Should Every Doctor be Able to Deliver a Baby?

To many, the answer to this question may seem obvious.  For those who feel an emphatic “yes” is called for, let me pose a scenario for your consideration.  Imagine an airline flight about 3 hours from destination.  A call goes out for someone who might assist a young woman who’s gone into premature labour.  Two people respond.  One is a mid career physician who underwent standard obstetrical training during medical school, delivering about 50 babies during that time, but subsequently trained as an Ophthalmologist and has had no obstetrical experience in the past 20 years.  The second is a registered nurse who graduated about 10 years ago and works in a busy hospital, mostly in the emergency department, but with frequent “float” shifts in Labour and Delivery.  Based on this scenario:

Who is more capable of providing competent care to the patient?

Who will most people aboard the plane (including the patient) assume is most qualified?

The point of this scenario and these questions is not to suggest some simmering interprofessional conflict.  One would expect that these two professionals would recognize each other’s strengths and work together for the benefit of the patient.  The point of this story, which could involve any subspecialty not involved in obstetrical care, is to highlight how much medical practice has evolved, and to suggest that our approach to medical education may not be keeping pace.  This point is made even more apparent by imagining a similar scenario playing out 50 or so years ago when there was much less specialization, the practice patterns of all physicians was much more homogeneous, and physicians were fully qualified to practice at the end of medical school.

My colleague Richard VanWylick is a pediatrician and curricular leader.  He and I have established a running joke regarding the toddler assessment in medical school.  The examination of small children, like the ability to deliver a baby, is an aspect of medical practice that will be ultimately provided by a distinct minority of our medical class.  Further, those who do provide those services in their career will undertake considerable further postgraduate training before doing so.

So, one must ask, why do we devote so much curricular time and resources to these components of medical practice?  I would suggest there are a number of valid justifications:

  1. It’s important that our students experience all aspects of medical practice in order to make valid career decisions
  2. An appreciation of these areas of practice provides insights and awareness that makes us all better Doctors, and better able to understand the needs of our patients, regardless of their presenting problem or our area of interest.  When I consult on cardiac issues during pregnancy, for example, it’s important to have had a practical understanding of the principles of labour and delivery.
  3. There exists a societal expectation that all doctors should be able to provide a minimal level of service, particularly in emergency situations.  That “minimum level”, it must be said, is completely undefined.
  4. Our students very much appreciate the opportunity to experience all aspects of medical practice, and expect the opportunity to do so

On a purely pragmatic note, medical schools are required to provide a comprehensive exposure in order to achieve accreditation status in Canada and the United States.  To quote from “Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree” (the bible of accreditation):

ED-15. The curriculum of a medical education program must prepare students to enter any field of graduate medical education and include content and clinical experiences related to each phase of the human life cycle that will prepare students to recognize wellness, determinants of health, and opportunities for health promotion; recognize and interpret symptoms and signs of disease; develop differential diagnoses and treatment plans; and assist patients in addressing health- related issues involving all organ systems.

Although schools are expected to define for themselves what constitutes adequate preparation “to enter any field of graduate medical education”, I think any program would be hard pressed to exclude active participation in basic obstetrical care and child assessments as components of that preparatory process.

However (and this is a big “however”), with the massive increase in knowledge and emergence of over 60 recognized specialties, medical education is becoming increasingly expansive and expensive.  More and more, medical schools are required to make choices regarding what components of education are relevant to every physician, regardless of what specialty they chose to practice.  Such decisions are being made in isolation since we lack any accepted framework or value assumptions that would support such decisions.

But (and this is a big “but”), things are changing.  Leadership organizations such as the Association of Faculties of Medicine of Canada, Royal College of Physician and Surgeons, College of Family Physicians and Medical Council of Canada, are all acknowledging the need to recognize more explicitly the continuum of education from medical school entry through to full qualification.  The Future of Medical Education in Canada initiative is calling for sweeping reform, including the recommendation to “Ensure Effective Integration and Transitions along the Educational Continuum”.  Three committees have recently been established to develop strategies to implement this key recommendation.  These groups are just beginning to grapple with some very difficult and discomfiting questions, such as:

What knowledge, skills, approaches are common and essential to all physicians, regardless of specialty?

