Unintended casualties of Medical Assistance in Dying

There shouldn’t be much more to say about this subject. The highly contentious and divisive issue of medical assistance in dying (MAID) has been widely and publicly discussed. From a legal perspective, the issue has been settled in Canada. Citizens can now opt to have their lives ended given they fulfill certain criteria. The medical profession and our hospitals have an obligation to support patients who qualify. Individual physicians who chose to actively end the lives of these patients will be legally protected in doing so. Those who conscientiously object are not required to provide MAID but are professionally and ethically required to support their patients in making the decision and seeking the service, which is now being provided, both in and out of our hospitals. There would seem to be no need for further debate or discussion.

However, little has been written about the impact on those involved in the care of patients opting for MAID.

I’ve recently been hearing from medical students who, in the course of clerkship rotations, became involved with patients who elected for medically assisted death. They have found the experience, to say the least, highly unsettling.

For those readers not familiar, senior medical students, in the course of their clinical placements, will become part of medical teams caring for groups of hospital in-patients. The medical student is the most junior member of that team, consisting of graduate physicians training in particular specialties and supervised by a fully qualified Attending Physician. The student is assigned a small number of patients who they are expected to assess and follow throughout their hospital stay. They report regularly on their patients to senior residents and the Attending Physician who review the patient with them and must approve all investigations, treatments and major decisions.

In the course of these rotations, medical students get to know their patients quite well. In fact, they may become the member of the team most familiar with all aspects of the patient’s history and current care, most familiar with the patient as an individual, often even meeting their family, and may become a source of support and information to the patient and family. In short, they “bond” with their patients. Because these are the first such experiences for medical students, these relationships can be quite significant for them, and very memorable. Most practicing physicians can recall with considerable detail and deep feeling patients they encountered as medical students.

When a patient assigned and followed by a medical student dies, it can therefore be quite an emotional experience for the student. They can experience a sense of very personal loss. They grieve. When that death occurs as a consequence of the medical illness under treatment, that loss and associated grief are difficult but valuable components of the learning experience. They understand that this is something that every physician must learn to deal with. Doing so is a part of professional development that must be experienced. In the learning context, senior members of the team can support them by sharing the sense of loss and their own experiences. Within the medical school environment, they can also seek help from knowledgeable and experienced advisors and counselors.

Medically assisted death brings new dynamics and challenges to physicians involved in the care of the patients.

Although always prepared intellectually for the eventuality of death as a consequence of illness, students (and qualified physicians) are not prepared either intellectually or emotionally for the concept of deliberately ending a patient’s life, even if they’re not directly involved in the final act. Coming to grips with this in the abstract is one thing, but encountering it in a person one has engaged as a patient and has gotten to know personally is quite another. No one engages medicine as a career with this purpose in mind.

We teach and practice that medical care should continue throughout a patient’s life, and that compassionate attention and care to a patient’s needs and comfort should not stop when cure is no longer possible. Participation in MAID seems, for many, very difficult to reconcile with that approach, even when carried out at the request of the patient.

Medical students on clinical rotations who have been involved with MAID situations, I’ve come to learn, are particularly vulnerable. There are a number of reasons for this. They may be reluctant to express and undertake “conscientious objection” out of fear of being seen as weak or inadequately trained. They may not be aware of that option. They may not yet be clear about their own perspectives on the issue or reactions to these situations. They are young, and for many these may be their first experiences with professional or personal loss. The playing field, therefore, is far from even.

Moreover, supervising physicians and residents who are themselves engaging MAID for the first time may be coming to grips with their own involvement and therefore uncomfortable and unprepared to counsel students involved in these situations.

For all these reasons, we need to give some consideration as to how we can best support students as they (and we) come to grips with MAID. This will involve ensuring:

  1. They understand the legislated rights of patients
  2. They understand the ethical/professional obligations of physicians
  3. They understand the procedures in place to provide MAID in their hospitals and communities
  4. They learn of the needs and how to best support patients with chronic pain and other end-of-life challenges
  5. They understand that when patients under their care die, they will experience a personal reaction they won’t be able to fully anticipate until it happens.
  6. That they know how to seek help to deal with these situations.

We also need to ensure our residents and faculty are aware and prepared to respond.


There is a danger that raising such concerns may be regarded as callous to the suffering of patients with terminal diseases, or opposition to their right to choose an option that is legally available to them. That is not the intention. The right to assisted death has been legally provided and should be honoured. However, the well-intentioned efforts to provide MAID has placed new and impactful demands on physicians and learners which were either unanticipated or ignored. We must consider these consequences as we come to grips with how this legislated right is to be provided.

In the end, there is something profoundly dissonant about expecting that those who have dedicated their lives to preserving life will also participate willingly in ending it, and without personal consequence. There is a price to be paid, and that toll may be falling on the most vulnerable among us.


Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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The Creative Spirit in Doctors: Medicine’s Two-edged Sword.

Over two full and very busy weekends in March, about 600 young people from across Canada are invited to Queen’s to apply for admission to our medical school. As they do so, they are welcomed, guided and encouraged by our first year class. Part of their welcome to our school is a video they screen for the applicants and their families, intended to entertain, but also to give some sense of our values and identity as a school and community. That video, essentially a fairly sophisticated mini-musical, is written, performed and produced entirely by members of the first year class. In fact, almost every member of the first year class is involved in some way in the production process.


Later this week (April 7th and 8th – get your tickets), our students will be putting on the latest version of Medical Variety Night “The Phantom of the Operation”. Anyone who has attended one of these productions in recent years will realize it has become much more than satirical commentary and slapstick humour (although both are still very much in evidence). MVN has become a showcase for the considerable musical and creative talents of our students, from sophisticated dance to rather impressive musicianship. In fact, as you get to know our students, you will find that a surprising number of them have deep interest and maintain active involvement in artistic pursuits. In many cases, there’s almost a reluctance to admit to such interests, perhaps fearing it may suggest a lack of focus or dedication to their burgeoning medical career.


This deep-seated interest in the arts extends to our faculty, for whom it may be submerged or “put on hold” but never fully suppressed. In the Department of Medicine, several members

ODNT members Drs. Adrian Baranchuk, Gordon Boyd, Rachel Holden, Jim Biagi, Gerald Evans, Chris Frank and David Frank.

have combined their musical talents to form “Old Docs, New Tricks” which, it seems, brings as much satisfaction to the performers as those they entertain. I happen to know a certain department head and accomplished career scientist who is a remarkably gifted classical guitarist. A cardiovascular surgeon acquaintance of mine “moonlights” as an operatic tenor. Even if not actual performers, many of the great physicians I’ve encountered and gotten to know well over the years have deep appreciation for literature, music and the arts.

This shouldn’t come as any surprise.

Albert Einstein, who had a lifelong and active interest in the violin said:


“If I were not a physicist, I would probably be a musician. I often think in music. I live my daydreams in music. I see my life in terms of music.”


Largely self taught, he also observed “love is a better teacher than a sense of duty.”



Winston Churchill possessed a remarkable creative energy that found expression in multiple ways. He was a prolific amateur painter, and also enjoyed bricklaying fences, gardening and breeding butterflies at Chartwell. His two great literary contributions The Second World War and A History of the English Speaking Peoples read not as dry historical accounts, but as personal memoirs written in a highly engaging narrative.



