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:

  1. Try to change the admissions system to correct or modify the various issues, or
  2. 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)
Associate Dean,
Undergraduate Medical Education

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Medical School Admissions: Striving for fairness despite “ill-designed” tools

February is, easily, the most difficult month of the year for many involved in undergraduate medical education, including Deans, admissions committees and administrative staff.  This is not simply because of the long and dreary Canadian winter.  It’s during this month that letters go out to applicants for admission indicating whether they’ve advanced to the next stage of the process: the on-site interview.  All those involved in the selection process struggle with the knowledge that, for every letter that brings welcome relief and encouragement, several will result in bewildered disappointment.  Two brief applicant profiles may serve to illustrate the issue.

Jessica is a bright, articulate and engaging young woman who, for as long as she or anyone can remember, has wanted to be a Doctor.  She graduated from high school at the top of her class, with numerous awards recognizing not only her academic accomplishments, but also student leadership and community involvement.  She received multiple university entrance scholarships and undertook an undergraduate program with courses that would provide a basis in biologic and physical science, which she feels is relevant to the study of medicine, but also selected to optimize her marks.  She is very successful, maintaining a 3.8 GPA over her first three years.  She also undertook a variety of volunteer activities, locally and abroad, involving health care in various settings.  She took the Medical College Admission Test (MCAT) after both studying from a manual and taking a preparation course at significant expense.  She did generally well, but was concerned about her mark in one of the four exam categories.  Jessica applied to our medical school, but failed to even get an interview.  This was related entirely to the MCAT score, as she feared.

Matt is not only an excellent student finishing in the top 5% of his high school graduating class, but also an elite athlete who accepts a full scholarship to an Ivy League university.  He chooses this school because it will allow him to pursue his interests in philosophy and political studies at an institution with an international reputation for excellence in both disciplines.  While there, he continues to excel academically, while becoming an accomplished varsity athlete.  He also develops an interest in Medicine and, specifically, Public Health.  He decides to apply to medical school and takes the MCAT, in which he excels in all categories.  He would like to return to Canada for medical school, but also fails to even get an offer for an interview, largely because the grades for his philosophy and political science courses, although near the top of the class for every course, fall below our GPA cutoffs.

Jessica, Matt, their families, and everyone who knows them and their career aspirations, are understandably devastated and rather perplexed.  “How can this be?”

Although these are both fictional accounts, a recent review of our applications at Queen’s shows that no fewer than 247 submissions matched the “Jessica” scenario almost exactly.  The number of “Matts” is more difficult to determine, but likely similar and probably underestimated because many people in such circumstances will decline to even apply, recognizing the GPA issue.

For every jubilant success, we know there are about 7 “Jessicas” and “Matts” who will be very disappointed and may have to set aside or delay their life’s dream, despite being very capable, motivated and deserving.  That reality is also personally distressing to the faculty and staff involved in the admissions process who, recognizing they cannot admit every applicant, endeavor diligently to develop fair and equitable processes.

A few realities about the medical admission process in Canada:

Among Canadians, there is a very high demand for medical education.  At Queen’s we received 3818 applications for our 100 positions this past year. All Canadian schools receive many times more applications than they can accommodate. Statistics collected and published annually by the Association of Faculties of Medicine of Canada indicate that the Canadian schools collectively received 34,048 applications for their 2,877 total available positions in 2011.  Assuming an application per candidate ratio of 3.3 (as Ontario statistics would suggest), it would appear that at least 10,318 individuals submitted applications that year.  The hunger for a career in medicine is such that increasing numbers of Canadians are enrolling in medical schools in Australia, the Caribbean, Ireland and other countries, at considerable personal expense and with no assurance of postgraduate training or eventual qualification in Canada.  Although no accurate data is available, it’s estimated that there are now more Canadians studying Medicine outside Canada than within.

Applicants to Canadian medical schools are knowledgeable regarding the process, and highly accomplished academically.  Although, again, no data is collected on this subject our observation at Queen’s, which seems to be shared by other schools, is that the average GPA, MCAT scores and personal experiences reported by our applicants are increasing each year.  Applicants understand the “system” and are highly strategic as they undertake their education and personal activities.

The number of medical school positions in Canada is fixed by public authority.  Medical education is expensive and largely subsidized by provincial governments.  Those governments therefore define the number of available positions, based loosely on anticipated demands for physicians.  These estimations have fluctuated in the past such that we have seen periods of both contraction and expansion.  At present, there are no plans in Ontario for expansion.

Medical schools place a priority on fairness and equity in their application processes.  In the face of the virtual impossibility of selecting the “most worthy” from so many worthy applicants, schools opt to ensure objectivity and fairness in their processes.  They are therefore drawn to metrics that provide some basis for objectivity.  Unfortunately, all available metrics are inherently blunt and imperfectly aligned with the qualities all would agree are important.

