Author: Anthony Sanfilippo
The Humble, Inspiring Leadership of Sir Tom
The spectacle of a 94 year old Queen wielding a large sword to “knight” a 100 year old gentleman, stooped and standing with the assistance of a walker, might seem somewhat anachronistic and perhaps even a little inappropriate to those whose tolerance for tradition and ritual is strained even in the best of times. Certainly, the double-whammy of the COVID crisis and racism activism are very much front of mind for most people and understandably so. Jaded suspicion and negativism have easy footholds in our consciousness. Hope and optimism struggle for attention.
Nonetheless, that’s exactly what’s to be found behind this brief ceremony conducted Friday at Windsor Castle.
The gentleman being knighted is Captain (now Sir) Tom Moore. He is a veteran of World War II, having been “conscripted” at the age of twenty. He was assigned to an armoured corps, but eventually served as part of what came to be known as the “forgotten army” in Burma (now Myanmar) surviving, among other things, a bout with dengue fever. After the war, he became a businessman and motorcycle enthusiast. Recently, not content to simply observe the COVID pandemic from the comfort of his retirement home, he resolved to do something to assist the overburdened National Health Service. Options being limited, he decided to do 100 laps of his garden on his 100th birthday, which he did with the support of his walker, but otherwise unaided. The project was widely picked up by social media and the press. Contributions started rolling in. To date, 33 million Pounds ($56.2 million CDN) have been raised.
These efforts, together with tons of natural charm, have made him the very embodiment of British pluck and resilience in the face of adversity, and this past week he was knighted by his slightly younger Queen, who herself knows a thing or two about maintaining a stiff upper lip in the face of adversity.
There are many words that come to mind in describing Sir Tom’s actions. “Charitable”, “altruistic”, “selfless” would all seem to apply but there are other aspects of his remarkable story that, although equally valid, may not immediately come to mind.
One is “humility”. Sir Tom was not looking for acclaim or to make a “big splash”. He simply saw a need, felt obligated to make a contribution, and set out to do whatever was in his power to do. In the case of a now one hundred year old man with obvious limitations, that consisted of walker-wheeling around his backyard.
The other word that comes to mind is “leadership”. Although its doubtful he would describe himself in such terms he has, despite advanced age and physical limitations, done much more than simply raise funds. He has provided leadership in a time of crisis. By choosing to act rather than simply bemoan his situation, by acting without artifice or expectation of self-promotion, by rejecting victimhood and bitterness, his actions inspire us all to simply get up and keep moving ahead. With his walker firmly in hand, he shows us the way.
The “Greatest Generation” indeed.
Thank you, Sir Tom.
Engaging Diversity, Then, Now, Always.
This week, I’m reprising an article that first appeared on this blog September 8, 2014. It was part of a series of articles that were developed at the time to examine the concept of diversity in the context of medical education. The motivation was to develop a more focused approach to diversity within all aspects of our school. As will become apparent in subsequent installments, all this led to a number of changes and innovations within the school, most of which are still operational today.
Recently, as described in a recent article (https://meds.queensu.ca/ugme-blog/archives/4880), we have re-committed to engaging diversity within our school. As we do so, it’s important to emphasize the particular importance of this initiative within medical education, and to review and reassess steps previously taken.
The Educational Value of Diversity
UGME Blog: September 8, 2014
In October of 1931, a 16-year-old college student joined a group of friends for a night of carousing and entertainment at the Driskill Hotel, in Austin Texas. He had no idea what to expect of the entertainment, the focus of the evening being on the “carousing” component. Rather unexpectedly, he is deeply moved by the performance, and particularly by the featured musician. Many years later, that student writes about that experience in his memoirs:
“He played mostly with his eyes closed. Letting flow from that inner space of music things that had never existed. He was the first genius I’d ever seen.”
The “genius” he was referring to was Louis Armstrong, who was himself only 31 at the time, at the beginning of a career that would eventually identify him as one of the greatest virtuosi and innovators in the history of American music.
The young man was Charles Lund Black, who would go on to become a Professor of Law at Yale and expert in American constitutional law and contribute importantly to a number of cases involving key civil rights issues.
Professor Black would later say the following about his experience that evening:
“It is impossible to overstate the significance of a sixteen year old Southern boy’s seeing genius, for the first time, in a black. We literally never saw a black man, then, in any but a servant’s capacity…Blacks, the saying went, were ‘alright in their place’, but what was the place of such a man, and of the people from which he sprung?” http://www.nytimes.com/2001/05/08/nyregion/charles-l-black-jr-85-constitutional-law-expert-who-wrote-on-impeachment-dies.html
In Black’s eulogy, a former student would say of him, “He was my hero…He had the moral courage to go against his race, his class, his social circle.”
In Medical Education, the concept of Diversity has become entrenched in our collective vision as expressed in both the Future of Medical Education in Canada recommendations and in accreditation standards. The rationale for such initiatives has been largely perceived to be the need to ensure equity of opportunity, and a need for medical schools to respect and reflect the gender, cultural, religious influences of the societies they serve. Laudable and worthy justifications, to be sure. However, Mr. Black’s encounter with Mr. Armstrong hints at deeper, even greater benefits. Does diversity within a learning environment, or as a deliberate component of a curriculum, have educational value? Does it shape thought and attitudes? Does it make students better practitioners of whatever career they undertake? Does it make them better citizens?
These questions have had particular relevance and attention in the United States for the past several decades, where they have been the focus of legal as well as pedagogical attention. Affirmative Action initiatives and subsequent legal challenges have required both jurists and educators to engage this question critically and analytically.
