One Day in Clinic…

Sarah (fictitious name to protect the innocent) is a second year medical student attending my Cardiology clinic for an “observership”. Like her peers, Sarah had an outstanding academic career prior to entering medical school, as well as a variety of personal experiences that demonstrated an interest in the human condition and commitment to public service. Since entering medical school, she has continued to excel academically, easily passing all her courses. She participates in a number of extracurricular activities, is well liked by her classmates and well regarded by faculty.

She is now exploring career interests, which is what brings her to my clinic. Sarah requested this observership because she feels she may be well suited to Internal Medicine, and Cardiology in particular, and would like to explore that interest in greater depth.

As we chat before clinic, she tells me that she hopes to both increase her knowledge and learn more about the practice of Cardiology. It’s obvious that she’s prepared herself for the clinic by reviewing course content from the previous term, and arrives in her crisp white clinical jacket with stethoscope in hand.

My approach with second year students in clinic is to introduce them to a few selected patients and give them about 30 minutes alone to take a history of the presenting issue and carry out a directed physical examination, including vital signs and cardiovascular and respiratory components. The student then presents their findings to me in a separate room, and we then see the patient together.

Sarah sees three patients.

The first is a 79 year old gentleman who underwent aortic valve replacement and coronary bypass grafting about 6 weeks previously having been followed with gradually increasing symptoms over the previous year. He is a retired construction worker of Portuguese background who speaks no English, but is accompanied by his wife (who also speaks no English) and their devoted daughter who translates for them both. In fact, the daughter doesn’t translate so much as respond directly to questions on behalf of both parents. Although he’s doing well, they have a number of questions and concerns. Sarah has difficulty because she feels she needs to pay attention to three anxious people simultaneously, and isn’t sure the responses she’s getting from the daughter are valid. In discussion afterward, she has missed a number of key issues, and feels somewhat frustrated by the encounter.

Sarah’s second patient is a 60 year old adult who has been followed for over 10 years because of Hypertrophic Cardiomyopathy. The patient is developmentally handicapped and, although very pleasant and cooperative, responds to every enquiry in the same polite manner, affirming how well she feels without elaboration or apparent depth of thought. This is in distinction to the results of the recent echocardiogram that indicate the condition is getting progressively more severe, to an extent that treatment would usually be indicated. The case worker who accompanies our patient and knows her well, tells us that she’s “slowing down”, but never complains of any of the symptoms about which we have enquired. Sarah is aware of a number of treatment options that are known to improve symptoms and prognosis in this condition, but isn’t sure how they should be applied given her patient’s apparent lack of symptoms and inability to understand the indications and possible side effects reliably enough to participate in the decision.

The third patient is a 21 year old native woman who lives in lives near Moose Factory and works in the local hospital. She is referred by her Family Physician because she’s experienced two syncopal episodes within the past month. Sarah takes a complete history, and uncovers a number of issues that might suggest a cause, including a history of drug and alcohol abuse, and a family history of sudden cardiac death at young ages. We discuss a plan for investigations, as well as the need to inform the patient that her driver’s license must be suspended until we’ve resolved the problem. The patient is angry and upset, and doesn’t know how she’ll be able to carry out further investigations, since she was expecting to return home on the first flight early the next morning.

After clinic, Sarah and I take some time to “debrief”. She’s clearly a bit shaken by these encounters. We agree that her level of knowledge about the medical conditions she’s encountered (aortic stenosis, coronary artery disease, syncope, cardiomyopathy) is excellent, entirely in line with her level of training. However, she felt very limited in her ability to obtain a complete history and to apply accepted management strategies to these patients. In addition, she found the experience of encountering a person close to her own age with so many issues complicating her care particularly troubling on a personal level.

We were able to identify the various physician competencies that were required to effectively manage these patients. Sarah found, somewhat to her surprise, that the Medical Expert components, which she’d always assumed were the most important in her learning were, in fact, not much of a problem for her. It became obvious as we reviewed the cases that the Portuguese family and disabled adult challenged her communicator skills. The young lady with so many social issues required advocacy and highlighted her professional role to enforce public policy. Deciding what managements were applicable to the cardiomyopathy patient required an exercise of the scholar role, and coordinating all these aspects of care was a manager challenge, as was dealing with her personal responses to the young woman’s social situation. Some of the recommendations we made required collaboration with community physicians, therapists, pharmacists and other health providers. Even more importantly Sarah was able to see that providing comprehensive patient care requires these roles to be integrated rather seamlessly. They simply don’t segregate conveniently for us, as early medical education would suggest.

It also became apparent that these aspects of the learning experience had little to do with the cardiology-specific content but are relevant to any discipline. The “career exploration” element that Sarah was initially seeking certainly took place, but in a much broader and likely more effective way than she had imagined.

So, in summary, what did Sarah gain from her clinic experience:

  1. A deeper understanding of the pathophysiology, clinical presentation, physical examination and fundamental management of four specific medical conditions.
  2. An appreciation of the importance, complexity and subtlety of communication as a key physician skill.
  3. The relevance of all physician roles, and how they come together in every patient encounter as integrated, “intrinsic” competencies.
  4. Considerable self-awareness regarding her own level of professional development, personal strengths and preferences.
  5. Something about how different medical specialties differ, and how her particular strengths and preferences might fit those choices.

