Month: July 2014
Out of adversity, gifts of learning.
In the course of my career, I’ve unfortunately had many occasions to deliver “bad news” to patients and their families. This usually involves making them aware that treatments are either not working or no curative options are available, and that the end is imminent. In these moments, reactions are personal, individual and usually unpredictable. No matter how much one rationally anticipates the end of life, the actual reality can never be fully prepared for. The responses are raw, without pretense or veneer. As physicians delivering such news, we’re never truly prepared, and never feel adequate to the task.
I particularly recall an occasion when I participated in delivering “bad news” to a patient I’d been following for many years through several cardiac crises and surgeries. Together with two of my colleagues also involved in his care, and a number of involved students and residents, we informed him, his wife and teen-aged sons that, despite the fact that he was only in his mid 50’s, there were no options any longer available to treat his severely damaged heart and that he had only a short time to live.
There is no truly good way to deliver “bad news” to a patient. There are, however, a number of very bad ways to go about it. My experience and readings would suggest a number of key considerations:
- Clarity is a virtue. The use of euphemisms or expressions of uncertainty about the outcome just increase anxiety. If we’re not sure, we shouldn’t be having the conversation.
- Patients appreciate hearing bad news from someone they know and have come to trust. We should try to have such people involved, even though current patterns of practice make this difficult.
- Patients don’t usually need or desire detailed medical descriptions of why treatments have failed, but once they realize the outcome is certain, will have very practical questions about what will happen. How long? How will it happen? Will there be pain?
- Patients are often more aware of the realities than we anticipate. They are, after all, experiencing the success or failure of treatments. What we’re telling them is often much less of a surprise and we’re really confirming their impressions.
- Patients need to know they will not be abandoned. We need to express the ongoing plan for management.
I was anticipating all this when we spoke to my patient. I was ready for anger, disappointment, denial and all the other responses we’re taught to anticipate and I’ve seen before. I was not, however, prepared for his reaction. Sadness, to be sure, but his first response was to thank us. He shook our hands. Incredibly, his only question was whether any of his organs would be suitable for donation.
Physicians have recognized for many years that our patients are our best teachers. For the most part, this relates to what they teach us about medical matters. What’s less apparent is that they also have the capacity to teach us so much about the human condition and the human spirit, at its worst and at its very best. We have the privilege of sharing life-altering experiences and witnessing not only the suffering, but also how people are able to summon incredible reservoirs of strength and generosity of spirit in times of apparent hopelessness. It’s simply inspiring. That day, in a few moments, that patient, with a few gestures and comments, provided invaluable gifts of learning, not only for myself and my colleagues, but also for the nurses, residents and students in attendance. Perhaps most importantly, he provided an inspiring example for his young family. Out of his adversity, those gifts of learning will affect other patients and other lives.
By the way, I’ve since signed my organ donor card.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
MD Program Executive Committee Meeting Highlights – Wednesday July 16, 2014 at 4:30 pm
MD PEC Participation:
In recognition of the importance of input from our faculty and staff in the governance of the MD program, MD PEC would like to encourage faculty and staff to attend its meetings. Guests to these meeting will be non-voting “Gallery members” and may be asked to leave during particular discussions, if deemed necessary by the Chair. Interested participants should contact the Committee Secretary (Faye Orser, (orserf@KGH.KARI.NET)) for information relating to agenda items and meeting schedules.
Process for Subcommittee Reporting:
As part of the reporting requirements of the various UGME committees, each will be requested to submit an annual report to MD PEC. These reports should provide a summary of each committee’s activities from the previous year as well as plans for the upcoming year. A retreat for members of MD PEC will be scheduled in September, annually, to review these progress reports.
The students have now completed an independent report on the program for inclusion in the accreditation report. Results of this report will be discussed at a future MD PEC meeting dedicated to reviewing areas of concerns.
Conflict of Interest Procedures:
Staff have been looking into ways to implement an annual conflict disclosure for faculty. Discussions are underway with the Education Technology unit to investigate the possibilities of including a statement in MedTech.
Travel Safety Guidelines for Students:
Dr. Sanfilippo presented a draft document entitled “Student Vehicle Travel Safety Guidelines” developed by COFM. This document relates to concerns about student safety while traveling on curricular “business”. A “go to” document will be compiled listing current processes for Queen’s Medical students in the event travel conditions are considered unsafe. Once completed, this document and the draft guidelines will be posted on the UGME website as information for the students.
