Accreditation issues and progress
Accreditation Success Stories…and lessons going forward.
Medical school accreditation has been described, with some justification, as the colonoscopy of medical education. The parallels are rather striking:
- Both require a long and distinctly uncomfortable period of preparation.
- Both require a public exposure of personal features most would prefer to keep modestly hidden.
- Both can get messy.
- Both carry high potential for embarrassment.
- In both cases, the procedure itself can be tortuous and painful.
- And finally, for the asymptomatic and fundamentally healthy, their value is highly debatable.
Also like colonoscopy, one emerges from a successful examination with a sense of great relief. That relief, in part, is simply related to having completed the process. Doing so with a successful report of findings adds immeasurably to that sense of relief.
At Queen’s, we are fortunate to have recently emerged from our own collective internal examination with that great relief, having achieved a full eight year approval, with no further invasive procedures required until 2023.
Reflecting now on a process that really started after our last review in 2007, it’s possible (and probably healthy in a preventive sense) to set aside for a moment the struggles and various deficiencies that required attention, and focus rather on the positives that have emerged. A few come particularly to mind and merit attention because they bear important messages we should carry into the future.
Firstly, our success was based on our ability to mount a common effort. Without question, the very real threats to our school imposed by the 2007 review galvanized our efforts and collective will in a way that made possible the changes that we needed to make.
Our Deans (both Drs. Walker and Reznick), engaged accreditation efforts with resolve and unconditional support. Our university leadership (particularly Principal Woolf whose first duty in his new role was to publicly defend a medical school he had just inherited), have been staunch supporters of the accreditation effort. Our Department Heads, to a person, have been nothing but supportive of the school. Our curricular leadership, undergraduate office, medical education team, medical technology unit, hospital partners and, critically, our students, all came together to meet the various challenges, and did so with methodical efficiency, driven by a shared desire to support (dare I say, defend) our school. One sees such common, focused effort only rarely, and usually only when necessitated by great and imminent peril. It is nonetheless rather inspiring to consider what our common efforts achieved and speculate on what might be possible if we could continue to work collaboratively without the need for external motivation.
Secondly, one must acknowledge that many significant and enduring changes emerged from these efforts. A robust and effective new curriculum, effective assessment methodologies, creative and updated approaches to teaching, a revised and much more effective governance structure, a refurbished framework of policies and procedures, our highly impressive and sought after MedTech curricular management system, and even our new School of Medicine Building itself were all, at least in part, motivated or accelerated in their development by our accreditation efforts.
The process brought welcome attention to a number of areas of strength within our school, often overlooked as we focus attention on problem areas. Refreshingly, and unexpectedly, the recent report made reference to our teaching, which it identified as an area of strength. To quote from our report:
As reported by students in the ISA [Independent Student Analysis] and by the survey team, the program benefits from many capable and dedicated teachers. For example, in the MEDS 125 [Blood and Coagulation] course, with 99% of students commenting on the course, no negative comments were made within the 9 pages of comments, and the survey report suggests that the Course Director and the faculty involved in this course are to be congratulated…. Another course that received similar accolades was MEDS 127 [Musculoskeletal], where the team reported: “Dr. L Davidson who continually monitors and enhances the course. This is a “poster child course” and Dr. Davidson deserves significant recognition for the evolution of this highly innovative and interactive course.”
In fact, we are truly blessed with many dedicated and talented teachers, knowledgeable and committed faculty leaders in all key portfolios, committed and hard working undergraduate administrative and educational support teams, and a receptive and engaged student body.
In the final analysis, the most enduring lesson we should take away from our eight-year struggle with the accreditation process must be that we never again require a “crisis” to spur us to collective action in order to ensure we are providing the very best educational experience for our students. Complacency is poison. The continual, collective pursuit of quality improvement and courageous innovation must be our continuing goals. These are the lessons of the day.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Towards higher ideals…Reflections on our current and our first accreditation experience
The first accreditation visit to the Queen’s School of Medicine occurred in October of 1909, and didn’t go particularly well.
The reviewer was Abraham Flexner, a rather determined iconoclast and career educator who had been commissioned by the Carnegie Foundation to carry out a review of all North American medical schools. Flexner undertook his charge with a shrewd earnestness that his biographers would later describe as “determination bordering on espionage”. He was both relentless and scrupulous, leaving no stone unturned and taking nothing at face value. He wasn’t above, for example, sneaking back into a school at night after the formal visit had ended to bribe his way into laboratories or wards from which he’d been tactfully steered away during the official tour. Some of his reviews were truly scathing, and would certainly lead to lawsuits today. Of the 155 American and Canadian medical colleges in existence at the time, fully 95 closed within the 20 years following the publication of his report in 1911.
