Should medical students be examined by each other, or by Faculty?

A few years ago, with Lynel Jackson’s capable assistance, I established a confidential portal on MedTech which allows students to submit commentary to me in a completely anonymous fashion.  Over the years, it’s proven to be a remarkably effective means for students to articulate concerns that are of a sensitive nature or which, for a variety of reasons, they are reluctant to express in person.  It has provided insights into issues which I’m sure would not have otherwise come to attention or, if they had, would have done so in much less effective ways.  One such issue was raised recently which has caused me to reflect and led to some conversations which I thought should be extended to the wider faculty and student body.  To quote our anonymous student:

“I have feedback regarding students being required to practice on each other in formal clinical skills sessions, such as the peripheral nerve exam the 2017s are learning tomorrow. This also relates to random students being called up to volunteer for clinical skills demonstrations in front of the class. This can (and has) caused exposure of students’ own medical problems. In one case this year a student’s disability was somewhat unwittingly revealed in front of all of the class of 2017. Some students are uncomfortable with/unable to comply with this for religious reasons. Others, such as myself, get anxious at the thought of potentially having private medical info disclosed in a public forum.”

I, like many of our teaching faculty, came through a medical school experience where “practicing” aspects of the physical examination on classmates was common practice and, in some instances, became informally incorporated into the curriculum.  It was also common practice for faculty to ask for student “volunteers” to demonstrate various aspects of the physical examination for small groups or even the class.  I’ve certainly been guilty of this in demonstrating the approach to cardiac examination and auscultation.  Over the years, our Clinical Skills program has placed boundaries on the peer-to-peer examination, limiting it to head, cranial nerves and peripheral limbs.  This has been in an attempt to avoid any potential embarrassment that might arise from exposure to even the abdomen and male thorax.

The note above, together with a brief review of the literature, would suggest attitudes are changing and deserve reconsideration, for a number of reasons:

  1. Students may have medical conditions, scars, or deformities they do not wish to reveal and do not wish exposed.
  2. Students may have personal or religious objection to exposure or touching
  3. Students may simply be shy or self-conscious about such contact

Although it’s easy to say that students can excuse themselves from such activities, doing so may be difficult for many and, in itself, essentially “expose” a concern.  This raises the issue of peer pressure to comply with the majority attitude of the group, and further raises the real concern as to whether faculty may be exerting a subtle form of coercion by even making a request.  We therefore seem to be confronted with an issue that affects a distinct minority of any class, but in a potentially very profound way that therefore deserves our attention.

To engage such an issue, I’ve found it’s always helpful to consult the students themselves early in the process and, wherever possible, involve them in developing solutions.  I therefore turned to Elizabeth Clement (Meds 2016), who is Vice-President (Academic) of the Aesculapian Society and student representative to our Curriculum Committee.  Liz engaged this with characteristic thoughtfulness and enthusiasm, reviewing the literature, conducting a student survey, and presenting this information in the form of a Briefing Note to the Curriculum Committee for consideration.  That note, in its entirety, is as follows:

Clinical and Communication Skills: peer teaching of the physical exam

Issue:

Recently, some Queen’s medical students have communicated their discomfort with respect to physical examination of peers or being examined by peers in clinical skills sessions. Reasons for discomfort include but are not limited to religious and cultural customs as well as gender modesty. It is also important to consider the impact that peer physical examination can have on the student who has real findings, both known and unknown.

Background:

Currently, Clinical and Communication Skills is run with Standardized Patients for specific and more invasive exams, including the cardiac, respiratory and abdominal exams; a practice that is both valuable and costly. Exams that are considered less invasive, such as lymph nodes, cranial and peripheral nerves and head & neck are learned and rehearsed using same-year classmates as patients.

In a survey of first and second year medical students:

  • 36% of students are comfortable with the current practices, where peer physical examination is only performed using specific exams, including vital signs, cranial nerves.
  • 58% of students stated they would be comfortable performing more invasive examinations on peers, with exceptions including the rectal, pelvic and genital examinations, while 4% of students said they would be comfortable with peer examination for any aspect of the physical exam.
  • 2% of students say that they are uncomfortable with any form of peer physical examination.

The survey also elucidated that 36% of students would be more comfortable with peer physical examination if they were working with individuals of the same gender; 61% said they would be neither more nor less comfortable.

