Our Graduating Doctors. What qualities should they, and every Physician, possess?

At last month’s Convocation, we celebrated the beginning of 102 new medical careers. As the new graduates walked across the stage of Grant Hall, they stepped from their shared four-year undergraduate experience, into a diversity of career paths.

2014-grads

  • Twenty-six will begin training programs in Family Medicine.
  • Fourteen have chosen Internal Medicine.
  • Eleven are entering Anaesthesia.
  • Six in Pediatrics.
  • Six in Urology.
  • Five each in Emergency Medicine, General Surgery and Psychiatry.
  • Four each into Obstetrics-Gynecology, Neurology and Diagnostic Radiology.
  • Three will be entering Orthopedic Surgery, and three in Dermatology.
  • Two of our graduates will be undertaking training in Plastic Surgery.
  • One will be entering each of Ophthalmology, Cardiovascular Surgery, Neurosurgery and Radiation Oncology.

Over the next several years, they will differentiate further, into a potential of over 100 different practice disciplines now offered by the Royal College of Physicians and Surgeons and College of Family Medicine. This increasing diversification reflects the incredible expansion of medical practice, and the ever-expanding base of knowledge and skills we’re able to offer our patients. Although this is obviously welcome, it has caused many to question whether our current paradigm of medical education, beginning with a common three or four year, university-based curriculum, has kept pace or, perhaps more charitably expressed, should be reviewed.

In actual fact, our students’ educational experience in medical school is already differentiating, although unintentionally. Our current curriculum allows students considerable latitude to tailor their experience along lines of their choosing. Their 16 weeks of curricular electives, observerships and student-initiated interest groups allow each student to direct a significant proportion of their medical school experience. Although pedagogically intended to provide “learner-directed”, diversified educational experiences, it’s quite clear that these various elective options are used to explore and promote career interests, and are usually undertaken within the same discipline the student eventually enters. This is of obvious benefit to our students who struggle to come to career decisions and position themselves favourably in an increasingly competitive postgraduate matching process. Tampering with this largely unintended but nonetheless effective process could therefore disadvantage students and would bring considerable risk if considered in isolation.

However, we should recognize what’s happened by necessity rather than intention, reflect on what it’s telling us about the relevance of our current programs, and how we might intentionally design more effective training paradigms given the realities of current medical practice.

Central to this discussion is the need to grapple with the a key question: What are the knowledge components, skills and personal attributes that could be considered essential to every practicing physician, regardless of the discipline they eventually undertake? What qualities should we expect of every one of our graduates who walked across Grant Hall stage recently, or of those who will undertake our programs in the coming years? Put another way, one could consider what particular skills and qualities a physician should bring to patient care in an era of increasingly compartmentalized care provided by an expanding array of highly qualified professionals.

This reality was brought into particular focus for me last week by remarks made by Dr. Henry Dinsdale at a ceremony honouring his long and distinguished career. In his remarks, Dr. Dinsdale described his educational experience during an era when few specialty options existed, and a physicians training focused on core competencies common to all practitioners. Hearing of his many accomplishments in patient care, research and education, the message was clear: although knowledge expands and technology becomes more integrated, the core qualities that allow a physician to excel in his or her role are consistent, immutable, and should guide both our educational programs and selection processes.

And so, what are these attributes and qualities? I would suggest that any consideration of that question should be guided by three basic considerations: the responsibility to deliver excellent patient care; the responsibility to advance our profession through education and research; and the need to demonstrate a value-added role in an increasingly specialized health care workforce. With these considerations in mind, I would provide the following list for consideration:

  1. Curiosity. An insatiable and relentless drive to understand the human condition, in all its complexity from the subcellular to population levels, is the motivation that propels the lifelong pursuit of knowledge and skills and provides allows the physician to become the “medical expert”, both in breadth and depth of understanding. It also drives the desire to expand practice and share discoveries through research.
  2. Diligence. Getting into medical school requires persistence and hard work. Medical school itself and residency training that follows is even harder work. Medical practice, despite our increasing attention to maintaining health life balance, is the most challenging of all. Enough said.
  3. Communication. Arguably, the most important quality. A two way street – Doctors must be able to gather information and understand from all types of people, including those with limited ability to communicate themselves or understand their problems, and those of markedly diverse backgrounds. The greatest fund of information or technical expertise is useless without the ability to understand the patient in need or help them understand their needs. It’s also essential to effective education.
  4. Ability to deal with uncertainty. No two patients suffering with the same condition will present in exactly the same way. Each patient’s response to even the most accepted treatment will be unique to that patient. No diagnostic test is perfect. Physicians must therefore continually navigate in uncertain waters, balance risks with benefits, and guide their patients through that voyage.
  5. Judgement. Information about health issues is all around us, and universally available to our patients and the public. Knowledge is the considered consolidation of information into accepted practices, generally applicable to populations of patients with common characteristics. Judgement is required to extend that knowledge to individual patients. This may be the most difficult, but also singularly most characteristic quality of physicians.
  6. Composure under stress. One needs only to step into the Emergency Department or Intensive Care Unit of any hospital to see this quality in action, but it can also be found in Doctor’s offices, outpatient treatment units, research labs, medical schools, and any of the many places physicians undertake their diverse roles. In addition to being necessary to their own effectiveness, this quality provides a tone of stability for the patients and co-workers involved.
  7. Resilience. Things will go wrong, both personally and professionally. Effective physicians are not defeated by these experiences, but learn from them and become even more effective.
  8. Creativity. This speaks to the ability to think “outside the box”, extrapolating beyond commonly accepted approaches when the need (or opportunity) arises. Given the uncertainties inherent in clinical medicine noted previously, the physicians with single and inflexible approaches to each situation will find themselves both limited and frustrated.
  9. Humility. I struggled with this one, but in the final analysis, I felt that the ability to collaborate, work in teams, recognize personal limits and self-analyze (all of which are essential competencies) are made possible by this simple human quality which allows one to set aside personal gratification in the interests of the patient. In contrast, arrogance and relentless self-promotion make all these goals virtually impossible and underlie most complaints about physician performance.
  10. Compassion. Last on the list, but certainly not least. When asked what they expect of their physicians, patients consistently rate “compassion”, “caring” or similar qualities very highly. They expect, and deserve, their doctors to connect with them on a purely human level and share, in some way, in their suffering. Practically, it’s that sharing that provides true understanding and commitment.

And so, a long list of demanding attributes. Note the focus here is not on knowledge acquisition, skill development or even specific competencies, but rather on the personal qualities that make all those things possible. I provide it not to suggest that these qualities are unique to or only apparent in physicians. In fact, these qualities are exhibited and shared by many other professions, and particularly those engaged in health care. However, they are seen as essential to the effective physician and, as such, a valid starting point in establishment of selection processes, and educational programs common to the myriad roles that modern day medical graduates may undertake. This is, however, one person’s perspective. I welcome comment and refinement.

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“Try to leave the world just a little bit better…”

Each year, our graduating class is asked to nominate a member to speak on their behalf at the Convocation ceremony. Last week, Yan Sim delivered an address on behalf of the Meds 2014 class. Yan’s heartfelt remarks certainly seemed to capture the sentiments of his colleagues and resonated with everyone in Grant Hall that afternoon.   It seemed clear that his words should be shared more broadly and so, with his permission, I am providing the complete and unaltered text of his address below. All who are involved in our school in any way, be it teaching, leadership, administration or support, should take justifiable pride that our graduates should feel this way about their educational experience and upcoming careers. Yan’s words reaffirm the faith that what we do is worthwhile, and we must be doing something right. And so, the words of Dr. Sim:

Yan-SimGood afternoon Chancellor Dodge, Principal Woolf, Rector Young, Dean Reznick, Associate Dean Sanfilippo, distinguished faculty, ladies and gentlemen:

My name’s Yan Sim and I have the privilege today of speaking on behalf of the Graduating Class of 2014. I’d like to start by first, welcoming our loved ones who have come from near and far to celebrate this moment we’ve been working towards for the past four years.

