Author: Anthony Sanfilippo
Plastic Snow? It’s official…we’ve gone too far. It’s time to act.
Meet my grand-nephew, Tristan. He’s been visiting from Nova Scotia with his parents. He’s 7 months old and, this past week, is starting to crawl and had his first haircut. He’s also the inspiration for this week’s blog. But more about him later…
We’ve grown accustomed to reading reports of grave environmental threats. For most of us, there is as yet little direct impact and we’re able to regard these concerns in the abstract. With time and repetition, we develop something akin to resigned indifference, participating in recycling efforts with reluctant acquiesce.
I’ve recently come across some information that should cause us all to pause, consider what’s happening to our environment and our own, personal culpability.
In a 2017 article appearing in Science Advances (Geyer, Jambeck, Law, Sci. Adv. 2017; 3: e1700782), researchers from three American universities and institutions with expertise in environmental issues reported on the “Production, use and fate of all plastics ever made.” Their conclusions are, to say the least, rather sobering. To summarize:
- 8.3 billion metric tons of plastics have been manufactured to date
- Of that, 6.3 billion metric tons remain as plastic waste accumulated in landfills.
- Only 9% has been recycled, 12% incinerated
- If current trends continue, it’s projected that 12 billion metric tons of plastic waste will find its way either into landfills or the natural environment by 2050.
The projections they have developed are rather frightening as portrayed in this graph from their paper:
Plastic products are, of course, designed to be durable. Basically, they don’t go away, and this article makes it clear that our current recycling efforts aren’t nearly adequate.
To put this into more comprehensible terms, researchers at the Rochester Institute of Technology have recently estimated that 22 million pounds of plastic debris enter the Great Lakes every year. Our own Lake Ontario, which we Kingstonians walk or drive by every day, receives the equivalent of 28 Olympic size swimming pools of plastic bottles each year, and they don’t go away.
If that’s not enough to get our attention, consider work recently published by Dr. Melanie Bergmann and her colleagues at the Alfred Wegener Institute in Germany, also in Science Advances (Bergmann et al, Sci. Adv. 2019; 5: eaax1157).
They point out that plastics don’t dissolve harmlessly into the environment, but under a number of physical stresses (mechanical abrasion provided by waves, for example, or temperature fluctuations) they can be broken into much smaller particles, termed microplastic, measuring less than 5mm. It’s already been well established that these can be found not only near large urban centres, but also in northerly ocean seabeds and coastal sediment. What hasn’t been clear is how they get there. It’s been postulated that microplastics have the capacity to be carried into the atmosphere and find their way to points very remote from their original dumping grounds. The capacity to become airborne not only explains this wide distribution, but potentially threatens human and animal exposure through inhalation.
To test this possibility, they set out to look for microplastics associated with snow because, in the words of the authors “snow is a scavenger for diverse impurities, and acts as a filter on the ground by dry deposition”. Using techniques far beyond my understanding, they measured levels of various microplastics in snow samples gathered from ice floes and islands in the Arctic, and compared with samples from urban centres in northern Europe and from the Alps.
They found plastic microparticles in snow gathered from all sites. Although there was much more from the cities, there were detectable levels in the snow scooped up from ice floes drifting in the Fram Strait and on Svalbard Island in the far north, far from any population centre, in quantities they described as “substantial for a secluded location”.
They conclude that snow has the ability to bind these airborne particles and carry them back to earth, a process they term “scavenging”. They conjecture that this process can allow for microparticles to find their way into water supplies and food chains. They even recommend that large northern cities give thought to where they deposit collected snow in the winter, to avoid contamination of water sources.
If we needed any further convincing about the need to curb use of plastics, I think it’s now available. Particles from the bottles or straws that we use to conveniently transport beverages to quench our thirst are finding their ways to the most remote, unpopulated regions of our planet, previously considered pristine. The ice and snow, always symbols of purity, are now tainted. Children who will soon be running outdoors to frolic in the first winter snowfall may be putting themselves at risk.
Getting back to young Tristan, what sort of world are we shaping for he and his peers? What can we do, given the virtually ubiquitous presence of plastics in our society? Personal action, to be sure. We should make all efforts to minimize our own usage and maximize recycling efforts. But also political awareness, particularly in this election year. No political leader or party that fails to understand the true impact of environmental contamination is worthy of our support. We should expect well-articulated platforms that address both local and international approaches. We have a responsibility to be vigilant, not only for ourselves, but also for those not yet able to speak for themselves but have so much at stake.
Welcoming Meds 2023
As the days get shorter and leaves begin to fall we reluctantly acknowledge that summer is giving way to autumn. In any university community another sure sign is the return of students, heralding the beginning of another academic cycle. At Queen’s School of Medicine, this past week marked the 165th time a group of young people arrived to begin their careers.
This year’s group consists of 108 students, drawn from an applicant pool of over 5500. They come all regions of our country and backgrounds. One hundred and eight individual paths leading to a common goal that they will now share for the next four years. Eighty-four of them have completed undergraduate degrees, 30 Masters degrees, and five PhDs
They hail from no fewer than 53 communities spanning the breadth and width of Canada. The universities they have attended and degree programs are listed below:
An academically diverse and very qualified group, to be sure. Last week, they undertook a variety of orientation activities organized by both faculty and their upper year colleagues.
On their first day, They were welcomed by Dr. Richard Reznick who challenged them to be restless in the pursuit of their goals and the betterment of our patients and society.
They were called upon to demonstrate commitment to their studies, their profession and their future patients. They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers. They were welcomed by Mr. Danny Jomma, Asesculapian Society President, who spoke on behalf of their upper year colleagues, and Dr. Rachel Rooney provided them an introduction to fundamental concepts of medical professionalism.
Over the course of the week, they met curricular leaders, including Drs. Andrea Guerin, Lindsey Patterson and Laura Milne. They were also introduced to Dr. Renee Fitzpatrick (Director of Student Affairs) and our excellent learner support team, including Drs. Martin Ten Hove, Jason Franklin, Mike McMullen, Josh Lakoff, Erin Beattie, Lauren Badalato and Susan MacDonald who oriented them to the Learner Wellness, Career Counseling and Academic Support services that will be provided throughout their years with us. They met members of our superb administrative and educational support teams led by Jacqueline Findlay, Jennifer Saunders, Theresa Suart, Eleni Katsoulas, Amanda Consack, and first year Curricular Coordinator Jane Gordon.
