How much course evaluation feedback is “just right”?

How much feedback is too much feedback? How much is just enough?

That’s a question both the Course and Faculty Evaluation Committee (CFRC) and our students have been exploring.

At present, students are required to complete a 15-question course evaluation for each course as they complete it. As well, they’re required to complete faculty evaluations for each faculty member who taught at least four hours during that course. For our pre-clerkship students, this translates into 24 courses over the first two years of our program. Some courses are divided into units for evaluation, so that further increases the evaluation load.

As noted in a recent CFRC report to the Curriculum Committee: “Response rates have dropped significantly during the previous academic year on all course and faculty evaluations. It is assumed that a major contributing factor to the fall is the number of evaluations students are being asked to complete.”

We won’t ever do away with student course evaluations as these provide valuable feedback for curricular improvements. The CFRC is interested, however, in reducing the evaluation workload for students while still collecting solid feedback.

After consulting with the Aesculapian Society, the CFRC has proposed that only a subset of students will be asked to complete course and faculty evaluations for each course. Remaining students will have the option to complete evaluations. (In other words, students will always be able to comment on any of their courses and faculty if they want to provide additional feedback).

To determine if this will result in greater compliance (and data adequate for evaluation purposes), the CFRC will pilot this procedure on several Term 2 and 4 courses. The pilot project (Reduced number of targeted respondents for course and faculty evaluations), was approved by the Curriculum Committee at its November meeting.

For the pilot, students in both Meds 2019 and 2020 will be divided into randomized groups of 25 students each. One group of 25 students will be assigned to complete evaluations for each of the courses in the pilot.

Courses included in the pilot will be:course-eval-screen-shot

Meds 2020

  • Meds 121 Fundamentals of Therapeutics
  • Meds 125 Blood and Coagulation
  • Meds 127 MSK

Meds 2019

  • Meds 240 Genitourinary and Reproduction
  • Meds 241 Gastroenterology and Surgery
  • Meds 245 Neurosciences
  • Meds 246 Psychiatry

All students will be asked to complete the term 2 and term 4 course and faculty evaluations for those courses not included in the pilot. Also, Course Directors for the targeted pilot courses will be asked to confirm if there are any faculty to be excluded from the reduced pool of respondents and included in a group to be completed by the entire class.

Results of the pilot will be reported to the Curriculum Committee in August 2017.

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Lost Friends

“You don’t know what you got ‘til it’s gone”
(from “Big Yellow Taxi” by Joni Mitchell)

Joni Mitchell’s melancholy lyrics remind us of how easy it can be to take for granted those people around us who we get to know and who enrich our lives in so many ways. Even when we know that their remaining time with us is limited, we’re never really prepared, and the sense of loss is real when the end finally comes.

We’ve recently experienced two such losses at our school. Dr. Ron Wigle was a skilled clinician, committed teacher and mentor to a generation of students, many of whom continued to benefit from his gentle wisdom and humour up to the time of his passing. Moreover, he was a truly special person who had a remarkable ability to connect with people, breaking through all the barriers and pretensions that we often allow to get in the way of real understanding.

Karen Nicole Smith didn’t allow her chronic health issues to prevent her from making valuable contributions to our school and hospital. In fact, her determination to make a difference and find meaning in her own struggles made her contributions all the more valuable and remarkable. Kate Slagle, Manager of our Standardized Patient Program, worked closely with Karen Nicole, and provides the following tribute:

Living close to death empowered Karen Nicole Smith to embrace LIFE.  She not only embraced life but chose to celebrate it and shared her powerful experiences with others as a Patient Experience Advisor.  Sadly, Karen Nicole passed away on Sunday October 16, 2016 in her home on her own terms.

karen-nicoleAt the age of 18 Karen Nicole was diagnosed with chronic kidney disease.  In 1996 she received a kidney transplant which ultimately failed in 2009.  Since then she had been independently completing home hemodialysis.  Her chronic kidney disease left her body susceptible and at the age of 39 she went into cardiac arrest and nearly died.  After her cardiac arrest Karen Nicole made the conscious decision to take control through “active living”.  She worked with teams of medical and non-medical professionals to stabilize and regain her health. In December of 2015 Karen Nicole was diagnosed with angiosarcoma, a rare form of heart cancer which was removed during an emergency open heart surgery.  A few months ago Karen Nicole’s cancer returned.  Karen Nicole knew her time was coming to an end and made the conscious decision to stop dialysis and pass away peacefully at home.