Scratch the surface of greatness, it seems, and an artistic temperament usually emerges.


So is all this just coincidental? Do bright people just naturally engage multiple interests, or is there a connection between career success and a creative, artistic personality? Are there particular lessons here for the medical profession, and for medical education? I’m sure there are many, but I would highlight three:


Creativity is creativity.

Whether it is conveyed in music, words, or scientific innovation, the expression of new ideas, or interpretation of existing ideas in fresh and unexpected ways, is the essence of the creative process. This does not apply only to research. Because every patient and every clinical situation presents unique challenges, the effective physician is required to continually develop creative approaches. Our best administrative minds are able to “think outside the box”. Algorithms, practice guidelines and standard approaches can only take us so far.


It broadens our appreciation of the human experience.

Creative art, in any form, is fundamentally an attempt to express some aspect of the human experience, and hold it up for all to see, consider and learn from. David Skorton, a cardiologist (and jazz flautist) who is currently head of the Smithsonian Institution perhaps expressed this best in an impassioned keynote address at the recent annual meeting of the American College of Cardiology entitled “Medicine Needs Art to Flourish”.

“There is a reason we hang art on our walls and venture out to hear live music and watch theatrical productions. There is a reason the words of Shakespeare or Angelou or Springsteen move us. There is a reason we gather in temples, cathedrals, libraries and museums. The reason is that we learn fundamental truths about ourselves.”

Those truths, I would argue, are critical to the practice of medicine.


It promotes wellness.

At the risk of being overly simplistic and offending those much more knowledgeable in such matters, let me simply say that I believe the creative process is good for us. There is something fundamentally and rather profoundly satisfying about producing something new and uniquely personal. Whether it’s music, performance, creative writing or whatever doesn’t seem to matter. It doesn’t even matter whether it is carried out privately or very publicly. Creative expression somehow connects us with ourselves and with the world in a way that is validating and allows us to better face all our various challenges. We need it. We crave it. It’s almost intoxicating. If you need convincing, watch the expressions and body language of students or physicians as they engage their various artistic interests. Consider how many immensely talented young people engage careers in the arts with little prospect of personal security, or even opportunities to indulge their passion. Again quoting Einstein, who knew a thing or two about the creative process, “I know that the most joy in my life has come to me from my violin.”


So the advantages seem obvious. A creative mind and artistic spirit provide an ideal starting point and are quite probably essential to learning and practicing medicine. It could even be considered quite natural that creative thinkers will be drawn to careers in medicine. But, as with most natural processes, there are counterpoints, or consequences to consider.


The artistic spirit follows its own path and naturally resists external control. Since the profession so often attracts these free and independent thinkers, developing consensus and unified approaches to controversial issues can be hugely challenging. This reality is in rather public and painful display in Ontario at present and, I’m sure, at any department or practice group meeting. Doctors will never be found marching lockstep for any cause, or at least not for long.


Leadership within the medical profession is therefore a considerable challenge for those who bravely take on such positions. To be effective, that form of leadership must be much less about exerting authoritarian control and much more about harnessing and nurturing the considerable creative and highly-motivated energy available. That harnessing and nurturing takes interpersonal skill, patience, energy and self-sacrifice, a rare but very valuable combination of attributes.


The other unfortunate consequence of an artistic spirit engaged in work that demands high level performance of repetitive tasks is restlessness. Creative minds require continual and changing challenges. Put simply, they get bored doing the same thing, even if that thing is critically important and demands perfection. Failure to recognize this, I would conjecture, leads to job dissatisfaction and what we might identify as “burn out”. On the other hand, recognition of this issue by both the individual and those in leadership positions can provide opportunities to harness that creative restlessness and use it to great advantage, salvaging careers while strengthening groups and institutions.


So the artistic temperament can truly be regarded as both a great advantage and potential liability for the profession. Like the metaphorical two-edged sword (or scalpel), it can be very effective, but must be grasped carefully and handled skillfully.




Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Embracing a Proactive, Preventive Approach to Student Wellness


Preventive medicine: Medical practices that are designed to avert and avoid disease. For example, screening for hypertension and treating it before it causes disease is good preventive medicine. Preventive medicine takes a proactive approach to patient care.


Clinical medicine and medical education often intersect in intriguing ways. The concept of Preventive Medicine, defined above, is well understood and accepted in medical practice. Fundamentally, the concept involves:

  1. Identification of modifiable conditions that promote development of a particular disease, called “risk factors”. (The term “modifiable” is key here, since many known risk factors, such as family history and age, are beyond our ability to influence).
  2. Detection of those who harbour the risk factor
  3. Development and implementation of strategies or treatments to prevent or neutralize the culprit risk factor


In my own field of cardiology, hypertension, hypercholesterolemia, and smoking are among the most well established risk factors, all known to contribute to the development of coronary and cerebral vascular disease. All are modifiable through lifestyle changes and appropriate application of medications.

The challenge of preventive medicine, of course, is that folks who have these risk factors are unaware and feel fine before they actually develop symptomatic manifestations of vascular disease. It’s therefore often difficult to detect them and, once detected, convince those at risk that they should change their lifestyle or accept the need to take a medication (with potential for unwelcome side effects). The challenge for physicians promoting and practicing Preventive Medicine is therefore considerable. It requires them to not only be aware of the science and evidence related to risk modification, but to develop personal and effective relationships with their patients. It requires much more than dogmatic pronouncements. “Do what I say because I know better” seldom works, or survives the first minor adverse effect. It requires, dare I say it, a relationship of trust. Patients accept preventive treatment not because of the diploma on the wall, but because of they trust the intentions and motivations of the person providing the advice. That trust, in turn, is rooted in a distinctly human and interpersonal perception that the physician truly cares for them and is making recommendations solely on that basis. Patients, I’ve come to believe, possess an almost instinctive ability to perceive authentic altruism in medical encounters.

Medical students are also an “at risk” population. As many studies have demonstrated, rates of “burn out”, mental disorders and even suicide, exceed rates expected in the general population. (http://jamanetwork.com/journals/jama/article-abstract/2589340)



Unfortunately, prevention of medical student risk remains an imprecise science, with much speculation but little objective evidence that would guide appropriate preventive interventions. Nonetheless, here at Queen’s and at medical schools across the country, curricular leaders are not content to simply respond to crises that emerge, but are developing approaches they hope will raise awareness and allow students to identify and modify risk in themselves and their classmates. They are, in essence, extending the principles of Preventive Medicine to the world of medical education.

At Queen’s, Dr. Renee Fitzpatrick and the Student Affairs team has developed a Wellness program that is not an “add on”, but rather embedded within our core curriculum. That approach embraces multiple components, including didactic content, embedded scenarios, easy and confidential access to help, and Wellness Retreats. The latter are half-day sessions planned in conjunction with the students themselves, to promote awareness and preventive interventions.

In addition, the recently revised School of Medicine strategic plan will, for the first time, identify Wellness as a strategic priority for all our programs.

