Category: Associate Dean
Dynamic Learning Environments – not just for academic centres
Several years ago, the Association of American Medical Colleges (AAMC) developed and publicized a statement on the learning environment.
The statement nicely articulates three key points about effective medical learning environments:
- Medical education and exemplary patient care go hand-in-hand.
- They feature a pervasive atmosphere (dare I say “culture”) of mutual respect and collaboration on the part of all involved in the delivery of patient care.
- Everybody involved is both a learner and a teacher, and feel free and comfortable in both roles.
Lofty goals and expectations, to be sure. In fact, the skeptical among us may consider these to be merely aspirational statements, expressing unachievable ideals.
I’m pleased to report that this is not the case. In my experience, I often encounter learning environments that are nicely meeting those lofty goals. Most commonly, these are in large teaching hospitals where available resources, space and academic focus combine to produce close-to-ideal learning environments. Recently, I had the opportunity to see similar success in a much smaller site.
I attended the Third Annual Georgian Bay Healthcare Wellness Research and Innovation Day held at the Collingwood General and Marine Hospital.
Organized by Collingwood Chief of Staff Dr. Michael Lissi and supported by Dr. Peter Wells and Program Manager Michelle Hunter of the Rural Ontario Medical Program, this year’s theme was Geriatrics and involved a thoughtful panel discussion followed by a series of very well-qualified and engaging speakers.
The hospital cafeteria, re-purposed for the occasion, was standing-room-only as about 150 folks from all areas of the health care community, as well as interested local residents, packed the room and contributed to the discussion. The sessions were live-streamed to several sites.
In addition to the presentations, hospital corridors were used to feature about 60 posters featuring studies carried out by local practitioners and learners working in the community.
I was there largely because two of our students who are in Collingwood completing placements.
Claire Tardif and Daniel Weadick of Meds 2019 are, by all accounts, both enjoying the experience and learning a great deal. They’re integrating well into that local learning environment, working with multiple physicians, other learners and health care providers. Dan summarized it all rather effectively. In his own words “there’s a lot to like”.
For me, the whole experience was a little surreal. Having grown up in Collingwood and worked in the various jobs in and out of the local hospital, I found myself reviewing posters and meeting local physicians in the same rooms and corridors in which I’d made deliveries and portered patients many years ago.
Medical education theorists have described the learning process in many ways, but all agree that the knowledge and skills
learned through largely classroom and simulated settings are insufficient unless integrated and applied to real patients. That process of application must be progressive, beginning with highly supervised settings where learners can begin to experience clinical care and decision making in safe and nurturing environments, while at the same time allowing them to progress to increasing levels of independence as their skills and growing confidence allows. For the medical student, highly-structured and learner-dense academic hospital settings are certainly valuable and essential, but may provide unintentional “ceilings” to professional development, and limit the appreciation of continuity of care that occurs outside the specialized ward and is so critical to patient outcomes. Community placements in smaller centres can complement their learning by providing that context.
In the end, medical education is fundamentally about providing and identifying environments where motivated, talented students can encounter generous and welcoming practitioners in settings that strive to provide excellent patient care and learning for all involved.
I’m pleased (and perhaps a little proud) to say that my home town is one of those places.
Wolves among the sheep
How does a nurse, working in public hospitals and nursing homes, manage to murder frail, elderly patients without detection?
How does it go on for 20 years, resulting in the deaths of eight patients under her care?
Why did it only come to attention and stop when the perpetrator herself confessed openly to the crimes?
These questions are the focus of an inquest commissioned to investigate the actions of Elizabeth Wettlaufer, a former nurse now serving a life sentence for the crimes to which she has confessed.
The inquest is scheduled to release its final report this summer, but documents recently released reveal a number of very sobering facts that should concern any health care professional and, particularly, those with leadership or administrative positions:
- She was fired from her first nursing job in 1995 for stealing medications. However, following intervention by her nursing
professional association, the firing was noted officially as a voluntary resignation.
- Between 2007 and 2014, while working at the Caressant Care centre in Woodstock, Ms. Wettlaufer was reprimanded no fewer than nine times for medical errors and general incompetence, refused recommendations to take leaves of absence and ignored threats from her colleagues that her increasingly suspicious behaviour would be reported to her licensing body.
- She was finally fired in 2014. That firing was again officially noted as a voluntary resignation after her union intervened. As a result of that settlement, Ms. Wettlaufer actually received $2,000 and a letter of recommendation.
- Between 2007 and 2014, while all these concerns were under review, she continued to kill residents of the Caressant Care centre by administering lethal doses of Insulin.
- On two occasions, the coroner’s office was notified about deaths at chronic care facilities where Ms. Wettlaufer worked. No autopsies or investigations were ordered.
If Ms. Wettlaufer had not voluntarily confessed her crimes, they might never have come to attention. She has recently spoken out about loose regulatory processes governing the use of Insulin which made it possible for her to administer overdoses without detection.
This is, regrettably, not the first instance of a health care provider using a position of trust to facilitate murder.
