Author: Anthony Sanfilippo
Introducing Queen’s Meds 2017
One of the special benefits of working in a university environment is the sense of renewal that comes each fall with the entry of new students. This week we welcome members of Meds 2017, the 159th class to enter the study of Medicine at Queen’s since the school opened its doors in 1854.
A few facts about our new colleagues:
They were selected from the largest applicant pool in recent memory – 3818 highly qualified students submitted applications last spring.
Their average age is 23 with a range of 20 to 36 years. Fifty-seven percent of the class are women.
They hail from no fewer than 49 communities across Canada, including Abbotsford, Ajax, Ancaster, Ariss, Barrie, Bedford, Brampton. Brockville, Burlington (3 students), Calgary (2), Coquitlam, Delta, Edmonton, Etobicoke, Hamilton, Inverary, Kamloops, Kingston (5), Kitchener, London (4), Maple, Markham (9), Mississauga (6), Montreal, North York (2), Ottawa (4), Owen Sound, Palgrave, Peterborough (2), Pickering, Puslinch, Richmond Hill (2), Scarborough, Stittsville, Thornhill (2), Tillsonburg, Toronto (19), Upper Island Cove, Shrewsbury, Vancouver (2), Vaughan, Waterloo, West Vancouver, Whitby (3), Windsor, Winnipeg, Woodbridge (2) and Yarmouth.
Ninety of our new students have completed an Undergraduate degree, and 27 have postgraduate degrees, including 4 PhDs. The average grade point average achieved by these students in their pre-medical studies was 3.82. Their undergraduate universities and degree programs are listed in the tables below:
Undergraduate Degree Programs
Postgraduate Degree Programs
An eclectic and academically very qualified group, to be sure. This week they will undertake a variety of orientation activities organized by both faculty and their upper year colleagues. At their welcoming session they were called upon to demonstrate commitment to their studies, their profession and their 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. I invite you to join me in welcoming these new members of our school and medical community.
Remembering three great mentors and teachers
Over the past few months, our faculty and medical school have lost three people who made tremendous contributions over the course of their careers. Peter Munt, Robert Hudson, and Ed Yendt were all master clinicians, leaders in our medical community and contributors to our understanding of illness and disease. They were also gifted teachers and mentors who were always willing and eager to pass on their wisdom. As we approach the beginning of another academic year and are about to welcome a new class of medical students, it seems appropriate to reflect on the lessons and legacies that they’ve so ably provided.
Dr. Peter Munt was recruited to Queen’s after postgraduate training in Respiratory Medicine to head the newly formed Division of Respirology and Critical Care Medicine. He went on to head the Department of Medicine through a time of tremendous transition, and then became Chief of Staff at KGH. As his medical resident many years ago, I recall caring for a patient with a pulmonary infection eventually traced to a rather novel organism. Not content to simply identify and treat the infection, he encouraged me to identify the source and explore for any patients who may have suffered from similar infections. By doing so and documenting the results of our search, we were able to contribute to the care of many more patients, and raise awareness among other physicians of a little appreciated source of infection. Moreover, he taught me and my fellow residents the importance of pursuing root causes and the value of documentation and publication in disseminating knowledge. His career, both as a physician and administrator, was characterized by this quality of uncompromising attention to all facets of an issue, and unwillingness to accept the expedient solution.
Dr. Bob Hudson was head of our Division of Endocrinology for many years. In addition to his clinical responsibilities, he maintained a very active research career making important contributions to the understanding of androgen function. I’ll remember him for his dedication to physical examination and bedside teaching. His ward rounds were highly valued by housestaff. Not content with mere identification and demonstration of physical findings, Dr. Hudson challenged us to understand the underlying cause and pathogenesis. “So I agree this patient has exophthalmos” he would concede, but always follow with something like “but why do patients with thyroid disease develop this finding? What’s the mechanism?” His great skill was to help the learner work his or her own way through the problem without intimidation or belittlement. In fact, you emerged from these sessions not simply knowing something about a particular finding, but with a mechanism that could be applied to a variety of findings and conditions.
Dr. Ed Yendt had already developed a reputation as a leading specialist in calcium disorders by the time he was recruited to Queen’s to head the Department of Medicine. He led that department through a period of rapid growth, and development of many of the subspecialty divisions. He continued to do basic research through his career, becoming an internationally recognized expert in osteoporosis. Always a dedicated clinician, he continued to see patients long after usual retirement age and long after financial considerations provided any motivation. He was the embodiment of what we would today refer to as “translational” or “bench to bedside” research. I had opportunity to talk to him on numerous occasions in recent years, and was continually impressed at his knowledge of recent literature and eagerness to apply new findings to his patients. He was intrigued by patients with unusual presentations or responses to therapy, and continually used those experiences to learn more and apply that knowledge. He never lost his excitement for discovery or dedication to patient care.
Three great teachers, three different styles, but all sharing an insatiable curiosity, dedication to advancing the science of medicine, and to applying that science to their first concern – the care of their patients. Their families might find some solace in the knowledge that those lessons are not lost and that their examples and teaching will continue to inspire our students and those currently charged with their learning.
Mentoring – a “win-win-win” proposition
What do practicing physicians remember about their medical school experience? What do they feel had the greatest impact on their development? What do they retain? My guess, based on many reunions and even more conversations with graduates, is that it’s not the classes, labs or examinations, but rather the faculty they encountered along the way. Of course we all remember the “characters” and the “larger than life” personalities that populate every medical school, but it’s those faculty with whom we were fortunate enough to develop a personal, one-on-one relationship that have the most enduring and significant impact on our development as physicians, and on our personal lives. We call such folk “Mentors”.
The derivation of the word “mentor” is interesting. The origin is Greek and is traced to Homer’s Odyssey. Mentes was a wise and valued friend of Odysseus to whom he entrusted the education of his son Telemachus when he set out on his epic voyage. The elements of wisdom and trust are therefore intertwined in the term, qualities obviously central to the role as we understand it today.
The value of mentorship is well known in all facets of professional education. It’s this realization that leads many schools and departments to deliberately develop programs designed to promote these mentoring relationships. At Queen’s, we have developed a program that assigns a mixture of students from all years in groups led by two faculty members. Like all such programs, much depends on the specific and usually unpredictable “chemistry” that develops among the group. When it works (and it usually does) the relationships that emerge are highly rewarding. Below I provide testimonials from two students and one faculty member regarding their mentorship experience that may provide some insights.
In a 1973 article “Indoctrination of the Medical Student” Dr. Vilter pointed out that turning a new, eager medical student into a competent, caring physician takes more than just training in science, more even than just training in science and clinical skills. The mentorship program at Queen’s has been a special part of my indoctrination to the profession. Our group’s main goal is to have fun in a relaxed way but I am always surprised at the impact of these casual interactions. Whether it be a night of bowling, an intense night of trivia or a simple evening over shared drinks and food, I always leave more energized and excited about what’s to come.