They attended an excellent session on inclusion and challenges within the learning environment, organized by third year student Alisha Kapur and student members of the diversity panel, supported by Drs. Mala Joneja and Renee Fitzpatrick. The presentation included dialogue from a panel of upper year students (Leah Allen, Palika Kohli, Vivesh Patel and Naveen Sivaranjan) who provided candid and very useful insights to their first year colleagues. That was followed by a thought-provoking and challenging presentation by Stephanie Simpson University Advisor on Equity and Human Rights.
Dr. Susan Moffatt organized and coordinated the very popular and much appreciated “Pearls of Wisdom” session, where fourth year students nominate and introduce faculty members who have been particularly impactful in their education, and invite them to pass on a few words of advice to the new students. This year, Drs. Erin Beattie, Wiley Chung, Bob Connelly, Jackie Duffin, Michelle Gibson, Brigid Nee, Siddhartha Srivastava and David Walker were selected for this honour.
On Friday, the practical aspects of curriculum, expectations of conduct and promotions were explained by Drs. Michelle Gibson, Cherie Jones and Lindsey Patterson.
Their Meds 2021 upper year colleagues welcomed them with a number of formal and not-so-formal events. These included sessions intended to promote an inclusive learning environment, as well as orientations to Queen’s and Kingston, introductions to the mentorship program, and a variety of evening social events which, judging by appearances the next morning, were much enjoyed.
For all these arrangements, skillfully coordinated, I’m very grateful to Rebecca Jozsa, our Admissions Officer and Admissions Assistant Rachel Bauder.
I invite you to join me in welcoming these new members of our school and medical community. I leave you (and they) with the Bob Dylan lyrics that Dr. Reznick shared with the class this past week:
May your heart always be joyful
May your song always be sung
And may you stay forever young
Dedication and organizational effectiveness are key leadership qualities, but do not always combine in the same individual. When they do, the result is a person who is a hugely valuable resource to the organization they serve. At Queen’s, we’ve been very fortunate (some would say “blessed”) to have many such dedicated and effective people involved in medical education. One would hope such people could continue in their roles indefinitely. However, from time to time, change is necessary. In the Undergraduate program, a number of changes are occurring at this time, partly because of life transitions, but also in order to ensure that we continue to refresh perspectives, allow gifted people the opportunity to learn multiple roles, and position ourselves optimally for our next major accreditation review about three years from now. I would like to use this article to announce a number of those changes.
Although these have already announced, I thought it appropriate to re-iterate that, over the past year, we have appointed four Assistant Deans with responsibility for key components of the UG program. In the cases of Dr. Hugh MacDonald, Assistant Dean UG Admissions, and Dr. Renee Fitzpatrick, Assistant Dean Student Affairs, these appointments recognized the increased scope of responsibility that had evolved in positions previously designated as committee chairs or directorships. In the case of Dr. Cherie Jones, Assistant Dean Academic Affairs and Programmatic Quality Assurance, and Dr. Michelle Gibson, Assistant Dean Curriculum, these are de novo positions addressing key components of our program that were previously undertaken either solely by the Associate Dean or committee chairs. These consolidated responsibilities will provide focused attention and responsibility for critical aspects of program delivery.
The clinical clerkship, spanning the final two years of medical school, consists of two components. The Clinical rotations consist of discipline-based rotations and/or integrated, longitudinal community-based rotations, and Electives. For the past several years, this aspect of the clerkship has been very capably directed by Dr. Andrea Winthrop. During that time, it has grown and evolved steadily, notably with expanded regional experiences and integration of EPAs as the basis for assessment. Dr. Winthrop is now moving to take on a new, needed role in our curriculum (see below). Dr. Andrea Guerin, who has been directing Year 2 of our curriculum, will be taking on the Clerkship directorship.
The Clerkship Curriculum consists of three blocks interspersed through the final two years where the students re-assemble as a class and undertake learning in Clerkship Preparation, Complex Presentations, and Preparation for Residency. They have been very skillfully and thoughtfully developed, planned and directed by Dr. Susan Moffatt, and have become very highly valued by our students. Over the next year, directorship of the Clerkship Curriculum will be transitioning to Dr. Heather Murray who, as Dr. Moffatt, is a highly accomplished and recognized educator. (Dr. Murray won the Chancellor Charles A. Baillie Award from the Queen’s University Centre for Teaching and Learning this year).
In the early years of our curricular reform, the extensive structural and content change required separate directorship of Years 1 and 2. As our curriculum becomes more established, and our curricular coordinators become more familiar with roles and operational issues, we have arrived to a point that the roles can be combined into that of a Pre-Clerkship Director, which is consistent with practice at most other medical schools. I’m very pleased to announce that Dr. Lindsey Patterson, current Year 1 Director, will be taking on this expanded responsibility.
Intrinsic Role Director
Our last major curricular revision introduced explicit objectives and teaching regarding the so-called “non-Medical Expert competencies”, and development of committee and chair to oversee the activity of individuals charged with the development of each role (Competency Leads). Dr. Ruth Wilson initially chaired that group and was instrumental in the development of those aspects of our curriculum. When Dr. Wilson stepped away from that role, we elected to allow the Competency Leads to function independently. It’s now clear that the importance and complexity of these roles, together with the administrative requirements to ensure appropriate curricular design and delivery, necessitate centralized support. We are therefore re-establishing the role of Intrinsic Role Director, and Dr. Andrea Winthrop will be taking this on. Dr. Winthrop’s extensive knowledge and experience with our curriculum, together with excellent organization skills, make her an excellent choice for this key role
Term 3 Clinical Skills
Dr. Laura Milne directs our Clinical Skills program, which spans all four terms of the pre-clerkship, and is consistently very highly reviewed by our students and seen as a highlight or our curriculum. For the past few years, Dr. Basia Farnell been directing the Term 3 component of Clinical Skills, and has provided energy and creativity in revising the format and curricular content. As Dr. Farnell moves on to other challenges, Dr. Meg Gemmill, a member of the Department of Family Medicine who has been a highly regarded teacher in that course, will be a taking on it’s leadership.