The major challenge, as with any preventive strategy, will be to reach those who are at risk but unaware, and are therefore the most reluctant to engage the issue with necessary commitment. The reluctant include both students and faculty. In addressing this difficult but critical challenge we must recall the lessons of the clinical world, that effective intervention must be rooted in the development of trust, and that trust evolves naturally from truly caring about the welfare of those affected


Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Residency Match Day 2017: What our students are experiencing, and how to help them get through it


“When you come to a fork in the road, take it.” Yogi Berra


Mr. Berra definitely had a knack for the deceptively profound. This is one of my favourite “Yogi-isms”. He reminds us, in his inimitable style, that making and committing to a decision can be difficult but essential if we are to progress. In contrast, indecision, can be both paralyzing and damaging to long-term success.

His words particularly come to mind this time of year when our senior students face what might be termed a “life altering event”.

We’re all familiar with that concept. These are moments when the course of our lives pivots on a single event or decision. Many of these are unexpected and their impact only appreciated retrospectively. However, when they’re known and anticipated, they’re understandably accompanied by much emotion – excitement, speculation, and trepidation.

For medical students in Canada, “Match Day” is one of those events. For those of you not familiar, Match Day is when all fourth year students learn which postgraduate program they will be entering. The match is the final step in a long process of contemplation, exploration and application. The match and the day itself are full of drama, with all results being released simultaneously at noon.

This year, Match Day is March 1. By approximately 12:00:05 that day, all students will know their fate. As you can imagine, there will be much anxiety leading up to the release. For most (hopefully all), the day will be one of relief and celebration. For a very few (and hopefully none), there may be disappointment and confusion. Many schools release their fourth year clinical clerks from clinical duties on Match Day. At Queen’s we have taken the position that our students take on professional obligations during their training and their personal celebrations should not supervene those obligations. Having said that, I’d like to remind any faculty supervising our fourth year students on March 1st of the following:

  1. Anticipate that your student will be distracted that morning
  2. Please ensure your student is able to review their results at noon.
  3. Check on your student. If he or she is disappointed, please be advised that the student counselors and myself are standing by that day to help any student deal with their situation and develop a plan.
  4. Be advised that the students will almost certainly be holding some type of celebratory event that evening. Although your students are not excused for personal purposes, I would ask that you give them every reasonable consideration.


Fortunately, we have an excellent Student Affairs team, headed by Dr. Renee Fitzpatrick, who is available and very willing to answer any questions you may have and respond to concerns regarding our students. The team can be accessed through our Student Affairs office learnerwellness@queensu.ca, or 613-533-6000 x78451. The faculty counselors can also be contacted directly at the following:


Dr. Renee Fitzpatrick

Director, Student Affairs






Dr. Kelly Howse

Career Advisor






Dr. Susan Haley

Career Advisor








Dr. Josh Lakoff

Career Advisor






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.




Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean, Undergraduate Medical Education

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It’s who we are.

Can a nation be characterized? Is it possible, or at all reasonable, to ascribe traits and qualities to an entire people, as one would for individuals? Until recently, I thought the answer to that question was clearly “no”, and that attempts to do so were rather narrow-minded, fodder for advertisers and late night television hosts, but not worthy of serious consideration. A collective of millions, or hundreds of millions, one would think, is far too complex and multi-faceted to be understood with a few adjectives and pithy phrases.

Two events, recently very much in the news, have changed my perspective, at least with regard to the Canadian national identity.

The horrific murders of six men while at prayer in a Quebec City mosque have shaken our nation. Although we’re all too familiar with such tragic events around the world, we’re never truly prepared for such an occurrence so close to home.

It’s said for individuals that true character emerges in times of adversity. If so, this was surely a test for the Canadian national character. How would we, and our press, respond? Would current world tensions and the attitudes of the newly elected American president influence reporting or mute our response?

What did we see?

We saw the six victims described not primarily as members of a particular religious or ethnic group, but as fathers, husbands, friends, members and strong contributors to their communities.

We learned from CBC, our national broadcaster, (http://www.cbc.ca/news/canada/montreal/quebec-city-mosque-shooting-victims-1.3958191) that Azzeddine Soufiane was a 57 year-old father of three who worked as a grocer and butcher. He was a longtime Quebec City resident who often volunteered to orient newcomers to the city.

We learned that Khaled Belkacemi was a 60 year-old professor of agricultural engineering at Laval University, who earned his PhD at Sherbrooke. He was described by one of his colleagues as “a kind person, someone appreciated by everyone… a renowned scientist who was very well known…an enormous loss.”

Aboubaker Thabti was a 44 year-old father of two young children who worked in a local pharmacy. Friends said “he’s so kind: everyone loves him – everyone.”

Mamadou Tanou, 42, and Ibrahima Barry, 39, were friends originally from Guinea. Tanou, who worked in Information Technology, had two young children, aged 3 and 1. Barry worked in the Quebec Revenue Ministry and was the father of four, all under the age of 14.

Abdelkrim Hassane, 41, worked as a programming analyst for the Quebec government and had three daughters aged 10, 8 and 15 months.

Our collective choice, expressed through a press well attuned to the sensibility of its readers and ethos of the nation, was not to stoke discord and controversy, but to regard the victims with compassion and sensitivity. They chose inclusion.

We saw the leaders of our three major political parties express, jointly, our collective grief and sentiments in terms that reflect a society truly accepting of diversity, with nothing overtly political or varnished in their words or actions. They proved themselves to be decent people and dedicated leaders who were able to give expression to the Canadian character, because they truly understood and believed in it.

We saw a French Canadian Premier of Quebec engage the events and those affected not as a marginalized “minority” within his province, but as fully accepted members.

We saw people of all religious backgrounds express support and unity in any way they could imagine, from writing letters of support, to marching, rallying around their local communities, or attending memorial services. We saw $80,000 raised within 17 hours for the support of families of the victims.

We saw a common rallying cry against religious intolerance and terrorism of any kind. We did not see demonstrations in the street by minorities who felt themselves victimized.

At the same time, we are confronted with the American travel advisory prohibiting access to people on the basis of their nationality. Various stories emerge about terrible consequences of this decision. Again, adversity reveals character. This past week, our provincial Minister of Health invited one of our teaching hospitals to take on the care of children scheduled for life-saving surgery in American hospitals but now unable to enter the country.

Not only is this the right thing to do, but a decision entirely in keeping with Canadian values, and one that would get approval of virtually every Canadian, regardless of political or religious affiliation


We live in a troubled world, during troubling times, but can take pride in being part of a nation that has deeply held and noble values.

The world, now more than ever, needs Canada to stay true to those values.


Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education


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Are we all latent bigots? The troubling and threatening implications of Implicit Bias

Last October, on an airline flight from Detroit to Houston, a passenger became seriously ill, eventually losing consciousness. The attendants asked for medical help. A doctor on the flight came forward to provide assistance. One of the flight attendants refused to allow the doctor to attend the patient without some proof of their qualifications, despite verbal reassurances and the patient’s obvious need. While this was going on, a second doctor appeared who was welcomed and permitted to examine the patient. No qualifications were either requested or offered from the second doctor.

The first doctor was a black woman. The second was a white man.