When a clerk in your mentorship group gives you a tip for the wards next year, you don’t forget. When the fourth year students graduate, you celebrate with them and picture yourself walking across the stage in a few years’ time. When a mentorship group leader encourages you to dream big, you might just.
And a few more interesting links that I have come across about mentorship in medicine:
Trivia…or is it? – this is a link to a post on my blog about trivia night earlier this year
Being a Mentor for Undergraduate medical Students Enhances Personal and Professional Development
Mentoring Programs for Medical Students- a review of the literature
Informal Mentoring Between Faculty and Medical Students
The Queen’s Medicine Mentorship Program has provided me the opportunity to have informal interaction and communication with Queen’s faculty and residents that I wouldn’t be able to experience anywhere else. In the hospital or after a lecture, it is hard to just walk up to a physician to inquire about what they enjoy about their profession or how they balance their personal lives with their work. Through the mentorship program, I have been able to build relationships with faculty and residents in a more relaxed atmosphere that is conducive to conversations about one’s future directions in medicine. Additionally, the mentorship program has also increased that sense of Queen’s community for me. As a pre-clerkship medical student, it can be intimidating to enter the hospital during your first clinical experiences. With something like the mentorship program in place, you begin to see the quality of physicians we have here at Queen’s and the encouraging, open teaching environment that they create. Ultimately, this interaction and positive community that the mentorship program has created for me has contributed to my learning and career exploration as a Queen’s medical student.
It is About Mentorship
Being a mentor in the mentorship program has been one of the most exciting aspects of being on faculty at Queen’s. At my mentorship group’s last meeting, we had breakfast. For our group, breakfast was a good time to get everyone together without the distractions that can happen with an evening out.
One of the first year students asked if we should have an agenda for the meeting, but the senior students just laughed. The agenda is always the same. I ask the senior students: “what is cool in what you are doing right now”? They answer, in the usual spectrum of experiences, and the junior students say: “wow, how do I get to do that”! That is mentorship in action.
While I enjoy checking in with all the students to see what is cool or if they are struggling, I think the students would rather hear from their near peers. I see our relationships not so much as a vertical structure, but a horizontal one. The clerk explains how to get an elective to the second year student. The second year student describes the observership program as a kind of “back stage pass” to the first year student.
Our group has enjoyed the group events and while I couldn’t make the “Great Mentorship Race & BBQ” in the park this spring, our group was well represented. Over the years we have had fun with Guitar Hero, and had pot luck suppers (which means that everyone has some food that they can surely eat without looking into all the dietary restrictions).
At the Convocation in May, I enjoyed meeting the family of one of my mentees. He said: “Dad, this is Dr. O’Neill, I beat him at guitar hero the second month of medical school. You couldn’t believe it when I told you we were playing guitar hero in his basement. I smoked him at guitar hero. In spite of that, three years later he taught me how to deliver a baby.”
In the years to come, memories of delivering a baby might fade in this future internist, but I will bet he will remember beating me at guitar hero. He may never know that I let him win.
And so it seems mentoring is truly a “win-win-win” proposition, benefiting both parties involved, as well as our school, which is becoming known for the value we place on faculty-student interactions at many levels. We’re always looking for more faculty willing to become involved in this program. If you’re interested, or simply wish to learn more about it, feel free to contact myself, Peter O’Neill or Erin Meyer in the UG office who coordinates the program. Erin can be reached at firstname.lastname@example.org.
Student Directed Learning ”Everything old is new again”
My undergraduate education was enlivened by a number of professors who were fond of taking rather unconventional points of view, many of which would be considered “politically incorrect” in today’s parlance. They were even fonder of defending those perspectives with spirited and colourful debate. Perhaps the leading proponent of this approach was Dr. Tony Travill, professor of Anatomy, who would spend more of his curricular time discussing points of professional practice and social foibles than the assigned topics of embryology or anatomy. On the rare occasion that one of us mustered the temerity to point this out, he would make the rather emphatic point that “universities aren’t centres of teaching, they’re centres of learning”. The message was clear – it wasn’t his business to teach so much as it was our responsibility to learn. Our goal should be to learn for the benefit of our future patients, not simply to satisfy curricular goals. I recognize in retrospect that his not-to-subtle shift of emphasis helped us to transition from being passive consumers of information to what today’s educational theorists would term “active learners”, although we had no idea this was happening at the time.
Turing our attention to the present, one of our 2015 students, Eve Purdy, spoke eloquently at the recent Celebration of Teaching Day of how she addressed her interest in the process of clinical decision-making. She searched the internet and came upon a free web-based seminar series from the University of California (San Francisco) that she accessed over several weeks and found quite useful. She shared the information with others, both students and faculty who also made use of this resource. As teaching faculty, we should take considerable comfort in the fact that our students are, on their own, seeking opportunities to advance their learning, often going beyond the baseline requirements of our curriculum.
In fact, our students make use of a wide variety of unstructured learning opportunities in addition to standard curricular offerings such as Courses, Integrated Learning Streams, various types of Small Group Learning, clinical rotations and assigned projects.
Last academic year, about 20 Student Interest Groups were active, each developing a series of at least 8 learning sessions outside standard curricular time that were devoted to a particular discipline or theme. Although supported by faculty on a voluntary basis, students developed the themes and content of these sessions. The following is a list of some of the groups that were active this past academic year:
In addition, our students informally access the world of information available to them through the internet and social media. A world of information is literally at their fingertips, and they make use of this almost continuously, both to search information and to dialogue with each other, with faculty (sometime during lectures), and people farther afield. The challenge is not access, but rather discernment of relative value.
Perhaps the most powerful non-curricular learning experience our students engage is what’s been termed the Hidden Curriculum. This term refers to all of the unintentional but incredibly powerful messaging that occurs in the context of their environment and clinical experiences. Observing a respectful and effective interaction between an attending physician and nursing staff provides a much more effective and durable lesson than hours of formal teaching on the topic of professionalism.
The challenge for teaching faculty in the midst of all this is to keep pace what’s happening around us, and to shift our focus from delivering content to guiding the learning process. To borrow an old adage – we can’t control the wind, we can only set our sails. In this environment, it becomes more important to set the objectives and provide direction than to attempt to rigidly control the process.