Take 2 minutes to meet Karen Nicole by watching her “Hello” video: http://youtu.be/hwuW2Oww9sE

Karen Nicole was widely known throughout the Kingston community for her a work as a Patient Experience Advisor at Kingston General Hospital and role of Trainer and Community Outreach Consultant for the Queen’s Standardized Patient & OSCE Program.  Karen Nicole was an advocate for those living with chronic illness and shared her messages on a larger scale as a distinguished public speaker, writer and blogger.  She knew that “sharing her opinion was helpful no matter how difficult the topic.”  In 2016 Karen Nicole made contributions to Reader’s Digest, The Heart Failure Report, Health Quality Ontario and may more publications.  She traveled across the country passionately speaking about the patient perspective in palliative care, organ and tissue donation, chronic illness, independent dialysis, cardiac rehabilitation and physical & mental barriers to exercise.

Karen Nicole knew her journey had purpose.  Instead of focusing on illness she focused on LIFE and dedicated her work to improving the lives of others living with chronic illnesses.  Her messages of active living, patient centered care and hope will continue to resonate with all those who had the privilege of knowing Karen Nicole.  In honor of Karen Nicole we can each do our part to help her legacy live on by being an advocate for our health and choosing to live life to its fullest.

Recent Media Contributions:

Living Well with Heart Failure (Reader’s Digest 2016): Outlines Karen Nicole’s journey of active living following her cardiac arrest.

Quote: “One of the most important things I learned is that you can be a person with chronic illness and still be quite healthy and active.”

Link: http://blog.heartandstroke.ca/2016/01/heart-failure-survivor-karen-nicole-smith/

Living Life Honestly (Queen’s Gazette 2016): Karen Nicole’s perspective on the delivery of bad news and advice for those living with chronic illness to become their “own best advocate”.

Quote: The conversation does not have to go perfectly. The communication just has to be real.”

Link: http://www.queensu.ca/gazette/alumnireview/stories/living-life-honestly

The Journey to Heart Failure (Heart Failure Report 2016): Karen Nicole’s message of hope following her cardiac arrest.

Quote: “There is hope.  There are places to go for support. You can rebuild your life.”

Link: https://karennicolesmith.files.wordpress.com/2016/06/heart-failure-report.pdf

Palliative Care at the End of Life (Health Quality Ontario 2016): Karen Nicole’s honest thoughts regarding end of life care and death.

Quote: “I’d put my hospital bed right here, with sunlight coming in, and I’d get to pass with dignity and in comfort, with help in my own home. At times that has been my comfort, my solace.”

Link: http://www.hqontario.ca/Portals/0/documents/system-performance/palliative-care-report-en.pdf

Kingston Woman Choosing Unassisted Death (Kingston Whig 2016): Karen Nicole’s decision to stop dialysis and her plan to pass away on her own terms.

Quote: “I’m just hoping that the right people will read this. And they will change their minds or think differently about someone they’re taking care of. I hope it will touch lives then can makes things better.”

Link: http://www.thewhig.com/2016/10/07/kingston-woman-choosing-unassisted-death

To Find Out More Visit Karen Nicole’s Website: https://karennicolesmith.wordpress.com/

 

Two gifted, generous people who who were willing to share their energy and time with us. We’re all the better for it.

 

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

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Applying decluttering principles to learning event planning

My family and I recently relocated from a 2300-square-foot, five-bedroom house to an under-1100-square foot, three-bedroom townhouse to be closer to my son’s school and my office at Queen’s. This has required divesting ourselves of a great many belongings. Some things were easy (no more guest room = get rid of bedroom suite of furniture), but now we’re down to what home organizers call decluttering.

Decluttering is trendy; there are blogs and articles and entire shelves of books about this movement to pare down belongings to what is truly essential.

Near the beginning of my downsizing project, a colleague passed along a copy of one such book, Marie Kondo’s The Life-Changing Magic of Tidying Up: The Japanese Art of Decluttering and Organizing. (Yes, there was some irony in acquiring a new book when I was purging others, but that’s another story).

In this bestselling book, Kondo sets out principles for determining how to declutter. Since I’m immersed in decluttering (and unpacking can be a mind-numbing task) I started thinking about applying Kondo’s principles to learning events.

Decluttering principle: Uncover what you want your space to be

Learning Event translation: Uncover what you want your learning event to be

What underlies this principle is visioning: think about what it is you want your sj-bubblegirllearning event to look like before you start making changes. What do you need and want to accomplish in your 60- or 120-minute session? What are your assigned learning objectives? Keep in mind this planning cannot be a solo activity as your events are connected to others – course directors need to balance topics and learning event types throughout a course, so check in with anyone impacted by changes you’re thinking about making. Do you want to add interactive components? Revise case studies? Improve group work? Streamline the order of MCC presentations?

