Not your Father’s (or Mother’s) Clinical Clerkship

Meds 2015 students get their white coats and begin the contemporary Clinical Clerkship 

This week, the students of Meds 2015 begin the phase of medical education still referred to as the Clinical Clerkship.  Last Friday afternoon, family and friends joined them to celebrate the White Coat Ceremony, a longstanding tradition that marks this important transition.  It was a pleasure to meet many family members, some of whom were physicians who remarked on the changes between their own educational experiences and those of their offspring.

white-coats

The need to provide supervised learning within the clinical setting has always been regarded as essential to the development of future physicians.  Indeed, early versions of medical education consisted entirely of what could only be termed apprenticeships under the direction of a fully qualified physician who was engaged by the student as their tutor, mentor and assessor.  It was largely as a result of Abraham Flexner’s (pictured) transformational 1911 review of medical education in North America that medical schools were required to provide formal instruction in the basic and medical sciences.  However, Flexner continued to emphasize the critical role of education within the context of clinical service.  flexnerThe role of medical students within service delivery, largely in hospital settings, became consolidated into the discrete role that came to be known as the Clinical Clerkship.  Being a “Clerk” was to have a job or role within the hospital’s complex service delivery.  The role consisted of “clerking” patients (carrying out admission histories and physicals), following the progress of patients through their hospital stay, arranging and following up on investigations, and coordinating discharge and post hospitalization follow-up.  In addition, Clerks had unofficial but widely accepted service delivery roles of their own within hospitals, including phlebotomy, administering intravenous medications, performing simple procedures such as Foley catheter insertion and cast removal, simple suturing and recording electrocardiograms.  Appropriately supervised and monitored, this role provided opportunities to engage patient care in all its complexity in a transitional fashion, leading eventually to the ability to engage patient care independently after graduation.  The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today.  Interestingly, the role of the Clerk varied very little between services, specialties and differing patient populations, the goal being to develop strong foundational skills in patient assessment and management, which were felt to be consistent and “learnable” within any patient care context.

As the “service” component of the clerkship grew and hospital care became more procedurally driven, understandable concerns were raised regarding the balance between service delivery and education.  Medical educators, buttressed by increasingly specific and prescriptive accreditation standards, developed standards and objectives for the medical student role, coupled with a need for more structured and objective assessment.  At the same time, our students were developing an increasing need to use clerkship experiences to explore career options in an increasingly complex and competitive postgraduate training environment.

Today’s clinical clerkship has evolved considerably from the model experienced by most mid or late career practitioners.  Now usually consisting of the final 2 years of medical school, it is intended to provide clinical exposures that vary not only in focus but also in setting, recognizing the reality that our students have a critical need to explore career options and to encounter patients in a variety of settings that will reflect their own career paths.  The rotations are enhanced with formal educational experiences, formalized feedback on all curricular objectives, and structured assessments of various types.  To illustrate the modern clerkship, the following example profile is provided to illustrate the journey of one medical student through a clerkship:

  • A six week General Surgery rotation on an in-hospital unit at either Kingston General Hospital or our affiliated teaching hospital in Oshawa.
  • A six week Peri-operative Medicine rotation rotating through a series of experiences with surgical subspecialties (such as Plastics, Orthopedics, Urology), Anaesthesia and Emergency Medicine.
  • Six weeks on Core Internal Medicine spent as part of the care team assigned to a Clinical Teaching Unit in Kingston, Oshawa or Peterborough.
  • A further six weeks on Specialty Medicine spent undertaking consultation or out-patient clinics within three medical sub-specialties.
  • Six weeks of Psychiatry in Kingston, Oshawa or Markham, generally office or consultation- based.
  • Six weeks of Family Medicine working with a community family physician or Family Health Team.
  • Six weeks of Pediatrics, provided in either a hospital ward or community practice.
  • Six weeks of Obstetrics and Gynecology, consisting of shifts in Labour and Delivery, gynecology ward, or outpatient clinics.
  • Sixteen weeks of electives, during which the students a series of 2 week experiences in specialty services and locations across Canada designed to broaden their clinical experience and exposure to career options.
  • Three 4 week “Core Curriculum” rotations placed at the beginning, within and at the end of the clinical rotations, intended to provide common instruction and assessment in advanced topics and practice related instruction.