Chair, Progress and Promotions Committee
For the past several years, Dr. Richard van Wylick has been providing exemplary service as chair of our Progress and Promotions Committee. In addition to very capably directing the complex activities of that group, he has developed a robust collection of policies and procedures to guide various aspects of student promotion, curricular management, student conduct and professionalism in our school. As Dr. Van Wylick has taken on other leadership roles, he has continued to direct P&P, but it is no longer either reasonable or fair to ask him to continue. Fortunately for us all, Dr. Fred Watkins, who has longstanding experience on the committee, consistently demonstrating excellent judgement and sensitivity, has agreed to take on the chairmanship.
Chair, Student Assessment Committee
With Dr. Gibson’s move to the new position of Assistant Dean Curriculum, Dr. Peter MacPherson will replace her as Chair, Student Assessment Committee. Dr. McPherson completed a Master of Education degree at Memorial University during his Pediatrics residency with an academic and research focus on medical education. He brings his experience from across the curriculum, both pre-clerkship and clerkship, to his new duties as Chair.
New Course Directors
Dr. Greg Davies has been directing the Obstetrics and Gynecology clinical clerkship rotation for the past few years. During that time, Dr. Davies has built on the success established by that department. As Dr. Davies moves toward retirement, we welcome Dr. Brigid Nee to this new role.
Over the past few years, the Pediatrics clinical rotation has benefited from the input of many members of that department, including Drs. Richard Van Wylick, Karen Grewal and, most recently, Dr. Peter McPherson. As Dr. McPherson concentrates his attention on the pre-clerkship course and new interests, we welcome Dr. Gillian MacLean.
These changes will provide much more corporate knowledge within the leadership group, since most individuals will have had experience directing multiple portfolios spanning different aspects of our curriculum. This should allow for much more effective and helpful sharing of experience and knowledge, and thus better problem solving and anticipation.
These changes are intended to begin with the new academic cycle that starts in September, but the various incoming and outcoming individuals are already developing specific transition plans to provide for smooth and effective turnover.
I thank all those who’ve been filling these positions in past years for their dedication to our students and our school. Please join me in welcoming and supporting all those moving into these new challenges.
The Rapture of the Raptors. Why do we care?
It shouldn’t matter that Kawhi Leonard decided to play basketball in Los Angeles instead of Toronto.
And yet it does.
The anticipation leading up to his decision was unprecedented. The media were in a frenzy. Speculation was rampant. Helicopters followed his every move. There were “spottings” of house sales and reported purchases of moving containers!
It shouldn’t matter that a dozen or so very highly-paid Americans won a championship for playing basketball while employed by a Toronto-based sporting corporation.
And yet it does.
The public celebration, the pride, the pure, unadulterated joy this brought to the people of Toronto and, indeed, all of Canada, went far beyond anything experienced by most living people, and rivalled the memory of celebrations triggered by the end of world wars.
It shouldn’t matter whether Canadian-born hockey players fail to win the gold medal at a two week long international tournament played every four years.
And yet it does.
It’s viewed as a national shame and calamity, eliciting much hand-wringing, introspection, and calls for reviews, re-focusing on “priorities” and enhanced commitment.
There is, undeniably, something about sports and our identification with teams that simply transcends logic or rational thought. It goes far beyond our collective interest in politics, environmental concerns or the economy.
Just this past week Lisa MacLeod, a provincial cabinet minister, was required to apologize for unleashing an obscenity-riddled diatribe upon the owner of a professional hockey team. In her tweet, she tries to justify the attack:
“Let me set the record straight, I gave @MelnykEugene some feedback at the Rolling Stones concert and I apologized to him for being so blunt. I have serious concerns about the state of our beloved Ottawa Senators!”
One of my favourite history writers, Pulitzer Prize winner Doris Kearns Goodwin, writes in her memoir “Wait Till Next Year” of her “childhood love” of the Brooklyn Dodgers and her “desolation when they moved to California”.
And I certainly can’t claim to be immune. I find the current mediocrity of the Blue Jays a personal offense and, for the past 50+ years, have gone into an annual spring funk when the Maple Leafs make their inevitable and ignominious exit from the playoffs.
Why do I care? Why do any of us care?
Certainly, there’s no question that the passion is real.
For those who need convincing, I would refer them to a 2008 article by Ute
Wilbert-Lampen and colleagues (NEJM 2008;358:475-483). They looked at the
incidence of cardiac events in the greater Munich area during the 2006 World
Cup of soccer. On days when the German team was playing, the incidence was 2.66
higher than during control periods (p<0.001). Men were more likely to be
affected (3.26 times higher), but women were affected as well (1.82 times
higher). There were clear spikes on days, and times, that the German team
played, as illustrated below, points 5 and 6 being days Germany was playing the
most critical games (Game 6 being their loss to eventual champion Italy, I
might point out):
Need more convincing? Consider a study carried out by Paul Bernhardt as part of his doctoral project. He measured testosterone levels in male spectators of sporting events, specifically basketball games at Georgia State University (Physiology and Behaviour 1998;65:59-62). He found that levels rose in a pattern similar to that of the players during the game, and decreased in the fans of the losing team. It seems that rabid fans are very much “in the game”.
But what’s driving all this?
Psychologists and sociologists have explored the topic. Theories abound. Some believe team fanaticism allows for permission to step out of everyday lives and take on a different, more outgoing persona. The term “deindividuation” has been bandied about, which seems to mean that you can behave in a crowd in a way you never would alone. There’s a certain connection that occurs between fans of the same team that appears to promote self-esteem and carries over to everyday life. Terms like “relationship” and “bonding” have been applied to what happens between fans and their team.
Daniel Murray is a psychology professor at Murray State University. In his book “Sport Fans: The Psychology and Social Impact of Fandom”, he presents a combination of research and theory and makes a case that fandom promotes a sense of belonging, and overall psychological health. It appears to happen even if your team is unsuccessful – witness the Chicago Cubs whose fan base remained loyal despite not having won the World Series for 108 years or, dare I say it, our long-suffering Maple Leaf fans.
The term “Basking in Reflected Glory” (BIRG) has been used to describe the tendency to identify with successful teams and is ascribed to Professor Robert Cialdini who observed that the usage of team apparel in high school and college students varied in concert with the success of school teams. No surprise, I’m sure, to vendors of Raptors jerseys these past few weeks.