Harold Frederick Shipman was an English physician, considered one of the most prolific serial killers of all time. In January of 2000 he was found guilty of killing 15 patients under his care and sentenced to life imprisonment, but a subsequent inquiry linked him to over 250 murders over his thirty year career. It seems that, in retrospect, numerous warnings of misbehaviour were ignored, including the fact that one of his first victims, an elderly lady previously in good health who was found dead only a few hours after a visit from Dr. Shipman, had recently changed her will to bequeath her entire fortune to him. In fact, most of his patients were in good health prior to visits with him during which injections were administered. It appears that at least three of the murders were directly witnessed by other personnel but nonetheless went unreported.
Joseph Michael Swango is an American who is currently serving three consecutive life sentences imposed in the year 2000 for the murder of patients who were under his care while he was practicing as a physician. It now appears he was responsible for as many as 60 fatal poisonings of both patients and colleagues. In retrospect, it is clear that there were signs of very troubling behaviour during medical school. Although considered intellectually brilliant, he exhibited a fascination with dying patients, to the extent of preferring to work as an ambulance attendant rather than going to his classes. It was found at one point that he had submitted falsified documents regarding completion of required tasks. Numerous fellow students and faculty raised concerns about his behaviour and honesty. He was nearly expelled but was allowed to stay on because one member of a review panel felt he should be given a chance to remediate. He was allowed to graduate one year after his entering class and, despite a very poor evaluation in his dean’s letter, secured a surgical internship. While on clinical rotations, nurses had reported multiple instances of apparently healthy patients dying mysteriously while he was on duty. On one occasion, he was caught injecting a substance into a patient who subsequently became very ill. Despite these warnings, no major sanction was imposed, although the program revoked its residency offer. He went on to work as a paramedic and laboratory technician. By changing his name and falsifying documents he was able to get into a variety of different residency programs at medical schools across the United States, and therefore work as a physician, all the time murdering both patients and co-workers, usually with injections of arsenic. The American Medical Association eventually did a thorough background check on one of his applications and uncovered the pattern of previous incidents. As a result, all 125 American medical schools and over 1,000 teaching hospitals were alerted to his identity and record. Effectively blacklisted from further residencies, he fled to Africa where he secured positions and continued to commit murder. A very complex and thorough investigation eventually led to his extradition, indictment and conviction.
These are, mercifully, very rare and extreme examples. However, they remind us that the intelligent sociopathic personality may find the medical or nursing professions ideal environments to prey on the innocent and satisfy the craving to kill. They also remind us that the patterns of deviant behaviour start early and without major impact until fully empowered. Set amongst trusting patients and innocent, often naive colleagues who would have difficulty even conceiving such behaviour, these monstrous individuals are like wolves among sheep. They may also benefit from the well-meaning protection of colleagues and supervising faculty whose first instinct will always be to help and cure rather than condemn. As in the case of Ms. Wettlaufer, they may also benefit from professional organizations and legal processes that put the interest of the individual above potential impact on current and future victims. Unless counterbalanced by administrations and leadership willing to undertake legal challenges and defend the broader interests of the public, profession, and future patients, these behaviours can go unchecked.
The upcoming inquest report will surely identify several points at which our processes failed to act and put an end Ms. Wettlaufer’s serial murders. However, there are lessons here for us all who are involved in medical education. The degrees and qualifications we bestow convey an assurance to licensing bodies, institutions and the public that the individuals who hold them are not only knowledgeable and technically qualified, but also trustworthy. We must be vigilant with respect all those considerations, and be prepared to defend the integrity of our educational and evaluative processes. Our responsibilities extend beyond the individual learner, to the public and to potential future patients.
We must never set wolves among the sheep.
Great Teaching. You know it when you see it.
What makes for a great teaching session? In medical school, we make prodigious efforts to answer that question. We collect reams of information, ranging from the extensive student feedback collected about all aspects of their learning experience, to analyses of objective measures of student success in both internal and external examinations. There is also much written about educational methodology, and which approaches are felt to optimize effectiveness. We establish policy and take effort to ensure those are applied throughout our curriculum.
But beyond all this, there is something about a successful teaching session that defies formal analysis and simply goes beyond the aggregate of measurable parameters. To use a phrase originally applied by a Supreme Court Justice to the understanding of pornography, “you know it when you see it”.
My walking route from the hospital to the undergraduate office takes me by the main lecture hall in the School of Medicine Building at least a couple of times each day. I often stop as I go by to see what’s happening. Sometimes, I’ll drop in and look in on the teaching session for a few minute
It is easy to spot a session that’s going well. There’s a certain energy in the room that is immediately apparent. The students are engaged, attentive, anticipating what’s to come. But even easier to read is the teacher. Whether it’s a basic scientist or clinician, something special happens when a natural teacher encounters a group of eager learners. Like the activation of a long dormant instinct, the encounter seems to set off a response in the teacher that energizes the session. It is no longer a recitation of facts and directives but rather a sincere effort to pass along acquired wisdom. Students, for their part, sense the effort and value of what the teacher is trying to do. They reciprocate with attention that energizes the teacher, setting up a feedback loop that makes the whole thing work.
