Category: Associate Dean
Are we all latent bigots? The troubling and threatening implications of Implicit Bias
Last October, on an airline flight from Detroit to Houston, a passenger became seriously ill, eventually losing consciousness. The attendants asked for medical help. A doctor on the flight came forward to provide assistance. One of the flight attendants refused to allow the doctor to attend the patient without some proof of their qualifications, despite verbal reassurances and the patient’s obvious need. While this was going on, a second doctor appeared who was welcomed and permitted to examine the patient. No qualifications were either requested or offered from the second doctor.
The first doctor was a black woman. The second was a white man.
The attendant apparently had difficulty characterizing a black woman as a doctor, but had no such difficulty with the white man. As you might imagine, this has led to considerable media attention and some rather creative groveling on the part of the airline involved which has vowed to extend its diversity and inclusion training (previously provided only for corporate leaders) to frontline employees.
We’re left nonetheless to ponder how such a thing could happen. The flight attendant involved, we must assume, is neither a raving lunatic nor card-carrying bigot. She is likely a regular citizen who, in a highly stressful situation that required her to make a critical judgment, did so instinctively. In doing so, she exhibited (or made explicit) what could be termed an Implicit Bias.
The notion of Implicit Bias is rather unsettling, particularly to those who quite sincerely believe themselves to be accepting of diversity and inclusion. The concept is that we all harbour prejudicial impressions and attitudes of which we are blissfully unaware. These attitudes, apparently related to personal associations and memories, reside deep in our subconscious but are capable of influencing our decisions and actions without our intention or awareness. Fundamentally, even if we truly, even fervently believe in the principles of equality and attempt to conduct ourselves accordingly, we are all “hard-wired” to identify with and therefore feel greater affinity with those who are like us, and less so with those who differ from us in some way. It can be regarded as a developmental survival adaptation that allowed our ancient predecessors to recognize threats and react quickly to avoid them. It’s what alerts the gazelles to instantly run at the first sign of a lion without taking the time to process the decision. In terms consistent with Daniel Kahneman’s Thinking Slow and Fast approach, it’s the ultimate triumph of Type 1 over Type 2 thinking.
The concept of Implicit Bias is certainly gaining attention and being taken seriously by the scientific community. In a recent edition of Science (352:6289,1035) editor-in-chief Marcia McNutt reports on a forum of editors and publishers of prominent journals convened by the American Association for the Advancement of Science to discuss how Implicit Bias might be countered in the peer review process. Blinding reviewers as to authorship is apparently insufficient.
The Ontario Human Rights Code has, as one if its core principles, the primacy of the consequence or effect of an action over the intention that led to it, surely an acceptance of the influence of subconscious or implicit biases.
In the medical world, there have been a number of rather disturbing reports on the subject. In a study on the diagnostic approach to patients presenting with chest pain (Schulman et al, NEJM 1999;340:618) the authors prepared a series of videos of eight different patients (portrayed by actors) who described their symptoms and medical history. The descriptions and factual information were identical. The authors went to painstaking lengths to ensure the videos were also identical in all aspects, even the facial expressions, hand gestures, background and gowns worn by the patient-actors. The “patients” (pictured below in an illustration taken from the paper) differed only with respect to gender and race.
The videos were shown to 720 (mostly white) physicians who practiced either Family Medicine or Internal Medicine specialties. The results showed that the physicians were statistically more likely to suspect ischemic disease and therefore order cardiac catheterization in the men than the women, and in the white patients than blacks.
A study of 215 surgical attendings and residents at Johns Hopkins (Hader AH et al; JAMA Surg 2015:150:457) used a combination of clinical vignettes and Implicit Association Test (IAT) to assess attitudes and decision making. The instrument identified race and social class biases in most respondents, who were found more likely to suspect alcohol abuse in black patients than whites, less likely to order an MRI in a lower socioeconomic class patient with suspected cervical spine injury, and more likely to suspect pelvic inflammatory disease as a cause of right lower quadrant pain in black than white women.
A similar study was carried out in Oncology programs in Detroit (Penner LA et al; J Clin Oncol 2016;34:2874) involving white oncologists and black patients. Results showed that higher implicit bias in attending physicians (as determined by the IAT survey instrument) was associated with patient interactions that were shorter and perceived to be both less supportive and less effective. Higher Implicit Bias scores were also associated with lack of patient confidence with treatment plans and perceived difficulty in completing the course of treatment.
A recent systematic review of 15 studies of health care providers using the IAT showed low to moderate levels of bias (similar to the general population) in all but one (Hall WJ et al: American Journal of Public Health 2015;105:e60-76).
Many of these studies have evoked considerable criticism. There are certainly counter arguments to be made. Survey instruments like the IAT, even if previously validated, have limitations. The diagnostic process we utilize and teach incorporates known risk factors which are known to vary among genders and racial groups, so what’s perceived to be bias, some argue, may simply be the appropriate application of epidemiological data and “real life” knowledge.
However the real and deeply disturbing concern is that the concept of individual physician judgment or intuition that the profession has valued so greatly, and both clinicians and their patients rely upon to develop effective and efficient treatment decisions, is under threat. If we’re all subject to Implicit Bias, are we capable of making valid decisions on any issue that strays from a strict guideline algorithm? Indeed, will this threaten the confidence clinicians require to make critical decisions?
Fortunately, hope springs forward in the form of several perceptive approaches that are being advanced to counter the threat of Implicit Bias. For those interested in reading further, I will list some relevant papers below, including one by Dr. Geoff Norman and colleagues at McMaster that was published just this month in Academic Medicine. Those articles describe educational, administrative or societal approaches to the issue. What seems to be missing, however, is practical advice to individual physicians and learners as to how they might approach these concerns personally. Taking the liberty to provide a personal and non-expert perspective on this, I would offer the following seat-of-my-pants prescription to combat Intrinsic Bias:
- Brutal honesty. It would appear from the literature that no one is immune from these influences. We are all complicated, unique individuals with our own mix of life experiences. Recognizing that these biases exist, are natural and not indicative of a disordered personality of some type, but are nonetheless capable of influencing our decision-making would seem to be the best first step.