Important elements of the Clinical and Communication Skills course go beyond routine examinations. The communication component of this course can intermingle with an individual’s personality and sense of self. The current structure at Queen’s allows for students to form meaningful relationships with one or two faculty members as well as nine colleagues as they explore how to optimize their communication for the practice of medicine. Any alterations to the structure and setup of this course need to take into account the impact that those changes could have of the value and strength of these important relationships.

Research and Analysis:

Other institutions are considering these same practices, but a clear solution has yet to surface. Many have evaluated attitudes toward using peers as ‘patients’, including a study conducted in Australia. This project used a Likert 5-point scale (1: not at all willing; 5: very willing) to evaluate overall willingness of students to participate in physical examination teaching using peers. The study’s trends suggest that students are more willing to participate when examining the extremities and typically unclothed areas (head and neck), and that both men and women are more willing to be examined by women.2

Another article, a response to a study of peer physical examination, stated that “students must be endowed with the same rights to which they are dutifully bound to grant patients, namely refusal of investigation, including examination.”1 The author concluded that the practice of peer examination is appropriate when students are able to pick their partner, but that the integrity of the physical examination as it is learned should be upheld with the use of simulated patients. For examinations of the pelvis, rectum and genitalia, the author recommends table-top models. A more moderate approach was elucidated in a letter to the editor of Academic Medicine, where the authors directly address the issue of consent – perhaps the crux of the issue of the Queen’s model of physical examination teaching. Their overarching comment suggests that schools should obtain consent from students, and that an important component of consent is to provide information about risks and benefits of peer examination in the learning of the physical exam.3

The data collected from students at Queen’s medicine demonstrates that most students are comfortable with our current practices, and, in fact, many would be willing to participate to a greater extent. However, in this instance, a minority of students expresses discomfort, and given the nature of this issue, it is important to consider whether alternatives could be made available so as to facilitate these students’ full participation in the learning of the physical exam.

Potential solutions

  • Consider no adaptation of the current model for physical exam teaching.
  • Consider a shift to physical exam teaching using solely standardized patients.
  • Consider a method of allowing students who are uncomfortable to self-identify, and manage them individually based on their concerns.

References

1Rizan CT, Shapcott L, Nicolson AE & Mason JD. (2012). PPE: A UK perspective, ‘All for one, NOT one for all’.  Medical Teacher, 34, 82; author reply 82-3.

2Reid KJ, Kgakololo M, Sutherland RM, Elliott SL & Dodds AE. (2012). First-year medical students’ willingness to participate in peer physical examination.  Teaching & Learning in Medicine, 24, 55-62.

3Delany C & Frawley H. (2011). We need a new model for obtaining students’ consent to conduct peer physical examinations.  Academic Medicine, 86, 539; author reply 539.

The Curriculum Committee had a preliminary discussion about this last week and have asked for a procedural approach to be drafted and presented to them, that will allow for student concerns to be addressed effectively while not eliminating the instructional value of peer examination completely.  In doing so, feedback from members of faculty and other students would be very much appreciated.  Please feel free to share your perspectives on this issue, either by responding to this post, or sending commentary to myself, Liz, Curriculum Committee chair, Michelle Gibson or Clinical Skills Director Cherie Jones.  My confidential portal is always available to students who wish to comment anonymously.

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MD Program Executive Committee Meeting Highlights – Wednesday April 16, 2014 at 4:30 pm

Convocation for MEDS 2014

The class of 2014 is now preparing for their MCC Part 1 exams which will take place in about 3 weeks.   Convocation for these students will take place on May 22 at 2:30 pm in Grant Hall.  Similar to ceremonies over the last few years, our students will be the sole participants in the event, therefore Faculty are encouraged to participate in the ceremony.  Information on how to make arrangements can be obtained at  http://www.queensu.ca/registrar/currentstudents/convocation/faculty.html.

CARMS:

The 2nd iteration of the CARMS match was completed this week.  As a result, CARMS hosted a teleconference with the UGME Deans announcing that 55 graduates would remain unmatched this cycle.  This is the largest number of unmatched students to date.  Therefore, there is the possibility that this will be an escalating problem in upcoming years, and further discussions are underway at both the provincial and national levels.  As discussed in previous meetings, the Learner Wellness team will work closely with our students providing them with continued support and counseling regarding their career possibilities.