All these rotations feature, in addition to the clinical experiences, structured teaching, all guided by objectives linked to the overall Curricular Goals and Competency Based Objectives document which was developed and is regularly reviewed by our Clerkship Committee and approved by the Curriculum Committee. 

In addition, students can elect to undertake our Integrated Community Clerkship, consisting of an 18 week placement within a smaller community working with community tutors and Family Health Teams, intended to provide longitudinal experiences in Family Medicine, Pediatrics and Psychiatry.

Students can also apply for an increasing number of International exchanges which allow them to undertake a core rotation at universities in another country.

All rotations feature content relevant to the various Professional Competencies (Professionalism, Advocacy, Collaboration, Management) and their achievement in these domains is a component of rotation assessments.

All students continually log their clinical experiences and technical procedures in order to ensure all learning objectives are being met.  They also undertake comprehensive structured clinical examinations (OSCEs) in order to ensure core clinical skills are mastered and maintained.

So…a far cry from the service dominated Clinical Clerkship so familiar to most practicing physicians.  A key, and very reasonable question could be posed: Does it matter?  Are our students better prepared for the demands and rigours of residency and practice than their predecessors?  This intriguing question will be the subject of my next Blog.

 

 

 

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Visiting with Dr. Vincent Lam Making the case for Humanities in Medical Education

I have always loved reading novels.  I’m particularly drawn to those that feature complex and fully fleshed out characters battling various personal “demons”, confronting sundry human challenges in interesting contexts.  I must confess to having always regarded the reading of such books as something of a “guilty pleasure”, a self-indulgence taking time away from more immediate, directly relevant pursuits.

This week, vincent_lambthanks to the efforts and insight of the Aesculapian Society, particularly Michael Chaikoff and Soniya Sharma, many of us had the opportunity to hear from and meet with Dr. Vincent Lam, who was this year’s H.G. Kelly Memorial lecturer.  Dr. Lam is an Emergency Medicine physician and award-winning author of a number of works including “Bloodletting and Miraculous Cures” and “The Headmaster’s Wager”.  In his address, Dr. Lam made the case for the role of storytelling as a way of understanding and deepening communication between physicians and their patients, not only as a means of transferring important information, but he also spoke of how it can contextualize the relationship in more human and personally meaningful terms.  In conversation afterward, I asked him about the process of novel writing.  I had always naively assumed that the author begins the process with an outline of the completed story and goes about adding detail and context.  Apparently not so.  Most authors, including Dr. Lam, begin by imagining and developing their characters as fully formed people with all their individual traits and uniqueness.  They then go about studying and researching the context in which those characters will “live”.  Using characters and contexts with which the author is already somewhat familiar is obviously a good start, but considerable research and immersion is required in order to produce stories with depth, realism and relevance.  In researching for “The Headmaster’s Wager”, Dr. Lam made two trips to Vietnam in order to better appreciate the environment in which his story would evolve.  With character and setting in place, the author allows his characters to “live”.  Their actions and reactions become a natural consequence of the interaction of their personality with the times and situations in which they find themselves.

One can’t help but recognize parallels within the physician-patient relationship.  Our patients come to us as uniquely formed individuals who find themselves in a new, baffling and threatening context, specifically an illness or health challenge of some type.  Our role as physicians is to come to the encounter already prepared with understanding of the illness, or “setting” of that challenge.  Our “art” is to find within ourselves ways to efficiently and effectively engage the patient, understand the uniquely individual responses to the illness and guide the patient through the terrain.  In doing so, the physician must develop a broad appreciation of the human experience in all its fascinating complexity.  In this sense, the reading and appreciation of quality literature would seem at least as valuable as reading the latest thrombolysis trial.  Certainly the former is likely to be of more enduring significance.

At Queen’s, we have benefitted over the years from the efforts of numerous faculty who have steadfastly championed various components of the Humanities within and around our curriculum.  Dr. Jackie Duffin, herself an award-winning author, has been providing History of Medicine lectures integrated with various teaching blocks for many years, as well as student projects and excursions intended to deepen their appreciation of the history of their chosen profession.  Students have consistently found her teaching to be a highlight of their medical school experience, as evidenced by Dr. Duffin being a recipient of the Connell Teaching Award which the graduating class bestows annually on the faculty member considered to have had the greatest influence on their education at Queen’s.  Drs. Shayna Watson and Peter O’Neill have provided, largely on their own initiative, contributions to elective courses devoted to various themes related to literature, spirituality and the humanities.  We have maintained strong curricular content in Medicine and the Law (led by Patti Peppin of the Faculty of Law) and Medical Ethics (led by Drs. Cheryl Cline, Susan MacDonald and previously Ellen Tsai).  Many others have contributed in informal but highly meaningful ways.

