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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Dick Cheney’s Medical Odyssey: Lessons about advances in care, and about our role as providers

I recently received and read with great interest a book entitled “Heart: An American Medical Odyssey”, co-authored by former American Vice-President Dick Cheney and his cardiologist, Dr. Jonathan Reiner.

In it, they provide both patient and physician perspectives on Mr. Cheney’s longstanding struggles with coronary artery disease, an illness that began with a myocardial infarction in 1978 at age 37, and progressed steadily through the years with several further infarctions, multiple cardiac catheterizations and angioplasties, stenting, coronary bypass grafting, recurring atrial and ventricular arrhythmias, implantation of a cardioverter-defibrillator, endovascular stenting and vigorous application of all available medical preventative therapies.  Despite all this, Cheney developed progressive cardiac damage and heart failure refractory to medications, eventually resulting in implantation of a left ventricular assist device, followed by cardiac transplantation, all of which appears to have been very successful in restoring him to good health.

bushRemarkably, most of this illness and treatment occurred while Mr. Cheney held positions of considerable responsibility and public trust over a 30 year political career, including serving as a Congressman, Secretary of Defense and Vice-President in the Administration of President George W. Bush.

Their book therefore provides a remarkable account of the numerous medical and technologic advances that have occurred within a generation and provide patients with this very common condition so much hope for more quality and length of life.  It also provides, particularly for students, a rather touching example of a very effective patient-physician relationship and how a skilled and caring practitioner is able to advocate and guide his/her patient through the myriad of emerging options as they become available.

However, Mr. Cheney was far from the average patient.  Access to immediate state-of-the-art care was simply not an issue for him.  The book describes several episodes when he would be whisked away immediately by his support staff to hospitals where numerous highly skilled physicians were waiting to provide care.  He also had access to very efficient care at his place of work, where numerous specialists would often convene to advise as to various options available to him.  He was offered every therapeutic advance, and had the advantage of the counsel and care of leaders (often pioneers) of each of those advances.  In short, his story provides an illuminating and somewhat utopian example of what’s possible in the absence of the practical barriers most of our patients encounter.

All this can seem rather distressing to patients and practitioners who struggle with various economic and social access issues in order to take advantage of even standard care.  Perhaps most distressingly is the issue of cardiac transplantation, the treatment that effectively reversed what would have been the natural end of Mr. Cheney’s long struggle. Although highly effective, cardiac transplantation is a very limited resource.

As I reflected on all this, discussed it with colleagues and friends, and surveyed the internet for reactions, I experienced and encountered very mixed feelings.  The optimism and “good news” of Mr. Cheney’s story was counterbalanced with a vague sense of unease.  To many, it seems, the application of so much effort and resource to a single individual seems somehow cheney3unjust, unfair, and counter to some very Canadian values of universal and equal access to care.  Somewhat distressingly, there appeared to be an undercurrent of resentment fueled by the fact that Mr. Cheney is a very polarizing figure who’s persona is, shall we say, somewhat unsympathetic.  Certainly his experience has fueled the popular media that has taken umbrage and humour at his expense.  I suspect Dr. Reiner has also come under some criticism from colleagues in the medical community.  In the book, he provides a particularly poignant account of an interaction with a colleague who appeared to question the vigour with which he was pursuing end stage treatments for his patient.

It seems that this story provokes a visceral reaction in all of us.  For late night television hosts and the general public, this is a source of speculation and casual amusement.  But for physicians, it holds much greater significance.  It forces us to examine how we engage care on an individual level, particularly when confronted with “special” patients.  Advocacy is one of the most difficult lessons for medical students.  Its application to the disadvantaged is easy to understand.  The appropriate advocacy role for the patient who is demanding, unsympathetic and has the means to access above standard care is more complex and difficult.  Was Mr. Cheney’s care “reasonable”, particularly given the large number of Americans without access to even basic care?  Did he “jump the queue”?  How was he considered worthy of this new lease on life?  Was he simply too old, and should this option be reserved for younger patients?  Most importantly, should any of these considerations influence the care we provide any individual patient we encounter.

When confronted with such profound and emotionally charged questions, I’ve found it always helpful to return to the facts.

In Canada, the Heart and Stroke Foundation estimates the number of Canadians living with Heart Failure to be about 500,000, with about 50,000 new cases emerging per year (http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm). The annual mortality rate for patients with heart failure is about 10% with about 50% of patients surviving 5 years.  The same report indicates that 167 cardiac transplants were carried out in 2010. The major limitation, of course, is the availability of donor hearts, which remains very limited despite high profile campaigns to promote public awareness and expedite the transplantation process, summarized nicely in a June 2009 Parliamentary Report (http://www.parl.gc.ca/Content/LOP/researchpublications/prb0824-e.pdf).  The survival rate after cardiac transplantation was recently reported by Dr. Marc Ruel at the Canadian Cardiovascular Congress to be 86% at one year and 75% at 5 years (http://www.theglobeandmail.com/life/health-and-fitness/heart-transplant-survival-rates-improve-study/article558645/).  This figure is consistent with the experience of most Canadian and American transplant centres.

It appears, then, that we have a highly effective, but also very limited therapy that will never be adequate to the potential demand.  The situation in the United States will feature larger volumes but likely very similar proportions and restrictions.  In both countries the access to cardiac transplantation is a highly regulated and understandably controversial process.

What does our society have to say on this issue?

  • A comprehensive and excellent consensus document by Dr. Heather Ross and colleagues provides standards guiding the application of cardiac transplantation in Canada (Canadian Journal of Cardiology 2003;19:621).  With regard to use of transplantation for patients with end stage coronary disease, the document states:

“Patients with severe coronary artery disease (CAD), although it is an uncommon indication for transplantation, may beconsidered for cardiac transplantation if they experience Canadian Cardiovascular Society class IV symptoms not amenable to high risk revascularization and in whom maximal medical therapy has failed.”

Mr. Cheney would therefore certainly have met our Canadian criteria for cardiac transplantation.

  • Mr. Cheney had no condition that would disqualify him from consideration for transplantation.  Although he had many medical problems, they all related to his diseased heart.  In other words, he had no other life limiting issues.
  • According to all accounts, Mr. Cheney and his physicians utilized the standard referral processes available to them, through the United National Organ Sharing (UNOS) registry.  He waited 20 months for his transplantation, existing on a mechanical, externally driven assist device during that time.  This waiting time is reported to be longer than average.
  • According to UNOS, 332 people over the age of 65 received a cardiac transplantation in 2011.  To put that figure in perspective, approximately 2300 cardiac transplants are carried out annually in the US.  Dick Cheney was 72 at the time of his transplantation.