Admissions:

The QuARMS application assessment process has now been completed and offers are waiting to go out to the top 10 candidates.  The Admissions team continues to work on the application results for the MD program.  Offers will go out in mid-May.

Awards:

The Awards Committee is preparing to review the Terms of Reference of several of our awards.  As our curriculum is now competency based with a Pass/Fail status, many of the terms of the awards are no longer relevant.  Once finalized these new Terms of Reference will be presented to the Progress and Promotions Committee and MD-PEC for approval.

Learner Wellness Update:

The proposed changes to the Learner Wellness Program which include an Advisory Panel and the addition of an arms-length counselor are now being finalized.  The Advisory Panel would be put in place to develop, review and approve plans for the management or accommodation of student disabilities.   In addition to the panel, plans are underway to secure an additional student counselor who would work at arms-length from the School of Medicine to act as both a Student Counselor and Ombudsman.    Funding arrangements are being discussed and it is hoped that this person will be in place for the beginning of the Fall Term.

Clarification to the Policy on Attendance and Absences in Undergraduate Medical Education (Policy # SA-07):

Under the policy, absences from mandatory teaching sessions must be sanctioned and approved.  It has been the procedure that absences occurring due to short term illnesses would require the student to submit a doctor’s note.  However, as this process put an undue burden on the student at the time of an illness and as these notes are no longer provided by Queen’s Student Health, it has been decided to eliminate this requirement.  Long term illnesses or repeat occurrence may still necessitate a note at the request of the Progress, Promotion and Remediation Committee.

Marks Release:

Progress, Promotion and Remediation Committee in conjunction with the Student Assessment Committee have altered the process for the release of marks.  The new process allows for the release of marks to students after finalization at the Examiner’s Committee level.  Students with performance issues will be notified in advance of the release.  These students will then be notified of the official outcomes and consequences following the Progress, Promotion and Remediation Committee meeting.   This new process was piloted with the release of marks for the Fall Term and was received favourably by the students.

Conflict of Interest Procedures and Access to Student Records Procedures:

The Committee discussed two draft documents outlining procedures for both conflicts of interest and the access to student records.  The conflict of interest process is being developed in advance of the finalization of the Faculty policy on Conflict of Interest.  The process document relating to access to student records is in support the Queen’s University Student and Record Access Policy.  Changes to both of these documents will be made prior to faculty dissemination.

 

 

 

Next Meeting:  May 21, 2014

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Can first year medical students carry out cardiac ultrasound examinations? Recent graduates publish results of recent trial.

Two former Queen’s medical students, Thomas R. Cawthorn, MD and Curtis Nickel, MD, of the recently graduated class of Meds 2013 conducted ultrasound education research during their time as students at Queen’s School of Medicine.   They worked with Dr. Michael O’Reilly, Dr. Henry Kafka, and Dr.  Amer M. Johri, of Queen’s and Dr. James W. Tam, of Winnipeg.  Their results have been recently published in the Journal of the American Society of Echocardiography, in the article Development and Evaluation of Methodologies for Teaching Focused Cardiac Ultrasound Skills to Medical Students.

There are several noteworthy aspects about this:   One is that our students embarked on this research during their time at Queen’s UGME, and worked on medical education in echocardiography as their field.

Secondly, the Journal of the American Society of Echocardiography published an article on medical education.  It’s uplifting to see focus on education in medicine as well as continuing professional development and new issues in medicine in a scholarly medical journal.

Thirdly, the article outlines an excellent, innovative education program that the authors developed, using sound pedagogy to assist learning of a key skill in medical education.

And for me, their conclusion is most exciting:

Third-year medical students were able to acquire FCU image acquisition and interpretation skills after a novel training program.  Self-directed electronic modules are effective for teaching introductory FCU interpretation skills, while expert-guided training is important for developing scanning technique. (Cawthorne, et al, 302)

The authors emphasize the importance and benefits of teaching/learning via self-directed electronic modules:

  • reduction of overall resource costs
  • provision of readily available resource easily accessed by students for future reference
  • opportunity to learn at the pace and setting desired by the learner
  • provision of standardized educational material to centres where specialists may not be found (Cawthorne, et al.  307)

They cite Ruiz et al. (2006) for literature about the benefits of this type of learning.  Ruiz’ excellent article is worth a read as well. (See Sources below.)