To our proud friends and families, you’ve had the opportunity to see us change and grow during our time here at Queen’s. I think I speak for us all in saying, we wouldn’t be here without you. Your support pushed us to be the physicians we are today as we trained, acquired knowledge and searched for answers. More specifically, the answers to your sometimes very personal medical questions.

Questions ranging from “Will cracking my knuckles give me arthritis?” to “What’s that on my leg?” and “why does this hurt when I do that?” After four years of training I think I can say with confidence: “No”, “I don’t know”, and “Please not at dinner”. All jokes aside – please be assured of our sincere gratitude.

As we sit here today, a class representing the most successful residency match in the history of Queen’s medicine, we couldn’t have done so without the care of our beloved faculty and staff. I can’t think of many medical school deans who would attempt to host dinners at his home to feed a hundred starving first year med students and yet you did, Dr. Reznick, even providing tupperware to take the leftovers home. And to Dr. Sanfilippo, Dr. Winthrop, Dr. Moffatt and our many teachers, thank you for your inspired teaching and for continuously involving us in shaping the medical curriculum. Thank you for believing in us, for being our role models, and for always pointing us upward as we have now ascended to the very bottom of the totem pole that will be residency.

It has been a memorable four years at Queen’s. There’s a uniqueness about the place and it’s not just the grandeur of the ivy and limestone buildings, but built from the heart of a tight-knit community raising friendships that will continue to stand even after the ivy has faded away. To my classmates, thank you for the honour of speaking on your behalf today. More importantly, thank you for the last four years as we’ve walked this journey of medicine from being just classmates to colleagues to friends, and now even family. No words can express my deep affection for each and every one of you. Almost on a daily basis, I have been overwhelmed with the support you’ve shown me to pick me up when I’ve fallen down, the laughs that have kept me smiling and the love that has kept me growing up. I hope the words I speak today resonate with you as well.

Since our first day at Queen’s, we’ve always been a class that has been a little unconventional. It’s been documented on more than one occasion how we love to have fun. However, I think that being the “fun class” masked how seriously and earnestly we took our studies. As a class, we seemed to push boundaries in all areas of medicine and life, much to the delight and frustration of our faculty. And even throughout the last couple years, as our lives transitioned from the lecture hall to the hospital ward, we’ve continually stretched the limits, striving for perfection as evidenced by our many successes in research, academics and even extending far beyond the field of medicine. And while we’ve had some edges that needed smoothing and corners that needed rounding, I believe that these successes stem from a passion for life, for medicine and for our future patients. A dissatisfaction, if you will, with the status quo. It is an ambition that is birthed from asking the seemingly simple and yet difficult questions – “What more can I do for my patient? What am I doing to better the lives of those around me?” These are the questions that not only shape who we choose to be, but also, define the contributions we are going to make.

And it’s so easy, to let these deep and introspective questions that we’ve asked of ourselves slip away into the busyness of everyday life. As we get older, the years seem to move faster, the demands on our time grow greater and the noise from the waiting room gets louder. In attempt to fight the fatigue, we mistakenly substitute lives of significant contribution and meaning for a busy routine.

We replace the difficult and vast questions with smaller, more manageable, questions. Prominent physician activist, Dr. Samantha Nutt, said questions like “What am I going to do with my life?” quickly evolves into “should I rent or buy?”, which lives next door to “how can I get a bigger house in a better neighbourhood?”, and coincides with “should we have two cars?”, “is this a good time to renovate the bathroom?” and “is this wall big enough for a flat screen TV?” and before you know it…” the defining questions that once gave us a passion to attain this year’s grand accomplishments have been replaced with next year’s daily grind.

And yes, we’ve come a long way and should be proud of our accomplishments as medical graduates of Queen’s University. In the days and years to come, we will be tempted to drown out the big questions with the noise of our busy lives. Sir William Osler said that “To have striven, to have made the effort, to have been true to certain ideals – this alone is worth the struggle.”My hope is we remember the questions we have asked of ourselves here at Queen’s and to dare to ask bigger questions. Whether we search for these in answers in our life’s work, our family, our friends or our faith, let us stay as hungry to make a difference as we were four years ago.

My late grandfather, Sir Harry Fang, was one of the first orthopaedic surgeons in Hong Kong, China. And at the end of his memoirs he wrote: “None of us are the same people we were even a few years ago. We have come through some rough times, and we face some tough challenges ahead. We can only do what each of us can do, to the limit of our abilities, to try to leave the world just a little bit better than we found it.”

And I know we’ll make that difference in the years to come.

But for today and for right now friends, family, esteemed faculty and my dearest classmates:

Congratulations.

 

Fang, Sin-yang Harry, and Lawrence Jeffery. Rehabilitation: A Life’s Work. Hong Kong: Hong Kong UP, 2002. Print.

 

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

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Dear Meds 2014… One last SAQ

Dear Meds 2014,

Since this picture was taken in September 2010, you have successfully undertaken no fewer than 38 courses of study, as well as numerous projects, reflections, surveys, and various exercises intended to prepare you to be effective physicians.  In doing so, you have engaged and answered (usually correctly) several thousand individual questions of various types.

classof2014

I have one more for you.  Don’t worry, it’s formative.  Here it is:

Identify these five famous historical figures, and describe what they have in common? Warning: The second part has an easy answer, but bonus points for the less obvious.

famous

From left to right:

Albert Einstein was, arguably, the most famous scientist of the twentieth century, revolutionizing the way we consider nuclear power, time and space.  In his later career, he became very much involved in social causes, largely related to promoting peaceful applications of this emerging technology.

Mahatma Ghandi led the Indian nation to independence.  In doing so, he became a symbol of non-violent protest.

Mother Teresa originated and led a charitable movement in Calcutta that has not only given rise to numerous similar efforts, but also drawn attention to the plight of the poor worldwide and provided an example of what can be accomplished through non-political personal effort.

Martin Luther King led the American civil rights movement in the fifties and sixties.  Through his brilliant oratory and philosophy of non-violent protest he became the rallying point for millions.  He was considered to be more influential than any elected official, including the President.

Norman Bethune was a Canadian physician who devoted his career to a series of roles, all serving underserviced populations in need.  He has become an internationally famous example and embodiment of the socially active physician.  His recently released biography (Pheonix: The Life of Norman Bethune, by Roderick Stewart and Sharon Stewart) is a great read.

The obvious similarity is that they all led positive social change.  Different contexts and different styles to be sure, but all tremendously effective leaders.

The less obvious answer is that they led without any political or organizational mandate to do so.  They had no direct authority over others (although Ghandi was eventually elected to public office, I would argue it was after he had achieved social activism). Their leadership emanated from their ability to express their vision, and their willingness to become personally involved in the solutions.  The qualities they exhibited were compassion (to the needs of their fellow citizens), courage (to express dissenting or unpopular views), and commitment (to give of themselves and become personally involved in the solutions).  Their leadership was not in the pursuit of personal advancement or glory, and their influence arose from the recognition of that truth by their fellow citizens.  To use a well-worn vernacular, they not only talked the talk, they also walked the walk, and that quality is always intuitively obvious to everyone.