How should physicians progress through training, and when should various training streams begin to diverge?

How should the number of specialty training opportunities be determined, and how should learners be selected for those specialties?

When should medical students be expected to declare their area of interest, and what, if any, provision should be made for those who wish to transition between specialties?

These issues will require considerable thought and reflection by all involved in medical practice, including students, postgraduate learners and teaching faculty.  All involved should feel free to contribute to this dialogue, which has the potential to reform our educational systems in rather profound ways, hopefully leading to a much more aligned, efficient and relevant process.  As a co-chair of one of those implementation groups, I would certainly welcome input on these issues.  In the meantime, I will continue to hope to be sitting next to an experienced ER nurse if someone goes into labour during a future flight.

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

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How could I have forgotten Medical Humanities?

I arrived to the CCME amidst a huge storm on Saturday at 4:30 and immediately went off to a presentation and discussion with other Ed. Developers and new faculty in med ed. So I missed the Medical/Health Humanities Creating Spaces III symposium which had just wrapped up. However, our own Jackie Duffin did not miss it–in fact she was part of a panel on Medical Humanities to wrap up the Symposium, Medical Humanities: Whence and Whither? As well, meds students Emily Swinkin (2014) and Renee Pang (2013) presented — and a recent grad Jennifer Baxter (2012) — was attending just to listen from her family med residency in Chiliwack BC. To see more about this important initiative which I was able to attend and enjoy last year, go to http://medhealthhumanities.ca/Programme_Presentations.html

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Why go to conferences?

Why go to conferences… In which Sheila Pinchin offers a purely personal viewpoint of the CCME Conference (13) .

Well, here I am at the Canadian Conference on Medical Education (CCME) in Quebec City, along with a great number of faculty from Queen’s, 15 meds students from Queen’s (some came up to volunteer!) Matt Simpson, Lynel Jackson from MEdTech and Andrew dos Santos from IT. As well, many staff are here (Kathy Bowes, and Jen Saunders), and our faithful Educational Team members, Eleni Katsoulas and Theresa Suart are here, too. Dean Richard Reznick, Associate Dean Tony Sanfilippo, Vice Dean Leslie Flynn, Associate Dean Ross Walker and Associate Dean Karen Smith are here. Suzanne Maranda, our head of Bracken Library is also here. And now I’m going to stop naming people as I know I’ll miss some. But these are just some of the people I’ve seen in the past day or two!

On the train up to Quebec City, we got a lot of work done, with people dropping by and talking about ideas and challenges. Dr. Sue Moffatt and we managed to squeeze in an entire planning session for the next Course Directors’ Retreat! We think the train back will offer a similar opportunity—all of us together for seven odd hours. This is a consultant’s dream: Captive faculty all in one space! ☺

I enjoy this conference so much! When I first started in Medical Education 7 years ago, I was one of the few, if not the only, Educational Developer at the conference. Now there are many more of us, and several Educational Researchers too. I don’t feel as odd, and I also feel more at home with all the faculty that come. And when you mix Ed Devs, clinical faculty, technologists and health education librarians together as we did in the workshop Lindsay Davidson, Lynel Jackson and I gave, you get powerful results! Flipped learning has never been so creative–thanks to Lynel’s wonderful graphics, and Lindsay’s really ingenious puzzle pieces activity!

Networking is happening with our faculty here—Tony Sanfilippo and Hugh MacDonald got together with their counterparts from across the country, as did Andrea Winthrop and countless others who were in interest groups and business meetings. Many other faculty were involved in formal meetings and symposia.

But informal networking has happened at mealtime breaks, and at other times, when you could see two or more heads bowed over computers or papers in the lobby and other places where you could sit. Memorably several people were sitting on the floor near the buffets– the better to be connected—to the electrical plugs in the wall and to each other, I presume.