- Self-awareness. A truly honest exploration of our comfort in engaging patients from various backgrounds and with personal choices or perspectives that differ from our own would seem to be a key step. There’s nothing inherently wrong with not feeling equally comfortable with everyone we encounter. Something will be very wrong if that discomfort influences the care we provide.
- Increasing personal diversity experiences. Personal, one-on-one experiences with people from different backgrounds is the most effective way to increase understanding, promote comfort in engaging diversity and break down the threat of intrinsic bias. We need to seek such opportunities for ourselves and, as a school, develop and promote such opportunities for our students. Our Diversity Committee, under the direction of Dr. Mala Joneja, has this goal firmly in their sights and is making considerable progress.
- Do the mental “double-check”. When making a clinical decision involving a patient from a diverse group or background, a helpful and simple exercise might be to imagine the same scenario being played out in a patient of your age, gender, culture and socioeconomic/social circumstances. If the decision you would make is different in anyway, there should be a valid medical reason for that different approach. If not, a second thought might be in order.
In summary, Intrinsic Bias is a distinctly uncomfortable topic, particularly for physicians. It is threatening, unsettling, humbling and personal disturbing. But it’s also probably real, and worthy of study and personal reflection on the part of both practitioners and learners.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Approaches to Implicit Bias:
Byrne A, Tanesini A. Instilling new habits: addressing implicit bias in healthcare professionals. Adv. In Heath Sci Educ 2015; 20: 1255.
Norman GR et al. The causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine 2017; 92: 23.
Penner LA et al. Reducing racial heath care disparities: A social psychological analysis. Policy insights from the behavioral and brain sciences. 2014; 1: 204.
Stone J, Moskowitz GB. Non-conscious bias in medical decision making: what can be done to reduce it. Medical Education 2011; 45: 768.
Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.
Our hospital and institutional problems are formidable, but not unprecedented: Finding lessons (and validation) in the past.
“The study of history is an antidote to the hubris of the present – the idea that everything we have, everything we do and everything we think is the ultimate, the best.”
Mr. McCullough’s wise words can also serve as a reminder that the various challenges we find so troublesome today almost always have parallels in the past. Learning how previous generations dealt with the dilemmas of their time can be instructive, encouraging, and often rather humbling.
This became very apparent to me recently as I read a copy of Margaret Angus’ “Kingston General Hospital: A Social and Institutional History” which I came upon while browsing in the book section of a local antique market (actually, while killing time waiting for my wife to complete her browsing). In it, Ms. Angus documents the trials and tribulations faced by those who originally planned, built and operated KGH. Despite the vastly different cultural context and technology, what comes through are accounts of determined and community-minded people coming together to overcome challenges and improve the health care available to their families and fellow citizens. A brief summary of that early history as recorded by Ms. Angus is illuminating.
The first petition for the establishment of a public hospital in Kingston came in 1809 from a group of 44 residents and was made to Governor Sir James Craig. Fully nine years later, land for a hospital site was granted by an 1818 Order in Council by the Lieutenant Governor, but no funds were provided for building. A number of public subscription programs resulted in pledges amounting to about £1,000 for the purpose, and led the 11th Parliament of 1832 to finally grant £3,000 for the erection of a Kingston hospital. Drs. James Sampson and Edmund Armstrong were appointed “commissioners for superintending and managing the erection and completion of the said hospital, and for the purchasing or otherwise obtaining, choosing and determining the site thereof”. After much negotiation and consideration, they purchased six acres of a farm lot from Rev. G.O. Stuart between the present-day Barrie Street and Lower University Avenue.
At this point the population of the town was 3,500 with an additional 1,000 in the military garrison, and considerable growth was anticipated with the development of the Rideau Canal. Local architect Thomas Rogers was engaged, plans developed, tenders for work awarded. However, work on the hospital was delayed by the tragic cholera epidemic of 1834 and competition for workmen from two other major local building projects, the Kingston Penitentiary and rebuilding of Fort Henry. In response to a request from government for a progress report, Dr. Sampson exhibits a rather cheeky eloquence in his December 1834 report:
“and first with respect to the ‘period in which it has existed’ we beg to remark that the establishment which was the object of the address presented to His Majesty by the House of Assembly last session, and in which His Excellency has been pleased to take a warm and very gratifying interest, cannot yet be said to ‘exist’.”
Nonetheless, work was finally completed in 1835, now 26 years after the initial request. Ms. Angus reports the following description from the Upper Canada Herald:
“The Kingston Hospital, which has been in the course of erection for almost two years, is now nearly completed. It presents a fine appearance. Eighty-nine feet four inches long fifty-three feet four inches wide, four stories high, rooms lofty and well ventilated: can accommodate about 120 patients. It has two fronts and is approached by a handsome flight of stone steps.”
Unfortunately, it was far from complete. The interiors had not been completed. It was unpainted, no baths or washrooms, no furnishing and large mounds of excavated earth had been left impeding access to the hospital. The funds provided were practically depleted (although not exceeded). The commissioners went back to government asking for an additional £500 pounds to finish the project. The request was initially denied, but was followed by a more direct petition to the legislature, which, in 1837, eventually provided the funds. By this time, that amount was inadequate due to damage that had occurred in the unused, unheated building.
Social problems now intervened and led to further delays. Rebellions were breaking out in Upper Canada and resources now had to be concentrated on military defense. Dr. Sampson, the chief commissioner and champion of the hospital, was appointed Chief Magistrate, in charge of organizing military patrols for protection and defense of the town. He was nonetheless able to eventually report on the hospital, explaining how the £500 pounds had been used to purchase beds and linen, as well as a large stove in the basement to heat the building. With the hospital now in reasonable working order, operating funds were required. He made a request for ongoing support of the hospital:
“(we) take this opportunity to state to Your Excellency, that they are not aware that any provision has yet been made to meet the expenses, which must unavoidably be increased in order to carry the benevolent intention of the Legislature, and private donors, into effective operation, and that without such provision the building must necessarily remain useless and the just expectations of the public disappointed, all of which is most respectfully submitted.”