Queen’s, at that time, was one of 8 Canadian schools in existence. Three were in Ontario (Toronto and Western being the others), three in Quebec (McGill and Laval, which had campuses in Montreal and Quebec City), Winnipeg and Halifax Medical Colleges. All were “proprietary” or commercial schools, operated by the medical community who charged students fees for instruction without standards for admissions, qualification of faculty, curriculum, teaching, assessment or any of the issues we take for granted today.
In 1909, the population of Kingston was about 20,000. In the School of Medicine 38 faculty (including 16 Professors) were responsible for the teaching of 208 students drawn largely from Ontario. The five-year program was expected to graduate students able to “comply with the requirements of the province in which they expect to practice”. The total income to the school, consisting entirely of student fees, was $19,978.
Flexner’s review was characteristically precise, perceptive and honest. He felt laboratory and library facilities were “adequate”. His major criticisms related to the paucity of clinical experiences – “the opportunities for out patient work are slight”. He expanded:
“The future of Queen’s is at least doubtful. It could certainly maintain a two year school; for the Kingston General Hospital would afford pathological and clinical material amply sufficient up to that point. But the clinical years require much more than the town now supplies. Its location – halfway between Montreal and Toronto, on an inconvenient branch line – greatly aggravates the difficulties due to the smallness of the community”.
However, he concluded by describing the school as “a distinct effort towards higher ideals”, and compared it favourably to a number of American schools he’d encountered in similar circumstances, holding out hope with the following observations:
- “liberal policy has largely overcome the disadvantages of location in a small town”
- “the thoroughness and continuity with which the cases can be used to train the student in the technique of modern methods go far to offset defects due to limitations in their number and variety”
The leadership of the school at the time was not amused. Dean Cowell’s report to the Board following the publication of Flexner’s report went as follows:
“The report of the Carnegie Foundation relating to Medical Education, published last summer, contained some statements and criticisms which are unfavourable to our school. As these were manifestly based on inadequate knowledge of the actual conditions, they have not been taken very seriously by the Faculty.”
(from Medicine at Queen’s 1854-1920, A.A. Travill).
And that, as they say, was that.
Last week, 105 years after the publication of Flexner’s findings, a team of six visited Kingston and again undertook to review our school, this time utilizing a rather extensive set of standards developed by both Canadian and American accrediting agencies. Although the full report won’t be available for a couple of months, the panel provided a preliminary report that appeared to find little fault with our core educational program, but did contain some rather eerie echoes of Flexner’s observations over a century ago. They felt the caseload available for teaching in some disciplines, for example, is low and the efforts put in place to offset this may require “ongoing monitoring”. At a number of points during the many meetings that occurred over the four day visit, the panel seemed to probe our ability, as a small school, to provide what appeared, almost surprisingly, to be a strong education and learning experience to our students.
The reality is that Kingston and the southeastern Ontario region does have a small and more senior population, tightly bound by our neighbouring schools, much larger and more diverse population centres, and our national border. This is as true today as it was in Flexner’s era.
So how does it work? Why has Flexner’s prediction, honestly and pragmatically derived, not proven true? How is it that this “effort to higher ideals” has not only survived but, I would humbly suggest based on our recent review, flourished despite the geographic and epidemiologic challenges?
The answer to these questions was in evidence this past week when our Dean, Vice-Deans, Associate Deans, Department Heads (every one of them by the way), hospital partners, Program Directors, Course Directors, Competency Leads, Administrative staff and students, met in a series of meetings with the accreditation team. What was apparent to myself and to the review panel as each group came through, was the same spirit of determined commitment to medical education that has sustained our school through the generations since Mr. Flexner’s visit. Such commitment trumps issues of size and location, converts potential liabilities into advantages and results in development of a particular and enviable learning community where education is valued in not only theoretical but also highly practical ways, where students are vitally involved, where innovation is very much encouraged, where conventional thinking is challenged, where problems can be solved with a phone call today rather than a meeting next month, where effort required is no barrier to a good idea, where people know, respect and support each other and share in the common mission because, quite simply, they care. They care about providing the best possible medical education experience for our students, they care about our school, and they care about each other. It’s really that simple, and it’s no secret. An “effort toward higher ideals”, indeed.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
A.A. Travill. Medicine at Queen’s 1854-1920: A peculiarly happy relationship. The Hannah Institute for the History of Medicine. 1988.