In 1978, Chief Justice Lewis Powell wrote the following opinion regarding the case Regents of the University of California vs. Bakke. He argued “the atmosphere of speculation, experiment and creation – so essential to the quality of higher education – is widely believed to be promoted by a diverse student body…It is not too much to say that the nation’s future depends upon leaders trained through wide exposure to the ideas and mores of students as diverse as this Nation of many peoples.”
Chief Justice Powell’s decision, however, did not settle the issue. Challenges have continued and the wisdom of mandated diversity initiatives has been repeatedly questioned. This is largely due to the lack of a theoretical framework or evidential basis demonstrating value. Since then, considerable work has either emerged or been resurrected to provide such evidence, which is summarized in an excellent paper by Gurin and colleagues (Harvard Educational Review 2002; 72: 330).
From the theoretical perspective, the work of a number of sociologists and psychologists is particularly relevant, and fascinating to review. In attempting to describe their work, I freely admit to venturing far beyond my expertise and apologize in advance to those much more knowledgeable.
Erik Erikson, as far back at the early 1950s, postulated that late adolescence and early adulthood were critical times in the development of personal and social identity. He theorized that such identity develops most effectively when people at that stage of life are provided what he called a “psychosocial moratorium”, by which he meant a time and situation during which they could feel free to “sample” and experiment with various social roles for themselves before taking on a more fixed and permanent role, i.e., before they “committed” to a profession, personal philosophy, or relationship. Colleges and universities are critical to providing this environment for most young people, certainly in North America. But how can they promote this critical social development? In the words of Gurin and colleagues:
“Higher education is especially influential when its social milieu is different from students’ home and community background and when it is diverse and complex enough to encourage intellectual experimentation and recognition of varied future possibilities.”
In other words, the real power to influence goes far beyond lofty mission statements and curriculum, and arises largely from developing an environment where students are able to interact both passively and actively with individuals who are “different” and therefore force new thought and new perspectives during this critical developmental phase.
Sociologist Theodore Newcomb carried out a series of studies and long-term follow-ups of Bennington College students between 1943 and 1991. (Newcombe et al 1967. Persistence and change: Bennington College and its students after 25 years. New York: John Wiley and Sons), (Alwin et al 1991. Political attitudes over the life span. Madison: University of Wisconsin Press). To medical folks, this is the sociologic equivalent of the Framingham studies. He and his colleagues found that political and social attitudes were most likely to change and remain so in students who had encountered novel concepts and attitudes, largely through peer influences, while attending college, thus supporting Erikson’s theory and demonstrating long term durability of the early life experience.
In the Gurin paper, the authors draw on the work of Jean Piaget and Diane Ruble in extending the concept of disequilibrium, to the early learning experience. In Guerin’s words:
“Transitions are significant because they present new situations about which individuals know little and in which they will experience uncertainty. The early phase of transition, what Ruble calls construction, is especially important, since people have to seek information in order to make sense of the new situation. Under these conditions individuals are likely to undergo cognitive growth unless they are able to retreat to a familiar world.”
In simple terms (that even a cardiologist would understand) the greater the difference between the students prior life experience and the learning environment in which they find themselves, the greater potential for new thought, new concepts and personal growth.
The Michigan Student Survey (MSS) and Cooperative Institutional Research Program (CIRP) are longitudinal studies examining, among other things, how diverse education processes influence attitudes and career success. The MSS is a single site study involving 1,582 students. The CIRP is a national cooperative involving 11,383 students from 184 American institutions. Both involved racially and culturally diverse populations of students assessed on the basis of their pre-university and university cultural environments i.e. their “diversity experience”. For detailed description of results, I would refer the reader to Gurin et al. Harvard Educational Review 2002;72:330. The key findings relevant to those considering diversity initiatives in university programs:
- There was a positive relationship between diversity experiences and educational outcomes
- The influence of a diverse educational environment was consistent across schools and cultural groups
- “interactional” diversity was more influential than “classroom diversity”
But are these effects also relevant to medical education, where one might suppose that students are older and further along developmentally, and perhaps pre-selected for cultural diversity and preparedness?
- In 2003, Whitla and colleagues (Academic Medicine 78:460) reported on a study involving medical students at Harvard Medical School and the University of California, San Francisco. Students surveyed reported that contact with diverse peers enhanced their educational experience and supported ongoing affirmative action initiatives.
- A graduation questionnaire administered by the Association of American Medical Colleges to 20,112 graduates from 118 medical schools (Saha et al, JAMA 2008; 300: 1135), demonstrated that, for white students, attendance at a school with high proportions of peers from underrepresented minorities was associated with greater confidence in caring for minority patients and positive attitudes regarding equity issues. These associations were not found for non-white students.
- Niu and colleagues (Academic Medicine 2012; 87: 1530) surveyed 460 Harvard medical students and found that those who reported spending more than 75% of their study time with students from diverse backgrounds or having participated in diversity related extracurricular activities felt more prepared to care for diverse patients.
And so, it seems Mr. Black’s experience in 1931 was not simply an isolated event, but indicative of the potential for great things to emerge when open minds are exposed to new situations, new social constructs, new paradigms. The value of Diversity in education is about much more than a need to exhibit “fairness” and some notion of social justice, but rather an active educational intervention capable of expanding the vision, imagination and therefore potential of students.
So, what does all this psychosocial theory and American experience say to those of us engaged in medical education in Canada in 2014? We might feel, with some justified smugness, that we are not faced with the same social divides and engrained class issues as our southern neighbours. We might also take solace in the knowledge that our schools are uniformly committed to the concepts of equity, fairness and diversity in the workplace, and have rather rigorous policies in place intended to ensure the issue of structural diversity. However, we might also see this as an opportunity to enhance our approaches to medical education, where the ability to effectively engage people of diverse backgrounds and with diverse needs would seem particularly relevant. Finally, many in 2014 Canada might define Diversity as more of a socioeconomic as opposed to racial/ethnic issue, given the well-documented struggles of our First Nations and immigrant populations. With all this in mind, I pose a few perhaps unsettling questions for consideration:
- Do our students engage in medical school in the type of passive and active learning environment that theories and studies suggest could truly influences their development as physicians?