Tony Sanfilippo took advantage of the time to meet up with students as well as other faculty. Here he is bonding with meds student James Simpson over a bowl of rice pudding.
Sanfilippo and Simpson

And here’s Eve Purdy, conference volunteer par excellence, finding common ground with Dr. Dave Williams, keynote speaker, president and CEO of Southlake Regional Health Centre, and former astronaut.
Dave Williams

In addition to networking, our Ed Team members (Eleni Katsoulas, Theresa Suart and I) also roam the poster aisles (we greedily snap up the mini versions), chat with people at the booths (hello CMPA Good Practice Modules, and MedicAlert Bracelet Free Curriculum!), and divide up and conquer when it comes to attending moderated poster, oral and workshop sessions. That means we’re synthesizing all this knowledge and bringing it home for everyone here—and do we have some terrific ideas!

I can’t forget to mention the White Coat Warm heART exhibit showcasing student and faculty artwork and a place of peace and provocation in a bustling conference. Here’s a shot of Dr. Carol Ann Courneya from UBC who’s been running the art exhibit since 2010 (with thanks to Dr. Ali L. Jalali for this photo from Twitter)
ART EXHIBIT

Kudos to the many Queen’s faculty, staff and students who gave oral presentations, poster presentations and workshops! One reason we come to conferences is to celebrate this scholarship and efforts of our educational community.

So it’s a real pleasure to celebrate and congratulate Paxton Bach, Meds 2013, on being awarded the Sandra Banner Student Award for Leadership. This prestigious award from the Canadian Resident Matching Service (CaRMS), consists of up to $5,000 annually to be given to a medical student or resident who demonstrates an interest in or an aptitude for leadership among their peers. Congratulations Paxton!

Here’s a shot of one of the many fine peer-reviewed Queen’s submissions, Dr. Michelle Gibson’s poster about her W. Dale Dauphinee Fellowship work on formative feedback: MCG Poster

And here, Kathy Bowes and I are standing in front of our poster (with Tony Sanfilippo) about the First Patient Program telling the world (well some of it) that Queen’s is the first Canadian medical school to bring this kind of longitudinal learning from patients to years 1 and 2 students in medical education. This was a great idea Tony Sanfilippo brought back from an AAMC conference two years ago. I wonder what great ideas he’ll be bringing back from this conference!
Kathy Bowes and Sheila

Eve Purdy, Meds 2015, wrote this for our UG blog:
“For me the highlight was the huge social media at the conference allowing for faculty and students across the country to engage whether or not they could make it to Quebec City. It became evident that the efforts of Queen’s students and faculty to model online professionalism are significant and unique. We’re among those leading the charge! This blog is great evidence of those efforts. Having the opportunity to interact with online mentors, people from all over the country having significant impact on my medical education, in real life was well worth the trip (Dr. Jalali, Dr. Yiu and Deirdre Bonnycastle to name a few)!”

Here is a sample of faculty from U of T and Ottawa U tweets to Eve.

Screen Shot 2013-04-22 at 5.43.27 PM copy

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For stats on Social Media use at the conference see:

http://www.symplur.com/healthcare-hashtags/CCME13/analytics/?hashtag=CCME13&fdate=04/18/2013&shour=0&smin=0&tdate=04/23/2013&thour=0&tmin=0&ssec=00&tsec=00&img=1

Ben Frid, also Meds 2015 and Aesculapian Society President, wrote this for us:
“Here is a photo of the Queen’s CFMS delegates, all of whom stayed in Quebec City an extra day and a half to attend the first part of CCME and the Dean’s reception.”