So, what has all this to do with you, the graduates of Meds 2014, shown below at your White Coat Ceremony only 2 years ago, and now ready to be released upon an unsuspecting world?

2014grads

This is all obviously my fairly heavy-handed challenge as you leave the nest and take up the next stage of your professional careers.  A physician’s work, as I’m sure you’ve come to learn, is in large part about the very qualities of compassion, courage and commitment exhibited by the famous historical figures I described.  You have those qualities.  Beyond your individual practices, each of you will encounter opportunities to have a positive influence within the communities and organizations in which you find yourselves.  I hope you’ll be open to those opportunities, enticed by the potential to bring about positive change within your world, and willing to devote the effort required realizing those results.  Real leadership is tough.

Dare to lead.

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Real life lessons in Interprofessional Practice

real-life-lessonsThe term “ivory tower” apparently has its origin in the Song of Solomon (7:4) where the writer describes the beauty of his beloved with a list of poetic terms, including “your neck is like a tower of ivory”.  The image found its way into descriptions of venerable figures, as depicted in “Hunt of the Unicorn Annunciation” (circa 1500).  For obscure reasons, the term has, over the centuries, come to be used to refer to “a world or atmosphere where intellectuals engage in pursuits that are disconnected from the practical concerns of everyday life” (Wikipedia).

University faculty are often accused of such intellectual self-indulgence.  They can seem disconnected from the “real world” issues and challenges faced by practitioners of their respective disciplines.  Physicians engaged in both care delivery and medical education might think themselves somewhat protected from the “ivory tower” mentality.  I have certainly been of that opinion; at least until a recent “real life” experience has caused me to question that assumption as it relates to how we educate our learners with respect to interprofessional practice.

The development of educational processes that teach and promote Interprofessional Care and Practice has proven to be one of the biggest challenges faced by our school and faculty.  The largest obstacles, in my view, have been two-fold.  The first is purely pragmatic.  It is very difficult to bring together the complex and very full curricula of multiple educational programs.  Finding “space” in the packed schedules of our learners that coincide with compatible points in their separate learning continuums is a considerable logistic challenge, and will always be limited.  The second issue is more philosophical.  To be successful, any educational initiative must be directed toward clearly understood and mutually accepted objectives.  Both teachers and learners must have a common understanding of the desired outcome.  Simply put, they need to share a vision of the “final product”.  Although we, and most schools, have developed articulate vision statements, I believe we lack a practical and commonly accepted understanding of that “final product” of Interprofessional Education programs.  Our “ivory tower”, in this instance, has perhaps become a little too high to see what’s needed on the ground.

This brings me to my recent “real life” revelation.  My parents are now 91 and 86 years of age.  My father has increasing health issues that require regular supervision and assistance.  They have lived in the same small community all their 60+ years of marriage, and wish to remain in the home that they built for their retirement.  My siblings and I, as well as all involved in their care, agree this is the best option for them and, frankly, the desired option for all seniors wherever practical.  Achieving this is becoming increasingly complex.  They are blessed to have an absolutely incredible Family Physician with whom I communicate regularly.  On a recent visit to my parents, we agreed to meet while I was there to update on a few issues.  He took the opportunity to ask some other individuals involved in my parents care to join us.  So, on a weekday morning, in my parents’ living room in that small community, a Family Physician, visiting Home Care nurse and Personal Support Worker met with myself and one of my sisters with both my parents in attendance.  We were in telephone contact that morning with the Home Care supervisor, Respiratory Technician, Heart Failure Nurse Specialist, as well as the local Pharmacist who packages my father’s medications and is very familiar with recent changes.  The complexity and extent of care required to support my parents was not a surprise to me.  What I’ve had trouble imagining is how it could all possibly be coordinated in the home.

That morning, as I watched this process work so effectively, it became apparent that the single most essential key to success was that the contributions of each person were consistently centred on the welfare of their common patient.  People knew the technical aspects of their jobs, to be sure, but their focus never deviated from the patient.

The second key to success was in the listening.  Each individual was receptive to and respectful of the input of the other contributors, recognizing that the input of each was independently important to the central goal.  Interestingly, the input of the PSW was perhaps the most relevant and led the discussion, because that person was closest to and most familiar with the impact of everyone’s work on my parents themselves.  The Family Physician initiated the conversations, provided medical input a couple of times and, at the end, ensured everyone (including my parents themselves), had had the opportunity to get all their concerns and issues discussed.  There was no jockeying for dominance.  There was an openness and acceptance of each role that allowed everyone to make suggestions without fear of compromising their status.  There was, in short, a sense of trust and mutual respect that allowed full and effective collaborative effort.

Although this particular experience crystallized this issue in a personal way for me, I realize that these highly effective interprofessional interactions play out in our wards, clinics, offices, emergency departments and operating rooms every day.  They are becoming part and parcel of effective health care delivery, and provide a prime example of how our university based teaching programs must emulate and promote exemplary practice.

So what makes this work in the “real world”, and what lessons can we, ensconced in our Ivory Tower, take back to our educational programs that strive to teach and model optimal IP practice?  Based on our real world exemplars, I would suggest five principles that may provide useful points of departure to examine any IP teaching program:

  1. The purpose of IP practice must be to optimize patient care.  This is accomplished through common understanding and coordinated effort.  Our educational programs and those who lead them must share that single goal and reinforce it in their teaching programs.  IP must not be used to promote “political” causes.
  2. The various providers involved understand and accept that they cannot provide optimal care in isolation.  That is simply no longer a realistic goal, a reality that a visit to the home of my parents or any patients living with chronic issues will quickly make apparent.  Our educational programs must not simply state, but allow our learners to experience this reality.
  3. Health care providers must understand each other’s role in care delivery.  In practice, this is learned by practical experience.  Our educational processes must find ways to ensure providers learn these roles.  For this purpose, experiential learning in active practice is much more effective than theoretical exercises.
  4. There must be mutual respect.  This must be built on an understanding of the value of all contributions, and is best modeled through the behavior and attitudes of faculty.  The converse, of course, is that negative attitudes expressed through “hidden curriculum” behaviours can be highly damaging.
  5. Active practice opportunities are essential.  The awareness of roles, value, and mutual respect are best built through shared and successful practice opportunities where learners will find that their combined efforts bring added value. Their combined and cooperative effort, in essence, will be of greater value to their patients than the sum of individual and isolated efforts.

Our university based “ivory tower” can certainly provide a protected environment, isolated from the realities of clinical practice, and perhaps thus distracted by theoretical rather than practical concerns.  However, it can also provide a perspective from which we can appreciate the value of practices that are tested and successful in the “real life” arena, and motivated solely by the best interests of the patients we serve.  Many schools, including ours, have made great strides in IP education.  As we continue to strive to improve, we’d be well advised to pay close attention to the lived experience and successes occurring every day, so close to us all.

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Should medical students be examined by each other, or by Faculty?

