures, graphs, etc.
  • Note all the underlined, italicized, bold printed words or phrases
  • Study graphic aids
  • Reduce your speed for difficult passages
  • Stop and reread parts which are not clear
  • Read only a section at a time and recite after each section or look away from the text and ask a stimulus question–this breaks your habitual reading and allows you to re-focus

Recite after you’ve read a section: ask yourself questions about what you have just read, or summarize, in your own words, what you read through writing

  • Take notes from the text but write the information in your own words
  • Underline or highlight important points you’ve just read
  • Reciting: for difficult passages especially:
    The more senses you use the more likely you are to remember what you read: Triple strength learning: Seeing, saying, hearing
    Quadruple strength learning: Seeing , saying , hearing, writing!

Recitation requires mental activities far beyond those possible through “stroking the words with eyeballs” in a textbook: a technique so commonly used by students. Reciting promotes and speeds learning while rereading and rereading actually slows, impedes, and in some cases, prevents leaning.

Review:  put it all back together again.  Very few people a whole chapter by reading it once.  The Question-Read-Recite process divides a chapter into sections that can be assimilated separately, into manageable chunks. This allows you to set your own pace.

Regular review puts a chapter back together again. In review, you are answering the question that was made from the chapter title.
Review means regular and frequent recitation (or written recitation) of the material to be learned. This is an excellent check for learning.

So how do you review?  Here are review techniques that have worked for me, for my students and from the literature:

  1. Review one day later, one week later, two weeks later
  2. Make a Table of Contents for a chapter from your notes or from memory
  3. Make a point form outline from your larger notes or from highlighted sections
  4. Put a concept map together:  make a visual diagram of what the chapter’s key concepts are
  5. Review out loud (remember the Triple Strength Learning above)
  6. Cover up parts of a page and test your self on  the corresponding parts.

A Problem and Solutions for Students and Faculty:

One last thing:SQ3R is slow.  At least it is slower than the speed at which many students “read.”  That doesn’t mean we shouldn’t look at it for medical education.  It’s slower than skimming but really effective in retention.  Perhaps students who are faced with large amounts of difficult material can take pieces from this process and add to their own.  Perhaps teachers can recommend or even put in place requirements for a point form outline or list of key questions or a concept map to be brought to class after assigned reading.

Do any of these techniques strike a chord with you?  Do you have other reading/reviewing suggestions?


Concept Mapping. accessed Oct. 7, 2013

Robinson, Francis Pleasant. (1970) Effective study. New York: Harper & Row.

SQ3R reading method.  The Reading and Research Series. accessed Oct. 7, 2013.

SQ3R accessed Oct. 7, 2013

SQ3R Textbook study system.  Worcester Polytechnic Institute.‎ accessed        Oct.7, 2013.

Weideman, M. & Kritzinger, C. (2003).  Concept Mapping – a proposed theoretical model for implementation as a knowledge repository. A working paper from the “ICT in Higher Education” research project.



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Education Workshops for New Faculty (and those who’d like a refresher)

The Education Team is providing workshops for new faculty (and those who’d like a refresher) on a variety of topics.

What we’ll cover:

The 3.5 hour session will give you the basic tools you need, including:
• Foundations of the UGME curriculum
• Who’s Who in UGME & what they can help you with
• Introduction to Small Group Learning (SGL)
• Assessment 101 (MCQs and Beyond)
• MEdTech & You
• Classroom equipment
And, we’ll share with you information on other training that the Education Team can provide for you.

Three sessions to choose from:

Session 1
Monday, August 26
9 a.m. – 12:30 p.m. (Then join us for lunch with the incoming first year class)

Session 2
Monday, August 26
1 -4:30 p.m (But come at 12:30 for lunch with the incoming first year class)

Session 3
Friday, September 20
8:30 – 4 p.m.

We are submitting this workshop for approval for CME credits for you.

To register, please email

Theresa Suart (, indicating your preferred session.