There are certainly positives to all this. In addition to transcending logic, sports fandom also appears to transcend issues of race and economic disparity. Sports appear to have a power to unite our society in a way that goes far beyond anything that can be achieved through any public policy. The Raptor players, taking in the adoring multitudes that turned out to celebrate their recent success, commented on the visible diversity of the crowds, something they’d not seen previously.
In the end, I would suggest that all this is about something much more fundamental. We have a basic human need to belong, to connect with others, to be part of something greater than ourselves. We can call it family, community, religion, social group, tribe, any or all of the above. We need to belong. We may wander, but will always identify with “home” and, to some extent, yearn to return. Allegiance with a particular team seems, to some extent, to address that need. For some of us, it’s ingrained in childhood and difficult to expunge (as much as we might like to). For others it’s acquired along the way, but no less real.
Returning to the topic at hand, what are we to make of Mr. Leonard’s recent departure? Certainly, it wasn’t motivated by monetary considerations or need to find a winning team, since he’d already achieved both those goals. In the end, his motivation seems to be something that the millions of fans who wished him to remain in Canada can easily understand. Having been born and raised in Southern California, he didn’t so much reject Toronto as he chose to return to his own home, his own roots. Not many professional athletes have that option, and we should not begrudge him the choice. How many of us, given the same circumstances, would do the same? In the end, it’s about home It’s about belonging.
Can admissions committees measure adversity? Should they?
“If you can’t measure it, it doesn’t exist.”
This was the mantra of a former mentor and research supervisor with whom I had the opportunity to work during my fellowship. In the early days of Echocardiography we, and many others, were working hard to bring some degree of quantitative rigour and credibility to a developing imaging modality which, at that time, consisted of rather blurry black and white recordings of the beating heart on a small screen. The images could be photographed and even videotaped. As such, they were remarkably informative to the person obtaining the image and treating the patient under observation, but the technology provided no inherent measurements and could not be transmitted to referring physicians. If Echocardiography was to have sustaining value as a service to the larger medical community, most contended, it must yield measurements that would differentiate normal structure and function from the pathologic. Hence countless postulates, projects, manuscripts, publications and fellowships, including mine.
In most cases these efforts to derive measurements and “normal ranges” from moving images have been of great clinical value and has advanced patient care. However there have been, and continue to be, numerous instances where over-zealous attempts to quantitate have caused misinterpretation, often due to over-simplification of a complex image or set of images that has much more value to the observer than any static measurement can convey. Trying to compress the meaning of an image into a set of simple measures will always have inherent limitations. What numeric value could one apply to da Vinci’s Mona Lisa that would convey even a fraction of what the human eye and mind can perceive in a few seconds of observation?
Recently, considerable controversy has arisen in the United States as a result of attempts to incorporate measurements of adversity into the college admission process. The Scholastic Aptitude Test (SAT) is undertaken by American high school graduates and is a key component of their application to colleges and universities. It is widely considered to be a primary driver of admission decisions in an environment where admission to “top tier” universities is highly competitive and, recently, the subject of criminal prosecution in the United States.
This new score, dubbed the “Adversity Index” is a composite of 15 factors, including measures of crime rate and poverty in the neighbourhood in which the applicant has been raised and an assessment of the “quality” of the high school attended.
It provides a score scaled between 1 and 100, with higher scores indicating greater degrees of “disadvantage”. The Adversity Index is not used to adjust SAT test scores in any way, but provided separately to admission committees, presumably to “contextualize” the scores as they see fit.
The intent appears to be to level the admissions playing field that most agree favours applicants from wealthier backgrounds who can attend more academically rigourous high schools and benefit from more time and support for academics. It is also felt to identify students who have overcome personal adversity and demonstrated commitment and resourcefulness in order to achieve their success. The New York Times article cited above quotes Mr. David Coleman, CEO of the College Board:
“Merit is all about resourcefulness. This is about finding young people who do a great deal with what they’ve been given. It helps colleges see students who may not have scored as high, but when you look at the environment that they have emerged from, it is amazing.”
As one might imagine, not all agree. American College Testing (ACT) provides an alternative admission test for college applicants. Its CEO, Mr. Marten Roorda states the counter-argument in a recent blog post:
“The algorithm and research behind this adversity score have not been published. It is basically a black box. Any composite score and any measurement in general requires transparency; students, teachers and admissions officers have the right to know. Now we can’t review the validity and the fairness of the score. And even if that changes, there is also an issue with the reliability of the measure, since many of the 15 variables come from an unchecked source — for example, when they are self-reported by the student.”
All this comes about at a time when college and university admission processes are under siege as a result of a number of highly publicized reports of inappropriate influence exerted by wealthy and influential parents.
The repercussions and resulting enquiries have uncovered dubious practices, even in venerable institutions.
And so, what are we to make of all this? Does any of this translate to Canada, and specifically to medical school admission, certainly among the most competitive choices available to young people? A few key questions and postulated answers. (Please note: following are the opinions of the author, and the author alone).
Q. Does wealth and privilege facilitate admission?
A. Almost certainly yes. For further discussion see previous blogs:
Does every Canadian have equal opportunity to pursue a Medical Education?
Medical School Admissions: Unintended Consequences
Medical Student Debt: A problem, or shrewd investment?
Q. Do we wish to admit a more diverse student population, including students from traditionally socioeconomically disadvantaged groups?
A. Yes. All medical schools have engaged this challenge in various ways. At Queen’s both the medical school and university have made clear statements to this effect.
Q. Do adversity experiences build qualities desirable in medical school applicants?
A. They may, but not necessarily. Simply experiencing adversity is not sufficient. That experience must have resulted in a valuable learning experience that has contributed to the applicants ability to choose and undertake a career in medicine. In fact we must recognize that adversity experiences, unfortunately, have the potential to be highly damaging.
Q. How does “disadvantage” equate to “adversity”.
A. They correlate, but not precisely. To use an example from the cardiology world, sedate hypercholesterolemic people are at higher risk of developing premature ischemic heart disease, but they may not, and many active folks with normal cholesterol levels will. This is the nature of a “risk factor”. Lower socioeconomic status certainly puts one at risk for greater life adversity, probably at a linear fashion where poverty levels virtually guarantees adversity. Conversely, socioeconomic stability certainly provides no immunity from adversity experiences.