The challenge, of course, is determining how best to integrate the Humanities and Social Sciences within a rather dense and highly scrutinized curriculum.  How does a Curriculum Committee, charged with meeting the various competencies and objectives established by professional bodies, accrediting agencies and well-intentioned interest groups, ensure these are achieved and balanced?  How does it weigh the value of medical literature or history against understanding the management of hemoptysis or causes of renal failure?

As a means of engaging this challenge, I recently asked Drs. Duffin, Cheryl Cline and Shayna Watson to develop a review and make recommendations on the teaching of Humanities within our school.  They involved three of our students, Alicia Nicke-Lingefelter (Meds ‘16), Amanda Lepp (Meds ‘15) and (now Dr.) Renee Pang (Meds ‘13).  That excellent report has already motivated changes in representation within our curricular committees and is leading to changes in how we “label” and integrate various teaching opportunities within our curriculum.  It has also raised a consciousness about the Humanities and Social Sciences that is always the first step to ensuring appropriate balance.  I’m arranging for the report to be posted on the UG Website and welcome feedback from all faculty and students.  It can be accessed at: https://meds.queensu.ca/central/community/curriculumcommittee:reference_material

I’m most grateful to the authors of this report and to all who have and continue to champion the Humanities within our school.  I’m also very grateful to Dr. Lam who has made me feel much better about my guilty pleasure.

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Introducing Queen’s Meds 2017

One of the special benefits of working in a university environment is the sense of renewal that comes each fall with the entry of new students.  This week we welcome members of Meds 2017, the 159th class to enter the study of Medicine at Queen’s since the school opened its doors in 1854.

meds 2017

A few facts about our new colleagues:

They were selected from the largest applicant pool in recent memory – 3818 highly qualified students submitted applications last spring.

Their average age is 23 with a range of 20 to 36 years.  Fifty-seven percent of the class are women.

They hail from no fewer than 49 communities across Canada, including Abbotsford, Ajax, Ancaster, Ariss, Barrie, Bedford, Brampton. Brockville, Burlington (3 students), Calgary (2), Coquitlam, Delta, Edmonton, Etobicoke, Hamilton, Inverary, Kamloops, Kingston (5), Kitchener, London (4), Maple, Markham (9), Mississauga (6), Montreal, North York (2), Ottawa (4), Owen Sound, Palgrave, Peterborough (2), Pickering, Puslinch, Richmond Hill (2), Scarborough, Stittsville, Thornhill (2), Tillsonburg, Toronto (19), Upper Island Cove, Shrewsbury, Vancouver (2), Vaughan, Waterloo, West Vancouver, Whitby (3), Windsor, Winnipeg, Woodbridge (2) and Yarmouth.

Ninety of our new students have completed an Undergraduate degree, and 27 have postgraduate degrees, including 4 PhDs.  The average grade point average achieved by these students in their pre-medical studies was 3.82.  Their undergraduate universities and degree programs are listed in the tables below:

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Undergraduate Degree Programs

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Postgraduate Degree Programs

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An eclectic and academically very qualified group, to be sure.  This week they will undertake a variety of orientation activities organized by both faculty and their upper year colleagues.  At their welcoming session they were called upon to demonstrate commitment to their studies, their profession and their patients.  They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers.  I invite you to join me in welcoming these new members of our school and medical community.

 

 

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Remembering three great mentors and teachers

Over the past few months, our faculty and medical school have lost three people who made tremendous contributions over the course of their careers.  Peter Munt, Robert Hudson, and Ed Yendt were all master clinicians, leaders in our medical community and contributors to our understanding of illness and disease.  They were also gifted teachers and mentors who were always willing and eager to pass on their wisdom.  As we approach the beginning of another academic year and are about to welcome a new class of medical students, it seems appropriate to reflect on the lessons and legacies that they’ve so ably provided.

