Category: Associate Dean
The Educational Value of Diversity
In October of 1931, a 16-year-old college student joined a group of friends for a night of carousing and entertainment at the Driskill Hotel, in Austin Texas. He had no idea what to expect of the entertainment, the focus of the evening being on the “carousing” component. Rather unexpectedly, he is deeply moved by the performance, and particularly by the featured musician. Many years later, that student writes about that experience in his memoirs:
“He played mostly with his eyes closed. Letting flow from that inner space of music things that had never existed. He was the first genius I’d ever seen.”
The “genius” he was referring to was Louis Armstrong, who was himself only 31 at the time, at the beginning of a career that would eventually identify him as one of the greatest virtuosi and innovators in the history of American music.
The young man was Charles Lund Black, who would go on to become a Professor of Law at Yale and expert in American constitutional law and contribute importantly to a number of cases involving key civil rights issues.
Professor Black would later say the following about his experience that evening:
“It is impossible to overstate the significance of a sixteen year old Southern boy’s seeing genius, for the first time, in a black. We literally never saw a black man, then, in any but a servant’s capacity…Blacks, the saying went, were ‘alright in their place’, but what was the place of such a man, and of the people from which he sprung?” http://www.nytimes.com/2001/05/08/nyregion/charles-l-black-jr-85-constitutional-law-expert-who-wrote-on-impeachment-dies.html
In Black’s eulogy, a former student would say of him, “He was my hero…He had the moral courage to go against his race, his class, his social circle.”
In Medical Education, the concept of Diversity has become entrenched in our collective vision as expressed in both the Future of Medical Education in Canada recommendations and in accreditation standards. The rationale for such initiatives has been largely perceived to be the need to ensure equity of opportunity, and a need for medical schools to respect and reflect the gender, cultural, religious influences of the societies they serve. Laudable and worthy justifications, to be sure. However, Mr. Black’s encounter with Mr. Armstrong hints at deeper, even greater benefits. Does diversity within a learning environment, or as a deliberate component of a curriculum, have educational value? Does it shape thought and attitudes? Does it make students better practitioners of whatever career they undertake? Does it make them better citizens?
These questions have had particular relevance and attention in the United States for the past several decades, where they have been the focus of legal as well as pedagogical attention. Affirmative Action initiatives and subsequent legal challenges have required both jurists and educators to engage this question critically and analytically.
In 1978, Chief Justice Lewis Powell wrote the following opinion regarding the case Regents of the University of California vs. Bakke. He argued “the atmosphere of speculation, experiment and creation – so essential to the quality of higher education – is widely believed to be promoted by a diverse student body…It is not too much to say that the nation’s future depends upon leaders trained through wide exposure to the ideas and mores of students as diverse as this Nation of many peoples.”
Chief Justice Powell’s decision, however, did not settle the issue. Challenges have continued and the wisdom of mandated diversity initiatives has been repeatedly questioned. This is largely due to the lack of a theoretical framework or evidential basis demonstrating value. Since then, considerable work has either emerged or been resurrected to provide such evidence, which is summarized in an excellent paper by Gurin and colleagues (Harvard Educational Review 2002; 72: 330).
From the theoretical perspective, the work of a number of sociologists and psychologists is particularly relevant, and fascinating to review. In attempting to describe their work, I freely admit to venturing far beyond my expertise and apologize in advance to those much more knowledgeable.
Erik Erikson, as far back at the early 1950s, postulated that late adolescence and early adulthood were critical times in the development of personal and social identity. He theorized that such identity develops most effectively when people at that stage of life are provided what he called a “psychosocial moratorium”, by which he meant a time and situation during which they could feel free to “sample” and experiment with various social roles for themselves before taking on a more fixed and permanent role, i.e., before they “committed” to a profession, personal philosophy, or relationship. Colleges and universities are critical to providing this environment for most young people, certainly in North America. But how can they promote this critical social development? In the words of Gurin and colleagues:
“Higher education is especially influential when its social milieu is different from students’ home and community background and when it is diverse and complex enough to encourage intellectual experimentation and recognition of varied future possibilities.”
In other words, the real power to influence goes far beyond lofty mission statements and curriculum, and arises largely from developing an environment where students are able to interact both passively and actively with individuals who are “different” and therefore force new thought and new perspectives during this critical developmental phase.