Diversity and Equity Initiatives
The Committee discussed the need to develop a Diversity Advisory Panel to promote and advance diversity initiatives. This panel will advise MD PEC on the administration of a Diversity Fund being established to encourage and develop Diversity initiatives and projects. Membership on this panel will include representatives from the school’s teaching faculty, students, education leaders and staff. Terms of reference for this new committee were reviewed and accepted.
Student Academic Affairs Committee
The Committee reviewed and accepted a proposal to develop a Student Academic Affairs Committee. This new Committee would operate as a subcommittee of MD PEC to recommend policy and practice on matters related to the academic experience of students in the MD Program and the QuARMS Program. This would include recommendations on policy and practice related to student progress and promotion, professionalism, communicable diseases and immunization, student registration, leave of absence and reintegration, student awards, content of transcripts, medical student performance records, academic accommodation, complaints and ethical conduct and the content and management of student records. It would refer and receive recommendations for policy and practice in these areas from the Professionalism Advisory Committee, Student Awards Committee, QuARMS Committee, and Communicable Diseases and Immunization Committee.
Next Meeting: August 27, 2014
A great read: Faculty Focus Blog
As part of your summer reading list, may I encourage you to look at Faculty Focus, higher ed teaching strategies from Magna Publications. Whenever Maryellen Weimer writes, I sit up and pay attention, but actually the other contributers have great ideas, and provide evidence for them too. This is not just for medical education, but for all educators in general.
How to integrate science into clinical courses and vice versa
How hard is this? Not too hard.
Here are some ways to integrate science into the clinical courses (and vice versa)
Hi all: I’m recycling a recent post, having drastically reduced it. I hope to write more about examples of integration and integrators from our curriculum in the future.
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, some key principles:
- 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.
- Use various media (words,pictures,practical experiences, lab results, microscope slides, etc.) to link science concepts to the clinical picture.
- 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: Practical ideas:
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.
- 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.)
- 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.)
- 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.
Work with one of the scientists in terms 1 or 2 and build one that will be useful from years 1-4.
- Bedside teaching: Ask a question about the underlying science of the case, in order to activate that learning.
- Questions and Cues that activate learning:
- 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!)
Basic Science Questions for 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:
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?
B. Cortex *
- 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.
- 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.
- 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.
- Modify 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.
- Who could be involved in preclerkship or clerkship? See how these faculty and concepts are located around a single node or bolus?
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.
- In FSGL, we have the opportunity to integrate pathology, anatomy, imaging, etc. into cases.
- In Expanded Clinical Skills, there exist spaces for this integration.
- Problem solving exercises in SGL require foundational science for solutions and diagnoses. See above re. cases for some examples.
- 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.
- 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.
I hope I’ve given you some insight into the how and the where of integration. In later blog articles I hope to feature the “who”.
Let me know your thoughts on integration of science into clinical courses.
Thank you Dr. McLean
The following note was sent by one of our fourth year students to her community preceptor at the end of her Integrated Community Clerkship. Both parties have graciously agreed to allow me to share it with you.
Dear Dr. McLean
- Teaching me Medicine
- Trusting me with your patients
- Introducing me to Perth
- Letting me be wrong
- Helping me get to the right answer
- Asking my opinion
- Demonstrating to me how to make patients feel heard
- Having office hours that work for patients (the 7am start makes so much sense)
- Encouraging me to be curious about patients’ personal histories
- Stashing Fudgeo’s
- Asking me hard questions
- Not making me feel silly when I didn’t know the answer
- But expecting that I know it next time
- Being patient as I learn procedural skills
- Filling out the paperwork while I finish the fun jobs
- Showing me that people are the most interesting part of medical practice
- Helping the office get through an entire Costco bag of Swiss chocolate…in a week.
- Demonstrating the type of discipline you keep teaching me to foster
- Taking me to the family medicine update conference
- Letting me draft on the bike and in the office!
- Building me up in front of patients
- Laughing with me at the occasional absurdities of family practice
- Teaching me to look
- To always look
- Introducing me to DQ milkshakes
- Telling me something isn’t right with a simple glance during procedures
- And feedbacking a quiet “better” once I corrected
- Magically knowing when I was prepared enough for you to disappear behind the curtain
- Giving me generations of social history in one or two sentences
- Helping me process hard-to-process patients
- Teaching me to dictate after every patient
- Showing me that the chart can be your friend…
- …it lets you go on holiday
- …and remind you of things you forget
- Patching up the first-year medical student
- Saying “I don’t know” with patients
- Saying “I don’t know” to me
- Showing me that we have a responsibility to advocate aggressively but politely for our patients
- Not using much technology but having an awesome EMR
- Teaching me to look for the why
- Reminding me why I do not want to be a rhythmologist
- Post-clinic Buster Bars
- Teaching me to punt when appropriate, better too soon than too late
- Stressing the importance of good documentation
- Making me remember the type of doctor I wanted to be as a kid
- Walking down to radiology.