Dr. Peter Munt was recruited to Queen’s after postgraduate training in Respiratory Medicine to head the newlymunt formed Division of Respirology and Critical Care Medicine.  He went on to head the Department of Medicine through a time of tremendous transition, and then became Chief of Staff at KGH.  As his medical resident many years ago, I recall caring for a patient with a pulmonary infection eventually traced to a rather novel organism.  Not content to simply identify and treat the infection, he encouraged me to identify the source and explore for any patients who may have suffered from similar infections.  By doing so and documenting the results of our search, we were able to contribute to the care of many more patients, and raise awareness among other physicians of a little appreciated source of infection.  Moreover, he taught me and my fellow residents the importance of pursuing root causes and the value of documentation and publication in disseminating knowledge.  His career, both as a physician and administrator, was characterized by this quality of uncompromising attention to all facets of an issue, and unwillingness to accept the expedient solution.

hudsonDr. Bob Hudson was head of our Division of Endocrinology for many years.  In addition to his clinical responsibilities, he maintained a very active research career making important contributions to the understanding of androgen function.  I’ll remember him for his dedication to physical examination and bedside teaching.  His ward rounds were highly valued by housestaff.  Not content with mere identification and demonstration of physical findings, Dr. Hudson challenged us to understand the underlying cause and pathogenesis.  “So I agree this patient has exophthalmos” he would concede, but always follow with something like “but why do patients with thyroid disease develop this finding? What’s the mechanism?”  His great skill was to help the learner work his or her own way through the problem without intimidation or belittlement.  In fact, you emerged from these sessions not simply knowing something about a particular finding, but with a mechanism that could be applied to a variety of findings and conditions.

yendtDr. Ed Yendt had already developed a reputation as a leading specialist in calcium disorders by the time he was recruited to Queen’s to head the Department of Medicine.  He led that department through a period of rapid growth, and development of many of the subspecialty divisions.  He continued to do basic research through his career, becoming an internationally recognized expert in osteoporosis.  Always a dedicated clinician, he continued to see patients long after usual retirement age and long after financial considerations provided any motivation.  He was the embodiment of what we would today refer to as “translational” or “bench to bedside” research.  I had opportunity to talk to him on numerous occasions in recent years, and was continually impressed at his knowledge of recent literature and eagerness to apply new findings to his patients.  He was intrigued by patients with unusual presentations or responses to therapy, and continually used those experiences to learn more and apply that knowledge.  He never lost his excitement for discovery or dedication to patient care.

Three great teachers, three different styles, but all sharing an insatiable curiosity, dedication to advancing the science of medicine, and to applying that science to their first concern – the care of their patients.  Their families might find some solace in the knowledge that those lessons are not lost and that their examples and teaching will continue to inspire our students and those currently charged with their learning.

 

 

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Mentoring – a “win-win-win” proposition

What do practicing physicians remember about their medical school experience?  What do they feel had the greatest impact on their development?  What do they retain?  My guess, based on many reunions and even more conversations with graduates, is that it’s not the classes, labs or examinations, but rather the faculty they encountered along the way.  Of course we all remember the “characters” and the “larger than life” personalities that populate every medical school, but it’s those faculty with whom we were fortunate enough to develop a personal, one-on-one relationship that have the most enduring and significant impact on our development as physicians, and on our personal lives.  We call such folk “Mentors”.

mentorThe derivation of the word “mentor” is interesting.  The origin is Greek and is traced to Homer’s Odyssey.  Mentes was a wise and valued friend of Odysseus to whom he entrusted the education of his son Telemachus when he set out on his epic voyage.  The elements of wisdom and trust are therefore intertwined in the term, qualities obviously central to the role as we understand it today.

The value of mentorship is well known in all facets of professional education.  It’s this realization that leads many schools and departments to deliberately develop programs designed to promote these mentoring relationships.  At Queen’s, we have developed a program that assigns a mixture of students from all years in groups led by two faculty members.  Like all such programs, much depends on the specific and usually unpredictable “chemistry” that develops among the group.  When it works (and it usually does) the relationships that emerge are highly rewarding.  Below I provide testimonials from two students and one faculty member regarding their mentorship experience that may provide some insights.

Eve Purdy
Eve Purdy, MEDS 2015

In a 1973 article “Indoctrination of the Medical Student” Dr. Vilter pointed out that turning a new, eager medical student into a competent, caring physician takes more than just training in science, more even than just training in science and clinical skills. The mentorship program at Queen’s has been a special part of my indoctrination to the profession. Our group’s main goal is to have fun in a relaxed way but I am always surprised at the impact of these casual interactions. Whether it be a night of bowling, an intense night of trivia or a simple evening over shared drinks and food, I always leave more energized and excited about what’s to come. 