By 1837, a building was in place, but lacked the ongoing support or organizational structure to function as a hospital. However, it didn’t go unused. Over the next several years, it was used intermittently as a military barracks. The first “patients” treated at the site were 20 wounded American soldiers captured in November 1838 at the Battle of the Windmill near Cornwall, two of whom died of their wounds (making our first case mortality rate 10%). In 1840, permission was granted by the Lieutenant Governor to lease the building to the Presbyterian community in Kingston for the housing of a theological college that would eventually become Queen’s University. Dr. Sampson who, in addition to his medical practice and responsibilities as hospital commissioner, was now serving as Mayor of Kingston and negotiated the lease. However, the Queen’s College Trustees, decided to decline the offer, finding the £150 pounds per year cost excessive. The first attempt to develop a working hospital-university partnership therefore failed miserably.
By 1841, Kingston had been selected as the site for the capital of the United Provinces of Upper and Lower Canada, and construction on parliament buildings on Ontario Street (currently our city hall) was underway. The hospital building, still empty, was available and selected to serve as the temporary accommodation of the legislature. This decision not only provided a source of income (£300 pounds per year), but also required the completion and expansion of building facilities. The interior was re-configured into two large rooms, for the House of Assembly and Legislative Council, as well as a number of smaller offices and a library. In addition, a number of government buildings and private homes were constructed nearby to accommodate services and officials.
Kingston remained capital only two years, but during that time the economy and population boomed, expanding even further the need for a hospital. By the time the capital was moved to Montreal in 1843, most patient care took place in private homes or boarding houses provided by the Ladies Benevolent Society, and was greatly aided by the arrival of the Religious Hospitalers of Saint Joseph who began to admit patients to their Brock Street facility (eventually Hotel Dieu Hospital) in 1845.
The building now needed to be re-converted to its original purpose. Dr. Sampson, having been re-elected as Mayor, was again instrumental in leading the charge to re-possess the building for the city and securing funding for the conversion, all of which took considerable legal and political activity. Finally, in 1845, the hospital commissioners and Ladies Benevolent Society formed a successful collaboration that resulted in the building finally being opened for the admission of patients. The following notice appeared in the Kingston Chronicle and Gazette on November 12, 1845:
“The Hospital for the use of the town of Kingston, under the superintendence of the Ladies of the Female Benevolent Society, is open in the building lately occupied by the Provincial Parliament and patients will, on the certificate of a medical man that they are proper recipients for public charity, be admitted on the order of one of the following ladies who have consented to act as Directresses of the Society.”
And so, the hospital initially conceived and petitioned for 39 years previously, began to admit those in need of medical care under the direction of local physicians and care of volunteer citizens.
The problems faced by our hospitals and providers today are certainly daunting, but no more so than those faced by our dedicated predecessors. They needed to make valid cases for resources despite competing societal needs, while simultaneously delivering the best care possible for those in need. Sound familiar? Doing so required ingenuity, patience, perception and the political savvy to take advantage of opportunities that arose, often in times of crisis. It also required forging strong collaborative links to community members and organizations with common values and goals.
With regard to the later, the recent move to amalgamate our hospitals seems a highly sensible and effective initiative. It’s again a little humbling to read the following excerpt from the Foreword to Ms. Angus’s book, written by Mr. Harvey L. Millman, President of the KGH Board of Governors in 1971:
“Today the Kingston General Hospital stands at the beginning of a new era. We are moving into closer association with the Hotel Dieu Hospital, St. Mary’s of the Lake Hospital, Kingston Psychiatric Hospital, Ongwanada Hospital, Queen’s University, and the St. Lawrence College of Applied Arts and Technology to form the Kingston Health Science Complex, an integrated system of health care delivery to meet today’s community needs.”
Forty-six years later, we find ourselves taking tentative steps toward realizing at least a portion of that grand vision. That shouldn’t be seen as an indictment, but rather encouragement that we’re on the right path. Sensible and worthy ideas usually find their way to full realization, not always when we think they should, but when concept and opportunity converge.
Examining the past can indeed counter our “hubris of the present”. It provides perspective, illuminates the future and keeps us humble.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Blogging on Blogs
I was initially a reluctant blogger. Perhaps even skeptical. The advice and impetus to proceed came largely from our trusty MedTech folks, particularly Matt Simpson and Lynel Jackson, with encouragement from Jacqueline Findlay and other UG office staff. They felt it was the best option to address my request (they might term it whining) for a means to communicate on a regular basis with our students and teaching faculty. I had in mind something more akin to a newsletter or mass email. I had no idea what a blog even was. With thinly veiled condescension, they explained that a blog would reach more people, allow for embedding of images, links to other material and, most importantly, allow people to respond.
Now, a hundred posts later, I must admit they were right. As I reflected on the milestone, I also came to realize I still didn’t know anything about the term “blog”, how they came about, or how extensively they’re used.
It seems blogs evolved from something called the online diary, publications wherein folks would give regular accounts of their personal lives. Many developed themes of personal interest with the added element of dialogue with readers. The term “online journal” appears to have emerged in the late 1990’s with Ian Ring prominent in promoting the concept of web-based publication of journals.
Most seem to agree, however, that the term “weblog” is rightfully attributed to Jorn Barger who applied it to his Robot Wisdom site in 1997. The term was later contracted to “blog” by Peter Merholz in 1999.
Mr. Barger (shown) sounds, and looks, like an iconoclast and free-thinker with eclectic interests. In his own words, he was hoping to find “an audience who might see the connections between (his) many interests”. His postings featured “a list of links each day shaped by his own interests in the arts and technology”, thus offering “a day-to-day log of his reading and intellectual pursuits”. Those intellectual pursuits include history, Internet technology, artificial intelligence and the writings of James Joyce.