The other telling aspect of their findings  is the importance of  “practical small-group instruction under the supervision of experienced sonographers and echocardiographers.”  They recommend that supervised simulation training be combined with practical instruction sessions on volunteer patients (Cawthorne et al,  308).

The key to Drs. Cawthorne’s and Nickel’s recommendations  is the combination of demonstration, practice, and feedback.  And educational literature emphasizes that these are key aspects of learning skills as well.  It’s also intuitive:  just think back to learning to play a sport.  These three facets of skills-based learning helped you learn that sport;  without one of them, you would have found the learning challenging.

Educational literature calls this  “deliberate practice” where the following are involved:

  • repetitive performance of intended cognitive or psychomotor skills in a focused domain, coupled with
  • rigorous skills assessment, that provides learners with
  • specific, informative feedback, that results in increasingly
  • better skills performance, in a controlled setting. (Issenberg et al, 2005)

What does that mean for teachers?  It means that despite the savings and other benefits of online learning, it’s important to pair that type of learning with practice and feedback from experts, especially in skills-based learning.  That has implications for us all–online, independent, self-regulated learning works best when there is an additional face-to-face demonstration, practice/feedback component, especially when new skills are being taught.  (I’ve written before about the importance of  feedback–without feedback, “it’s like learning archery in the dark.”)

So rather than saving wholly on faculty’s time by building online modules for student independent learning, what this suggests is that we use faculty in other ways. Not only do faculty lecture and facilitate group work, they are instrumental in providing feedback on skills, as happens in our Clinical and Communication Courses.  In clerkship this emphasis on independent learning complemented by practice and feedback becomes crucial.

Congratulations to our students for their hard work and success, and that of their mentors and colleagues as well!  Dr. Sanfilippo writes,

It’s rather remarkable for medical students to produce work that would be accepted for presentation at a national meeting, and then be published in the leading Canadian cardiovascular journal.  It’s also rather unique to see a study that combines cardiac and educational components.  This is quite a tribute to Tom and Curtis, and to Dr. Johri who mentored and guided them through the process.

Would you like to read the article (and accompanying editorial!) yourself?  Here is the link:

http://www.onlinejase.com/article/S0894-7317%2813%2900964-4/fulltext

References
Cawthorne, T.R., Nickel, C.  O’Reilly, M., Kafka, H., Tam, J. W., Jackson, L., Sanfilippo, A. J., Johri, A.M.  (2014).  Development and evaluation of methodologies for teaching focused cardiac ultrasound skills to medical students.  Journal of the American Society of Echocardiography, 27(3), 302-309.

Ruiz, et al.  (2006).  Impact of e-learning in medical education. Academic Medicine, 81, 207-212

Issenberg, B. et al. (2005).  Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review:  BEME guide 4.  Medical Teacher, 27(1), 10-28.

 

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Meds students to discuss nutrition at next Queen’s Medicine Health Talks

Next, Thursday, April 17, from 6:00 to 7:00 p.m., Queen’s Medical students are giving another in the Queen’s Medicine Health Talks for the public.

This time, the topic is Nutrition and Dr. Cathy Ferri, PhD, Nutritional Physiology, will field questions after the talk.

The talk is given in Room 132 of the School of Medicine Building at 15 Arch Street.

All are welcome!  Please rsvp if possible to qmht@qmed.ca.

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Curricular Council Meeting Highlights Wednesday April 9, 2014 at 4:30 pm

Admissions:

Admission for the UGME program is becoming increasingly complex.  Not only have applications for the general MD streams increased by 14% over last year, we also now admit students to the MD/PhD and QuARMS programs.

The general admissions process relies heavily on a large number of faculty participants to review application files and to participate in the interview process.  The application and interview process for this year is now complete.  The Admissions team is currently ranking the applicants for offers to be made in mid-May.

The MD/PhD program is now in its 3rd admission cycle.  File review and interviews for this stream occur earlier than the general stream.  However, it is a parallel process to the general stream with the addition of supplemental application reviews and separate interviews conducted by members of the Graduate program.  The process has concluded for this year with the acceptance of offers from our top ranked candidates.

The QuARMS process is now in its second cycle.  The top 40 applications have recently been to our school for interviews and tours.  It is anticipated that offers will be made next month.

Accreditation:

Preparation is well underway for the creation of the Institutional Self Study as the Subcommittees being to wrap up their work.  The full accreditation site visit is planned for March 31 to April 2, 2015 with a mock visit scheduled for October 2014.