- Do our policies, which focus largely on identifying numbers and proportions of various groups in our school relative to the general population, truly promote the development of that effective learning environment, or simply attempt to demonstrate token compliance with regulations?
- Our students, raised in and drawn from a Canadian culture that promotes equity and fairness, are good and instinctively fair people, unfailingly tolerant of diverse individuals and eager to contribute, but do they develop a deep understanding of the issues of those less-advantaged, and are we, as the stewards of their education, doing all we can to develop a learning environment that will promote that understanding?
Can we do better? Can’t help but think so.
Next article will focus on initiatives that were undertaken at that time, and then update on current evolving plans.
The Legacy of George Floyd – What will it be?
We watch, horrified, recordings of the last few seconds of George Floyd’s life. We hear his last words– “I can’t breathe”. The symbolism of the white, uniformed figure whose knee is at this neck, unresponsive to his pleas, could not be more stark. For many, George Floyd is the most recent, most poignant example of a history of racial subjugation, mistreatment and killing that spans the past four centuries. For many, it’s a sad reminder that similar crimes and protests of five decades ago were not the final expression of that discontent. For us all, it forces a confrontation with the reality that the dream of Martin Luther King “that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character” has, sadly, not yet been realized.
Locally, we have been challenged by these events to consider what, if any, implications they have for each of us personally, and for our school. Many faculty and students have expressed very clearly their concerns, their discontent and have called for change. In the interest of exploring this further, I met recently with our student leadership and medical students. Those discussions were candid, sincere and highly illuminating. They expressed realities about the experience of Black medical students at Queen’s with clarity and openness. The tragic killing of George Floyd, it seems, has opened a discourse and raised to the surface issues and concerns that are not new, but not previously expressed as bluntly. It has also, it must be said, caused all of us to listen with greater sensitivity.
Out of those discussions, a number of themes and practical measures are being developed and advanced. I have since had opportunity discuss these with our current Dean Dr. Reznick and our incoming Dean Dr. Philpott who are both very supportive.
- All medical schools have a responsibility for social accountability. The exact nature of the commitment, expressed in a Diversity Statement, is school specific and should reflect the regions served and values of the particular school. That statement should drive a variety of school activities, including curriculum, recruitment and admissions. In the light of recent events, it seems appropriate to re-assess our Diversity statement. Our Diversity and Equity Committee, chaired by Dr. Mala Joneja, will be charged to draft a renewed statement to be considered by our faculty council
- Our curriculum should prepare our students to provide comprehensive care to patients of all ethnic and racial backgrounds. This should be reflected in both the content and delivery of the curriculum. Our Curriculum Committee will be charged with re-assessing both aspects through the lens of the Black population. It will also be asked to ensure that opportunities exist for open and constructive dialogue between students for discussion of difficult and contentious topics.
- The Black population of Canada is under-represented in our medical school. This is despite the fact that our admissions processes are scrupulously unbiased with respect to racial considerations. In fact, I realized as we discussed this issue recently that it was impossible to even determine the racial make-up of our incoming class, simply because this information is in no way documented or considered. The under-representation of Black people is almost certainly a complex and multi-factorial issue. Our Admissions Committee will be tasked with giving consideration to what factors may be active and to consider how they might be addressed.
- Very concerningly, and despite numerous (and I believe very sincere) efforts to address this over the past few years, our students report a lingering perception within the Black applicant community that Queen’s is an unwelcoming environment. This no doubt contributes to the under-representation issue and merits deep consideration at all levels.
- It seems clear that the promotion of mentorship opportunities for our Black students and applicants would be of benefit and should be pursued actively, both within our schools, and through effective collaborations outside our school.
None of this will occur if efforts are restricted only to a vocal minority who have themselves been the subject of racism in their lives and therefore need no convincing of its existence. It is rather for those of us in the “silent majority” of society who abhor racism but have not been its direct victims to take stock. We need to listen and, in those ways that are available to us, act.
Many will question why a murder in Minneapolis, tragic as it is, should influence the discourse and decisions at our small, somewhat secluded and seemingly tranquil medical school in Kingston, Ontario. I will admit to initially sharing that skepticism. I have come, through reflection on my own experiences with racism and through discussion with our students, to a different perspective. I would now say to those people who question these directions that no community in the western world can consider itself immune or unaffected by racism. I would say that injustice of any form diminishes and affects us all. I would say that we bear a collective obligation to the memory of George Floyd, to all the George Floyds of the past and to every person today afraid to jog alone through a park or be pulled over for a minor traffic violation. We owe it to them to take whatever action is in our power to take. We act for them but, in the end, we are acting for us all and for those who will follow.
The Event Was Virtual. The Graduation Was Real!
In its 166 year history, the Queen’s School of Medicine has no doubt hosted many memorable events to mark the achievement of graduating students. None, I’m sure we can assume, compared to last week’s celebration.
For the past few months, a small committee let by Drs. Renee Fitzpatrick and Andrea Winthrop has been meeting and struggling to develop some appropriate way to recognize the graduation of our Meds 2020 class, given the limitations imposed by the pandemic. The result was a “virtual” event made possible by Zoom technology, our dedicated MedVC team and coordinated by Jacqueline Findlay, UG Program Manager.
Our virtual graduation celebration was “attended” by 300 sites that signed in, as well as an unknown number live streaming the event. Attendees were located in cities all across Canada, as well as several in the US and Europe.