A few years ago, with Lynel Jackson’s capable assistance, I established a confidential portal on MedTech which allows students to submit commentary to me in a completely anonymous fashion.  Over the years, it’s proven to be a remarkably effective means for students to articulate concerns that are of a sensitive nature or which, for a variety of reasons, they are reluctant to express in person.  It has provided insights into issues which I’m sure would not have otherwise come to attention or, if they had, would have done so in much less effective ways.  One such issue was raised recently which has caused me to reflect and led to some conversations which I thought should be extended to the wider faculty and student body.  To quote our anonymous student:

“I have feedback regarding students being required to practice on each other in formal clinical skills sessions, such as the peripheral nerve exam the 2017s are learning tomorrow. This also relates to random students being called up to volunteer for clinical skills demonstrations in front of the class. This can (and has) caused exposure of students’ own medical problems. In one case this year a student’s disability was somewhat unwittingly revealed in front of all of the class of 2017. Some students are uncomfortable with/unable to comply with this for religious reasons. Others, such as myself, get anxious at the thought of potentially having private medical info disclosed in a public forum.”

I, like many of our teaching faculty, came through a medical school experience where “practicing” aspects of the physical examination on classmates was common practice and, in some instances, became informally incorporated into the curriculum.  It was also common practice for faculty to ask for student “volunteers” to demonstrate various aspects of the physical examination for small groups or even the class.  I’ve certainly been guilty of this in demonstrating the approach to cardiac examination and auscultation.  Over the years, our Clinical Skills program has placed boundaries on the peer-to-peer examination, limiting it to head, cranial nerves and peripheral limbs.  This has been in an attempt to avoid any potential embarrassment that might arise from exposure to even the abdomen and male thorax.

The note above, together with a brief review of the literature, would suggest attitudes are changing and deserve reconsideration, for a number of reasons:

  1. Students may have medical conditions, scars, or deformities they do not wish to reveal and do not wish exposed.
  2. Students may have personal or religious objection to exposure or touching
  3. Students may simply be shy or self-conscious about such contact

Although it’s easy to say that students can excuse themselves from such activities, doing so may be difficult for many and, in itself, essentially “expose” a concern.  This raises the issue of peer pressure to comply with the majority attitude of the group, and further raises the real concern as to whether faculty may be exerting a subtle form of coercion by even making a request.  We therefore seem to be confronted with an issue that affects a distinct minority of any class, but in a potentially very profound way that therefore deserves our attention.

To engage such an issue, I’ve found it’s always helpful to consult the students themselves early in the process and, wherever possible, involve them in developing solutions.  I therefore turned to Elizabeth Clement (Meds 2016), who is Vice-President (Academic) of the Aesculapian Society and student representative to our Curriculum Committee.  Liz engaged this with characteristic thoughtfulness and enthusiasm, reviewing the literature, conducting a student survey, and presenting this information in the form of a Briefing Note to the Curriculum Committee for consideration.  That note, in its entirety, is as follows:

Clinical and Communication Skills: peer teaching of the physical exam

Issue:

Recently, some Queen’s medical students have communicated their discomfort with respect to physical examination of peers or being examined by peers in clinical skills sessions. Reasons for discomfort include but are not limited to religious and cultural customs as well as gender modesty. It is also important to consider the impact that peer physical examination can have on the student who has real findings, both known and unknown.

Background:

Currently, Clinical and Communication Skills is run with Standardized Patients for specific and more invasive exams, including the cardiac, respiratory and abdominal exams; a practice that is both valuable and costly. Exams that are considered less invasive, such as lymph nodes, cranial and peripheral nerves and head & neck are learned and rehearsed using same-year classmates as patients.

In a survey of first and second year medical students:

  • 36% of students are comfortable with the current practices, where peer physical examination is only performed using specific exams, including vital signs, cranial nerves.
  • 58% of students stated they would be comfortable performing more invasive examinations on peers, with exceptions including the rectal, pelvic and genital examinations, while 4% of students said they would be comfortable with peer examination for any aspect of the physical exam.
  • 2% of students say that they are uncomfortable with any form of peer physical examination.

The survey also elucidated that 36% of students would be more comfortable with peer physical examination if they were working with individuals of the same gender; 61% said they would be neither more nor less comfortable.

Important elements of the Clinical and Communication Skills course go beyond routine examinations. The communication component of this course can intermingle with an individual’s personality and sense of self. The current structure at Queen’s allows for students to form meaningful relationships with one or two faculty members as well as nine colleagues as they explore how to optimize their communication for the practice of medicine. Any alterations to the structure and setup of this course need to take into account the impact that those changes could have of the value and strength of these important relationships.

Research and Analysis:

Other institutions are considering these same practices, but a clear solution has yet to surface. Many have evaluated attitudes toward using peers as ‘patients’, including a study conducted in Australia. This project used a Likert 5-point scale (1: not at all willing; 5: very willing) to evaluate overall willingness of students to participate in physical examination teaching using peers. The study’s trends suggest that students are more willing to participate when examining the extremities and typically unclothed areas (head and neck), and that both men and women are more willing to be examined by women.2

Another article, a response to a study of peer physical examination, stated that “students must be endowed with the same rights to which they are dutifully bound to grant patients, namely refusal of investigation, including examination.”1 The author concluded that the practice of peer examination is appropriate when students are able to pick their partner, but that the integrity of the physical examination as it is learned should be upheld with the use of simulated patients. For examinations of the pelvis, rectum and genitalia, the author recommends table-top models. A more moderate approach was elucidated in a letter to the editor of Academic Medicine, where the authors directly address the issue of consent – perhaps the crux of the issue of the Queen’s model of physical examination teaching. Their overarching comment suggests that schools should obtain consent from students, and that an important component of consent is to provide information about risks and benefits of peer examination in the learning of the physical exam.3

The data collected from students at Queen’s medicine demonstrates that most students are comfortable with our current practices, and, in fact, many would be willing to participate to a greater extent. However, in this instance, a minority of students expresses discomfort, and given the nature of this issue, it is important to consider whether alternatives could be made available so as to facilitate these students’ full participation in the learning of the physical exam.

Potential solutions

  • Consider no adaptation of the current model for physical exam teaching.
  • Consider a shift to physical exam teaching using solely standardized patients.
  • Consider a method of allowing students who are uncomfortable to self-identify, and manage them individually based on their concerns.

References

1Rizan CT, Shapcott L, Nicolson AE & Mason JD. (2012). PPE: A UK perspective, ‘All for one, NOT one for all’.  Medical Teacher, 34, 82; author reply 82-3.

2Reid KJ, Kgakololo M, Sutherland RM, Elliott SL & Dodds AE. (2012). First-year medical students’ willingness to participate in peer physical examination.  Teaching & Learning in Medicine, 24, 55-62.

3Delany C & Frawley H. (2011). We need a new model for obtaining students’ consent to conduct peer physical examinations.  Academic Medicine, 86, 539; author reply 539.

The Curriculum Committee had a preliminary discussion about this last week and have asked for a procedural approach to be drafted and presented to them, that will allow for student concerns to be addressed effectively while not eliminating the instructional value of peer examination completely.  In doing so, feedback from members of faculty and other students would be very much appreciated.  Please feel free to share your perspectives on this issue, either by responding to this post, or sending commentary to myself, Liz, Curriculum Committee chair, Michelle Gibson or Clinical Skills Director Cherie Jones.  My confidential portal is always available to students who wish to comment anonymously.

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Can students achieve excellence without stress or competition?

Striving for a Culture of Competency

A few days ago walking through the hospital I ran into a very excited third year medical student who was anxious to tell me about a recent clinical experience.  Apparently she’d admitted a patient with a complex array of medical problems and, after considering the differential diagnosis, ordered a test that confirmed the presence of fairly rare condition that led to a very effective therapeutic approach.  The patient was much improved and our student, for the first time in her experience, felt that she had personally made a significant contribution to a patient’s care.  Importantly, she wasn’t telling me this to boast or claim personal credit.  She was simply very excited in the moment and wanted to share.