Sociologist Theodore Newcomb carried out a series of studies and long-term follow-ups of Bennington College students between 1943 and 1991. (Newcombe et al 1967. Persistence and change: Bennington College and its students after 25 years. New York: John Wiley and Sons), (Alwin et al 1991. Political attitudes over the life span. Madison: University of Wisconsin Press). To medical folks, this is the sociologic equivalent of the Framingham studies. He and his colleagues found that political and social attitudes were most likely to change and remain so in students who had encountered novel concepts and attitudes, largely through peer influences, while attending college, thus supporting Erikson’s theory and demonstrating long term durability of the early life experience.
In the Gurin paper, the authors draw on the work of Jean Piaget and Diane Ruble in extending the concept of disequilibrium, to the early learning experience. In Gurin’s words:
“Transitions are significant because they present new situations about which individuals know little and in which they will experience uncertainty. The early phase of transition, what Ruble calls construction, is especially important, since people have to seek information in order to make sense of the new situation. Under these conditions individuals are likely to undergo cognitive growth unless they are able to retreat to a familiar world.”
In simple terms (that even a cardiologist would understand) the greater the difference between the students prior life experience and the learning environment in which they find themselves, the greater potential for new thought, new concepts and personal growth.
The Michigan Student Survey (MSS) and Cooperative Institutional Research Program (CIRP) are longitudinal studies examining, among other things, how diverse education processes influence attitudes and career success. The MSS is a single site study involving 1,582 students. The CIRP is a national cooperative involving 11,383 students from 184 American institutions. Both involved racially and culturally diverse populations of students assessed on the basis of their pre-university and university cultural environments i.e. their “diversity experience”. For detailed description of results, I would refer the reader to Gurin et al. Harvard Educational Review 2002;72:330. The key findings relevant to those considering diversity initiatives in university programs:
- There was a positive relationship between diversity experiences and educational outcomes
- The influence of a diverse educational environment was consistent across schools and cultural groups
- “interactional” diversity was more influential than “classroom diversity”
But are these effects also relevant to medical education, where one might suppose that students are older and further along developmentally, and perhaps pre-selected for cultural diversity and preparedness?
- In 2003, Whitla and colleagues (Academic Medicine 78:460) reported on a study involving medical students at Harvard Medical School and the University of California, San Francisco. Students surveyed reported that contact with diverse peers enhanced their educational experience and supported ongoing affirmative action initiatives.
- A graduation questionnaire administered by the Association of American Medical Colleges to 20,112 graduates from 118 medical schools (Saha et al, JAMA 2008; 300: 1135), demonstrated that, for white students, attendance at a school with high proportions of peers from underrepresented minorities was associated with greater confidence in caring for minority patients and positive attitudes regarding equity issues. These associations were not found for non-white students.
- Niu and colleagues (Academic Medicine 2012; 87: 1530) surveyed 460 Harvard medical students and found that those who reported spending more than 75% of their study time with students from diverse backgrounds or having participated in diversity related extracurricular activities felt more prepared to care for diverse patients.
And so, it seems Mr. Black’s experience in 1931 was not simply an isolated event, but indicative of the potential for great things to emerge when open minds are exposed to new situations, new social constructs, new paradigms. The value of Diversity in education is about much more than a need to exhibit “fairness” and some notion of social justice, but rather an active educational intervention capable of expanding the vision, imagination and therefore potential of students.
So, what does all this psychosocial theory and American experience say to those of us engaged in medical education in Canada in 2014? We might feel, with some justified smugness, that we are not faced with the same social divides and engrained class issues as our southern neighbours. We might also take solace in the knowledge that our schools are uniformly committed to the concepts of equity, fairness and diversity in the workplace, and have rather rigorous policies in place intended to ensure the issue of structural diversity. However, we might also see this as an opportunity to enhance our approaches to medical education, where the ability to effectively engage people of diverse backgrounds and with diverse needs would seem particularly relevant. Finally, many in 2014 Canada might define Diversity as more of a socioeconomic as opposed to racial/ethnic issue, given the well-documented struggles of our First Nations and immigrant populations. With all this in mind, I pose a few perhaps unsettling questions for consideration:
- Do our students engage in medical school in the type of passive and active learning environment that theories and studies suggest could truly influences their development as physicians?
- Do our policies, which focus largely on identifying numbers and proportions of various groups in our school relative to the general population, truly promote the development of that effective learning environment, or simply attempt to demonstrate token compliance with regulations?
