Author: Anthony Sanfilippo
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.
Residency Match Day 2019: What our students are experiencing, and how to help them get through it
If life were a roller coaster, our fourth year students have, for the past few months, been on quite a wild ride, slowly rumbling upward, gradually ascending to the summit, stopping for a moment as they stare downward to a distant, small landing point, readying themselves for a rapid and rather scary descent.
The process by which learners transition from undergraduate to postgraduate medical education has evolved into a rather jarring and extremely stressful experience (don’t get me started – a subject for another blog/rant). It has required them to not simply consider what specialties are best suited to their interests and skills, but engage an application process that requires strategic selection of elective experiences, preparation of voluminous documents, meeting multiple deadlines (twelve, no less), and commitment of personal time and expense to travel and interviewing which, for many, spans the country in the midst of the Canadian winter.
This year, the roller coaster reaches its summit at 12:00 noon on February 26th. The much anticipated Residency “Match Day” is when all fourth year medical students in Canada learn which postgraduate program they will be entering. By approximately 12:00:05 that day, all students will know their fate. As you can imagine, there will be much anticipation and anxiety leading up to the release. For most (hopefully all), the roller coaster ride will end with the exhilaration and satisfaction of having successfully overcome the process. For a few (and hopefully none), it will bring a realization that their efforts to date have not been successful, that their ride is not yet over, and they have to begin again. They will be profoundly disappointed, they will be afraid, they will be confused. They will need the understanding and help of the faculty who are currently supervising their training, and much help from our Student Affairs staff.
This year, we are again prepared to provide all necessary supports, but there are a few changes to the process which I’d like to clarify for both students and the faculty that will be supervising them that day:
- Unlike previous years, our Undergraduate Office will not automatically receive match results the day before the full release. However, students have the option of directing CaRMS to release their results the day before (February 25th) if they fail to match. They can do so by going into the CaRMS website and providing the appropriate permission.
- Any unmatched students who have
allowed early release will be contacted directly by myself to notify them of
the result. This is for three purposes:
- to arrange for immediate release from clinical duties
- to allow the student some time to prepare for the release moment the following day when most of their classmates will be hearing positive results
- to arrange for the student to meet our student counselors who will provide personal support and begin the process for re-application through the second iteration of the residency match.
- Unmatched students who did not opt to provide early release will similarly be contacted and offered the same support and services after we get their results on match day.
- Because we may not have full information in advance, we have decided to release all students from clinical obligations beginning noon on match day, until the following morning.
I’d also like to remind all faculty supervising our fourth year students on or around match day to anticipate that your student will be distracted. Please ensure your student is able to review the results at noon. If you sense he or she is disappointed with the result, please be advised that the student counselors and myself are standing by that day to help any student deal with the situation and provide support.
Fortunately, we have an outstanding Student Affairs team which has been working hard to guide the students through the career exploration and match process, and will be standing by to provide support for match day and beyond.
The team can be accessed through our Student Affairs office firstname.lastname@example.org, or 613-533-6000 x78451.
Thanks for your consideration, and please feel free to get in touch with myself or any of the Student Affairs Team if you have questions or concerns about Match Day or beyond.
A Brief History of Walls
Are walls effective? As we’re all aware, this seemingly innocent question has become a focus of considerable controversy for our neighbours to the south. Of course, it’s not about the sort of walls that separate rooms of your house, or the barriers around your property that deter trespassers and prevent your dog from molesting your neighbour’s flower bed. Rather it’s about massive barricades erected by political leaders to prevent or control the movement of large populations of people at borders. As it happens, there’s a rather interesting and intriguing history of such structures, both real and mythical.
Publius Aelius Hadrianus Augustus (76-132 AD) ruled when the Roman Empire was at its peak and is considered by many historians to be one of the “good emperors”. He seemed less interested in further expansion than in consolidation and security of his already vast empire. As part of that approach, he commissioned the building of a wall to define and secure the northernmost extent of the empire. Construction of Hadrian’s Wall began in AD 122. The wall is composed mostly of stone and is about 10 feet wide and up to 10 to 20 feet in height. The wall connects a series of fortifications located every 5 (Roman) miles. It runs about 73 miles, from the banks of the River Tyne near the North Sea in the east, to the Solway Firth on the Irish Sea to the west. It required a garrison of about 1,500 men and was intended to prevent the “barbarians” (ancient Britons and Picts) from troubling Roman Britain.
