Remembering three great mentors and teachers

Over the past few months, our faculty and medical school have lost three people who made tremendous contributions over the course of their careers.  Peter Munt, Robert Hudson, and Ed Yendt were all master clinicians, leaders in our medical community and contributors to our understanding of illness and disease.  They were also gifted teachers and mentors who were always willing and eager to pass on their wisdom.  As we approach the beginning of another academic year and are about to welcome a new class of medical students, it seems appropriate to reflect on the lessons and legacies that they’ve so ably provided.

Dr. Peter Munt was recruited to Queen’s after postgraduate training in Respiratory Medicine to head the newlymunt formed Division of Respirology and Critical Care Medicine.  He went on to head the Department of Medicine through a time of tremendous transition, and then became Chief of Staff at KGH.  As his medical resident many years ago, I recall caring for a patient with a pulmonary infection eventually traced to a rather novel organism.  Not content to simply identify and treat the infection, he encouraged me to identify the source and explore for any patients who may have suffered from similar infections.  By doing so and documenting the results of our search, we were able to contribute to the care of many more patients, and raise awareness among other physicians of a little appreciated source of infection.  Moreover, he taught me and my fellow residents the importance of pursuing root causes and the value of documentation and publication in disseminating knowledge.  His career, both as a physician and administrator, was characterized by this quality of uncompromising attention to all facets of an issue, and unwillingness to accept the expedient solution.

hudsonDr. Bob Hudson was head of our Division of Endocrinology for many years.  In addition to his clinical responsibilities, he maintained a very active research career making important contributions to the understanding of androgen function.  I’ll remember him for his dedication to physical examination and bedside teaching.  His ward rounds were highly valued by housestaff.  Not content with mere identification and demonstration of physical findings, Dr. Hudson challenged us to understand the underlying cause and pathogenesis.  “So I agree this patient has exophthalmos” he would concede, but always follow with something like “but why do patients with thyroid disease develop this finding? What’s the mechanism?”  His great skill was to help the learner work his or her own way through the problem without intimidation or belittlement.  In fact, you emerged from these sessions not simply knowing something about a particular finding, but with a mechanism that could be applied to a variety of findings and conditions.

yendtDr. Ed Yendt had already developed a reputation as a leading specialist in calcium disorders by the time he was recruited to Queen’s to head the Department of Medicine.  He led that department through a period of rapid growth, and development of many of the subspecialty divisions.  He continued to do basic research through his career, becoming an internationally recognized expert in osteoporosis.  Always a dedicated clinician, he continued to see patients long after usual retirement age and long after financial considerations provided any motivation.  He was the embodiment of what we would today refer to as “translational” or “bench to bedside” research.  I had opportunity to talk to him on numerous occasions in recent years, and was continually impressed at his knowledge of recent literature and eagerness to apply new findings to his patients.  He was intrigued by patients with unusual presentations or responses to therapy, and continually used those experiences to learn more and apply that knowledge.  He never lost his excitement for discovery or dedication to patient care.

Three great teachers, three different styles, but all sharing an insatiable curiosity, dedication to advancing the science of medicine, and to applying that science to their first concern – the care of their patients.  Their families might find some solace in the knowledge that those lessons are not lost and that their examples and teaching will continue to inspire our students and those currently charged with their learning.

 

 

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Mentoring – a “win-win-win” proposition

What do practicing physicians remember about their medical school experience?  What do they feel had the greatest impact on their development?  What do they retain?  My guess, based on many reunions and even more conversations with graduates, is that it’s not the classes, labs or examinations, but rather the faculty they encountered along the way.  Of course we all remember the “characters” and the “larger than life” personalities that populate every medical school, but it’s those faculty with whom we were fortunate enough to develop a personal, one-on-one relationship that have the most enduring and significant impact on our development as physicians, and on our personal lives.  We call such folk “Mentors”.

mentorThe derivation of the word “mentor” is interesting.  The origin is Greek and is traced to Homer’s Odyssey.  Mentes was a wise and valued friend of Odysseus to whom he entrusted the education of his son Telemachus when he set out on his epic voyage.  The elements of wisdom and trust are therefore intertwined in the term, qualities obviously central to the role as we understand it today.

The value of mentorship is well known in all facets of professional education.  It’s this realization that leads many schools and departments to deliberately develop programs designed to promote these mentoring relationships.  At Queen’s, we have developed a program that assigns a mixture of students from all years in groups led by two faculty members.  Like all such programs, much depends on the specific and usually unpredictable “chemistry” that develops among the group.  When it works (and it usually does) the relationships that emerge are highly rewarding.  Below I provide testimonials from two students and one faculty member regarding their mentorship experience that may provide some insights.

Eve Purdy
Eve Purdy, MEDS 2015

In a 1973 article “Indoctrination of the Medical Student” Dr. Vilter pointed out that turning a new, eager medical student into a competent, caring physician takes more than just training in science, more even than just training in science and clinical skills. The mentorship program at Queen’s has been a special part of my indoctrination to the profession. Our group’s main goal is to have fun in a relaxed way but I am always surprised at the impact of these casual interactions. Whether it be a night of bowling, an intense night of trivia or a simple evening over shared drinks and food, I always leave more energized and excited about what’s to come. 

When a clerk in your mentorship group gives you a tip for the wards next year, you don’t forget. When the fourth year students graduate, you celebrate with them and picture yourself walking across the stage in a few years’ time. When a mentorship group leader encourages you to dream big, you might just. 

And a few more interesting links that I have come across about mentorship in medicine: 

Trivia…or is it? – this is a link to a post on my blog about trivia night earlier this year

Being a Mentor for Undergraduate medical Students Enhances Personal and Professional Development

Mentoring Programs for Medical Students- a review of the literature

Informal Mentoring Between Faculty and Medical Students

simmons
Graydon Simmons, MEDS 2016

The Queen’s Medicine Mentorship Program has provided me the opportunity to have informal interaction and communication with Queen’s faculty and residents that I wouldn’t be able to experience anywhere else. In the hospital or after a lecture, it is hard to just walk up to a physician to inquire about what they enjoy about their profession or how they balance their personal lives with their work. Through the mentorship program, I have been able to build relationships with faculty and residents in a more relaxed atmosphere that is conducive to conversations about one’s future directions in medicine. Additionally, the mentorship program has also increased that sense of Queen’s community for me. As a pre-clerkship medical student, it can be intimidating to enter the hospital during your first clinical experiences. With something like the mentorship program in place, you begin to see the quality of physicians we have here at Queen’s and the encouraging, open teaching environment that they create. Ultimately, this interaction and positive community that the mentorship program has created for me has contributed to my learning and career exploration as a Queen’s medical student.