And so, as the song says “Everything old is new again” when it comes to student directed learning in medical education, although technical advances and connectivity expand the potential (and our challenge) tremendously. I like to think Dr. Travill would be amused.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
“The Light Who Pursues Kindness”
Each year, our graduating class is asked to nominate a member to speak on their behalf at the Convocation ceremony. Last week, Alex Summers delivered an address he entitled “The Light Who Pursues Kindness” on behalf of the Meds 2013 class. It was clear to me and to many other faculty attending that Alex’s words deserved a broader audience and so, with his permission, I am providing the complete and unaltered text of his address below. Alex’s words require no editorializing on my part, but I would simply say that all who are involved in our school in any way, be it teaching, leadership, administration or support, should take justifiable pride that our graduates should feel this way about their careers, to date and beyond. In the midst of the day-to-day challenges we all face, Alex’s words reaffirm the faith that what we do is worthwhile, and we must be doing something right. And so, the words of Dr. Summers:Mr. Chancellor, Principal, Rector, ladies and gentlemen; Let me get started by taking you back to the spring of 1885 with some words borrowed from a day just like today: “Medicine is a liberal profession, requiring culture and knowledge and skill. It is not a trade for money making, nor a field for vaulting ambition. The physician’s object is to combat disease; he is, therefore, the servant of the suffering.” Those are the words of George Spankie, Queen’s Medicine 1885, spoken during his convocation address. Since the fall of 1854, medical students have trained here at Queen’s. Trained, and despite all the doubts, graduated too. And today, it’s our turn to cross this stage. We’ve been done for almost a month, but I know many of us have been resisting the urge to call each other doctor, for as we know from last week’s hockey game, it isn’t over till it’s over. Unless you’re the Senators of course; even Alfie says it’s over. But be re-assured folks, I think we’ve made it. My hope today is to quote the collective voice of the Class of 2013, an outstanding group of people for whom my respect and admiration has grown daily since September 2009. To my classmates, may the words I speak for you today echo your thoughts, and may the words I speak to you have value and meaning. For the wisdom imparted, the memories shared, the friendship and support, and for the humbling privilege to stand here today, thank you. The medical school journey is not one that is walked alone. It is only through the support of so many that we have achieved what we have achieved. To the staff of the UGME, thank you for tireless efforts on our behalf. To the faculty, we are grateful to you for so many things, but most especially for the examples of professionalism and excellence that you have modeled for us. Queen’s, in my overtly biased opinion, is a remarkable place, and it is so because of its people. Leonard Brockington, Rector of Queen’s from 1947 to 1966 (and the last non-student rector), said that this university was “…an example of the personal and national good that springs from intimate association between devoted teachers and eager learners.” That sentiment still holds true. Thank you for your commitment to us, and to Queen’s.
And to our families and friends, words simply are not enough. Our gratitude for your support, encouragement, and love, cannot be adequately conveyed from a stage. To all of you, may the lives we have lived thus far, and the lives we will lead from this day on make you proud, and be our most sincere expression of thanks. I last addressed a graduating class in June 2002. I was fourteen years old, and it was the graduation ceremony for Grade 9 students at Montgomery Junior High School in Calgary. I do not remember one word of my speech. But I remember what followed. With spiky fluorescently dyed hair and skater shoes to accent the dress pants, Cassie, David, Terry and Cam came to the stage to play, you guessed it, the convocation classic Good Riddance, aka Time of Your Life, by the punk rock band Green Day. It was a beautiful rendition of that four-chord tune, and I even think David, the guitar player, managed to slip in that little four-letter word that follows the second prematurely attenuated guitar lick. At the time, there was no better articulation of our feelings and hopes. The words were simple and the band was cool, and it was our anthem. Today however, 11 years later, would that song still cut it? Would it still capture the significance of a day like today? Of course not. Certainly, part of today is very much about remembering the last four years. But that’s not it. That song doesn’t cut it because today is only so much about yesterday. Today is about tomorrow. Not only does the university acknowledge today four years of effort by bestowing upon us this degree, in accepting that degree we answer, with humility and respect, a call. We accept a profound responsibility; a social contract between us and our neighbours. As we begin to feel the weight of that responsibility, it is good to once more reflect upon what exactly we have been called to do. In my first year of medical school, under the guidance of Dr Duffin, I had the opportunity to learn about Dr Norman Bethune. For a man long dead, he has made a transformational impact on my understanding of what it means to be a physician. A Canadian physician of overwhelming humanitarianism and global compassion, he plied his trade across the globe, believing there was “code of fundamental morality and justice between medicine and the people.” He died in 1939 in rural China, and is remembered in that country as a hero for his selflessness and sacrifice. His name amongst the Chinese is Bai Qiu En – The Light Who Pursues Kindness.
I love that. And I find purpose and inspiration in the idea that we too can be, and should be, lights who bring and share kindness in the darkest hours of human suffering. As we go from here, we tread in the footsteps of giants like Norman Bethune and others – just look around this stage. As our forbearers have, may we stumble courageously and persistently in the pursuit of compassion and excellence. Let us never forgo the good of the patient and the public for the advancement of ourselves or the profession. If the economy does finally manage to implode on itself and the funds for public salaries disappear, may it be seen that Queen’s physicians are the ones that will still show up for work; that Queen’s physicians are, in the words of that valedictorian of old, “servant[s] of the suffering.” Whether we are destined for a career in a ward, a clinic, an OR, a lab, or a public health unit, if we embark from this place, humbly emboldened with a commitment to pursue kindness in everything we do, we will not go wrong.
Let me finish with one more quote; with words borrowed from Dr Bethune. Spoken in 1938 at the opening of a military hospital in remote China, he would die within the year at the age of 41 as a result of a blood-borne infection he would acquire while operating on a soldier.
“There’s an old saying in the English hospitals… “A doctor must have the heart of a lion and the hand of a lady.” That means he must be bold and courageous, strong quick and decisive yet gentle, kind and considerate. Constantly think of your patients and ask “Can I do more to help them?”
Congratulations, my friends. Thank you for the last four years, for today, and most especially for the good work you will do as you go from this place.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
It Takes a Village
Last week’s convocation ceremonies provided opportunities to not only pay tribute to the 2013 class, but also reflect on the progress of our school and curriculum. I was congratulated several times for the changes that have taken place, and the success of our graduating class. In truth, those changes have been made possible only by the efforts of many faculty and support staff, who are the real heroes of any success we’ve achieved. I thought it appropriate to devote an article to those remarkable people. In doing so I tread cautiously, always wary of omitting someone, but not willing to pass up the opportunity to recognize the deserving. So, here goes:
Ted Ashbury. Several years ago, he (perhaps foolishly) Ted agreed to become a curricular advisor. From that, he has become the “heart and soul” of Professionalism within our curriculum and within our medical school. He began by chairing a working group that examined and developed a competency framework, the work of which served as a model for all the professional competencies. He has continued to teach and advocate for professionalism, serving on our Curriculum Committee since it’s inception. He does not speak often, but is always thoughtful and his usually incisive commentary often brings the group back to fundamentals and keeps our collective eye on what’s important. I’ve come to count on his advice. Ted’s trying to retire and I guess we’re going to have to let him do that at some point, but we don’t have to be happy about it.