Hadrian’s successor, Antoninus Pius, seemed to like the concept but felt the boundary should be expanded and so, in 138 AD constructed a second wall about 100 miles to the north. The Antonine Wall was 40 miles in length. Despite the wall, Antoninus was unable to contain the northern tribes and so subsequent emperors abandoned his wall and re-occupied Hadrian’s Wall.
Today, Hadrian’s Wall is a tourist destination. It was declared a World Heritage Site in 1987, but remains unguarded. Tourists commonly climb and stand on the wall, although this is not encouraged for fear of damage to the historic structure.
The Walls of Troy
Troy was an ancient city located on the northwest coast of Turkey.
Archeological research of that site has revealed that it has been inhabited since about 3000 BC. Dutch researcher Gert Jan van Wijngaarden notes in a chapter of “Troy: City, Homer and Turkey” (University of Amsterdam, 2013) that there are at least ten settlements layered on top of each other.
It is not clear whether the ten year siege by Greeks led by King Agamemnon and described so famously in Homer’s Iliad is wholly or even partially true, but both the legend and the archeologic evidence indicate that the city was, at one time, surrounded by a rather impressive defensive wall. Van Wijngaarden notes that deep under the surface evidence exists of a“small city surrounded by a defensive wall of unworked stone.” In the period after 2550 B.C, the city “was considerably enlarged and furnished with a massive defensive wall made of cut blocks of stone and rectangular clay bricks”.
The legend, of course, indicates that the Trojans were able to hold out for ten years, but the wall was eventually overcome not by force but by clever deception: Ulysses famous “Trojan Horse”.
The Walls of Babylon
Babylon was a city and city-state located in Mesopotamia and a dominant presence in the world for over twelve centuries, ending about 600 BC. It was a key commercial and cultural centre and it is believed that, at various times, Babylon was the largest city in the world, and perhaps the first with a population exceeding 250,000.
A prominent feature of Babylon were its extensive walls. Various rulers would add successively to the work of their predecessors. Nebuchadrezzar II surpassed most by fortifying the existing double wall and actually adding a third. He also added a separate wall north of the city between the Euphrates and Tigris rivers. Considered to be over 100 feet high at points and extending 41 miles, both the sheer magnitude and artistic features of the walls were remarkable, notable particularly for the “hanging gardens”. They are considered one of the “Seven Wonders of the Ancient World”.
Extensive efforts have been made to excavate various components of the ancient city, which has been partially reconstructed as a historic and tourist site. Unfortunately, the reconstruction has been damaged by the development of oil pipelines and military conflicts. In April 2006, American Colonel John Coleman, former Chief of Staff for the 1st Marine Expeditionary Force, issued an apology for the damage done by military personnel under his command.
The Great Wall of China
Perhaps the most famous extant wall in the world was built to protect the then northern border of China from invasion by various nomadic tribes. The “Great Wall” was actually built in portions over several centuries beginning in the 7th century BC
and finally enlarged and united into a single structured with embedded towers and fortifications. The main construction of the existing wall dates to the Ming Dynasty (1368-1644).
In addition to its defensive purpose, the wall also had a border control function, controlling immigration and, serving as a tariff collection station for goods being transported along the “Silk Road” between eastern and western markets.
It extends 21,196 km making it clearly the most extensive wall ever constructed. Whether it is the only man-made structure visible from space is a point of contention. There has never actually been a recorded “sighting” from space, although a Chinese astronaut in the space station claims to have taken a photograph using high resolution equipment. What is clear is that it is a UNESCO World Heritage Site and a symbol of modern China. Although many portions of the wall are in disrepair and eroding, it remains an extremely popular tourist attraction, arguably, the world’s most sought-after selfie opportunity.
