Author: Anthony Sanfilippo
Silent Victims of the Pandemic
“Jean died last night.”
That was my first email message of the morning. It came from Jean’s daughter. Jean (not her real name) had been in hospital being treated for heart failure. She didn’t want to be in hospital, to be sure. It took her daughter, her family physician and I to convince her that she could no longer manage on her own, up most of the night sitting in her chair panting for breath, the skin of her swollen legs beginning to break down.
Although I wasn’t her attending cardiologist during this admission, I had treated her for many years and dropped by to visit with her the day before. Propped up in her high backed hospital chair with her feet elevated, she almost reluctantly admitted she was feeling a bit better. Her legs were clearly less edematous. But she didn’t think she was going to go home this time and that, she said, was OK. She had made her wishes clear to all. Her “comfort care” status was well documented.
Although in her late 80’s, Jean retained a perceptive intelligence and disdain for convention. Anything she didn’t approve of was quickly dismissed as “nonsense”. The word that immediately comes to mind to describe her is “feisty”.
She’d immigrated to Canada with her husband and infant daughter shortly after the second world war. They worked various jobs eventually opening and operating a successful small business . When her husband passed away, she operated the business, eventually turning it over to her daughter.
Jean had rheumatic fever in her youth which left her with valvular heart disease. In the early part of the twentieth century, rheumatic mitral stenosis was a major cause of morbidity and mortality in young women, resulting not only in heart failure but also stroke due to cardiac thrombi precipitated by the onset of atrial fibrillation, often during pregnancy. Many years ago, when she began to develop symptoms, Jean underwent a closed mitral commissurotomy. This was one of the first surgical approaches available. The surgeon would attempt to break the fusion of the mitral leaflets caused by the rheumatic inflammatory process, either with dilators or a finger passed across the valve.
This approach, which sounds rather crude to us today, was very effective in relieving symptoms and is the same basic approach used today with catheter based balloon valvuloplasty.
She did well for many years after the commissurotomy and even had a baby despite conventional medical wisdom at the time advising against pregnancy. Her mitral stenosis gradually progressed, and she went on to have a valve replacement with a mechanical prosthesis about 25 years ago. Over the years, she evolved varied and expected cardiac manifestations including atrial fibrillation, progressive aortic valve disease, coronary disease and, most recently, right-sided heart failure. She faced each challenge with grace and acceptance. As she said many times, she never expected to live to be an “old lady” and was grateful for whatever treatments were available to her. But, in recent years, she was quite clear that there would be no more interventions, catheterizations or surgeries. The goals of care were very clear: “I’ll take whatever pills you suggest, just keep me independent and out of hospital”.
And independent she was. In her own home until moving into a rather posh retirement complex a few years ago. I attended a reception in her honour organized by her daughter and friends for her 85th birthday. She was the epitome of charm, holding court like a duchess at a ball.
Her daughter’s message was accompanied by a request to call. She let me know how very important it was that she was able to visit with her mother the evening before she passed away. Given the pandemic restrictions, what they both feared most about the hospitalization was the separation from each other. This, no doubt, was the main reason they delayed so long in asking for help. However, the medical and nursing staff went out of their way to make arrangements for them to see each other. She asked me to express how important this was to them and to pass along their gratitude, which was one of the motivations for this article. What may have seemed to be a small act of kindness was highly meaningful.
The other objective of this article is to highlight the impact this pandemic is having on management of chronic disease and end-of-life care. Jean’s reluctance to come to hospital despite a clear need for help is typical of many patients suffering from cardiac and other chronic diseases.
A recent article examining emergency room visits for acute heart failure found a 43.5% reduction in 2020 compared to the previous year, and a 39.3% reduction in hospital admissions (Frankfurter et al. Can J Cardiol 2020;36:1680).
The authors conclude with this important observation:
“The precipitous decline observed in ADHF (acute decompensated heart failure)-related ED visits and hospitalizations raises the timely question of how these patients are managing beyond the acute-care setting and reinforces the need for broad public education on the continued availability and safety of emergency services throughout the COVID-19 pandemic.”
This issue is not limited to heart failure patients. In fact, while preparing this article, I was contacted by another patient with known multi-vessel coronary artery disease and previous myocardial injury who was awaiting much needed surgical intervention. He’d been experiencing chest pain for two hours and was calling to ask whether it was “safe” to go to the emergency department. He’s now being admitted awaiting surgery while being treated for his unstable ischemic syndrome.