It featured an opening welcome to families and supporters of our graduates, followed by individual recognitions of each graduate. Dean Richard Reznick paid tribute to the class, challenging them to make a difference. Dr. Susan Moffatt was selected by the students to provide remarks on behalf of faculty. Drs. Heather Murray, Erin Beattie and Brigid Nee were selected by the graduates to receive the prestigious Connell awards for outstanding lecturing, mentorship and clinical teaching. Dr. Akshay Rajaram was selected by the students to receive the award for outstanding teaching by a resident.
Dr. Cale Templeton and Julia Milden were selected by their classmates as Permanent Class President and Class Valedictorian.
In her address, Dr. Milden spoke of the gratitude of her classmates for family, friends and teachers. She acknowledged admiration for her classmates and the bonds of friendship that had developed during medical school and would persist through their careers.
“I am struck today reflecting on what exactly it means to be called a doctor, the thrill and duty of carrying this new title and the letters MD. This particular moment in time seems to make incredibly clear the power and responsibility of this role. On the wards or on television, writing orders or writing policy, doctors of all kinds are illuminating the challenges of their patients and of the system, and working together to help shape what we do as a whole world to take care of one another.
So what gives us this influence?
I think it’s the message we send when we say ‘I’m a doctor’ – to whomever we’re meeting, it means: I’m listening, I respect your wishes and your opinions, I know how to learn and am motivated to investigate your problem, and I will do everything in my power to help you.
And most remarkably, the skills and qualities this social trust is based on are ones that we have right now: our willingness to listen, and our ability to care.”
Certainly, we must acknowledge that the event was decidedly not what anyone envisioned when Meds 2020 began medical school one September morning over four years ago. Nonetheless, it was every bit as real as the degrees earned by our graduates and received by them last week. It occurred because of a very real refusal to allow any mere pandemic to diminish the significance of what these young people have accomplished, nor overcome our desire to express our pride and extend our good wishes.
To them, our admiration and congratulations…really.
Balancing Social Responsibility and Personal Rights in a Time of Crisis
Reading the New York Times these days can be a rather jarring emotional experience. It is replete with stories of people and families devastated by the COVID crisis. Excruciatingly detailed and poignant accounts of people dying in their homes or hospitals, isolated from surroundings and those who have been significant to them. Married couples dying within hours of each other leaving shattered families behind, all deprived of the end of life processes that would normally help with the grieving process and achievement of some emotional closure. Hospital workers struggling to provide some modicum of solace and dignity before having to move along to the next patient.
Turn the page, and you read accounts of protests by those decrying the restrictions that have been imposed by their governments, claiming their rights to choose to assemble and assume personal risk.
These stories are not limited to New York or even the United States. They come from Italy, Britain, Mexico, South America, the Far East. It seems no place is spared, although the impact and time course varies considerably.
In our own characteristically muted fashion, the same dramas are playing out in Canada. Political leaders, hearing loud and clear from all constituencies and all perspectives, struggle to strike a balanced and responsible approach.
All this serves to highlight two great realities of this pandemic. Firstly, it is affecting virtually every human being on the planet. The sheer scope is mind boggling and it’s difficult to think of any prior catastrophe that even comes close. The second reality is that its very nature is such that it renders each of us both a target and a mechanism for spread. We are simultaneously potential victims and potential perpetrators. We are all therefore forced to make choices, and those choices are expressed not through words so much as through our actions.
For the vast majority, the choice is clear. Simply remaining secluded and abiding by social isolation directions from authorities is not only in their personal best interest, but also their means of contributing to the public good. It can be inconvenient, unsettling and, depending on personal and family circumstances, very demanding. It also requires a degree of trust and faith that decisions are being made with best information and with the best of intentions. It requires political leadership that evokes that trust. But most importantly, it requires a willingness to endure some degree of personal hardship for a perceived greater good.
For those who provide essential services, the choice is very different. For those people, the greater good is to continue their duties while exercising appropriate precautions. The willingness of health workers and the many essential service providers who allow our society to continue to function in these very challenging times is a testimony not only to their dedication and courage, but to their belief that they have a role in contributing to the welfare of others. They are nothing short of heroic.
All of us are affected. All of us are making sacrifices that require us to balance our personal interests with our obligations to those around us. Our fundamental values, both individually and collectively, are being exposed. The ideological and moral differences between individuals, communities and even countries are being laid bare in the face of this crisis. The early results are largely positive and even inspiring. But the real test is yet to come. As the acute crisis abates to some extent, and it becomes clear that a complete return to “normal” is a long way off, how will we engage this “new normal”? Our leaders and governments are making decisions that require them to determine the very nature of what constitutes “common good”. What seems clear is that what will determine success is not our ability to protect our personal interests, but the extent to which we are willing to sacrifice those personal interests for that common good.
It’s science, not speculation, that will get us through this.
Why do COVID patients experience such profound hypoxia without feeling dyspneic?
Why is there such heterogeneity in clinical severity among young, previously healthy patients?
Are asymptomatic people able to carry and transmit the virus, and for how long?
Does immunity develop after infection, and how long does it persist?
Does antibody status indicate complete protection from re-infection?
Do currently available anti-viral agents have effect?
Will previous approaches to vaccine development be effective?
These are some of key questions still under investigation as we now pass 6 months since this infection originally came to attention. The answers to these questions are the keys to resolving the greatest heath and economic catastrophe the world has faced. The answers will not be provided by scientists or politicians working in isolation, but rather by the application of scientific approaches, supported by political and economic action.
This past week, we’ve seen examples of how this can work well, and how a lack of synergy will impede progress.
In Canada, our government has announced a billion dollar investment in COVID-19 medical research, and support for a Task Force to determine the extent of the disease.