The Berlin Wall
A more contemporary example is the Berlin wall that physically divided that city between 1961 and 1989. Its history is both fascinating and instructive.
After World War II, the Potsdam Agreement determined that the victorious allies would divide Germany into four zones of occupation controlled by the United States, the United Kingdom, France and the Soviet Union. The German capital, Berlin, was the centre of administrative control of all four powers and so was similarly divided into four sectors. However, Berlin was entirely within the Soviet controlled portion of former Germany. Within a short period of time, political tensions mounted between the Soviets and the other three nations, largely related to the Soviets’ reluctance to agree to the Marshall Plan which called for the reconstruction, self-governance and economic support of post-war Germany. The United States, United Kingdom and France decided to proceed nonetheless, uniting their portions into a single country which came to be called West Germany (officially, the Federal Republic of Germany), with a capital located in Bonn. East Germany (known as the German Democratic Republic) emerged as a separate and Soviet controlled state, with its capital in Berlin. This left Berlin under divided governance but entirely within a separate and rather unfriendly state.
East Germans began to use West Berlin as a means to defect to western countries. It is estimated that 3.5 million circumvented emigration regulations by simply crossing into West Berlin and then on to West Germany and other countries. To prevent this exodus, the GDR (East German) leadership constructed a concrete, militarized wall essentially separating and isolating West Berlin within East Germany. During the time it was in place, over 100,000 people attempted to escape and about 5,000 succeeded in doing so. They were taking serious risks. According to the Centre for Contemporary History, a research institute concentrating on recent European history, at least 140 people are known to have been killed attempting to cross the wall, ranging from a one-year old child to 80-year old woman. Most believe the number to be considerably higher.
Eventually bowing to anti-communist sentiments in neighbouring countries and civil unrest, the East German government lifted restrictions on movement within Berlin in November of 1989, which led to open and euphoric celebration. People began chipping away parts of the wall until the government removed what was left of it. Germany officially became re-unified October 3, 1990.
Today, only small segments of the wall remain, including “Checkpoint Charlie”, its best known militarized crossing point. The Berlin wall is seen as a failed attempt by a government to impose its will on its citizens. Because it is so recent in our collective memory and so well documented, it has become a powerful image of oppression and courageous defiance. It too has become a popular tourist destination.
“The Wall” (Game of Thrones version)
The most famous albeit imaginary wall of our time no doubt comes from “Game of Thrones”, a hugely popular HBO series based on the fantasy novels of George R.R. Martin. A key feature is “The Wall”, a massive fortified structure composed of solid ice stretching across the northern border of the “Seven Kingdoms”. It is intended to provide protection from the various miscreants beyond, including “Wildlings” and a wandering army of frozen zombies referred to as the “White Walkers”.
Seemingly inspired by Hadrian’s Wall, this frozen barricade stretches from coast to coast, has fortifications along the way, and is manned by a garrison of exiled misfits referred to as the “Night’s Watch”. Apparently, Wildlings and White Walkers don’t swim or paddle. In any case, the wall has held up for millennia but, guess what happened at the end of last season?
(SPOILER ALERT: stop reading if you’re catching up on the series).
It comes down!!!….courtesy of a resuscitated and demonically-possessed fire-breathing dragon, no less! We’ll have to wait until next season to see if it becomes a tourist attraction.
And so, what does all this teach us about massive walls (real or imaginary) intended to separate populations of people? What themes and lessons emerge?
- They don’t work. People (even zombies) are smarter than walls, and are very capable of finding ways to overcome them. This is particularly true of people who are seeking better lives for themselves or families. Walls are static structures that can be overcome by imagination, determination and technology.
- Walls are hugely symbolic. They serve as a very visible expression of the values and priorities of those who construct them. The fences around our homes may not actually prevent a determined person from entering our property, but they certainly clarify for all the world that uninvited folks are unwelcome.
- They endure over time as artefacts, searched out and studied by historians and archeologists. They express and expose for posterity the true, unvarnished values and motives of those who constructed them. This persists long after they stop providing their original, intended purpose.