I’m pleased to report that, by both the objective and “know it when you see it” assessment, the vast majority of the teaching sessions we provide are highly effective. It is also apparent to me that the vast majority of our faculty truly enjoys their teaching experience and finds it personally satisfying. That fact, more than anything, is the source of our success as a medical school.
And it happens a lot. Over the course of our four-year curriculum, over 700 full time and part time faculty members provide teaching sessions to our students, most of them practicing physicians with schedules full of more immediately urgent and financially rewarding pursuits. So how does it happen, and happen so frequently?
In an insightful commentary entitled “What Makes a Good Teacher? Lessons from Teaching Medical Students” (Academic Medicine 2001:76(8);809) Ronald Markert identifies several factors that he believes characterize the best teachers. Although all are valid, two have always stood out to me as particularly relevant to the physician teacher. Quoting from Dr. Markert’s article:
A good teacher wants to be a good teacher. Teaching has to be its own reward. While recognition for outstanding teaching is commendable, faculty who are motivated only by formal honors will not achieve teaching excellence.
The focus of instruction should always be on student learning, not faculty teaching. Too often faculty members concentrate on what they want students to know. However, medical education is professional education, and we who teach medical students should go beyond our conceptions of what we think they should know and instead should search for what they actually need to know as practicing physicians.
Teaching, at its core, is a distinctly human interaction. It requires a connection, a mutual, unspoken relationship between two parties, one possessed of knowledge and the generosity to share, and one receptive to that knowledge. Essential to the learner is trust. They must assume their teacher is not only knowledgeable but is also motivated by their best interests.
Doctors are natural teachers. I believe this is, at least in part, because the selfless sharing of information and focus on the needs of the learner so well-described by Dr. Markert are also features of the physician-patient relationship. They also instinctively understand the concept of assumed trust, as critical to the teaching role as it is to provision of care to patients.
This week at medical school convocation, the graduating class will honour three such great teachers whom they have identified to receive the Connell Award. Named in honour of two previous heads of medicine, this award recognizes outstanding contributions to mentorship, lectureship and clinical teaching over their medical school experience. This year, Drs. Susan Moffatt, David Lee and Barry Chan have been selected and are, indeed, very worthy recipients.
Congratulations to them, and to all our faculty who contribute their time and natural talents to not only educating our students, but modelling for them the commitment and teaching skills that they will carry into their careers.
Learning through Community Service: From the classroom to Rideau Heights.
“Education is not preparation for life. Education is life itself.”
Those words are attributed to John Dewey (1859-1952), an American philosopher-educator who argued persuasively that the purpose of education is not simply to prepare young people to earn a living, but also to gain a deep understanding of the society in which they live and how they can function and contribute to it. In fact, he believed that achievement of a “democratic” society was not possible without that deep understanding, and that it could only be gained through personal experiences (Dewey J. Democracy and Education: An Introduction to the Philosophy of Education. MacMillan. 1916).
In the medical world, its axiomatic that doctors require a full understanding of the patients they serve. That understanding must go beyond the physiology and pathology of their medical diseases and extend to the circumstances of their patient’s lives and how those circumstances influence the genesis and treatment of their medical ailments. If medical education is to prepare students fully for this challenge, it can’t be achieved simply through expressions of commitment and recitation of facts. It requires personal encounters and lived experiences.
The concept of “service learning” in medical education is fundamentally a commitment to provide those experiences. The challenge, of course, is that it can’t be forced upon the unwilling. Medical schools need to firstly select young people in whom the consciousness of community service and social accountability already exists, and to then provide opportunities in which fruitful educational encounters can develop. Basically, we outline the concepts and point to opportunities. It’s up to our students to take up the challenge. And they do, which, I must say, is one of the most satisfying and affirming experiences for any medical educator.
A few weeks ago, I had opportunity to drop by just such an event. It occurred at the opening of the Rideau Heights Community Centre, a facility established by the city to serve an area that has been considered underserviced. Our students, through linkages established with the Loving Spoonful, a Kingston agency committed to providing healthy food security, had opportunity to contribute to that event. I’ll let them describe the experience in their own words, written by the lead organizer, Danielle Weber-Adrian of Meds 2021 (photos courtesy of Danielle and myself).
Last November 4th there was a Health and Human Rights weekend seminar hosted at the School of Medicine Building. This is where I met Mara Shaw (Executive Director of Loving Spoonful) and we started chatting in a food security workshop. During graduate studies, my class fundraised for and hosted a meal at a local soup kitchen. It had been a wonderfully rewarding way to engage with the local community, and I thought the class of 2021 would also enjoy something like this. I pitched the idea to Mara and she immediately said yes. She mentioned that the opening of the Rideau Heights Community Centre would be the prefect venue for this idea. She explained that the demographics of the Rideau Heights neighbourhood included some of those most in need in the Kingston area, and that she’d love to work with us.