Winston Churchill could have been talking about medical admissions when he famously described golf as “a game whose aim is to hit a small ball into a small hole, with weapons singularly ill-designed for the purpose”.   Academic records, the MCAT, and quantified assessment of reported personal experiences all have significant shortcomings, as our examples above illustrate, but have the significant advantage of providing a numerical assessment by which candidates can be ranked without prejudice.  Panel interviews and mini-medical interviews (MMIs) are being used increasingly by medical schools to better assess applicants personal qualities, and are certainly an improvement, but are very resource-intensive and difficult to conduct and evaluate in a reliable manner.  It’s therefore not possible to apply such methods to the large number of applicants.  Hence the staged application process and reliance on other academic and test metrics.

So, one must ask, do we have a problem?  Despite all these shortcomings, the students who are finally admitted to our medical schools are an exceptional group of very talented, intelligent and capable young people who, with rare exceptions, have all the necessary qualities to become outstanding physicians.  Our processes, although inherently blunt and likely misaligned, are objective and scrupulously fair to all applicants.  Importantly, the Jessicas and Matts of the world, and their families, can perhaps take some small comfort in the knowledge that they are far from alone and have been treated fairly.  Furthermore, medical schools recognize that even if they could personally interview or meticulously assess every applicant, most would still be disappointed.  So, should we change and, if so, how?  I welcome viewpoints, and will make that issue the subject of the next blog.

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

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Family Medicine and the Hidden Curriculum

Lessons from Medical Variety Night

Last November’s Medical Variety Night provided an impressive peek into the musical and comedic talents of our students.  Andrea Winthrop, Steve Archer and I were asked to serve as a “Judges Panel” to determine the best class skit.  We were all amazed at the poise and creativity on display.

The evening also provided a few lessons for both faculty and students as to how well intentioned humour and satire can appear quite different before a mixed audience not familiar with the contexts employed.  A number of conversations have ensued which I believe have been illuminating and instructive for both students and faculty.  As in the patient care context, “near misses” are opportunities to learn and avert more serious problems in the future, and I believe we have, as a school, availed ourselves of the opportunities this year’s production provided.

A theme that I and others in attendance found particularly troubling related to a number of references to Family Medicine as a less-than-appealing career option.  This perception is hard to fathom given that we a have superb and award winning faculty teaching Family Medicine.  Our Family Medicine training program is widely recognized as one of the best and most sought after programs in the country.  In addition, Family Medicine is, arguably, the most demanding of specialties.  In open and frank discussions with a number of students on this issue, a few underlying causes came to light which I found illuminating and felt would be useful to share with faculty.  They provide superb examples of the “Hidden Curriculum”, a term used to describe unintended influences that affect student learning, and are known to be very powerful shapers of student attitude and behavior.  So, in no particular order:

  1. Engaging Uncertainty.  Students find Family Physicians they encounter to more commonly express uncertainly in their ability to resolve patient presentations.  This is in contrast to other specialists who they find characteristically more definitive in their approach.  Family Physicians more commonly use statements like “we’ll have to look it up”, or “don’t be afraid to say you don’t know”.   With respect to other specialists, the expression “seldom wrong but never uncertain” comes to mind (my quote, not theirs).  Importantly, students do not see this difference as inappropriate or as reflecting any lack of competence, nor are they so naive as to believe other specialists always have the answer.  In fact, the students I met uniformly expressed admiration and respect for Family Physicians they encountered, and their ability to manage a diversity of patient populations and presentations.  However, it’s clear that our students are accustomed to success, and many are not yet comfortable facing uncertainty in their lives, or in their future practices.
  2. Technical/procedural expertise.  Many of our students are technically very savvy and excited by the prospect of being on the “leading edge” of innovation and application of emerging technologies and procedural approaches to various conditions.  Simply stated, they like the “toys” of modern medicine and they’re excited about applying evolving procedures.  They perceive that these exciting new approaches as the exclusive domain of sub-specialists.
  3. Prestige”.  Hospital in-patient services remain at the core of clinical training for our students.  Properly run and supervised, they are superb environments in which the learning of pre-clerkship can be applied to real patients, with appropriate overlays of scholarship, professionalism, advocacy, collaboration and all the intrinsic competencies we have adopted within our curriculum.  Although formal teaching remains valuable during these rotations, we all recognize that the major component of learning occurs through active participation as part of the team, and by observation of “real life medicine”.  With respect to Family Medicine, these rotations are problematic in two important ways.  Firstly, virtually no Family Physicians are involved or even visible during these rotations.  Secondly, and most disturbingly, they often see instances where primary care and primary care providers are disparaged.  A casual reference suggesting that a patient was inadequately cared for prior to admission, or a concern that appropriate care will not be continued after discharge can, in a stroke, undo all prior teaching.  These observations in the clinical setting trump teaching in the pre-clerkship.  Our actions, it would seem, speak more loudly than our words.
  4. Money.  I have become convinced that the single most powerful expression of Hidden Curriculum in our society is the OHIP Fee Schedule.  Students are very aware of the differential reimbursement of physician groups, and the high premium paid for procedural work relative to patient assessments.  This of course, results in two hugely damaging consequences, the equation of financial with professional “value” or “prestige”, and the enticing allure of higher income to students facing increasing debt loads by graduation.