Q. Will an Adversity Index developed from compiled demographic and self-reported data provide a valid reflection of a student’s development and preparation for a career in medicine?
A. In and of itself, probably not. The information upon which it is based is inherently flawed, imprecise, and subject to manipulation.
Q. Will an examination of personal adversity and its impact on personal growth be helpful?
A. Yes. The study and practice of medicine requires commitment and resilience, both of which can be developed by adversity experiences successfully engaged.
And so, examining disadvantage is essential to addressing diversity goals, but Admissions Committees must develop robust methods to determine if adversity has been experienced, and what impact has resulted from those experiences. A numerical index such as that developed by SAT may provide a useful starting point, but is no more revealing than is a linear dimension obtained from recordings of the beating human heart.
“We’re all Chinese”. The freedom to express our diversity…or not.
I recently had the opportunity to visit a Chinese medical school and spend some time with both faculty and students. The leadership of the school was interested in pursuing North American accreditation. I was part of a team invited to advise about the state of compliance with those standards, and to help prepare the faculty and curricular leadership for the review process.
The visit was organized in the style of a typical accreditation visit, structured as a series of interviews with groups of faculty, curricular leaders, students and administrative staff. Each meeting was typically focused on a subset of standards.
One such meeting, which I’d been dreading, involved the accreditation standards dealing with the issue of Diversity. I was not at all sure how the North American sensibility regarding diversity would translate to such a different cultural and political setting, and was concerned about inadvertently causing some offense to our hosts, who had been nothing but gracious.
The meeting involved about ten faculty and administrative staff. They were chosen, in part, because of facility in English, but their understanding and ability to express responses varied considerably. As a result, questions were often followed by spontaneous conversations in Mandarin where those with better understanding would translate to others and, presumably, responses were considered and formulated. These “huddles” sometimes got quite animated and the tone and gestures themselves seemed very revealing.
The preliminary questions for this particular session were quite straightforward, generally confirmation of factual information. All was going along quite smoothly with a generally light and friendly atmosphere in the room. Then, and in the interest of simulating a true accreditation visit, I probed further. “And how do your admission practices and curriculum recognize the diversity of your population?”
The previously relaxed and animated group went quiet, all eyes on me. After what seemed like a very long pause, the faculty member who’d been the lead discussant for the group asked me to clarify what I meant by “diversity”.
I tried to explain that North American medical school standards required a commitment to social accountability, a component of which was the recognition of cultural, gender and ethnic differences in the students and society they would eventually serve.
My explanation was translated to the group, followed by the most animated and prolonged exchange they’d had to date. The other panel members and I sat back taking all this in. The expressions and tone suggested confusion, perhaps mild offense and considerable concern about how to respond.
After what seemed like quite a long and somewhat uncomfortable time, the lead faculty member turned to me and said simply, “We’re all Chinese”.
With more than a little trepidation, I decided to press on. “But I’ve read recently that there are over 50 different ethnic and cultural groups within China. Diversity also extends to issues of gender and sexual orientation. How is that diversity accounted for in your admissions and faculty appointment processes, for example?”
After another translation, an even longer and more animated Mandarin huddle ensued. Finally, the response:
“But, we’re all Chinese”.
In the interests of maintaining good relations and ensuring the review team got home safely, I decided to leave it at that.
In the ensuing months, my thoughts have often returned to that particular exchange. Of all the conversations during that visit, that was the one that brought home most clearly the differences in our societies. Fundamentally, the Chinese political structure and the values that it espouses prioritize the state over the individual. It’s not that myriad cultural, racial, religious and language differences don’t exist or are unimportant to their 1.5 billion citizens, it’s simply that those differences are considered secondary to their common, unifying allegiance to the state. They’re all Chinese first. Other characteristics, choices or preferences come second, or not at all. They have, as a society, essentially chosen to suppress or ignore their diversity.
All this is in rather stark contrast to our culture in Canada where diversity is celebrated and even legislated, permeating even our educational programs. We are free, as Canadians, to identify in (almost) any way and with (almost) any group we chose, the exceptions being organizations that are known to advocate violence or hatred in the pursuit of their particular perceptions of diversity.
I came away from all this with a deeper appreciation of the incredible privilege our society provides. The freedom to choose how one wishes to be identified is precious. It’s also easily taken for granted, largely because most of us have never had to struggle to achieve it, and have never lived without it.
What my brief and admittedly superficial encounter with Chinese culture brought home to me is that we all have the freedom to choose how we wish to engage each other, and how we collectively wish to engage the world. For any two people, indeed for any two peoples, both common and differentiating issues can be easily identified. In any encounter, from simple to profound, the parties involved face a choice. Their encounter and their ongoing relationship can be defined by points of mutual interest, or by those characteristics that divide them.
All this brings to mind the words of President John F. Kennedy who, in a commencement address at American University in 1963, at the height of the Cold War, nuclear proliferation and the constant threat of accidental or intentional Armageddon, reached out to both his own people and his global adversaries with these words:
“So let us not be blind to our differences, but let us also direct attention to our common interests and the means by which those differences can be resolved. And if we cannot end now our differences, at least we can help make the world safe for diversity. For in the final analysis, our most basic common link, is that we all inhabit this small planet, we all breathe the same air, we all cherish our children’s futures, and we are all mortal.”
How will we, as Canadians, chose to use the freedom of choice that we have inherited? From time to time, might our chosen approach to our various diversity challenges be “We’re all Canadian”?
Who decides when the job is done?
How would you choose to pay the people entrusted with fire prevention and control in your community? One would hope that, whatever the method, it provided those with the appropriate knowledge and skill the freedom to operate without interference in the interests of those in need.
Imagine a world where fire fighters were directed in their efforts by a pre-determined public policy edict that required them to stop their efforts after some defined time limit, regardless of the condition of the building or its inhabitants.
Sounds absurd, but this is exactly analogous to the concerns raised in an article that appeared in the Globe and Mail April 6th, “In Ontario, a battle for the soul of psychiatry” (https://www.theglobeandmail.com/opinion/article-in-ontario-a-battle-for-the-soul-of-psychiatry/).