Getting the class on board was a cake walk. Bethany Ricker was also at the seminar and she was the first person I approached about this idea. She showed immediate interest and the two of us formed the Rideau Heights Community Meal Committee. After that, five more of our classmates were avid to join the team and we were “off to the races”! Mara put us in touch with a local culinary chef, Tibrata Gillies, and assigned Thea Zuiker from Loving Spoonful to help us organize logistics. Bethany had been a cook at a summer camp before medical school, and the chili was actually her idea. She also single-handedly secured sizable donations of ground beef and vegetables to support our efforts. Tibrata then guided us as to how to prepare our meal, scale up a recipe, and then lead us on the day-of. When I had originally spoken to Mara about this I thought we were going to make a meal for about 200 people, but she told us we were expecting closer to 500 (“if that would work for us”). So, the committee rallied fundraising efforts and took on the challenge! To help mitigate costs, Emily Wilkerson and Bethany spear-headed a mini telephone campaign targeting local bakeries and grocery stores to inquire about bread donations (this was ultimately unsuccessful, but speaks to their resourcefulness and ingenuity!).
Fundraising started in full force in January, and it was a true collective effort. Emily organized a 50/50 draw during a mentorship trivia night, which was wildly successful. Natasha Tang, Sarah Wong, Emma Spence, Angela Brijmohan and Bethany Ricker planned weekly (or biweekly) bake sales and organized volunteer bakers, and I sold “all you can drink” coffee most mornings until we had raised $974.60. Meanwhile, Emma had the fantastic idea of applying for the ASIA (Aesculapian Society Initiative Award) through which we were awarded another $900. This was almost double our initial fundraising goal of $1,000.
For the event itself, Loving Spoonful was a dream to work with. Once we had delivered the funds, they contacted a grocery wholesaler and had most of the food delivered right to the community centre, meaning I only had to make one trip to Walmart for plates and a few other essentials to prepare for the meal. Loving Spoonful was also in contact with the city while designing and planning the community centre kitchen, so they knew exactly what we would have available. Tibrata also got to weigh in and advise the city which kitchen hardware options to invest in.
In the end, we were able to provide a warm, nourishing meal for over 500 Rideau Heights community members, and we had plenty of 2021 (and 2018!) volunteers to cook, serve, and clean up. It was a fantastic experience, and I’ve heard really great feedback from both the class and the event participants.
The School of Medicine Building on Arch Street and the Rideau Heights Community Centre are separated geographically by 4.2 km. Culturally and socioeconomically, the separation is much greater. The students who took the initiative and made the effort to serve the families of north Kingston closed that gap and, in the process, both confirmed the wisdom of our admissions process and made great strides in their journey to becoming great physicians. In short, they did us proud. Congratulations to them.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Why medical students go unmatched, and why they deserve an opportunity to complete their training.
There is no longer any doubt that the number of unmatched Canadian medical graduates is on an upward trajectory that will certainly continue in the absence of significant interventions. We now know (https://afmc.ca/news/2018-04-17) that 115 students remain without residency positions after two attempts to “match” this year. That’s an increase from 68 from last year, 46 in 2016, and 39 in 2015, which means the number has almost tripled over those four years.
We also know of the tremendous individual burden of failing to engage a residency position which, while always very well understood by medical students and medical school faculty, has been made public through numerous articles and individual accounts:
Both the Association of Faculties of Medicine of Canada (AFMC) and Canadian Federation of Medical Students have developed position papers on this issue.
The upward trend is in keeping with the rather dire predictions of the AFMC position paper and has caused that organization, in a recent news release, to term the situation a “crisis”.
It has also spurred the Ontario Minister of Health, with urging from the provincial medical school Deans, to introduce a 23 million dollar program to provide supernumerary positions to, at least temporarily, provide relief.
This effort by our provincial government is very much welcome by both students and medical school faculty, and certainly provides very tangible evidence that the issue has gained attention and is being seriously engaged. However, it is clearly a temporizing measure, intended to stop the bleeding, not resolve the problem.
In medicine, we teach that problems can only be effectively engaged with a full understanding of their cause, or etiology. That process always starts with an examination of available facts, which are sometimes difficult to tease out from the subjective impression of a stressful experience.
So, what are the facts?
- The number of residency positions available to medical school graduates is established by our provincial governments. They also very strongly influence the distribution of those positions between the 30 or so entry level residency programs. This is entirely appropriate to their responsibility to safeguard the public interest, both in terms of provision of health care and financial stewardship. No doubt they and their advisors make every effort to ensure that those positions match the needs of the communities they serve. Given the lag time inherent in the medical education process, this requires predicting future needs which, all would agree, is a difficult and inherently imprecise process.
- Provincial governments have also made the decision to make some residency positions available to Canadian citizens and landed immigrants who have graduated from medical schools outside Canada (International Medical Graduates).
- Students enter medical school with the clear expectation that any medical specialty is available to them but with little idea of which medical specialty they wish to engage, and with no obligation to undertake any particular specialty. Considerable effort and thought is expended by students during medical school to make those determinations. Those efforts are strongly supported by undergraduate programs through counseling and provision of career exploration opportunities.
- Medical students make their own choices with respect to which programs they apply to, and how many programs they apply to. In doing so, they receive counseling from their schools, but are free to accept or reject any recommendations, and are well aware of which residency programs are more competitive.
- Although the absolute number of residency positions is numerically similar to the number of Canadian graduates, the choices of students do not match the distribution of positions, resulting in a number of specialty programs being heavily over-subscribed and therefore highly competitive.