- Our students, raised in and drawn from a Canadian culture that promotes equity and fairness, are good and instinctively fair people, unfailingly tolerant of diverse individuals and eager to contribute, but do they develop a deep understanding of the issues of those less-advantaged, and are we, as the stewards of their education, doing all we can to develop a learning environment that will promote that understanding?
Can we do better? Can’t help but think so.
My next article will focus on initiatives currently in place and being undertaken here at Queen’s to enhance the student experience through Diversity initiatives. As always, your input is welcome.
Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.
Introducing Queen’s Meds 2018
With the all-too-soon end of summer comes the beginning of a new academic year. This week we welcome members of Meds 2018, the 160th class to enter the study of Medicine at Queen’s since our school opened its doors in 1854.
A few facts about these new members of our learning community:
They were selected from our largest ever applicant pool – 4366 highly qualified students submitted applications last fall.
Their average age is 24 with a range of 20 to 31 years. For the first time in several years, there are slightly more men (55) than women (45) in the class.
They hail from no fewer than 38 communities across Canada, including; Ajax, Belle River, Belleville, Brampton (2), Brooklin, Burlington, Caledon, Calgary(4), Dundas, Edmonton, Fall River, Guelph, Halifax, Harrowsmith, Holland Landing, Kanata (3), Kingston (5), Langely (2), London (3), Markham (4), Midland, Mississauga (8), North Bay, North York (2), Oakville, Ottawa (10), Peachland, Peterborough, Sherwood Park, St Marys , Thornhill (5), Toronto (21), Vancouver, Waterloo (2), West Vancouver (2), Whitby (2), Whitehorse, Winnipeg
Ninety-one of our new students have completed an Undergraduate degree, and twenty-seven have postgraduate degrees, including nine PhDs. The average cumulative grade point average achieved by these students in their pre-medical studies was 3.76. Their undergraduate universities and degree programs are listed in the tables below:
An eclectic and academically very qualified group, to be sure. Last week they undertook a variety of orientation activities organized by both faculty and their upper year colleagues.
On their first day at Queen’s, they were welcomed to the study of Medicine by myself and Dean Richard Reznick. Over the course of the week, they met curricular leaders who will be particularly involved in their first year, including Dr. Michelle Gibson (Year 1 Director) and Dr. Cherie Jones (Clinical Skills Director). They were also introduced to Dr. Renee Fitzpatrick (Director of Student Affairs) and our excellent learner support team, including Drs. Jennifer Carpenter, John Smythe, Kelly Howse, Peter O’Neill and Susan MacDonald, who oriented them to the Learner Wellness, Career Counseling and Academic Support services that will be provided throughout their years with us. They met members of our superb administrative and educational support teams led by Jacqueline Schutt, Jennifer Saunders and Sheila Pinchin, and first year Curricular Coordinator Brittany Lovelock.
Dr. Jaclyn Duffin led them in the annual Hippocratic Oath ceremony, and coordinated the very popular and much appreciated “Pearls of Wisdom” session, where fourth year students nominate and introduce faculty members who have been particularly impactful in their education, and invite them to pass on a few words of advice to the new students. This year, Drs. Bob Connelly, Jay Engel, Michelle Gibson, Mala Joneja, Michael Leveridge, Susan Moffatt, Michael Sylvester, David Taylor, Ruth Wilson and former Dean David Walker were selected for this honour.
On Friday, they were welcomed to our Anatomy Learning Centre and facilities by Drs. Steve Pang, Conrad Reifel, Ron Easteal and facility manager Rick Hunt, and participated in the annual memorial service with a moving dedication by University Chaplin Kate Johnson.
Their Meds 2017 upper year colleagues welcomed them with a number of formal and not-so-formal events. These include orientations to Queen’s and Kingston, introductions to the mentorship program, and a variety of evening social events which, judging by appearances the next morning, were much enjoyed.
For all these arrangements, flawlessly coordinated, I’m very grateful to Rebecca Jozsa, our Admissions Officer, and second year President and Vice-President Jonathan Cluett and Arian Ghassemian.
At their first day welcoming session they were called upon to demonstrate commitment to their studies, their profession and their patients. They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers. I invite you to join me in welcoming these new members of our school and medical community.