In it, Dr. Norman Doidge describes his frustrations with a payment system that limits the number of encounters he can provide a patient.
While agreeing wholeheartedly with the arguments raised by Dr. Doidge, I would respectfully submit that the battle goes far beyond the practice of psychiatry. The concept that decisions about the nature and duration of any patient’s condition can or should be made on the basis of fiscal concerns and by individuals or groups under governmental influence should be seen by all physicians and their patients as repugnant. While government certainly has a responsibility to exercise fiscal oversight, it is (to use a contemporary metaphor) venturing far outside “its own lane”. Patients are individuals with unique illness experiences that cannot be conveniently categorized into tidy management algorithms. Doctors, of any specialty, must be free to undertake treatment for patients based on individual needs.
Doctors, in turn, must earn and safeguard that right. Our professional organizations should rise to the challenge posed by Dr. Doidge’s article with the same vigour that they have engaged issues of reimbursement, and the distribution of a few percentage points of income. Providing optimal patient care must trump income issues. Failure to do so rightfully condemns.
The profession and government should jointly recognize that the “covenant” between the government and people of Canada to provide universal, comprehensive health care is being broken daily, suffering death from a thousand cuts. Only with collective and collaborative recognition of that reality and engagement by a profession and government mutually focused on the interests of the people of Ontario can solutions even begin.
The fire fighters battling to save Notre Dame cathedral in Paris this past week didn’t stop their efforts until they had done everything possible. Those men and women were in a position of public trust that was not defined by the clock or budgets. Doctors are in a similar position of public trust which must be defended. I suspect Dr. Doidge will continue to care for his patient, but it will be despite and not because of our “system”. Our patients deserve better. We all deserve better.
(Portions of this article were published in the Globe and Mail April 9, 2019 as a letter to the editor)
It Takes a Village: Thanks to all involved in our Medical School Admission process
Over two weekends in March, over 500 applicants are invited to our school to undertake interviews, the final phase of our medical school admission process. They have been selected from over 5,000 who submitted applications.
That process, designed by our Admissions Committee, is the product of much thought and deliberation, with the goal of fairly and objectively matching the aspirations and attributes of applicants to those required to assure success not only in medical school, but in the practice of medicine and service of patients.
The process is a massive undertaking, requiring the participation of no fewer than 179 of our faculty and virtually all members of our first- and second-year classes. In fact, our admission process is the most resource intensive activity undertaken by our school.
Each year, I’m amazed and grateful for the willingness of our faculty and students to give of their time and energy for this purpose. File reviews and interviews are both carried out after regular work hours and on weekends, requiring sacrifice of precious personal time. Why do they do it? They recognize, I believe, that this admission process is critical not only to our success as a school, but for the future well-being of our profession and the society we serve.
Our applicants are also impressed. They consistently comment on the effort, which brings credit to our school and demonstrates a learning environment where faculty and students work together in mutual dedication to our school and profession.
I would like to recognize and extend sincere thanks to all the faculty members involved, who will be listed below. The numbers indicate those who filled multiple assignments. I’d like to particularly note the contributions of Drs. Fred Watkins and Mariana Silva, who were both involved in all aspects of both the File Review and Interview process.
I’d also like to thank our first- and second- year classes. I’d initially thought about listing them as well, but quickly realized that was unnecessary since there was essentially no one to exclude! Their presence and support of applicants speaks volumes about their support of our school, and confirms to me that the process is working well. Special thanks to first year president and vice-president Andriy Katyukha and Victoria-Lee Kim who organized their class events and made no fewer than eight presentations to applicants.
Finally, I’d like to recognize three individuals who deserve particular recognition, our Assistant Dean of Admissions, Dr. Hugh MacDonald, Admission Officer Rebecca Jozsa, and Admissions Assistant Rachel Bauder. They oversee a very complex process that ran flawlessly.
Faculty Members Involved in the Admission Process
Amy Acker (2)
Sussan Askari (2)
Allan Baer (2)
Lysa Boisse Lomax
Mark Bona (2)
Rozita Borici-Mazi (2)
J. Gordon Boyd
Cheryl Cline (3)
Ken Collins (2)
Robert Connelly (3)
Christine D’Arsigny (2)
Alexandra Di Lazzaro
Jennifer Flemming (3)
Kan Frederick (2)
Tom Gonder (2)
Mike Green (2)
Richard Gregg (3)
Andrea Grin (2)
Dianne Groll (3)
Andrea Guerin (2)
Karen Hall Barber (2)
Marisa Horniachek (4)
Robyn Houlden (3)
David Hurlbut (4)
Felicia Iftene (2)
Omar Islam (4)
Mala Joneja (2)
Cherie Jones-Hiscock (4)
Sarosh Khalid-Khan (3)
Faiza Khurshid (2)
Alenia Kysela (3)
Kirk Leifso (3)
Athen Macdonald (2)
Gillian MacLean (3)
Paul Manley (2)
Sarah McKnight (2)
Stephen McNevin (2)
Alex Menard (2)
Anne Moffat (5)
Benvon Moran (2)
Raveen Pal (2)
Stephen Pang (2)
Armita Rahmani (2)
Benjamin Ritsma (2)
David Ruggles (3)
M. Khaled Shamseddin (2)
Mariana Silva (9)
Marco Sivilotti (2)
Yi Ning Strube
Rob Tanzola (2)
Naji Touma (2)
Jessica Trier (3)
Todd Urton (3)
Janet van Vlymen
Maria Velez (2)
Ashley Waddington (3)
Ami Wang (4)
Fred Watkins (9)
Shayna Watson (2)
Hasitha Welihinda (2)
Gavin Wood (3)
David Yen (3)
Failure to Thrive in Medical School Syndrome: Signs, Symptoms and Diagnostic Approach
“Failure to Thrive” is a term well-established in the world of clinical medicine. In the pediatric context, it refers to a child who is failing to achieve anticipated developmental milestones. In the adult world, it’s more informally used to describe someone who is simply not doing well in their current circumstances, be it in hospital or in their community setting. Examples would be an elderly patient at home who is slowly declining and losing ability for independent living, or a hospital in-patient who is not improving despite what seems to be appropriate treatment.