Subcommittee activity has identified several “Red Flags”.  These include:  diversity, pipeline programs, Residents as Teachers, Learner Wellness and student safety.  Efforts are underway to address these issues prior to the site visit next year.

CaRMS:

It was reported that this year’s CaRMS match went extremely well for our students.  Of the 103 students in the match, 102 matched.  Most of these students secured a residency position in either their first or second choice.  17 of our students will be remaining at Queen’s.    These favourable results can be partly attributed to the excellent support and counseling that our students are receiving from the Learner Wellness Centre.

Workforce Summary:

Workforce numbers for the July 1, 2012 to June 30, 2013 year have now been tabulated.  Results will be distributed to all the department heads shortly.  The HD (half day) allocations remain very close to the numbers reported in the previous period.   Projected requirements for the upcoming academic year are now being prepared.

MCC Results:

MCC reports on LMCE Part I results over the last 3 years are currently being studied by a special task force.  This group has been asked to identify any trends which may result in direct changes in the UGME curriculum.  Results of this study will be report to MD PEC.

Learner Wellness Proposal:

Changes to the Learner Wellness Centre are being proposed.  This proposal includes the creation of an Advisory Panel and the addition of a counselor.  The Advisory Panel would be put in place to develop, review and approve plans for the management or accommodation of student disabilities.   In addition to the panel, plans are underway to secure an additional student counselor who would work at arms-length from the School of Medicine.  This new structure would provide additional avenues for student related wellness issues to be reported as well as help satisfy accreditation standards related student wellness.

 

 

 

 

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Can students achieve excellence without stress or competition?

Striving for a Culture of Competency

A few days ago walking through the hospital I ran into a very excited third year medical student who was anxious to tell me about a recent clinical experience.  Apparently she’d admitted a patient with a complex array of medical problems and, after considering the differential diagnosis, ordered a test that confirmed the presence of fairly rare condition that led to a very effective therapeutic approach.  The patient was much improved and our student, for the first time in her experience, felt that she had personally made a significant contribution to a patient’s care.  Importantly, she wasn’t telling me this to boast or claim personal credit.  She was simply very excited in the moment and wanted to share.

Our student experienced what could be referred to as the “magic moment”.  This is a term for that point in a physician’s development when they realize, for the first time, that they have acquired the ability to positively influence a patient’s life.  For some it comes in the form of a procedure well carried out, for others it’s a diagnostic success, for some the realization that they’ve brought resolution or comfort to a personal crisis in a patient’s life.  Whatever the form, the central element is the realization that their long and arduous learning process has borne fruit, and finally, rather unexpectedly, makes sense.  Their learning has transformed from an abstract, theoretical exercise to a pragmatic and practical application of knowledge and skills.  The “competency-based” construction of our curriculum suddenly seems sensible and, importantly, much less threatening.  I’ve also noted that when our students come to this point, the “stress” of medical school changes in a favourable way.  They realize that if they allow their learning to truly focus on their competency- based learning objectives, the rest will basically take care of itself.  With this realization comes confidence.  They come to regard exams as necessary inconveniences rather than fearsome high stakes threats.  They no longer require their teachers to validate their learning.  They have become, dare I say it, competent life-long learners.

Many medical schools have, over the past several years, adopted a competency-based framework to structure their curricula and assessment processes.  Here at Queen’s, we adopted this as the basis of our curricular reform which began 6 years ago.  It has provided a logical and comprehensive framework around which to establish objectives, courses, learning events, and all their associated assessment tools.  Unfortunately, I think we have to recognize that we have not yet adopted a competency culture.  Our students continue to have difficulty evolving from the consciousness that short-term knowledge assimilation and examination marks are the sole components of success.  Many continue to see medical school as a series of “hoops” through which they must pass, discarding now “unnecessary” information at each step in order to move on to the next challenge.  Experiences intended to build “softer” skills, such as reflective exercises and portfolio assignments, are often given short shrift, or at least secondary effort, because their relevance may be less apparent and “they’re hard to fail”.  To a novice mountain climber, the ability to effectively and efficiently tie knots seems a tedious and pedantic exercise, until one is perched on a ledge and relying on that skill to negotiate a climb.

This difficulty is, in many ways, completely understandable and we, as medical school faculty, are partially to blame.