In addition, public figures like Mr. Cheney must necessarily live their lives under intense scrutiny.  As noted previously, his medical issues become public knowledge and the fodder for late night television hosts.  He also had to deal with his illness while undertaking major public responsibilities with their attendant stresses, and under continuing public scrutiny, which could be quite cruel (as depicted) and eliminated any possibility of privacy and continually questioned his competence.  Admittedly, all this was undertaken with full knowledge and consent.

It appears, then, that Mr. Cheney received a therapy for which he was qualified and for which he engaged a standard and well controlled process.  His physician, Dr. Reiner, provided excellent support, directing him to therapies available to him and ensured he gained maximal value from them.  I’ve no doubt that he provides similar efforts to the care of all his patients, even those for whom therapy might not be so immediately available for reasons beyond his or their control.  We should strive for no less for all our patients.

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

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The Challenge of Career Selection

When are Medical Students ready to decide?

Medical students begin their studies believing they have decided upon and achieved their career path, and can now devote their energies and attention to advancing that goal.  They soon learn that even greater and more complex decisions lay ahead.  The process of career selection has become a major cause of concern and stress for both medical students and curricular leaders at our Canadian medical schools.  Students must, by the end of medical school, select from among over 30 postgraduate training program options, which will further differentiate into over 70 approved medical specialty certifications.  Are students ready?  A recent, informal survey was carried out among the first and second year classes at our medical school.  Students were asked to state their agreement with one of three statements:

  1. I have a single, clear career interest.
  2. I have narrowed my focus to between 2 and 5 options
  3. I have no idea

Results:
results

So it would appear only a minority of our students have established a choice by these early years, although it’s unclear how durable these choices will prove to be.  It also seems that some further clarity emerges even by second year, but the majority of students remain uncertain.  Studies from the British medical educational system would suggest that about a quarter of doctors change their career choice after qualification (Goldacre MJ, Lambert TW, Medical Education 2000:34:700-707).  A review of Canadian graduates reports that 83% of graduates felt somewhat or very well prepared to make career decisions, but that leaves a full 17% who described themselves as “not at all sure” by graduation (Columbia B. Can Med Assoc J 1997;156:1248)

To illustrate how much the medical landscape has evolved, it might be useful to consider a “Tale of Three Classes”.

1870This photograph provided by Queen’s Archives illustrates one of our earliest graduating classes, circa 1870.  Students of that era received a common 3-4 years of instruction and clinical training, after which they were fully qualified practitioners.  Their scope of practice throughout their careers was virtually identical, determined only by the needs of the communities they served.

 

1981

 

 

 

 

Let’s move forward about a hundred years.  The second photo was taken at the 25th reunion of my class, Meds ‘81.  My classmates and I also undertook a common four year curriculum.  With one further year of training, in virtually any “internship”, we were all deemed fully qualified as “General Practitioners”.  About half the class remained in General Practice, eventually becoming qualified by the College of Family Physicians when that body and its qualifying examinations came into being.  The remainder went on to additional training in one of the limited number of specialty programs and certification examinations offered by the Royal College of Physicians and Surgeons.  Importantly, I doubt any of my contemporaries regretted their general training, and even those eventually engaging very specialized disciplines would say that their clinical proficiency and effectiveness was enhanced by that background.

2009Contrast all this to the graduates of Meds 2009.  About a quarter of these students undertook training in Family Medicine.  Many will, by now, have completed the minimum two year training program and will have begun practice, having passed qualifying examinations and achieved full certification through the College of Family Physicians.  The remainder are still in training, having undertaken further training through the CFP or entered a variety of Royal College programs, all with their own entry requirements, training program and qualification examinations.  Although their undergraduate experience would have differed in many ways from that of their predecessors, it was based on a structurally similar four year model, common to all students regardless of career direction.

The routes to practice are, in fact, becoming increasingly tortuous, complex and longer.  In order to better understand this, I’ve consulted with my colleagues in our postrgraduate education office.  Jordan Sinnett, PG Program Manager, provided me with the accompanying table that outlines the various paths to the current available postgraduate programs.   The reasoning by which some programs are direct entry from undergrad whereas others diverge after core training, and the length of time of various programs is all rather opaque, but appears to reside with the individual program committees.

It’s important, in considering all this change, to recognize that the major driver is the increase in medical knowledge, available technologies and vast expansion of valuable service the profession is able to provide to our patients.  Our society requires (and demands) physicians who have the highly specialized knowledge and training that’s required to diagnose and manage our ever-expanding array of conditions and provide technologically complex treatments.  This is obviously all good.  However, as training needs have increased, we have simply added more time and qualifications to those previously available rather than to consider new educational paradigms.  At this point, a few questions must be posed:

  • Is this a problem?  Stated another way, are there unintended consequences of this evolutionary change that should be addressed?
  • What, if anything, is being done?
  • How will all this affect our learners, and can they be expected to engage career selection in a different way?

Unintended Consequences

1.  Increasing focus of attention and stress for medical students.  The expansion of career options and requirement to choose from so many postgraduate training tracks is becoming an increasing focus (some would say obsession) of our students during medical school.  Observerships, interest groups, electives and even summer voluntary placements are all seen, and used, as opportunities to explore career options and advance one’s suitability for the increasingly competitive application process.  Although all of value, these pursuits compete with ever increasing educational demands expected of our students.

2.  Unhealthy competition among students.  Many postgraduate programs are over- subscribed relative to available training positions.  This results in a competitive environment at the very time medical schools are working hard to “undo” the pre-medical focus on superficial academic success and advance principles of patient-centred learning, collaboration and cooperation among colleagues.

3.  Subversion of medical education.  Medical school curricula are increasingly directed toward career exploration, to the extent that both core content and Electives (18 to 20 weeks at most schools) are essentially devoted to this purpose.  Career exploration is, in essence, subverting the educational priority.

4.  Increased time required to achieve practice readiness.  With the expansion of postgraduate programs and numerous emerging competency tracks, the duration of training is getting progressively longer.  Becoming a qualified interventional cardiologist, for example, requires 15 years from university entry (4 year undergraduate degree + 4 years of medical school + 3 years General Internal Medicine + 3 years Cardiology + at least 1 year Interventional fellowship).  Given that much of that time is spent in educational pursuits not directly relevant to the eventual practice requirements, the need for such a long training period is, at the very least, debatable, and given the increasing resource limitations of our health care system, will come under increasing scrutiny.

What’s happening that will affect all this?

The Future of Medical Education Postgraduate recommendations included the following:

Screen Shot 2013-12-09 at 4.17.16 PM

To implement this recommendation, the Association of Faculties of Medicine of Canada has established three committees with mandates to explore methods to refine processes within undergraduate programs, the transition from undergraduate to postgraduate education, and the transition to practice.  Those groups have been encouraged to think beyond current models.  Those revisions may involve more “streaming” or specialty-specific teaching during medical school, a more gradual transition from foundational to specialty-specific learning, and effective career counseling processes.