Traffic under the Tuscan sun
Perhaps nowhere on earth do the ancient and modern come into such stark juxtaposition as on the narrow streets of a small Tuscan town. Pedestrians, pets, strollers, bicycles, walkers, wheelchairs, motorcycles, private cars, taxis, trucks, buses, ambulances and horses all share these cobbled laneways, apparently with equal access. There are no lane dividers (there being only one lane), no bicycle paths, no sidewalks. The only rule, unwritten of course, is that if something larger or faster is approaching, best get out of the way. Adding to the apparent confusion, most people are smoking, texting and talking (actually yelling) on cellphones, some all at the same time. Keep in mind that most of these folks are Italian, a people not known for either patience or stoicism. And yet, it all seems to work. Everybody moves along, no fuss, surprisingly little agitation.
To the North American sense of order and compulsion for efficiency, all this seems bewildering. How is this allowed in a presumably civilized country? How do these people tolerate such apparent chaos and, one must ask, why do we in Canada seem to have so much angst about what we perceive as “traffic”, given more space, wider streets, fewer people, and sensible rules that are generally adhered to. How do we account for this? Is there something to learn here?
To all this, I offer some theories, developed after making the strategic decision to stop moving and instead spend more time sitting in one of the many sidewalk cafes and watch the flow of humanity over plenty of espresso, dolci and vino rosso.
Firstly, there’s a sense of permanence and continuity in such places that provides perspective. When you find yourself casually leaning against a column or archway that dates back two millennia, you gain a sense of yourself in time and history that is rather humbling, promotes acceptance and disavows one of the responsibility to improve upon every imperfection. The urge to “bring order” becomes a decidedly new world notion.
There’s also a profound respect for what is established and has withstood the test of time. One would no more paint a traffic line on these ancient streets than one would paint trousers on Michelangelo’s David. There is a certain humanity and humility in the acceptance of chaos in order to preserve the history.
And, of course, there’s that famous Italian temperament. Italians, it must be said, have no love of rules and regulations. In fact, they fundamentally reject direction. However, they are an instinctively generous people who will generally do the right thing, as long as it isn’t required of them. Moreover, they seem to almost admire a creative flouting of the rules. Any understanding of how Silvio Berlusconi was able to gain and hold power for so long in the famously fickle Italian political structure must really begin with an acceptance of this quintessentially Italian characteristic.
Finally, perhaps the best lesson of all, I found I learned much more when I stopped trying to dodge collisions and instead found a comfortable vantage point to observe and ponder. Surely, a lesson to take home and apply to the steady stream of challenges and unexpected obstacles that continually come our way. And the vino rosso certainly didn’t hurt.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
The Virtue of Resilience
Should Medical Schools be looking for it?
Should Medical Schools be teaching it?
What do professional sports teams, executive search firms and medical school admissions committees have in common? (This is not a trick question). Answer: they are searching for young people with the quality of resilience.
This particular quality may go by many names, both formal and colloquial: grit, perseverance, determination, truculence, tenacity, gutsiness. These are all terms for the quality perhaps best defined as “the ability to function in the face of adversity”. What professional hockey managers, headhunters and admissions committees have come to learn through bitter experience are three great truths common to their respective worlds:
Resilience, quite simply, is essential if the talented are to achieve success.
This is nothing new in the world or in human history:
Resilience is what has allowed communities and even peoples to survive and rebuild despite incredible suffering and losses.
Resilience is what got the British through the bombardments of the Second World War.
Resilience is what motivated so many of our ancestors to seek greater opportunities in this country.
Resilience is what our patients demonstrate as they endure their illnesses.
Resilience is what allows physicians to deal with stress, long hours, inability to “cure” every patient, and to function in a world that often fails to recognize or even acknowledge their efforts.
The lack of resilience has been cited as a major cause of “burn out” in students, residents and qualified physicians. So how can we characterize resilience in learners and practitioners of Medicine?
- In a 2013 article, Zwack and Schweitzer (Academic Medicine 2013; 88:382) pose the intriguing question “If Every Fifth Physician is Affected by Burnout, What About the Other Four?” They conducted 200 interviews with physicians of various ages, disciplines and level of training who, upon assessment, were found to exhibit high levels of personal accomplishment and low levels of characteristics associated with “burnout” (emotional exhaustion, depersonalization). The analysis identified a number of factors these high functioning physicians shared, including gratification from the doctor-patient relationship and satisfaction from medical successes. These also exhibited what the authors called “resilience practices”, including leisure time activities intended to reduce stress, cultivation of contact with colleagues, good relations with family and friends, proactive engagement with the limits of skills and treatment errors, personal reflection, spiritual practices, and ritualized “time-out” periods in their schedules. They also identified a number of “useful attitudes”, including acceptance and realism, self-awareness and reflexivity, active engagement with limitations, recognizing when change is necessary, and appreciation of positive experiences.