Henry Averns has, for the past 5 years directed our Clinical Skills program. A difficult portfolio at the best of times, Henry had to manage through the departure of a number of faculty leads, transition from a five to four term format, introduction of new teaching requirements, and transition to a new Clinical Education Centre. Henry managed all this with characteristic aplomb, the final result a program that continues to be highly regarded by our students and accreditors, and improved for his contributions. More recently, he has taken on chairmanship of our OSCE committee, a role that continues to bring both learning and administrative challenges, but he is engaging with his usual enthusiasm and characteristic pragmatism.
Paul Belliveau has been a consistent liaison and representative of Surgery within our curriculum, both at the pre-clerkship and clerkship levels. He has also willingly taken on a number of key roles, including initially chairing our Student Assessment Committee and taking on leadership of our Student Awards Committee as it undergoes necessary reforms.
Jennifer Carpenter has, for many years, provided counseling for students experiencing a variety of personal and health problems. In doing so, she has made herself continuously available to them and, since most of what she does is held in confidence, she largely carries out this role without attention or fanfare. She has also led the development of our Advocacy curriculum and promoted the development of Learner Wellness initiatives. She is unfailingly supportive of our students, and I have come to rely on and trust her advice on many student related issues.
Sue Chamberlain has been instrumental in developing our curriculum and clerkship in Obstetrics and Gynecology, shaping both into a very well regarded components of our curriculum, reflected by high levels of success of our students in Medical Council of Canada examinations and disproportionate interest in Ob-Gyn careers among our students. For these past 4 years, she took on Chairmanship of our Student Assessment Committee. This was a mammoth task, requiring a combination of policy development, faculty support and oversight of the curricular courses. Her success in developing effective assessment methodologies for our courses was absolutely essential and key to our accreditation success.
Lindsay Davidson is a dedicated and successful career educator who has also been part of our curricular transition from the start. During her time as Clerkship Director she guided the clerkship through its transition to a 2 year model. She has also taken on the roles of MSK Course Director for many years and, more recently, Year 2 Director. Her overriding contributions, however, relate to her willingness to fearlessly engage novel educational models, combined with technological expertise rare in medical faculty. She has been an unapologetic champion of small group learning techniques, leading the way and assisting many faculty in making that transition. She has become a growing presence within the university and national education communities.
As the Hannah Chair for the History of Medicine, Jackie Duffin has provided our students insights into the history of our profession and done so in a highly engaging manner, mixing award winning lectureship with individual research and highly regarded field trips which she personally organizes and supervises. Her contributions, however, go far beyond that role. She engages the students on a personal level with enthusiasm and warmth, and is held in high regard by all. Her publications and global work bring much credit to our school.
Renee Fitzpatrick has provided steadfast and innovative leadership for all aspects of our Psychiatry curriculum. She has developed novel approaches to teaching complex psychiatric presentations through the use of standardized patients, as well as developing individualized preparation opportunities for students undertaking the Integrated Community Clerkship. She has become the champion of Psychiatry within the UG curriculum, and her efforts have provided our students with a much more realistic and attractive impression of that career track. As she moves on to other challenges, she leaves strong pre-clerkship and Clerkship programs for colleagues to follow.
Michelle Gibson has skillfully and efficiently guided Year 1 of our curriculum for several years, been an important member of our Curriculum Committee (taking over responsibilities as Chair for these past 2 years), all while completing her Master’s degree in Medical Education and carrying out her practice in Geriatric Medicine. During that time, she managed to have a baby, and young Conor has become an honorary member of Curriculum Committee, amassing an impressive attendance record.
Cherie Jones-Hiscock has provided leadership and oversight for two key competencies within our curriculum, those related to the Collaborator and Communicator roles. In doing so, she has developed curricular content and novel, creative methods to provide that content. These roles have required that uncommon combination of educational creativity and administrative skill. She has brought these skills to her roles with our Professional Foundations and Curriculum Committees.
Hugh MacDonald has guided our Admissions Committee through a transition to a much more sophisticated and, in my view, effective process based on an understanding of key applicant attributes and incorporating mini-medical interviews. The committee’s mandate has also expanded to involve admission of students to our MD-PhD and QuARMS programs, each requiring creative thinking and novel processes. Hugh has guided these processes with a steady hand and good judgment, all the time filling other key clinical and administrative roles in our school.
Sue MacDonald, as our first Academic Advisor, has taken on this new role with energy and commitment. She provides personal counseling with students experiencing academic challenges, effectively identifying opportunities for improvement and complementing the efforts of other counselors. Many students have benefitted from her counseling and sound, practical advice. She has also been very active in the delivery of our Professionalism/Ethics curriculum, and a strong contributor to our Student Progress and Promotions Committee.
Jennifer MacKenzie has, together with Theresa Suart, developed a de novo pre-medical curriculum for our QuARMS program which is highly creative, delivering competency based learning in a variety of creative teaching formats. This program, and Jennifer’s continued oversight, will be key to the success of this exciting new initiative.
Sue Moffatt has been making major contributions to our curriculum for more years than she would like me to mention. Most recently, her contributions to our curricular renewal process, guidance of the Cardio-Respiratory course through transition, and wholesale development of the three Clerkship Curriculum courses have been remarkable even for someone with her track record. Her recent selection by our graduating students to receive the Connell Award (given to the faculty member deemed to have made the greatest contributions to their medical education) speaks clearly to her dedication and commitment to our students. It’s always clear to me and others that Sue’s perspectives and opinions on various issues, although often controversial, are always motivated by a genuine concern for the interests of our students.
Heather Murray has transformed the teaching and expression of Scholarship within our curriculum. She has done so by developing and managing the CARL (Critical Appraisal, Research and Learning) course, now in it’s third year, and building on Albert Clarke’s longtime contributions to transform our Critical Enquiry course. She is transforming those components of our curriulum into a very active and highly relevant learning experience for our students. The Student Research Showcase, which she developed and offered for the first time last fall, promises to become a regular highlight of the academic year.
Peter O’Neill tirelessly guides our students through their career planning and CARMS application processes. He also, quietly and without fanfare, provides personal guidance and advocacy for those few who have difficulty with the postgraduate match process. In his spare time, he has developed a program in Spirituality, which has been well received by both students and other medical schools.
Conrad Reifel and Steve Pang have provided a Normal Human Structure course that is, in the view of many, among the best programs in the country. They have also been open to change and cooperation with clinical course directors that continues to promote integration throughout our curriculum.
Mike Sylvester has developed and operated a Family Medicine course in first semester that not only introduces our students to that specialty, but provides their first exposure to clinical presentations and diagnostic reasoning. He has represented and promoted the integration of Generalism within our curriculum tirelessly through his participation on the Curriculum Committee.