In an examination of patients with coronary artery disease presentations, Natarajan et al (Canadian Journal of Cardiology Open 2020: 678e683) reported both lower rates of myocardial infarction and delays to coronary angiography in 2020 compared with the previous year.
Clearly, the coronavirus has not reduced the prevalence of either heart failure or coronary disease. It has, however, imposed barriers to access. Although we do not yet have precise information as to the nature of these barriers, it’s apparent that each step along the path from initial symptom assessment to final treatment is made more difficult by necessary pandemic precautions, and that patients, advised strongly to isolate, are understandably more fearful about venturing into emergency departments and diagnostic facilities.
And so, the accounts of these two patients have much to teach us.
It’s important to remember that, even during a terrible pandemic, most of the patients we’re treating do not have COVID-19. Most of them are suffering from the same medical and surgical conditions they’ve always had, and these diseases don’t wait for the pandemic to pass. However, the pandemic does impose barriers to their ability and/or willingness to access care. As the medical and public health communities message the public about the need to adhere to all the preventive measures, it’s important also emphasize the importance of continuing to manage all health concerns and work to diminish access barriers wherever possible.
As always, our patients are our greatest teachers. Jean taught me and the countless learners she was always pleased to engage along the way much about the natural history, features and available treatments for rheumatic heart disease. That’s a legacy that will benefit many future patients. For that, she deserves our gratitude, and the kindness shown her during her final admission seems well earned.
I will miss her.
Lessons in Diversity and Inclusion: The Legacy of Joey Moss
Joey Moss, by all accounts, achieved his dream job. He was an avid hockey fan who became locker room attendant for the Edmonton Oilers. The Oilers, it must be understood, are not just any hockey team. They were Mr. Moss’s favourite team and personal passion. During the 1980s, they were phenomenally successful, winning no fewer than five championships.
As a locker room attendant, he will have had a variety of tasks, including organizing equipment, looking after needs of players during games and generally bringing some order to the chaos that ensues when 20 or so young athletes are engaged in a fast-paced, high-pressure sport.
Mr. Moss, who was born with Down Syndrome, passed away last week. It appears, based on numerous testimonials that have come forward since his death, that his influence extended well beyond his designated tasks. His unrelenting good humour, infectious enthusiasm and continual encouragement of the players brought value far beyond his assigned duties. Wayne Gretzky, a star member of those teams, summed it up nicely when, upon hearing of Mr. Moss’s passing said simply “He made our lives better”.
Mr. Gretzky was, in fact, instrumental in bringing Mr. Moss to the attention of the hockey club. The two met when Gretzky became acquainted with Moss’s sister. Gretzky, at that time, was in the ascendancy of a career that was to eventually define him arguably (and these things are always arguable) as the greatest hockey player of all time. He arranged the introduction, but it was Mr. Moss’s work ethic, dedication and attitude that made him such a fixture and success with the team.
How did all this come about? What motivates a rising star and celebrity to go the trouble to advocate for someone they’ve just met? Gretzky is not known to be a comfortable public figure nor a vocal advocate for social change. At that time, he was a young man adapting to celebrity in a large city. He’d been born and raised Brantford, a town in southwestern Ontario best known (pre-Gretzky) as the birthplace of the telephone. His father Walter worked for Bell Canada and, together with wife Phyllis, taught their five children lessons of life and hockey in their busy home and on the ice rinks installed annually on their lawn. Those lessons, one might imagine, involved how to relate to the people in one’s community and a responsibility to help those in need when the opportunity presented itself. In advocating for Mr. Moss, it appears Gretzky was perceiving and responding to such an opportunity. What he did was not about publicity or self-promotion. It was something personal, a selfless act of kindness.
The struggle for inclusion and acceptance of diversity will not be won solely by legislation, public campaigns or vitriolic dialogue. It will be won through individual encounters that challenge assumptions and dispel fears. Mr. Gretzky and Mr. Moss did not set out to convince a team of young athletes, a business organization, a city or a nation that a person who looked different and was considered disabled could make a valuable contribution. And yet, that’s what they did, all beginning with a chance encounter and simple act of kindness. Indeed, making lives better.
Imagining the Post-Pandemic University: What COVID-19 is telling us about young people and higher education.