The concept, I’ve come to appreciate, can also be usefully applied in the context of medical education. Failure to Thrive in Medical School Syndrome (FTMSS), can be engaged as we would any clinical condition, with characteristic signs and symptoms.
There are six key cardinal signs or manifestations of FTMSS. These include:
- Poor academic performance.
- Absenteeism, or habitual lateness for scheduled events.
- Habitual failure to meet established deadlines for submission of academic reports or administrative requirements.
- Inter-personal conflicts with peers, administrative staff or faculty.
- Poor or unprofessional behaviour in the academic or clinical setting.
- Lack of attention to surroundings, or personal appearance.
Symptoms of the FTMSS sufferer might include lethargy, fragile confidence, diminished sense of self-worth, agitation, defensiveness, anxiety.
As with the approach to any medical syndrome, the objective is not simply to make a diagnosis, but to establish the underlying cause. Understanding the mechanism by which this syndrome develops is essential to helping the sufferer deal with the affliction, establishing appropriate treatment, and hopefully starting down the road to cure.
All the manifestations of FTMSS have the common feature of not being attributable to any intrinsic limitation on the part of the afflicted individual. Having come through the intensely competitive medical school admission process, it seems reasonable to assume that every medical student is fundamentally capable of performing academically, being on time, meeting deadlines, relating reasonably well to others, attending to their personal appearance and behaving professionally. Failure to do any of these things can therefore can reasonably be attributed to some external cause.
And so, what are the root causes of FTTMS? At this point, a disclaimer seems appropriate. In the absence of any tested and proven pathophysiological mechanism for the condition, I provide postulates based on many years of observation of afflicted individuals, perhaps as a basis for clinical management and hypotheses for future clinical trials. That being said, and in no particular order, here goes:
- Failure to adjust to medical education. The medical school curriculum, learning methods and, importantly, the use of assessment in medical school can vary considerably from many other undergraduate programs. Fundamentally, the goals of education are no longer strictly about the aspirations of the learner, but rather geared to preparation to meet the needs of future patients. This change in focus can be somewhat unsettling for some. Moreover, the curriculum can be intense and demanding. Educational methods include much small-group and collaborative activities, as well as required independent learning. Assessments can be frequent and geared not towards short term retention and determining comparisons with other learners, but in assessing individual achievement with respect to learning objectives. In medical school, students therefore find themselves confronted with a learning environment very different than that which they’ve experienced previously. They are also asked to established individual rather than comparative goals of achievement. All this adjustment can be difficult for the student who is accustomed to learning situations which are individual, easily self-controlled and targeted to parameters of external validation.
- Lack of motivation for a career in Medicine. For many students, the decision to engage the medical school application process begins at a very early age. The process can be all-consuming and require the applicant to forgo many opportunities and experiences usually undertaken in childhood and adolescence in order to undertake educational programs and volunteer activities that they, and perhaps their parents, feel relevant to their application. The decision to pursue a career in medicine can therefore prevent a young person from engaging valuable developmental experiences or from considering other interests and potential career options. Others may enter medical school with an incomplete understanding of a medical career. As they understand more clearly what doctors actually do and what is expected of them, they may begin to realize the career is not for them. Medical education and, more importantly, a career in medicine, are both rewarding and demanding. Both require deep commitment.
- Unresolved personal issues. Medical students, like all young people, experience a variety of personal stresses and adversities. There can be a reluctance to recognize or to admit to the full impact of such stresses and to seek help. There can be a concern that admitting that one is feeling challenged or overcome by such circumstances might be seen as signs of internal weakness or unsuitability for their chosen career. There can also be a tendency to defer feelings of loss, disappointment or grief. Over time such unresolved stresses can mount and express themselves in negative ways which may lead to the various manifestations of FTTMS.
- Medical students can become ill or simply run down. Many medical conditions can be gradual, subtle and insidious. Accumulated fatigue due to lack of attention to simple things like regular sleep habits, nutrition and fitness can gradually mount and imperceptibly affect performance. Not unlike practising physicians, medical students can have a remarkable ability to ignore features of illness and fatigue in themselves which they would very quickly recognize in others.
- Mental illness. Medical students, like all young people, could suffer from chronic mental illness or develop such conditions after entering medical school. These can be very difficult to recognize in oneself and there may be stigma associated with such conditions that inhibit affected individuals from recognizing their full significance or in seeking help.
The objective of any faculty advisor or mentor engaging the FTMSS sufferer, of course, is to help the afflicted student understand the problem and therefore engage effective therapies. The clinical approach for students exhibiting signs of FTTMS, ultimately, is not unlike that for other conditions that have behavioural manifestations. It begins with understanding and acceptance that the troublesome behaviour likely has an underlying precipitant that can be defined and therefore managed.
Diagnosis requires a thorough history focused on the potential causes listed above, and features that may help identify the underlying, culprit problem. Having identified a potential underlying mechanism, counseling is required to help the students themselves understand cause and effects. Together, management can be engaged.
What happens when none of the potential mechanisms seems to fit, and we come up with an idiopathic etiology? In my experience, this is very rare, but obviously troubling. Are we simply dealing with a poor “fit” for medicine? In such cases, we should provide compassionate support and oversight – what some clinical colleagues would term “watchful waiting”. Clarity usually emerges with time and, with it, the optimal approach becomes obvious to all.
And so, the process for assessing a medical education problem bears remarkable similarity to the process we teach and use for any clinical problem. Once again, there’s a striking parallel between patient care and medical education. Doctors instinctively engage their students as they do their patients. Without judgement, but rather thoughtful contemplation of how observed manifestations reveal underlying mechanistic causes, leading to understanding and, with it, effective intervention.
Evaluating the Student Experience: Assessing satisfaction is important, but not enough
“Universities are centres of learning, not teaching”
These were the words, uttered many years ago, by a former professor and teacher in response to some very demurely and deferentially expressed comments about the quality of lectures being provided in a particular medical school course. The message, directed to me and a couple of my classmates, was pretty clear. The university and faculty would provide opportunities to learn, in whatever manner they felt appropriate. It was not for us, as mere students and consumers, to question the methods. The responsibility for our education was ours.
In fact, in recent discussions with a number of my medical school contemporaries who I’m fortunate to meet with regularly, none of us could recall, during our four years of medical school, ever being asked for feedback of any kind about our educational program. If such processes existed, either internal or external to the school, they were largely invisible to the students of that time. This was certainly not unique to our school. For our generation, medical education was very much a “take it or leave it” proposition.