The phenomenon of the unmatched student is therefore the direct consequence of a mismatch between the specialty mix deemed to be in the public interest by our government, and the personal preferences of students.
It is also clear, given the current process and recent history, that the goal of matching every student to their specialty of choice is an impossibility. Intense competition for residency spots and increasing numbers of unmatched students are inevitable unless one or more of the operative realities noted above are changed. Fortunately, the Ministry of Health has, in the recent statement, committed to engage substantive change:
“Ontario is collaborating with partners throughout the country to develop and implement a longer-term solution to this pan-Canadian challenge.”
Those charged with developing this “longer term solution” will, no doubt, be facing a considerable challenge, attempting to balance the government’s primary responsibility to public accountability, with the full freedom of students to choose any specialty. As they do, they will need to consider a few other facts concerning the educational experience of our students.
Medical school graduates are not yet able to engage practice. Medical education is a continuing process that transitions from university-based degree programs to residency positions that last a minimum of two additional years and which must be completed before a learner is even eligible to engage practice. While it is certainly possible for medical school graduates to take up alternate careers, that is clearly not their intention at outset, nor is it the societal expectation that establishes the number of medical school positions to match needs and heavily subsidizes medical education. The graduate who fails to achieve a residency is therefore denied the opportunity engage medical practice, and the training they have received to date is essentially wasted.
One could argue persuasively that the public interest, honestly and objectively interpreted, should always take precedence over individual preferences. However, most would also agree that every individual in a free society should at least have the opportunity to engage the profession for which they have undertaken training at considerable effort and personal sacrifice, and for which they have successfully demonstrated qualification.
Our students deserve the opportunity to engage a career in medicine and our society deserves a return on the investment they’ve made in their education. For those things to happen, our graduating students must have an opportunity to engage a residency program. Our ultimate solution to the unmatched student problem must, at a minimum, provide that opportunity.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
The never-ending march for a better world.
“One of my best friends was killed by gun violence right around here”
With those few simple words to a reporter asking why he was participating in the recent gun control demonstrations, Paul McCartney not only perfectly summarized his intention, but also managed to unite the generations of people marching with him and remind us that you’re never get too old, or secure, to aspire for a better world.
He was participating in one of many demonstrations taking place as part of the “March for our Lives” movement staged last week in many American and Canadian cities. Responding to the Parkland Florida mass shootings and so many that have gone before, millions of young people took to the streets to demand action from their political leaders. The sight of these folks, many of them really just children, publicly and boldly prodding their leaders to action was inspiring and one of the most hopeful developments to come from our southerly neighbours in some time.
But among them were also many not-so-young people, spurred on by their own convictions and reminding all that there were older people among those lost in the shootings at Marjory Stoneman Douglas High School, and that gun violence is indiscriminate, targeting all.
The “best friend” Mr. McCartney referred to was, of course, John Lennon, who was killed by a gunman outside his New York apartment in 1980. Together with George Harrison and Ringo Starr, they formed the Beatles, the group which transformed the music world in the 1960s and, many believe, were key contributors to a massive social movement that influenced an entire generation – a generation that engaged protest and became quite familiar with marches and mass demonstrations.
What I recall from that time, and still persists for me today, is firstly how revolutionary their music was. Because their songs are now so familiar to us, it’s difficult to appreciate today just how fresh and original they were at that time. They really didn’t sound like anyone else, and didn’t fit any particular pre-existing style. They wrote all their own songs, which was apparently unheard of for a group of young people at the time. Their harmonization and musical instincts seemed like uncomplicated, pure perfection. For those who were young at the time and searching for an identity that distinguished them from previous generations, they provided the perfect vehicle. They brought hope and the sense than true change was possible. Over the years, particularly for those of my generation, their music still evokes that sense of optimism and promise that a better future is always achievable.
The other aspect I recall is their incredible irreverence. They were amazingly unpretentious, unapologetic and in no way intimidated by convention. They were audacious and genuine. I recently watched a documentary about them featuring film footage of interviews with seasoned, much older reporters who were completely unprepared for their refusal to condescend and were completely incapable of controlling the interview.
- Asked to characterize their musical genre, the response was “well, it’s just music, isn’t it?”
- Told that a music critic felt their music had “unresolved leading tones, a false modal frame ending in a plain diatonic”, John responded “he ought to see a doctor about that”.
- Asked who was their leader, Paul responded “whoever shouts the loudest.”
- Asked the meaning of their group’s name, John said “it means Beatles, doesn’t it? But that’s just a name, like shoe”.
Their rejection of convention, and refusal to be drawn into values not their own, was remarkable.
Over fifty years later, that spirit seems secure in the young people marching and speaking out last week, and in Mr. McCartney’s willingness to stand with them. It should remind us that issues such as gun control, climate change and social justice transcend age and generational stereotypes. It should remind those in positions of authority that the young people of today may indeed have concerns worthy of attention and are not really so different than they were. It should remind us all that young people have the considerable advantage of seeing the world through fresh and optimistic eyes, not yet worn down by the weight of responsibility and prior disappointments. They simply want a better world and ask “Why not?”. Didn’t we all? Shouldn’t we all? Don’t we all?