However (and this is a big “however”), any such change in the three or four-year common curriculum paradigm will necessarily require our students to make even earlier career choice decisions.  Is this a reasonable expectation?  The information I provided above would suggest they certainly are far from optimally prepared at this time.  So, what would be required to allow our students to make valid, durable career decisions earlier in their training?

The following would seem at least a reasonable place to start:

Clear and easily accessible information about the various career choices available to them.  Students need to understand the scope of specialty options and the essential differences, not only in clinical content, but also credible information about the “life” that goes with each.  They’re particularly interested in issues such as call expectations, mobility, and the availability of opportunities to integrate academic interests with their clinical obligations.

An understanding of their own preferences and aptitudes.  Students require direction and help in thoughtfully and honestly considering a number of personal issues relevant to career selection, such as:

  • Their willingness to engage patients with undifferentiated presentations
  • Their comfort with critically ill patients
  • Their comfort with continuing care versus issue-specific consultancy
  • Their comfort with surgery and procedural work
  • Their comfort with certain patient populations, such as children, the elderly, the terminally ill
  • Their comfort with various practice settings, such as hospital wards, emergency rooms, ICUs,  clinics, and offices
  • The degree of flexibility with respect to practice settings and mobility they wish to have

Although it can be very difficult for students, a full and candid consideration of issues such as these will allow them to reduce their reasonable options to a more manageable number.

Knowledge about availability of training and career opportunities.  Students have expressed very clearly their desire to know about long-term career availability.  Both shared experiences and recent studies (Frechette D et al,  http://www.para-ab.ca/upload/files/docs/employment/RoyalCollege_EmploymentSummary_2013.pdf) have suggested that many highly-qualified graduates of postgraduate programs have difficulty finding practice opportunities in certain specialties.  Students wish to have such information.  In this regard, they are allied with our provincial governments who seek to ensure our production of various medical specialists matches societal needs.  Unfortunately, accurate information is very hard to come by, particularly for students whose entry into the workforce is several years in the future.

An understanding of the application process.  Students need to understand the process by which they will apply and compete for postgraduate positions.  This requires clarity and transparency about both the matching and selection processes.  The former is carried out by the Canadian Residency Matching Service (CARMS), and is open, transparent and effectively provided.  The latter, which is in the hands of each specific postgraduate program, is considerably less transparent and subject to considerable rumour and “urban myth” among students.

Is there hope on the horizon?

All this requires a fresh, early and much more comprehensive approach to career exploration and counseling than medical schools have provided to date.   This week, those directing career counseling curricula and services at the six Ontario medical schools are assembling at the request of the Council of Ontario Faculty of Medicine Undergraduate committee to compare approaches, discuss challenges, and begin to develop more cooperative and effective approaches for our students.

The AFMC and ministry are jointly interested in providing more reliable definition of societal needs for all our specialties.  Such information will certainly be informative for our students.

The FMEC sub-committees mentioned above have, as a component of their collective mandate, consideration of improved student counseling and application processes.

These initiatives provide some optimism that students will be better prepared for their career decisions, and for the systematic changes likely to develop within our medical education programs in the coming years.  All these discussions and initiatives will be more effective if informed by those involved in (and effected by) the processes under discussion.  It’s in that spirit that this article is provided and your feedback is welcome. 

Many thanks to Jordan Sinett (Postgraduate Program Manager), Sarah Wickett (Health Informatics Librarian, Bracken Library), Jonathan Cluett (Meds 17 Class President), Sean Henderson (Meds 16 Class President), Jennifer Siu (Meds 16) and, as always, Lynel Jackson, for their assistance in the compilation of information for this article.

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Medical Students as Researchers

Should Medical Schools require, encourage, or support active research by students?

As I was recently completing Medical Student Performance Reviews (aka “Dean’s Letters”) for our fourth year class I was, once again, struck by the scope and quality of research undertaken by our students. Our curriculum provides instruction in research methodology, statistical analysis and critical appraisal. It also features active participation in the generation of research hypotheses and development of methodologic approaches to test those hypotheses. However, our students are not required to complete a project to the point of publication during medical school. Nevertheless, many do just that. With the help of members of our Undergraduate Office staff, I compiled the following summary information:

  • 69% of the class were authors of a published article during their medical school career
  • those students contributed to a total of 242 publications
  • in 137 of those publications, our student was the first author

Lest you think these are simple topics of minor interest, let me provide a few examples of publications first authored by one of our students, chosen to highlight the variety and scope of work undertaken. (For the entire list of first author publications go here).

Chang J, Munir S, Salahudeen S, Baranchuk A, Morris C, O’Reilly M, Pal R.  Atrial thrombi detection prior to pulmonary vein isolation: Cardiac computer tomography versus transesophageal echocardiography.  J American College of Cardiology (2013)

Cho CK, Drabovich AP, Batruck I, Diamandis EP.  Verification of a biomarker discovery approach for detection of Down syndrome in amniotic fluid via a multiplex selected reaction monitoring assay.  Journal of Proteomics (2011)

Cusimano M, Pudwell J, Roddy M, Cho CK, Smith GN.  The maternal health clinic: An initiative for cardiovascular risk identification in women with pregnancy-related complication.  American Journal of Obstetrics and Gynecology (2013)

Dossa F, Gao FQ, Scott CJM, Black SE.  Relationship between white matter hyperintensities and hippocampal atrophy in Alzheimer’s Disease.  Canadian Journal of Geriatrics (2009)

Eid L Helm K, Doucette S, McCloskey S, Duffy A, Grof P.  Bipolar disorder and socioeconomic status: What is the nature of this relationship?  International Journal of Bipolar Disorders (2013)

Fernando SM, Szulewski A, Baylis JB, Howes DW.  Motion artifact reduction of ECG signal allows for greater chest compression fraction during CPR.  Canadian Journal of Emergency Medicine (2013).