- Sarles and colleagues surveyed 141 general surgery residents and found that measures of “grit” were predictive of later psychological well-being (Am J Surgery 2014; 207(2): 251).
- In their editorial to the Zwack paper, Epstein and Krasner (Academic Medicine 2013; 88: 301) point out that physicians are at particularly high risk, and therefore even more vulnerable. “All too often, busy clinicians ignore the early warning signs of stress – fatigue, irritability, and feeling outside their comfort zone – in the hope that the situation will self-correct or that their baseline adaptive skills will carry them forward”.
- Angela Lee Duckworth, a PhD Psychologist at the University of Pennsylvania, has been studying the relationship between “grit” (defined as “the tendency to sustain passion and perseverance for long term goals”) and individual success. In “The Grit Effect: Predicting Retention in the Military, the Workplace, School and Marriage” (Eskries, Winkler, Shulman, Beal, Duckworth, Frontiers in Psychology 2014; 5: 36), she and her colleagues found that “grit predicted retention over and beyond established context-specific predictors of retention (eg. Intelligence, physical aptitude, Big Five personality traits, job tenure)…Grittier soldiers were more likely to complete an Army Special Operations Forces selection course, grittier sales employees were more likely to keep their jobs, grittier students were more likely to graduate from high school, and grittier men were more likely to stay married.”
All well and good, but can anything be done for the resilience-deficient? One might imagine that resilience is an inherent quality determined by one’s genetic makeup and therefore beyond learning or development. Apparently not.
- Sood and colleagues tested the utility of a resiliency training intervention consisting of single 90 minute one-on-one interactions among their colleagues in the Department of Medicine at the Mayo Clinic (J Gen Intern Med 2011; 26: 858) and found significant improvements in a number of measured wellness parameters, including resiliency, perceived stress, anxiety and overall quality of life.
- Gail Wagnild is both a Registered Nurse and PhD psychologist who has been promoting the concept that although we can’t avoid adversity in our lives, we can choose how to respond to such events in a way that promotes personal resilience. In “Discovering Your Resilience Core”, she describes five essential characteristics of resilience (purpose, perseverance, self-reliance, equanimity, and existential aloneness) and how each can be identified and strengthened.
So it appears the answer to the two questions I posed are “yes”, and that resilience is not only something that can be recognized, but also developed. Given its importance to career success, it would seem advisable for medical schools to both recognize it as an attractive (maybe essential) applicant quality that should be actively searched out, and also promote it’s further development in our students.
Admissions committees will have long debates about which personal qualities are the most relevant to career success. I vote for resilience.
Out of adversity, gifts of learning.
In the course of my career, I’ve unfortunately had many occasions to deliver “bad news” to patients and their families. This usually involves making them aware that treatments are either not working or no curative options are available, and that the end is imminent. In these moments, reactions are personal, individual and usually unpredictable. No matter how much one rationally anticipates the end of life, the actual reality can never be fully prepared for. The responses are raw, without pretense or veneer. As physicians delivering such news, we’re never truly prepared, and never feel adequate to the task.
I particularly recall an occasion when I participated in delivering “bad news” to a patient I’d been following for many years through several cardiac crises and surgeries. Together with two of my colleagues also involved in his care, and a number of involved students and residents, we informed him, his wife and teen-aged sons that, despite the fact that he was only in his mid 50’s, there were no options any longer available to treat his severely damaged heart and that he had only a short time to live.
There is no truly good way to deliver “bad news” to a patient. There are, however, a number of very bad ways to go about it. My experience and readings would suggest a number of key considerations:
- Clarity is a virtue. The use of euphemisms or expressions of uncertainty about the outcome just increase anxiety. If we’re not sure, we shouldn’t be having the conversation.
- Patients appreciate hearing bad news from someone they know and have come to trust. We should try to have such people involved, even though current patterns of practice make this difficult.
- Patients don’t usually need or desire detailed medical descriptions of why treatments have failed, but once they realize the outcome is certain, will have very practical questions about what will happen. How long? How will it happen? Will there be pain?