Dr. Peter O’Neill
Dr. Peter O’Neill

It is About Mentorship

Being a mentor in the mentorship program has been one of the most exciting aspects of being on faculty at Queen’s. At my mentorship group’s last meeting, we had breakfast. For our group, breakfast was a good time to get everyone together without the distractions that can happen with an evening out.

One of the first year students asked if we should have an agenda for the meeting, but the senior students just laughed. The agenda is always the same. I ask the senior students: “what is cool in what you are doing right now”? They answer, in the usual spectrum of experiences, and the junior students say: “wow, how do I get to do that”! That is mentorship in action.

While I enjoy checking in with all the students to see what is cool or if they are struggling, I think the students would rather hear from their near peers. I see our relationships not so much as a vertical structure, but a horizontal one. The clerk explains how to get an elective to the second year student. The second year student describes the observership program as a kind of “back stage pass” to the first year student.

Our group has enjoyed the group events and while I couldn’t make the “Great Mentorship Race & BBQ” in the park this spring, our group was well represented. Over the years we have had fun with Guitar Hero, and had pot luck suppers (which means that everyone has some food that they can surely eat without looking into all the dietary restrictions).

At the Convocation in May, I enjoyed meeting the family of one of my mentees. He said: “Dad, this is Dr. O’Neill, I beat him at guitar hero the second month of medical school.  You couldn’t believe it when I told you we were playing guitar hero in his basement. I smoked him at guitar hero. In spite of that, three years later he taught me how to deliver a baby.”

In the years to come, memories of delivering a baby might fade in this future internist, but I will bet he will remember beating me at guitar hero. He may never know that I let him win.

win-win-winAnd so it seems mentoring is truly a “win-win-win” proposition, benefiting both parties involved, as well as our school, which is becoming known for the value we place on faculty-student interactions at many levels.  We’re always looking for more faculty willing to become involved in this program.  If you’re interested, or simply wish to learn more about it, feel free to contact myself, Peter O’Neill or Erin Meyer in the UG office who coordinates the program.  Erin can be reached at ugmelwc@queensu.ca.

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Student Directed Learning ”Everything old is new again”

My undergraduate education was enlivened by a number of professors who were fond of taking rather unconventional points of view, many of which would be considered “politically incorrect” in today’s parlance.  They were even fonder of defending those perspectives with spirited and colourful debate.  Perhaps travillthe leading proponent of this approach was Dr. Tony Travill, professor of Anatomy, who would spend more of his curricular time discussing points of professional practice and social foibles than the assigned topics of embryology or anatomy.  On the rare occasion that one of us mustered the temerity to point this out, he would make the rather emphatic point that “universities aren’t centres of teaching, they’re centres of learning”.  The message was clear – it wasn’t his business to teach so much as it was our responsibility to learn.  Our goal should be to learn for the benefit of our future patients, not simply to satisfy curricular goals.  I recognize in retrospect that his not-to-subtle shift of emphasis helped us to transition from being passive consumers of information to what today’s educational theorists would term “active learners”, although we had no idea this was happening at the time.

Turing our attention to the present, one of our 2015 students, Eve Purdy, spoke eloquently at the recent Celebration of Teaching Day of how she addressed her interest in the process of clinical decision-making.  She searched the internet and came upon a free web-based seminar series from the University of California (San Francisco) that she accessed over several weeks and found quite useful.  She shared the information with others, both students and faculty who also made use of this resource.  As teaching faculty, we should take considerable comfort in the fact that our students are, on their own, seeking opportunities to advance their learning, often going beyond the baseline requirements of our curriculum.

In fact, our students make use of a wide variety of unstructured learning opportunities in addition to standard curricular offerings such as Courses, Integrated Learning Streams, various types of Small Group Learning, clinical rotations and assigned projects.

Last academic year, about 20 Student Interest Groups were active, each developing a series of at least 8 learning sessions outside standard curricular time that were devoted to a particular discipline or theme.  Although supported by faculty on a voluntary basis, students developed the themes and content of these sessions.  The following is a list of some of the groups that were active this past academic year:

hidden

In addition, our students informally access the world of information available to them through the internet and social media.  A world of information is studentsliterally at their fingertips, and they make use of this almost continuously, both to search information and to dialogue with each other, with faculty (sometime during lectures), and people farther afield.  The challenge is not access, but rather discernment of relative value.

Perhaps the most powerful non-curricular learning experience our students engage is what’s been termed the Hidden Curriculum.  This term refers to all of the unintentional but incredibly powerful messaging that occurs in the context of their environment and clinical experiences.  Observing a respectful and effective interaction between an attending physiciansphysician and nursing staff provides a much more effective and durable lesson than hours of formal teaching on the topic of professionalism.

The challenge for teaching faculty in the midst of all this is to keep pace what’s happening around us, and to shift our focus from delivering content to guiding the learning process.  To borrow an old adage – we can’t control the wind, we can only set our sails.  In this environment, it becomes more important to set the objectives and provide direction than to attempt to rigidly control the process.

And so, as the song says “Everything old is new again” when it comes to student directed learning in medical education, although technical advances and connectivity expand the potential (and our challenge) tremendously.  I like to think Dr. Travill would be amused.

 

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

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“The Light Who Pursues Kindness”

Each year, our graduating class is asked to nominate a member to speak on their behalf at the Convocation ceremony.  Last week, Alex Summers delivered an address he entitled “The Light Who Pursues Kindness” on behalf of the Meds 2013 class.  It was clear to me and to many other faculty attending that Alex’s words deserved a broader audience and so, with his permission, I am providing the complete and unaltered text of his address below.  Alex’s words require no editorializing on my part, but I would simply say that all who are involved in our school in any way, be it teaching, leadership, administration or support, should take justifiable pride that our graduates should feel this way about their careers, to date and beyond.  In the midst of the day-to-day challenges we all face, Alex’s words reaffirm the faith that what we do is worthwhile, and we must be doing something right.  And so, the words of Dr. Summers:

Picture - Alexander SummersMr. Chancellor, Principal, Rector, ladies and gentlemen; 
Let me get started by taking you back to the spring of 1885 with some words borrowed from a day just like today:
“Medicine is a liberal profession, requiring culture and knowledge and skill. It is not a trade for money making, nor a field for vaulting ambition. The physician’s object is to combat disease; he is, therefore, the servant of the suffering.”
Those are the words of George Spankie, Queen’s Medicine 1885, spoken during his convocation address. Since the fall of 1854, medical students have trained here at Queen’s. Trained, and despite all the doubts, graduated too. And today, it’s our turn to cross this stage. We’ve been done for almost a month, but I know many of us have been resisting the urge to call each other doctor, for as we know from last week’s hockey game, it isn’t over till it’s over. Unless you’re the Senators of course; even Alfie says it’s over. But be re-assured folks, I think we’ve made it.
My hope today is to quote the collective voice of the Class of 2013, an outstanding group of people for whom my respect and admiration has grown daily since September 2009. To my classmates, may the words I speak for you today echo your thoughts, and may the words I speak to you have value and meaning. For the wisdom imparted, the memories shared, the friendship and support, and for the humbling privilege to stand here today, thank you.
The medical school journey is not one that is walked alone. It is only through the support of so many that we have achieved what we have achieved. To the staff of the UGME, thank you for tireless efforts on our behalf. To the faculty, we are grateful to you for so many things, but most especially for the examples of professionalism and excellence that you have modeled for us. Queen’s, in my overtly biased opinion, is a remarkable place, and it is so because of its people. Leonard Brockington, Rector of Queen’s from 1947 to 1966 (and the last non-student rector), said that this university was “…an example of the personal and national good that springs from intimate association between devoted teachers and eager learners.” That sentiment still holds true. Thank you for your commitment to us, and to Queen’s.
And to our families and friends, words simply are not enough. Our gratitude for your support, encouragement, and love, cannot be adequately conveyed from a stage. To all of you, may the lives we have lived thus far, and the lives we will lead from this day on make you proud, and be our most sincere expression of thanks.
I last addressed a graduating class in June 2002. I was fourteen years old, and it was the graduation ceremony for Grade 9 students at Montgomery Junior High School in Calgary. I do not remember one word of my speech. But I remember what followed. With spiky fluorescently dyed hair and skater shoes to accent the dress pants, Cassie, David, Terry and Cam came to the stage to play, you guessed it, the convocation classic Good Riddance, aka Time of Your Life, by the punk rock band Green Day. It was a beautiful rendition of that four-chord tune, and I even think David, the guitar player, managed to slip in that little four-letter word that follows the second prematurely attenuated guitar lick.
At the time, there was no better articulation of our feelings and hopes. The words were simple and the band was cool, and it was our anthem. Today however, 11 years later, would that song still cut it? Would it still capture the significance of a day like today?                                                   
Of course not.
Certainly, part of today is very much about remembering the last four years. But that’s not it. That song doesn’t cut it because today is only so much about yesterday. Today is about tomorrow. Not only does the university acknowledge today four years of effort by bestowing upon us this degree, in accepting that degree we answer, with humility and respect, a call. We accept a profound responsibility; a social contract between us and our neighbours. As we begin to feel the weight of that responsibility, it is good to once more reflect upon what exactly we have been called to do.
In my first year of medical school, under the guidance of Dr Duffin, I had the opportunity to learn about Dr Norman Bethune. For a man long dead, he has made a transformational impact on my understanding of what it means to be a physician. A Canadian physician of overwhelming humanitarianism and global compassion, he plied his trade across the globe, believing there was “code of fundamental morality and justice between medicine and the people.” He died in 1939 in rural China, and is remembered in that country as a hero for his selflessness and sacrifice. His name amongst the Chinese is Bai Qiu En – The Light Who Pursues Kindness.

I love that. And I find purpose and inspiration in the idea that we too can be, and should be, lights who bring and share kindness in the darkest hours of human suffering. As we go from here, we tread in the footsteps of giants like Norman Bethune and others – just look around this stage. As our forbearers have, may we stumble courageously and persistently in the pursuit of compassion and excellence. Let us never forgo the good of the patient and the public for the advancement of ourselves or the profession. If the economy does finally manage to implode on itself and the funds for public salaries disappear, may it be seen that Queen’s physicians are the ones that will still show up for work; that Queen’s physicians are, in the words of that valedictorian of old, “servant[s] of the suffering.”  Whether we are destined for a career in a ward, a clinic, an OR, a lab, or a public health unit, if we embark from this place, humbly emboldened with a commitment to pursue kindness in everything we do, we will not go wrong.

Let me finish with one more quote; with words borrowed from Dr Bethune. Spoken in 1938 at the opening of a military hospital in remote China, he would die within the year at the age of 41 as a result of a blood-borne infection he would acquire while operating on a soldier.

“There’s an old saying in the English hospitals… “A doctor must have the heart of a lion and the hand of a lady.” That means he must be bold and courageous, strong quick and decisive yet gentle, kind and considerate. Constantly think of your patients and ask “Can I do more to help them?”

Congratulations, my friends. Thank you for the last four years, for today, and most especially for the good work you will do as you go from this place.

 

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

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Meds 2013 – Congratulations, thanks and one more story.

This week, Meds 2013 will become the 157th class to graduate from the Queen’s School of Medicine.  Despite that long history, their experience in medical school has been distinct in many ways from the 156 classes that have preceded them.  In part, that uniqueness has been due to their engagement of novel teaching methods.  Beginning with the “Pearls” session during Orientation Week (see photo below), the use of clinical and personal “stories” and reflections has been woven into their learning.  With that in mind, I offer another “story” as a parting gift to this special class.

Class of 2013

Professional sport is sometimes capable of becoming more than just games played by privileged millionaires.  On those increasingly rare occasions it becomes a metaphor, with lessons that can resonate through other aspects of our lives.

In the late 1980s, while training in Boston, I developed a fascination with basketball or, more specifically, the Boston Celtics.  The starting five of the Celtics at that time consisted of players who had all enjoyed great careers – Larry Bird, Kevin McHale, Robert Parrish, Danny Ainge and Dennis Johnson – but, by that time, they were all well past their peak, suffering from a variety of physical ailments common to the older athlete – backs, knees, shoulders.  Nonetheless, they remained a highly competitive team, largely because of their incredible savvy, guile and, most importantly, teamwork.  They were masters of the game and very familiar and comfortable with each other.  They were therefore able to consistently defeat younger, more physically talented teams.  They remained the team to beat, and were annually competing for the championship.

basketball1The best individual player at that time, by far, was Michael Jordan.  Still early in his career, Michael Jordan was like an alien dropped to earth to show the world a new way to play basketball.  He did things no one else could do, and did most of them while seemingly suspended in mid air.  He transformed basketball into a three dimensional game.  He literally, and figuratively, soared.  However his team, the Chicago Bulls, had no players who could complement his excellence.  Their main strategy was “get the ball to Michael”.  In a game where only five players compete at a time and one athlete can play almost the whole game, this approach can be quite effective if you have such a stellar player.  Indeed, Jordan dominated the regular season, finishing miles ahead of anyone else in the scoring race, leading his team to the playoffs in 1986, and a much anticipated match with the Celtics.  For basketball fans, it was a match for the ages, pitting a great team of very good veteran players against an incredibly talented star in his ascendancy.  For basketball mad Boston, it was nirvana.