- They seem to serve as ideal, although expensive, tourist attractions.
If the planned wall does get built, can’t help but wonder how future generations will interpret the existence of a massive barricade on the southern border of a nation that also erected this other symbol at its major eastern port, proudly declaring to the world, “Give me your tired, your poor, your huddled masses yearning to breathe free.”
Service Before Self: The Legacy of George H.W. Bush
I’ve always liked George Herbert Walker Bush.
I realize, as I write those words, that it’s somewhat inappropriate and maybe even a little pretentious to use the term “liked” in reference to a former President of the United States who I never met or knew personally. It implies a familiarity I certainly can’t claim. Words like “respected” or “admired” might be more suitable, and are certainly applicable. But, in truth, “liked” is what comes immediately to mind. So, why is that? I think it’s because what has resonated with me as I’ve watched and read the various tributes since his passing a couple of weeks ago, and what probably resonates with most Canadians, are the fundamental human qualities- honesty and vulnerability-he maintained through his life. A few quotations provide insight into the character of the man.
In describing his neurologic symptoms that confined him to a wheelchair during his later years:
“It just affects the legs. It’s not painful. You tell your legs to move and they don’t move. It’s strange, but if you have some bad-sounding disease, this is a good one to get.”
While he was president, he famously indulged a life-long food preference by banning broccoli on Air Force One:
“I do not like broccoli. I’m president of the United States, and I’m not going to eat any more broccoli.”
In ending a contentious discussion with his Secretary of State James Baker:
“If you’re so smart, Baker, why am I president and you’re not?”
How can you not like someone so genuine?
Despite being what we might term a person of privilege, he seemed and acted like a regular, decent, fair and unfailingly respectful person caught up in powerful roles and great events. In terms of attitude and character he was, one might respectfully conjecture, an American that many Canadians can identify with and feel a certain kinship.
But none of that should detract from what he did or accomplished through his life. He was, arguably, the most qualified and best prepared person ever to assume the presidency, having previously served his country as a World War II combat pilot, two terms in congress, Ambassador to the United Nations, Special Envoy to China, Director of the CIA and two terms as Vice-President.
He advanced environmental concerns and worked to reduce trade barriers in North America. He led the US at a time when it was the only significant superpower in the world and could therefore have exerted unilateral authority. But he chose not to. Instead, he responded to the Iraqi invasion of Kuwait by firstly seeking the advice of the Canadian Prime Minister of the time, Brian Mulroney, and then working through the United Nations to form a multi-national coalition to engage the threat. When the former Soviet Union collapsed, he cautioned against gloating and maintained a respectful attitude. In a recent statement current Russian President Vladimir Putin provided the following tribute:
“George Bush Sr. was well aware of the importance of a constructive dialogue between the two major nuclear powers and took great efforts to strengthen Russian-American relations and cooperation in international security,”
He never wrote an autobiography, but wrote thousands of personal letters, casually composed but highly articulate and poignant, cherished by those who received them.
What is perhaps most remarkable about him is that, despite being what we might consider a “person of privilege” who could easily have chosen a life of quiet and private comfort, he made deliberate choices to engage public service, beginning with his decision to drop out of school and voluntarily enlist in the Navy at the age of 18 against family advice. He became a naval aviator undertaking 58 combat missions, during one of which he was shot down and had to be rescued at sea. That would have been enough for most people. Returning home after the war, he could easily and understandably have entered a comfortable private life as a successful businessman, but instead chose public service leading to the numerous positions and culminating in the presidency in 1988.
His family members, who have themselves taken up positions of social and political responsibility, remember his exhortation of “Service before Self”.
Perhaps the most revealing GHW Bush quotation are the words of a note he left in the Oval Office for his successor, Bill Clinton, who defeated him in the 1992 presidential election:
The last five sentences are perhaps the most telling of all and speak volumes about the author
You will be our President when you read this note. I wish you well. I wish your family well. Your success is now our country’s success. I am rooting hard for you.
Truly a life of Service before Self. A legacy and example for his nation. Indeed, for us all.