As I write this, one of my favourite Beatles discs plays in the background. I linger on the lyrics and plaintive melody of “All You Need is Love”.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Basic Science in the Undergraduate Medical Curriculum. How much and how?
“There can be no doubt that the future of pathology and of therapeutics, and, therefore, of practical medicine, depends upon the extent to which those who occupy themselves with these subjects are trained in the methods and impregnated with the fundamental truths of biology.”
That statement, attributed to biologist and anatomist Thomas Huxley, appears in a 1909 paper entitled “The Preparation for the Study of Medicine” (Popular Science, volume 75). The author, Dr. Frederic T. Lewis, goes on to support this position by presenting the results of a study of first year medical students based on the number of science courses they’d taken before entering. Because Dr. Lewis didn’t have the benefit of Power Point, I’ve transcribed his findings into the chart below:
I provide this not because his findings are directly relevant to us today, but to make the point that the issue of how much science is needed or appropriate for the study of clinical medicine has been contentious since the beginning of formal medical education.
In his transformative review and 1910 report on the status of North American medical schools, Abraham Flexner strongly supports a scientific basis of medical education. In his second chapter “The Proper Basis of Medical Education”, he makes a strong case that, in order to provide optimal care and engage future developments, a physician must have a deep understanding of the scientific underpinnings of human function in health and disease.
Flexner goes on to say that those entering medical school must have a “competent knowledge” of the “fundamental sciences” of chemistry, biology and physics, so that the clinical sciences of anatomy, physiology, pathology, bacteriology and “physiological chemistry” can be engaged in medical school.
Flexner’s influence on medical education in the 20th century cannot be overstated. The fundamental model of basic science prerequisites to admission, followed by first and second year courses in anatomy, physiology, biochemistry, microbiology, pathology and pharmacology became standard, and the basis for accreditation standards. Medical students took courses and labs in these subjects that were very similar to those taken by undergraduates taking degrees in those subjects, sometimes even in combined classes.
In recent years, a number of factors have influenced the choice of basic science content in undergraduate medical education, and how it should be taught:
- A desire to ensure the science being taught was relevant to medical practice
- A very practical need to be selective with respect to curricular content, given the tremendous expansion of material to be taught.
- A desire to integrate the teaching of basic science with the clinical skills and reasoning courses
- The development of new areas of science that are highly relevant to practice and must now also be taught, such as immunology, genetics and advanced imaging.
- The desire to take advantage of more effective teaching methodologies, recognizing that the lecture format is limited as a means of promoting individual understanding, and that traditional laboratory experiments are both logistically impractical and of limited relevance to those learning clinical applications.
Medical schools have therefore been very much challenged with two key issues of what basic science should they teach and, critically, how should it be taught?
At Queen’s, we re-organized our basic science teaching at the time of last major curricular revision in 2008. The Foundations Curriculum developed at that time included two consolidated first year Scientific Foundations courses, Normal Human Structure and Normal Human Function.
This came at a time when our basic science departments were amalgamating into a single consolidated Department of Biomedical and Molecular Sciences which, under the leadership of Department Head Dr. Michael Adams, took on the directorship of these courses.
Last year, in an effort to integrate the courses both with each other and with the other courses running in the same terms (particularly Clinical Skills) and our Facilitated Small Group Learning curriculum, it was decided to amalgamate the two into a single Human Structure and Function course that would run through the entire first year.
This past week, I met with Course Director Dr. Chris Ward, Year 1 Director Dr. Michelle Gibson, and Dr. Adams to discuss our approach to next year’s course. We recognized that there is a wonderful opportunity here to better link it not only to contemporaneous courses, but also to those clinical courses that will follow in subsequent terms and years.
We’ll therefore be putting out a call to invite clinical teaching faculty to provide input as to basic science content they feel would facilitate teaching in their courses and would better prepare students to engage the teaching of clinical presentations.
In fact, we invite all faculty to share their views regarding the nature of basic science that is now relevant to clinical practice and their perspectives as to when and how that science should be introduced. We also welcome opportunities for clinicians and pathologists to participate in the basic science teaching in first year in partnership with our basic science instructors. This type of cooperative teaching is not only highly effective but models the collaborative practice that we wish our students to emulate.
So, whether you share Dr. Huxley’s perspective above or not, we’d love to hear from you.
Undergraduate Medical Education
Residency Match Day 2018: What our students are experiencing, and how to help them get through it
“Keep trying. Stay humble, Trust your instincts. Most importantly, act. When you come to a fork in the road, take it.”
The last sentence of Mr. Berra’s famous statement is usually quoted in isolation. Without the context of the first few phrases, it’s humorous, but doesn’t carry much meaning, and is something of a disservice to its author. The full statement, in contrast, is a call to commitment and action, and conveys real wisdom.
His words come particularly to mind at 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:
- Anticipate that your student will be distracted that morning
- Please ensure your student is able to review their results at noon.
- 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.