David Taylor and Cathy Lowe have very effectively reformed our Internal Medicine Clerkship rotations, converting what were weaknesses to strengths within the clerkship. In doing so, they have introduced innovative teaching and assessment methodologies.
Lewis Tomalty, during his term as Senior Associate Dean, was a strong supporter of curricular change and continuing source of advice, guidance and support. Since then, he has assumed responsibility for our Mechanisms of Disease course and is in the process of reforming that curriculum.
Richard VanWylick seems to be everywhere. He has, over the past few years, directed the development and implementation of our Pediatrics pre-clerkship curriculum, directed the Pediatric Clerkship, directed our Integrated Community Clerkship Program and, just for good measure, Chaired the Progress and Promotions Committee, a role that requires the knowledge of a litigator, diplomacy of a career diplomat and patience of Job. I’m not really sure how he’s managed all this, but I’m smart enough not to ask. He’s one of those folks who just does everything well, and can be relied upon with difficult jobs. In addition, I know he is a source of advice and counsel to many of our junior faculty.
Chris Ward has quietly, effectively, deliberately reformed our teaching in basic science through his leadership of the Normal Human Function course, and dedicated participation in our Curriculum Committee. He has also found ways to interact effectively with clinical course directors and thereby promote integration of basic and clinical science in our curriculum.
Ruth Wilson has generously taken on the considerable challenge of chairing our Professional Foundations Committee. Her steady leadership has guided and promoted the development and integration of those essential components of our curriculum.
Andrea Winthrop, in a short period of time back at Queen’s, has taken on and successfully engaged a number of challenging and critical portfolios, including Clerkship Director and Chair of the Course and Faculty Review Committee. She has also been the person most responsible for developing and managing our successful exchange program with the University of Queensland. In all these roles, Andrea brings incredible energy, commitment and an attention to detail that is both apparent and rather astounding to everyone who works with her. Her dedication to the welfare of our students is obvious to all.
Brent Wolfram has quietly and effectively assumed responsibility for the Family Medicine clerkship, as well as providing valuable contributions to our Course and Faculty Review and Curriculum committees.
In addition, many faculty have provided leadership as Course Directors:
Michael Adams who has energetically revised the curriculum and teaching of Fundamentals of Therapeutics, receiving important recognitions for his teaching from the students and university in the process.
Stephanie Baxter who developed our Ophthalmology curriculum, recently transferring that role to Jim Farmer
Cheryl Cline has been instrumental in developing and leading the Professional Foundations course content.
Basia Farnell has taken on leadership of our Term 2 Clinical Skills course.
Melissa Fleming leads the challenging Perioperative Medicine rotation in our Clerkship, which integrates experiences in Anaesthesia, Emergency Medicine and Surgical Subspecialties.
Keith Gregoire who has recently taken on responsibility for the Pediatrics Clerkship, building on the program developed by Richard VanWylick and Maxine Clarke.
Russell Hollins has directed and supervised Elective rotations for many years, an administratively and educationally challenging role very important to our students as they consolidate their career directions.
Robyn Houlden and David Holland have developed a very effective Renal-Endocrine curriculum in second year.
Paula James and her colleagues have developed and implemented a course in Blood and Coagulation that is consistently very highly regarded by our students.
Paul Malik coordinates and teaches many sessions of the Cardiovascular component of our Cario-Resp course.
Romy Nitsch has expanded and refined the teaching within our Reproduction and Genito-urinary course.
Chris Parker and Armita Rahmani have worked diligently with Sue Moffatt to develop and deliver the first interation of Clerkship Curriculum Courses, which was very highly rated by out students.
Lindsey Patterson directs the development and delivery of Technical Skills within our curriculum.
Stuart Reid directs our Neuroscience course which, under his leadership, has undergone considerable revision in both content and teaching methods which have resulted in a much more effective and well reviewed curriculum.
Richard Thomas directs the Obstetrics and Gynecology rotation within our Clerkship, traditionally one of our most highly rated rotations, and a discipline where our students have excelled in their Medical Council of Canada examinations.
Shayna Watson has been a very effective liaison with the Oncology group, directing the integration of that content within our “GOP” course.
I also wish to make special mention of two Educators who have been essential components of our school and our transformation process:
Sheila Pinchin has been central to our curricular reform since the outset. She now leads a highly effective educational support team (Theresa Suart, Eleni Katsoulis, Alice Rush-Rhodes, Catherine Isaacs) and remains a key member of our leadership team, providing sound and practical advice, while maintaining a critical link to our students that allows us to understand and respond to issues and concerns.
Elaine VanMelle was an original member of our Curricular Review group and, in those formative days, provided sound guidance and insights as to relevant educational theory that allowed us to ensure our changes were solidly grounded. Her work as the original chair of our Teaching and Learning Committee led to policies and practices that were instrumental in our accreditation success and continue to guide the curriculum.
Finally, our Undergraduate support staff, under the capable leadership of Jacqueline Schutt, provide highly effective and much appreciated support to our students throughout their years with us. In recent Canadian Graduation Surveys, the students have rated our support services well above national averages.
The origin of the phrase “it takes a village to raise a child” is obscure, but appears to derive from an African proverb. Whatever the origin, it is certainly well applied to the tremendous effort that has gone into our curricular evolution here at Queen’s.
What motivates all these people? Certainly not simply the money or prestige, both of which are entirely inadequate to their contributions. In all cases, the primary motivation is a remarkable dedication to our school, our students, and the very best interests of our profession. They deserve our admiration and our gratitude.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Meds 2013 – Congratulations, thanks and one more story.
This week, Meds 2013 will become the 157th class to graduate from the Queen’s School of Medicine. Despite that long history, their experience in medical school has been distinct in many ways from the 156 classes that have preceded them. In part, that uniqueness has been due to their engagement of novel teaching methods. Beginning with the “Pearls” session during Orientation Week (see photo below), the use of clinical and personal “stories” and reflections has been woven into their learning. With that in mind, I offer another “story” as a parting gift to this special class.
Professional sport is sometimes capable of becoming more than just games played by privileged millionaires. On those increasingly rare occasions it becomes a metaphor, with lessons that can resonate through other aspects of our lives.
In the late 1980s, while training in Boston, I developed a fascination with basketball or, more specifically, the Boston Celtics. The starting five of the Celtics at that time consisted of players who had all enjoyed great careers – Larry Bird, Kevin McHale, Robert Parrish, Danny Ainge and Dennis Johnson – but, by that time, they were all well past their peak, suffering from a variety of physical ailments common to the older athlete – backs, knees, shoulders. Nonetheless, they remained a highly competitive team, largely because of their incredible savvy, guile and, most importantly, teamwork. They were masters of the game and very familiar and comfortable with each other. They were therefore able to consistently defeat younger, more physically talented teams. They remained the team to beat, and were annually competing for the championship.