The web-based accessibility and brevity of blogs makes them a highly effective means of communication. It was estimated in 2010 that 150 million blogs were being published regularly, read by 10% of the world population. What makes blogging possible for most are platforms such as WordPress, which, for a modest fee, provide a fairly user-friendly means to publish.
All this popularity comes, of course, with a huge caveat. Blogs are entirely self-published, unreviewed and unfiltered. They are the very personal musings of the author. All very appropriate in a society where freedom of expression is a valued right, and arguably not a problem in the hands of an informed readership. However, by putting the burden for validity solely in the hands of the author, the line between fact and opinion becomes blurred. By breaking down the barriers required to express ideas to the public, they may also contribute to a sense of permissiveness and thus erode any sense of self-regulation on the part of potential authors. Authors who have never published in a regulated environment may be unaware of any responsibility to verify facts or clarify when expressing personal opinions. Readers may stop caring about the difference.
With all this in mind, it seems blogs, or whatever evolves technologically from them, are here to stay; they can and do provide a great means to communicate widely. Despite all their drawbacks, I’m a big fan of the concept for two key reasons:
First and foremost, they work. They reach the intended audience, and far beyond. In my own case, I’m continually encouraged not only by those who choose to post responses, but even more by those who send private messages (not always in agreement, to be sure) or simply chat in the hallways about some issue or other that’s come under discussion. I’m particularly pleased by the thought and varied perspectives that emerge from our students on controversial topics that, I’m certain, would otherwise have been silent. I think this dialogue helps faculty and students, understand each other more clearly and forge therefore better solutions to the various problems that emerge.
Secondly, and this is my non-factual, biased view, open dialogue is healthy and even essential to any organization, and particularly one committed to education. The freedom to express individual ideas and free thought should always be encouraged, and that will require uncensored “buyer beware” media. Whether it’s dialogue in the Greek agora, pamphlets by folks like Thomas Paine and Benjamin Franklin or stump speeches of political revolutionaries, free and controversial perspectives must and will find their way to expression. It’s important that they do. Full exposure of all ideas and points of view is healthy, if sometimes disturbing. Blogs are simply our generation’s technological solution. We can rail about the lack of control and its potential impact but, in the end, freedom to express must trump any form of censorship and we must rely on the judgment and conscience of consumers.
And so, with this one hundredth post coming at the end of another year, let me, with uncensored sincerity; wish all our faculty and students very best wishes for the Christmas season, the New Year, and continuing open, healthy dialogue.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
After working so hard and achieving success, why are so many medical students depressed?
The first time David thought about becoming a doctor, he was 13 years old, in the eighth grade. He recalls that everyone thought it was a great idea. As a bright, naturally curious and diligent student with an outgoing personality, it seemed to his parents, teachers and friends a natural and entirely appropriate decision. All were supportive. In fact, they were enthusiastic. What loomed ahead, all came to realize, was the task negotiating the highly competitive medical school application process. For the next several years, this became a major focus of attention for David, his parents and teachers. The process was researched in some detail. Most decisions, from what courses to take, what recreational and volunteer activities to pursue, even vacation destinations, became framed, or at least influenced, by how it would impact David’s medical school aspirations. David committed himself to his goal. Adept in sciences and an avid learner, he achieved remarkable academic success through high school and his undergraduate degree program, all while accumulating an impressive portfolio of volunteer and other experiences designed to reflect his interest and commitment to public service and medicine in particular. He engaged the application process with vigour and strong support (including financial) from his parents. He was successful, getting accepted to medical school. He, his parents, his friends, were jubilant, and shared in his success. All, it seemed, was good and proper. All was as it should be.
David continued his academic success in his first year where the curriculum is largely about knowledge acquisition, a process with which he had become very comfortable. But the clinical aspects of medicine were troubling to him. He found that engaging patients and their illness distinctly uncomfortable, causing him to be nervous and anxious before, during and after each encounter. He found it difficult to deal with emotionally charged issues and, accustomed to engaging problems one at a time at his own pace, he found dealing with multiple simultaneous and urgent problems very difficult and stressful. This caused him to feel guilty and somewhat ashamed. As an aspiring doctor, shouldn’t all this come naturally to him? For the first time ever, he began to question his career choice. He greatly feared disappointing his parents and those who’ve supported him. To his peers, seemingly enjoying their medical school experience, questioning the benefit of being a medical student was incomprehensible. Not sure where to turn, he came to a faculty member to seek help.
What happened here, or perhaps more appropriately, what didn’t happen? Did David make a bad decision? Is he ill suited for a career in medicine, or simply adjusting to practical realities and challenges that are new to him?
In considering David’s dilemma, it’s helpful to consider the process that leads young people to make informed and, hopefully, durable career commitments. Fortunately, there’s an extensive and very interesting literature on this subject and considerable active investigation. Unfortunately, it’s largely in the realm of developmental psychology, an area in which most physicians are far from expert. “Career Theorists” abound, with various approaches and perspectives on the subject. I provide a list of representative articles below for those interested. There’s certainly much for us to learn that will help guide and support medical students struggling with career choice.
Career decision, it seems, is a developmental milestone that can only be achieved after an individual acquires and reconciles two key components; 1) knowledge of self, and, 2) knowledge of the world around them.
The first component, development of self-awareness, promotes independent thought and self-confidence. With those attributes comes the ability to make good decisions. Put another way, one can only make good decisions if they’re based on a full and honest understanding of one’s own attributes, interests and motivations. The term that’s been used for this process of personal development is “Individuation”, and has been attributed to the esteemed psychologist Carl Gustav Jung who describes it as follows:
“In general, it is the process by which individual beings are formed and differentiated (from other human beings); in particular, it is the development of the psychological individual as being distinct from the general, collective psychology”.
It is a progressive personal process that has no fixed schedule. It requires engagement of increasingly independent roles and challenges. It can be thought of as beginning the first time a child steps alone into a school bus for their first day of school and progresses through increasingly complex and increasingly independent life challenges. The challenge for parents, who must progressively relinquish control and security, is to allow these events to occur naturally, continuing to balance their desire to influence and guide while not inhibiting needed growth experiences.