For my part, I was again impressed with the value of providing patient-centred opportunities that allow our students to experience the real life application of the knowledge and skills they are acquiring. Beginning early in their medical education, these experiences provide a framework and relevance that invigorates their learning process, and informs their career choices. Guiding our students through these formative experiences, and watching the immediate impact they can have, is also one of the most powerful and satisfying roles for any clinician-educator.

 

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

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How hard is it to integrate basic science and clinical learning?

How hard?  Not too hard…Ways to Integrate Science into the Clinical Courses (and vice versa)

integrate

For this blog, I need your help. And also I’ve tried something new.

First of all, I need help with some of the questions I’m positing. I’ve used questions used in activation of prior knowledge generally.  So please read them, and add your clinical know-how to them.

Secondly, I’m putting the theory last. I’m going to begin with practical ideas for integrating clinical and basic sciences in hopes you’ll agree that this is warranted.  I’ll put the reasons and the concepts behind integration later on at the end.

I’ll need your help with the practical too—what ideas do you have to integrate basic science and clinical concepts?

So… to get started:

You may think you don’t use basic science knowledge anymore.  Think about this case:

An adult patient comes into the outpatient office of
a doctor complaining of facial pain and nasal
obstruction for 2 days duration. Instantly, from these
2 signs, knowledge about acute facial pain pops into
the clinician’s mind, with sinusitis being especially
salient because of its frequency of occurrence in this
age group. This specific knowledge then orients the
questions asked and physical examinations administered.
A few minutes later, a new patient comes in
with vertigo signs. Instantly, knowledge about sinusitis
and facial pain is dismissed from active memory,
and knowledge of vertigo takes over. (Charlin, 2007).

Many physicians, encountering these patient presentations would react exactly as the physician above did.  We call the virtually unconscious use of basic science in this scenario “encapsulation.” (Schmidt, 2007) Alternatively,  a physician mobilizes organized knowledge in an “illness script.” (Charlin et al 2007, Schmidt, 2007) It’s not that you as a physician don’t use basic science–it’s just that experience, and practice has blended it seamlessly into your thinking.

But how can we get our students there? Of course, practice makes perfect and experience tells.  However, the  practice needs to be guided and scaffolded by good teaching and learning.  Here are some good teaching and learning interventions:

In pre-clerkship or clerkship:

  1. Be explicit about the science that grounds the clinical case or knowledge.  Insert science slides into your lecture/seminar slides that speak to basic science concepts at work.
  2. Use various media (words,pictures,practical experiences, lab results, microscope slides, etc.) to link science concepts to the clinical picture.
  3. Link to assessment. Critically, the assessment of integrated learring should reflect students’ sophisticated understanding of how the basic science relates to clinical understanding–not their ability to recall facts.   (Mandin, 2000).

In Clerkship:

Here are my ideas: What are yours?ideas 1

Provide opportunities for students to explore, research and strengthen their knowledge base of basic science issues relevant to commonly encountered clinical problems. Context is critical…for example, Laplace’s law describes fluid flow in the lungs which you can relate to asthma.

  1. Try: Case of the week? Case of the day? In rounds, or in a seminar, or in  Case of the Week such as Internal Medicine undertakes, consider questions for students to investigate:  What are the basic science issues that underlie this case? What is the pathophysiology at work here? (See Questions and Cues below.)
  2. Complement the mini-scholar CEX with a “Mini-science CEX”: ask students to use the same case as for their mini-Scholar CEX and inquire into the underlying science principles. Provide a worksheet or table for them to fill in that allows them to capture what you’re looking for. (See Questions and Cues, below.)
  3. Use some of the online modules developed for pre-clerkship as refreshers for clerkship. Students do this already.  Why not make it a part of the learning?

Need some help finding the modules? Ask an Educational Developer –we’re working with students to update the list.

OR

Work with one of the scientists in terms 1 or 2 and build one that will be useful from years 1-4.

  1. Bedside teaching: Ask a question about the underlying science of the case, in order to activate that learning.
  2. Questions and Cues that activate learning:

help from a docCan you help me provide some specific clinical applications?

 

Cues and Questions:questions you could ask

  • What organ system(s) draws your attention here?
  • How does this system normally work?
  • What normally happens?
  • What’s likely to have interrupted the process here?
  • What does that look like? What changes does that precipitate?
  • What are the basic processes used in reaching this state?
  • What changes occur when someone reaches this state?
  • What influences:  the quality, location, duration, precipitation, course of symptoms
  • What could be misleading you (confounding)?
  • What are limitations to your knowledge of this?
  • Use this blank schema/organizer to illustrate what is going wrong…(you’ll have to fill this one in!)

Now, you can see that your questions will be better than mine. Please write in with them!