Our student experienced what could be referred to as the “magic moment”.  This is a term for that point in a physician’s development when they realize, for the first time, that they have acquired the ability to positively influence a patient’s life.  For some it comes in the form of a procedure well carried out, for others it’s a diagnostic success, for some the realization that they’ve brought resolution or comfort to a personal crisis in a patient’s life.  Whatever the form, the central element is the realization that their long and arduous learning process has borne fruit, and finally, rather unexpectedly, makes sense.  Their learning has transformed from an abstract, theoretical exercise to a pragmatic and practical application of knowledge and skills.  The “competency-based” construction of our curriculum suddenly seems sensible and, importantly, much less threatening.  I’ve also noted that when our students come to this point, the “stress” of medical school changes in a favourable way.  They realize that if they allow their learning to truly focus on their competency- based learning objectives, the rest will basically take care of itself.  With this realization comes confidence.  They come to regard exams as necessary inconveniences rather than fearsome high stakes threats.  They no longer require their teachers to validate their learning.  They have become, dare I say it, competent life-long learners.

Many medical schools have, over the past several years, adopted a competency-based framework to structure their curricula and assessment processes.  Here at Queen’s, we adopted this as the basis of our curricular reform which began 6 years ago.  It has provided a logical and comprehensive framework around which to establish objectives, courses, learning events, and all their associated assessment tools.  Unfortunately, I think we have to recognize that we have not yet adopted a competency culture.  Our students continue to have difficulty evolving from the consciousness that short-term knowledge assimilation and examination marks are the sole components of success.  Many continue to see medical school as a series of “hoops” through which they must pass, discarding now “unnecessary” information at each step in order to move on to the next challenge.  Experiences intended to build “softer” skills, such as reflective exercises and portfolio assignments, are often given short shrift, or at least secondary effort, because their relevance may be less apparent and “they’re hard to fail”.  To a novice mountain climber, the ability to effectively and efficiently tie knots seems a tedious and pedantic exercise, until one is perched on a ledge and relying on that skill to negotiate a climb.

This difficulty is, in many ways, completely understandable and we, as medical school faculty, are partially to blame.

  • Our admission processes are heavily reliant on academic success as a criterion.  Our students are therefore pre-selected and “hard-wired” to excel in relative terms (relative to other students), rather than against pre-determined competency goals.
  • We continue to use very traditional assessment processes to evaluate success.  While it’s true that our major purpose in setting assessments is to inform rather than select or stratify, our students can’t help but have a very fundamental and visceral response to the examination experience.  If you breed thoroughbreds to race, it seems, they will run when the gate opens.
  • We continue to award academic “standing” through a multitude of awards that our schools have administered for generations, the very purpose of which is becoming increasingly irrelevant in our current curricular structures, and may be unintentionally promoting many behaviours we now recognize as counter to our competency goals.
  • Perhaps most troubling of all, shortly after admission to medical school, we thrust our students into another increasingly competitive process to select and engage postgraduate training positions.

The environment, intentionally or not, is highly competitive.  Is this productive?  Does it drive desirable qualities?  Does it result in better (more competent) physicians?  Many would argue that competition for personal success is inevitable, drives learning and selects for qualities that will serve our students well in their careers and personal life.  The counter argument is that it drives the wrong (short term) approach to learning and requires students to make strategic decisions regarding their learning that are unaligned with the needs of their future patients.  The inconsistency between internal competition and the “collaborator” and interprofessional competencies we strive to achieve is obvious, as is the potential to disrupt peer-to-peer education that we recognize is so valuable.  Many schools, including our own, have taken baby steps to address this issue by moving to “pass-fail” assessments, but even this has been met with considerable internal controversy.

So, what’s to be done?  Can we do better?  I would respectfully offer a few suggestions for consideration and discussion.

1. Frank discussion early in medical school.  We need to engage the issue early on, clarifying for our student the reality that their learning objectives have fundamentally changed.  Essentially, their objective needs to shift from personal achievement to the needs of their future patients.
2. The concept of “relevance” is best learned through patient contact.  More contacts, in more “real life” venues, earlier in the medical school experience will be key.  Observerships, the First Patient Program and Week in the Country are great examples, but need to be contextualized in a way that allow the student to recognize the importance of competency acquisition.

3. More clarity regarding our learning objectives.  I think we have to acknowledge that the competency domains as defined by our professional colleges are insufficient unless buttressed by concrete applications.  Being a good Manager, for example, means very little.  However, when broken down into more practical applications, students not only see the purpose, but can navigate the learning much more efficiently.  For example:

  • Managing personal time
  • Managing a medical practice
  • Managing diagnostic testing for your patient
  • Managing your finances

This now become more than knot-tying for the sake of knot-tying.  Fortunately, there is considerable activity currently underway that will help.  The Royal College is in the process of revising and refreshing the CanMEDS framework.  A joint AAMC/AFMC committee is in the process of developing a set of competencies required of the medical student about to enter residency training, and documents such as “The Scottish Doctor” represent thoughtful and comprehensive attempts to catalogue practical physician competencies.

4. Testimonies from near peers and role models.  The experiences of senior colleagues who have recently and successfully navigated the challenges our students are facing can provide powerful motivation and validation.  It can also provide critical perspective to reduce unnecessary stress.

5. Assessment review.  There has been movement in recent years toward competency-based assessments, such as Objective Structured Clinical Examinations (OSCEs), both by the Medical Council of Canada and most medical schools.  However, these are very difficult to design, complicated to administer and very resource intensive.  We need to develop more practical approaches that will allow our students to demonstrate their achievement of the various competencies in an open, objective way.

6. Reconsideration of our awards.  Recognizing excellence and personal achievement is undeniably of value, but do our awards recognize the qualities and achievements we strive to develop?

7. Rethink and refine the process of transition to postgraduate training.  This has been identified as a concern by the Future of Medical Education in Canada initiative of the Association of Faculties of Medicine of Canada (AFMC), and is under active discussion at this time.  Models for more graduated transition are being considered, and will come under increasing discussion in coming months and years.

In summary, some degree of competitive tension will likely always be present within our medical training processes, and some degree of stress is not only inevitable, but may have a useful role in preparing students for the pressures of clinical practice.  However, are we doing our best to use both intentionally and intelligently?  Can we ensure they all experience their “magic moment” early in their training?  I think we could do better.  What do you think?

 

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Beyond Apprenticeship – Lessons from Coach K

I’ve often wondered what makes Mike Krzyzewski so incredibly successful.

For those of you not familiar, he is a highly accomplished college basketball coach. In the 34 years he has coached at Duke University, his teams have won 76% of their games. He has won 4 national championships, 13 ACC championships, been named Coach of the Year 5 times. He has coached the US Men’s National Team twice and won gold medals both times. Incredibly, he’s been admitted to the Basketball Hall of Fame, before he’s even retired! Conclusion: the man knows what he’s doing.
Coaching
Remarkably, he has remained steadfastly loyal to his school and to the college game, having turned down numerous offers to coach professionally. It’s reported that he most recently turned down $15 million dollars per year to coach the Nets. Conclusion: the man likes his job.

What’s always been a little perplexing is that he doesn’t look like a coach, or even an athlete. In fact, he looks more like a barber or accountant (no offense to barbers or accountants). As a 67 year old son of Polish catholic immigrants and West Point graduate who never played beyond the college level, he would seem to be as culturally, generationally, physically removed as one could imagine from the uber-talented, remarkably athletic young men who come under his tutelage.