So what can be done?  A few suggestions, humbly submitted for consideration:

  1. Awareness of these influences, and of the Hidden Curriculum in general.  Hopefully this article is a start.  I hope it will generate some discussion, particularly at department meetings.  Dr. Leslie Flynn is chairing a group of which I’m a member to study and address Hidden Curriculum issues, and I think this may provide some focus for those discussions.  This awareness must extend to physicians of all disciplines who teach and supervise our students, particularly in the practice setting.  Those who attend on these services are, in my experience, largely unaware of the serious impact of casual commentary, and almost never intend to disparage any other specialty.
  2. Within our curriculum, developing strategies to address the “uncertainty principle” in a more open fashion.  This is both an academic and student wellness issue.  Our students require means to cope with the uncertainty that will inevitably develop in their professional and personal lives.
  3. Serious consideration of the troubling question:  To what extent do our admission processes pre-determine career choice?  Medical school admission remains a highly competitive process (applicant to admission ratio 38:1 at our school), and is likely to become even more competitive in the near future.  This environment favours the goal oriented, determined self-starter who is able to engage this single goal with appropriate compromises and sacrifices along the way.  It can be argued that such “survivors” will be naturally attracted to practice environments that provide definitive resolution of problems, technical mastery and perceived prestige.  There is a recognition, even embedded in the Future of Medical Education in Canada initiative, that admission processes should favour resiliency, personal maturity and problem solving, qualities valuable to any physician and not necessarily reflected by academic success.  Our admissions committee has, in fact, been inoculating these considerations into their procedures for the past few years.  However, as for all schools, academic success remains a key component of the application process.  Perhaps it’s time to consider more radical approaches.
  4. Increasing Family Physician presence in the hospital.  Our students perceive that in-hospital care, and the acuity, complexity and technologic innovation that goes with it, is the exclusive domain of sub-specialists, and fail to appreciate the role of Family Physicians in the continuum of care.  They also get little exposure to the in-patient care provided by Family Physicians in smaller communities.  Our Integrated Clerkship and “Week in the Country” programs address this to some extent, but we need to develop and engage initiatives to integrate Family Physicians effectively into the care of our in-patients.
  5. Advice regarding financial planning and practice management.  Although we can’t influence the fee schedule, we can certainly provide our students with sound financial advice to lessen any economic drivers of career choice.

I would like to end this article by thanking the many students who were willing to speak to me candidly about this issue.  I welcome their further commentary and impressions of faculty.  Open discussion is always the first and perhaps most necessary step to improvement.

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Back to the Future: Our Early Entry to Medical School Program (QuARMS)

What’s True and What’s Not

The School of Medicine is currently in the process of accepting applications for a two year, entry level educational initiative which, if successfully completed, would lead to admission to the first year of the MD Program. This initiative, dubbed QuARMS (Queen’s University Accelerated Route to Medical School) by governance committee co-chair Dr. Mike Kawaja, would be the only one of its kind in Canada. Students admitted to QuARMS in September 2013 would enter the MD Program, if successful, in September 2015, joining the class of Meds 2019.

Although it would be unique in Canada, this approach is certainly not novel. In fact, direct entry is the most common approach in many parts of the world, including Australia and most European nations. North American medical schools, including Queen’s, admitted students directly from high school until the early 1970’s. The factors that led to a shift to delayed entry included the increasing demand for medical school positions, the increasing emphasis on basic science preparation, and the demise of common examinations at the secondary school level.

This initiative, which has been under development for approximately two years, has attracted considerable attention across the country and has raised a number of questions among our student body. This led to a very well attended Town Hall recently during which Dr. Hugh MacDonald (QuARMS governance committee co-chair) and I answered a number of questions and accepted a number of very helpful insights. It was suggested that it would be appropriate to follow up that discussion with a newsletter to the entire student body to provide further clarification. I thought it might be best to structure this as a number of questions that seem to be arising repeatedly, and to make it available to faculty as well as students.

1) How many students will be admitted?

A maximum of ten students will be admitted each year. They will be part of the 100 ministry funded positions and not increase the overall class size.

2) How will they be selected?

The application process is linked with two scholarship programs, the Queen’s University Chancellor’s Scholarship and the Loran Scholarship. The Chancellor’s scholarship program invites every high school in Canada to nominate a student who has demonstrated a combination of academic accomplishment and community involvement. This is a well-established program. We are inviting students applying to that program to indicate interest in QuARMS. The Loran scholarship is a national level high profile scholarship which provides undergraduate funding for students who demonstrate a similar combination of academic accomplishment, social awareness and community involvement. These applicants will be similarly invited to apply to QuARMS. From these two sources, a group of 50 candidates will be invited to Queen’s for a series of interviews and encounters with faculty and students that will result in a ranking list that will be used to guide offers of admission.