The attendant apparently had difficulty characterizing a black woman as a doctor, but had no such difficulty with the white man. As you might imagine, this has led to considerable media attention and some rather creative groveling on the part of the airline involved which has vowed to extend its diversity and inclusion training (previously provided only for corporate leaders) to frontline employees.

We’re left nonetheless to ponder how such a thing could happen. The flight attendant involved, we must assume, is neither a raving lunatic nor card-carrying bigot. She is likely a regular citizen who, in a highly stressful situation that required her to make a critical judgment, did so instinctively. In doing so, she exhibited (or made explicit) what could be termed an Implicit Bias.

The notion of Implicit Bias is rather unsettling, particularly to those who quite sincerely believe themselves to be accepting of diversity and inclusion. The concept is that we all harbour prejudicial impressions and attitudes of which we are blissfully unaware. These attitudes, apparently related to personal associations and memories, reside deep in our subconscious but are capable of influencing our decisions and actions without our intention or awareness. Fundamentally, even if we truly, even fervently believe in the principles of equality and attempt to conduct ourselves accordingly, we are all “hard-wired” to identify with and therefore feel greater affinity with those who are like us, and less so with those who differ from us in some way. It can be regarded as a developmental survival adaptation that allowed our ancient predecessors to recognize threats and react quickly to avoid them. It’s what alerts the gazelles to instantly run at the first sign of a lion without taking the time to process the decision. In terms consistent with Daniel Kahneman’s Thinking Slow and Fast approach, it’s the ultimate triumph of Type 1 over Type 2 thinking.

The concept of Implicit Bias is certainly gaining attention and being taken seriously by the scientific community. In a recent edition of Science (352:6289,1035) editor-in-chief Marcia McNutt reports on a forum of editors and publishers of prominent journals convened by the American Association for the Advancement of Science to discuss how Implicit Bias might be countered in the peer review process. Blinding reviewers as to authorship is apparently insufficient.

The Ontario Human Rights Code has, as one if its core principles, the primacy of the consequence or effect of an action over the intention that led to it, surely an acceptance of the influence of subconscious or implicit biases.

In the medical world, there have been a number of rather disturbing reports on the subject. In a study on the diagnostic approach to patients presenting with chest pain (Schulman et al, NEJM 1999;340:618) the authors prepared a series of videos of eight different patients (portrayed by actors) who described their symptoms and medical history. The descriptions and factual information were identical. The authors went to painstaking lengths to ensure the videos were also identical in all aspects, even the facial expressions, hand gestures, background and gowns worn by the patient-actors. The “patients” (pictured below in an illustration taken from the paper) differed only with respect to gender and race.


The videos were shown to 720 (mostly white) physicians who practiced either Family Medicine or Internal Medicine specialties. The results showed that the physicians were statistically more likely to suspect ischemic disease and therefore order cardiac catheterization in the men than the women, and in the white patients than blacks.


A study of 215 surgical attendings and residents at Johns Hopkins (Hader AH et al; JAMA Surg 2015:150:457) used a combination of clinical vignettes and Implicit Association Test (IAT) to assess attitudes and decision making. The instrument identified race and social class biases in most respondents, who were found more likely to suspect alcohol abuse in black patients than whites, less likely to order an MRI in a lower socioeconomic class patient with suspected cervical spine injury, and more likely to suspect pelvic inflammatory disease as a cause of right lower quadrant pain in black than white women.

A similar study was carried out in Oncology programs in Detroit (Penner LA et al; J Clin Oncol 2016;34:2874) involving white oncologists and black patients. Results showed that higher implicit bias in attending physicians (as determined by the IAT survey instrument) was associated with patient interactions that were shorter and perceived to be both less supportive and less effective. Higher Implicit Bias scores were also associated with lack of patient confidence with treatment plans and perceived difficulty in completing the course of treatment.

A recent systematic review of 15 studies of health care providers using the IAT showed low to moderate levels of bias (similar to the general population) in all but one (Hall WJ et al: American Journal of Public Health 2015;105:e60-76).

Many of these studies have evoked considerable criticism. There are certainly counter arguments to be made. Survey instruments like the IAT, even if previously validated, have limitations. The diagnostic process we utilize and teach incorporates known risk factors which are known to vary among genders and racial groups, so what’s perceived to be bias, some argue, may simply be the appropriate application of epidemiological data and “real life” knowledge.

However the real and deeply disturbing concern is that the concept of individual physician judgment or intuition that the profession has valued so greatly, and both clinicians and their patients rely upon to develop effective and efficient treatment decisions, is under threat. If we’re all subject to Implicit Bias, are we capable of making valid decisions on any issue that strays from a strict guideline algorithm? Indeed, will this threaten the confidence clinicians require to make critical decisions?

Fortunately, hope springs forward in the form of several perceptive approaches that are being advanced to counter the threat of Implicit Bias. For those interested in reading further, I will list some relevant papers below, including one by Dr. Geoff Norman and colleagues at McMaster that was published just this month in Academic Medicine. Those articles describe educational, administrative or societal approaches to the issue. What seems to be missing, however, is practical advice to individual physicians and learners as to how they might approach these concerns personally. Taking the liberty to provide a personal and non-expert perspective on this, I would offer the following seat-of-my-pants prescription to combat Intrinsic Bias:

  1. Brutal honesty. It would appear from the literature that no one is immune from these influences. We are all complicated, unique individuals with our own mix of life experiences. Recognizing that these biases exist, are natural and not indicative of a disordered personality of some type, but are nonetheless capable of influencing our decision-making would seem to be the best first step.
  1. Self-awareness. A truly honest exploration of our comfort in engaging patients from various backgrounds and with personal choices or perspectives that differ from our own would seem to be a key step. There’s nothing inherently wrong with not feeling equally comfortable with everyone we encounter. Something will be very wrong if that discomfort influences the care we provide.
  1. Increasing personal diversity experiences. Personal, one-on-one experiences with people from different backgrounds is the most effective way to increase understanding, promote comfort in engaging diversity and break down the threat of intrinsic bias. We need to seek such opportunities for ourselves and, as a school, develop and promote such opportunities for our students. Our Diversity Committee, under the direction of Dr. Mala Joneja, has this goal firmly in their sights and is making considerable progress.
  1. Do the mental “double-check”. When making a clinical decision involving a patient from a diverse group or background, a helpful and simple exercise might be to imagine the same scenario being played out in a patient of your age, gender, culture and socioeconomic/social circumstances. If the decision you would make is different in anyway, there should be a valid medical reason for that different approach. If not, a second thought might be in order.

In summary, Intrinsic Bias is a distinctly uncomfortable topic, particularly for physicians. It is threatening, unsettling, humbling and personal disturbing. But it’s also probably real, and worthy of study and personal reflection on the part of both practitioners and learners.


Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education


Approaches to Implicit Bias:

Byrne A, Tanesini A. Instilling new habits: addressing implicit bias in healthcare professionals. Adv. In Heath Sci Educ 2015; 20: 1255.

Norman GR et al. The causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine 2017; 92: 23.

Penner LA et al. Reducing racial heath care disparities: A social psychological analysis. Policy insights from the behavioral and brain sciences. 2014; 1: 204.