Ferrara S, Bradi A, Pokrupa R.  Decreasing neurologic consequences in patients with spinal infection: the testing of a novel diagnostic guideline.  Canadian Journal of Surgery (2012)

Fitzpatrick AM, Gao LL, Smith BL, Cetrulo CL, Cowell AS, Winograd JM, Yaaremchuk MJ, Austen WG, Liao EC.  Cost and outcome analysis of breast reconstruction.  Annals of Plastic Surgery (2013)

Gray AB et al.  The effect of a coronoid prosthesis on restoring stability to the coronoid-deficient elbow: A biomechanical study.  The Journal of Hand Surgery (2013)

Joundi RA et al.  Persistent suppression of subthalamic beta-band activity during rhythmic finger tapping in Parkinson Disease.  Clinical Neurophysiology (2013)

Kokorovic A, Cheung GW, Breen DM, Chari M, Lam CK, Lam TK.  Duodenal mucosal protein kinase regulates glucose production in rats.  Gastroenterology (2011)

Koppikar S, Baranchuk A, Guzman JC, Morillo C.  Stroke and ventricular arrhythmias>  International Journal of Cardiology (2013)

Lacombe SP, Goodman JM, Spragg CM, Liu S, Thomas SG.  Interval and continuous exercise elicit equivalent postexercise hypotension in prehypertensive men, despite differences in regulation.  Applied Physiology, Nutrition and Metabolism (2011)

Lun G, Atenafu EG, Knox JJ, Sridhar SS, Tannock IF, Joshua AM.  Use of a clinical assistant to screen patients with genitourinary cancer to encourage entry into clinical trials and use of supportive medication: A pilot project at a Canadian cancer centre.  Clinical Genitourinary Cancer (2013)

Osumek JE, Revesz A, Morton JS, Davidge ST, Hardy DB.  Enhanced trimethylation of histone H3 mediates impaired expression of hepatic glucose-6-phosphatase expression in offspring from rat dams exposed to hypoxia during pregnancy.  Reproductive Sciences (2013)

Rogers E, Wang BX, Zhu C, Rowley DR, Ressler SJ, Vyakarnam A, Fish EN.  A host factor that influences the neutrophil response to murine hepatitis virus infection.  Anitviral Research (2012)

Tohidi M, Robinson L, Graham T, Smith G.  Effect of caffeine ingestion on fetal heart rate activity.  J Obstetrics and Gynecology (2013)

Wang M, Reid D.  Virtual reality in pediatric neurorehabilitation: Attention deficit hyperactivity disorder, autism and cerebral palsy.  Neuroepidemiology (2010)

So all this begs two key questions:

How does this happen?

Should it happen? Put another way: Should active participation in research be encouraged or intentionally embedded into medical school curricula?

Let’s start with the easier, first question. Research participation of this breadth and quality comes about, in my view, as a result of three key and mutually interdependent factors.

blog-clarke1. Faculty leadership. We have been fortunate at Queen’s to have the strong support of our current and previous Deans (Richard Reznick and David Walker respectively) to the fostering of research at our centre. Undergraduate education has benefitted from this commitment in many ways, both directly and indirectly. blog-murrayImportantly, our student research efforts have been guided by the dedication and tenacity of two key undergraduate program leaders. Albert Clarke, now Emeritus Professor of Biochemistry, guided a Critical Enquiry course which was, for many years, a distinctive feature of our curriculum and engaged every student at Queen’s in an active research project. More recently, Heather Murray, Associate Professor in the Department of Emergency Medicine, has taken on leadership of the Scholar Competency in our revised curricular structure. In doing so, she has incorporated the spirit of Albert’s Critical Enquiry and embedded it into our curriculum such that every student participates in a discipline specific research group with the goal of developing a hypothesis generating proposal and appropriate research methodology.

2. Faculty support. These efforts, of course, could not have taken place without the active participation of many faculty whose commitment to medical education and research drives them to contribute their time and creative energy. In fact, no fewer than 60 of our full time clinical and basic science faculty members are involved in the support and mentoring of our students in the Critical Enquiry program. The effort they provide, I can assure you, is far beyond the compensation or recognition they receive. They do this, quite simply, because they “buy in” to the value of research in general, and its development in medical school in particular.

blog-students-13. Student engagement. As mentioned earlier, our students are not required to complete or publish their research proposals. At our annual Research Showcase, most of our student body and many faculty turn out to review and celebrate the student research accomplishments of the previous year. A casual stroll through the many posters, conversation with the authors and review of the works selected for oral presentation are sufficient to convince that the dedication of our students to the themes they have engaged is original, genuine and highly insightful. It also speaks to many of the qualities that we should be seeking in medical school applicants and fostering in medical school. All this would suggest we must be doing something right in both domains, and should certainly encourage our ever-evolving admissions processes and curricular design.blog-students-2

The second question I’ve posed is perhaps more complex and controversial. There is increasing competition for time within MD programs as curricular objectives and accreditation requirements become more expansive. Curriculum Committees are called upon to make judgments between equally meritorious proposals for “real estate” and for the attention of students. In doing so, they must address a variety of forces and influences from disparate sources. The relevant accreditation standard from the joint Canadian/American agencies reads as follows:

IS-14. An institution that offers a medical education program should make available sufficient opportunities for medical students to participate in research and other scholarly activities of its faculty and encourage and support medical student participation.

Medical schools would seem to be required to provide opportunities but not ensure all students participate actively. The implied meaning would seem to be that research participation is desirable but not mandatory component of physician training.

The Future of Medical Education in Canada initiative, now in implementation phase, has two key recommendations that would seem to speak to this issue, but perhaps with somewhat divergent messages.

Recommendation III: Build on the Scientific Basis of Medicine

Given that medicine is rooted in fundamental scientific principles, both human and biological sciences must be learned in relevant and immediate clinical contexts throughout the MD education experience. In addition, as scientific inquiry provides the basis for advancing health care, research interests and skills must be developed to foster a new generation of health researchers.

The final sentence of this recommendation would certainly seem to support an active research agenda. On the other hand another FMEC recommendation would seem to suggest medical education should take on a broader, less discipline-focused approach…

Recommendation VII: Value Generalism

Recognizing that generalism is foundational for all physicians, MD education must focus on broadly based generalist content, including comprehensive family medicine. Moreover, family physicians and other generalists must be integral participants in all stages of MD education.

While the call for medical schools to emphasize generalism is certainly not intrinsically inconsistent with a strong research interest, and recognizing that many family medicine specialists make valuable research contributions, it is equally true that the highly focused and largely university-centred approach of those interested in research careers seldom overlaps with the generalist approach. These two recommendations therefore provide a considerable challenge to medical schools and those developing admission criteria and designing curricula.

Another obstacle to the establishment of individual research within a medical school relates simply to the demands on faculty. Effective research requires one-on-one mentoring and supervision. That faculty-student interaction, to be effective, must be intensive and continuing.

So given all these challenges, why bother? There are probably many reasons we could cite, but I’ll provide my top three:

  • The ability to critically assess new information is an essential physician skill, and will be even more important in future years as the volume and pace of new information increases. There is perhaps no better way to acquire that skill than to have engaged personally in the process of hypothesis generation, study design, data collection, analysis, presentation, and finally defending that work through the peer review process.
  • The research process requires mastery of many of the physician competencies we value and aspire to develop in our students, specifically medical expertise, communication, management, scholarship and collaboration.
  • The possibility of sparking, in even a few of our students, an interest in a particular topic or simply an awareness of the power of research process itself is enticing and potentially far reaching. It’s hard to imagine that the minds that developed or contributed to the works listed above won’t be positively influenced and perhaps inspired as a result of the experience.