- Trudeau announces $1.1-billion for COVID-19 research (https://www.theglobeandmail.com/politics/article-trudeau-announces-11-billion-for-covid-19-research/)
- Government of Canada funds 49 additional COVID-19 research projects (https://www.canada.ca/en/institutes-health-research/news/2020/03/government-of-canada-funds-49-additional-covid-19-research-projects.html)
- Ottawa to fund existing coronavirus research projects (https://www.theglobeandmail.com/politics/article-ottawa-to-fund-existing-coronavirus-research-projects/)
In Germany, a nation-wide public health investigation has begun to carry out widespread serologic testing intended to define the true extent of disease and implications of prior infection.
- With Broad, Random Tests for Antibodies, Germany Seeks Path Out of Lockdown (https://www.nytimes.com/2020/04/18/world/europe/with-broad-random-tests-for-antibodies-germany-seeks-path-out-of-lockdown.html?ref=oembed)
- Blood tests show 14% of people are now immune to covid-19 in one town in Germany (https://www.technologyreview.com/2020/04/09/999015/blood-tests-show-15-of-people-are-now-immune-to-covid-19-in-one-town-in-germany/)
In the United Kingdom, vaccine development is well underway with massive investments already in place.
- UK boost support for CEPI to spur COVID-19 vaccine development (https://cepi.net/news_cepi/uk-boosts-support-for-cepi-to-spur-covid-19-vaccine-development/)
All these have come about through effective collaborations between government, funding agencies and scientific and medical communities. We’ve also seen examples of what can transpire when those collaborations are not effective. We’ve seen that, even if well intentioned, speculative assertions by a political leader can be assumed by the public to be scientifically informed and thereby lead to dangerous actions.
- U.S. President and top doctor spar over unproven drug (https://www.theglobeandmail.com/world/article-trump-vs-fauci-us-president-and-top-doctor-spar-over-unproven-drug/)
- Nigerians poisoned after taking doses of drug praised by Trump (https://www.theglobeandmail.com/world/article-at-least-two-cases-of-chloroquine-poisoning-in-nigeria-after-trump/)
- Trump’s COVID-19 disinfectant ideas horrify health experts (https://www.reuters.com/article/health-coronavirus-trump-disinfectant-idUSKCN2261OL)
- Lysol maker warns against internal use of disinfectants after Trump comments (https://www.nbcnews.com/politics/donald-trump/lysol-manufacturer-warns-against-internal-use-after-trump-comments-n1191586)
There has been much debate in recent years within the medical education community regarding the relevance of research and critical appraisal in undergraduate medical education. These topics have been gradually and rather insidiously receiving decreased attention in favour of the many other competencies and “hot items” that have been emerging, all with justification. I would suggest that recent events have resolved that debate. The questions posed at the beginning of this article were not posed exclusively by basic scientists and epidemiologists, but also by clinicians trained to accurately observe patient responses, critically assess current understanding and pose valid, useful hypotheses for testing. Clinicians will also be very much involved in developing protocols and executing investigations to find answers. Medical schools have a responsibility to ensure that fundamental training continues to be a core component of their programs, now more than ever.
Getting students back into the clinical workplace. Why? When? How?
Medical education is not just a program for building knowledge and skills in its recipients… it is also an experience which creates attitudes and expectations.
It’s long been appreciated that medical education must provide much more than academic knowledge about human biology and pathology. It must also provide opportunities to observe and participate in the application of that knowledge to real people with real problems. In fact, the earliest forms consisted entirely of “on the job’ practical experience in apprenticeship-like arrangements with practicing physicians. The contemporary model of medical education incorporates the Clinical Clerkship which, since early in the twentieth century, has provided opportunities for medical students to work alongside fully qualified physicians and make active contributions to clinical care while observing, learning and advancing their skills. It has been modified considerably over the years, extending into a variety of clinical settings and incorporating embedded formal learning activities. It has proven highly effective in preparing students to both develop fundamental skills and better understand their own place in the rapidly expanding world of clinical medicine.
Until, that is, about a month ago.
As a result of the massive disruptions caused by the COVID pandemic and as reported in the last edition of this blog (https://meds.queensu.ca/ugme-blog/archives/4797), it became unavoidably necessary to pull medical students from their clinical placements. This was not because of a lack of perceived value, but because the simple logistics of maintaining safe and educationally viable experiences in the face of the stresses currently being faced by our hospitals and faculty became insurmountable. Since then, students have been undertaking an on-line, remotely delivered curriculum intended to provide learning that would normally have been undertaken in conjunction with their clinical placements. By doing so, it’s hoped they will be in a better position to complete their training within whatever time remains when clinical placements are eventually resumed.
Over the past few weeks, medical schools across the country have been almost continuously engaged in discussions to determine when and under what circumstances students will be able to re-engage this very necessary component of their education.
Why the rush?
Firstly, these clinical placements are essential components of learning and training. To undertake medical education without experiencing clinical application would be like trying to learn to play the piano without ever touching one. One might learn everything about how the instrument is constructed, how it works and the principles of music, but could never become a musician without guided, progressive application of all that knowledge.
Secondly, Clinical Clerks are able to provide useful clinical service. Although their scope of activity is obviously limited, they are able to off-load certain tasks to allow more advanced learners and fully qualified physicians more time to concentrate on more complex patient interactions and procedures, all the time observing and learning through active participation. They will also, and very importantly, learn the value and satisfaction that comes from helping provide useful service to patients and thus further their growth as professionals.
Thirdly, and very pragmatically, failure to graduate on time will be very damaging. Our medical schools serve our society and are expected to provide a steady infusion of trained physicians to the Canadian workforce. There will be a point at which insufficient time is available to complete degree requirements. A failure to graduate the 2021 class on time, or close to it, will result in gaps in that supply line, at a time when need is particularly urgent and is likely to continue well into the future. In addition, overlapping with subsequent classes will put further stresses on already limited clinical training sites and have implications well into the future.