Queen's CFMS

Ben continues, “One highlight for me was a fascinating presentation on Hidden Curriculum by a PGY-4 from McGill. She was exploring factors and common experiences amongst clerks that lead to hostile learning environments. She was very clearly advocating for medical students and progressive medical education, and it was inspiring to see another resident speak up at the end of the talk to lend his full support as well. I think residents are in a uniquely favourable position to mediate and collaborate between medical students and attending physicians and it was terrific to see these residents take up this important cause.

Another highlight was the Dean’s reception last night. It’s always fun to interact with faculty in an informal setting, and when I looked around the room I saw a mix of students, faculty, administrative staff, and alumni all enjoying each other in lively conversation — a shining example of Queen’s collegiality! Queen’s pride was abounding and amidst the Queen’s tartans and flags, I’m quite sure I saw the classic Queen’s pin on every lapel in the room. I had the chance to shake hands and share stories with John Ruedy, Aesculapian Society President in 1955, who has spent his time since then making incredible strides in transforming clinical and academic medicine across Canada. A very neat experience indeed!”

Theresa Suart, our new Educational Developer, who used her journalist’s background to ferret out literally every learning opportunity, says, “What’s really amazing is how so many people are working so hard to educate our future physicians! The energy is amazing and very inspiring.” Eleni Katsoulas, our new Assessment and Evaluation Consultant, who attended eighteen oral sessions, nine moderated poster debriefs, and one workshop, all on assessment, says she learned a lot. “But what sticks out in my mind is how important and energizing the networking is—so many helpful and collaborative people!”

I entitled this blog, “Why go to conferences?” They are a lot of hard work, a lot of travel, long hours, and a lot of time away from home, family and work.

But they also mean a great deal of learning about the best and latest in our fields, great ideas for helping our students, the ability to peer forward into the future, new people to connect and work with, a chance to do some thinking, a chance to drink in knowledge, and a chance to celebrate scholarship from our own institution as well as inhale that from others.

Don’t take my word for this! Go into Twitter and see the scope of the learning that went on at #CCME13.

Next CCME is in Ottawa—see you there!

My thanks to Eve Purdy for most of the photos and the comments, Ben Frid for the CFMS Delegates’ photo and comments, Dr. Jalali for the twitter photo of Dr. Courneya and her poster, Theresa Suart and Eleni Katsoulas for the company and the great quotes, and Dr. Sanfilippo for sending us here!

Do you have any CCME 13 experiences to share? Post them here!

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Reflecting on Reflection

Reflection in Medical Education

I love those who can smile in trouble, who can gather strength from distress, and grow brave by reflection.–Leonardo da Vinci

I thought I’d write to you about reflection in this blog entry.  I can hear the meds students groaning already:)  You see, we ask the meds students to do a fair bit of reflection in undergraduate medical education, starting with term 1 when we ask them to reflect on being a physician, and on through to their last portfolio assignment in pre-clerkship when we ask them to reflect on how well they have progressed in their learning about the roles of a physician.

Reflect is a rather over-used and under-thought term and so as I progress through this, you may want to substitute another term.  I happen to like “critical analysis” because a lot of reflection should include that, and a lot of what we’re asking the meds students to do includes critical thinking.

When we talk to the medical students we talk to them about the stages of reflection and we use one model of reflection for learning or “reflection in and on action” (Schon, 1983), that of experiential learning by David A. Kolb.  Kolb (with Roger Fry) is well-known for his conceptualization of reflection as a critical part of learning (Kolb, 1984).  He postulates a cycle of reflection where a learner experiences something concrete (Concrete Experience), observes and reflects upon it (Observation and Reflection), generalizes the learning in Abstract Conceptualization and then applies the learning to new experiences in Active Experimentation.  This starts the cycle again, with a spiral approach so that one is not repeating the same learning over and over.    Kolb also notes that one can enter the cycle at any stage in the 4 steps.