Stone J, Moskowitz GB. Non-conscious bias in medical decision making: what can be done to reduce it. Medical Education 2011; 45: 768.


Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.

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Our hospital and institutional problems are formidable, but not unprecedented: Finding lessons (and validation) in the past.

“The study of history is an antidote to the hubris of the present – the idea that everything we have, everything we do and everything we think is the ultimate, the best.”

David McCullough


Mr. McCullough’s wise words can also serve as a reminder that the various challenges we find so troublesome today almost always have parallels in the past. Learning how previous generations dealt with the dilemmas of their time can be instructive, encouraging, and often rather humbling.


This became very apparent to me recently as I read a copy of Margaret Angus’ “Kingston General Hospital: A Social and Institutional History” which I came upon while browsing in the angushistorykghbook section of a local antique market (actually, while killing time waiting for my wife to complete her browsing). In it, Ms. Angus documents the trials and tribulations faced by those who originally planned, built and operated KGH. Despite the vastly different cultural context and technology, what comes through are accounts of determined and community-minded people coming together to overcome challenges and improve the health care available to their families and fellow citizens. A brief summary of that early history as recorded by Ms. Angus is illuminating.


The first petition for the establishment of a public hospital in Kingston came in 1809 from a group of 44 residents and was made to Governor Sir James Craig. Fully nine years later, land for a hospital site was granted by an 1818 Order in Council by the Lieutenant Governor, but no funds were provided for building. A number of public subscription programs resulted in pledges amounting to about £1,000 for the purpose, and led the 11th Parliament of 1832 to finally grant £3,000 for the erection of a Kingston hospital. Drs. James Sampson and Edmund Armstrong were appointed “commissioners for superintending and managing the erection and completion of the said hospital, and for the purchasing or otherwise obtaining, choosing and determining the site thereof”. After much negotiation and consideration, they purchased six acres of a farm lot from Rev. G.O. Stuart between the present-day Barrie Street and Lower University Avenue.


At this point the population of the town was 3,500 with an additional 1,000 in the military garrison, and considerable growth was anticipated with the development of the Rideau Canal. Local architect Thomas Rogers was engaged, plans developed, tenders for work awarded. However, work on the hospital was delayed by the tragic cholera epidemic of 1834 and competition for workmen from two other major local building projects, the Kingston Penitentiary and rebuilding of Fort Henry. In response to a request from government for a progress report, Dr. Sampson exhibits a rather cheeky eloquence in his December 1834 report:


“and first with respect to the ‘period in which it has existed’ we beg to remark that the establishment which was the object of the address presented to His Majesty by the House of Assembly last session, and in which His Excellency has been pleased to take a warm and very gratifying interest, cannot yet be said to ‘exist’.”


Nonetheless, work was finally completed in 1835, now 26 years after the initial request. Ms. Angus reports the following description from the Upper Canada Herald:


“The Kingston Hospital, which has been in the course of erection for almost two years, is now nearly completed. It presents a fine appearance. Eighty-nine feet four inches long fifty-three feet four inches wide, four stories high, rooms lofty and well ventilated: can accommodate about 120 patients. It has two fronts and is approached by a handsome flight of stone steps.”


Unfortunately, it was far from complete. The interiors had not been completed. It was unpainted, no baths or washrooms, no furnishing and large mounds of excavated earth had been left impeding access to the hospital. The funds provided were practically depleted (although not exceeded). The commissioners went back to government asking for an additional £500 pounds to finish the project. The request was initially denied, but was followed by a more direct petition to the legislature, which, in 1837, eventually provided the funds. By this time, that amount was inadequate due to damage that had occurred in the unused, unheated building.


Social problems now intervened and led to further delays. Rebellions were breaking out in Upper Canada and resources now had to be concentrated on military defense. Dr. Sampson, the chief commissioner and champion of the hospital, was appointed Chief Magistrate, in charge of organizing military patrols for protection and defense of the town. He was nonetheless able to eventually report on the hospital, explaining how the £500 pounds had been used to purchase beds and linen, as well as a large stove in the basement to heat the building. With the hospital now in reasonable working order, operating funds were required. He made a request for ongoing support of the hospital:


“(we) take this opportunity to state to Your Excellency, that they are not aware that any provision has yet been made to meet the expenses, which must unavoidably be increased in order to carry the benevolent intention of the Legislature, and private donors, into effective operation, and that without such provision the building must necessarily remain useless and the just expectations of the public disappointed, all of which is most respectfully submitted.”


By 1837, a building was in place, but lacked the ongoing support or organizational structure to function as a hospital. However, it didn’t go unused. Over the next several years, it was used intermittently as a military barracks. The first “patients” treated at the site were 20 wounded American soldiers captured in November 1838 at the Battle of the Windmill near Cornwall, two of whom died of their wounds (making our first case mortality rate 10%). In 1840, permission was granted by the Lieutenant Governor to lease the building to the Presbyterian community in Kingston for the housing of a theological college that would eventually become Queen’s University. Dr. Sampson who, in addition to his medical practice and responsibilities as hospital commissioner, was now serving as Mayor of Kingston and negotiated the lease. However, the Queen’s College Trustees, decided to decline the offer, finding the £150 pounds per year cost excessive. The first attempt to develop a working hospital-university partnership therefore failed miserably.


By 1841, Kingston had been selected as the site for the capital of the United Provinces of Upper and Lower Canada, and construction on parliament buildings on Ontario Street (currently our city hall) was underway. The hospital building, still empty, was available and selected to serve as the temporary accommodation of the legislature. This decision not only provided a source of income (£300 pounds per year), but also required the completion and expansion of building facilities. The interior was re-configured into two large rooms, for the House of Assembly and Legislative Council, as well as a number of smaller offices and a library. In addition, a number of government buildings and private homes were constructed nearby to accommodate services and officials.


Kingston remained capital only two years, but during that time the economy and population boomed, expanding even further the need for a hospital. By the time the capital was moved to Montreal in 1843, most patient care took place in private homes or boarding houses provided by the Ladies Benevolent Society, and was greatly aided by the arrival of the Religious Hospitalers of Saint Joseph who began to admit patients to their Brock Street facility (eventually Hotel Dieu Hospital) in 1845.


The building now needed to be re-converted to its original purpose. Dr. Sampson, having been re-elected as Mayor, was again instrumental in leading the charge to re-possess the building for the city and securing funding for the conversion, all of which took considerable legal and political activity. Finally, in 1845, the hospital commissioners and Ladies Benevolent Society formed a successful collaboration that resulted in the building finally being opened for the admission of patients. The following notice appeared in the Kingston Chronicle and Gazette on November 12, 1845:


“The Hospital for the use of the town of Kingston, under the superintendence of the Ladies of the Female Benevolent Society, is open in the building lately occupied by the Provincial Parliament and patients will, on the certificate of a medical man that they are proper recipients for public charity, be admitted on the order of one of the following ladies who have consented to act as Directresses of the Society.”


And so, the hospital initially conceived and petitioned for 39 years previously, began to admit those in need of medical care under the direction of local physicians and care of volunteer citizens.