- 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 email@example.com, or 613-533-6000 x78451. The faculty counselors can also be contacted directly at the following:
Director, Student Affairs
Career Counselor firstname.lastname@example.org
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
A Final Gift from a First Patient
Bill died last week. He was 93 and, at the end, his passing could be considered neither tragic nor unexpected. His daughter thoughtfully called my office to let me know, and that he wouldn’t be keeping his next clinic appointment.
The last few years hadn’t been easy for him, bringing increasing disability and dependency. Things hadn’t been really right since Daphne passed away about three years ago, after over 60 years of marriage.
Before that they’d always come to clinic together and supported each other through their health issues, surgeries and increasing fragility. Bill was one of those people who seemed incapable of despondency or self-pity. Always smiling, he began every appointment by asking me how I was doing, and never left without thanking me. He never refused a request to allow a learner to listen to his heart. In fact, he usually offered before being asked. Like many of his generation, he never lost that sense of gratitude for what his new country made available to him and felt a need to repay that debt.
He’d emigrated from England in the 1950s. He was an engineer and worked in various projects over the years both in Canada and Europe, finally retiring in Kingston over 30 years ago, building his “dream house” with Daphne. In retirement, he developed a large community of friends, including many neighbours (some of whom were physicians in our hospitals) who would support him as he continued to live there alone. They would often bring him into clinic appointments, or call with concerns about him.
In one of his last selfless acts, he agreed to participate in our First Patient Program. Two of our first year students, Madison Price and Michael Christie, got the opportunity to meet Bill, visit with him, accompany him to appointments, and hear about his medical history and life story. He taught them something about heart disease and its various complications, but mostly he taught them about the patient experience of living with a chronic condition, about how physicians can provide valuable care even after cure is no longer possible, about the remarkable courage and grace with which patients can face the end of life, and about how communities can come together to support those in need.
He shared personal stories with them, telling them about how he had worked on developing radar equipment for Lancaster bombers during the Second World War. He told of how his brother was a tail gunner on those aircraft, which provided Bill even more incentive to ensure the radar was effective.
He believed he had something valuable to impart to these young people and future physicians and indeed he did. In the end, his final gift was to teach them about bereavement and, particularly, how physicians and health care providers can be affected by the loss of patients they’ve cared for, come to know, and admire. He made medicine real to them by giving it a human face that, I believe, they will never forget.
With his willingness to engage these students during his final days, he provided a priceless and lasting gift, not only to these two aspiring physicians, but also to their future patients.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
“To boldly go where no (Doctor) has gone before”
Those as nerdy as I will recognize the title of this article as paraphrased from the introduction to the original Star Trek television series. That program, set in a technologically advanced future, was about a long journey of discovery. Perhaps the most peculiar aspect of that journey is that it had no particular destination. The voyagers were simply wandering aimlessly, hoping to run into something interesting. Consequently, they often found themselves woefully unprepared for the challenges they faced – an excellent means to provide dramatic tension to a fictional story, but a dubious strategy for real life.
A medical school curriculum is basically a journey. For our students, it’s a journey that will take them into an unknown future. Like any real journey (and in contrast to the intrepid Star Trek crew), establishing a destination is the first, critical step. A long journey may consist of many stages and stops along the way that demand our immediate attention, but those stages are only meaningful if they move the traveler toward some ultimate goal. That goal, of course, is to become effective, fulfilled providers of medical care to members of our society.
The students currently in medical school will be practicing into the mid 21st century. If we’re to provide them an education that will best prepare them to make meaningful contributions, we need to give some thought what that world will look like, and what it will require of them as physicians and professional leaders.
This was the topic of a presentation and subsequent discussion at our semi-annual Curricular Retreat this past week. In preparing some remarks to begin that discussion, I attempted to draw on changes that have occurred in the course of my career and use those observations to extrapolate into the future. I came up with five that I think are particularly relevant. This is, by no means, a complete list, but perhaps sets the tone and the challenge.
In no particular order:
- The role of physicians as purveyors of medical knowledge.
Knowledge is the fundamental fuel of medical practice, and the commodity that gives legitimacy to those providing care. A generation ago, medical knowledge was elusive. It had to be searched out, a process that was paper based and time consuming. Physicians were the primary source and conveyors of medical knowledge. People who wished to become physicians went to medical schools largely to seek out the knowledge and skills that were embodied in the practicing physicians who taught there.
That has all changed. Medical knowledge is now available, almost instantly, who anyone who wishes to find it. Physicians are no longer the primary source of that knowledge. They no longer hold any monopoly on knowledge.
- The expanding applications of Artificial Intelligence and robotic technology.
We were all impressed when Watson defeated chess masters and Jeopardy champions. In my field of cardiology, I think many dismissed automated interpretations of electrocardiograms as simple algorithm-driven time savers that would always require physician verification. The same is happening with respect to interpretation of diagnostic imaging such as chest x-rays and CT scans.
But AI is moving far beyond these applications that are based simply on prodigious memory storage and processing capacity. Applications are becoming much more sophisticated and are developing the ability to learn and adapt to dynamic situations. Diagnostic algorithms are available that will provide reasonable differential diagnoses for patient presentations, and computer interfaces are under development that are frighteningly life like in their ability to interpret individual patient speech and even facial expressions.