Coaching 2Jabari Parker is one of those young men. This 18 year old native of South Chicago is considered by many to be the most talented college player in the nation, and the next rising star of the game. Seems he thinks the world of his coach. To quote: “Coach K and I have a great friendship. We have a father-son relationship. I love the man. And I’ve put my complete trust in him.”

In considering all this, I can’t help but draw a parallel to those of us engaged in the education of medical students. We also find ourselves challenged to connect with exquisitely talented young people who’s educational and cultural experience is very different than our own. How do we connect? How do we ensure we’re helping them reach their full potential? What might we learn from Coach K?

Coaching 3For most of these weightier educational issues, I turn to one of my favourite sources – Sports Illustrated. In “The Education of Jabari Parker” (Feb 24, 2014), Jeff Benedict provides an account of the relationship between these two. Reviewing that article provides some intriguing parallels to the principles of medical education. For example:

1. They have established common goals. This happened at their very first meeting and, interestingly, was motivated by Jabari’s mother who told the coach in no uncertain terms “Jabari needs to know how you are going to play him and what goals you want to set.” The wisdom of a mother! Clearly, the coach and the student are on the same page. They have a common understanding of what they hope to achieve. Developing a medical education program and curriculum similarly begins with established objectives and the acceptance of those objectives by all teachers and learners. It’s been my experience that most of the tensions and problems we encounter with our teaching sessions and assessments relates to a lack of clarity with respect to objectives.

2. The coach provides useful, relevant feedback with direction as to how errors can be corrected. After reviewing game videos: “Look at your feet. They are in the wrong position.” “Look at your hands. They are not ready.” Followed by the justification: “It’s not personal. It’s the truth.” Jabari’s response: “I never realized I looked that bad. I gotta change that.” Coach K seems to understand that simply telling a student they are not performing adequately is not only useless, but damages the teaching relationship. Students accept criticism if they know how and why they went wrong (hence the importance of understood objectives) and are given the necessary instruction and opportunity to correct the problem.

Coaching 4
Al Tielemans/SI

3. The coach understands the student on a deeper, personal level and uses those insights to help him improve. The coach recognized early on that Jabari’s desire to fit in was causing him to play hesitantly and below his potential in order to avoid standing out among his teammates. He also picked up on an unwillingness to admit to nearsightedness, again motivated by a fear of appearing different than his peers. We recognize that medical school is much more than a time during which information is learned and skills acquired. It is also a time of personal growth for our students, during which they develop the self-awareness and professional confidence that will enable them to become effective physicians. Excellent educators recognize limitations or personal barriers and are able to help students grow despite them.

4. They are open and honest with each other, and out of that honesty comes trust. Benedict describes an incident where the coach confronts the student: “I think you love it here so much that you want to be good, but not too good…I’m a little bit angry with you…I don’t think you’re giving me all you can give me. Agreed?” “Yes,” Parker replied. Another time, the coach is suffering through a personal loss that affects his attention and interest. He’s open about his grief, and about his distraction. To quote the coach: “Overall this will be a great experience for them because they see someone who in their minds is very powerful who can’t be penetrated…and they see me being penetrated to where I’m moved to tears.”

Most physicians seem to have the desire and instinctive ability to pass along what they know, and what they can do. These qualities underlie the apprenticeship model that characterized pre-Flexner medical education, and continues to drive our clinical training, both in medical school and residency. A fundamental limitation of this model is that the “upper limit” is the expertise of the teacher. The introduction of educational principles and the focus on the professional development elevates the relationship to one which provides the learner not simply with knowledge and technical skills, but with insights, self-awareness and inspiration that propels them forward and sustains them through their careers

Mike Krzyzewshi is, first and foremost, an educator, and he has something to teach all of us who hope to influence the young and gifted among us.

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

For medical students in Canada, there are three days in the course of their career that stand out above all others: the day they receive their letter of acceptance to medical school; convocation (when they officially become graduate physicians); and Match Day.  The most emotionally charged by far, is Match Day.  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.  By approximately 12:00:05 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 5th 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 Renee Fitzpatrick, who are available and very willing to answer any questions you may have and respond to concerns regarding our students.  They can be accessed through Erin Meyer at meyere@queensu.ca, or directly at the following:

Screen Shot 2013-05-24 at 4.11.03 PMPeter O’Neill
Careers Counselor
oneillp@kgh.kari.net

Screen Shot 2014-02-24 at 9.30.45 AMKelly Howse
Careers Counselor
kelly.howse@dfm.queensu.ca

 

 

 

Screen Shot 2013-05-24 at 3.55.07 PMJennifer Carpenter
Student Counselor and Wellness Advisor
carpentj@queensu.ca

Screen Shot 2014-02-24 at 9.34.46 AMJohn Smythe
Student Counselor and Wellness Advisor
smythej@kgh.kari.net

 

 

 

 

Thanks for your consideration, and please feel free to get in touch with myself or any of the Student Affairs Team if you have any questions or concerns about Match Day or beyond.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean, Undergraduate Medical  Education

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Does every Canadian have equal opportunity to pursue a Medical Education?

I’m not normally inclined to idle conversation at 4:30 in the morning, but the cab driver who picked me up for my early morning flight home was simply too engaging.  Obviously of African descent, he was possessed of that captivating quality that can only be described as charm.  Although he spoke with a heavy accent, his vocabulary and language hinted at a subdued intelligence, and his warmth suggested a genuine interest in learning about the people he encountered.  He drew me in with the usual questions:

“Where are you travelling today?”
“Have you enjoyed Victoria?”
“Must be nice to get away from the snow for a few days”. 

Finally, I succumbed:

“So when do you get off work?”  

Turned out, he gets out at noon, and would then be taking his youngest son, Grade 10, to basketball practice.  Crazy about basketball, that boy.

“Do you have other kids?”

And he was off.  Since immigrating from Ethiopia, he and his wife have had four children.  His eldest son has graduated from a college business program.  His second son is in his fourth year at university and contemplating law school.  Although obviously proud of all his children, there was a particular affection for his only daughter, now in her second year at university.  He was quick to point out that she had led her high school class academically and still excelling despite her part time job at a fast food establishment.

“What’s she thinking about doing?” 

“Something in healthcare, not sure what.”

“Has she thought about medical school?”

At this point he looked into the rear view mirror and, for the first time during our encounter, seemed sheepish and somewhat lost for words.  I felt like I’d crossed a line – asked something a little too personal, perhaps slightly embarrassing for him.  After a pause he responded that she was giving it some thought, but hadn’t decided.  Things went a little quiet at that point.  I had the strong sense that the idea of going to medical school and becoming a doctor seemed beyond her (and his) reach.

“You know”, I said finally, “you remind me of my father”.

This seemed to take him completely by surprise.

“Really?”

“Sure.  He immigrated with very little money, took on whatever work he could, and put six children through schooling, including sending me to medical school”.

We chatted for a while, even after arriving at the airport.  Certainly we left on very friendly terms, and I don’t think it was just the sizable tip I left.

Although I’ve known for some time about socioeconomic and cultural barriers to medical education, the abstract took on a sense of reality for me sometime during that early morning cab ride through the darkened streets of Victoria.

So what do we know about this?  What are the facts, and what do the studies tell us?