Unfortunately, we can’t look into any crystal ball to know how many of the young researchers in our graduating class will carry that interest into their careers, or what influence their work will have. However, I think we can take some satisfaction that we have collectively done our best to provide opportunities that will enrich and inform those careers.

Many thanks to Katie Jones, Amanda Consack, Jane Gordon and Jacqueline Schutt of the Undergraduate Office for their assistance in the compilation of information for this article.

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Understanding Competency Based Education
Lessons from an unlikely source

I was recently asked to speak at a conference on the topic of Competency Based Education.  My assignment was to provide definitions of that topic and to discuss the advantages and challenges associated with developing such an approach in an undergraduate medical program.

graph-nov12My search for a universally accepted definition of CBE began with a call to Theresa Suart, Educational Developer, who promptly alerted me to the reality that no such thing exists and, in fact, I had stumbled into an area of considerable controversy.  She directed me to helpful references, including a 2010 paper by Jason Frank and colleagues (Medical Teacher 32; 631-637) that is actually a systematic review of published definitions!  They reviewed a total of no fewer than 173 published definitions and, as illustrated in this table from their paper, the topic has been attracting increasing interest in recent years.  All this leads me to doubt the practical utility or relevance of a topic that so many bright people have difficulty even defining.  However, one becomes accustomed to such dilemmas when venturing into the world of medical education, and begins to view such uncertainties as opportunities to re-examine basic principles and search for patterns or examples of prior success that may be applicable.

Screen Shot 2013-11-11 at 2.36.58 PMThe principle I always find useful in assessing educational change is the fundamental triad of associations between Objectives, Learning and Assessment.  One of my first practical lessons in curricular design (and accreditation standards) is that these three components must be closely linked if any medical curriculum is to be effective.  Objectives must drive instruction and learning, and assessment must be linked to the teaching provided and the stated objectives.

 

With this in mind, I searched for a simple example that might help advance our understanding of Competency Based Education.  A conversation with one of my nieces who’d recently completed her Driver’s Education course provided that example.  The granting of a Driver’s License is, in fact, recognition of a competence for which there exists an easily understood and widely accepted global objective, specifically the ability to safely operate an automobile.  That global objective requires a body of knowledge, skills and personal CanDriveattributes which, with apologies to the Royal College and with tongue firmly in cheek, could be expressed as the CanDRIVE competency domains, which centre around a body of knowledge and understanding (the Driving Expert) but require additional attributes, such as (we might conjecture) Judgement, fundamental Literacy, physical Coordination, Social Accountability, Alertness (no cell phones) and Sobriety.  The knowledge component is completely and clearly articulated by the Ministry of Transportation in the Driver’s Manual, and the assessment of competencies is demonstrated in three parts, a written examination with questions taken directly from the manual, a cursory visual assessment involving recognition of traffic signs, and a performance based driving test during which the candidate must demonstrate the global objective (drive the car) while exhibiting the component competency domains (show up sober, pay attention, etc…).

And so, two parts of the educational triad are provided.  The true brilliance of the Ministry of Transportation however, is in how they handle the teaching/learning component.  Fundamentally, they don’t.  Learning is the responsibility of the applicant.  That learning is guided, to be sure, by both implied and explicit expectations, but the candidate is expected to seek out their own education, at their own expense, carried out at their own schedule.  There is absolute clarity, however, of the ultimate goals and no mystery about the eventual summative evaluation (answer the questions, read the eye chart, drive the car).

Screen Shot 2013-11-11 at 9.39.27 AMThus, the Ministry of Transportation has (whether intentionally or not) developed a masterful model of Competency Based Education that:

  • Is based on objectives that are clearly understood by learners and assessors alike.
  • Built on a knowledge base that is discrete, well-described and accessible by all.
  • Requires a set of personal attributes that are understood by all and accepted as relevant to mastery of the competency
  • Does not attempt to assess those attributes individually, but rather evaluates the overall competency in a blended, performance based method, the format (and content) of which is completely understood and open to everyone involved.
  • is truly Learner centred

But, you’ll note, there’s obviously a world of difference between driving a car and practicing Medicine.  Indeed there is.  However, the ability to assess and manage a patient presenting with a particular clinical presentation is, like driving a car, a competency set that requires a combination of knowledge, skills, personal attributes (a set of objectives), that must be learned and must be reliably evaluated.  What can we learn from our simple example that’s relevant to any attempt to develop a Competency Based Medical Education program?

  1. The learning objectives must be developed and expressed in meaningful, pragmatic terms.  Competency to do what?  What specific things should the “competent” learner be able to do?  In this regard, the emerging development of Entrustable Professional Activities will no doubt play a major role.
  2. The assessment should be performance-based and relate clearly and directly to those objectives.  There should be no mystery as to what will be expected, and the method of evaluation must be pre-defined and understood by all.
  3. Learning is primarily driven by the learner, not an inflexible curriculum, nor should it be based on any particular schedule.
  4. The responsibility of the program (or institution) should be to provide clarity regarding learning goals, an environment in which learning can occur, and support for the learning process.

Finally, I provide the reader with the best definition of CBE that I’ve encountered to date, which emerged from the previously mentioned article by Frank and colleagues.  It not only expresses these principles succinctly, but does so in a manner applicable to either driving a car or caring for a trauma patient, perhaps the best test of any definition attempting to capture such a complex combination of knowledge, skills and personal attributes.

 Screen Shot 2013-11-11 at 2.40.05 PM

Thanks to Theresa Suart (Educational Developer) and Lynel Jackson (master graphic designer) for their assistance in the development of this article. 

Posted on

Understanding Competency Based Education Lessons from an unlikely source

I was recently asked to speak at a conference on the topic of Competency Based Education.  My assignment was to provide definitions of that topic and to discuss the advantages and challenges associated with developing such an approach in an undergraduate medical program.

graph-nov12My search for a universally accepted definition of CBE began with a call to Theresa Suart, Educational Developer, who promptly alerted me to the reality that no such thing exists and, in fact, I had stumbled into an area of considerable controversy.  She directed me to helpful references, including a 2010 paper by Jason Frank and colleagues (Medical Teacher 32; 631-637) that is actually a systematic review of published definitions!  They reviewed a total of no fewer than 173 published definitions and, as illustrated in this table from their paper, the topic has been attracting increasing interest in recent years.  All this leads me to doubt the practical utility or relevance of a topic that so many bright people have difficulty even defining.  However, one becomes accustomed to such dilemmas when venturing into the world of medical education, and begins to view such uncertainties as opportunities to re-examine basic principles and search for patterns or examples of prior success that may be applicable.

