Author: Anthony Sanfilippo
“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
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)
Undergraduate Medical Education
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:
- 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.
- 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.
- “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.
- 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:
- 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.
- 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.
- 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.
- 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.
- 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.
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.
- 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.
- 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.
- 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.
- 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)
Undergraduate Medical Education
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:
- 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.
- 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.
- 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.