Contemporary developmental theorists, notably David Kegan and Marcia Baxter Magolda, provide what might be considered a pragmatic perspective. They describe “Self-Authorship” as the ability to take charge of one’s own decisions, shifting from a developmental stage where we uncritically accept external authority to one where we consider information from multiple sources but ultimately make our own decision, achieving that they term “internal authority”. They argue (I think convincingly) that this is essential not only to personal well being, but to effective and responsible citizenship.
How does this happen? In simple terms (that even a non-psychologist would understand), self-authorship develops by engaging the world. This brings us to the second key component required for effective career decision making – learning. Baxter Magnola and others remind us that not all worldly experiences provide valuable learning experiences that will promote effective personal development. She describes three key foundations of effective learning. Cognitive maturity involves intellectual rigour, judgment and problem solving ability (what the medical world might term critical thinking). Integrated Identity refers to understanding of one’s own history, autonomy, connections and “place in the world”. Finally, the Interpersonal component involves the development of mature relationships, respect for self and others, expressed through effective collaboration. The point is made that the latter can only be achieved by engaging diversity during the critical developmental years.
These three foundations are essential to the development of independent and effective decision making. They also provide a very effective blueprint for the design of effective educational systems. From kindergarten to university, our teaching and learning should promote cognitive maturity, individual autonomy and engagement of mature, diverse and collaborative relationships with peers and the broader world.
The case of David (fictitious name) is provided because it is representative of many students caught up in the modern world of pragmatic, goal-oriented and often competitive career engagement, and raises a number of rather unsettling questions:
- Does the process that students must undertake to achieve success delay or inhibit the growth experiences necessary to achieve individual maturation?
- By vigorously supporting a child’s early ambitions, are parents and others inhibiting that child’s development and self-realization?
- Are our educational systems moving in the wrong direction, catering to targeted career development and placement rather than the development of personal attributes necessary to life success and effective citizenship?
In short, we must recognize that all these factors may result in students who come to full self-realization late in the game, after they’ve already engaged careers in which they (and those close to them) have invested considerable energy and resources. Change, or adaptation to new challenges, becomes very difficult, and they may feel trapped. But the failure to fully consider their true interests or the struggle to sublimate their interests in favour of what they feel is expected of them may have disastrous long-term consequences, and may, at least in part, underlie the recently publicized concerns regarding the physical and psychological health of medical students.
As medical educators and mentors of these vulnerable young people, at various and individual points along their developmental journey, it’s critical that we’re fully aware of their environment, pressures and needs. These considerations should both inform our admission processes and provide perspective to those counseling troubled students.
Admission processes should seek to identify students who’ve achieved the developmental characteristics that allow for a fully informed career decision.
When students like David struggle, we should suspect that their personal circumstances or the process they’ve undertaken to get accepted may have prevented them from achieving some critical developmental milestones. Identifying that deficiency, helping them complete their development, and exploring what aspects of medical practice might best suit their true strengths may well be the keys to both their success as a physician and personal wellness.
David is modeled on a former student. To allay your fears, he’s doing fine, now content and making effective contributions in a medical specialty where acute patient contact is minimal. That resolution only came about after a considerable period of reflection and engagement of very uncomfortable issues in his life.
As Dr. Rotenstein’s study points out, there are other Davids out there who need and deserve our understanding and support.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Baxter Magolda MB. Evolution of a Constructivist Conceptualization of Epistemological Reflection. Educational Psychologist 2004; 39: 31
Baxter Magolda MB. Three Elements of Self-Authorship. J of College Student Development 2008; 49: 269.
Earl JK, Bright JEH. Undergraduate Level, Age, Volume and Patternof Work as Predictors of Career Decision Status. Aust Journal of Psychology 2003; 55: 83.
Hodge DC, Baxter Magolda MB, Haynes CA. Engaged Learning: Enabling Self-Authorship and Effective Practice. Liberal Education 2009; 95(4).
Kegan R. In over our heads: the mental demands of modern life. Harvard University Press. Cambridge MA. 1994.
Super DE, Developmental Concept. https://www.careers.govt.nz/assets/pages/docs/career-theory-model-super.pdf
Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.
Was Plato being Pimped?
A medical student and attending physician arrange to meet near a nursing station to discuss a recently admitted patient the student has reviewed. The patient has presented earlier that day to the emergency department with a severe headache and visual disturbance. The student relates a description of the symptoms, past history and physical findings, after which the attending asks:
“So, what do you think is going on?”
“I think its migraine”.
“Really? Does the patient have any history of migraine?”
“Not that I’m aware.”
“Did you ask?”
“Is it common for someone to get their first migraine at age 70?”
“Is the patient on anticoagulants?”
“So what else might be in the differential?”
For the next 10 minutes or so they engage in a question and answer session regarding the findings and management plan. They develop a number of other possibilities and a diagnostic plan, which includes an urgent CT scan. At the end, the attending suggests the student reviews the features of both migraine headache and intracranial bleeding.
So, what just happened there?
It’s very likely that the attending physician and student left the encounter with vastly different impressions of what had transpired.
The attending physician likely feels they have provided a “teaching moment” in which some important issues of clinical management have been passed on to the student. They may feel they have left the student better prepared for having had this encounter, and may very well feel more confident in the ability of the student going forward. They likely leave feeling they have fulfilled their obligation as a teaching clinician. They may even feel they have engaged in a version of what’s been termed the Socratic method; a term used loosely to refer to a method of teaching that utilizes questioning as a means to promote learning.
The student involved in the interaction may feel differently. They will likely describe what they experienced as having been “pimped”.
Pimping, in this sense, isn’t referring to the practice of soliciting clients for prostitutes (a very unfortunate association). It refers, rather, to the practice of posing a series of increasingly difficult and obscure questions to a learner with the purpose of identifying knowledge deficiencies.