When we present to the meds students we use this graphic:

Screen Shot 2013-04-09 at 7.28.32 AM

To me this theory is important as it allows for some very practical outcomes for reflection.  As Peter Drucker says, “Follow effective action with quiet reflection. From the quiet reflection will come even more effective action.”  Two leaders in the field agree: Dr. John Sandars defines reflection as  “A metacognitive practice that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters.” (Sandars, 2009) Jack Mezirow when writing about “transformative learning” describes reflection as critical awareness of how we are constrained, and how to reformulate so as to act. (Mezirow, 1997)

So how can we assist learners to reflect in order to change their actions? How can we promote “rigourous reflection?”

Dr. Ted Ashbury and I start by asking them to jot down some thinking:  “Think of a situation where you have said, “I’m not going to fall into that trap again. I’ve thought about this, and I know I’m prone to…”!  We show them the cartoon of Charlie Brown and Lucy and the infamous football… This is helpful because one goal of reflection can be to change action, to break a cycle or pattern.


Next, we ask the students to think about a situation that has engaged their attention in the past few weeks and fill in a chart based on the 4 steps in Kolb’s theoretical framework:

 

Identify

  • Prompt
  • Observation
  • Idea
  • Catalyst
Analyze:Make connections Prior experience

Links to knowledge of yourself

Broaden:Reinforcement, Generalizations,Perspectives,

New Knowledge

Apply/Plan (Now What?)Changes or shiftsCommitment to future action/plans

And we ask them to set some goals:  SMART Goals

Specific (straightforward, not ambiguous)

Measurable (It is clear under which conditions the goals are achieved)

Acceptable (The goals should be acceptable to all stakeholders)

Realistic (The learner should be able to achieve the goals)

Time-bound (It should be clear when the goal is to be achieved)

Free Writing:  We give students time to write—free writing for at least 5 minutes (an engaging and difficult task—I recommend it!) about the prompt from the beginning of the session or “Write about your First Patient Experience, your Clinical Skills experience, your learning elsewhere in term 1, a key challenge you have chosen to work on recently, Mid-terms…???”  We also offer them a reflection written by a student in another meds school and a rubric that Eleni Katsoulas and I  designed to help us and them assess reflective writing.  They get to analyze their colleague’s writing based on the rubric:

Prompt or Catalyst Ideas (What?) Connections (So what?) Extensions (Now what?)
Observed behaviours of other Describes the behavior and the context in which it occurred -Interprets the behavior, its cause, or provides a rationale  (impact)-Seeks out primary resources/information/circumstances, to connect to and make sense of the observation  – Provides an alternative to problematic behavior based on consideration of all primary observations-Discusses implications and considers how or whether to implement change in their own behaviour-Problem may be reframed, and there is an explanation of how this represents a change from previously held beliefs

-Considers impact of framework on behavior (culture, system, etc.)

-Commits to future  action, reflection, or advocacy

 

This seems like a lot of work to accomplish reflection, doesn’t it?  However, it’s like learning skills for anything…we provide opportunities to break down the skill into discrete parts, and learners time to practice.  The idea is that the more they practice this, the more intuitive and natural it becomes.  This doesn’t negate the possibility and importance of a 30 second reflection on an interesting, provocative, or disturbing matter, but it does lead, we hope to rigourous reflection.

I thought I’d finish this section with a quotation from a medical student who was reflecting:

“If I had to choose what I felt to be the most important thing that I have taken from these experiences, it would be to remind myself, no matter how I feel, to think about how the patient is feeling. To never forget that off-hand comments made when tired or stressed have the potential to upset people to such an extent that they remember them for years.” (Macauley & Winyard, 2012).

If this is the result of rigourous reflecting, I’m all for it!

What are your thoughts on reflection in medical education?  What use do you see for it? (or do you see a use?) What strategies do you recommend?  In the next blog, I’ll send some tips for reflection, along with your suggestions.

 

Sources

Kolb, D. A. (1984) Experiential Learning, Englewood Cliffs, NJ.: Prentice Hall.

Kolb. D. A. and Fry, R. (1975) ‘Toward an applied theory of experiential learning;, in C. Cooper (ed.) Theories of Group Process, London: John Wiley.