Finally, it must be recognized that the students of today will be the leaders and front-line providers of whatever health care crises face our society in the future. We must not deny them the learning that this crisis provides. There is valuable, perhaps unique, learning available to them that will shape not only their understanding, but their attitudes and personal preparedness.
For all these reasons, much thought has been given to the “when”. In doing so, a number of principles and practical criteria have been developed.
Principle 1: Patient Safety.
Would the presence of students in the clinical environment jeopardize or promote optimal patient care?
- Would students be able to provide valuable service by “off-loading” specific aspects of care from other providers?
- Would students increase the risk of disease transmission?
- Would students consume valuable PPE?
Principle 2: Student Safety.
Can students be protected from, or excluded from, excessive risk?
- Although some small risk is inherent in any clinical placement, would students be exposed to risks considered above the “norm”, or without protections and considerations that would be reasonably expected?
- Will students be provided with the full, minimum PPE that is suggested as required by scientific knowledge with respect to COVID-19?
- Are there local occupational health processes in place to protect students who may be exposed to COVID-19?
- If it is deemed essential to exclude students from some clinical situations and not others, can that exclusion be reliably achieved?
- Do current student liability arrangements cover the current clinical environment?
Principle 3: Safety of clinical teaching faculty and hospital staff.
Would student placements jeopardize the safety or wellness of teaching faculty or other hospital staff?
- Would students provide valuable service that would be of benefit to faculty or other providers?
- Would students integrate into care teams as currently constituted during this crisis?
Principle 4: Learning.
Can a valuable learning experience be provided?
- Are there sufficient roles in which students can engage?
- Do these roles have educational value?
- To what extent is any involvement at this time a valuable and possibly unique learning experience?
Principle 5: Supervision.
Are there sufficient clinical teaching faculty available to provide student supervision?
- Can continuing oversight of learners be provided?
- Can learners be assessed?
- Are these available in all areas necessary to provide a full clerkship experience?
In terms of the “how”, criteria such as these will be continuously assessed and the current state of readiness for re-entry evaluated on an ongoing basis. It’s understood that a certain minimum time, at least a month, will be required to “on-board” students to the altered workplace. The earliest possible return is therefore always at least a month displaced from a final decision. At this point, only the most optimistic estimates would suggest a return before July.
In addition, schools are striving very hard to coordinate their efforts and synchronize both entry and graduation dates. Given the differences in curricula and clerkship structures across the country, and the differing regional impacts of COVID, it seems unlikely all schools will reach a state of preparedness at precisely the same time, but there is strong commitment to minimize discrepancies.
There is also a growing recognition that the elements of clerkship and the residency matching process are almost certainly going to be substantially altered. Discussions about the number and type of elective opportunities that will be available, and the implications for residency selection are very much “on the radar” of undergraduate programs, postgraduate programs and CaRMS, but substantive decisions must await more clarity about timing of return and graduation dates. Whatever those dates, schools all recognize the critical importance of ensuring that all graduates are provided equivalent opportunities to achieve graduation requirements and engage residency positions.
It will be important through this process to maintain full transparency and communication between schools and, critically, with our students whose lives and careers are literally “on hold”. This article is an attempt to promote that communication, which will no doubt continue across our country in the weeks and months ahead.
Stay tuned. We will get through this, together.
The Crisis is the Curriculum. Education in the Midst of COVID-19
When I was a young father fretting about whether I was doing all I could to advise and guide my children, a very wise man provided some sage advice. “If there’s one thing I know about young kids, it’s that they don’t listen to much of what you say, but they watch everything you do.” His point was that we teach through example. Our behaviour, the decisions we make and the principles that we rely upon to guide those decisions are what really matter. They are what impress and persist in the memory of learners.
That advice has withstood the test of time and, I’ve found, extended beyond parenthood to influence my perspectives on medical education. As factual information becomes more widely and easily accessible, medical students have less and less need for didactic teaching, but more and more need to understand how to manage that information and, importantly, how to “live the life” of a practicing physician. How decisions are made. How uncertainty is engaged. How stress and fatigue are managed. They’re watching, and they’re very astute observers.
All this has never been truer than during the current COVID-19 crisis.
The roles and routines of our students have been altered dramatically. In a short period of time, the first and second years have shifted from a curriculum featuring predominantly whole-class presentations, small group learning and regular clinical skills sessions with standardized and volunteer patients, to a remotely delivered curriculum that they’re accessing individually from their homes scattered across the country. Clinical Skills is being “parked”, to be made up when circumstances allow, in a manner not yet determined.
Our final year students have, fortunately, completed their clinical rotations and are also utilizing remote access to complete their curricular requirements. They are on schedule to graduate and enter their residencies July 1, but are facing adjustment and disappointment, with the cancellation of Convocation ceremonies, delay of the MCC Part 1 examination to some future date, no doubt after they start residency, and the uncertainty of what sort of hospital environment they will be engaging.
Perhaps the greatest impact has been on our third year class. About three weeks ago, we had to make the very difficult decision to suspend their clinical placements. This was not because of a lack of perceived value, but because the simple logistics of maintaining safe and educationally viable experiences in the face of the stresses currently being faced by our hospitals and faculty became insurmountable. For them, we are developing a completely original on-line, remotely delivered curriculum intended to provide learning that would normally have been undertaken in conjunction with their clinical placements. By doing so, we hope to be in a better position to complete their training within whatever time remains when clinical placements are eventually resumed.
How has all this been possible? Two simple answers: people and technology.