The best individual player at that time, by far, was Michael Jordan. Still early in his career, Michael Jordan was like an alien dropped to earth to show the world a new way to play basketball. He did things no one else could do, and did most of them while seemingly suspended in mid air. He transformed basketball into a three dimensional game. He literally, and figuratively, soared. However his team, the Chicago Bulls, had no players who could complement his excellence. Their main strategy was “get the ball to Michael”. In a game where only five players compete at a time and one athlete can play almost the whole game, this approach can be quite effective if you have such a stellar player. Indeed, Jordan dominated the regular season, finishing miles ahead of anyone else in the scoring race, leading his team to the playoffs in 1986, and a much anticipated match with the Celtics. For basketball fans, it was a match for the ages, pitting a great team of very good veteran players against an incredibly talented star in his ascendancy. For basketball mad Boston, it was nirvana.
The teams split the first 6 games, with the Celtics using the standard strategy against Jordan, which was to double or triple team him. Basically, the approach was to assign one of their tallest and most skilled players to cover the 6’6” (not very tall for basketball) Jordan, moving another player or two over as soon as he got the ball, thus boxing him in laterally and vertically. By doing so, a team could hope to hold Jordan to 20 or 25 points, which would be regarded as a highly successful defensive effort. For Game 7 in Boston, the Celtics shocked their fans and all those watching by taking a dramatically unconventional and courageous approach. They decided to play Jordan man-to-man and, for most of the game, Dennis Johnson was assigned the task of covering Jordan.
Dennis Jordan was a very capable guard who had a long and successful career. He had become a key component of the Celtics team and knew his role very well. However, he was only 6’4” and, by 1986, couldn’t jump. Basically, he had no chance of covering Michael Jordan alone.
Throughout the game, the highly knowledgeable Celtics fans watched in shocked disbelief as poor Dennis was left to do the impossible. For a proud athlete with the entire basketball world watching, including his wife and children who were in the crowd, it would have been a humiliating experience. Michael Jordan scored in every possible way, eventually amassing an amazing 63 points – still the record for most points in a professional post-season game. But…the other four Celtics starters, freed from defensive responsibilities, all dominated their opponents and Boston won the game in double overtime – the most exciting and interesting basketball game I’ve ever seen. The team of grizzled and self-sacrificing veterans had triumphed over the transcendent star, at least that night. After the game, as players and fans swarmed the court, it was obvious that Jordan felt defeated and unfulfilled despite his incredible personal triumph. Dennis Johnson, on the other hand, emerged as the battered hero of the game despite his personal drubbing. He became, and has been, my favourite basketball player. I was saddened to learn of his premature death in 2007 from apparent cardiac causes. His Celtics teammates eulogized him as “one of the most underrated players of all time”.
So, what relevance does this story hold for the newly minted doctors of Meds 2013? You are about to engage postgraduate training of various types. You will, believe it or not, become highly proficient in your chosen specialties. You will have days when you feel capable of handling any challenge – of being able to soar like Michael Jordan. On those days, it will serve to recall the lessons of that April 1986 game, that you can lose the game despite personal triumph, and that even Michael Jordan never felt fulfilled as a player until years later when the Bulls assembled teammates capable of complementing Jordan’s talent and finally winning championships. By all means, strive to soar, but remember that most of our triumphs as physicians come when we toil with integrity like Dennis Johnson; without fanfare, with quiet effectiveness, with very few aware of what we’ve done, with the patient’s welfare as our ultimate goal.
Meds 2013 has been a remarkable class. An eclectic and unassuming mix of the quirky and conventional, the pragmatic and idealistic. Gracious and accepting in the midst of massive curricular change, unfailingly supportive of their school, of their world, of each other. You have earned the respect and affection of your faculty who will proudly follow your careers with great interest in coming years. It has been our pleasure.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Should Every Doctor be Able to Deliver a Baby?
To many, the answer to this question may seem obvious. For those who feel an emphatic “yes” is called for, let me pose a scenario for your consideration. Imagine an airline flight about 3 hours from destination. A call goes out for someone who might assist a young woman who’s gone into premature labour. Two people respond. One is a mid career physician who underwent standard obstetrical training during medical school, delivering about 50 babies during that time, but subsequently trained as an Ophthalmologist and has had no obstetrical experience in the past 20 years. The second is a registered nurse who graduated about 10 years ago and works in a busy hospital, mostly in the emergency department, but with frequent “float” shifts in Labour and Delivery. Based on this scenario:
Who is more capable of providing competent care to the patient?
Who will most people aboard the plane (including the patient) assume is most qualified?
The point of this scenario and these questions is not to suggest some simmering interprofessional conflict. One would expect that these two professionals would recognize each other’s strengths and work together for the benefit of the patient. The point of this story, which could involve any subspecialty not involved in obstetrical care, is to highlight how much medical practice has evolved, and to suggest that our approach to medical education may not be keeping pace. This point is made even more apparent by imagining a similar scenario playing out 50 or so years ago when there was much less specialization, the practice patterns of all physicians was much more homogeneous, and physicians were fully qualified to practice at the end of medical school.
My colleague Richard VanWylick is a pediatrician and curricular leader. He and I have established a running joke regarding the toddler assessment in medical school. The examination of small children, like the ability to deliver a baby, is an aspect of medical practice that will be ultimately provided by a distinct minority of our medical class. Further, those who do provide those services in their career will undertake considerable further postgraduate training before doing so.
So, one must ask, why do we devote so much curricular time and resources to these components of medical practice? I would suggest there are a number of valid justifications:
- It’s important that our students experience all aspects of medical practice in order to make valid career decisions
- An appreciation of these areas of practice provides insights and awareness that makes us all better Doctors, and better able to understand the needs of our patients, regardless of their presenting problem or our area of interest. When I consult on cardiac issues during pregnancy, for example, it’s important to have had a practical understanding of the principles of labour and delivery.
- There exists a societal expectation that all doctors should be able to provide a minimal level of service, particularly in emergency situations. That “minimum level”, it must be said, is completely undefined.
- Our students very much appreciate the opportunity to experience all aspects of medical practice, and expect the opportunity to do so
On a purely pragmatic note, medical schools are required to provide a comprehensive exposure in order to achieve accreditation status in Canada and the United States. To quote from “Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree” (the bible of accreditation):
ED-15. The curriculum of a medical education program must prepare students to enter any field of graduate medical education and include content and clinical experiences related to each phase of the human life cycle that will prepare students to recognize wellness, determinants of health, and opportunities for health promotion; recognize and interpret symptoms and signs of disease; develop differential diagnoses and treatment plans; and assist patients in addressing health- related issues involving all organ systems.