(For the August 26 sessions, please register by August 21, so we can let the Orientation team know how many to expect for the lunch. For the September 20 session, please register by September 16).

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Clinical Problem Solving: A student and a teacher talk about lessons learned from an online course

By Heather Murray, MD, and Eve Purdy, MD Candidate, 2015

For many medical students, the process involved in turning a presenting complaint into an appropriate and focused differential diagnosis seems like a big black box. For clinicians who do this many times every day, the process is unconscious, and it is hard to explain to medical student learners how to break it down. Both students and teachers sometimes struggle with how to transition early medical learners to competent diagnosticians.

black boxSo, when a clinician (Heather Murray) and a second year medical student (Eve Purdy) independently stumbled across the link to a Massive Open Online Course (MOOC) on Clinical Problem Solving offered through Coursera both of us jumped at the opportunity to learn more about diagnostic reasoning. Eve registered with the hope of shedding light on the type of problem solving that she might be faced with in clerkship, while Dr. Murray registered with the intention of improving her teaching around diagnostic reasoning for students.

Though it is difficult to summarize the six-week course in one blog post there were a few takeaways from the course that we will outline. These key points might help medical students improve clinical reasoning and the same tips might help teachers in clarifying the process for learners. Much of this approach to clinical reasoning comes from the NEJM article  “Educational Strategies to Promote Clinical Reasoning” by Judith Bowen (2006).

1. Organize the way you learn about diseases using Disease Illness Scripts

If you have a structured approach to the way you learn about diseases, then you will be more efficient at recalling that information and comparing diseases effectively. One way to organize information is into “Disease Illness Scripts”. This requires organizing information about the conditions into four broad categories.

Epidemiology Timing Clinical Presentation Pathophysiology
-who gets the disease?-what are the risk factors?

-making a mental picture of who you would expect to see with the disease can help

-over what time period does the condition present? 

hyperacutely: hours

acutely: days

sub-acutely:    days-months

chronic: months-years

acute on chronic

-a good way to think about this is where you would expect to see the patient (ER, vs walk-in vs family doctor)

-what are the symptoms? 

-physical signs?

*key features are signs and symptoms that are essential to the diagnosis

*differentiating signs and symptoms are those that make this disease different then diagnoses that present similarly

*excluding signs and symptoms are those that, if present, exclude the disease

-describe and understand the underlying disease mechanism

2. Organize the way you think about patients using Patient Illness Scripts

When thinking about patients try to frame their presentation using the same structure as the disease illness scripts.

Epidemiology Timing Clinical Presentation
What important risk factors does the patient have-age


-relevant medical history

-presentation specific risk factors i.e. recent transcontinental  air travel in a patient with shortness of breath

How long has the patient had the symptoms, have they changed?  What symptoms and clinical signs does the patient have? 

-try to group as many as possible to shorten the list (e.g. group febrile, tachycardic and hypotensive as septic)

3. Compare disease illness scripts and patient illness scripts to generate a tiered differential diagnosis

Generate a differential diagnosis based on the chief complaint. You can compare your understanding about each disease on your differential with your patient using the illness scripts easily. Pay close attention to key features, differentiating features and excluding features. The closer a disease illness script is to the patient illness script the higher it should end up on your differential. Your final differential has three tiers:

Tier 1: Diseases that are those most likely belong here. The epidemiology, time course and clinical presentation are concordant with the patient illness script.

  • Tier 1e: Diseases on tier 1e are diagnoses that may be less likely than tier 1 but if missed will cause immediate and serious harm. These are dangerous diagnoses! The “e” in this tier stands for “emergency” and diseases on this list must be ruled out, even if they are less likely.

Tier 2: Diseases that have some similarities to the patient illness script but aren’t a perfect fit belong here. They are still possible but less likely than tier 1 diagnoses.

Tier 3: Diseases on your original list that do not fit the illness script. They may have excluding features or lack key features.