The teams split the first 6 games, with the Celtics using the standard strategy against Jordan, which was to double or triple team him.  Basically, the approach was to assign one of their tallest and most skilled players to cover the 6’6” (not very tall for basketball) Jordan, moving another player or two over as soon as he got the ball, thus boxing him in laterally and vertically.  By doing so, a team could hope to hold Jordan to 20 or 25 points, which would be regarded as a highly successful defensive effort.  For Game 7 in Boston, the Celtics shocked their fans and all those watching by taking a dramatically unconventional and courageous approach.  They decided to play Jordan man-to-man and, for most of the game, Dennis Johnson was assigned the task of covering Jordan.

Dennis Jordan was a very capable guard who had a long and successful career.  He had become a key component of the Celtics team and knew his role very well.  However, he was only 6’4” and, by 1986, couldn’t jump.  Basically, he had no chance of covering Michael Jordan alone.

basketballThroughout the game, the highly knowledgeable Celtics fans watched in shocked disbelief as poor Dennis was left to do the impossible.  For a proud athlete with the entire basketball world watching, including his wife and children who were in the crowd, it would have been a humiliating experience.  Michael Jordan scored in every possible way, eventually amassing an amazing 63 points – still the record for most points in a professional post-season game.  But…the other four Celtics starters, freed from defensive responsibilities, all dominated their opponents and Boston won the game in double overtime – the most exciting and interesting basketball game I’ve ever seen.  The team of grizzled and self-sacrificing veterans had triumphed over the transcendent star, at least that night.  After the game, as players and fans swarmed the court, it was obvious that Jordan felt defeated and unfulfilled despite his incredible personal triumph.  Dennis Johnson, on the other hand, emerged as the battered hero of the game despite his personal drubbing.  He became, and has been, my favourite basketball player.  I was saddened to learn of his premature death in 2007 from apparent cardiac causes.  His Celtics teammates eulogized him as “one of the most underrated players of all time”.

So, what relevance does this story hold for the newly minted doctors of Meds 2013?  You are about to engage postgraduate training of various types.  You will, believe it or not, become highly proficient in your chosen specialties.  You will have days when you feel capable of handling any challenge – of being able to soar like Michael Jordan.  On those days, it will serve to recall the lessons of that April 1986 game, that you can lose the game despite personal triumph, and that even Michael Jordan never felt fulfilled as a player until years later when the Bulls assembled teammates capable of complementing Jordan’s talent and finally winning championships.  By all means, strive to soar, but remember that most of our triumphs as physicians come when we toil with integrity like Dennis Johnson; without fanfare, with quiet effectiveness, with very few aware of what we’ve done, with the patient’s welfare as our ultimate goal.

Meds 2013 has been a remarkable class.  An eclectic and unassuming mix of the quirky and conventional, the pragmatic and idealistic.  Gracious and accepting in the midst of massive curricular change, unfailingly supportive of their school, of their world, of each other.  You have earned the respect and affection of your faculty who will proudly follow your careers with great interest in coming years.  It has been our pleasure.

 

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

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Should Every Doctor be Able to Deliver a Baby?

To many, the answer to this question may seem obvious.  For those who feel an emphatic “yes” is called for, let me pose a scenario for your consideration.  Imagine an airline flight about 3 hours from destination.  A call goes out for someone who might assist a young woman who’s gone into premature labour.  Two people respond.  One is a mid career physician who underwent standard obstetrical training during medical school, delivering about 50 babies during that time, but subsequently trained as an Ophthalmologist and has had no obstetrical experience in the past 20 years.  The second is a registered nurse who graduated about 10 years ago and works in a busy hospital, mostly in the emergency department, but with frequent “float” shifts in Labour and Delivery.  Based on this scenario:

Who is more capable of providing competent care to the patient?

Who will most people aboard the plane (including the patient) assume is most qualified?

The point of this scenario and these questions is not to suggest some simmering interprofessional conflict.  One would expect that these two professionals would recognize each other’s strengths and work together for the benefit of the patient.  The point of this story, which could involve any subspecialty not involved in obstetrical care, is to highlight how much medical practice has evolved, and to suggest that our approach to medical education may not be keeping pace.  This point is made even more apparent by imagining a similar scenario playing out 50 or so years ago when there was much less specialization, the practice patterns of all physicians was much more homogeneous, and physicians were fully qualified to practice at the end of medical school.

My colleague Richard VanWylick is a pediatrician and curricular leader.  He and I have established a running joke regarding the toddler assessment in medical school.  The examination of small children, like the ability to deliver a baby, is an aspect of medical practice that will be ultimately provided by a distinct minority of our medical class.  Further, those who do provide those services in their career will undertake considerable further postgraduate training before doing so.

So, one must ask, why do we devote so much curricular time and resources to these components of medical practice?  I would suggest there are a number of valid justifications:

  1. It’s important that our students experience all aspects of medical practice in order to make valid career decisions
  2. An appreciation of these areas of practice provides insights and awareness that makes us all better Doctors, and better able to understand the needs of our patients, regardless of their presenting problem or our area of interest.  When I consult on cardiac issues during pregnancy, for example, it’s important to have had a practical understanding of the principles of labour and delivery.
  3. There exists a societal expectation that all doctors should be able to provide a minimal level of service, particularly in emergency situations.  That “minimum level”, it must be said, is completely undefined.
  4. Our students very much appreciate the opportunity to experience all aspects of medical practice, and expect the opportunity to do so

On a purely pragmatic note, medical schools are required to provide a comprehensive exposure in order to achieve accreditation status in Canada and the United States.  To quote from “Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree” (the bible of accreditation):

ED-15. The curriculum of a medical education program must prepare students to enter any field of graduate medical education and include content and clinical experiences related to each phase of the human life cycle that will prepare students to recognize wellness, determinants of health, and opportunities for health promotion; recognize and interpret symptoms and signs of disease; develop differential diagnoses and treatment plans; and assist patients in addressing health- related issues involving all organ systems.