Like any species that migrates annually in search of a more nurturing habitat, young people around the world have, for centuries, left their homes in the late summer to attend university or college. For the vast majority, this has meant moving to another city and, for the first time, separating from family, friends and familiar surroundings.
The presumed primary reason for this migration has been to seek advanced education in order to pursue interests and prepare for chosen careers. A second purpose, less overtly expressed, is to further personal independence. Over the years, those two purposes have been intimately interwoven. Moving away, for the vast majority, was an indisputable requirement of advanced education. For some it has been seen as difficult and a major personal hurdle. For others, it is welcome and long overdue. For virtually all, it has been seen as necessary, beyond personal choice or preference.
COVID-19 has changed all that. Because of the massive shift to alternative forms of curricular delivery required by the pandemic, most (all but those in programs where personal attendance is considered essential) have been provided a choice. They are, for the first time, able to continue their studies whether or not they move to the community in which their learning institution is located. By making personal attendance optional, COVID-19 has provided a fascinating natural experiment. What have we observed?
Here at Queen’s, about 1,900 students have returned to university residences, despite the fact that only a small minority of them need to be on campus to engage any part of their curriculum. In addition, the Office of the University Registrar estimates that a further 8,600 students have moved to local Kingston accommodations. Although exact figures aren’t available, a reasonable guess would be that about 1,000 of these are required to do so to engage required in-person curriculum. It’s therefore reasonable to estimate that over 9,000 young people have chosen to move to Kingston to take up their education even though it has been deemed pedagogically unnecessary for them to do so by those overseeing their programs.
We also know that there is historical experience to support the desire of students to move away from home to pursue their education even if it isn’t essential to do so. Young people who happen to live in communities that house excellent institutions of higher learning will very often choose to move away for the “university experience”. Even those who remain in the same city will often choose to “move out”, seeking separate accommodations away from home.
All this should, of course, come as no surprise. It’s all part of the process of normal human development. 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. For that environment to fully meet the needs of students, it must allow them to interact, both passively and actively, with other young people and with teachers with differing life experiences and perspective who can challenge assumptions and promote new thought during this critical developmental phase. Much of those encounters are passive and unanticipated, occurring in various social contexts, small and large.
And so, the “education” that young people seek by leaving home and moving to universities isn’t simply limited to the acquisition of new knowledge or qualifications. They’re also seeking, and very much need, an environment where their personal development can continue to grow and expand. The “social” components of university life, the “partying” so troubling to many, are not simply troublesome indulgences. They are very much part of the overall growth/educational experience.
The 9,000 or so young people moving back to Kingston this month are basically “voting with their feet” in stating what’s important to them, and what they’re seeking at this point in their lives. As they return, their integration into the community given the threats of COVID has never been more difficult or potentially divisive. Their presence brings an understandable degree of fear. Although their return has been rather muted compared to previous years, many social behaviours previously easily tolerated are now considered unacceptable and, on occasion, infringements of new public health requirements.
Given all this, what are the implications for universities and colleges once the stresses and problems of the pandemic are finally resolved and we are able to resume “normal” operations? If they wish to remain relevant and attractive to young people, what lessons are they to take forward in considering their post-COVID world? I offer a few (very personal) perspectives.
- The concept of university education being defined by rigid schedules and classrooms of defined capacity should now be considered antiquated and obsolete. The educational adaptations to COVID have shown rather conclusively that the transmission and learning of information and fundamental knowledge can be accomplished quite well without these time-honoured constructs, vestiges of early childhood education.
- We are also learning that higher level teaching about integrative or complex concepts, knowledge application and simple exchanges of thought between learner and teacher are clearly not fully accomplished through computer interfaces. The absence of personal interaction lessens the educational experience, for both learner and teacher. To be truly a community of higher learning, universities must find effective ways for students and teachers to interact, at the right times, and for the right reasons.
- Behaviour has to be interpreted realistically. Expecting young people to not socialize is like expecting a fish not to swim. It’s in their nature. It’s how they navigate the world. Expecting that they won’t be overly boisterous from time to time is like expecting a puppy to be placid and stationary. Socializing is not inherently evil but rather a necessary part of development. In young adults who may be somewhat lacking in both experience and judgement, borderline behaviour is an inevitable consequence. This is not to say that anti-social or criminal behaviour should be condoned. Far from it. It should be condemned in the strongest terms. But our condemnation should consider whether there was intent to do harm, be directed at the behaviour and not the individual, and should reflect support, understanding and efforts to educate.