 4. Use your tiered differential to determine what tests to order

The tier that a possible diagnosis falls into will help you decide what tests to order to determine the final diagnosis. Think of each tier as a pretest probability.

Tier 1 diagnoses have a “high” pretest probability

  • No tests or few tests may be needed to convince you that a diagnosis in tier 1 is responsible for the patient’s presentation and similarly you would need very convincing information to take it off your list completely.
  • These and Tier 1e diagnoses should drive your initial investigations

Tier 1e diagnoses may have varying pretest probability

  • These diseases may or may not be likely but regardless tests with high sensitivity are needed to rule them out (remember “SnOUT”)

Tier 2 diagnoses have a “medium” pretest probability

  • Diseases on this tier are tricky. You really have to evaluate the sensitivity, specificity and information given from each test. You may need a few good tests get from a “medium” pretest probability to final diagnosis.

Tier 3 diagnoses have a “low” pretest probability

  • Even relatively good tests may not move diagnoses from Tier 3 up to tier 1. The positive result that you get might be due to chance. Investigating these diagnoses should be a last resort.

Gear box

These four tips won’t magically turn a medical student into an expert at clinical reasoning but they might serve to expose the way that experts think. They offer concrete ways for medical students to approach clinical reasoning and a common language for experts to discuss their approach with their learners.

For more information about MOOCs and why explicit discussion of clinical reasoning is important, see these links.

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What’s on your summer reading list?

Theresa Suart, our Educational Developer weighs in on how to nurture your educational self over the summer. We compiled a list of reading that may help stretch your medical/educational muscles over the summer. To make our list a book had to be recommended by a clinical faculty member as one that has changed or enhanced her/his perception of medicine or medical matters. Dr. Shayna Watson was very helpful in bringing to light some of the Medicine in Literature books. We’ve asked for your help in referring other books, so please jump in!

Remember days lazing at the beach, latest bestselling novel in hand? Or too-short summers with too-long required reading lists? Whatever your summer reading memories, longer days seem to go hand-in-hand with book list suggestions, so the Education Team decided to add its five-cents’ worth to the conversation.

Whether you’re getting away for a couple of weeks to the cottage, or still slogging away on the wards of KGH, summer can be a great time to expand perspectives, explore new ideas and nurture your soul with a good book.

So here’s our “Summer Ten” list (it’s not a “top 10” or a “10 must read”, it’s a “consider this” list… just to get you started). If you pull one of these from the shelves, please let us know what you think of it.

1. The Emperor of All Maladies: A biography of cancer by Siddhartha Mukherjee (available in the Stauffer Library)

2. The Curious Incident of the Dog in the Night-time by Mark Haddon (available in the Education Library)

3. Nocturne: On the life and death of my brother by Helen Humphreys (On order by Stauffer Library)

4. Care of the Soul in Medicine by Thomas Moore

5. Kitchen Table Wisdom by Rachel Naomi Remen (available in the Kingston Frontenac Public Library)

6. Intoxicated by My Illness by Anatole Broyard (available in the Kingston Frontenac Public Library)

7. Cutting for Stone by Abraham Verghese (available in the Kingston Frontenac Public Library)

8. Bloodletting and Miraculous Cures: Stories by Vincent Lam (available in the Stauffer Library)

9. The Checklist Manifesto: How to get things right by Atul Gawande (available in the Bracken Health Science Library)

10. Any of Atul Gawande’s essays from the New Yorker:

And a bonus #11 since any reading list needs some poetry (thank my Dad, the English teacher and poet, for instilling this in me):

In Whatever Houses We May Visit: Poems that have inspired physicians, edited by Michael A. LaCombe, and Thomas V. Hartman.
(Here’s a sample, from the previews on the site, Pathology Report by Veneta Masson:

If you pull any of these from the shelves, please let us know what you think of it.

What’s on your list? Share your suggestions in the comments section below.

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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:


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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