Abraham Flexner. Medical Education in the United States and Canada. New York. The Carnegie Foundation for the Advancement of Teaching. 1910.
Thomas Neville Bonner. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins University Press. 2002.
In Defense of the Lecture
Medical Grand Rounds are a longstanding (dare I say, traditional) feature of the academic medical centre. In fact, their durability and continuing appeal might be considered somewhat perplexing in an age of increasing, almost frantic, busy-ness, and easy access to medical information and prepared presentations ready for review at our convenience. Here at Queen’s, they have become rejuvenated and are now a highlight of the academic week with the support of Dr. Archer and guidance of Dr. Mala Joneja.
The format is very simple: a formal lecture, followed by commentary and discussion from the audience. That audience tends to be quite eclectic, including medical students, residents, nurses, hospital administrators, and attending physicians ranging from junior staff to senior clinicians, some very much expert in the topic under discussion. The discussion following provides opportunity for those attending to add depth and perspective to the topic. Because it’s a gathering of thoughtful clinicians who lack for neither opinions nor willingness to express them, the dialogue following can be rich, far-reaching and highly entertaining. The challenge of the presenter is therefore considerable. With minimal technical “tricks”, relying largely on the content and style of their presentation, they must not simply inform but provide texture, context and deeper meaning to the topics under discussion.
Three recent, excellent Grand Rounds on contrasting topics delivered by individuals of different backgrounds and practice profiles provide insights about the “art and science” of the well- crafted and well-delivered lecture.
Dr. Zachary Liederman, a senior Internal Medicine resident, presented the topic of Myelodysplastic Syndrome. He described very nicely the current state of knowledge and clinical approach, and did not shy away from describing the complexities facing the treating physician when counseling a patient who has a condition that is causing minimal if any symptoms, and carries uncertain risk for progression. In the discussion that followed, senior departmental members questioned the obligation of treating physicians to disclose to every patient all information about conditions that are identified, but not the cause of symptoms, and of uncertain clinical significance.
Dr. Al Jin is a Neurologist with a impressive research background and clinical training in stroke. He is actively involved in “leading edge” approaches to diagnosis and management of this condition, sharing with the audience his insights about these emerging innovations, balancing thoughtfully the established and speculative, referencing the underlying scientific principles with practical clinical experience. As an acknowledged and respected expert in this field, he combined high levels of personal credibility with an engaging, respectful and balanced presentation. There was truly something for everyone, from the novice learner to seasoned clinician who treats stroke patients regularly.
Dr. David Holland is a well-established and highly-respected Nephrologist and educator. He presented a superb lecture on the topic of Disruptive Innovation in Patient Centred Care. He drew upon his clinical experience with chronic kidney disease and dialysis, but extended far beyond, providing insights drawn from industry and various models of change and innovation. Presenting with considerable panache and directness, he provided concepts and insights novel to most in the audience, and did so in a highly engaging and thought provoking discussion.
Three very different topics.
Three individuals of very different backgrounds.
All were highly effective in engaging their audience and presenting them with novel, fresh insights about topics in which many in attendance may have felt reasonably informed beforehand. In short, they all made a room full of people sit back, listen, and think again about something important to them.
How did they manage it? What makes any lecture effective? I would suggest there are a few common denominators.
· The content has relevance to the audience. It is something that is, for whatever reason, important to them in their occupation, private lives or, better yet, both.
· The content goes beyond simple transfer of knowledge. It extends facts and figures to a thoughtful discussion of the application, implications or meaning of the basic information.
· The presentation differentiates that which is factual and proven from that which is speculative, hypothetical or aspirational. In doing so, the presenter draws the audience into the discussion, allowing them to develop their own conclusions and thus extend thought and provoke further discussion
· The presenter is credible. This arises not simply from their background and qualifications, but from the way in which they interpret and present the information. The effective presenter, in fact, earns the trust of the audience by manner in which they present.
· The presenter is passionate about the topic under discussion. The audience must perceive that, at some level, the presenter cares about the subject on a personal level, to an extent that assures integrity about conclusions that are drawn.
· The presenter respects the audience. They truly wish to inform and advance understanding of the topic under discussion.
· The material is presented in a “user-friendly” and entertaining manner. This is not showmanship or a simple sprinkling of humorous anecdotes. It involves a skillful use of familiar concepts, analogies and parallel discussion lines to weave a narrative that informs while telling a story. It also requires a sense of the needs and preferences of the audience.