The problems faced by our hospitals and providers today are certainly daunting, but no more so than those faced by our dedicated predecessors. They needed to make valid cases for resources despite competing societal needs, while simultaneously delivering the best care possible for those in need. Sound familiar? Doing so required ingenuity, patience, perception and the political savvy to take advantage of opportunities that arose, often in times of crisis. It also required forging strong collaborative links to community members and organizations with common values and goals.


With regard to the later, the recent move to amalgamate our hospitals seems a highly sensible and effective initiative. It’s again a little humbling to read the following excerpt from the Foreword to Ms. Angus’s book, written by Mr. Harvey L. Millman, President of the KGH Board of Governors in 1971:


“Today the Kingston General Hospital stands at the beginning of a new era. We are moving into closer association with the Hotel Dieu Hospital, St. Mary’s of the Lake Hospital, Kingston Psychiatric Hospital, Ongwanada Hospital, Queen’s University, and the St. Lawrence College of Applied Arts and Technology to form the Kingston Health Science Complex, an integrated system of health care delivery to meet today’s community needs.”


Forty-six years later, we find ourselves taking tentative steps toward realizing at least a portion of that grand vision. That shouldn’t be seen as an indictment, but rather encouragement that we’re on the right path. Sensible and worthy ideas usually find their way to full realization, not always when we think they should, but when concept and opportunity converge.


Examining the past can indeed counter our “hubris of the present”. It provides perspective, illuminates the future and keeps us humble.



Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Blogging on Blogs

I was initially a reluctant blogger. Perhaps even skeptical. The advice and impetus to proceed came largely from our trusty MedTech folks, particularly Matt Simpson and Lynel Jackson, with encouragement from Jacqueline Findlay and other UG office staff. They felt it was the best option to address my request (they might term it whining) for a means to communicate on a regular basis with our students and teaching faculty. I had in mind something more akin to a newsletter or mass email. I had no idea what a blog even was. With thinly veiled condescension, they explained that a blog would reach more people, allow for embedding of images, links to other material and, most importantly, allow people to respond.


Now, a hundred posts later, I must admit they were right. As I reflected on the milestone, I also came to realize I still didn’t know anything about the term “blog”, how they came about, or how extensively they’re used.


It seems blogs evolved from something called the online diary, publications wherein folks would give regular accounts of their personal lives. Many developed themes of personal interest with the added element of dialogue with readers. The term “online journal” appears to have emerged in the late 1990’s with Ian Ring prominent in promoting the concept of web-based publication of journals.


Most seem to agree, however, that the term “weblog” is rightfully attributed to Jorn Barger who applied it to his Robot Wisdom site in 1997. The term was later contracted to “blog” by Peter Merholz in 1999.


Mr. Barger (shown) sounds, and looks, like an iconoclast and free-thinker with eclectic interests. In his own words, he was hoping to find “an audience who might see thejorn_barger connections between (his) many interests”. His postings featured “a list of links each day shaped by his own interests in the arts and technology”, thus offering “a day-to-day log of his reading and intellectual pursuits”. Those intellectual pursuits include history, Internet technology, artificial intelligence and the writings of James Joyce.


The web-based accessibility and brevity of blogs makes them a highly effective means of communication. It was estimated in 2010 that 150 million blogs were being published regularly, read by 10% of the world population. What makes blogging possible for most are platforms such as WordPress, which, for a modest fee, provide a fairly user-friendly means to publish.


All this popularity comes, of course, with a huge caveat. Blogs are entirely self-published, unreviewed and unfiltered. They are the very personal musings of the author. All very appropriate in a society where freedom of expression is a valued right, and arguably not a problem in the hands of an informed readership. However, by putting the burden for validity solely in the hands of the author, the line between fact and opinion becomes blurred. By breaking down the barriers required to express ideas to the public, they may also contribute to a sense of permissiveness and thus erode any sense of self-regulation on the part of potential authors. Authors who have never published in a regulated environment may be unaware of any responsibility to verify facts or clarify when expressing personal opinions. Readers may stop caring about the difference.


With all this in mind, it seems blogs, or whatever evolves technologically from them, are here to stay; they can and do provide a great means to communicate widely. Despite all their drawbacks, I’m a big fan of the concept for two key reasons:


First and foremost, they work. They reach the intended audience, and far beyond. In my own case, I’m continually encouraged not only by those who choose to post responses, but even more by those who send private messages (not always in agreement, to be sure) or simply chat in the hallways about some issue or other that’s come under discussion. I’m particularly pleased by the thought and varied perspectives that emerge from our students on controversial topics that, I’m certain, would otherwise have been silent. I think this dialogue helps faculty and students, understand each other more clearly and forge therefore better solutions to the various problems that emerge.


Secondly, and this is my non-factual, biased view, open dialogue is healthy and even essential to any organization, and particularly one committed to education. The freedom to express individual ideas and free thought should always be encouraged, and that will require uncensored “buyer beware” media. Whether it’s dialogue in the Greek agora, pamphlets by folks like Thomas Paine and Benjamin Franklin or stump speeches of political revolutionaries, free and controversial perspectives must and will find their way to expression. It’s important that they do. Full exposure of all ideas and points of view is healthy, if sometimes disturbing. Blogs are simply our generation’s technological solution. We can rail about the lack of control and its potential impact but, in the end, freedom to express must trump any form of censorship and we must rely on the judgment and conscience of consumers.


And so, with this one hundredth post coming at the end of another year, let me, with uncensored sincerity; wish all our faculty and students very best wishes for the Christmas season, the New Year, and continuing open, healthy dialogue.



Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education


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After working so hard and achieving success, why are so many medical students depressed?

The first time David thought about becoming a doctor, he was 13 years old, in the eighth grade. He recalls that everyone thought it was a great idea. As a bright, naturally curious and diligent student with an outgoing personality, it seemed to his parents, teachers and friends a natural and entirely appropriate decision. All were supportive. In fact, they were enthusiastic. What loomed ahead, all came to realize, was the task negotiating the highly competitive medical school application process. For the next several years, this became a major focus of attention for David, his parents and teachers. The process was researched in some detail. Most decisions, from what courses to take, what recreational and volunteer activities to pursue, even vacation destinations, became framed, or at least influenced, by how it would impact David’s medical school aspirations. David committed himself to his goal. Adept in sciences and an avid learner, he achieved remarkable academic success through high school and his undergraduate degree program, all while accumulating an impressive portfolio of volunteer and other experiences designed to reflect his interest and commitment to public service and medicine in particular. He engaged the application process with vigour and strong support (including financial) from his parents. He was successful, getting accepted to medical school. He, his parents, his friends, were jubilant, and shared in his success. All, it seemed, was good and proper. All was as it should be.


David continued his academic success in his first year where the curriculum is largely about knowledge acquisition, a process with which he had become very comfortable. But the clinical aspects of medicine were troubling to him. He found that engaging patients and their illness distinctly uncomfortable, causing him to be nervous and anxious before, during and after each encounter. He found it difficult to deal with emotionally charged issues and, accustomed to engaging problems one at a time at his own pace, he found dealing with multiple simultaneous and urgent problems very difficult and stressful. This caused him to feel guilty and somewhat ashamed. As an aspiring doctor, shouldn’t all this come naturally to him? For the first time ever, he began to question his career choice. He greatly feared disappointing his parents and those who’ve supported him. To his peers, seemingly enjoying their medical school experience, questioning the benefit of being a medical student was incomprehensible. Not sure where to turn, he came to a faculty member to seek help.