Clerkship and Pre-Clerkship:

I found  some examples of questions in Bierer et al’s work, Methods to assess students’ acquisition, application and integration of basic science knowledge in an innovative competency-based curriculum in Medical Teacher. Their examples come from a first year course (!) that integrates science and clinical teaching. Please read about what they do in the article, but here are some of the questions:

  1. What are the urea and creatinine clearances in ml/min and L/day?
  2. If they are not the same as inulin, explain the difference.  Which substance provides the most accurate estimate of glomerular   flitration rate?
  3. How is it possible that the volume of urine is so high with such a low inulin clearance?
  4. In the above patient, assuming that the daily intake of sodium chloride is 5g, the plasma sodium concentration is 140mEq/L and the 24 h urine sodium excretion is 86mEq,

o   What percentage of filtered sodium is being excreted?  Reabsorbed?

o   Is the patient in sodium balance?

o   What does this information tell you about the kidney’s role in sodium homeostasis?

I like these Self-Assessment Questions too:

1. The renal clearance of inulin and creatinine are different. What explains this?

A.  Creatinine is not freely filtered through the glomerulus, whereas inulin is.

B.   Creatinine is only filtered while inulin is both filtered and secreted.

C.   Creatinine is both filtered and secreted while inulin is only filtered. *

D.   Creatinine is metabolized in the urine while inulin is not.

 2. Which of the following events is most likely to result in lower extremity edema?

A.   Low capillary hydrostatic pressure

B.   High plasma oncotic pressure

C.   Low plasma oncotic pressure *

D.   High tissue oncotic pressure

3. The majority of glomeruli are found within which region of the kidney?

A.  Calyces

B.   Cortex *

C.  Infundibula

D.  Medulla

E.   Papilla

 

Some Great Examples in Pre-Clerkship examples

We have some great examples of how to do this in our curriculum. The  key is the spiral curriculum where a student revisits a topic, theme, or subject several times, in deepening complexity (including science helps increase complexity), and a new learning relationship attached to old information. You’ve heard me talk about this before. See below for the theory and my conception.

Nowhere does this make sense more than in the clinical application of concepts from basic science.  For the first 2 years, here at Queen’s, there are some excellent examples of this.  Many of these came from a Curricular Leaders’ Retreat last year, with my thanks!

Have you clerkship examples?  Please send them here!

  1. Develop a weekly or monthly, undifferentiated case, where possible, “Case of the Week”, either in pre-clerkship or clerkship, to look at 20 main opportunities or “boluses” or “nodes”.   In clerkship these can be sent electronically, similar to “NEJM” Case, to create an online curriculum. Focus can be given to special populations. Course Directors would need to get together to do this to include the Course Directors from year 1. Year Directors can provide a focus.
  2. Dr. Romy Nitsch in Obs/Gyn has created an excellent introductory lab idea. Contact Dr. Nitsch for ideas.
  3. GI/Surgery and Neurology are trying a similar approach during the first week of the courses. Neurology is trying an online “diagnostic” test to assess student retention of anatomy and other scientific themes. Students who fall below a threshold will be required to participate in a tutorial. See Dr. Stuart Reid for ideas.
  4. Shared or Team Teaching: Dr. Sue Moffatt has worked with Dr. Conrad Reifel in his NHS course and Dr. Les MacKenzie has taught in Dr. Moffatt’s Respirology unit. See attached handout for ideas, or contact one of the participants.
  5. In Renal part of Endocrine/Renal, Dr. Jocelyn Garland and Dr. Iain Young work to show a “real time pathology consult” for each case. See Drs. Garland or Young for ideas.
  6. In therapeutics, it’s important for students to understand the visual process of how a drug works and the mechanism of the action. Students are provided with clinical cases from internal medicine to illustrate different mechanisms. In future, goals are to develop sessions/modules around classes of medicines for specific courses e.g. antibiotics and asthma meds for pediatrics/ beta-blockers for cardiology, etc. As well, the evidence base for use of these therapies is important.
  7. Bring clerks into pre-clerkship sessions you’re teaching. E.g. if you’re teaching about Acid Base in Renal/Endocrine, bring clerks from the service into the class to assist students with the learning and to show how it’s applicable to them in future. Can also occur in first year courses.
  8. Build online resources that may be used in different ways by different faculty in the future into clerkship. E.g. Sodium/Acid Base. Consult the foundational science faculty for assistance, as they have a huge database of images for use.
  9. OR consult the library for existing modules that may be used similarly. There are several videos, and other media, such as Anatomy TV which may be used.
  10. Use the Clinico-Pathologic Conference Approach used in the NEJM cases (examples at http://oac.med.jhmi.edu/cpc/links.cfm) where a case is presented to a clinician, who then demonstrates the process of reasoning that leads to his or her diagnosis. A pathologist then presents an anatomic diagnosis, based on the study of tissue removed at surgery or obtained in autopsy. Students work on the diagnosis, and discussion ensues.
  11. Who could be involved in preclerkship or clerkship? See how these faculty and concepts are located around a single node or bolus?

node

Great Places to Integrate

places for integration

We have some places in pre-clerkship that are waiting for some basic science; and some great places that are waiting for some clinical applications.