Although schools are expected to define for themselves what constitutes adequate preparation “to enter any field of graduate medical education”, I think any program would be hard pressed to exclude active participation in basic obstetrical care and child assessments as components of that preparatory process.
However (and this is a big “however”), with the massive increase in knowledge and emergence of over 60 recognized specialties, medical education is becoming increasingly expansive and expensive. More and more, medical schools are required to make choices regarding what components of education are relevant to every physician, regardless of what specialty they chose to practice. Such decisions are being made in isolation since we lack any accepted framework or value assumptions that would support such decisions.
But (and this is a big “but”), things are changing. Leadership organizations such as the Association of Faculties of Medicine of Canada, Royal College of Physician and Surgeons, College of Family Physicians and Medical Council of Canada, are all acknowledging the need to recognize more explicitly the continuum of education from medical school entry through to full qualification. The Future of Medical Education in Canada initiative is calling for sweeping reform, including the recommendation to “Ensure Effective Integration and Transitions along the Educational Continuum”. Three committees have recently been established to develop strategies to implement this key recommendation. These groups are just beginning to grapple with some very difficult and discomfiting questions, such as:
What knowledge, skills, approaches are common and essential to all physicians, regardless of specialty?
How should physicians progress through training, and when should various training streams begin to diverge?
How should the number of specialty training opportunities be determined, and how should learners be selected for those specialties?
When should medical students be expected to declare their area of interest, and what, if any, provision should be made for those who wish to transition between specialties?
These issues will require considerable thought and reflection by all involved in medical practice, including students, postgraduate learners and teaching faculty. All involved should feel free to contribute to this dialogue, which has the potential to reform our educational systems in rather profound ways, hopefully leading to a much more aligned, efficient and relevant process. As a co-chair of one of those implementation groups, I would certainly welcome input on these issues. In the meantime, I will continue to hope to be sitting next to an experienced ER nurse if someone goes into labour during a future flight.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Basic Science in Medical School. Too much? Too Little?
In his 1988 book “All I Really Need to Know I Learned in Kindergarten”, Robert Fulghum takes a tongue-in-cheek approach to education. His intuitively attractive postulate is that early learning is the most durable we will experience, and those fundamental lessons and principles, well established early in life, can be the most valuable contributors to lifelong learning.
I found myself thinking about this recently after reading a “state-of-the-art” article in the Journal of the American College of Cardiology entitled “Pathogenesis of Acute Coronary Syndromes” (Crea F, Liuzzo G, JACC 2013;61:1-11). The authors provide a contemporary review of the pathophysiologic underpinnings of ACS, describing a complex interplay of structural, inflammatory, metabolic, hematologic and genetic factors that can be at play and can lead to the various clinical presentations we recognize.
Over the years that I’ve been in practice, the understanding of what causes ACS has evolved in a steady and very gratifying manner. In medical school, the concept of myocardial ischemia my classmates and I engaged was encapsulated by a famous Frank Netter drawing of a businessman with a briefcase clutching his chest leaving a restaurant (presumably having enjoyed a large meal) on a cold day. In retrospect, it’s easy to dismiss that image as a rather quaint and simplistic model of what turns out to be a rather complex process.
However, when I think about the fundamental science that underlies the current mechanisms developed in Crea and Liuzzo’s article, I realize how many of those key concepts were first, and very accurately, developed within basic science courses we undertook in our first year. Concepts such as:
• the structure and histology of coronary arteries
• the inflammatory response
• platelet aggregation and thrombosis
• arterial vasospasm
• genetic predisposition to disease
• lipid metabolism
• sympathetic responses to exertion and emotional stress
These topics, esoteric in isolation, have a few, very interesting things in common.
• They are all necessary to understanding current concepts of ACS
• Knowing something about them allows me to appreciate (and even enjoy reading about) contemporary approaches as outlined in the JACC article.
• They were all part of my medical school experience 35 years ago
While I was struggling to learn those concepts, I had no idea they would ever have practical impact on my practice. In fact, my classmates and I were of the very strong opinion that learning these concepts was a decided waste of time that could be better spent seeing patients and learning the “nuts and bolts” of clinical medicine.
Today, undergraduate curriculum committees, including ours, continually struggle with the questions “what should we be teaching” and “what will they need to know”. The desire to ensure the scientific foundations are appropriately presented has to be balanced against current trends to provide more “patient-centred” content, to provide “clinically relevant” content, to ensure our students are introduced to the ever-expanding compendium of clinical knowledge and therapeutics.
But are these forces really at odds? Do we really need to choose between what’s “science” and “clinical”? We don’t, as long as we’re willing to consider new approaches to education. The answer to this apparent dilemma lies in development of integrated learning that doesn’t segregate and marginalize the “science”, but brings it front and centre, linked appropriately and logically to the clinical contexts in which they’re utilized.
Within the next few weeks and months, Dr. Michelle Gibson, Year 1 Director, and Dr. Chris Ward, Course Director for Normal Human Function, are leading a comprehensive review of our objectives in Basic Science. It’s become clear after five years of application that the current framework outlined in our “red book” (Curricular Goals and Competency-based Objectives) merits review and likely revision. In doing so, they will be engaging the faculty at large and will welcome your contributions.
So, do I believe I learned everything I really needed to know in medical school? No. But I certainly didn’t appreciate at the time how useful that learning would prove to be.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Medical School Admissions: Unintended Consequences
The response to my last article on the topic of medical school admissions would suggest that there’s both interest and concern regarding our current processes. In addition to the very interesting responses that were posted, a number of practicing physicians and students communicated with me directly with similar insights. It seems clear from this feedback, and from our own experiences here at Queen’s, that the combination of high demand for medical school positions and the “ill-designed tools” I alluded to in the previous article is giving rise to consequences that are at least unintended and, in the worst case, undesirable. Examples of those unintended consequences:
Strategic selection of undergraduate courses and programs. Academic Records have always been the cornerstone of the admission process. However, lack of uniformity regarding course content and evaluation rigour between institutions (and even departments in the same institutions) has eroded their reliability. It’s widely appreciated that some universities and programs take pride in the demands they place on their students and the meaning of an honours grade. Students attending such institutions therefore put themselves at a competitive disadvantage, despite receiving what all would agree is an excellent educational experience. In addition some disciplines, such as English and the Humanities, rarely award marks above the mid 80’s. Postgraduate science courses tend to award higher marks than undergraduate courses in the same discipline. Although all these vagaries are widely appreciated, there is no acceptable or fair means to equilibrate these inequities. Consequently, students interested in pursuing medical school admission may be making choices based on strategic priorities rather than interest or natural aptitude.
Resume construction. Applicants perceive a need to ensure their non-academic resumes reflect interest in medical and humanitarian pursuits. Although such efforts are obviously laudable, they may be chosen for strategic rather than purely altruistic value, and come with the price of exclusion from other very healthy growth experiences. In addition, such experiences may not be equally available to applicants from diverse communities and socioeconomic backgrounds.