3) What program will these students undertake?

These students will undertake a two year program with a combination of courses, seminar work and community projects. The intention is provide these students foundations in all of the component competencies that we recognize as essential to the practice of medicine and which are developed within the MD Program. This provides an opportunity to develop a premedical curriculum which is more relevant, integrated and linked to the MD Program. It also provides an opportunity for these students to learn in what we believe will be a more effective manner and one more consistent with the collaborative and lifelong learning that will required of them as physicians.

4) Is there an intention for this program to grow beyond these ten students and to replace our standard application process?

No. We recognize that it is the uncommon student who is sufficiently aware at the high school level to make a valid career decision regarding medicine. We do not wish to close off medical school to individuals who come to that decision later in life.

5) Who will oversee this program?

A governance committee has been established and co-chaired by Dr. Hugh MacDonald of the Department of Surgery and Dr. Michael Kawaja of the Department of Biomedical Science. Dr. Jennifer MacKenzie is in charge of the curriculum and is a member of the governing committee. Other members of the governing committee include the Associate Dean for Undergraduate Medical Education, three faculty members and two students.

6) Will all students in this program “automatically” enter medical school?

Students within this program will have to be academically successful and meet standards established by the governance committee. If they meet those standards they will enter the first year of the MD Program after two years. We anticipate that some students will either not achieve those standards or decide in the course of this program to undertake an alternative career.

7) Why are we doing this?

I feel there are a number of advantages to this initiative.

  1. A small number of students are aware and ready to undertake medical training early. We believe this provides them an opportunity to complete their training in a shorter period of time.
  2. This initiative addresses, to some extent, the socioeconomic disparities in admission to medical school in that it provides entry after a shorter period of time with less overall expense. We hope this will make medical education available to students who might not otherwise consider the option.
  3. It provides an opportunity to develop a premedical education that is more appropriate and aligned to medical school without the highly competitive and stressful environment that sometimes accompanies premedical education.
  4. It provides an opportunity to begin the development of core qualities and competencies essential to medical practice such as collaboration, communication and lifelong learning, qualities that are sometimes challenging to provide for students who have come through a traditional premedical education.

This is, and will remain, a controversial undertaking. It represents a significant break from convention and is somewhat uncharacteristic of a school that has tended to avoid controversy, and been described by some as being “on the leading edge of tradition”. In the final analysis, the leadership of our school and most faculty and students comprising it’s main decision making body felt that the potential of this rather bold and “back to the future” approach outweighed the risks and effort required. Appropriately, it was a characteristically medical “risk/benefit” analysis that carried the day. So, let’s buckle up, we’re in for an interesting ride.

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

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What really drives learning?

Lessons from the famously self-taught.

Holidays are a great time to catch up on reading.  My own preferences are history and biographies.  This past couple of weeks, I’ve found it rather humbling to learn that some of the most influential thinkers and shapers of our society were essentially self-taught.  In fact, they seemed in some cases to thrive despite the benefits of traditional education or academic success.

Benjamin Franklin (1706-1790) led a peripatetic life, meandering through a variety of career interests, excelling in all.  He’s perhaps best remembered as, arguably, the most important and essential influence on the Continental Congress that would draft and ratify the American Declaration of Independence.  Along the way, he was a writer/journalist/publisher/politician/diplomat and, in his spare time, a scientist of considerable renown, receiving honorary degrees from both Harvard and Yale, and becoming the first person living outside Britain to receive the prestigious Copley Medal from London’s Royal Society.  Remarkably, all this was accomplished without the benefit of college or university level education.  In his excellent biography of Franklin, author Walter Isaacson describes three key educational components: the formative influence of his father who encouraged conversation and debate in the home, Franklin’s insatiable curiosity that spanned a huge variety of topics, and his access to books.  “Indeed”, Isaacson writes, “books were the most formative influence in his life, and he was fortunate to grow up in Boston, where libraries had been carefully nurtured”.  Despite this abundance, Franklin was required to actively seek out these books, generally housed in private libraries.  His apprenticeship in his brother’s print shop provided him opportunities to “sneak books from the apprentices who worked for the booksellers, as long as he returned the volumes clean”.

The facts regarding the education of Abraham Lincoln (1809-1865) are almost lost in the mythology that’s developed regarding his early life.  In Team of Rivals, author Doris Kearns Goodwin describes the challenges faced by the impoverished Lincoln as a “Herculean feat of self-creation”.  “Books”, she writes, “became his academy, his college. The printed word united his mind with the great minds of generations past”.  He also treasured conversation and stories he shared with interesting, informed people, and would analyze and reconstruct arguments afterward. He also undertook “solitary researches” in the study of geometry, astronomy, political economy, and philosophy.  “Life was to him a school, and he was always studying and mastering every subject which came upon him.”