Despite a longstanding and venerable place in the history of medical education, the lecture format has come under considerable criticism, and is somewhat at odds with modern educational theory. It has been rightfully pointed out we no longer need lectures for simple knowledge transfer, since students have available to them a myriad of other information sources. It is also true that the lecture format can be a very passive experience for the learner, and may not engage them in the “active learning” process which is essential to deep and retained understanding of any topic. Medical schools, including Queen’s, have all engaged a variety of active, small group learning techniques. Many have abandoned the lecture format entirely.
The three examples and characteristics described above illustrate that the lecture format, appropriately structured and delivered, can be an integral part of a medical education curriculum, going far beyond passive information transfer, challenging students to extend their basic knowledge to the implications and application of the factual, thus deepening their understanding and providing a model for thoughtful reflection that should model processes they take into their professional lives.
At Queen’s, we have given considerable thought to the place of lectures and various learning techniques in our curriculum. A number of key decisions were made about 7 years ago when we engaged curricular renewal:
1. We would engage a variety of learning methods, including team based learning, case based presentations, facilitated small group learning, and lectures. In short, we would strive for a balanced blend of teaching methods. In addition to taking advantage of the benefits of all approaches, this allows us to model all methodologies for our students, who need to learn to teach themselves, a component of the scholar competency (the “medium is the message” approach).
2. We would use lectures not to provide basic information, but to allow experienced faculty to extend that information into discussions of significance, professional implications and clinical applications of knowledge.
3. We would structure into our courses sufficient resources, time and guidance for students to acquire basic information in a variety of formats, including on-line material, learning modules, reference material and reliable information sources that we would recommend. We would, to use the educational terminology, engage Directed independent learning.
4. We would dedicate significant components of our curriculum to helping students identify and recognize reliable information. In fact, much of the Scholar competency and most of our Critical Appraisal, Research and Learning (CARL) course (developed and guided by Dr. Heather Murray) is devoted to this goal.
5. We would promote faculty development opportunities for teaching faculty and recognize outstanding lectureship.
In short, we wanted fewer but better and more meaningful lectures, delivered to students already prepared with basic information and able to both discern credible information and make valid clinical decisions. To accomplish this, we required a committed, engaged and well-supported faculty, clarification among our students about the learning goals, and teaching spaces that allowed all this to happen.
Our School of Medicine Building, opened in September of 2011, was purpose built with these objectives in mind. The large group rooms were designed to allow for both lecture and small group teaching, and easily allow a teacher to transition between the two methods, so students can move easily between attending to a single lecturer and small group discussions on the issue under discussion.
The building also includes 30 small group rooms for both formal and informal learning.
Has it worked? Lectures continue to be featured in every course we offer but are now part of a teaching mix that includes all the other small group based methods we promote. The graph provided depicts the current percentages, a significant change over the past few years and a tribute to our faculty.
Do our students value lectures? Each year, the Aesculapian Society presents a “Lectureship Award” for the teacher in each course who they felt provided the most effective sessions. These are awarded after each course and are very highly valued by faculty.
The Canadian Graduation Survey, completed by all medical students at the completion of their final year, including 102 (99%) of our 2014 class, asks them to rate the overall quality of their medical education. Seventy-two percent of our graduates rate their experience as “excellent”, comparing to a national average of 29.6%.
So it seems we’re doing something right, and that the lecture has a secure future in undergraduate education, thanks in no small part to the example and contributions of excellent lecturers like Drs. Holland, Jin and Liederman.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Why, What and How We Teach at Queen’s Medicine.v3
For a teenage boy growing up in a small town, the local auto mechanic can become a best friend and key to social success. I had great admiration for one in particular who would let me watch and explain what he was doing as he went about trying to resuscitate whatever antiquated pile of spare parts I was currently passing off as my “drive”. He always seemed to be able to find a way to repair whatever part was ailing, or adapt yet another spare part to replace whatever previously adapted spare part was no longer operational. But sometimes, even he would throw in the proverbial towel. “There are times”, he would say, wiping grease from his hands, “when you just need to jack up the horn and drive under a new car”.
Many times, when grappling with really difficult and highly complex problems, we are tempted to just “blow it up and start all over again”. The concept of going back to first principles and taking a new and fresh approach that sets aside all of the partial “patch work” fixes and “spare parts” that have been put in place over the years can be hugely tempting, particularly when it’s obvious that those noble and well-intentioned attempts are now resulting in a system that is unnecessarily complex and no longer addresses the initial intent.
But we don’t often get those opportunities, particularly when dealing with established and multifaceted systems like, for example, medical schools. Former United States President Calvin Coolidge is credited with remarking that “changing a college curriculum is like moving a graveyard – you never know how many friends the dead have until you try to move them.” We tend to resist change and cling to the familiar, particularly when those changes may be seen as threatening or offensive to folks who have developed or embraced them with every good intention.