This is not to say we didn’t get excellent teaching, role modelling and mentorship. We certainly did, and many of us found our inspiration for education in those early experiences. It’s also almost certainly true that many of the teachers of that time quietly observed and responded to the impact of their methods on their learners. However, the culture of the day simply did not provide methods by which the student experience could be collected and analyzed.
This rather parochial approach was not exclusive to medical education. Patients of the past were rarely, if ever, surveyed for feedback about the quality of care they received from institutions or individual physicians. Corporations and businesses largely allowed the public to “vote with their feet”. If the product wasn’t good, people wouldn’t buy it, or would simply walk away.
Clearly, things have changed.
In the business world “Consumer Satisfaction” is an industry in itself. Successful businesses aggressively seek out customer feedback because they have learned that responding to real or even perceived needs drives future spending. IBM has taken this a step further. They go beyond the need to ask questions and, instead, are building and offering services that track consumer behaviour and provide that information to service and product providers. To quote from their site:
In health care, knowledge of the patient experience is now considered essential to a well- run institution. Hospitals are expected, through accrediting processes, to actively seek out patient perspectives
The Agency for Healthcare Research and Quality operates within the U.S. Department of Health and Human Services. Its mission is “to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable”. To quote from their site:
“Understanding patient experience is a key step in moving toward patient-centered care. By looking at various aspects of patient experience, one can assess the extent to which patients are receiving care that is respectful of and responsive to individual patient preferences, needs and values. Evaluating patient experience along with other components such as effectiveness and safety of care is essential to providing a complete picture of health care quality.” (https://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html)
They make an important distinction between patient satisfaction and the patient experience. Satisfaction is a subjective impression of a patient’s interaction with an institution or individual, and is largely based on whether their personal expectations were met. The patient experience relates to gathering information, available only through patient reporting, that is relevant to determining whether certain institutional goals are being achieved.
A person test driving a new automobile, for example, is able to report on both the driving experience (acceleration, braking, ease of handling, visibility etc…) and their personal satisfaction (enjoyment, comfort, excitement) driving the car. To those designing and building the car, evaluating the driving experience allows them to determine if the equipment and concepts they developed are working as expected. Evaluating driver satisfaction determines whether the consumer is getting what was expected from the car, which may be unclear to the designers. Both are relevant to success. Both are certainly relevant to the likelihood that the consumer will purchase the car.
In medical education, the value of student feedback is widely appreciated and schools go to considerable effort and expense to collect it. In fact, the systematic collection of feedback is mandated by accreditation standards, and the evidence required to establish compliance with those standards is based largely on student feedback. The distinction between measurements of the student experience and student satisfaction is relevant, both being important goals. Systematic Program Evaluation must encompass both.
At Queen’s, we recognize that many goals of our educational program can only be fully assessed with the perspective of those actually experiencing and living the process. We also recognize that a full picture only emerges if many points of feedback are provided. We have therefore put in place many and varied opportunities for students to provide both their personal perspectives and objective observations.
After each course, students are invited (and expected) to provide feedback that consists of responses to questions exploring pre-determined educational objectives, and provision for narrative commentary in which they can elaborate or explore other aspects. Those end-of-course evaluations also provide opportunity to provide similar feedback regarding the effectiveness of teaching faculty.
We receive and carefully review the results of course-related examinations undertaken by our students, not only to gauge their learning, but also the effectiveness of the teaching and learning opportunities provided.
We anticipate and review closely the results of external examinations undertaken by our students, such as the Medical Council of Canada Part 1 and 2 examinations, and all National Board of Medical Examiners tests we utilize. These provide valuable comparators to other institutions and, to a limited extent, further feedback about our teaching effectiveness.
The Canadian Graduation Questionnaire is completed annually by all graduating medical students and provides a comprehensive review of all aspects of their educational experience. We review it in great detail, and many aspects of the CGQ are incorporated into the accreditation process.
We have established a Program Evaluation Committee that, for the past few years has been under the leadership of Dr. John Drover. That group collects, collates and analyzes data from a variety of sources to provide an overarching analysis of our performance relative to our programmatic goals. The PEC recently released a comprehensive report, which has been passed along to the Curriculum Committee for analysis and action. I am very grateful to Dr. Drover who has generously and effectively provided PEC leadership. He is now passing that role along to Dr. Cherie Jones as she assumes her role as Assistant Dean, Academic Affairs and Programmatic Quality Assurance.
We have also developed a number of more informal ways by which students can provide feedback.
We meet regularly with student leadership and curricular leads to get “on the fly” feedback about courses as they are taught. This often causes us to undertake adjustments or provide supplemental content even before the course is completed.
We provide numerous ways in which students can report personal distress or incidences of mistreatment at any point during their medical school experience. These range from direct contact with selected faculty members, our external counselor (who can be contacted directly and is completely segregated from faculty or assessment) or submission of reports that can be embargoed until a mutually agreed to time. All these are outlined in our policies and accessible through convenient “Red Button” on MedTech.
I have found “Town Halls” to be very valuable sources of feedback on all aspects of the MD program. These are held at least once per term with each class and consist of a few “current events” items I provide, followed by “open mike” time when students are invited to bring forward any commentary or questions they may have, about any aspect of the program. The issues that emerge and dialogue among students in attendance can be highly revealing and have certainly provoked new directions and changes over the years.
Recognizing that not all students are comfortable with speaking out, or may not wish to be identified as they raise sensitive issues, a confidential portal was established on MedTech a number of years ago. Students are able to provide their commentary in a completely anonymous fashion if they wish. My commitment is to read and consider (but not necessarily act on) all commentary provided, and to respond personally if students choose to identify themselves. To date, I have received almost 500 such submissions, about 70% of which are provided anonymously. The commentary has been thoughtfully provided and has spanned all aspects of our program and learning environment. Importantly, it often brought to light issues that had not previously emerged in any other way.
In all these ways, student feedback has become a continuing, multi-faceted component of our school and, more broadly, our learning environment. It goes beyond being a mechanical, mandated exercise and data collection. It is embedded and cultural. It is what we do. It is who we are.