 Decluttering principle: Only keep those items that give you a “spark of joy”

Learning Event translation: Only keep those activities that spark learning

Take a good look at the activities and materials you’re using in your learning event: are these aligned with your objectives? Do they provide meaningful learning for your students? Are the points clear? How many cases are you using? Would it be better to have three well-constructed, in-depth cases, or the five you’re currently using? Are you being deliberate in what you’re including, or just force of habit?

Decluttering principle: Have a designated place for everything

Learning Event translation: Have a designated time for everything

Consider making a timeline plan for your learning event to keep everything “in its place.” This doesn’t have to be rigid to the last second, but can help keep things on track. If you have an outline that includes each topic or case, discussion/question time, breaks, wrap-up/summarizing time, it will help keep you on track and ensure finish on time. It also helps let you know when to wrap up discussions (no matter how interesting) to move onto the next important point.

* * * *

Not everyone can – or should – dive into decluttering their home (see this New York Times opinion piece which argues very clearly that there’s class politics involved in the decluttering movement). Likewise, not every learning event is in need of decluttering. However, if you’re frequently going over time, or find that you’re not meeting the learning objectives you have, or you’re just generally dissatisfied with your teaching sessions, decluttering may be a place to start.

One caveat: Decluttering can’t be done in a vacuum – either at home or for a learning event. For every fan of Kondo’s work, there are partners, children and other relatives who complain (rightly) that stuff they needed, wanted or sparked joy for them has been summarily tossed by an obsessive tidier. If you’re interested in decluttering your learning events on a larger scale (for example, does this MCC presentation even belong in my session?), that necessitates conversations and cooperation with your course director and fellow instructors and I’m happy to pitch in, too.

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Entrustment in Medical Education – a distinctly human challenge.

It’s two o’clock in the morning. The phone rings, waking the on-call attending physician from what had been a sound sleep. A resident is calling to review a case she has been asked to evaluate in the emergency department. She feels the patient has stabilized and can be sent home with arrangements for outpatient follow-up, but must “clear” that decision with her supervising physician.

The resident, a qualified physician having graduated from a fully accredited medical school over two years ago, is now in the third year of specialty training. The attending physician has only a casual acquaintance with this particular resident, never having worked directly with her before, but is aware that she is generally considered to be very capable and reliable.

The patient’s presenting problem is neither unusual nor particularly complex. The information provided is complete. The attending physician asks a couple of further questions that are competently answered. Finally the attending asks, “so are you comfortable sending this person home, or would you like me to come in to review him with you?” The resident confirms that she is satisfied with the decision and doesn’t see a need for further review. They hang up. Both go back to bed. The attending physician may or may not get back to sleep.

 

This scenario, played out countless times in countless variations every day in teaching hospitals, illustrates the concept of entrustment. For entrustment to occur, the essential operative driver is trust.

 

Many definitions of trust are available, but the one that I think best captures the key elements relevant to the clinical setting is provided by Mayer et al (Acad Manag Rev 1995;20:709):

 

“The willingness of a party to be vulnerable to the actions of another party based on the expectation that the other will perform a particular action important to the trustor, irrespective of the ability to monitor or control that other party.”

 

So how does this occur? What allows the attending physician to accept “vulnerability” and trust in the judgment of the resident sufficiently to agree to a plan of action without personal verification? What, for that matter, allows any person to trust another?

There has been much written on this topic, dating back to ancient philosophy. Trusting, it seems, is a rather complex, distinctly human and highly personal interaction. It requires a relationship between the person who grants the trust (the trustor) and the one who is trusted (the trustee). The vulnerability that the trustor accepts is based a number of assumptions, but principally their assessment of two key attributes of the trustee: their capability, and their motivation to do the right thing. The whole matter is further complicated by the fact that trust is usually contextual, but may become unconditional. We begin by trusting a specific person within the limits of a certain task or scope of responsibility. We may, with continued experience and appropriate reinforcement, extrapolate and extend that sphere of trust. To do so, the trustor is required to judge broader attributes of the trustee, which will determine their willingness to extend trust further, to more complex situations.

In medical education, this is no abstract or purely philosophical issue. As illustrated by the scenario above, the concept of endowed trust has been, and continues to be, central to the provision of competent, safe care in our clinical teaching centres. In fact, it’s becoming increasingly complex in settings where the interaction between supervising physicians and trainees is more sporadic and truncated (as illustrated above), and where the sheer volume of cases requires efficient decision making. The concept of admitting patients to hospital for “observation” has become a thing of the past.