Screen Shot 2013-11-11 at 2.36.58 PMThe principle I always find useful in assessing educational change is the fundamental triad of associations between Objectives, Learning and Assessment.  One of my first practical lessons in curricular design (and accreditation standards) is that these three components must be closely linked if any medical curriculum is to be effective.  Objectives must drive instruction and learning, and assessment must be linked to the teaching provided and the stated objectives.

 

With this in mind, I searched for a simple example that might help advance our understanding of Competency Based Education.  A conversation with one of my nieces who’d recently completed her Driver’s Education course provided that example.  The granting of a Driver’s License is, in fact, recognition of a competence for which there exists an easily understood and widely accepted global objective, specifically the ability to safely operate an automobile.  That global objective requires a body of knowledge, skills and personal CanDriveattributes which, with apologies to the Royal College and with tongue firmly in cheek, could be expressed as the CanDRIVE competency domains, which centre around a body of knowledge and understanding (the Driving Expert) but require additional attributes, such as (we might conjecture) Judgement, fundamental Literacy, physical Coordination, Social Accountability, Alertness (no cell phones) and Sobriety.  The knowledge component is completely and clearly articulated by the Ministry of Transportation in the Driver’s Manual, and the assessment of competencies is demonstrated in three parts, a written examination with questions taken directly from the manual, a cursory visual assessment involving recognition of traffic signs, and a performance based driving test during which the candidate must demonstrate the global objective (drive the car) while exhibiting the component competency domains (show up sober, pay attention, etc…).

And so, two parts of the educational triad are provided.  The true brilliance of the Ministry of Transportation however, is in how they handle the teaching/learning component.  Fundamentally, they don’t.  Learning is the responsibility of the applicant.  That learning is guided, to be sure, by both implied and explicit expectations, but the candidate is expected to seek out their own education, at their own expense, carried out at their own schedule.  There is absolute clarity, however, of the ultimate goals and no mystery about the eventual summative evaluation (answer the questions, read the eye chart, drive the car).

Screen Shot 2013-11-11 at 9.39.27 AMThus, the Ministry of Transportation has (whether intentionally or not) developed a masterful model of Competency Based Education that:

  • Is based on objectives that are clearly understood by learners and assessors alike.
  • Built on a knowledge base that is discrete, well-described and accessible by all.
  • Requires a set of personal attributes that are understood by all and accepted as relevant to mastery of the competency
  • Does not attempt to assess those attributes individually, but rather evaluates the overall competency in a blended, performance based method, the format (and content) of which is completely understood and open to everyone involved.
  • is truly Learner centred

But, you’ll note, there’s obviously a world of difference between driving a car and practicing Medicine.  Indeed there is.  However, the ability to assess and manage a patient presenting with a particular clinical presentation is, like driving a car, a competency set that requires a combination of knowledge, skills, personal attributes (a set of objectives), that must be learned and must be reliably evaluated.  What can we learn from our simple example that’s relevant to any attempt to develop a Competency Based Medical Education program?

  1. The learning objectives must be developed and expressed in meaningful, pragmatic terms.  Competency to do what?  What specific things should the “competent” learner be able to do?  In this regard, the emerging development of Entrustable Professional Activities will no doubt play a major role.
  2. The assessment should be performance-based and relate clearly and directly to those objectives.  There should be no mystery as to what will be expected, and the method of evaluation must be pre-defined and understood by all.
  3. Learning is primarily driven by the learner, not an inflexible curriculum, nor should it be based on any particular schedule.
  4. The responsibility of the program (or institution) should be to provide clarity regarding learning goals, an environment in which learning can occur, and support for the learning process.

Finally, I provide the reader with the best definition of CBE that I’ve encountered to date, which emerged from the previously mentioned article by Frank and colleagues.  It not only expresses these principles succinctly, but does so in a manner applicable to either driving a car or caring for a trauma patient, perhaps the best test of any definition attempting to capture such a complex combination of knowledge, skills and personal attributes.

 Screen Shot 2013-11-11 at 2.40.05 PM

Thanks to Theresa Suart (Educational Developer) and Lynel Jackson (master graphic designer) for their assistance in the development of this article. 

Posted on

Goalies, Poets and Medical Students Fallibility and “the highway to success”

Jonathan Quick made a mistake.

Jonathan Quick
© http://wpmedia.o.canada.com/2013/10/quick.jpg?w=660&h=330&crop=1[i]

For those of you not familiar, Jonathan Quick is a professional hockey player.  Moreover, he is a goaltender.  Moreover still, he is one of the best goaltenders in the world.  Yes, I said world.   Last year, playing for the Los Angeles Kings, he amassed an impressive numbers of wins and statistics in all things relevant to goaltending, and was the most valuable player on a team that competed deep into the playoffs.  His accomplishments have been acknowledged in numerous ways, including being recognized recently by Sports Illustrated as one of the best four goalies in the National Hockey League and, perhaps most significantly, with a 10 year contract with Los Angeles said to be worth 58 million dollars.

Last Monday evening Jonathan was tending goal early in the third period of a home game against the New York Rangers.  His team was down 2-1 but on the power play, pressuring the Rangers for the tying goal.  One of the Rangers managed to nab the puck and send it into the Kings’ end of the rink.  Jonathan, alone in that half of the rink, came out of his net to play the puck, presumably to pass it up to one of his players to continue the power play.  In a manner later described as “comical” by a sports writer, he dropped his stick, misplayed the puck, attempted to recover with his blocker, but instead sent the puck slowly but inexorably into his own net, forced to watch it helplessly, along with the 20,000 or so folks in the arena, as well as most of the sporting world who would relive the moment repeatedly in broadcasts the next morning.  Perhaps most painful of all was Jonathan’s body language after this mishap – arms in the air, head down, clearly devastated.

Significant in all this was the reaction of his teammates and even opposing players.  Their manner at the time and in commentary afterward was in no way condemning, but rather sympathetic and supportive.  “Tough break”…”It could happen to any of us”.  Even the opposing goaltender, Hendrik Lundqvist, himself a stellar player, was quoted as saying “I feel for him”.

The message was clear.  Jonathan Quick is still one of the best goaltenders in the world.  What happened to him is regarded by those who labour in the same business as an occupational hazard in a profession that has no tolerance for error and very high public scrutiny.   To his lasting credit, Jonathan met with the press afterward and took responsibility for what had happened.  Regret, but no excuses.