Commercialization of Medical Education. The large number of young people seeking admission to medical school have become an economic “market” and medical education has become a “commodity”. The $270 cost of writing the MCAT does not seem unreasonable, but must be coupled with the cost of preparatory material, preparation courses, travel to and from examination sites, and multiple examinations that many candidates undertake in order to ensure competitive results. University undergraduate courses in biologic sciences have increasingly taken on a distinctly “medical school prep” tone, to the point that program designations have evolved to terms that denote closer links to medical education (“health science”, “medical sciences”), even providing MCAT preparation as part of the curriculum and publishing statistics regarding the rate of medical school acceptance among enrolled students. Although such programs may be of intrinsic value, one wonders whether there is sufficient value and career opportunity for the majority of participants who will not be successful in their medical school applications. Finally, the steadily increasing number of international medical schools that are offering positions to students able to bear the financial burden and accept the uncertainties of postgraduate placement is a clear consequence of the mismatch between demand and positions in Canada.
Premature exclusion (or selection) of Medicine as a career option. Admission to medical schools is increasingly seen as the ultimate award for academic excellence. There is an emerging perception that only academically very successful students need apply and, conversely, that high academic success carries the expectation of medical school admission, almost as an earned right. Both perceptions are problematic. The former excludes (or at least fails to encourage) students on the basis of very early and likely unrepresentative academic experiences. The latter runs the risk that students will set themselves, and parental expectations, on a very determined career path with an incomplete understanding of the demands of that career or their own suitability.
Socioeconomic barriers. Many of the factors noted result in significant barriers to less economically advantaged members of our society. A 2002 analysis of medical school enrolments revealed that only 10.8% of first year students came from rural areas, despite the fact that 22.4% of Canadians live in rural settings (CMAJ 2002; 166: 1029-35). The same study showed that 17% of medical students came from families with household incomes over $160,000, although only 2.7% of Canadian households had incomes over $150,000. Conversely, 15.4% of medical student families had household incomes less than $40,000 in 2002, although 39.7% of Canadian households are in this range. Although such observations do not allow us to conclude that a “barrier” exists, it does appear that our students are drawn from the socioeconomically advantaged sectors of our society, and some of the observations noted above provide explanations for this trend.
I ended my previous blog article by posing the question “Do we have a problem?” Most of the respondents felt we do, based on the issues noted above, all of which suggest the system is neither fully accessible to all deserving applicants, nor fundamentally aligned with the values our society would expect of the medical profession. However, no one seems to question the integrity of the process, nor the quality of the students who are ultimately being selected to medical school. We’re therefore left with the much more difficult issue, specifically: What, if anything, are we prepared to do about it?
There would seem to be two potential options:
- Try to change the admissions system to correct or modify the various issues, or
- Expand the number of medical school positions to admit more applicants
Both are obviously quite complex and far-reaching. The first option would require directed approaches to each of the issues listed above. For each, strategies could be developed and, in many cases, have been implemented with some success. Examples of such strategies could include any or all of the following:
- Adjustment of undergraduate grades to account for university or program “degree of difficulty”
- Development of a more valid and aligned standard entrance examination
- Greater scrutiny regarding the content and impact of non-academic experiences
- More scrutiny regarding the content and outcomes of undergraduate programs
- Development of more aligned pre-medical undergraduate experiences, perhaps linked to medical school admission
- Provision of economic support to socioeconomically disadvantaged students seeking medical education
- Stronger links with high school programs to ensure students are aware of the expectations of medical education and practice
- Linkage of medical school admission with specific service requirements
These and many other options are controversial, highly complex to implement and individually incomplete solutions to the problems we’ve identified. In addition, we would be left with the fundamental issue of still not having enough places for what would be a slightly different, but no smaller applicant pool.
The second approach (increasing medical school positions) has, in Canada, been linked to considerations of physician supply. As thoughtfully reviewed recently by my friend and colleague Dr. Steven Archer, new Head of Medicine at Queen’s (http://deptmed.queensu.ca/blog/?p=266) and also by Dr. Reznick, Dean of Health Sciences (http://meds.queensu.ca/blog/?p=2072), this is a highly complex issue, with no clear data and considerable controversy currently swirling as to questions as fundamental as whether Canada is under or over-supplied with physicians. However, we might engage this issue somewhat differently if we reflect on two realities of modern medical education:
1. The MD degree historically designated readiness to engage medical practice. This has not been the case for at least 50 years. Although our MD programs all provide fundamental clinical training and experience, it is with the intention that students will transition to more intense and direct clinical involvement in their specialty based postgraduate years. In fact, graduates now require a minimum of two (and often up to 7) additional years of postgraduate training, predominantly based in clinical settings.
2. The major limitation to expanding undergraduate MD programs is the availability of appropriately supervised clinical practice experiences. Every medical school in Canada struggles with finding educationally rigourous clinical experiences for their students. The widespread development of regional programs and distributed educational models is largely a result of this challenge.
The logical possibility exists, therefore, to confine undergraduate medical education to foundational science, clinical science and clinical skills, leaving clinical practice to postgraduate training. It would therefore be possible to open undergraduate training to a much larger number of applicants. The “bottle-neck” in the system would therefore occur at the entry to postgraduate training, which would still be limited by clinical placement opportunities and tied to whatever information was available regarding societal requirements for physicians.
The advantages of such a program would be to allow a much larger number of students to enter what would be a shorter and much less expensive educational program, probably directly from high school. That program, properly constructed, would allow students to better understand the realities of medical education and practice, and allow for more standardized assessments on which postgraduate entry could be based. This provides an opportunity to repatriate many Canadians studying Medicine abroad. For students not successful in achieving postgraduate placements, such programs could, if appropriately constructed, provide a solid basis to pursue a variety of alternative career paths. Many of the socioeconomic barriers would be lessened.
Disadvantages are numerous, including loss of the supportive, patient and learner-centred atmosphere most medical schools currently achieve, and further dividing an already “siloed” medical education system. Such programs would, in essence, become more specifically designed pre-medical programs without assurance of admission to postgraduate training, and would require many graduates to seek alternative career paths. The very designation “M.D.” would fundamentally be devalued, unless an alternative application of the term were developed, possibly to be awarded at the end of clinical training.
And so, what began as a discussion of medical school admissions has evolved into a reconsideration of the entire educational paradigm, and the very meaning of the MD degree. I would personally find this approach highly unappealing as, I believe, would most Undergraduate Deans across the country. So why raise it? Because the system is fundamentally flawed, the meaning of the MD degree has already changed substantially, and radical proposals have a way of focusing discussion, often toward useful ends.
I welcome your views.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education