The campus of the future should reflect these lessons learned. The ability to deliver foundational information and basic knowledge more efficiently and flexibly through various remote interfaces shouldn’t be seen as a temporary bridge back to “normal” but rather the beginning of new and promising innovations. Technologies for remote delivery should be embraced and enhanced. At the same time, the critical importance of personal interactions between teachers and learners for higher level teaching of core concepts, knowledge application and exchange of ideas merits preservation and emphasis. The development of creative and effective ways to enhance such exchanges, using both traditional and innovative formats warrants encouragement and support. Finally, the university environment should recognize the critical requirement of young people to socialize and allow them to do so in a safe and responsible manner. Campuses that evolve from being collections of buildings and rooms accessed according to rigid schedules, to more open communities where learning is a more natural lived experience will better meet the needs of students and find themselves in high demand.
The pandemic is, along with many troubling challenges, also providing valuable insights and opportunities. We should learn from this natural experiment playing out around us. We should aspire to more than to simply return to “normal”.
I’m very grateful to Stuart Pinchin, University Registrar, for his assistance in the preparation of this article.
Opinions expressed in this article are those of the author.
A Quirky, Unique and Heartfelt Welcome to Meds 2024
Everything is different during a pandemic. Last week’s orientation events for our first-year students proved to be no exception. In fact, I on the first day I found myself standing alone in large hall speaking to a medical school class and their families, none of whom I could see.
To explain, the Orientation Week usually starts off with a gathering of the entire class in the main lecture hall of the School of Medicine Building with a series of welcomes and presentations. I’ve always found it a particular pleasure to meet the newly gathered class for the first time and share in their enthusiasm and excitement. Because of pandemic restrictions, we had decided some time ago to hold the first session in Grant Hall, with the hope that we’d be able to bring the entire group together in a large venue that could provide appropriate social distancing. Since the hall was updated over the summer with appropriate audiovisual capacity for large class use during the semester, that seemed like a reasonable idea. Alas, the escalating requirements necessitated by the changing characteristics of the pandemic made that impossible. Nonetheless, we felt we could still use that space as a base for the presentations and livestreaming to family members (a pandemic bonus!). When we arrived Monday morning for what would prove to be the first such session from that site, we found that the set up was such that the speaker could only be seen by viewers by standing not on the stage, which would provide scale and an academically appropriate backdrop, but from the floor.
And so, I found myself a small figure in a large space speaking to people I couldn’t see. Fortunately, I wasn’t completely alone. I was followed by Dr. Renee Fitzpatrick, Assistant Dean Student Affairs, Mr. Anthony Li, Aesculapian Society President and finally Dr. Jane Philpott, our new Dean who delivered an inspiring address about the privilege and responsibilities of a medical career. Many thanks to our MedsVC team, and Bill Deadman in particular, for very capable assistance and guidance through all this.
This year’s group consists of 107 students, drawn from an applicant pool of over 5500. They come all regions of our country and backgrounds. One hundred and seven individual paths leading to a common goal that they will now share for the next four years. Sixty-two of them have completed undergraduate degrees, 27 have Masters degrees, and three have received PhDs
They hail from no fewer than 47 communities spanning the breadth and width of Canada:
They have attended a variety of universities and undertaken an impressive diversity of educational programs prior to medical school:
An academically diverse and very qualified group, to be sure. Last week, they undertook a variety of orientation activities organized by both faculty and their upper year colleagues. They were called upon to demonstrate commitment to their studies, their profession and their future patients. They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers.
Over the course of the week, they met a number of curricular leaders, including Drs. Lindsey Patterson and Laura Milne. They were also introduced by Dr. Fitzpatrick to our excellent learner support team, including Drs. Martin Ten Hove, Jason Franklin, Mike McMullen, Josh Lakoff, Erin Beattie, Lauren Badalato and Susan MacDonald who oriented them to the Learner Wellness, Career Counseling and Academic Support services that will be provided throughout their years with us. They met members of our superb administrative and educational support teams led by Jacqueline Findlay.