- Patients are often more aware of the realities than we anticipate. They are, after all, experiencing the success or failure of treatments. What we’re telling them is often much less of a surprise and we’re really confirming their impressions.
- Patients need to know they will not be abandoned. We need to express the ongoing plan for management.
I was anticipating all this when we spoke to my patient. I was ready for anger, disappointment, denial and all the other responses we’re taught to anticipate and I’ve seen before. I was not, however, prepared for his reaction. Sadness, to be sure, but his first response was to thank us. He shook our hands. Incredibly, his only question was whether any of his organs would be suitable for donation.
Physicians have recognized for many years that our patients are our best teachers. For the most part, this relates to what they teach us about medical matters. What’s less apparent is that they also have the capacity to teach us so much about the human condition and the human spirit, at its worst and at its very best. We have the privilege of sharing life-altering experiences and witnessing not only the suffering, but also how people are able to summon incredible reservoirs of strength and generosity of spirit in times of apparent hopelessness. It’s simply inspiring. That day, in a few moments, that patient, with a few gestures and comments, provided invaluable gifts of learning, not only for myself and my colleagues, but also for the nurses, residents and students in attendance. Perhaps most importantly, he provided an inspiring example for his young family. Out of his adversity, those gifts of learning will affect other patients and other lives.
By the way, I’ve since signed my organ donor card.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Thank you Dr. McLean
The following note was sent by one of our fourth year students to her community preceptor at the end of her Integrated Community Clerkship. Both parties have graciously agreed to allow me to share it with you.
Dear Dr. McLean
- Teaching me Medicine
- Trusting me with your patients
- Introducing me to Perth
- Letting me be wrong
- Helping me get to the right answer
- Asking my opinion
- Demonstrating to me how to make patients feel heard
- Having office hours that work for patients (the 7am start makes so much sense)
- Encouraging me to be curious about patients’ personal histories
- Stashing Fudgeo’s
- Asking me hard questions
- Not making me feel silly when I didn’t know the answer
- But expecting that I know it next time
- Being patient as I learn procedural skills
- Filling out the paperwork while I finish the fun jobs
- Showing me that people are the most interesting part of medical practice
- Helping the office get through an entire Costco bag of Swiss chocolate…in a week.
- Demonstrating the type of discipline you keep teaching me to foster
- Taking me to the family medicine update conference
- Letting me draft on the bike and in the office!
- Building me up in front of patients
- Laughing with me at the occasional absurdities of family practice
- Teaching me to look
- To always look
- Introducing me to DQ milkshakes
- Telling me something isn’t right with a simple glance during procedures
- And feedbacking a quiet “better” once I corrected
- Magically knowing when I was prepared enough for you to disappear behind the curtain
- Giving me generations of social history in one or two sentences
- Helping me process hard-to-process patients
- Teaching me to dictate after every patient
- Showing me that the chart can be your friend…
- …it lets you go on holiday
- …and remind you of things you forget
- Patching up the first-year medical student
- Saying “I don’t know” with patients
- Saying “I don’t know” to me
- Showing me that we have a responsibility to advocate aggressively but politely for our patients
- Not using much technology but having an awesome EMR
- Teaching me to look for the why
- Reminding me why I do not want to be a rhythmologist
- Post-clinic Buster Bars
- Teaching me to punt when appropriate, better too soon than too late
- Stressing the importance of good documentation
- Making me remember the type of doctor I wanted to be as a kid
- Walking down to radiology.
- Talking to me about my future
- And making me think twice about what it might hold
- Deliberately debriefing the patient who coded
- Reminding me that I cannot solve all of a patient’s problems but can stand by her as she chooses to make her life better, or not
- Organizing similar experiences for so many other medical students
- So proudly showing me Lanark Lodge
- Teaching me an approach to explain the “needs further testing” imaging results with patients
- Challenging me to make a real difference for patients, not just correct their serum sodium concentration
- Auto-bolusing the syncopal wedding guest
- Taking off early one afternoon to go biking
- Reminding me to read around patients
- Teaching me that if to make a clinical decision you need more information, then go get that information
- To help me in my first “teaching role” during community week
- Letting me check all the well babies
- Including me in the joys and sorrows of rural family practice
- Helping me to find even more fulfillment in Medicine
- And…inspiring me to dream big while rooting my future in discipline, curiosity, wonder, humility and purpose.