  1. In FSGL, we have the opportunity to integrate pathology, anatomy, imaging, etc. into cases.
  2. In Expanded Clinical Skills, there exist spaces for this integration.
  3. Problem solving exercises in SGL require foundational science for solutions and diagnoses. See above re. cases for some examples.
  4. CAUTION: Don’t overload. Use these examples of integration judiciously. Perhaps imaging is all that Dr. Davidson will use in a case of a limping child. Or perhaps Dr. Murray will use knowledge of histology and pathology or drug therapies in a case of a female patient presenting with shortness of breath that could be a case of myocardial infarction.
  5. Looking for some places and people with which to integrate?
  • In term 1, we teach Normal Human Structure (anatomy/histology), Normal Human Function (Physiology) and Critical Appraisal, Research and Learning (Epidemiology, stats, methods of study).
  • In term 2 we teach Therapeutics (pharmacology) and Mechanisms of Disease (immunology, infection, pathology). We teach about neoplasia, etc. in Blood and Coagulation. Genetics is taught in Genetics and Pediatrics in Term 2.
  • In the C courses, many concepts are bundled together, often by faculty who taught in pre-clerkship.

Some Theory:

As promised, here’s the theory (with a few practical applications to keep you reading)

theory 2

What is integration?   It refers to situations in which knowledge from different sources (basic science, clinical, factual, experiential, etc.) connect and interrelate (Regehr, 1996) in a way that fosters understanding and performance of the professional activities of medicine (diagnosis, management,etc.). (Kulasegaram, 2013).

  1. Integration of concepts is a two way street. We may bring aspects of clinical cases back to foundational Basic Science Courses. We may bring aspects of basic science and other concepts into clinical courses and clerkship.
  2. The key to this is communication, and knowledge of what each other is teaching.

See Integrating across years and courses: Lessons learned in NHS and Circ/Resp Handout attached. Educational Developers and Year Directors know what’s going on in the whole curriculum.

  1. Integration works in many ways from year 1 to year 2 and vice versa, and from year 1 to year 2 to clerkship and vice versa.
  2. Think of integration as “booster dose” to increase learning. Foundational courses provide the initial “vaccine” but students require booster doses to boost their learning.
  3. A “spiral curriculum” is a curricular model where students revisit specific aspects of previous learning but build on it to move forward. Integration is the key concept here. See below.

Integrated teaching offers many advantages (Harden, 2000)and may be a key factor in the delivery of an effective educational programme.

For the following, I am indebted to Kulasegaram, KM et al. (2013) in Cognition Before Curriculum: Rethinking the Integration of Basic Science and Clinical Learning.

Kulasegaram et al write, “Causal integration is not just an aid for memory and retention (Woods, 2007).  Rather, the cause and-effect relationship between the basic sciences (such as the physiology of upper motor neurons) and clinical features (such as the symptoms of stroke) creates a framework within learners’ minds that allowed them to organize the constellation of the features of a diagnosis. (Woods, 2007). This cognitive conceptual coherence is the advantage of integrated basic science teaching.” See this excellent article for more theory behind integration.

In a spiral curriculum, “a curriculum as it develops should revisit this basic ideas repeatedly, building upon them until the student has grasped the full formal apparatus that goes with them” (Bruner, 13).  Different terms are used to describe such an approach, including “distributed” and “spaced.” A spiral approach is often contrasted with “blocked” or “massed” approaches.

In a spiral curriculum,

  • The student revisits a topic, theme or subject several times throughout their school career.
  • The complexity of the topic or theme increases with each revisit.
  • New learning has a relationship with old learning and is put in context with the old information.

The benefits ascribed to the spiral curriculum by its advocates are:

  • The information is reinforced and solidified each time the student revisits the subject matter.
  • The spiral curriculum also allows a logical progression from simplistic ideas to complicated ideas.
  • Students are encouraged to apply the early knowledge to later course objectives.

Here’s how I envision our spiral curriculum at Queen’s. What do you think? Advice and feedback most welcome!

sheila arrow-2

References

These articles are either cited above, or were consulted in putting these arguments together.

Bierer, S. B.,  Dannefer, E .F., Taylor, C., Hall, P. (2008).  Methods to assess students’ acquisition, application and integration of basic science knowledge in an innovative competency-based curriculum. MedTeach.30.

Bruner, Jerome. (1960). The Process of Education. Cambridge, MA:  The President and Fellows of Harvard College.

Charlin, B. et al. (2007). Scripts and Clinical Reasoning.  Medical Education, 41(12).

Harden, R. (2000). The integration ladder: a tool for curriculum planning and evaluation.  Medical Education, 34(7).

Harden, R.M., Sowden, Susette, Dunn W.R. (1984). Some educational strategies in curriculum development: The SPICES model. Medical Education. 18 (4).

Kulasegaram, KM et a.(2013). Cognition before curriculum: Rethinking the integration of basic science and clinical learning. Academic Medicine, 88 (10).

Mandin, H. (2000). Evaluation: The engine that drives us forward—or back.  Clin Invest Med., 23 (1).

Regehr, G, Norman, GR. (1996). Issues in cognitive psychology: Implications for professional education. Acad Med., 71(9).