Although schools are expected to define for themselves what constitutes adequate preparation “to enter any field of graduate medical education”, I think any program would be hard pressed to exclude active participation in basic obstetrical care and child assessments as components of that preparatory process.

However (and this is a big “however”), with the massive increase in knowledge and emergence of over 60 recognized specialties, medical education is becoming increasingly expansive and expensive.  More and more, medical schools are required to make choices regarding what components of education are relevant to every physician, regardless of what specialty they chose to practice.  Such decisions are being made in isolation since we lack any accepted framework or value assumptions that would support such decisions.

But (and this is a big “but”), things are changing.  Leadership organizations such as the Association of Faculties of Medicine of Canada, Royal College of Physician and Surgeons, College of Family Physicians and Medical Council of Canada, are all acknowledging the need to recognize more explicitly the continuum of education from medical school entry through to full qualification.  The Future of Medical Education in Canada initiative is calling for sweeping reform, including the recommendation to “Ensure Effective Integration and Transitions along the Educational Continuum”.  Three committees have recently been established to develop strategies to implement this key recommendation.  These groups are just beginning to grapple with some very difficult and discomfiting questions, such as:

What knowledge, skills, approaches are common and essential to all physicians, regardless of specialty?

How should physicians progress through training, and when should various training streams begin to diverge?

How should the number of specialty training opportunities be determined, and how should learners be selected for those specialties?

When should medical students be expected to declare their area of interest, and what, if any, provision should be made for those who wish to transition between specialties?

These issues will require considerable thought and reflection by all involved in medical practice, including students, postgraduate learners and teaching faculty.  All involved should feel free to contribute to this dialogue, which has the potential to reform our educational systems in rather profound ways, hopefully leading to a much more aligned, efficient and relevant process.  As a co-chair of one of those implementation groups, I would certainly welcome input on these issues.  In the meantime, I will continue to hope to be sitting next to an experienced ER nurse if someone goes into labour during a future flight.

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

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Basic Science in Medical School. Too much? Too Little?

In his 1988 book “All I Really Need to Know I Learned in Kindergarten”, Robert Fulghum takes a tongue-in-cheek approach to education. His intuitively attractive postulate is that early learning is the most durable we will experience, and those fundamental lessons and principles, well established early in life, can be the most valuable contributors to lifelong learning.

I found myself thinking about this recently after reading a “state-of-the-art” article in the Journal of the American College of Cardiology entitled “Pathogenesis of Acute Coronary Syndromes” (Crea F, Liuzzo G, JACC 2013;61:1-11). The authors provide a contemporary review of the pathophysiologic underpinnings of ACS, describing a complex interplay of structural, inflammatory, metabolic, hematologic and genetic factors that can be at play and can lead to the various clinical presentations we recognize.

blog12Over the years that I’ve been in practice, the understanding of what causes ACS has evolved in a steady and very gratifying manner. In medical school, the concept of myocardial ischemia my classmates and I engaged was encapsulated by a famous Frank Netter drawing of a businessman with a briefcase clutching his chest leaving a restaurant (presumably having enjoyed a large meal) on a cold day. In retrospect, it’s easy to dismiss that image as a rather quaint and simplistic model of what turns out to be a rather complex process.

However, when I think about the fundamental science that underlies the current mechanisms developed in Crea and Liuzzo’s article, I realize how many of those key concepts were first, and very accurately, developed within basic science courses we undertook in our first year. Concepts such as:

• the structure and histology of coronary arteries
• the inflammatory response
• platelet aggregation and thrombosis
• arterial vasospasm
• genetic predisposition to disease
• lipid metabolism
• sympathetic responses to exertion and emotional stress

These topics, esoteric in isolation, have a few, very interesting things in common.
• They are all necessary to understanding current concepts of ACS
• Knowing something about them allows me to appreciate (and even enjoy reading about) contemporary approaches as outlined in the JACC article.
• They were all part of my medical school experience 35 years ago
While I was struggling to learn those concepts, I had no idea they would ever have practical impact on my practice. In fact, my classmates and I were of the very strong opinion that learning these concepts was a decided waste of time that could be better spent seeing patients and learning the “nuts and bolts” of clinical medicine.

Today, undergraduate curriculum committees, including ours, continually struggle with the questions “what should we be teaching” and “what will they need to know”. The desire to ensure the scientific foundations are appropriately presented has to be balanced against current trends to provide more “patient-centred” content, to provide “clinically relevant” content, to ensure our students are introduced to the ever-expanding compendium of clinical knowledge and therapeutics.

But are these forces really at odds? Do we really need to choose between what’s “science” and “clinical”? We don’t, as long as we’re willing to consider new approaches to education. The answer to this apparent dilemma lies in development of integrated learning that doesn’t segregate and marginalize the “science”, but brings it front and centre, linked appropriately and logically to the clinical contexts in which they’re utilized.

Within the next few weeks and months, Dr. Michelle Gibson, Year 1 Director, and Dr. Chris Ward, Course Director for Normal Human Function, are leading a comprehensive review of our objectives in Basic Science. It’s become clear after five years of application that the current framework outlined in our “red book” (Curricular Goals and Competency-based Objectives) merits review and likely revision. In doing so, they will be engaging the faculty at large and will welcome your contributions.

So, do I believe I learned everything I really needed to know in medical school? No. But I certainly didn’t appreciate at the time how useful that learning would prove to be.

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

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Medical School Admissions: Unintended Consequences

The response to my last article on the topic of medical school admissions would suggest that there’s both interest and concern regarding our current processes. In addition to the very interesting responses that were posted, a number of practicing physicians and students communicated with me directly with similar insights. It seems clear from this feedback, and from our own experiences here at Queen’s, that the combination of high demand for medical school positions and the “ill-designed tools” I alluded to in the previous article is giving rise to consequences that are at least unintended and, in the worst case, undesirable. Examples of those unintended consequences:

Strategic selection of undergraduate courses and programs. Academic Records have always been the cornerstone of the admission process. However, lack of uniformity regarding course content and evaluation rigour between institutions (and even departments in the same institutions) has eroded their reliability. It’s widely appreciated that some universities and programs take pride in the demands they place on their students and the meaning of an honours grade. Students attending such institutions therefore put themselves at a competitive disadvantage, despite receiving what all would agree is an excellent educational experience. In addition some disciplines, such as English and the Humanities, rarely award marks above the mid 80’s. Postgraduate science courses tend to award higher marks than undergraduate courses in the same discipline. Although all these vagaries are widely appreciated, there is no acceptable or fair means to equilibrate these inequities. Consequently, students interested in pursuing medical school admission may be making choices based on strategic priorities rather than interest or natural aptitude.