- Talking to me about my future
- And making me think twice about what it might hold
- Deliberately debriefing the patient who coded
- Reminding me that I cannot solve all of a patient’s problems but can stand by her as she chooses to make her life better, or not
- Organizing similar experiences for so many other medical students
- So proudly showing me Lanark Lodge
- Teaching me an approach to explain the “needs further testing” imaging results with patients
- Challenging me to make a real difference for patients, not just correct their serum sodium concentration
- Auto-bolusing the syncopal wedding guest
- Taking off early one afternoon to go biking
- Reminding me to read around patients
- Teaching me that if to make a clinical decision you need more information, then go get that information
- To help me in my first “teaching role” during community week
- Letting me check all the well babies
- Including me in the joys and sorrows of rural family practice
- Helping me to find even more fulfillment in Medicine
- And…inspiring me to dream big while rooting my future in discipline, curiosity, wonder, humility and purpose.
Despite the complexity of modern pedagogical theory, expectations of multiple “shareholders” and increasing demands of accrediting agencies, the essence of medical education remains constant since the pre-Flexner apprenticeship days. Fundamentally, the overriding objective of any program hoping to graduate competent physicians is to identify motivated, receptive learners, and put them into contact with capable, inspiring physicians in a setting that allows the interchange to flourish. That’s basically what any medical school struggles to accomplish. And when those three elements come together….well, the effect is just magical and wonderful to behold.
Motivated learners aren’t hard to come by. As we’re all aware, there are many more highly motivated young people pursuing medical education than positions available. The considerable challenge, as we’ve discussed in previous blogs, is identifying those with the right motivations.
Medical School Admissions: Striving for fairness despite “ill designed” tools http://meds.queensu.ca/blog/undergraduate/?p=363
Medical School Admissions: Unintended Consequences http://meds.queensu.ca/blog/undergraduate/?p=407
Effective educational settings are essential and include appropriately structured and resourced classrooms, clinical learning centres, simulation laboratories, libraries and a continually evolving variety of learning facilities. However, medical education must necessarily extend to clinical settings where students can engage “real” patients in “real” venues. Our Integrated Community Clerkships, which have been in operation in Perth, Picton, Brockville and Prescott for the past four years, are true immersion experiences for our students. They spend 18 weeks living in those communities, working with local physicians, seeing patients in offices, emergency departments, hospital wards, nursing facilities, their homes, or wherever the circumstances require. In addition to learning a great deal about a variety of clinical problems, they become part of those communities and learn about how physicians manage their professional and personal lives. Importantly, they develop a more complete sense of themselves as independent physicians. These rotations have proven remarkably successful, as measured by student satisfaction and academic success. Although many educational leaders and affiliated community faculty have contributed to this success, the two most responsible have been Richard VanWylick, who took on and still provides administrative leadership for the program, and Ross McLean, who not only participates so effectively in the teaching, but has provided steadfast and highly effective support for the program through his role as leader of the Eastern Ontario Regional Medical Education Program (ERMEP).
Which brings us to the most important and valuable of our three key ingredients: the capable, inspiring physician-teachers. At Queen’s, we’re blessed with many such people, none more dedicated or effective than Dr. McLean. Although he’d never describe himself as an “educator”, he is an instinctive teacher with an abiding drive to pass on his 40+ years of experience and wisdom to the next generation of learners (I can assure you he’s not in this for the monetary awards). The qualities of responsible advocacy, sensitivity, professional commitment and diligence that make him such an effective physician, translate naturally to his role as a teacher. His dedication to the profession and to his community are legendary and have been recognized by his having been presented with the Glenn Sawyer Award honouring “a distinguished career of service” in 2011. I understand there is a lively debate in Perth as to how many physicians will be required to replace him when he retires. Estimates range from three to five.
Eve Purdy’s letter captures more effectively than any treatise on educational theory or compendium of accreditation standards, the elements of an effective learner-teacher interaction. I can’t really add to it, except to join her in saying…Thank you Dr. McLean.
Tackling your summer “To Be Read” pile
Do you have an ever-growing “to-be-read” (TBR) pile of books and journals that you’ve told yourself all year you’ll get to “in the summer”? And now it’s summer and the pile is daunting and the beach is calling. What to do? Try these five steps to get started.