The term has a considerable history. A rather infamous 1989 JAMA article by Frederick Brancati1 provides a tongue-in-cheek review of the practice and is well worth reading. As he points out, the first known use of the term was by no less than the esteemed William Harvey who lamented in 1628 his students failure to understand his early theories about the circulation:
“They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped”.
Robert Koch, the prominent Dutch microbiologist of the mid nineteenth century recorded a series of “Pumpfrage” (pump questions) for use on ward rounds. Apparently William Osler was a master pimper. Abraham Flexner commented on his style after his 1916 visit to Johns Hopkins:
“Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping’. Delightful.”
It’s often done in the presence of others, and has the potential to leave the learner feeling embarrassed and, possibly, humiliated. It’s felt by many that the main purpose of pimping is not to impart learning, but to establish an operational hierarchy – to put the learner “in their place”. It’s been characterized by many as an initiation ritual.
Its value is, at best, debatable. Detsky2, reprising Brancato’s article, concludes “the purpose of pimping is to increase retention of the key teaching points by being provocative”. In a contemporary commentary Kost and Chen3 take a much more negative view and suggest the term be reserved for undesirable behaviours, specifically:
“questioning of a learner with the explicit intent to cause discomfort such as shame or humiliation as a means of maintaining the power hierarchy in medical education”.
Medical students bring helpful perspective to the issue. In an interesting study carried out by fourth year students at a midwestern American medical school4, a differentiation was drawn between “malignant” pimping, and that done “with good intentions”. To quote from their conclusions:
“At its best, pimping assesses students’ knowledge and skills, stimulates critical thinking, and encourages self-assessment. At its worst, the competitiveness that pimping generates may inhibit students from learning how to work as a team, and how to rely on each other.”
It also seems that medical students not only accept that they will be subjected to directed questioning in their clinical rotations, but have adapted mechanisms to “manage” these situations. Interestingly, that management is intended not only to optimize their learning, but also to project a positive image of their skills and teachability. To quote a student interviewed as part of this study by Lo and Reghr5:
“I think my goal is basically to come away from that session with the instructor thinking that I do know my stuff, I know my material. And even if I got some questions wrong, it’s okay, because in the greater context I have a good understanding of the subject.”
It would seem that directed questioning is certainly eliciting an adaptive response, but perhaps not entirely what was intended.
In Canada, about 57% of graduating students report have been “publicly embarrassed” and 29% report having been “publicly humiliated” at least once during medical school6. Although not explicitly stated, it’s reasonable to presume that the majority of these relate to episodes of pimping.
In a recent perspective, Soddard and O’Dell posit “the term ‘Socratic method’ has been so often misapplied that Socrates himself might not recognize the clinical education techniques that often bear his name.”7.
Socrates, prominent Greek philosopher of the fourth century BCE, believed his role as a teacher was not to simply deliver information, but to help his students develop their own methods of thinking and examining the world. In fact, it seems he seldom made statements of fact but, rather, provoked his students by posing a series of challenging questions, many of which had no clear answer, but required examination of their own assumptions and values. These “dialogues” subsequently recorded by Plato (his most famous student) were probably not comfortable experiences for his students who may have felt challenged, cross-examined, and perhaps even attacked. (Interesting to speculate what sort of teaching evaluations Socrates would get today). The opposite of the Socratic method is the Didactic, which entails the teacher delivering information with a minimum of student participation. It is certainly more comfortable for the student and simpler for the teacher, but fraught with limitations regarding the appropriateness of information provided, and benefit for the learner.
Moreover, it’s a long way from the Athenian agora to the wards and hallways of our teaching hospitals. It’s therefore more than a little presumptuous to refer to what we’re doing as Socratic teaching. However, perhaps the message for us is that there is great value and potential in questioning if questions are appropriately posed, and posed for the right purpose. We need to carefully consider what features differentiate effective questioning in clinical education from what students rightfully identify as “malignant pimping”.
- Why is the question being asked, and for whose benefit? The issue of intention is central and critical. Questions should be posed for one of two purposes: to advance the student’s understanding and comfort with clinical medicine or to ensure optimal patient care. The concept of “toughening up” students in preparation for perceived future abuses is archaic and never justifies, but potentially perpetuates, demeaning behaviour.
- Is the question reasonable and relevant? Does it relate to the clinical issue under discussion? Will the answer advance the student’s understanding or patient care? Does it really matter whose name is historically associated with pulsatile nailbeds?
- Is this the time and place? Questions asked in highly public places or with patients in attendance can be highly-charged for students, and are not rendered more educationally valuable by that added scrutiny.
- How well do you know the student? Within the context of a continuing relationship, a degree of trust develops between teacher and learner that allows the student to contextualize criticism and eventually demonstrate improvement. Brief, or one-time encounters, have no such trust, resulting in considerable vulnerability on the part of the student.
- Questioning in the workplace should be provided in the spirit of formative educational experiences. However, students may perceive they are being formally assessed through these questions.
Based on these considerations, I would not consider the exchange described at the beginning of this article to be an example of pimping, but rather directed questioning intended to both teach and ensure optimal patient care
To return to my initial question, was Plato being pimped? Given the definitions we’ve developed and what we understand of the Socratic approach, almost certainly not. But he was certainly being questioned, likely aggressively, but by a benevolent teacher intent on making him a better person and more accomplished philosopher.
Seems that turned out fairly well.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
- Brancato FL. The Art of Pimping. JAMA 1989; 262(1). 89.
- Destsky AS. The Art of Pimping. JAMA 2009; 301(13). 1379.
- Kost A, Chen FM. Socrates was not a Pimp: Changing the Paradigm of Questioning in Medical Education. Academic Medicine 2015; 90(1). 20.
- Wear D, Kokinova M, Keck-McNulty C, Aultman J. Pimping: Perspectives of 4th Year Medical Students. Teaching and Learning in Medicine 2005; 17(2). 184.