They attended an excellent session on inclusion and challenges within the learning environment, organized by third year student Chalani Ranasinghe supported by Drs. Mala Joneja and Renee Fitzpatrick. Stephanie Simpson, University Advisor on Equity and Human Rights, provided a thought-provoking and challenging presentation intended to raise self-awareness regarding diversity and inclusion issues. This was followed by a very informative dialogue from a panel of upper year students (Nabil Hawaa, Sabreena Lawal, Andrew Lee and Ayla Raabis) who provided candid and very useful insights to their first-year colleagues.
On Thursday, the practical aspects of curriculum, expectations of conduct and promotions were explained by Drs. Renee Fitzpatrick, Cherie Jones and Lindsey Patterson.
Dr. Susan Moffatt organized and coordinated the very popular and much appreciated “Pearls of Wisdom” session, where fourth year students nominate and introduce faculty members who have been particularly impactful in their education and invited them to pass on a few words of advice to the new students. This year, Drs. Peter Bryson, Casi Cabrera, Bob Connelly, Jay Engel, Chris Frank, Debra Hamer, Nazik Hammad, Mala Joneja, Michelle Gibson, and Narendra Singh were selected for this honour.
Their Meds 2021 upper year colleagues, led by Miriam Maes, welcomed them with a number of (generally virtual) events. A highlight included the always popular distribution of backpacks, this year in brilliant school-bus-yellow (the group is already becoming knows as “the Hive”). Thanks to Molly Cowls (Meds 2024) for sharing this collage.
For all these arrangements, skillfully coordinated, I’m very grateful to Erin Meyer and Hayley Morgenstern of our Student Affairs team.
I’m also grateful to Erin for not allowing the first years to be deprived of the traditional Orientation Week group picture which, this year, required some creativity and extra effort:
I invite you to join me in welcoming these new members of our school and medical community. Their first week be long remembered for the most unique in the history of our school, and hopefully also for the commitment, persistence and adaptability of all involved.
This is Not Normal. Let’s Not Get Used to it.
We are growing accustomed to the sight of people wearing masks in public.
We are growing accustomed to maintaining a distance between ourselves and others.
We are becoming wary, even fearful, of personal contact.
We are no longer expecting that we will be able to celebrate accomplishments or significant events in large gatherings.
We are growing accustomed to not assembling to grieve the loss of friends or loved ones.
We are accepting the need to interact with our patients through remote interfaces.
All this is necessary given our current circumstances. These measures deserve and require our support. We may even be coming to regard many of these changes as beneficial, efficient, a “new normal” in how we engage our professional and casual relationships.
But they are not desirable. They are not virtuous. They come with a price.
Nelson Mandela, who learned a thing or two about isolation during his 27 years of imprisonment on Robben Island, is quoted as saying “Nothing is more dehumanizing than isolation from human companionship”. Although our restrictions may seem like trifling inconveniences in comparison to his experience, the parallel is valid.
Personal relationships require personal contact. An image on a screen can never convey the same meaning or depth of understanding. The concept of caring or concern for another person cannot fully be expressed or understood remotely. Learning how to encounter, assess and care for a person in need can only be accomplished through individual, personal contact.
Beyond these individual considerations, our social structure is built on the concept of “community”. Communities can be defined in purely geographic terms as a group of people inhabiting the same location. The deeper and more significant meaning relates to the commonality of values, attitudes and goals. Communities, in short, are made up of people who share certain understandings of how they wish to live and what they hope to accomplish collectively. Community requires its members to be accepting and concerned about each, which can only come through personal interaction.
The education of its young people is, by any measure, a defining characteristic of a community.
The very word “education” has etymological roots that are both interesting and revealing. It evidently derives from the Latin “educo”, roughly translated “I lead forth” or “I raise up”. “Educatio” is “a breeding; a bringing up; a rearing”. The definition that I prefer is simpler and more consistent with the origin and intent of the process; “an enlightening experience”.
Facts and information can be learned in isolation. True education requires contact with teachers, mentors and, in the case of medical education, patients.
A community without social interaction and personal exchanges is not a community. A society without healthy and vibrant communities is not a society.
Getting back to Mandela, the remarkable thing is not that he survived 27 years of social isolation, but that he emerged from it all not embittered but with an even greater sense of purpose and understanding. The quote cited above continues as follows…“there I had time to just sit for hours and think.”
Let’s hope we emerge from our own prisons soon, a little more appreciative of what we are sacrificing, and a little more enlightened.
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.