One can’t help but draw a parallel to the medical profession, where adverse outcomes are regarded as “errors” and draw understandable scrutiny.  Doctors have always recognized the value of reviewing and studying cases where outcomes are anything less than optimal.  Those reviews must necessarily involve all aspects of the care delivery, from simple administrative process, through equipment performance to decision-making and technical provision of procedures.  Perfection, although never attainable in any human endeavour, must always be the goal.  Every adverse outcome provides a lesson and learning opportunity that makes the overall process safer and approaches that perfection.  Like poor Jonathan, alone, sprawled on the ice, physicians feel isolated and very responsible when events go badly, and struggle to interpret these in broader, depersonalized contexts, a necessary struggle if they are to learn and go on to provide care to their next patient.  The open acknowledgement and reporting of errors is a fundamental ethic, and legal responsibility of both the physician and profession.

Medical students begin this struggle very early.  Entering medical school with stellar and usually unblemished records of academic accomplishment, many students have great difficulty dealing with even minor “failures” in their course work or professional behaviour.  The ability to accept and even welcome feedback is a necessary professional competency and one of the most difficult to both teach and learn.  We are accustomed to success and the praise that comes with it.  Anything short of this is seen as a personal “failure” and something to be avoided and even contested.

My colleague Dr. Michelle Gibson likes to quote a particularly revealing study in which a group of medical students were randomized to receive feedback that was either laudatory but non-specific, or very specific and critical of their ability to perform a technical task, in this case tying surgical knots.  When asked to evaluate the value of their feedback, those who received laudatory feedback rated their feedback as much more valuable than those who’d been critically reviewed.  However, when assessed objectively with respect to their ability to tie knots at a follow-up test, the critically appraised students performed significantly better.  The tough medicine, it would appear, is more effective.

Teaching faculty struggle with providing feedback.  It’s much easier to praise and non-specifically encourage than to critique.  Finding ways to provide that critical feedback is equally challenging.  It’s not much help to simply say, “your knots aren’t very good, you should work on that”.  Pointing out the specific issue and even demonstrating correct technique takes time and patience, but will ultimately lead to real improvement.

None of this, of course, is surprising.  It’s the critical analysis and setbacks that help us improve and learn.  That lesson, however, is much more evident and easy to accept in mid or late career than it is to a novice learner.  Medical educators are in full agreement that the ability of a student to accept and assimilate criticism is a marker of both academic and career success.  The converse is equally true – that an inability to accept and grow from critical feedback is a marker of poor performance and poor behaviour in future years.  Humility, it would seem, is truly the beginning of wisdom, but it’s hard to be humble if you’ve never experienced or acknowledged failure.

The romantic poet John Keats (1795-1821) only lived to be 26 years of age, but in that time wrote the following: poet

“Don’t be discouraged by a failure. It can be a positive experience. Failure is, in a sense, the highway to success, inasmuch as every discovery of what is false leads us to seek earnestly after what is true, and every fresh experience points out some form of error which we shall afterwards carefully avoid.”

It may seem quite a stretch to connect a twenty-something English romantic poet of the early 19th century with 21st century hockey players and medical students of the same age, but the wisdom transcends both time and culture.

Jonathan Quick made a mistake.
Jonathan Quick is a great goaltender.
Last week, he got even better.

 

Image from:

[i] http://o.canada.com/sports/los-angeles-kings-jonathan-quick-deflects-puck-into-his-own-net/

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Not your Father’s (or Mother’s) Clinical Clerkship

Meds 2015 students get their white coats and begin the contemporary Clinical Clerkship 

This week, the students of Meds 2015 begin the phase of medical education still referred to as the Clinical Clerkship.  Last Friday afternoon, family and friends joined them to celebrate the White Coat Ceremony, a longstanding tradition that marks this important transition.  It was a pleasure to meet many family members, some of whom were physicians who remarked on the changes between their own educational experiences and those of their offspring.

white-coats

The need to provide supervised learning within the clinical setting has always been regarded as essential to the development of future physicians.  Indeed, early versions of medical education consisted entirely of what could only be termed apprenticeships under the direction of a fully qualified physician who was engaged by the student as their tutor, mentor and assessor.  It was largely as a result of Abraham Flexner’s (pictured) transformational 1911 review of medical education in North America that medical schools were required to provide formal instruction in the basic and medical sciences.  However, Flexner continued to emphasize the critical role of education within the context of clinical service.  flexnerThe role of medical students within service delivery, largely in hospital settings, became consolidated into the discrete role that came to be known as the Clinical Clerkship.  Being a “Clerk” was to have a job or role within the hospital’s complex service delivery.  The role consisted of “clerking” patients (carrying out admission histories and physicals), following the progress of patients through their hospital stay, arranging and following up on investigations, and coordinating discharge and post hospitalization follow-up.  In addition, Clerks had unofficial but widely accepted service delivery roles of their own within hospitals, including phlebotomy, administering intravenous medications, performing simple procedures such as Foley catheter insertion and cast removal, simple suturing and recording electrocardiograms.  Appropriately supervised and monitored, this role provided opportunities to engage patient care in all its complexity in a transitional fashion, leading eventually to the ability to engage patient care independently after graduation.  The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today.  Interestingly, the role of the Clerk varied very little between services, specialties and differing patient populations, the goal being to develop strong foundational skills in patient assessment and management, which were felt to be consistent and “learnable” within any patient care context.

As the “service” component of the clerkship grew and hospital care became more procedurally driven, understandable concerns were raised regarding the balance between service delivery and education.  Medical educators, buttressed by increasingly specific and prescriptive accreditation standards, developed standards and objectives for the medical student role, coupled with a need for more structured and objective assessment.  At the same time, our students were developing an increasing need to use clerkship experiences to explore career options in an increasingly complex and competitive postgraduate training environment.

Today’s clinical clerkship has evolved considerably from the model experienced by most mid or late career practitioners.  Now usually consisting of the final 2 years of medical school, it is intended to provide clinical exposures that vary not only in focus but also in setting, recognizing the reality that our students have a critical need to explore career options and to encounter patients in a variety of settings that will reflect their own career paths.  The rotations are enhanced with formal educational experiences, formalized feedback on all curricular objectives, and structured assessments of various types.  To illustrate the modern clerkship, the following example profile is provided to illustrate the journey of one medical student through a clerkship:

  • A six week General Surgery rotation on an in-hospital unit at either Kingston General Hospital or our affiliated teaching hospital in Oshawa.
  • A six week Peri-operative Medicine rotation rotating through a series of experiences with surgical subspecialties (such as Plastics, Orthopedics, Urology), Anaesthesia and Emergency Medicine.
  • Six weeks on Core Internal Medicine spent as part of the care team assigned to a Clinical Teaching Unit in Kingston, Oshawa or Peterborough.
  • A further six weeks on Specialty Medicine spent undertaking consultation or out-patient clinics within three medical sub-specialties.
  • Six weeks of Psychiatry in Kingston, Oshawa or Markham, generally office or consultation- based.
  • Six weeks of Family Medicine working with a community family physician or Family Health Team.
  • Six weeks of Pediatrics, provided in either a hospital ward or community practice.
  • Six weeks of Obstetrics and Gynecology, consisting of shifts in Labour and Delivery, gynecology ward, or outpatient clinics.
  • Sixteen weeks of electives, during which the students a series of 2 week experiences in specialty services and locations across Canada designed to broaden their clinical experience and exposure to career options.
  • Three 4 week “Core Curriculum” rotations placed at the beginning, within and at the end of the clinical rotations, intended to provide common instruction and assessment in advanced topics and practice related instruction.