Despite the complexity of modern pedagogical theory, expectations of multiple “shareholders” and increasing demands of accrediting agencies, the essence of medical education remains constant since the pre-Flexner apprenticeship days. Fundamentally, the overriding objective of any program hoping to graduate competent physicians is to identify motivated, receptive learners, and put them into contact with capable, inspiring physicians in a setting that allows the interchange to flourish. That’s basically what any medical school struggles to accomplish. And when those three elements come together….well, the effect is just magical and wonderful to behold.
Motivated learners aren’t hard to come by. As we’re all aware, there are many more highly motivated young people pursuing medical education than positions available. The considerable challenge, as we’ve discussed in previous blogs, is identifying those with the right motivations.
Medical School Admissions: Striving for fairness despite “ill designed” tools http://meds.queensu.ca/blog/undergraduate/?p=363
Medical School Admissions: Unintended Consequences http://meds.queensu.ca/blog/undergraduate/?p=407
Effective educational settings are essential and include appropriately structured and resourced classrooms, clinical learning centres, simulation laboratories, libraries and a continually evolving variety of learning facilities. However, medical education must necessarily extend to clinical settings where students can engage “real” patients in “real” venues. Our Integrated Community Clerkships, which have been in operation in Perth, Picton, Brockville and Prescott for the past four years, are true immersion experiences for our students. They spend 18 weeks living in those communities, working with local physicians, seeing patients in offices, emergency departments, hospital wards, nursing facilities, their homes, or wherever the circumstances require. In addition to learning a great deal about a variety of clinical problems, they become part of those communities and learn about how physicians manage their professional and personal lives. Importantly, they develop a more complete sense of themselves as independent physicians. These rotations have proven remarkably successful, as measured by student satisfaction and academic success. Although many educational leaders and affiliated community faculty have contributed to this success, the two most responsible have been Richard VanWylick, who took on and still provides administrative leadership for the program, and Ross McLean, who not only participates so effectively in the teaching, but has provided steadfast and highly effective support for the program through his role as leader of the Eastern Ontario Regional Medical Education Program (ERMEP).
Which brings us to the most important and valuable of our three key ingredients: the capable, inspiring physician-teachers. At Queen’s, we’re blessed with many such people, none more dedicated or effective than Dr. McLean. Although he’d never describe himself as an “educator”, he is an instinctive teacher with an abiding drive to pass on his 40+ years of experience and wisdom to the next generation of learners (I can assure you he’s not in this for the monetary awards). The qualities of responsible advocacy, sensitivity, professional commitment and diligence that make him such an effective physician, translate naturally to his role as a teacher. His dedication to the profession and to his community are legendary and have been recognized by his having been presented with the Glenn Sawyer Award honouring “a distinguished career of service” in 2011. I understand there is a lively debate in Perth as to how many physicians will be required to replace him when he retires. Estimates range from three to five.
Eve Purdy’s letter captures more effectively than any treatise on educational theory or compendium of accreditation standards, the elements of an effective learner-teacher interaction. I can’t really add to it, except to join her in saying…Thank you Dr. McLean.
One Day in Clinic…
Sarah (fictitious name to protect the innocent) is a second year medical student attending my Cardiology clinic for an “observership”. Like her peers, Sarah had an outstanding academic career prior to entering medical school, as well as a variety of personal experiences that demonstrated an interest in the human condition and commitment to public service. Since entering medical school, she has continued to excel academically, easily passing all her courses. She participates in a number of extracurricular activities, is well liked by her classmates and well regarded by faculty.
She is now exploring career interests, which is what brings her to my clinic. Sarah requested this observership because she feels she may be well suited to Internal Medicine, and Cardiology in particular, and would like to explore that interest in greater depth.
As we chat before clinic, she tells me that she hopes to both increase her knowledge and learn more about the practice of Cardiology. It’s obvious that she’s prepared herself for the clinic by reviewing course content from the previous term, and arrives in her crisp white clinical jacket with stethoscope in hand.
My approach with second year students in clinic is to introduce them to a few selected patients and give them about 30 minutes alone to take a history of the presenting issue and carry out a directed physical examination, including vital signs and cardiovascular and respiratory components. The student then presents their findings to me in a separate room, and we then see the patient together.
Sarah sees three patients.