Although Albert Einstein (1879-1955) did have the benefit of formal education, attending the Swiss Federal Polytechnic School, he was a mediocre, somewhat embittered student and was unable to secure a teaching position after graduation.  It seems he found formal curriculum far too rigid and stifling.  He eventually undertook relatively menial work at a patent office, which allowed him time alone to read and think.  It was during those years that he developed many of the theories that would revolutionize the field of physics and define his life’s work.  He also developed a social consciousness that, although less publicized than his scientific work, is in many ways equally intriguing.

So should these notable examples, drawn from three separate centuries, diminish our commitment to formal education?  Obviously not.  However, it would also be a disservice to simply dismiss them as prodigious intellects who managed to excel despite more primitive educational systems.  Simply put, it took more than brainpower for them to rise above their circumstances and become pre-eminent learners and, as a result, leaders of their times.  They also shared three essential qualities:

  1. Relentless curiosity and desire to understand.  Although the focus of that drive may have differed, the intensity and commitment were consistent.  They simply could not be deterred from learning.
  2. Willingness to apply themselves to their goal.  We tend to believe that people as gifted as Franklin, Lincoln and Einstein came by their success effortlessly, but this is far from the case.  Franklin was known by his contemporaries to habitually arrive at work earlier than anyone else and to work long into the night.  Lincoln often read or worked through the night, and photographs from the time document dramatically the physical toll.
  3. Commitment to betterment of their communities.  All three were motivated by a desire to improve their societies.  In fact, the energy and commitment that was so evident in their work appears to arise from this altruism rather than any personal self-interest.

It would seem that when these three qualities triangulate in an individual, great things are possible.  However, those possibilities are only realized if their environment provides a few necessary things, including access to information and people with whom they can converse, share and test ideas.

How does all this relate to our work as medical educators?  I think two important lessons emerge.  Firstly, it would seem that any admissions process would benefit by concentrating on means to identify within applicants the three essential attributes listed above.  Any student with these attributes is essentially programmed to succeed and will do so within, or in spite of, any educational system we choose to impose.  Put simply, the appropriately motivated, reasonably capable learner is essentially unstoppable.  Conversely, the absence of these attributes virtually dooms the process from the start, despite our best efforts.  Secondly, these examples would suggest that the learning environment we develop is at least as important as the methods we employ to deliver and assess knowledge.  Providing our learners with direction and opportunities to explore concepts and develop their personal learning skills is critical and, from the perspective of their ongoing career, much more durable than simply requiring them to reproduce pre-determined dollops of factual information.

All this should reassure us that the changes we’ve undertaken over the past few years with our admissions processes, curriculum, information technology, physical space, mentoring programs and educational methodologies are all positive developments, clearly moving in the right direction.  We should also be encouraged to creatively and boldly go further.

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Looking for a Few Good People

We’re incredibly fortunate at Queen’s to be blessed with a faculty that engages educational leadership with enthusiasm, creativity and dedication.  When new positions emerge, or when people who have been key contributors come to the end of their terms or move off to other phases of their career or life, the program faces both challenges and opportunities.  The challenge is obviously to fill the position, which is particularly difficult when it’s been filled so capably in the past.  The opportunity, of course, is that it allows another faculty member to engage a new challenge, which allows them to influence medical education and advance their careers in new ways.   A number of such positions will become available by the end of this academic year.  I will describe them below and invite all faculty members to forward any enquiries or expressions of interest to me.  In all cases, there will be opportunity for a phase transition working with the incumbent, support from our Educational Team, and opportunities to develop individual faculty development plans to complement the role.

Curricular Lead for the Professionalism Role Competency

For the past 6 years, Dr. Ted Ashbury has been providing inspirational and creative leadership as we have refined and consolidated the Professionalism role within our new Foundations Curriculum.  Ted would now like to transition to reduced responsibilities and eventually retirement, and so we would like to identify a successor who could work with Ted for the remainder of this academic year, taking over the portfolio completely in September 2013.  Major components of this role:

  1. Facilitation and maintenance of all current curricular components that address the Professionalism competency.
  2. Opportunities to develop innovative curricular components as the vision of the role suggests, particularly with extension into the clerkship
  3. Teaching within the curriculum on Physicianship and Professionalism

Director, Clinical and Communication Skills (CCS)

Given the obvious importance of CCS within undergraduate education, this is a key role and responsibility within our curriculum.  Dr. Henry Averns has been filling this role with creative energy and unique panache for the past 4 years, enhancing the content and assessment within the program while guiding it through a particularly challenging time of curricular transition.  As he comes to the end of his term at the end of this academic year, we have opportunity to identify a successor who will work with Henry through next term, taking over the role independently in September 2013.  Key components of this role:

  1. Working with the CCS Co-Directors to ensure the component courses CCS 1,2 and 3 are well maintained.
  2. Fostering the elements of the over-arching CCS mandate.
  3. Ensuring integration of the CCS curriculum with other curricular courses
  4. Working with and coordinating the efforts of administrative staff who support or work closely with the CCS program, such as the CCS Curricular Coordinator, Standardized Patient Program Coordinator, and UG Operations Manager.