Robotic applications in the operating rooms and procedure suites hold the promise of increasing technical expertise and consistency while reducing infection rates. They also allow for interventions in locations where the human hands are simply incapable of performing.
Extrapolating forward, it’s not at all hard to imagine a world where most diagnostic imaging and many therapeutic interventions will require much less, or perhaps no human intervention.
- Our fundamental understanding of human disease.
For generations, physicians have understood and characterized disease states based on what they could observe clinically. “Consumption”, “Whooping Cough” and “Scarlet Fever” are examples of conditions described solely on symptoms and visual inspection. As the ability to image patients and do laboratory analyses improved, patients with Consumption were found to have pulmonary damage caused by Tuberculosis, Whooping Cough became Pertussis and Scarlet Fever became associated with streptococcus infection.
I have lectured students for over 20 years on the classification, diagnosis and management of cardiomyopathies based on morphologic distinctions (Dilated, Hypertrophic, Restrictive) established by clinical examination and imaging appearances. My teaching is now changing, based on new classification schemes based not on morphology, but on the genetic mutations that result in abnormal development of cardiac muscle cells and channels.
This is not only highly appropriate, but promises to bring genetically based therapeutics that promise to alter the natural history of these conditions in ways currently not available. It also represents an entirely new science, involving genomics and an understanding of sub-cellular processes that practitioners of the future will need to understand and develop comfort with if they’re to provide optimal care.
- Standardized approaches to disease management.
Physician order sheets used to be blank and on paper. They have not only become electronically integrated into patient management systems of various designs, but have also become prepopulated with standard orders for many, even most, clinical conditions. Often, all that’s required are patient specific data such as body size and renal function, and a physician’s signature (real or virtual) at the bottom of the page.
This is good in the sense that it promotes consistent and evidence based approaches to these conditions, and reduces transcription errors. However, it can also diminish the educational experience of medical students, and may not fully account for the needs of patients with multiple medical problems or individual characteristics that require an individualized approach.
- Expanding role of non-physicians in health care delivery.
The widespread availability of medical knowledge in general and guideline based management strategies specifically has allowed for other health care providers, such as nurse practitioners, pharmacists and physician assistants, to participate more fully many situations. Another example from my field would be the expanding role of nurse practitioners in heart failure clinics. NPs are fully capable of managing the introduction and maintenance of standard therapies in this population of patients who often require close and continuing surveillance. They do so very effectively, and their participation has been shown to improve patient functional status and reduce hospital admissions.
And so, what to do…
It’s important to state from the outset that this is all good. These five changes will make health care more effective and efficient. Like any development they have potential pitfalls, but, appropriately managed, they will bring significant advantages to our patients. It’s also important to recognize that they are not going away. Technologic progress does not wait for us, or any group, to be ready.
And so, we must engage some very difficult and disturbing questions, summarized in this slide I presented at our recent retreat:
Obviously, there are no definitive answers, but I provide a few thoughts that emerged from recent discussions.
- Students no longer need to undertake medical education in order to locate knowledge – they are quite capable of doing that on their own. They do, however, require guidance as to what will be relevant to their careers, and an ability to interpret and evaluate the merits of the tsunami of information that will come their way.
- AI has the potential to dramatically improve the delivery of care, but can be highly threatening, partly because applications can develop out of context and without clear applications. Physicians of the future need to be more than consumers of AI, they need to involved in the development of applications, the purpose of which should always be to advance care. To do so, they will need fundamental education that develops familiarity with the technology and its potential.
- Medical education has always been rooted in science, but the nature of that science is changing rapidly. Fundamental knowledge about normal human structure and function will always be required, but will need to extend beyond the superficially observable to penetrate the genetic and subcellular levels of normal and abnormal human function.
- As Physicians are needed less and less to interpret test results or manage standard, well-defined clinical issues, their role will extend to ensuring patients enter the care system appropriately, and managing situations where the complexity or multiplicity of issues goes beyond standard management. This will require them to be even more acute assessors of patients at the primary presentation, develop high levels of sensitivity to patient outcomes that deviate from optimal, and have a depth of understanding of the scientific underpinnings of disease and system management that will allow them to step in and provide “customized” management when required. Indeed, “personalized medicine” may become the primary focus of the physician of the future.
All this, and no doubt much more, will require a vastly different approach to medical education, one that we need to begin to consider today. The future is closing in very rapidly. I’ll end with a quote regarding the future role of physicians from someone who was always technologically ahead of his time and not shy about expressing disruptive views:
“The doctor of the future will give no medicine, but will instruct his patient in care of the human frame, in diet, and in the cause and prevention of disease.”
Thomas Alva Edison (1847-1931)
Edison may have been somewhat overly optimistic about the “give no medicine” prediction, but was certainly perceptive in predicting fundamental change in approach. Over the next few months, we’re going to engage a series of dialogues about the doctor, and medical school, of the future, beginning with our recent retreat and this article. Please feel free to participate with your thoughts as we “boldly go” about charting a course into the next few decades of medical practice and education.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education