Resume construction. Applicants perceive a need to ensure their non-academic resumes reflect interest in medical and humanitarian pursuits. Although such efforts are obviously laudable, they may be chosen for strategic rather than purely altruistic value, and come with the price of exclusion from other very healthy growth experiences. In addition, such experiences may not be equally available to applicants from diverse communities and socioeconomic backgrounds.

Commercialization of Medical Education. The large number of young people seeking admission to medical school have become an economic “market” and medical education has become a “commodity”. The $270 cost of writing the MCAT does not seem unreasonable, but must be coupled with the cost of preparatory material, preparation courses, travel to and from examination sites, and multiple examinations that many candidates undertake in order to ensure competitive results. University undergraduate courses in biologic sciences have increasingly taken on a distinctly “medical school prep” tone, to the point that program designations have evolved to terms that denote closer links to medical education (“health science”, “medical sciences”), even providing MCAT preparation as part of the curriculum and publishing statistics regarding the rate of medical school acceptance among enrolled students. Although such programs may be of intrinsic value, one wonders whether there is sufficient value and career opportunity for the majority of participants who will not be successful in their medical school applications. Finally, the steadily increasing number of international medical schools that are offering positions to students able to bear the financial burden and accept the uncertainties of postgraduate placement is a clear consequence of the mismatch between demand and positions in Canada.

Premature exclusion (or selection) of Medicine as a career option. Admission to medical schools is increasingly seen as the ultimate award for academic excellence. There is an emerging perception that only academically very successful students need apply and, conversely, that high academic success carries the expectation of medical school admission, almost as an earned right. Both perceptions are problematic. The former excludes (or at least fails to encourage) students on the basis of very early and likely unrepresentative academic experiences. The latter runs the risk that students will set themselves, and parental expectations, on a very determined career path with an incomplete understanding of the demands of that career or their own suitability.

Socioeconomic barriers. Many of the factors noted result in significant barriers to less economically advantaged members of our society. A 2002 analysis of medical school enrolments revealed that only 10.8% of first year students came from rural areas, despite the fact that 22.4% of Canadians live in rural settings (CMAJ 2002; 166: 1029-35). The same study showed that 17% of medical students came from families with household incomes over $160,000, although only 2.7% of Canadian households had incomes over $150,000. Conversely, 15.4% of medical student families had household incomes less than $40,000 in 2002, although 39.7% of Canadian households are in this range. Although such observations do not allow us to conclude that a “barrier” exists, it does appear that our students are drawn from the socioeconomically advantaged sectors of our society, and some of the observations noted above provide explanations for this trend.

I ended my previous blog article by posing the question “Do we have a problem?” Most of the respondents felt we do, based on the issues noted above, all of which suggest the system is neither fully accessible to all deserving applicants, nor fundamentally aligned with the values our society would expect of the medical profession. However, no one seems to question the integrity of the process, nor the quality of the students who are ultimately being selected to medical school. We’re therefore left with the much more difficult issue, specifically: What, if anything, are we prepared to do about it?

There would seem to be two potential options:

  1. Try to change the admissions system to correct or modify the various issues, or
  2. Expand the number of medical school positions to admit more applicants

Both are obviously quite complex and far-reaching. The first option would require directed approaches to each of the issues listed above. For each, strategies could be developed and, in many cases, have been implemented with some success. Examples of such strategies could include any or all of the following:

  • Adjustment of undergraduate grades to account for university or program “degree of difficulty”
  • Development of a more valid and aligned standard entrance examination
  • Greater scrutiny regarding the content and impact of non-academic experiences
  • More scrutiny regarding the content and outcomes of undergraduate programs
  • Development of more aligned pre-medical undergraduate experiences, perhaps linked to medical school admission
  • Provision of economic support to socioeconomically disadvantaged students seeking medical education
  • Stronger links with high school programs to ensure students are aware of the expectations of medical education and practice
  • Linkage of medical school admission with specific service requirements

These and many other options are controversial, highly complex to implement and individually incomplete solutions to the problems we’ve identified. In addition, we would be left with the fundamental issue of still not having enough places for what would be a slightly different, but no smaller applicant pool.

The second approach (increasing medical school positions) has, in Canada, been linked to considerations of physician supply. As thoughtfully reviewed recently by my friend and colleague Dr. Steven Archer, new Head of Medicine at Queen’s (http://deptmed.queensu.ca/blog/?p=266) and also by Dr. Reznick, Dean of Health Sciences (http://meds.queensu.ca/blog/?p=2072), this is a highly complex issue, with no clear data and considerable controversy currently swirling as to questions as fundamental as whether Canada is under or over-supplied with physicians. However, we might engage this issue somewhat differently if we reflect on two realities of modern medical education:

1. The MD degree historically designated readiness to engage medical practice. This has not been the case for at least 50 years. Although our MD programs all provide fundamental clinical training and experience, it is with the intention that students will transition to more intense and direct clinical involvement in their specialty based postgraduate years. In fact, graduates now require a minimum of two (and often up to 7) additional years of postgraduate training, predominantly based in clinical settings.

2. The major limitation to expanding undergraduate MD programs is the availability of appropriately supervised clinical practice experiences. Every medical school in Canada struggles with finding educationally rigourous clinical experiences for their students. The widespread development of regional programs and distributed educational models is largely a result of this challenge.

The logical possibility exists, therefore, to confine undergraduate medical education to foundational science, clinical science and clinical skills, leaving clinical practice to postgraduate training. It would therefore be possible to open undergraduate training to a much larger number of applicants. The “bottle-neck” in the system would therefore occur at the entry to postgraduate training, which would still be limited by clinical placement opportunities and tied to whatever information was available regarding societal requirements for physicians.

The advantages of such a program would be to allow a much larger number of students to enter what would be a shorter and much less expensive educational program, probably directly from high school. That program, properly constructed, would allow students to better understand the realities of medical education and practice, and allow for more standardized assessments on which postgraduate entry could be based. This provides an opportunity to repatriate many Canadians studying Medicine abroad. For students not successful in achieving postgraduate placements, such programs could, if appropriately constructed, provide a solid basis to pursue a variety of alternative career paths. Many of the socioeconomic barriers would be lessened.