Weeding the list (or culling the pile): If it’s been a while since you organized your list or your pile, don’t be afraid to remove titles. Your needs and interests may have changed in the intervening months. Also, if you start a book and find it’s not living up to its promise, ditch it. Why waste your time? I give a book 40-50 pages to impress me; otherwise, I move on. (This works for non-fiction and fiction alike).
Book time (sorry for the pun): We schedule times for meetings, but reading – even to keep up with our professions – often drops to the “squeeze it in somewhere” category. Consider scheduling 30 minutes a day of dedicated reading time. Can’t manage one half-hour slot? If it’s something you plan for, you could break it into two 15-minute chunks. Stow the book in your briefcase or make sure it’s downloaded to your eReader. Experiment to see what works.
Balancing interests: Sheila Pinchin shares that she uses two categories for her TBR list: Feed the Program and Feed the Soul. “This helps my priority lists and helps me balance profession and personal or other interests.”
Choose your own adventure: Sure, there are some books that require a start-to-finish reading strategy, but sometimes reading a single chapter can give us the information or tools we’re looking for. Sheila’s using this strategy for Engaging Ideas: The Professor’s Guide to Integrating Writing, Critical Thinking, and Active Learning in the Classroom by John C. Bean. “It’s a wonderful but huge book,” she says. “I’m going to dip into the book at different parts, and just read a chapter or two as they strike my interest or need.” Make use of Introductions and Tables of Contents to find what’s relevant to you and just read that.
Let technology serve you: How can tools you already use help with your TBR list? I routinely use my iPhone to read journal articles in those “gap” times — when I’m early for an appointment or waiting to pick up one of my children from an activity. I also keep two folders on my computer desktop: “Journal Articles Unread” and “Journal Articles Read”. When I scan the e-versions of journals, I’ll save the PDFs to the Unread folder, then move them over when I’ve completed them. I use key subject words in my “Save as” file names.
Do you have a favourite way of managing your TBR pile? Is there an app or computer program or maybe a filing system that works for you? Please share!
Finally, here are (some of) the titles on the Education Team’s summer lists which might be of interest to you, too. (Sorry that this could add to your TBR pile!)
From Sheila Pinchin’s TBR Pile:
- See John C. Bean’s book, Engaging Ideas above. Two chapters that have caught my eye: Using small groups to coach thinking and teach disciplinary argument and Bringing more critical thinking into lectures and discussions.
- Our Queen’s Meds SGL is founded on Team-Based Learning. A great book with ideas for all of us is Team-Based Learning for Health Professions Education, edited by Larry K. Michaelsen, et al. The frontpiece says “A guide to using small groups for improving learning” and they certainly carry through on that promise.
- Medical Teacher’s newest edition has an article, “Developing questionnaires for educational research: AMEE guide no. 87” (2014, 36: 463-474). A lot of us are doing educational research and developing surveys. This article’s 7-step process looks very practicable.
- “Assume hope all you who enter here.” This is the first line of Getting to Maybe: How the World is Changed (2006) by Westley, Zimmerman and Patton. This book, “not for heroes or saints or perfectionists” helps us see how to harness the complex relationships to lead to change. Education is all about change…this is a wonderful read about “how to.”
From Eleni Katsoulas’ TBR List:
- Remediation in Medical Education by Adine Kalet and Calvin L. Chou. I have had this book for about a month now and only looked over the table of contents. My plan is to delve into it during my holidays next month but from what I can see it offers practical tips to remediation. Looking ahead: Dr. Michelle Gibson will give us some key points from this book in a later blog.
- Quiet by Susan Cain. This book comes highly recommended to me by a friend that works as a consultant for the school board. A must read that explores “the power of introverts in a world that cant stop talking”.
And from my own teetering stack:
- Creating Self-regulated Learners by Linda B. Nilson. This is one of the goals of our curriculum. I bought this book back in February and have neglected it. I’m interested in Nilson’s strategies and if they can be applied in the UGME setting.
- Where’s the Learning in Service-Learning by Janet Eyler and Dwight G. Giles, Jr. I’ve dipped into this one for work on a service-learning module for QuARMS, but I’m eager to delve into the whole thing. Formalizing service-learning in UGME curricula could become increasingly important.
- Life, Animated by Ron Suskind I read an excerpt of this book in the New York Times earlier this year. The author’s son, who has autism, used Disney movies to understand the world. It’s a story of resilience and innovation; of seeing the world through a different lens. Important lessons in whatever walk of life we find ourselves.
- Mindset by Carol Dweck Although this book is about seven years old, it’s new to me. Dweck’s research on motivation is intriguing and could have application to our goal of creating self-regulated learners.
Send some suggestions from your TBR pile and… Happy Reading!