When a clerk in your mentorship group gives you a tip for the wards next year, you don’t forget. When the fourth year students graduate, you celebrate with them and picture yourself walking across the stage in a few years’ time. When a mentorship group leader encourages you to dream big, you might just. 

And a few more interesting links that I have come across about mentorship in medicine: 

Trivia…or is it? – this is a link to a post on my blog about trivia night earlier this year

Being a Mentor for Undergraduate medical Students Enhances Personal and Professional Development

Mentoring Programs for Medical Students- a review of the literature

Informal Mentoring Between Faculty and Medical Students

simmons
Graydon Simmons, MEDS 2016

The Queen’s Medicine Mentorship Program has provided me the opportunity to have informal interaction and communication with Queen’s faculty and residents that I wouldn’t be able to experience anywhere else. In the hospital or after a lecture, it is hard to just walk up to a physician to inquire about what they enjoy about their profession or how they balance their personal lives with their work. Through the mentorship program, I have been able to build relationships with faculty and residents in a more relaxed atmosphere that is conducive to conversations about one’s future directions in medicine. Additionally, the mentorship program has also increased that sense of Queen’s community for me. As a pre-clerkship medical student, it can be intimidating to enter the hospital during your first clinical experiences. With something like the mentorship program in place, you begin to see the quality of physicians we have here at Queen’s and the encouraging, open teaching environment that they create. Ultimately, this interaction and positive community that the mentorship program has created for me has contributed to my learning and career exploration as a Queen’s medical student.

Dr. Peter O’Neill
Dr. Peter O’Neill

It is About Mentorship

Being a mentor in the mentorship program has been one of the most exciting aspects of being on faculty at Queen’s. At my mentorship group’s last meeting, we had breakfast. For our group, breakfast was a good time to get everyone together without the distractions that can happen with an evening out.

One of the first year students asked if we should have an agenda for the meeting, but the senior students just laughed. The agenda is always the same. I ask the senior students: “what is cool in what you are doing right now”? They answer, in the usual spectrum of experiences, and the junior students say: “wow, how do I get to do that”! That is mentorship in action.

While I enjoy checking in with all the students to see what is cool or if they are struggling, I think the students would rather hear from their near peers. I see our relationships not so much as a vertical structure, but a horizontal one. The clerk explains how to get an elective to the second year student. The second year student describes the observership program as a kind of “back stage pass” to the first year student.

Our group has enjoyed the group events and while I couldn’t make the “Great Mentorship Race & BBQ” in the park this spring, our group was well represented. Over the years we have had fun with Guitar Hero, and had pot luck suppers (which means that everyone has some food that they can surely eat without looking into all the dietary restrictions).

At the Convocation in May, I enjoyed meeting the family of one of my mentees. He said: “Dad, this is Dr. O’Neill, I beat him at guitar hero the second month of medical school.  You couldn’t believe it when I told you we were playing guitar hero in his basement. I smoked him at guitar hero. In spite of that, three years later he taught me how to deliver a baby.”

In the years to come, memories of delivering a baby might fade in this future internist, but I will bet he will remember beating me at guitar hero. He may never know that I let him win.

win-win-winAnd so it seems mentoring is truly a “win-win-win” proposition, benefiting both parties involved, as well as our school, which is becoming known for the value we place on faculty-student interactions at many levels.  We’re always looking for more faculty willing to become involved in this program.  If you’re interested, or simply wish to learn more about it, feel free to contact myself, Peter O’Neill or Erin Meyer in the UG office who coordinates the program.  Erin can be reached at ugmelwc@queensu.ca.

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Student Directed Learning ”Everything old is new again”

My undergraduate education was enlivened by a number of professors who were fond of taking rather unconventional points of view, many of which would be considered “politically incorrect” in today’s parlance.  They were even fonder of defending those perspectives with spirited and colourful debate.  Perhaps travillthe leading proponent of this approach was Dr. Tony Travill, professor of Anatomy, who would spend more of his curricular time discussing points of professional practice and social foibles than the assigned topics of embryology or anatomy.  On the rare occasion that one of us mustered the temerity to point this out, he would make the rather emphatic point that “universities aren’t centres of teaching, they’re centres of learning”.  The message was clear – it wasn’t his business to teach so much as it was our responsibility to learn.  Our goal should be to learn for the benefit of our future patients, not simply to satisfy curricular goals.  I recognize in retrospect that his not-to-subtle shift of emphasis helped us to transition from being passive consumers of information to what today’s educational theorists would term “active learners”, although we had no idea this was happening at the time.