Disadvantages are numerous, including loss of the supportive, patient and learner-centred atmosphere most medical schools currently achieve, and further dividing an already “siloed” medical education system. Such programs would, in essence, become more specifically designed pre-medical programs without assurance of admission to postgraduate training, and would require many graduates to seek alternative career paths. The very designation “M.D.” would fundamentally be devalued, unless an alternative application of the term were developed, possibly to be awarded at the end of clinical training.

And so, what began as a discussion of medical school admissions has evolved into a reconsideration of the entire educational paradigm, and the very meaning of the MD degree. I would personally find this approach highly unappealing as, I believe, would most Undergraduate Deans across the country.  So why raise it? Because the system is fundamentally flawed, the meaning of the MD degree has already changed substantially, and radical proposals have a way of focusing discussion, often toward useful ends.

I welcome your views.

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

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Medical School Admissions: Striving for fairness despite “ill-designed” tools

February is, easily, the most difficult month of the year for many involved in undergraduate medical education, including Deans, admissions committees and administrative staff.  This is not simply because of the long and dreary Canadian winter.  It’s during this month that letters go out to applicants for admission indicating whether they’ve advanced to the next stage of the process: the on-site interview.  All those involved in the selection process struggle with the knowledge that, for every letter that brings welcome relief and encouragement, several will result in bewildered disappointment.  Two brief applicant profiles may serve to illustrate the issue.

Jessica is a bright, articulate and engaging young woman who, for as long as she or anyone can remember, has wanted to be a Doctor.  She graduated from high school at the top of her class, with numerous awards recognizing not only her academic accomplishments, but also student leadership and community involvement.  She received multiple university entrance scholarships and undertook an undergraduate program with courses that would provide a basis in biologic and physical science, which she feels is relevant to the study of medicine, but also selected to optimize her marks.  She is very successful, maintaining a 3.8 GPA over her first three years.  She also undertook a variety of volunteer activities, locally and abroad, involving health care in various settings.  She took the Medical College Admission Test (MCAT) after both studying from a manual and taking a preparation course at significant expense.  She did generally well, but was concerned about her mark in one of the four exam categories.  Jessica applied to our medical school, but failed to even get an interview.  This was related entirely to the MCAT score, as she feared.

Matt is not only an excellent student finishing in the top 5% of his high school graduating class, but also an elite athlete who accepts a full scholarship to an Ivy League university.  He chooses this school because it will allow him to pursue his interests in philosophy and political studies at an institution with an international reputation for excellence in both disciplines.  While there, he continues to excel academically, while becoming an accomplished varsity athlete.  He also develops an interest in Medicine and, specifically, Public Health.  He decides to apply to medical school and takes the MCAT, in which he excels in all categories.  He would like to return to Canada for medical school, but also fails to even get an offer for an interview, largely because the grades for his philosophy and political science courses, although near the top of the class for every course, fall below our GPA cutoffs.

Jessica, Matt, their families, and everyone who knows them and their career aspirations, are understandably devastated and rather perplexed.  “How can this be?”

Although these are both fictional accounts, a recent review of our applications at Queen’s shows that no fewer than 247 submissions matched the “Jessica” scenario almost exactly.  The number of “Matts” is more difficult to determine, but likely similar and probably underestimated because many people in such circumstances will decline to even apply, recognizing the GPA issue.

For every jubilant success, we know there are about 7 “Jessicas” and “Matts” who will be very disappointed and may have to set aside or delay their life’s dream, despite being very capable, motivated and deserving.  That reality is also personally distressing to the faculty and staff involved in the admissions process who, recognizing they cannot admit every applicant, endeavor diligently to develop fair and equitable processes.

A few realities about the medical admission process in Canada:

Among Canadians, there is a very high demand for medical education.  At Queen’s we received 3818 applications for our 100 positions this past year. All Canadian schools receive many times more applications than they can accommodate. Statistics collected and published annually by the Association of Faculties of Medicine of Canada indicate that the Canadian schools collectively received 34,048 applications for their 2,877 total available positions in 2011.  Assuming an application per candidate ratio of 3.3 (as Ontario statistics would suggest), it would appear that at least 10,318 individuals submitted applications that year.  The hunger for a career in medicine is such that increasing numbers of Canadians are enrolling in medical schools in Australia, the Caribbean, Ireland and other countries, at considerable personal expense and with no assurance of postgraduate training or eventual qualification in Canada.  Although no accurate data is available, it’s estimated that there are now more Canadians studying Medicine outside Canada than within.

Applicants to Canadian medical schools are knowledgeable regarding the process, and highly accomplished academically.  Although, again, no data is collected on this subject our observation at Queen’s, which seems to be shared by other schools, is that the average GPA, MCAT scores and personal experiences reported by our applicants are increasing each year.  Applicants understand the “system” and are highly strategic as they undertake their education and personal activities.

The number of medical school positions in Canada is fixed by public authority.  Medical education is expensive and largely subsidized by provincial governments.  Those governments therefore define the number of available positions, based loosely on anticipated demands for physicians.  These estimations have fluctuated in the past such that we have seen periods of both contraction and expansion.  At present, there are no plans in Ontario for expansion.

Medical schools place a priority on fairness and equity in their application processes.  In the face of the virtual impossibility of selecting the “most worthy” from so many worthy applicants, schools opt to ensure objectivity and fairness in their processes.  They are therefore drawn to metrics that provide some basis for objectivity.  Unfortunately, all available metrics are inherently blunt and imperfectly aligned with the qualities all would agree are important.

Winston Churchill could have been talking about medical admissions when he famously described golf as “a game whose aim is to hit a small ball into a small hole, with weapons singularly ill-designed for the purpose”.   Academic records, the MCAT, and quantified assessment of reported personal experiences all have significant shortcomings, as our examples above illustrate, but have the significant advantage of providing a numerical assessment by which candidates can be ranked without prejudice.  Panel interviews and mini-medical interviews (MMIs) are being used increasingly by medical schools to better assess applicants personal qualities, and are certainly an improvement, but are very resource-intensive and difficult to conduct and evaluate in a reliable manner.  It’s therefore not possible to apply such methods to the large number of applicants.  Hence the staged application process and reliance on other academic and test metrics.

So, one must ask, do we have a problem?  Despite all these shortcomings, the students who are finally admitted to our medical schools are an exceptional group of very talented, intelligent and capable young people who, with rare exceptions, have all the necessary qualities to become outstanding physicians.  Our processes, although inherently blunt and likely misaligned, are objective and scrupulously fair to all applicants.  Importantly, the Jessicas and Matts of the world, and their families, can perhaps take some small comfort in the knowledge that they are far from alone and have been treated fairly.  Furthermore, medical schools recognize that even if they could personally interview or meticulously assess every applicant, most would still be disappointed.  So, should we change and, if so, how?  I welcome viewpoints, and will make that issue the subject of the next blog.