Schmidt, H. G. & Rikers, R. M. J. P.  (2007). How expertise develops in medicine: knowledge encapsulation and illness script formation. Medical Education, 41(12).

Woods, N. (2007). Science is fundamental: the role of biomedical knowledge in clinical reasoning. Medical Education, 41 (12).

Woods, N.N., Brooks, L.R., Norman, G.R. (2007). It all makes sense: Biomedical knowledge, causal connections and memory in the novice diagnostician. Adv Health Sci Educ Theory Pract., 12(4).

 

 

 

 

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Our Graduating Doctors. What qualities should they, and every Physician, possess?

At last month’s Convocation, we celebrated the beginning of 102 new medical careers. As the new graduates walked across the stage of Grant Hall, they stepped from their shared four-year undergraduate experience, into a diversity of career paths.

2014-grads

  • Twenty-six will begin training programs in Family Medicine.
  • Fourteen have chosen Internal Medicine.
  • Eleven are entering Anaesthesia.
  • Six in Pediatrics.
  • Six in Urology.
  • Five each in Emergency Medicine, General Surgery and Psychiatry.
  • Four each into Obstetrics-Gynecology, Neurology and Diagnostic Radiology.
  • Three will be entering Orthopedic Surgery, and three in Dermatology.
  • Two of our graduates will be undertaking training in Plastic Surgery.
  • One will be entering each of Ophthalmology, Cardiovascular Surgery, Neurosurgery and Radiation Oncology.

Over the next several years, they will differentiate further, into a potential of over 100 different practice disciplines now offered by the Royal College of Physicians and Surgeons and College of Family Medicine. This increasing diversification reflects the incredible expansion of medical practice, and the ever-expanding base of knowledge and skills we’re able to offer our patients. Although this is obviously welcome, it has caused many to question whether our current paradigm of medical education, beginning with a common three or four year, university-based curriculum, has kept pace or, perhaps more charitably expressed, should be reviewed.

In actual fact, our students’ educational experience in medical school is already differentiating, although unintentionally. Our current curriculum allows students considerable latitude to tailor their experience along lines of their choosing. Their 16 weeks of curricular electives, observerships and student-initiated interest groups allow each student to direct a significant proportion of their medical school experience. Although pedagogically intended to provide “learner-directed”, diversified educational experiences, it’s quite clear that these various elective options are used to explore and promote career interests, and are usually undertaken within the same discipline the student eventually enters. This is of obvious benefit to our students who struggle to come to career decisions and position themselves favourably in an increasingly competitive postgraduate matching process. Tampering with this largely unintended but nonetheless effective process could therefore disadvantage students and would bring considerable risk if considered in isolation.

However, we should recognize what’s happened by necessity rather than intention, reflect on what it’s telling us about the relevance of our current programs, and how we might intentionally design more effective training paradigms given the realities of current medical practice.

Central to this discussion is the need to grapple with the a key question: What are the knowledge components, skills and personal attributes that could be considered essential to every practicing physician, regardless of the discipline they eventually undertake? What qualities should we expect of every one of our graduates who walked across Grant Hall stage recently, or of those who will undertake our programs in the coming years? Put another way, one could consider what particular skills and qualities a physician should bring to patient care in an era of increasingly compartmentalized care provided by an expanding array of highly qualified professionals.

This reality was brought into particular focus for me last week by remarks made by Dr. Henry Dinsdale at a ceremony honouring his long and distinguished career. In his remarks, Dr. Dinsdale described his educational experience during an era when few specialty options existed, and a physicians training focused on core competencies common to all practitioners. Hearing of his many accomplishments in patient care, research and education, the message was clear: although knowledge expands and technology becomes more integrated, the core qualities that allow a physician to excel in his or her role are consistent, immutable, and should guide both our educational programs and selection processes.

And so, what are these attributes and qualities? I would suggest that any consideration of that question should be guided by three basic considerations: the responsibility to deliver excellent patient care; the responsibility to advance our profession through education and research; and the need to demonstrate a value-added role in an increasingly specialized health care workforce. With these considerations in mind, I would provide the following list for consideration:

  1. Curiosity. An insatiable and relentless drive to understand the human condition, in all its complexity from the subcellular to population levels, is the motivation that propels the lifelong pursuit of knowledge and skills and provides allows the physician to become the “medical expert”, both in breadth and depth of understanding. It also drives the desire to expand practice and share discoveries through research.
  2. Diligence. Getting into medical school requires persistence and hard work. Medical school itself and residency training that follows is even harder work. Medical practice, despite our increasing attention to maintaining health life balance, is the most challenging of all. Enough said.
  3. Communication. Arguably, the most important quality. A two way street – Doctors must be able to gather information and understand from all types of people, including those with limited ability to communicate themselves or understand their problems, and those of markedly diverse backgrounds. The greatest fund of information or technical expertise is useless without the ability to understand the patient in need or help them understand their needs. It’s also essential to effective education.
  4. Ability to deal with uncertainty. No two patients suffering with the same condition will present in exactly the same way. Each patient’s response to even the most accepted treatment will be unique to that patient. No diagnostic test is perfect. Physicians must therefore continually navigate in uncertain waters, balance risks with benefits, and guide their patients through that voyage.
  5. Judgement. Information about health issues is all around us, and universally available to our patients and the public. Knowledge is the considered consolidation of information into accepted practices, generally applicable to populations of patients with common characteristics. Judgement is required to extend that knowledge to individual patients. This may be the most difficult, but also singularly most characteristic quality of physicians.
  6. Composure under stress. One needs only to step into the Emergency Department or Intensive Care Unit of any hospital to see this quality in action, but it can also be found in Doctor’s offices, outpatient treatment units, research labs, medical schools, and any of the many places physicians undertake their diverse roles. In addition to being necessary to their own effectiveness, this quality provides a tone of stability for the patients and co-workers involved.
  7. Resilience. Things will go wrong, both personally and professionally. Effective physicians are not defeated by these experiences, but learn from them and become even more effective.
  8. Creativity. This speaks to the ability to think “outside the box”, extrapolating beyond commonly accepted approaches when the need (or opportunity) arises. Given the uncertainties inherent in clinical medicine noted previously, the physicians with single and inflexible approaches to each situation will find themselves both limited and frustrated.
  9. Humility. I struggled with this one, but in the final analysis, I felt that the ability to collaborate, work in teams, recognize personal limits and self-analyze (all of which are essential competencies) are made possible by this simple human quality which allows one to set aside personal gratification in the interests of the patient. In contrast, arrogance and relentless self-promotion make all these goals virtually impossible and underlie most complaints about physician performance.
  10. Compassion. Last on the list, but certainly not least. When asked what they expect of their physicians, patients consistently rate “compassion”, “caring” or similar qualities very highly. They expect, and deserve, their doctors to connect with them on a purely human level and share, in some way, in their suffering. Practically, it’s that sharing that provides true understanding and commitment.

And so, a long list of demanding attributes. Note the focus here is not on knowledge acquisition, skill development or even specific competencies, but rather on the personal qualities that make all those things possible. I provide it not to suggest that these qualities are unique to or only apparent in physicians. In fact, these qualities are exhibited and shared by many other professions, and particularly those engaged in health care. However, they are seen as essential to the effective physician and, as such, a valid starting point in establishment of selection processes, and educational programs common to the myriad roles that modern day medical graduates may undertake. This is, however, one person’s perspective. I welcome comment and refinement.

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Did you know? Faculty Evaluations are just a click away

An easy click to find your Faculty Evaluations

Undergraduate Meds has been working with MEdTech on enhancing the way faculty receive their faculty evaluations from students.

In MEdTech, go to “My Evaluations” at the top right hand side of the screen, and click.

 

MyEvaluations

All of your evaluations from the past years will be laid out for you there.

Tips for Processing Teaching Evaluations

Sometimes it’s challenging reading teaching evaluations.  Here are some tips for you to process this important information effectively:

1. Analyze.  Don’t get sidetracked by one outlier or a few negative comments.  To do that:

2.  Identify your key strengths. What are the questions that received the top three scores? Read the narrative comments that accompany these.

3.  Identify key areas to improve.  What questions received the lowest three scored?  Read the narrative comments that accompany these.

4.  How can you account for your strengths and weaknesses?  How are you teaching, or how are your learning events designed to give evidence for this?

5.  What will you ensure you keep doing in the future?

6.  What might you want to change in the future and how will you do this?

7.  Who can you consult with?  There are 3 categories of people who can assist you:

a.  Students:

  • Try to get earlier (formative) feedback in the future with a simple quiz that asks students how a session went.  Try questions like “Did this learning event meet the learning objectives?”  “Was the teaching clear?”  “Did I use enough steps, examples, figures and references to explain challenging concepts?”  “Was the session organized so that you could follow along?”
  • Use an “exit card” which asks students to put a statement of success on one side, and a challenge you can work on, on the other.
  • Or ask students “What is the muddiest point” in writing.  That will tell you what you have to clear up, and where your teaching may have met a challenge.  NOTE:  it’s important that you clear up the muddiest point, either through the Discussion Board on MEdTech, in another session, or through an email to the class academic reps.

b.  Peers or Course Director:  Peer coaching and getting advice from a colleague who has undoubtedly “been there” is a very useful way to get answers to questions and solutions to problems.

c.  The Educational Team:  This is what we are here for.  The Educational Developers work one-on-one with faculty to help them in all areas of their learning events.  Don’t hesitate to call.

Teaching is not easy, and for many, it’s not intuitive.  Focus on your strengths, and consult to build your skills.

Questions?  Write here, or write to sheila.pinchin@queensu.ca

 

 

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Medical Council of Canada (MCC) Clinical Presentations: How are they used in our curriculum?

Our UG curriculum has been built to accept the MCC clinical presentations as the core or spine for our Medical Expert role and competencies.

What are they?