The first is a 79 year old gentleman who underwent aortic valve replacement and coronary bypass grafting about 6 weeks previously having been followed with gradually increasing symptoms over the previous year. He is a retired construction worker of Portuguese background who speaks no English, but is accompanied by his wife (who also speaks no English) and their devoted daughter who translates for them both. In fact, the daughter doesn’t translate so much as respond directly to questions on behalf of both parents. Although he’s doing well, they have a number of questions and concerns. Sarah has difficulty because she feels she needs to pay attention to three anxious people simultaneously, and isn’t sure the responses she’s getting from the daughter are valid. In discussion afterward, she has missed a number of key issues, and feels somewhat frustrated by the encounter.
Sarah’s second patient is a 60 year old adult who has been followed for over 10 years because of Hypertrophic Cardiomyopathy. The patient is developmentally handicapped and, although very pleasant and cooperative, responds to every enquiry in the same polite manner, affirming how well she feels without elaboration or apparent depth of thought. This is in distinction to the results of the recent echocardiogram that indicate the condition is getting progressively more severe, to an extent that treatment would usually be indicated. The case worker who accompanies our patient and knows her well, tells us that she’s “slowing down”, but never complains of any of the symptoms about which we have enquired. Sarah is aware of a number of treatment options that are known to improve symptoms and prognosis in this condition, but isn’t sure how they should be applied given her patient’s apparent lack of symptoms and inability to understand the indications and possible side effects reliably enough to participate in the decision.
The third patient is a 21 year old native woman who lives in lives near Moose Factory and works in the local hospital. She is referred by her Family Physician because she’s experienced two syncopal episodes within the past month. Sarah takes a complete history, and uncovers a number of issues that might suggest a cause, including a history of drug and alcohol abuse, and a family history of sudden cardiac death at young ages. We discuss a plan for investigations, as well as the need to inform the patient that her driver’s license must be suspended until we’ve resolved the problem. The patient is angry and upset, and doesn’t know how she’ll be able to carry out further investigations, since she was expecting to return home on the first flight early the next morning.
After clinic, Sarah and I take some time to “debrief”. She’s clearly a bit shaken by these encounters. We agree that her level of knowledge about the medical conditions she’s encountered (aortic stenosis, coronary artery disease, syncope, cardiomyopathy) is excellent, entirely in line with her level of training. However, she felt very limited in her ability to obtain a complete history and to apply accepted management strategies to these patients. In addition, she found the experience of encountering a person close to her own age with so many issues complicating her care particularly troubling on a personal level.
We were able to identify the various physician competencies that were required to effectively manage these patients. Sarah found, somewhat to her surprise, that the “Medical Expert” components, which she’d always assumed were the most important in her learning were, in fact, not much of a problem for her. It became obvious as we reviewed the cases that the Portuguese family and disabled adult challenged her communicator skills. The young lady with so many social issues required advocacy and highlighted her professional role to enforce public policy. Deciding what managements were applicable to the cardiomyopathy patient required an exercise of the scholar role, and coordinating all these aspects of care was a manager challenge, as was dealing with her personal responses to the young woman’s social situation. Some of the recommendations we made required collaboration with community physicians, therapists, pharmacists and other health providers. Even more importantly Sarah was able to see that providing comprehensive patient care requires these roles to be integrated rather seamlessly. They simply don’t segregate conveniently for us, as early medical education would suggest.
It also became apparent that these aspects of the learning experience had little to do with the cardiology-specific content but are relevant to any discipline. The “career exploration” element that Sarah was initially seeking certainly took place, but in a much broader and likely more effective way than she had imagined.
So, in summary, what did Sarah gain from her clinic experience:
- A deeper understanding of the pathophysiology, clinical presentation, physical examination and fundamental management of four specific medical conditions.
- An appreciation of the importance, complexity and subtlety of communication as a key physician skill.
- The relevance of all physician roles, and how they come together in every patient encounter as integrated, “intrinsic” competencies.
- Considerable self-awareness regarding her own level of professional development, personal strengths and preferences.
- Something about how different medical specialties differ, and how her particular strengths and preferences might fit those choices.
For my part, I was again impressed with the value of providing patient-centred opportunities that allow our students to experience the real life application of the knowledge and skills they are acquiring. Beginning early in their medical education, these experiences provide a framework and relevance that invigorates their learning process, and informs their career choices. Guiding our students through these formative experiences, and watching the immediate impact they can have, is also one of the most powerful and satisfying roles for any clinician-educator.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
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.
- 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:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
“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:
Good 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:
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)
Undergraduate Medical Education
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.
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.
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?
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.