  • Applying to medical school is not only long and demanding, but also an expensive undertaking.  The application process itself, the MCAT examination, MCAT preparation and travel for interviews are all costs that applicants must bear.  The process also requires time, which favours those who are able to take time away from summer or part time jobs in order to study and travel.
  • The process favours students from urban settings.  This relates to the fact that students from rural areas must necessarily move away from home to attend university.  In addition, volunteer opportunities, MCAT preparation courses, the MCAT itself are much more available in urban centres.  All this is compounded by the fact that rural Canadians are known to have lower income than their urban counterparts (Rourke J. for the Task Force of the Society of Rural Physicians of Canada. Strategies to increase the enrolment of students of rural origin in medical school. CMAJ 2005;172:62).
  • Socioeconomic status has an influence on an individual’s perception of their suitability for medical school and a medical career.  This is partially because students from more advantaged backgrounds have more access to role models in medicine. (Greenlagh T et al. “Not a university type”: focus group study of social class, ethnic, and sex differences is school pupil’s perceptions about medical school. BMJ 2006;328:7455).
  • Students from higher income families receive more family and social encouragement to pursue medical education compared to those who self-identify as coming from “working class” families (Began B. Everyday classism in medical school: experiencing marginality and resistance. Medical Education 2005:39;777).
  • The Greenlagh study noted above also suggests that students from lower income families are more likely to over-estimate the costs of post secondary education, while simultaneously underestimating the financial benefits of post-secondary education.

It appears all this is having an effect.  An important study by Dhalla and colleagues (CMAJ 2002:166;1029) surveyed 1223 first year Canadian medical students and found that, compared to the general population, medical students were:

  • Less likely to be of Black (1.2% vs 2.5%) or Aboriginal (0.7% vs. 4.5%) heritage
  • Less likely to hail from rural areas (10.8% vs. 22.4%)
  • More likely to have parents with master’s or doctoral degrees (39.0% of fathers and 19.4% of mothers, compared to 6.6% and 3.0% respectively)
  • More likely to have parents who were professionals or high level managers (69.3% of fathers and 48.7% of mothers compared to 12.0% of Canadians), including 15.6% of medical students having physician parents.
  • Less likely to come from households with incomes under $40,000 annually (15.4% vs. 39.7%)
  • More likely to come from households with incomes over $150,000 (17.0% vs. 2.7%)

These findings have since been substantially confirmed by Steve Slade and and his colleagues, who compile the Canadian Post-MD Education Registry (CAPER). http://www.caper.ca/~assets/documents/CAPER_Poster_AAMC_Physician_Workforce_Conference_May-2012.pdf.

It appears, then, that the answer to the question posed in my title is a decided “no”, but do we accept this as an issue that should be addressed, and do we have the collective will to act?  To address this, I would turn to those perhaps most familiar with these issues, specifically our young colleagues who have successfully navigated the process and recently entered medical school.  None of this, of course, is lost on them, and they do not shy away from addressing the challenge.  The Canadian Federation of Medical Students has published a position paper entitled “Diversity in Medicine in Canada: Building a Representative and Responsive Medical Community.” http://www.cfms.org/attachments/article/163/diversity_in_medicine_-_updated_2010__cait_c_.pdf.  To quote their document:

“As medical students in a country that embraces diversity, we believe that our medical system should be representative of and responsive to the diversity within our communities.  Unfortunately, the medical school admissions process has traditionally favoured students from high-income, urban dwelling, majority groups, thereby limiting the diversity of medical students across Canada and further marginalizing underrepresented patients and communities…An increased emphasis on diversity in medicine would help ensure that medical students and physicians are in tune with the needs of the communities that they strive to serve and represent.”

Clearly, a strong case can be made to address this situation, based not only on the principle of simple fairness, but also the need to ensure our physician workforce appropriately reflects the cultural diversity and particular needs of the population they will ultimately serve.  Assuming we accept these points, what might be considered?  In seeking solutions, it’s important to recognize the fact that the financial barriers become much less an issue after students are accepted into medical school, at which point they qualify for various sources of private and university-based funding.  If the barriers to medical careers are to be truly addressed, mechanisms must be developed to help members of those underrepresented groups become more aware of medicine as a realistic career option, and provide practical assistance in working through the pre-medical educational and application processes.  Such initiatives might include:

  • High school programs to increase awareness of Medicine as a realistic career option, particularly targeting smaller, socioeconomically disadvantaged communities and underrepresented populations.  At Queen’s, our students have taken the first steps in this direction by developing the MedExplore program http://meds.queensu.ca/announcements?id=419.
  • Reconsideration of the MCAT as an admission criterion, and provision of viable alternatives
  • Reassessment of our admission processes to ensure they are equally accessible to all groups
  • Assistance programs for promising students to allow them to engage educational and community service options
  • Mentorship programs utilizing physicians and medical students from underrepresented populations
  • Programs whereby smaller and underserviced communities might identify promising students for mentoring and career assistance

Obviously, this is a complex issue that will require multiple and creative approaches, all of which seems rather daunting, but perhaps less so when viewed from the perspective of that daughter of a hardworking and devoted Ethiopian-Canadian cab driver.

As always, your perspectives are welcome.

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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It (still) Takes a Village

How we do what we do.

One of the greatest challenges we face in the accreditation process is convincing the outside world that we’re actually doing what we claim to be doing.  Accrediting councils and review teams, themselves made up of medical school Deans and Associate Deans, are well aware of the needs and challenges involved in recruiting committed and capable faculty leaders.  They recognize that our needs in this regard are no less than that of much larger schools, and have trouble reconciling that reality with the number of core academic faculty.

With that in mind, it’s useful to periodically review our governance structure and recognize those who provide key leadership in all the various domains required of a fully functioning medical school.

I last did this about a year ago.  At that time, I provided an article on this site describing the various positions and people who are so integral to the growth and ongoing quality of our MD program.  The past year has brought changes to our MD Program leadership structure, both in terms of its organization and faculty assignments.  In fact we’ve carried a rather extensive review of our governance structures and key responsibilities, recently reviewed and approved by School of Medicine Council.  It seems an appropriate time to review both and update all our faculty and students.

In terms of overall organization, we have developed a number of key leadership positions, termed Directorships.  Each of these carry responsibility for a discrete component essential to the overall mission of the program.  The general responsibilities are described below.

directorships

In many cases, Directorships have evolved from positions that existed previously, but in different forms.  Many were previously described simply as committee chairs.  It’s become clear over the years that the scope of responsibility and need for ongoing oversight has gone far beyond simply chairing a monthly meeting.  The Director designation is a more appropriate recognition of the effort, expertise and scope of responsibility required.  So, with that introduction, we’ll review these positions.

H_Macdonald_7472_

Director, Undergraduate Admissions

The complexity of our admissions process has increased dramatically over the past several years.  In addition to the 4300-plus applications to our MD Program, the Admissions Committee now has additional responsibility for admissions to our MD-PhD, QuARMS and International programs.  Each brings its unique challenges, and continuing scrutiny to ensure they reflect appropriate values and fairness to all applicants.  Hugh MacDonald has chaired our Admissions Committee for several years through these transitions, and I’m most grateful that he will be continuing in the Directorship role.

Director, Accreditation

The oversight and guidance of our accreditation related efforts is a continuous responsibility, that will be escalating as we move toward our full survey in March of 2015.  In addition to guiding our local processes, that individual serves as our representative at national and international accreditation committees. John Drover has been capably filling that role for the past 3 years and will be continuing to do so.