Moreover, as we move toward the concepts of Entrustable Professional Activities and Competency Based Assessment, our medical schools will be grappling with the challenge of developing methods by which these “entrustment decisions” can be made objectively within our increasingly busy and hectic workplaces.

This was the topic of a recent webinar provided by the Office of Faculty Development and featuring Dr. Olle ten Cate, widely regarded as the originator and major proponent of EPAs in medical education. Among the many insights he provided was a consideration of the key elements that should inform an entrustment decision. It begins with simple ability, which consists largely of knowledge and technical skills. Ability is relatively easy to observe and assess in brief encounters. It’s also fairly straightforward to simulate encounters so they can be practiced or tested, as with OSCEs. However, entrustment also involves a number of key elements that are much more complex and difficult to objectively assess, including integrity (truthfulness, honesty), reliability (consistency) and humility (awareness of limitations). These latter attributes defy objective quantification, can’t be reliably assessed in a single encounter, and are very difficult to simulate for practice or examination purposes. They require longitudinal observation, in a variety of clinical situations, carried out by appropriately oriented and consistent observers. They require, in fact, a continuing relationship between teacher and learner.

And so, to borrow a phrase from Hamlet, “there’s the rub”. Those continuing relationships, so essential to the development of trust, are notoriously difficult to establish in our current clinical clerkships and residency training programs, where teachers and learners collide almost randomly, de-linked by separate and independent schedules. What’s more, when they do come together, the number of learners, clinical volumes and primacy to expedite patient care makes it even more difficult to establish effective relationships. Paradoxically, the long abandoned apprenticeships and long, service-based clinical placements were, in some ways, much more suited to establishing the continuing workplace relationships that allowed this longitudinal, more holistic approach to assessment and entrustment decisions.

And so, what to do? We certainly can’t and shouldn’t attempt to turn back the clock. But can we learn from prior experience to develop a clinical workplace that better promotes more effective teacher-learner coordination, and therefore more valid entrustment decisions? Obviously there are no easy fixes, but a few observations are offered that may have some relevance:

 

Maximizing continuing contact between teacher-preceptors and learners is key. Coordination of assignments and call schedules is logistically challenging and would require coordination of multiple, currently siloed administrations, but would be well worth the effort, and should perhaps be seen as a priority and strategic direction for undergraduate and postgraduate programs. Integrated, community- based programs provide an environment much more conducive to establishing effective entrustment decisions. In this regard, Family Medicine programs are leading the way and may provide valuable guidance. Social programs and team building exercises involving trainees and faculty members, once a common component of training programs, may play a prominent role in building effective working relationships. We are, quite simply, more likely to trust people we know personally. Finally, it might well be time to reconsider the role of attending physician, and the assumption that the same individual can simultaneously manage a busy clinical service and provide effective educational supervision.

 

Clarity with respect to the scope of entrustment for each individual learner will facilitate decisions. In other words, teachers and learners need to be “on the same page” with regard to expectations. Dr. ten Cate refers to a “zone of proximal development” as the difference between what the learner has already mastered and the next level of proficiency. It’s important for both parties to not only understand the task for which entrustment is provided, but the level of proficiency or degree of resolution with respect to that task. This, of course, gets back to the issue of relationship and need for a greater level of understanding between trustor and trustee. It involves better communication regarding individual learner needs, and more targeted faculty development.

 

Transmission of learner information between programs is essential. We need to come to grips with our collective paranoia about “forward feeding” and develop effective means to get relevant and useful information about individual learner needs, goals and teaching requirements to the right people. Both learners and faculty must appreciate that the goal is to enhance the educational experience, not prejudice decisions. In this regard, the soon to be released Learner Handover Project initiated through the Future of Medical Education in Canada initiative and chaired by Dr. Leslie Nickell will provide a valuable contribution.

 

The concept of entrustment means we will occasionally (hopefully rarely) be required to say someone is not yet ready to take on a particular task, or advance within a program. We must be willing to engage these situations objectively and constructively. The development of key abilities essential to any discipline requires time, practice and immersion in the appropriate training environment. However, the attributes of integrity, reliability and humility can (and should) be identified early in the educational process. This provides an appropriate “division of labour” between undergraduate and postgraduate programs. Undergraduate programs, in addition to focusing on the development of appropriate foundational knowledge and skills, should ensure they are admitting and graduating individuals with the appropriate personal attributes to engage any field of medical practice. Postgraduate programs should be able to assume the individuals entering their programs are worthy of entrustment, and can concentrate on the development of discipline specific expertise.