All these rotations feature, in addition to the clinical experiences, structured teaching, all guided by objectives linked to the overall Curricular Goals and Competency Based Objectives document which was developed and is regularly reviewed by our Clerkship Committee and approved by the Curriculum Committee. 

In addition, students can elect to undertake our Integrated Community Clerkship, consisting of an 18 week placement within a smaller community working with community tutors and Family Health Teams, intended to provide longitudinal experiences in Family Medicine, Pediatrics and Psychiatry.

Students can also apply for an increasing number of International exchanges which allow them to undertake a core rotation at universities in another country.

All rotations feature content relevant to the various Professional Competencies (Professionalism, Advocacy, Collaboration, Management) and their achievement in these domains is a component of rotation assessments.

All students continually log their clinical experiences and technical procedures in order to ensure all learning objectives are being met.  They also undertake comprehensive structured clinical examinations (OSCEs) in order to ensure core clinical skills are mastered and maintained.

So…a far cry from the service dominated Clinical Clerkship so familiar to most practicing physicians.  A key, and very reasonable question could be posed: Does it matter?  Are our students better prepared for the demands and rigours of residency and practice than their predecessors?  This intriguing question will be the subject of my next Blog.

 

 

 

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Visiting with Dr. Vincent Lam Making the case for Humanities in Medical Education

I have always loved reading novels.  I’m particularly drawn to those that feature complex and fully fleshed out characters battling various personal “demons”, confronting sundry human challenges in interesting contexts.  I must confess to having always regarded the reading of such books as something of a “guilty pleasure”, a self-indulgence taking time away from more immediate, directly relevant pursuits.

This week, vincent_lambthanks to the efforts and insight of the Aesculapian Society, particularly Michael Chaikoff and Soniya Sharma, many of us had the opportunity to hear from and meet with Dr. Vincent Lam, who was this year’s H.G. Kelly Memorial lecturer.  Dr. Lam is an Emergency Medicine physician and award-winning author of a number of works including “Bloodletting and Miraculous Cures” and “The Headmaster’s Wager”.  In his address, Dr. Lam made the case for the role of storytelling as a way of understanding and deepening communication between physicians and their patients, not only as a means of transferring important information, but he also spoke of how it can contextualize the relationship in more human and personally meaningful terms.  In conversation afterward, I asked him about the process of novel writing.  I had always naively assumed that the author begins the process with an outline of the completed story and goes about adding detail and context.  Apparently not so.  Most authors, including Dr. Lam, begin by imagining and developing their characters as fully formed people with all their individual traits and uniqueness.  They then go about studying and researching the context in which those characters will “live”.  Using characters and contexts with which the author is already somewhat familiar is obviously a good start, but considerable research and immersion is required in order to produce stories with depth, realism and relevance.  In researching for “The Headmaster’s Wager”, Dr. Lam made two trips to Vietnam in order to better appreciate the environment in which his story would evolve.  With character and setting in place, the author allows his characters to “live”.  Their actions and reactions become a natural consequence of the interaction of their personality with the times and situations in which they find themselves.

One can’t help but recognize parallels within the physician-patient relationship.  Our patients come to us as uniquely formed individuals who find themselves in a new, baffling and threatening context, specifically an illness or health challenge of some type.  Our role as physicians is to come to the encounter already prepared with understanding of the illness, or “setting” of that challenge.  Our “art” is to find within ourselves ways to efficiently and effectively engage the patient, understand the uniquely individual responses to the illness and guide the patient through the terrain.  In doing so, the physician must develop a broad appreciation of the human experience in all its fascinating complexity.  In this sense, the reading and appreciation of quality literature would seem at least as valuable as reading the latest thrombolysis trial.  Certainly the former is likely to be of more enduring significance.

At Queen’s, we have benefitted over the years from the efforts of numerous faculty who have steadfastly championed various components of the Humanities within and around our curriculum.  Dr. Jackie Duffin, herself an award-winning author, has been providing History of Medicine lectures integrated with various teaching blocks for many years, as well as student projects and excursions intended to deepen their appreciation of the history of their chosen profession.  Students have consistently found her teaching to be a highlight of their medical school experience, as evidenced by Dr. Duffin being a recipient of the Connell Teaching Award which the graduating class bestows annually on the faculty member considered to have had the greatest influence on their education at Queen’s.  Drs. Shayna Watson and Peter O’Neill have provided, largely on their own initiative, contributions to elective courses devoted to various themes related to literature, spirituality and the humanities.  We have maintained strong curricular content in Medicine and the Law (led by Patti Peppin of the Faculty of Law) and Medical Ethics (led by Drs. Cheryl Cline, Susan MacDonald and previously Ellen Tsai).  Many others have contributed in informal but highly meaningful ways.

The challenge, of course, is determining how best to integrate the Humanities and Social Sciences within a rather dense and highly scrutinized curriculum.  How does a Curriculum Committee, charged with meeting the various competencies and objectives established by professional bodies, accrediting agencies and well-intentioned interest groups, ensure these are achieved and balanced?  How does it weigh the value of medical literature or history against understanding the management of hemoptysis or causes of renal failure?

As a means of engaging this challenge, I recently asked Drs. Duffin, Cheryl Cline and Shayna Watson to develop a review and make recommendations on the teaching of Humanities within our school.  They involved three of our students, Alicia Nicke-Lingefelter (Meds ‘16), Amanda Lepp (Meds ‘15) and (now Dr.) Renee Pang (Meds ‘13).  That excellent report has already motivated changes in representation within our curricular committees and is leading to changes in how we “label” and integrate various teaching opportunities within our curriculum.  It has also raised a consciousness about the Humanities and Social Sciences that is always the first step to ensuring appropriate balance.  I’m arranging for the report to be posted on the UG Website and welcome feedback from all faculty and students.  It can be accessed at: https://meds.queensu.ca/central/community/curriculumcommittee:reference_material

I’m most grateful to the authors of this report and to all who have and continue to champion the Humanities within our school.  I’m also very grateful to Dr. Lam who has made me feel much better about my guilty pleasure.

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