  • Our admission processes are heavily reliant on academic success as a criterion.  Our students are therefore pre-selected and “hard-wired” to excel in relative terms (relative to other students), rather than against pre-determined competency goals.
  • We continue to use very traditional assessment processes to evaluate success.  While it’s true that our major purpose in setting assessments is to inform rather than select or stratify, our students can’t help but have a very fundamental and visceral response to the examination experience.  If you breed thoroughbreds to race, it seems, they will run when the gate opens.
  • We continue to award academic “standing” through a multitude of awards that our schools have administered for generations, the very purpose of which is becoming increasingly irrelevant in our current curricular structures, and may be unintentionally promoting many behaviours we now recognize as counter to our competency goals.
  • Perhaps most troubling of all, shortly after admission to medical school, we thrust our students into another increasingly competitive process to select and engage postgraduate training positions.

The environment, intentionally or not, is highly competitive.  Is this productive?  Does it drive desirable qualities?  Does it result in better (more competent) physicians?  Many would argue that competition for personal success is inevitable, drives learning and selects for qualities that will serve our students well in their careers and personal life.  The counter argument is that it drives the wrong (short term) approach to learning and requires students to make strategic decisions regarding their learning that are unaligned with the needs of their future patients.  The inconsistency between internal competition and the “collaborator” and interprofessional competencies we strive to achieve is obvious, as is the potential to disrupt peer-to-peer education that we recognize is so valuable.  Many schools, including our own, have taken baby steps to address this issue by moving to “pass-fail” assessments, but even this has been met with considerable internal controversy.

So, what’s to be done?  Can we do better?  I would respectfully offer a few suggestions for consideration and discussion.

1. Frank discussion early in medical school.  We need to engage the issue early on, clarifying for our student the reality that their learning objectives have fundamentally changed.  Essentially, their objective needs to shift from personal achievement to the needs of their future patients.
2. The concept of “relevance” is best learned through patient contact.  More contacts, in more “real life” venues, earlier in the medical school experience will be key.  Observerships, the First Patient Program and Week in the Country are great examples, but need to be contextualized in a way that allow the student to recognize the importance of competency acquisition.

3. More clarity regarding our learning objectives.  I think we have to acknowledge that the competency domains as defined by our professional colleges are insufficient unless buttressed by concrete applications.  Being a good Manager, for example, means very little.  However, when broken down into more practical applications, students not only see the purpose, but can navigate the learning much more efficiently.  For example:

  • Managing personal time
  • Managing a medical practice
  • Managing diagnostic testing for your patient
  • Managing your finances

This now become more than knot-tying for the sake of knot-tying.  Fortunately, there is considerable activity currently underway that will help.  The Royal College is in the process of revising and refreshing the CanMEDS framework.  A joint AAMC/AFMC committee is in the process of developing a set of competencies required of the medical student about to enter residency training, and documents such as “The Scottish Doctor” represent thoughtful and comprehensive attempts to catalogue practical physician competencies.

4. Testimonies from near peers and role models.  The experiences of senior colleagues who have recently and successfully navigated the challenges our students are facing can provide powerful motivation and validation.  It can also provide critical perspective to reduce unnecessary stress.

5. Assessment review.  There has been movement in recent years toward competency-based assessments, such as Objective Structured Clinical Examinations (OSCEs), both by the Medical Council of Canada and most medical schools.  However, these are very difficult to design, complicated to administer and very resource intensive.  We need to develop more practical approaches that will allow our students to demonstrate their achievement of the various competencies in an open, objective way.

6. Reconsideration of our awards.  Recognizing excellence and personal achievement is undeniably of value, but do our awards recognize the qualities and achievements we strive to develop?

7. Rethink and refine the process of transition to postgraduate training.  This has been identified as a concern by the Future of Medical Education in Canada initiative of the Association of Faculties of Medicine of Canada (AFMC), and is under active discussion at this time.  Models for more graduated transition are being considered, and will come under increasing discussion in coming months and years.

In summary, some degree of competitive tension will likely always be present within our medical training processes, and some degree of stress is not only inevitable, but may have a useful role in preparing students for the pressures of clinical practice.  However, are we doing our best to use both intentionally and intelligently?  Can we ensure they all experience their “magic moment” early in their training?  I think we could do better.  What do you think?

 

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