MCC clinical presentations are part of the learning objectives for the MCC Exams, under the “Expert” section. They contain approximately 190 ways in which a patient with clinical issues may present to a clinician. The MCC clinical presentations are located at http://apps.mcc.ca/Objectives_Online/objectives.pl?loc=home&lang=english

The Medical Council of Canada changes and updates the presentations and keeps a record of this on its website. The website has a great search feature, under which you can search for disease entities, foundational science concepts, etc. http://apps.mcc.ca/Objectives_Online/objectives.pl?lang=english&loc=search

The website is newly updated with population health, and the intrinsic roles of a physician as well as a “Normal Values” section.

Queen’s Meds and the MCC’s

Previously we at Queen’s Undergraduate Medical Education (UGME) had modified the MCC presentations. However, the UGME Curriculum Committee has decided to use the full MCC presentations as they are represented on their website, and change annually to accord with the updates.

Important Note:  Soon, the UGME Educational Team will send out to Course Directors, on behalf of the UGME Curriculum Committee, a list of all the MCC presentations that have been assigned to each course. Course Directors are encouraged to review these as there may be some changes from previous assignments, due to MCC changes, and due to our conversion to the MCC presentations. With a new tracking report, Course Directors will also have access to data that shows where the MCC presentations have been tagged in their courses at the learning event level.

What if a Course contains other MCC’s than were assigned?

There may be MCC presentations that are taught in courses that have not been formally assigned by the UGME Curriculum Committee. A Course Director should bring this either to the Year Director for the Curriculum Committee or bring it directly to the Curriculum Committee.

The role of the committee is to ensure that all the MCC presentations are taught in the four years of medical school, and to ensure that there is a logical, spiral progression to the teaching. Thus, if two or more courses teach about the same presentations, there is usually no difficulty, but all concerned parties must be aware of who is teaching the presentation, how, and when. The Curriculum Committee will ensure that course directors are brought together to discuss this, usually through the Educational Team or the Teaching, Learning and Innovation Committee’s special projects.

What if a Course Director judges the teaching of a specific MCC to be a problem in a course?

If a Course Director feels that a specific MCC assigned to the course presents a problem, the process outlined above holds good here too…either bring the matter to the Year Director for Curriculum Committee or to the Curriculum Committee with an explanation. Again, the concern of the Committee is to ensure that the MCC presentation is taught in the appropriate place and manner within the four years of medical school.

How are the MCC presentations taught in our courses?

It’s important for us in UGME to consider how these MCC presentations may be taught in our classes. Our UGME curriculum is varied and integrated. In early pre-clinical years, MCC presentations may be a part of teaching such as:
1. Foundational science teaching and learning leading to clinical application
2. Links of a clinical presentation to systems and disease/conditions
3. Approaches to patient presentation
4. Collection and interpretation of information
5. Diagnosis
6. Intervention/Management
7. Complexities, multi-system integration, co-morbidities
8. A component of learning about “intrinsic” (non-medical expert) objectives

In clerkship, the MCC presentations are often integrated within all or many of the above.

But MCC clinical presentations often apply to more than one system or course…What then?

This is one of the reasons that the Curriculum Committee has adopted the MCC clinical presentations: because often a patient doesn’t come in knowing his/her disease or knowing which body system has been affected. In fact, it is important that our students learn undifferentiated diagnostic skills for “chest pain,” “cough,” “headache,” or “dyspnea.”It is one thing to know that dyspnea will be an indicator of a heart condition if the teaching is part of the Cardiovascular unit in the CV/Respiratory Course. It is a very different thing to encounter dyspnea in the Emergency Department, in Internal Medicine, or in Family Practice and trace it to a specific cause.

This is why we are building more undifferentiated diagnosis sessions into our preclinical years. As well, it’s why anatomists and physiologists in our first term of teaching in medical schools partner with clinicians to teach about the different aspects of a clinical presentation—considering anatomical/physiological changes and pathological insults that are of concern to the treatment and management of an illness or condition.

We are working on the spiral nature of our curriculum, building to an integrated approach to clinical presentations in the clerkship. That is, we’re revisiting topics from years 1-4, in greater complexity.  That’s why it’s important the different people teaching about the same presentation need to be in contact with each other and consider the best way to approach this shared teaching to create the spiral.

Do you have questions about this process of assignment of MCC Clinical Presentations in Queen’s UGME? If so, write here, or to sheila.pinchin@queensu.ca

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“Try to leave the world just a little bit better…”

Each year, our graduating class is asked to nominate a member to speak on their behalf at the Convocation ceremony. Last week, Yan Sim delivered an address on behalf of the Meds 2014 class. Yan’s heartfelt remarks certainly seemed to capture the sentiments of his colleagues and resonated with everyone in Grant Hall that afternoon.   It seemed clear that his words should be shared more broadly and so, with his permission, I am providing the complete and unaltered text of his address below. All who are involved in our school in any way, be it teaching, leadership, administration or support, should take justifiable pride that our graduates should feel this way about their educational experience and upcoming careers. Yan’s words reaffirm the faith that what we do is worthwhile, and we must be doing something right. And so, the words of Dr. Sim:

Yan-SimGood afternoon Chancellor Dodge, Principal Woolf, Rector Young, Dean Reznick, Associate Dean Sanfilippo, distinguished faculty, ladies and gentlemen:

My name’s Yan Sim and I have the privilege today of speaking on behalf of the Graduating Class of 2014. I’d like to start by first, welcoming our loved ones who have come from near and far to celebrate this moment we’ve been working towards for the past four years.