 

Stephen R. Covey, the late educator and author of “The Seven Habits of Highly Effective People” describes trust as “the glue of life…the most essential ingredient in effective communication…the foundational principle that holds all relationships”. In the end, trust is about people, effective working relationships and open communication. Our challenge is to find ways to ensure this uniquely human, essential ingredient can develop and flourish despite the challenges of our increasingly complex and stressed clinical learning environments.

 

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Curriculum Committee Meeting Information – August 18, 2016

Faculty and staff interested in attending Curriculum Committee meetings should contact the Committee Secretary, Candace Miller at candace.miller@queensu.ca for information relating to agenda items and meeting schedules.

A meeting of the Curriculum Committee was held on August 18, 2016.  To review the topics discussed at this meeting, please click HERE to view the agenda.

Faculty interested in reviewing the minutes of this meeting can click HERE to be taken to the Curriculum Committee’s page located on the Faculty Resources Community of MEdTech Central.

Those who are directly impacted by any decisions made by the Curriculum Committee have been notified via email.

Students interested in the outcome of a decision or discussion are welcome to contact the Aesculapian Society’s Vice President, Academic, Kate Rath-Wilson, at vpacademic@qmed.ca.

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On boy doctors, girl doctors, and advocating for my son

“I hope it’s a boy doctor.”

It was the spring of 2014, and I was walking with my then-10-year-old son from our car to our family health team’s office. Our doctor is part of the Queen’s Family Health team, so we often see residents rather than our assigned physician. For this reason (and because I don’t ask about the schedule when I book appointments), we don’t always know the gender of the person who’ll be providing care on a specific day. (We can always ask to see our doctor, however, I’ve never done this. I’ve always bought into this model of medical education – even before I started working as an educational developer in the undergraduate medical program).

It had never mattered to my son. Until that day in April.

We were heading to an appointment about recurring rectal bleeding. He had first presented with this on New Year’s Day. The digital rectal examination at the child out patient clinic the next day was an uncomfortable experience that he now refers to as “the butt thing”.

If they’re going to do “the butt thing” again today he wants a boy doctor, he said.

“You know,” I said, matter-of-factly (or at least I attempted to be matter-of-fact), “at the Med School where I work they teach boy doctors and girl doctors all the same things. They all learn how to look after everybody.”

“Yeah, I know,” he said. “But if they do the butt thing, I want a boy doctor.”

My son has autism. He’s seen multiple physicians, therapists and interventionists in his short life. Until this point, he had never commented on their genders. This was a new request. I had until his name was called to sort out for myself what I would do.

There was a flurry of news reports the previous fall, in October 2013, about whether patients should have the right to choose their physician based on race, religion or gender. (See here and here for some of this coverage). The news hook was a position statement by The Society of Obstetricians and Gynecologists that argued its members should resist such requests in emergency and other after-hours situations.

Perhaps because the articles were focused on obs/gyn, much of the commentary that followed focused on women, immigrants, and others with religious concerns. I can’t recall any discussion about children and their preferences in the gender of a treating physician. Until that day in 2014, I’d never given it any thought myself. My kids have been “stuck” with whichever family physician I’ve found for us.

Until my son’s request for a “boy doctor.”

Is this a reasonable request? Is my job as his mother to convince him that physicians of either gender will provide him with great care and that he should feel comfortable with either gender? Or is my job to talk with the clinic staff, explain his concerns, and ask to see a male doctor on duty that day?

The resident we were scheduled with that day was, indeed, the “boy doctor” so I was let off the hook of having to ask to have the attending (male) physician replace the other (female) resident. As a woman, as an educator, I’m uncomfortable with the idea of that conversation. As a mother and my son’s advocate, I think it’s something I would have had to do to support him in his request for a “boy doctor” for this invasive examination.

While I was happy to be off the hook that day, I have yet to resolve this conundrum. Is it reasonable for patients (or parents of patients) to make such requests? If gender requests are OK, are other requests OK, too — race, religion, age? Are children a special case?

In my role as an educational developer, I take these mental musings further: What does this mean for medical education? Do our students need special instruction on how to address these patient concerns? Would I have more or fewer reservations speaking up on this for my child if I weren’t involved in medical education? Are there other parents who feel they can’t bring things like this up for other reasons? Is this a problem? How can this be addressed?

These are questions I’ve continued to wrestle with and I suspect I will for a long time. What do you think?

 

 

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