What happened here, or perhaps more appropriately, what didn’t happen? Did David make a bad decision? Is he ill suited for a career in medicine, or simply adjusting to practical realities and challenges that are new to him?


In considering David’s dilemma, it’s helpful to consider the process that leads young people to make informed and, hopefully, durable career commitments. Fortunately, there’s an extensive and very interesting literature on this subject and considerable active investigation. Unfortunately, it’s largely in the realm of developmental psychology, an area in which most physicians are far from expert. “Career Theorists” abound, with various approaches and perspectives on the subject. I provide a list of representative articles below for those interested. There’s certainly much for us to learn that will help guide and support medical students struggling with career choice.


Career decision, it seems, is a developmental milestone that can only be achieved after an individual acquires and reconciles two key components; 1) knowledge of self, and, 2) knowledge of the world around them.


The first component, development of self-awareness, promotes independent thought and self-confidence. With those attributes comes the ability to make good decisions. Put another way, one can only make good decisions if they’re based on a full and honest understanding of one’s own attributes, interests and motivations. The term that’s been used for this process of personal development is “Individuation”, and has been attributed to the esteemed psychologist Carl Gustav Jung who describes it as follows:


“In general, it is the process by which individual beings are formed and differentiated (from other human beings); in particular, it is the development of the psychological individual as being distinct from the general, collective psychology”.


It is a progressive personal process that has no fixed schedule. It requires engagement of increasingly independent roles and challenges. It can be thought of as beginning the first time a child steps alone into a school bus for their first day of school and progresses through increasingly complex and increasingly independent life challenges. The challenge for parents, who must progressively relinquish control and security, is to allow these events to occur naturally, continuing to balance their desire to influence and guide while not inhibiting needed growth experiences.


Contemporary developmental theorists, notably David Kegan and Marcia Baxter Magolda, provide what might be considered a pragmatic perspective. They describe “Self-Authorship” as the ability to take charge of one’s own decisions, shifting from a developmental stage where we uncritically accept external authority to one where we consider information from multiple sources but ultimately make our own decision, achieving that they term “internal authority”. They argue (I think convincingly) that this is essential not only to personal well being, but to effective and responsible citizenship.


How does this happen? In simple terms (that even a non-psychologist would understand), self-authorship develops by engaging the world. This brings us to the second key component required for effective career decision making – learning. Baxter Magnola and others remind us that not all worldly experiences provide valuable learning experiences that will promote effective personal development. She describes three key foundations of effective learning. Cognitive maturity involves intellectual rigour, judgment and problem solving ability (what the medical world might term critical thinking). Integrated Identity refers to understanding of one’s own history, autonomy, connections and “place in the world”. Finally, the Interpersonal component involves the development of mature relationships, respect for self and others, expressed through effective collaboration. The point is made that the latter can only be achieved by engaging diversity during the critical developmental years.


These three foundations are essential to the development of independent and effective decision making. They also provide a very effective blueprint for the design of effective educational systems. From kindergarten to university, our teaching and learning should promote cognitive maturity, individual autonomy and engagement of mature, diverse and collaborative relationships with peers and the broader world.


The case of David (fictitious name) is provided because it is representative of many students caught up in the modern world of pragmatic, goal-oriented and often competitive career engagement, and raises a number of rather unsettling questions:


  • Does the process that students must undertake to achieve success delay or inhibit the growth experiences necessary to achieve individual maturation?
  • By vigorously supporting a child’s early ambitions, are parents and others inhibiting that child’s development and self-realization?
  • Are our educational systems moving in the wrong direction, catering to targeted career development and placement rather than the development of personal attributes necessary to life success and effective citizenship?


In short, we must recognize that all these factors may result in students who come to full self-realization late in the game, after they’ve already engaged careers in which they (and those close to them) have invested considerable energy and resources. Change, or adaptation to new challenges, becomes very difficult, and they may feel trapped. But the failure to fully consider their true interests or the struggle to sublimate their interests in favour of what they feel is expected of them may have disastrous long-term consequences, and may, at least in part, underlie the recently publicized concerns regarding the physical and psychological health of medical students.




As medical educators and mentors of these vulnerable young people, at various and individual points along their developmental journey, it’s critical that we’re fully aware of their environment, pressures and needs. These considerations should both inform our admission processes and provide perspective to those counseling troubled students.

Admission processes should seek to identify students who’ve achieved the developmental characteristics that allow for a fully informed career decision.

When students like David struggle, we should suspect that their personal circumstances or the process they’ve undertaken to get accepted may have prevented them from achieving some critical developmental milestones. Identifying that deficiency, helping them complete their development, and exploring what aspects of medical practice might best suit their true strengths may well be the keys to both their success as a physician and personal wellness.


David is modeled on a former student. To allay your fears, he’s doing fine, now content and making effective contributions in a medical specialty where acute patient contact is minimal. That resolution only came about after a considerable period of reflection and engagement of very uncomfortable issues in his life.


As Dr. Rotenstein’s study points out, there are other Davids out there who need and deserve our understanding and support.



Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education


Baxter Magolda MB. Evolution of a Constructivist Conceptualization of Epistemological Reflection. Educational Psychologist 2004; 39: 31

Baxter Magolda MB. Three Elements of Self-Authorship. J of College Student Development 2008; 49: 269.

Earl JK, Bright JEH. Undergraduate Level, Age, Volume and Patternof Work as Predictors of Career Decision Status. Aust Journal of Psychology 2003; 55: 83.

Hodge DC, Baxter Magolda MB, Haynes CA. Engaged Learning: Enabling Self-Authorship and Effective Practice. Liberal Education 2009; 95(4).

Kegan R. In over our heads: the mental demands of modern life. Harvard University Press. Cambridge MA. 1994.

Super DE, Developmental Concept. https://www.careers.govt.nz/assets/pages/docs/career-theory-model-super.pdf


Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.

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Was Plato being Pimped?

A medical student and attending physician arrange to meet near a nursing station to discuss a recently admitted patient the student has reviewed. The patient has presented earlier that day to the emergency department with a severe headache and visual disturbance. The student relates a description of the symptoms, past history and physical findings, after which the attending asks:


“So, what do you think is going on?”

      “I think its migraine”.

“Really? Does the patient have any history of migraine?”

     “Not that I’m aware.”

“Did you ask?”


“Is it common for someone to get their first migraine at age 70?”

     “Guess not.”

“Is the patient on anticoagulants?”


“So what else might be in the differential?”


For the next 10 minutes or so they engage in a question and answer session regarding the findings and management plan. They develop a number of other possibilities and a diagnostic plan, which includes an urgent CT scan. At the end, the attending suggests the student reviews the features of both migraine headache and intracranial bleeding.


So, what just happened there?


It’s very likely that the attending physician and student left the encounter with vastly different impressions of what had transpired.