- Lo L, Regehr G. Medical Students Understanding of Directed Questioning by Their Clinical Preceptors. Teaching and Learning in Medicine 2016. (http://dx.doi.org/10.1080/10401134.2016.1213169)
- Canadian Graduation Survey National Report. Association of Faculties of Medicine of Canada. 2016.
- Stoddard HA, O’Dell DV. Would Socrates have Actually Used the “Socratic Method” for Clinical Teaching? J Gen Intern Med 2016; 31(9). 1092.
Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.
Lovable Losers no Longer: The remarkable (and instructive) transformation of the Chicago Cubs
The Chicago Cubs have won the World Series.
Let me say that again with appropriate emphasis – The CHICAGO CUBS have won the World Series!
After 108 years of comfortable, predictable mediocrity, the lovable losers are now simply lovable. For anyone with even a passing interest in
baseball, this is hard to fathom. There has been a disruption in the Force. The space-time continuum is in disarray. Dogs and cats will live together. Is there nothing we can count on? Could our grandparents have actually been right when they assured us that anything is possible if we just set our minds to the task?
As we reel in disbelief and attempt to reconstruct our personal realities, it’s instructive to examine how this came about. The Cubs, I would suggest, were successful for two reasons, and there are lessons in their story.
Firstly, they established highly competent leadership. Five years ago, they hired Theo Epstein, a 42 year old lawyer-turned-baseball executive, who had previously extricated the Boston Red Sox from their own seemingly endless 86 year exile in baseball purgatory. Epstein began by taking his entire front office on retreat and re-establishing a new culture, centred on regaining respectability and building on fundamental competence. He then put in place a five-year plan to achieve those goals. Everybody, I would suggest, bought into the plan. The approach he took is not unique to baseball or sports. In fact, it reads like John Kotter’s eight-step approach to change management.
For the plan to work, however, the leadership had to have the courage to challenge conventional wisdom, and bank on teamwork and human qualities rather than pure athletic skill.
Let me try to explain. There are two types of players in baseball – pitchers and everybody else. Success is so dependent on a team’s ability to prevent players from getting on base, that conventional wisdom holds that you build a team around pitching. Teams therefore covet pitchers like bears (or cubs) covet honey. They will stop at nothing to obtain them, whether it’s by drafting, trading or prowling the playing fields of Caribbean elementary schools. They will pay astronomical, rather obscene sums to retain their services. Convicted felons with sociopathic personalities, if blessed with a 98 mph fastball, can be embraced as innocent victims of an unforgiving society. I fear the day that a baseball executive discovers cloning technology and considers exhuming the remains of Sandy Koufax or Satchel Paige.
The prevailing concept is that if you prevent players from getting on base, you needn’t worry about the defensive aspects of the game. Concentrate on pitching and take your chances on all the other parts of the game, like catching and fielding. These are considered lesser skills and an opportunity to preserve budget. This approach is also tactically less demanding because, by concentrating on pitching, what should be a team sport becomes essentially a single player issue. Teams can stop trying to find nine skillful, committed athletes who need to work together, and instead concentrate their attention (and money) on securing that one key piece.
Except for the Cubs. The Cubs took quite a different approach in building the team that finally found success. They recognized that even the very best, most highly paid pitchers will inevitably falter some of the time. They also tend to unravel when things go wrong, and things tend to go wrong at the worst times when pressure is greatest like the playoffs. They also recognized that shoddy fielding turns small pitching mistakes into disasters. Moreover, they seem to recognize that fielding requires more than requisite physical skills. It takes a strong and resilient personality to perform at peak efficiency if the opportunities to do so are infrequent and interspersed with long periods of inactivity and tedium. (Parallels to a few medical specialties come to mind.) They therefore emphasized and valued all aspects of the game, and searched for position players with skill and dedication to team play. In doing so, they took some unusual steps.
They searched diligently for the best defensive players available. In fact, they were quite exacting, seeking out very specific skills. Epstein describes one of their recruits, Javier Baez, as “the best tagger in baseball”.
They prioritized defensive play in their coaching, hiring no fewer than nine coaches, including a “Run Prevention Coordinator”.
They devoted time and resources to scouting opposing teams hitting tendencies to better position and prepare their players to defend against hits.
Most importantly, they were able to identify and recruit players who bought into the plan and understood their role in it. They supported and valued those players.
In doing all this, they developed a resilient, mutually supportive team, remarkably free of the high-priced prima donnas that can be so disruptive, and eventually falter.
Make no mistake, I would have preferred a Blue Jays victory, but the Cubs are a great consolation prize. They provide inspiration and instruction for us all. They illustrate how leadership and teamwork are not mutually exclusive. Effective leadership begets teamwork. Without good leadership, there is no team. And that holds whether it’s baseball, government, academic groups or health care.
Leadership and teamwork: interdependent, indispensible keys to success.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
“You don’t know what you got ‘til it’s gone”
(from “Big Yellow Taxi” by Joni Mitchell)
Joni Mitchell’s melancholy lyrics remind us of how easy it can be to take for granted those people around us who we get to know and who enrich our lives in so many ways. Even when we know that their remaining time with us is limited, we’re never really prepared, and the sense of loss is real when the end finally comes.
We’ve recently experienced two such losses at our school. Dr. Ron Wigle was a skilled clinician, committed teacher and mentor to a generation of students, many of whom continued to benefit from his gentle wisdom and humour up to the time of his passing. Moreover, he was a truly special person who had a remarkable ability to connect with people, breaking through all the barriers and pretensions that we often allow to get in the way of real understanding.
Karen Nicole Smith didn’t allow her chronic health issues to prevent her from making valuable contributions to our school and hospital. In fact, her determination to make a difference and find meaning in her own struggles made her contributions all the more valuable and remarkable. Kate Slagle, Manager of our Standardized Patient Program, worked closely with Karen Nicole, and provides the following tribute:
Living close to death empowered Karen Nicole Smith to embrace LIFE. She not only embraced life but chose to celebrate it and shared her powerful experiences with others as a Patient Experience Advisor. Sadly, Karen Nicole passed away on Sunday October 16, 2016 in her home on her own terms.