Course Director, Geriatrics, Oncology and Palliative Care

This course was newly introduced as a part of our curricular revision and is in its third iteration this year.  Dr. Michelle Gibson, Director for Year 1, has been capably filling in the Course Director role on an interim basis.  However, the maturity of the role and Michelle’s expanding responsibilities with the Curriculum Committee require us to appoint someone to take sole responsibility for the course.  Again, we have the opportunity for the person coming into this role to work closely with Michelle, who will continue to direct Year 1.  Key components of this role:

  1. Oversight of the curriculum of the course, including learning objectives, teaching methods, faculty assignments and assessment
  2. Teaching within the course

Course Director, Clerkship Curriculum 3

In distinction to the roles above, this course is a completely new assignment, since it is under development and will be offered for the first time, March 26 to April 13 2013.  The Clerkship Curriculum Courses are being provided as a part of our expanded two year clerkship and provide an opportunity for the students to engage advanced concepts and to consolidate their learning, particularly in areas that tend to lose focus during clinical rotations, such as critical thinking, comprehensive approaches to clinical presentations, and basic clinical skills.  CC3 will be the final such course in the series, offered at the end of clerkship, and will identify and consolidate key themes in preparation for the MCC examination and residency.  The overall Clerkship Curriculum is under the direction of Dr. Sue Moffatt, who has developed the first two courses in conjunction with Directors Dr. Armita Rahmani and Dr. Chris Parker.  The CC3 Director will join this team and benefit from their experience.  Key components of this role:

  1. Developing and supervising course curriculum, including learning objectives, teaching methods, faculty assignments and assessment.
  2. Teaching within the course.
  3. Working with the Curricular Coordinator responsible for the Clerkship Curriculum courses

Co-Director, Facilitated Small Group Learning

Facilitated Small Group Learning is an instructional methods (based on Problem Based Learning) used in Terms 2,3 and 4, where students work in small groups with a trained facilitator over the course of a term, on cases that relate directly to the material they are learning in their courses.  Dr. Michelle Gibson directs this program and is responsible for it’s overall structure and outstanding success.  Last year, she was assisted by Dr. Ellen Tsai who made significant further improvements.  This year, Dr. Brent Wolfram, who was a FSGL facilitator in Term 2 last year, has been working with Dr. Gibson to revise and improve the Term 2 cases.  We are looking for interested faculty to assist with case reviews and development in Terms 3 and 4.

Associate Director, Student Counseling

For several years, Dr. Jennifer Carpenter has been providing outstanding service to our students and our school as Director of Student.  She has also begun the process of building a Wellness program that will span all learners at our school.  It’s becoming clear that her role is expanding to such an extent that we should be identifying another faculty member to work with Jenn in further developing these programs.  Key components of the role include:

  • Providing personal counseling to students in need
  • Providing advice and support to faculty dealing with difficult student issues
  • Contributing to the development of our student wellness program.

Curricular Lead for Manager Role Competency

For the past two years, Dr. Ruth Wilson has not only chaired the Professional Foundations Committee, but she has been the lead for the Manager role and associated competencies. Ruth has pioneered the Manager Checklist for the Community Week and also introduced a new session on health care for the students.  However, as the Chair of the Professional Foundations Committee’s role increases, she must step aside from being the Curricular Lead for the Manager Role.  We would like to identify a successor who could work with Ruth for the remainder of this academic year, taking over the Curricular Lead completely in September 2013.  Major components of this role:

  1. Facilitation and maintenance of all current curricular components intended to address the Manager competency including careers, self-care, and time and study management, all of which currently have point people and faculty associated with them.
  1. Opportunity to develop innovative curricular components where the vision of the role suggests, especially into clerkship
  2. Some teaching within the curriculum on aspects of the Manager role.

All these positions will receive credit within our Workforce accountability system.  For information or further discussion regarding any of these positions, please contact me directly at ajs@queensu.ca.

Best wishes to all for a restful Christmas break and for continuing success in the new year.

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Boy Scouts, Role Models and the Hidden Curriculum

Last Saturday morning, entering our local Loblaws supermarket, my wife and I were confronted by an adorable and entirely engaging boy of about 8 years of age dressed in a Boy Scout uniform.  He handed us a plastic bag and explained in a most earnest and obviously practiced speech that they were collecting for the Food Bank and we were invited to fill the bag during our shopping.  He was polite, articulate, sincere and clear, both about the process and ultimate destination of the donations.  In short, he was utterly irresistible, and we would have been convinced even if his cause had not been so worthy.