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

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Family Medicine and the Hidden Curriculum

Lessons from Medical Variety Night

Last November’s Medical Variety Night provided an impressive peek into the musical and comedic talents of our students.  Andrea Winthrop, Steve Archer and I were asked to serve as a “Judges Panel” to determine the best class skit.  We were all amazed at the poise and creativity on display.

The evening also provided a few lessons for both faculty and students as to how well intentioned humour and satire can appear quite different before a mixed audience not familiar with the contexts employed.  A number of conversations have ensued which I believe have been illuminating and instructive for both students and faculty.  As in the patient care context, “near misses” are opportunities to learn and avert more serious problems in the future, and I believe we have, as a school, availed ourselves of the opportunities this year’s production provided.

A theme that I and others in attendance found particularly troubling related to a number of references to Family Medicine as a less-than-appealing career option.  This perception is hard to fathom given that we a have superb and award winning faculty teaching Family Medicine.  Our Family Medicine training program is widely recognized as one of the best and most sought after programs in the country.  In addition, Family Medicine is, arguably, the most demanding of specialties.  In open and frank discussions with a number of students on this issue, a few underlying causes came to light which I found illuminating and felt would be useful to share with faculty.  They provide superb examples of the “Hidden Curriculum”, a term used to describe unintended influences that affect student learning, and are known to be very powerful shapers of student attitude and behavior.  So, in no particular order:

  1. Engaging Uncertainty.  Students find Family Physicians they encounter to more commonly express uncertainly in their ability to resolve patient presentations.  This is in contrast to other specialists who they find characteristically more definitive in their approach.  Family Physicians more commonly use statements like “we’ll have to look it up”, or “don’t be afraid to say you don’t know”.   With respect to other specialists, the expression “seldom wrong but never uncertain” comes to mind (my quote, not theirs).  Importantly, students do not see this difference as inappropriate or as reflecting any lack of competence, nor are they so naive as to believe other specialists always have the answer.  In fact, the students I met uniformly expressed admiration and respect for Family Physicians they encountered, and their ability to manage a diversity of patient populations and presentations.  However, it’s clear that our students are accustomed to success, and many are not yet comfortable facing uncertainty in their lives, or in their future practices.
  2. Technical/procedural expertise.  Many of our students are technically very savvy and excited by the prospect of being on the “leading edge” of innovation and application of emerging technologies and procedural approaches to various conditions.  Simply stated, they like the “toys” of modern medicine and they’re excited about applying evolving procedures.  They perceive that these exciting new approaches as the exclusive domain of sub-specialists.
  3. Prestige”.  Hospital in-patient services remain at the core of clinical training for our students.  Properly run and supervised, they are superb environments in which the learning of pre-clerkship can be applied to real patients, with appropriate overlays of scholarship, professionalism, advocacy, collaboration and all the intrinsic competencies we have adopted within our curriculum.  Although formal teaching remains valuable during these rotations, we all recognize that the major component of learning occurs through active participation as part of the team, and by observation of “real life medicine”.  With respect to Family Medicine, these rotations are problematic in two important ways.  Firstly, virtually no Family Physicians are involved or even visible during these rotations.  Secondly, and most disturbingly, they often see instances where primary care and primary care providers are disparaged.  A casual reference suggesting that a patient was inadequately cared for prior to admission, or a concern that appropriate care will not be continued after discharge can, in a stroke, undo all prior teaching.  These observations in the clinical setting trump teaching in the pre-clerkship.  Our actions, it would seem, speak more loudly than our words.
  4. Money.  I have become convinced that the single most powerful expression of Hidden Curriculum in our society is the OHIP Fee Schedule.  Students are very aware of the differential reimbursement of physician groups, and the high premium paid for procedural work relative to patient assessments.  This of course, results in two hugely damaging consequences, the equation of financial with professional “value” or “prestige”, and the enticing allure of higher income to students facing increasing debt loads by graduation.

So what can be done?  A few suggestions, humbly submitted for consideration:

  1. Awareness of these influences, and of the Hidden Curriculum in general.  Hopefully this article is a start.  I hope it will generate some discussion, particularly at department meetings.  Dr. Leslie Flynn is chairing a group of which I’m a member to study and address Hidden Curriculum issues, and I think this may provide some focus for those discussions.  This awareness must extend to physicians of all disciplines who teach and supervise our students, particularly in the practice setting.  Those who attend on these services are, in my experience, largely unaware of the serious impact of casual commentary, and almost never intend to disparage any other specialty.
  2. Within our curriculum, developing strategies to address the “uncertainty principle” in a more open fashion.  This is both an academic and student wellness issue.  Our students require means to cope with the uncertainty that will inevitably develop in their professional and personal lives.
  3. Serious consideration of the troubling question:  To what extent do our admission processes pre-determine career choice?  Medical school admission remains a highly competitive process (applicant to admission ratio 38:1 at our school), and is likely to become even more competitive in the near future.  This environment favours the goal oriented, determined self-starter who is able to engage this single goal with appropriate compromises and sacrifices along the way.  It can be argued that such “survivors” will be naturally attracted to practice environments that provide definitive resolution of problems, technical mastery and perceived prestige.  There is a recognition, even embedded in the Future of Medical Education in Canada initiative, that admission processes should favour resiliency, personal maturity and problem solving, qualities valuable to any physician and not necessarily reflected by academic success.  Our admissions committee has, in fact, been inoculating these considerations into their procedures for the past few years.  However, as for all schools, academic success remains a key component of the application process.  Perhaps it’s time to consider more radical approaches.
  4. Increasing Family Physician presence in the hospital.  Our students perceive that in-hospital care, and the acuity, complexity and technologic innovation that goes with it, is the exclusive domain of sub-specialists, and fail to appreciate the role of Family Physicians in the continuum of care.  They also get little exposure to the in-patient care provided by Family Physicians in smaller communities.  Our Integrated Clerkship and “Week in the Country” programs address this to some extent, but we need to develop and engage initiatives to integrate Family Physicians effectively into the care of our in-patients.
  5. Advice regarding financial planning and practice management.  Although we can’t influence the fee schedule, we can certainly provide our students with sound financial advice to lessen any economic drivers of career choice.

I would like to end this article by thanking the many students who were willing to speak to me candidly about this issue.  I welcome their further commentary and impressions of faculty.  Open discussion is always the first and perhaps most necessary step to improvement.

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