Our curricular leadership has taken on this unprecedented challenge with great creativity and tenacious dedication. Our newly appointed Assistant Dean Curriculum, Dr. Michelle Gibson, as well as Year Directors Drs. Lindsey Patterson, Andrea Guerin, Heather Murray, Susan Moffatt and Andrea Winthrop have all stepped up despite their own individual obligations at this time to develop and manage this transformation. Assistant Deans Hugh MacDonald (Admissions), Renee Fitzpatrick (Student Affairs) and Cherie Jones (Academic Affairs and Accreditation) have all overseen adjustments in their respective portfolios.
Our administrative staff has managed all this with dedication, a cooperative spirit and good humour. Although working remotely in compliance with university directives, they have managed to maintain excellent working relationships and communication.
All this has largely been made possible through technologic advancements that have been under steady development for the past few years. Zoom technology, in particular, is what makes remote educational delivery possible. Our faculty has engaged this with remarkable alacrity, even the technology-challenged (myself, for example). This past week, I was able to hold a virtual Town Hall with 76 members of the fourth year class, in which I was able to both update them about key issues and hear from them on a variety of topics.
It also makes it possible for our administrative staff to “get together” for daily meetings to ensure the curriculum is being delivered effectively, and all administrative aspects of the program are attended to.
Curricular Coordinators Tara Hartman, Tara Callaghan, Jane Gordon, Vanessa Thomas, Assessment Coordinator Amanda Consack, Educational Developers Theresa Suart, Eleni Katsoulas, Student Affairs Coordinator Erin Meyer, Standardized Patient Manager Eveline Semeniuk, Admissions Team Rachel Bauder and Kristin Baker, Facility Manager Jennifer Saunders, Student Support Assistants Dana Halliday and Jessica Griscti and UG Program Manager Jacqueline Findlay are all managing their areas of responsibility with great skill at this most difficult time.
What makes the technology possible is the remarkable skill and dedication of our IT support staff, headed by Peter MacNeil.
All this is certainly impressive and worthy of recognition but, it must be recognized, it is far too early to celebrate or claim any victory. This crisis is far from over. In the weeks and months ahead, there will no doubt be new, vexing challenges that come our way. It is nonetheless appropriate to pause and recognize the efforts being made by so many, and to take comfort in the knowledge that we have the capacity and dedication to engage change.
It’s also appropriate to consider some early lessons that are emerging.
Education continues. Even if there were no formal structures or sessions in place, our students are witnessing a unique event. Their training to date allows them insights they otherwise wouldn’t have. In essence, the crisis itself is the curriculum. They are observing and learning. Much of that learning will relate to how the medical community is engaging the crisis, both collectively and individually. As I was told so many years ago, it’s not what we say but what we do that will persist.
We’re adaptable. Problems that seemed insolvable a short time ago are being solved. Impenetrable barriers are being easily breached. We’re learning to do things we didn’t have either the motivation or inclination to learn previously. And it’s working.
Communication is critical. The need to communicate efficiently and clearly has never been more apparent, or critical. Technology has allowed this to happen and, thankfully, was available when needed.
Opportunities are emerging. Circumstances are causing us to engage issues that have previously been ignored because the solutions seemed too disruptive and risky. We’re now forced to take on those issues by necessity and are beginning, in some cases, to find that those misgivings were preventing us from engaging valuable alternatives. Case in point, the role and electives in medical education will require a re-thinking and re-imagining that’s been long overdue.
And, most importantly…
Medical Students belong in the clinical workplace. All the efforts to maintain formal education remotely are certainly of great value and allow us to ensure our students are progressing in their basic learning, but it does not substitute for active engagement in the workplace. Students themselves, all across the country are coming forward to provide what service they can. They are providing home support for busy clinicians. They are manning phone lines for Public Health. They are collecting valuable equipment for use in hospitals. They’re donating blood to address current shortages. Over and above all this altruistic volunteerism, it’s becoming increasingly clear that there are many very useful roles they can play within the clinical workplace. Every medical school in the country is working tirelessly to determine when they can re-enter safely and in a supportive learning environment. Unfortunately, that doesn’t seem imminent at the time of this writing.
Finally, it must be recognized that the students of today will be the leaders and front-line providers of whatever health care crises face our society in the future. We must not deny them the learning that this crisis provides. By “watching everything we do” and through active involvement, they will emerge better prepared to engage the challenges the future.
“If I can help somebody”. Two voices challenging our concept of diversity.
You can’t be in a hurry listening to a Mahalia Jackson song. Her voice captures your attention like a moth to a flame. She extends each lyric and note, drawing you irresistibly into the heart of the song. You have to wait for her. You want to wait. You can’t not wait.
Her voice is like a warm blanket on a cold winter night. A refuge from the busy and hectic world, a place where haste is no longer a virtue and we’re reminded of the value of slow, deliberate contemplation and search for deeper meaning in what’s transpiring around us.
One of her songs, in particular, came to mind as I recently read an article about a young man named Logan Boulet. Logan was born in Lethbridge Alberta in 1997, the second child of two teachers who decided to name him for the highest mountain in Canada. He was an active child with many, constantly evolving interests. He loved hockey and more than made up for average size and natural talent with dedication, intensity and commitment to his team. His work ethic bordered on the obsessive. He eventually came to play for the Humboldt Broncos of the Saskatchewan Junior Hockey League. Logan was one of 16 people killed April 6, 2018 when their team bus was struck by a loaded tractor trailer that failed to stop at a highway intersection near Armley, Saskatchewan. His father, who was driving 15 minutes behind the bus, was one of the first on the scene.
Four weeks earlier, Logan had signed his organ donor card. He did so in honour of a former trainer who had died at 58 of a cerebral hemorrhage and been an organ donor. Logan’s heart, lungs, liver, kidney, pancreas and corneas have all been successfully transplanted.