All that notwithstanding, a rather courageous (and perhaps naïve) group set out to do just that at our medical school 7 years ago. There were multiple motivations. Many faculty were expressing frustration and a sense that we could do much better. Students were quite vocal in their view that the curriculum seemed out of keeping with their needs. The catalyst was provided by a recently received accreditation review that made it abundantly clear that multiple and key facets of our program required review and that no partial repair was going to address those concerns.
And so, an intrepid group was assembled and set out on what turned out to be a year long journey to “jack up the horn and drive under a new car”. The group consisted of three clinical faculty members who were established and respected medical educators and had great familiarity with our current curriculum and its history (Lindsay Davidson, Michelle Gibson, Sue Moffatt); two specialists in medical education theory and practice (Sheila Pinchin, Elaine VanMelle); a much respected clinician and teacher with longstanding interest in the development of Professionalism and the so called “non-medical expert” competencies (Ted Ashbury); a Pathologist/Immunologist who had led our basic science group in developing and delivering what was called “Phase 1” of the curriculum (Sherry Taylor); and a freshly minted and recently recruited Master of Education who was passionate about the role of generalism and the representation of Family Medicine within our curriculum and medical school (Michael Sylvester).
Despite their differences, the group gelled remarkably well. They were united by many things but, I believe, first and foremost by a shared commitment to provide the best possible educational experience for our students, summed up rather nicely in the following statement of intent:
Our graduates will have exemplary foundations in medical competencies that will prepare them for success in qualifying examinations and in post-graduate training programs and for fulfilling careers serving their patients and their communities.
A number of key decisions followed…
- We would base our curriculum on competencies as expressed by the CanMEDS framework and Family Medicine principles of practice.
- We would use the AAMC Scientific Basis of Medical Practice as a framework for our basic science teaching
- We would use the Medical Council of Canada Clinical Presentations as a basis for teaching the Medical Expert components of our curriculum
- We needed a course-based structure in order to assign competencies and clinical presentations in a logical, integrated and progressive fashion
- We would introduce more small group teaching to complement our lecture-based approach
- We would ensure students had opportunity to monitor their own learning process by introducing formative assessments into every course
- We would identify and retain aspects of our curriculum that were very successful, such as our Clinical Skills program
- We would provide more patient-centred experiences early in the curriculum in order for the students to engage their “physician” role early and to recognize the relevance of their early learning
- We would provide more opportunities for structured learning in later years by expanding our Clerkship to two years in order to develop three periods of “Core Curriculum” where the students would come back to school to learn complex issues or those that are best introduced after they’ve engaged clinical medicine.
What emerged was dubbed the “Foundations Curriculum” which had to be introduced over four years in order to ensure every class enrolled during those years received a full, albeit somewhat different, curricular experience.
The description of that new curriculum was articulated in a document entitled “Curricular Goals and Competency-Based Objectives” that was widely discussed, passed by our Curriculum Committee and endorsed by all faculty at School of Medicine Council. Because the undergraduate office happened to have a large supply of red printing paper that was used to produce a cover, the document became known as the “Red Book”.
That document has now been revised twice, based on experience with its implementation and considerable feedback from students, teaching faculty and curricular leaders. That third version, approved recently by our Curriculum Committee, has been packaged very attractively by Sheila Pinchin and her colleagues, and is being released this week. It will be made widely available in both electronic and print formats, and should serve as an articulation of the “why, how and what” we teach, and unifying focus for all the following:
- Student Learning – this document outlines what we expect our students to know, to do and to be, by the time they graduate
- Curricular Design – our course structure, sequencing and content will all be guided by this document. Each course will be assigned some subset of the Program Objectives and MCC presentations outlined.
- Teaching Events – each one of the 3,000 or so individual teaching sessions we provide over the four year curriculum will be structured with the goal of relating to one or more of the Curricular Objectives.
- Assessments – a comprehensive “blueprinting” process developed and monitored by our Student Assessment Committee will ensure that all summative assessments relate to a subset of the objectives assigned to the course or competency to which they relate.
In summary, the “Red Book” provides a basis to ensure that the key educational triad is maintained, interrelating the three pillars of any educational program – Objectives, Teaching and Assessment. It also serves to keep all of those engaged in our educational enterprise “on the same page”.
I’m very grateful to all of our educators, students, faculty and administrative staff whose dedication and commitment make our curriculum, and our school, so special – spare parts and all.