Director, Student Assessment

Michelle Gibson has recently assumed this role, previously carried out capably by Sue Chamberlain.  This Director is responsible for establishing policies, processes and oversight of all assessment activities within our program.  Having recently completed her Masters in Education, Michelle brings considerable expertise and practical experience to this role.

Director, Teaching, Learning and Innovation

Screen Shot 2013-05-24 at 3.57.52 PMPerhaps the biggest change (and challenge) undertaken by our faculty over the past few years has been the introduction of new and innovative teaching methodologies.  Our Director of Teaching, Learning and Innovation (and committee) are responsible for developing policy, processes and oversight that will guide the introduction and delivery of teaching methods.  We have also charged that group with developing methods to assist faculty in realizing scholarship opportunities as they provide their teaching.  Lindsay Davidson will bring a wealth of knowledge, experience and innovative energy to that position.

Screen Shot 2013-05-24 at 4.08.16 PMDirector, Course and Faculty Review

Over the past few years, we have developed a comprehensive process for continuing review of all our curricular courses.  We are in the process of expanding that process to provide more targeted and relevant feedback to all teaching faculty.  Andrea Winthrop has been integral to this process and will be continuing as Director.


Director, Student Affairs

One of the key changes involved in this governance renewal has been to develop a position that would provide oversight and coordination to our Student Wellness/Counseling, Career Counseling and Academic Counseling portfolios.  I’m very pleased that Renee Fitzpatrick has taken on this challenge and is already developing proposals to augment our Learner Wellness program.

vanwylickDirector, Student Progress, Promotion and Remediation

This complex and critical portfolio requires a combination of astute administrative skill and sensitivity to the needs many needs of students who struggle with various challenges.  Richard VanWylick has been chairing our P&P Committee with great skill for several years, and will be taking on this Directorship, which better recognizes the expertise and effort required.

In addition to these largely administrative roles, a number of Directorships are required to provide programmatic leadership;

Director, Year 1

The first year of our program introduces our students to a wide variety of material including Basic Science, introductory clinical medicine, Clinical and Communication Skills, Professional Competencies and Facilitated Small Group Learning.  It is also a time of considerable personal and professional growth for our students, during which they evolve their learning and interpersonal skills.  Michelle Gibson has been guiding Year 1 through our curricular transition process and, I’m pleased to say, will be continuing in this role.

blog-murrayDirector, Year 2

In second year, our students undertake more intensive learning within clinical medicine.  They are expected to not simply learn facts about various conditions, but to integrate that knowledge into cogent approaches to patient problems.  To do so, they undertake more small group approaches, more challenging FSGL cases, advanced Clinical and Communication Skills program, and integrated Professional Competencies.  Heather Murray, who has been active in the development of Scholarship in the curriculum, and its integration into Clinical Presentation courses, is very well suited to this role, and will be taking over from Lindsay Davidson who has been guiding Year 2 through our transition.

Director, Clinical and Communication Skills

This program, which runs through the first two years of our curriculum, is key to the development of our students as physicians.  It has benefitted over the years from the leadership of Sue Moffatt and Henry Averns.  The role requires a high level organizational and educational expertise.  I’m very pleased that Cherie Jones took on this role last year and has already brought considerable innovation to the both educational and assessment components.  Cherie would wish me to mention that components of the program are ably coordinated by a team of dedicated Course Directors, including Basia Farnell, Hoshi Abdollah, Laura Milne and Lindsey Patterson.

moffattDirector, Clerkship Curriculum

One of the major benefits of our curricular reform was to expand the clinical clerkship in a manner that would allow for the provision of three blocks within the clerkship dedicated to formal education on a variety of advanced clinical and professional topics.  Susan Moffatt has developed and coordinated the curriculum for those blocks, with capable assistance from Armita Rahmani and Chris Parker.  Sue’s dedication and extensive educational knowledge are evident in the quality of those blocks.

Director, Clerkship Rotations

Our clerkship consists largely of a series of clinical placements in the major clinical disciplines.  Although largely in Kingston, clerkship rotation options have been expanded dramatically over the past several years, to both expand our teaching capacity, and provide students experience in various contexts and systems. These include our Integrated Community Clerkships (in Perth, Picton, Brockville and Prescott), as well as rotations in Belleville, Oshawa, Markham and even Brisbane, Australia.  In addition, our students undertake about 18 weeks of Electives during the clerkship, intended to allow for career exploration and self-directed learning.  The coordination of these all these options requires a high level of organizational skill, sensitivity to student needs and attention to detail.  Andrea Winthrop has been very effectively coordinating and expanding this program since her return to Queen’s a few years ago.

Screen Shot 2013-05-24 at 4.17.46 PMCo-Director, QuARMS Program

Jennifer MacKenzie has developed and directed a de novo pre-medical curriculum for our QuARMS program which is highly creative, delivering competency based learning in a variety of creative teaching formats.  This program, and Jennifer’s continued oversight, will be key to the success of this exciting new initiative.

wilsonChair, Professional Competencies Committee

Ruth Wilson has generously taken on the considerable challenge of chairing our Professional Foundations Committee and coordinating the efforts of our Competency Leads.  Her steady leadership has guided and promoted the development and integration of those essential components of our curriculum.

In addition to these positions, our program relies on the contributions of about 40 Course Directors, Competency Leads and Discipline Coordinators.  These key people are listed in our MD Program Directory, which can be accessed here.

So how does all this fit together?  Most Directors work with committees that are charged with the various areas of responsibility, as well as the accreditation standards that relate.  Our MD Program Executive Committee brings together all the committees and Directors to provide integrated program governance.  The graph below illustrates these relationships and reporting structures.

MD-Program

In developing these positions, committees and organizational relationships, the underlying principle has been that “form follow function”.  Each one, with it’s associated responsibilities and inter-relationships, arises from a need based on the mission of our school – to prepare our students for success in postgraduate training and in their ongoing careers as highly successful and effective physicians.  In doing so, we’re guided by our need to meet and exceed all medical school accreditation standards.

Achieving this, as well as all the other varied tasks required to operate our medical school requires tremendous dedication and commitment on the part of our faculty, which has never been lacking.  Three examples:

  • A need arose last Fall for people to chair our Accreditation Self-Study Sub-committees.  Those who came forward to provide fill these valuable roles are among the busiest people in our school: Leslie Flynn (Vice-Dean, Education), Iain Young (Vice-Dean, Academic Affairs), Stephen Archer (Head, Department of Medicine), Michael Adams (Head, Biomedical and Molecular Sciences), and Karen Smith (Associate Dean, Continuing Professional Development).
  • This term we are offering a re-vamped Term 4 Clinical Skills curriculum that provides full patient encounters with groups of two students observed and tutored by a two faculty members.  This has been creatively developed by Course Directors Hoshiar Abdollah and Laura Milne, and involves no less than 50 faculty members, 37 of whom are members of the Department of Medicine.  We have had full support of the Departments and their leadership in this initiative.
  • Our Admissions committee and administrative support personnel process increasing number of applications each year, and have developed increasingly complex methodologies to review those applications.  The committee itself, document reviews, MMIs and panel interviews require the active participation of about 160 faculty members, who give of their free time to assist in ensuring all applications are reviewed thoughtfully and fairly.  They work side by side with members of our first and second year classes, almost all of whom contribute to the process in various ways.

What’s the motivation of all these people: building a better school – their school – in which they are valued members, and in which they take pride.

A village indeed, and an impressive expression of our collective dedication to the education of our students.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

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