When asked a few weeks before by his father why he decided to sign the card, Logan replied:
“If I can help save six people, I’m gonna to do it”
When I read the article, his words stuck with me. In fact, I couldn’t shake it. I’d heard those words before. Turned out it was a Mahalia Jackson song entitled “If I can Help Somebody”.
Mahalia Jackson and Logan Boulet. Hard to imagine any two human beings whose life experiences were more different. Mahalia Jackson, two generations removed from former slaves, was born in New Orleans in 1911 and lived her childhood in a three room dwelling with 12 other people, including her mother, aunts, siblings and cousins, and the family dog. She was afflicted with congenital genu varum (bowed legs) which would have caused pain and physical limitations but didn’t stop her from dancing for the white ladies for whom her mother and aunt cleaned house. Her childhood was difficult, particularly after her mother died when she was five. There was no schooling, but there was church and, with it, singing. And how she loved to sing. She was courted by choirs and choirmasters particularly after she moved to Chicago at age 20. She went on to become one of the most celebrated gospel singers of all time, the first to sing at Carnegie Hall and at John F. Kennedy’s inaugural ball. In 1963, she sang before 250,000 people assembled to hear Martin Luther King’s “I Have a Dream” speech in Washington. Five years later, she would sing at his funeral. She was an important force in the civil rights movement, but also the subject of racial prejudice and herself the target of assassination attempts. Despite all this, she remained hopeful and never embittered. When asked about her choice of gospel music over more popular forms, she said, “I sing God’s music because it makes me feel free. It gives me hope”. She is also quoted as saying that she hoped her music could “break down some of the hate and fear that divide the white and black people in this country”.
The particular song that came to mind when I read about Logan goes as follows:
If I can help somebody, as I pass
If I can cheer somebody, with a word or song
If I can show somebody, that he’s travelling wrong
Then my living shall not be in vain
Mahalia Jackson and Logan Boulet. Two very different people. Different races, genders, generations, talents, interests, culture, environment. Poster children for our concept of “diversity”. It’s hard to imagine they would ever have had occasion to encounter each other, even if they weren’t so separated by space and time. And yet, they were linked by a common value and simple, human interest in doing what they could to help people around them. Linked in their values. Linked in their humanity. And so, perhaps not so diverse after all.
Here’s a link to that song. Give it a listen, but don’t be in a hurry.
Residency Match Day: 2020 What our students are experiencing, and how to help them get through it
Anticipation is the title of a memorable Carly Simon song that tends to come to mind this time of year. That’s probably because that simple word nicely describes the prevailing mood of our fourth year class. What they’re anticipating, of course, is the results of the CaRMS match, which will be released March 3rd.
The process by which learners transition from undergraduate to postgraduate medical education has evolved into a rather jarring and extremely stressful experience (a subject for another blog/rant). It has required them to not simply consider what specialties are best suited to their interests and skills, but engage an application process that requires strategic selection of elective experiences, preparation of voluminous documents, meeting multiple deadlines (twelve, no less), and commitment of personal time and expense to travel and interviewing which, for many, spans the country in the midst of the Canadian winter. And so, as you can easily imagine, there will not only be anticipation, but also anxiety leading up to the release.
By approximately 12:00:05 on March 3rd, our students will know which program they’ll be entering next July. For most (hopefully all), the anticipation will end with the exhilaration and satisfaction of having successfully overcome the process. For a few (and hopefully none), it will bring a realization that their efforts to date have not been successful, that this part of their journey is not yet over, and they have to begin again. They will be profoundly disappointed. They will be afraid. They will be confused. They will need the understanding and help of the faculty who are currently supervising their training, and much help from our Student Affairs staff.
This year, we are again prepared to provide all necessary supports, but there are a few changes to the process which I’d like to clarify for both students and the faculty that will be supervising them that day:
- Unlike previous years, our Undergraduate Office will not automatically receive match results the day before the full release. However, students have the option of directing CaRMS to release their results the day before (March 2nd) if they fail to match. They can do so by going into the CaRMS website and providing the appropriate permission.
- Any unmatched students who have
allowed early release will be contacted directly by myself to notify them of
the result. This is for three purposes:
- to arrange for release from clinical duties
- to allow the student some time to prepare for the release moment the following day when most of their classmates will be hearing positive results
- to arrange for the student to meet our student counselors who will provide personal support and begin the process for re-application through the second iteration of the residency match.
- Unmatched students who did not opt to provide early release will similarly be contacted and offered the same support and services after we get their results on match day.
- Because we may not have full information in advance, we have decided to release all students from clinical obligations beginning noon on match day, until the following morning.
I’d also like to remind all faculty supervising our fourth year students on or around match day to anticipate that your student will be distracted. Please ensure your student is able to review the results at noon. If you sense he or she is disappointed with the result, please be advised that the student counselors and myself are standing by that day to help any student deal with the situation and provide support.
Fortunately, we have an outstanding Student Affairs team which has been working hard to guide the students through the career exploration and match process, and will be standing by to provide support for match day and beyond.
Dr. Renee Fitzpatrick
Assistant, Student Affairs
The team can be accessed through our Student Affairs office email@example.com, or 613-533-6000 x78451.
Thanks for your consideration, and please feel free to get in touch with myself or any of the Student Affairs Team if you have questions or concerns about Match Day or beyond.
I leave you, and especially our fourth year soon-to-be colleagues, with the lyrics and sounds of Carly Simon’s “Anticipation”:
We can never know about the days to come
But we think about them anyway
And I wonder if I’m really with you now
Or just chasin’ after some finer day
Is makin’ me late
Is keepin’ me waitin’