To our proud friends and families, you’ve had the opportunity to see us change and grow during our time here at Queen’s. I think I speak for us all in saying, we wouldn’t be here without you. Your support pushed us to be the physicians we are today as we trained, acquired knowledge and searched for answers. More specifically, the answers to your sometimes very personal medical questions.

Questions ranging from “Will cracking my knuckles give me arthritis?” to “What’s that on my leg?” and “why does this hurt when I do that?” After four years of training I think I can say with confidence: “No”, “I don’t know”, and “Please not at dinner”. All jokes aside – please be assured of our sincere gratitude.

As we sit here today, a class representing the most successful residency match in the history of Queen’s medicine, we couldn’t have done so without the care of our beloved faculty and staff. I can’t think of many medical school deans who would attempt to host dinners at his home to feed a hundred starving first year med students and yet you did, Dr. Reznick, even providing tupperware to take the leftovers home. And to Dr. Sanfilippo, Dr. Winthrop, Dr. Moffatt and our many teachers, thank you for your inspired teaching and for continuously involving us in shaping the medical curriculum. Thank you for believing in us, for being our role models, and for always pointing us upward as we have now ascended to the very bottom of the totem pole that will be residency.

It has been a memorable four years at Queen’s. There’s a uniqueness about the place and it’s not just the grandeur of the ivy and limestone buildings, but built from the heart of a tight-knit community raising friendships that will continue to stand even after the ivy has faded away. To my classmates, thank you for the honour of speaking on your behalf today. More importantly, thank you for the last four years as we’ve walked this journey of medicine from being just classmates to colleagues to friends, and now even family. No words can express my deep affection for each and every one of you. Almost on a daily basis, I have been overwhelmed with the support you’ve shown me to pick me up when I’ve fallen down, the laughs that have kept me smiling and the love that has kept me growing up. I hope the words I speak today resonate with you as well.

Since our first day at Queen’s, we’ve always been a class that has been a little unconventional. It’s been documented on more than one occasion how we love to have fun. However, I think that being the “fun class” masked how seriously and earnestly we took our studies. As a class, we seemed to push boundaries in all areas of medicine and life, much to the delight and frustration of our faculty. And even throughout the last couple years, as our lives transitioned from the lecture hall to the hospital ward, we’ve continually stretched the limits, striving for perfection as evidenced by our many successes in research, academics and even extending far beyond the field of medicine. And while we’ve had some edges that needed smoothing and corners that needed rounding, I believe that these successes stem from a passion for life, for medicine and for our future patients. A dissatisfaction, if you will, with the status quo. It is an ambition that is birthed from asking the seemingly simple and yet difficult questions – “What more can I do for my patient? What am I doing to better the lives of those around me?” These are the questions that not only shape who we choose to be, but also, define the contributions we are going to make.

And it’s so easy, to let these deep and introspective questions that we’ve asked of ourselves slip away into the busyness of everyday life. As we get older, the years seem to move faster, the demands on our time grow greater and the noise from the waiting room gets louder. In attempt to fight the fatigue, we mistakenly substitute lives of significant contribution and meaning for a busy routine.

We replace the difficult and vast questions with smaller, more manageable, questions. Prominent physician activist, Dr. Samantha Nutt, said questions like “What am I going to do with my life?” quickly evolves into “should I rent or buy?”, which lives next door to “how can I get a bigger house in a better neighbourhood?”, and coincides with “should we have two cars?”, “is this a good time to renovate the bathroom?” and “is this wall big enough for a flat screen TV?” and before you know it…” the defining questions that once gave us a passion to attain this year’s grand accomplishments have been replaced with next year’s daily grind.

And yes, we’ve come a long way and should be proud of our accomplishments as medical graduates of Queen’s University. In the days and years to come, we will be tempted to drown out the big questions with the noise of our busy lives. Sir William Osler said that “To have striven, to have made the effort, to have been true to certain ideals – this alone is worth the struggle.”My hope is we remember the questions we have asked of ourselves here at Queen’s and to dare to ask bigger questions. Whether we search for these in answers in our life’s work, our family, our friends or our faith, let us stay as hungry to make a difference as we were four years ago.

My late grandfather, Sir Harry Fang, was one of the first orthopaedic surgeons in Hong Kong, China. And at the end of his memoirs he wrote: “None of us are the same people we were even a few years ago. We have come through some rough times, and we face some tough challenges ahead. We can only do what each of us can do, to the limit of our abilities, to try to leave the world just a little bit better than we found it.”

And I know we’ll make that difference in the years to come.

But for today and for right now friends, family, esteemed faculty and my dearest classmates:

Congratulations.

 

Fang, Sin-yang Harry, and Lawrence Jeffery. Rehabilitation: A Life’s Work. Hong Kong: Hong Kong UP, 2002. Print.

 

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

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