Turing our attention to the present, one of our 2015 students, Eve Purdy, spoke eloquently at the recent Celebration of Teaching Day of how she addressed her interest in the process of clinical decision-making.  She searched the internet and came upon a free web-based seminar series from the University of California (San Francisco) that she accessed over several weeks and found quite useful.  She shared the information with others, both students and faculty who also made use of this resource.  As teaching faculty, we should take considerable comfort in the fact that our students are, on their own, seeking opportunities to advance their learning, often going beyond the baseline requirements of our curriculum.

In fact, our students make use of a wide variety of unstructured learning opportunities in addition to standard curricular offerings such as Courses, Integrated Learning Streams, various types of Small Group Learning, clinical rotations and assigned projects.

Last academic year, about 20 Student Interest Groups were active, each developing a series of at least 8 learning sessions outside standard curricular time that were devoted to a particular discipline or theme.  Although supported by faculty on a voluntary basis, students developed the themes and content of these sessions.  The following is a list of some of the groups that were active this past academic year:

hidden

In addition, our students informally access the world of information available to them through the internet and social media.  A world of information is studentsliterally at their fingertips, and they make use of this almost continuously, both to search information and to dialogue with each other, with faculty (sometime during lectures), and people farther afield.  The challenge is not access, but rather discernment of relative value.

Perhaps the most powerful non-curricular learning experience our students engage is what’s been termed the Hidden Curriculum.  This term refers to all of the unintentional but incredibly powerful messaging that occurs in the context of their environment and clinical experiences.  Observing a respectful and effective interaction between an attending physiciansphysician and nursing staff provides a much more effective and durable lesson than hours of formal teaching on the topic of professionalism.

The challenge for teaching faculty in the midst of all this is to keep pace what’s happening around us, and to shift our focus from delivering content to guiding the learning process.  To borrow an old adage – we can’t control the wind, we can only set our sails.  In this environment, it becomes more important to set the objectives and provide direction than to attempt to rigidly control the process.

And so, as the song says “Everything old is new again” when it comes to student directed learning in medical education, although technical advances and connectivity expand the potential (and our challenge) tremendously.  I like to think Dr. Travill would be amused.

 

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

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“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:

Picture - Alexander SummersMr. 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)
Associate Dean,
Undergraduate Medical Education

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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:

Screen Shot 2013-05-30 at 8.54.21 AMTed 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.

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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.

belliveauPaul 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.

Screen Shot 2013-05-24 at 3.55.07 PMJennifer 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.

Screen Shot 2013-05-24 at 4.20.34 PMSue 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.

 

Screen Shot 2013-05-24 at 3.57.52 PMLindsay 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.

Screen Shot 2013-05-27 at 9.12.59 PMAs 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.

H_Macdonald_7472_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.

Screen Shot 2013-05-24 at 4.26.11 PMSue 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.

Screen Shot 2013-05-24 at 4.17.46 PMJennifer 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 MoffattSue 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.

Screen Shot 2013-05-24 at 4.09.58 PMHeather 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.

Screen Shot 2013-05-24 at 4.11.03 PMPeter 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.

59Mike 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.

Screen Shot 2013-05-24 at 4.27.25 PMLewis 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.

vanwylickRichard 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.

Screen Shot 2013-05-24 at 4.07.30 PMChris 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.

wilsonRuth 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. 

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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.

013Brent 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:

Screen Shot 2013-05-27 at 9.26.05 PMMichael 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:

Screen Shot 2013-05-27 at 2.29.05 PMSheila 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.

Screen Shot 2013-05-24 at 4.15.59 PMElaine 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)
Associate Dean,
Undergraduate Medical Education

 

 

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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.

Class of 2013

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.

basketball1The 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.

basketballThroughout 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)
Associate Dean
Undergraduate Medical Education

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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:

  1. It’s important that our students experience all aspects of medical practice in order to make valid career decisions
  2. 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.
  3. 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.
  4. 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)
Associate Dean,
Undergraduate Medical Education

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