As he was speaking, I hadn’t really noticed the gentleman standing behind him, dressed in a version of the same uniform, who now spoke up and greeted me by name.  I recognized Bill Racz, my former Professor of Pharmacology, who had taught me many years ago about adrenergically active medications and the evils of pharmaceutical advertising.  I’ve continued to encounter Bill around campus over the years in contexts ranging from teaching and committee work to our mutual incompetence at noontime basketball at the gym.  In talking to Bill that morning, I learned for the first time that he’s been involved in the Boy Scouts movement for over 35 years.

On the way home, I couldn’t help reflecting on the tremendous generosity of spirit that motivates an accomplished and highly respected academic to donate time and energy to such a community cause and, more importantly, to modeling those values to young people in the most powerful way possible, by actually living the experience.  It’s easy to imagine that young boy one day taking on the same role and passing those lessons on to another generation.

The powerful influence of role modeling in medical education is well appreciated.  Medical graduates invariably recall particular teacher/mentors as much more influential to their eventual development than any curricular element or teaching methodology.  At a medical leadership symposium I attended recently, panelists were invited to individually list key components of effective leadership.  Common to every list was some variation on “lead by example”.  An extensive body of research is emerging on the “Hidden Curriculum”, a term used to refer to all the factors that influence learner development but are outside planned curriculum, arising as a result of observed behaviors and attitudes expressed unintentionally.  What’s becoming clear in the education world, and has always been clear to good parents, is that what we do is much more powerful that what we profess.  Good teachers and good leaders know this and therefore strive to “walk the walk”.

By “walking the walk” that Saturday morning, Bill Racz was providing an invaluable example and living lesson to a group of young boys.  He continues to teach and inspire me.

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Auda abu Tayi would have made a great Course Director

The Academy Award winning motion picture “Lawrence of Arabia”, provides surprising and instructive studies in leadership.   The main character, T. E. Lawrence, portrayed brilliantly by Peter O’Toole, is a junior officer in the British Army during the First World War.  He finds himself unable to conform to a model of leadership that demands unquestioning obedience to superiors of dubious competence, and threatens harsh punishment for questioning authority or any act of “insubordination”.  After being assigned to explore the Sahara desert and seek out alliances with the Bedouins, he encounters Auda abu Tayi, a tribal chief portrayed with equal brilliance by Anthony Quinn.  Lawrence is perplexed by the apparent paradox of Auda’s ability to unify usually rebellious and independent individuals, despite their “uncivilized” state and lack of any traditional military regulations or hierarchical command structure.   In a particularly memorable scene, the two are negotiating in Auda’s luxurious tent.  Lawrence presses Auda, challenging his authority and ability to maintain control of his people.   Auda rises in anger, lists the many wounds he has suffered for his people, points dramatically to the throngs of tribesmen waiting outside, and declares, “I AM A RIVER TO MY PEOPLE”.  The entire tribe, on cue, rises and cheers in agreement.  Lawrence gets the message.  He understands, for the first time, that Auda’s authority stems not from inherited right or fear of reprisal, but from the fact that his leadership is earned by understanding and providing for the needs of those he leads.  He will maintain his influence as long as he provides.

History teaches that every prominent and highly successful leader achieves and maintains authority by understanding and providing for the needs of whatever political or social structure they lead.  Leadership and service are intertwined.  Similarly, every great overthrow or rebellion can be traced to a failure to continue to provide for those needs.

Leadership in a medical or academic context would seem a long way from the Arabian Desert or rebellions, but some intriguing presentations I attended recently at the AAMC annual meeting on the topic would suggest there are similarities worth noting.  Dr. Eugene Washington, a highly respected leader in medical education and Dean of UCLA School of Medicine, lists the following elements as essential to leadership at any level, whether it’s direction of a course, department or entire university:

  1. Leaders create a shared vision of what the organization, or group, is striving to achieve.
  2. Leaders affirm the core values of the organization
  3. Leaders motivate individual members, by finding roles that are of value and interest to both the member and the organization
  4. Leaders achieve a “workable unity” within the organization, which is a commonly held understanding of every member’s role in achieving organizational goals
  5. Leaders manage, which means solving problems and ensuring both fairness and openness in the execution of those solutions.  This also means assuring accountability for all members.
  6. Leaders continually communicate and seek input from their members
  7. Leaders serve as a symbol and lead by example.

This might seem rather lofty and a long way from the role of a Course Director in the Undergraduate curriculum, but I believe these elements are operative in any leadership role, and that any effective change requires solid leadership.  We’ll explore this further in upcoming blogs.  In the meantime, I’d suggest dropping by Classic Video to pick up a copy of Lawrence of Arabia.