Schön, D. (1983) The Reflective Practitioner, New York: Basic Books

Saunders, John. (2009). The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher, 31(8), 685-95.

Mezirow, Jack. (1997). Transformative Learning: Theory to Practice. New Directions for Adult and Continuing Education, 74, 5–12.

Macauley, CP & Winyard, PJ. (2012). Reflection: tick box exercise or learning for all? BMJ Careers.  http://careers.bmj.com/careers/advice/view-article.html?id=20009702

 

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Basic Science in Medical School. Too much? Too Little?

In his 1988 book “All I Really Need to Know I Learned in Kindergarten”, Robert Fulghum takes a tongue-in-cheek approach to education. His intuitively attractive postulate is that early learning is the most durable we will experience, and those fundamental lessons and principles, well established early in life, can be the most valuable contributors to lifelong learning.

I found myself thinking about this recently after reading a “state-of-the-art” article in the Journal of the American College of Cardiology entitled “Pathogenesis of Acute Coronary Syndromes” (Crea F, Liuzzo G, JACC 2013;61:1-11). The authors provide a contemporary review of the pathophysiologic underpinnings of ACS, describing a complex interplay of structural, inflammatory, metabolic, hematologic and genetic factors that can be at play and can lead to the various clinical presentations we recognize.

blog12Over the years that I’ve been in practice, the understanding of what causes ACS has evolved in a steady and very gratifying manner. In medical school, the concept of myocardial ischemia my classmates and I engaged was encapsulated by a famous Frank Netter drawing of a businessman with a briefcase clutching his chest leaving a restaurant (presumably having enjoyed a large meal) on a cold day. In retrospect, it’s easy to dismiss that image as a rather quaint and simplistic model of what turns out to be a rather complex process.

However, when I think about the fundamental science that underlies the current mechanisms developed in Crea and Liuzzo’s article, I realize how many of those key concepts were first, and very accurately, developed within basic science courses we undertook in our first year. Concepts such as:

• the structure and histology of coronary arteries
• the inflammatory response
• platelet aggregation and thrombosis
• arterial vasospasm
• genetic predisposition to disease
• lipid metabolism
• sympathetic responses to exertion and emotional stress

These topics, esoteric in isolation, have a few, very interesting things in common.
• They are all necessary to understanding current concepts of ACS
• Knowing something about them allows me to appreciate (and even enjoy reading about) contemporary approaches as outlined in the JACC article.
• They were all part of my medical school experience 35 years ago
While I was struggling to learn those concepts, I had no idea they would ever have practical impact on my practice. In fact, my classmates and I were of the very strong opinion that learning these concepts was a decided waste of time that could be better spent seeing patients and learning the “nuts and bolts” of clinical medicine.

Today, undergraduate curriculum committees, including ours, continually struggle with the questions “what should we be teaching” and “what will they need to know”. The desire to ensure the scientific foundations are appropriately presented has to be balanced against current trends to provide more “patient-centred” content, to provide “clinically relevant” content, to ensure our students are introduced to the ever-expanding compendium of clinical knowledge and therapeutics.

But are these forces really at odds? Do we really need to choose between what’s “science” and “clinical”? We don’t, as long as we’re willing to consider new approaches to education. The answer to this apparent dilemma lies in development of integrated learning that doesn’t segregate and marginalize the “science”, but brings it front and centre, linked appropriately and logically to the clinical contexts in which they’re utilized.

Within the next few weeks and months, Dr. Michelle Gibson, Year 1 Director, and Dr. Chris Ward, Course Director for Normal Human Function, are leading a comprehensive review of our objectives in Basic Science. It’s become clear after five years of application that the current framework outlined in our “red book” (Curricular Goals and Competency-based Objectives) merits review and likely revision. In doing so, they will be engaging the faculty at large and will welcome your contributions.

So, do I believe I learned everything I really needed to know in medical school? No. But I certainly didn’t appreciate at the time how useful that learning would prove to be.

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

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