The attending physician likely feels they have provided a “teaching moment” in which some important issues of clinical management have been passed on to the student. They may feel they have left the student better prepared for having had this encounter, and may very well feel more confident in the ability of the student going forward. They likely leave feeling they have fulfilled their obligation as a teaching clinician. They may even feel they have engaged in a version of what’s been termed the Socratic method; a term used loosely to refer to a method of teaching that utilizes questioning as a means to promote learning.


The student involved in the interaction may feel differently. They will likely describe what they experienced as having been “pimped”.


Pimping, in this sense, isn’t referring to the practice of soliciting clients for prostitutes (a very unfortunate association). It refers, rather, to the practice of posing a series of increasingly difficult and obscure questions to a learner with the purpose of identifying knowledge deficiencies.


The term has a considerable history. A rather infamous 1989 JAMA article by Frederick Brancati1 provides a tongue-in-cheek review of the practice and is well worth reading. As he points out, the first known use of the term was by no less than the esteemed William Harvey who lamented in 1628 his students failure to understand his early theories about the circulation:


“They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped”.


Robert Koch, the prominent Dutch microbiologist of the mid nineteenth century recorded a series of “Pumpfrage” (pump questions) for use on ward rounds. Apparently William Osler was a master pimper. Abraham Flexner commented on his style after his 1916 visit to Johns Hopkins:


“Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping’. Delightful.”


It’s often done in the presence of others, and has the potential to leave the learner feeling embarrassed and, possibly, humiliated. It’s felt by many that the main purpose of pimping is not to impart learning, but to establish an operational hierarchy – to put the learner “in their place”. It’s been characterized by many as an initiation ritual.


Its value is, at best, debatable. Detsky2, reprising Brancato’s article, concludes “the purpose of pimping is to increase retention of the key teaching points by being provocative”. In a contemporary commentary Kost and Chen3 take a much more negative view and suggest the term be reserved for undesirable behaviours, specifically:


“questioning of a learner with the explicit intent to cause discomfort such as shame or humiliation as a means of maintaining the power hierarchy in medical education”.


Medical students bring helpful perspective to the issue. In an interesting study carried out by fourth year students at a midwestern American medical school4, a differentiation was drawn between “malignant” pimping, and that done “with good intentions”. To quote from their conclusions:


“At its best, pimping assesses students’ knowledge and skills, stimulates critical thinking, and encourages self-assessment. At its worst, the competitiveness that pimping generates may inhibit students from learning how to work as a team, and how to rely on each other.”


It also seems that medical students not only accept that they will be subjected to directed questioning in their clinical rotations, but have adapted mechanisms to “manage” these situations. Interestingly, that management is intended not only to optimize their learning, but also to project a positive image of their skills and teachability. To quote a student interviewed as part of this study by Lo and Reghr5:


“I think my goal is basically to come away from that session with the instructor thinking that I do know my stuff, I know my material. And even if I got some questions wrong, it’s okay, because in the greater context I have a good understanding of the subject.”


It would seem that directed questioning is certainly eliciting an adaptive response, but perhaps not entirely what was intended.


In Canada, about 57% of graduating students report have been “publicly embarrassed” and 29% report having been “publicly humiliated” at least once during medical school6. Although not explicitly stated, it’s reasonable to presume that the majority of these relate to episodes of pimping.



In a recent perspective, Soddard and O’Dell posit “the term ‘Socratic method’ has been so often misapplied that Socrates himself might not recognize the clinical education techniques that often bear his name.”7.


Socrates, prominent Greek philosopher of the fourth century BCE, believed his role as a teacher was not to simply deliver information, but tosocraticmethod1 help his students develop their own methods of thinking and examining the world. In fact, it seems he seldom made statements of fact but, rather, provoked his students by posing a series of challenging questions, many of which had no clear answer, but required examination of their own assumptions and values. These “dialogues” subsequently recorded by Plato (his most famous student) were probably not comfortable experiences for his students who may have felt challenged, cross-examined, and perhaps even attacked. (Interesting to speculate what sort of teaching evaluations Socrates would get today). The opposite of the Socratic method is the Didactic, which entails the teacher delivering information with a minimum of student participation. It is certainly more comfortable for the student and simpler for the teacher, but fraught with limitations regarding the appropriateness of information provided, and benefit for the learner.


Moreover, it’s a long way from the Athenian agora to the wards and hallways of our teaching hospitals. It’s therefore more than a little presumptuous to refer to what we’re doing as Socratic teaching. However, perhaps the message for us is that there is great value and potential in questioning if questions are appropriately posed, and posed for the right purpose. We need to carefully consider what features differentiate effective questioning in clinical education from what students rightfully identify as “malignant pimping”.


  • Why is the question being asked, and for whose benefit? The issue of intention is central and critical. Questions should be posed for one of two purposes: to advance the student’s understanding and comfort with clinical medicine or to ensure optimal patient care. The concept of “toughening up” students in preparation for perceived future abuses is archaic and never justifies, but potentially perpetuates, demeaning behaviour.
  • Is the question reasonable and relevant? Does it relate to the clinical issue under discussion? Will the answer advance the student’s understanding or patient care? Does it really matter whose name is historically associated with pulsatile nailbeds?
  • Is this the time and place? Questions asked in highly public places or with patients in attendance can be highly-charged for students, and are not rendered more educationally valuable by that added scrutiny.
  • How well do you know the student? Within the context of a continuing relationship, a degree of trust develops between teacher and learner that allows the student to contextualize criticism and eventually demonstrate improvement. Brief, or one-time encounters, have no such trust, resulting in considerable vulnerability on the part of the student.
  • Questioning in the workplace should be provided in the spirit of formative educational experiences. However, students may perceive they are being formally assessed through these questions.

Based on these considerations, I would not consider the exchange described at the beginning of this article to be an example of pimping, but rather directed questioning intended to both teach and ensure optimal patient care

To return to my initial question, was Plato being pimped? Given the definitions we’ve developed and what we understand of the Socratic approach, almost certainly not. But he was certainly being questioned, likely aggressively, but by a benevolent teacher intent on making him a better person and more accomplished philosopher.

Seems that turned out fairly well.



Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education



  1. Brancato FL. The Art of Pimping. JAMA 1989; 262(1). 89.
  2. Destsky AS. The Art of Pimping. JAMA 2009; 301(13). 1379.
  3. Kost A, Chen FM. Socrates was not a Pimp: Changing the Paradigm of Questioning in Medical Education. Academic Medicine 2015; 90(1). 20.
  4. Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping: Perspectives of 4th Year Medical Students. Teaching and Learning in Medicine 2005; 17(2). 184.
  5. Lo L, Regehr G. Medical Students Understanding of Directed Questioning by Their Clinical Preceptors. Teaching and Learning in Medicine 2016. (http://dx.doi.org/10.1080/10401134.2016.1213169)
  6. Canadian Graduation Survey National Report. Association of Faculties of Medicine of Canada. 2016.
  7. Stoddard HA, O’Dell DV. Would Socrates have Actually Used the “Socratic Method” for Clinical Teaching? J Gen Intern Med 2016; 31(9). 1092.


Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.


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