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Curricular Goals and Objectives

In an article entitled “The Case for Core Curriculum”, author James Bradshaw raises concerns regarding university teaching that should cause some unease as we consider our medical courses and curriculum.  “The tide seems to be turning”, he writes, “with business leaders lamenting that, although the new talent arriving at their doorsteps has deep technical knowledge, it lacks the skills needed to put this knowledge to full use”. (http://www.theglobeandmail.com/news/national/time-to-lead/why-university-students-need-a-well-rounded-education/article4610406/)

Rather disturbingly, this observation echoes the growing concern among postgraduate training directors and clinical faculty that our graduates seem adept and comfortable providing factual information, but considerably less so when challenged to assess undifferentiated patient presentations and integrate factual information into cogent and practical management plans.  Lest we dismiss such commentary as isolated rumblings, it’s useful to keep in mind that the results for Queen’s graduates on the MCC Part 2 examination would seem to support the contention that our graduates struggle in the domains of clinical reasoning and comprehensive patient management, in sharp distinction to their well above average performance in knowledge-based components of the Part 1 examination.  Although the effects of our revised curriculum and enhanced assessment practices are not yet influencing examination results, it would seem unwise to simply dismiss these observations.

Bradshaw goes on to point out that, at the university undergraduate level, there exist political, logistic and economic barriers to providing integrated educational experiences that address what we, in the medical education context, would term “competencies” rather than traditional discipline-based content.  Indeed, we are well aware of the challenges of blending traditional disciplines and developing both content and assessment that address what many refer to as the “softer skills” relevant to medical practice, such as critical thinking, communication with disparate populations, collaboration, and the ability to advocate effectively for patients, health system delivery, and oneself.

Our curricular goals and objectives, as well as our Competency Framework (see “Curricular Goals and Competency based Objectives”), was developed in 2007 and has served as the central focus for the restructuring of curriculum and assessment methods that has allowed us to both develop a much more effective learning experience for our students, and achieve compliance with all accreditation standards.  The principles it espouses should remain our central guiding force.  However, the observations noted above should cause us to consider whether a clearer definition of the expectations we have for our graduating students is in order, recognizing that many of the competencies we espouse (professionalism, advocacy, communication, collaboration) are not ends in themselves, but necessary components of a graduates “competence” to assess, diagnose and manage patients with a variety of clinical presentations.

I’ll be encouraging a dialogue on this issue at our major committees and among our Course Directors.  This blog seems an appropriate place to start.  Feel free to provide feedback.

 

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Think Different

In 2004, a young securities advisor named Salman Khan began tutoring his 10 year old cousin in basic math.  Despite her obvious intelligence, Nadia was having difficulty academically, was falling behind her classmates, and beginning to believe “I can’t do math”.  He began by talking to her by phone every evening for about an hour.  Between talks, he would send her emails with lessons or exercises to complete.  Before long, Nadia was doing much better in school and, in fact, surpassing her classmates and getting eager to learn more.  In addition, a number of other cousins began to join in on the lessons.  When the number reached about 15, Salman realized he needed a better method to post the lessons.  A friend suggested You Tube.  Although he admitted to a sense at the time that You Tube was “just for videos of cats playing the piano”, he began to use it.  In addition to reaching more of his cousins, this allowed him to develop lessons in other areas of need, such as history, English and general science.  In addition, the lessons started getting picked up by other people worldwide.  He began to develop a somewhat ambitious vision of providing “free education to anyone, anywhere”.  He quit his job to devote himself full time to his rather lofty goal.  The initiative began to grow and catch the attention of some prominent benefactors, notably Bill Gates.

The result of all this is the Khan Academy, a not-for-profit organization with no headquarters but about 40 employees who have developed and posted thousands of video lessons in a variety of subjects that reach about 43 million users world wide and now provide their on-line educational material at no charge in 16 languages.   The lessons are interconnected so that they build incrementally and allow learners to work at their own pace and develop expertise analogous to school courses.  The material has gone beyond individual usage and is now being picked up by school boards to supplement their curriculum.  In most cases, this is leading to a change in the teaching philosophy, since teachers can devote class time to group activities, consolidating experiences, or individual instruction.  Teachers have been particularly impressed with the ability to track individual student progress, and identify various patterns of learning and needs.  There are numerous personal testimonies from adults who had returned to learning after having given up themselves as a result of failure in the traditional school system.

Are there lessons here for medical schools?  I think a few:

  1. We now have technology that allows us to do things in drastically different ways.  Although we don’t have to change because of the technology, we no longer need to feel constrained by traditional models.
  2. The world belongs to those who are willing to set a goal and to engage solutions with an open mind, imagination, and a sense that anything is possible.  Steve Jobs changed the world with the philosophy that we need to  “Think Different”.
  3. We all learn differently, as children, as university students, as adults.  Our methods should identify and encourage those differences rather than limiting learning to those who happen to fit the traditional model.
  4. Learners need to consolidate the basics before moving on to advanced learning.  Khan identified early on that his students were having difficulty in traditional schools systems because the class had to move on to new topics before the basics were completely mastered by all students.
  5. The learning method Khan has developed is not only more effective, but, amazingly, requires less resources and expense to support than the traditional model.

The world is providing opportunities to do things better, and not necessarily by consuming more resources.  We need to Think Different.

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