At the age of 18 Karen Nicole was diagnosed with chronic kidney disease. In 1996 she received a kidney transplant which ultimately failed in 2009. Since then she had been independently completing home hemodialysis. Her chronic kidney disease left her body susceptible and at the age of 39 she went into cardiac arrest and nearly died. After her cardiac arrest Karen Nicole made the conscious decision to take control through “active living”. She worked with teams of medical and non-medical professionals to stabilize and regain her health. In December of 2015 Karen Nicole was diagnosed with angiosarcoma, a rare form of heart cancer which was removed during an emergency open heart surgery. A few months ago Karen Nicole’s cancer returned. Karen Nicole knew her time was coming to an end and made the conscious decision to stop dialysis and pass away peacefully at home.
Take 2 minutes to meet Karen Nicole by watching her “Hello” video: http://youtu.be/hwuW2Oww9sE
Karen Nicole was widely known throughout the Kingston community for her a work as a Patient Experience Advisor at Kingston General Hospital and role of Trainer and Community Outreach Consultant for the Queen’s Standardized Patient & OSCE Program. Karen Nicole was an advocate for those living with chronic illness and shared her messages on a larger scale as a distinguished public speaker, writer and blogger. She knew that “sharing her opinion was helpful no matter how difficult the topic.” In 2016 Karen Nicole made contributions to Reader’s Digest, The Heart Failure Report, Health Quality Ontario and may more publications. She traveled across the country passionately speaking about the patient perspective in palliative care, organ and tissue donation, chronic illness, independent dialysis, cardiac rehabilitation and physical & mental barriers to exercise.
Karen Nicole knew her journey had purpose. Instead of focusing on illness she focused on LIFE and dedicated her work to improving the lives of others living with chronic illnesses. Her messages of active living, patient centered care and hope will continue to resonate with all those who had the privilege of knowing Karen Nicole. In honor of Karen Nicole we can each do our part to help her legacy live on by being an advocate for our health and choosing to live life to its fullest.
Recent Media Contributions:
Living Well with Heart Failure (Reader’s Digest 2016): Outlines Karen Nicole’s journey of active living following her cardiac arrest.
Quote: “One of the most important things I learned is that you can be a person with chronic illness and still be quite healthy and active.”
Living Life Honestly (Queen’s Gazette 2016): Karen Nicole’s perspective on the delivery of bad news and advice for those living with chronic illness to become their “own best advocate”.
Quote: “The conversation does not have to go perfectly. The communication just has to be real.”
The Journey to Heart Failure (Heart Failure Report 2016): Karen Nicole’s message of hope following her cardiac arrest.
Quote: “There is hope. There are places to go for support. You can rebuild your life.”
Palliative Care at the End of Life (Health Quality Ontario 2016): Karen Nicole’s honest thoughts regarding end of life care and death.
Quote: “I’d put my hospital bed right here, with sunlight coming in, and I’d get to pass with dignity and in comfort, with help in my own home. At times that has been my comfort, my solace.”
Kingston Woman Choosing Unassisted Death (Kingston Whig 2016): Karen Nicole’s decision to stop dialysis and her plan to pass away on her own terms.
Quote: “I’m just hoping that the right people will read this. And they will change their minds or think differently about someone they’re taking care of. I hope it will touch lives then can makes things better.”
To Find Out More Visit Karen Nicole’s Website: https://karennicolesmith.wordpress.com/
Two gifted, generous people who who were willing to share their energy and time with us. We’re all the better for it.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Entrustment in Medical Education – a distinctly human challenge.
It’s two o’clock in the morning. The phone rings, waking the on-call attending physician from what had been a sound sleep. A resident is calling to review a case she has been asked to evaluate in the emergency department. She feels the patient has stabilized and can be sent home with arrangements for outpatient follow-up, but must “clear” that decision with her supervising physician.
The resident, a qualified physician having graduated from a fully accredited medical school over two years ago, is now in the third year of specialty training. The attending physician has only a casual acquaintance with this particular resident, never having worked directly with her before, but is aware that she is generally considered to be very capable and reliable.
The patient’s presenting problem is neither unusual nor particularly complex. The information provided is complete. The attending physician asks a couple of further questions that are competently answered. Finally the attending asks, “so are you comfortable sending this person home, or would you like me to come in to review him with you?” The resident confirms that she is satisfied with the decision and doesn’t see a need for further review. They hang up. Both go back to bed. The attending physician may or may not get back to sleep.
This scenario, played out countless times in countless variations every day in teaching hospitals, illustrates the concept of entrustment. For entrustment to occur, the essential operative driver is trust.
Many definitions of trust are available, but the one that I think best captures the key elements relevant to the clinical setting is provided by Mayer et al (Acad Manag Rev 1995;20:709):
“The willingness of a party to be vulnerable to the actions of another party based on the expectation that the other will perform a particular action important to the trustor, irrespective of the ability to monitor or control that other party.”
So how does this occur? What allows the attending physician to accept “vulnerability” and trust in the judgment of the resident sufficiently to agree to a plan of action without personal verification? What, for that matter, allows any person to trust another?
There has been much written on this topic, dating back to ancient philosophy. Trusting, it seems, is a rather complex, distinctly human and highly personal interaction. It requires a relationship between the person who grants the trust (the trustor) and the one who is trusted (the trustee). The vulnerability that the trustor accepts is based a number of assumptions, but principally their assessment of two key attributes of the trustee: their capability, and their motivation to do the right thing. The whole matter is further complicated by the fact that trust is usually contextual, but may become unconditional. We begin by trusting a specific person within the limits of a certain task or scope of responsibility. We may, with continued experience and appropriate reinforcement, extrapolate and extend that sphere of trust. To do so, the trustor is required to judge broader attributes of the trustee, which will determine their willingness to extend trust further, to more complex situations.
In medical education, this is no abstract or purely philosophical issue. As illustrated by the scenario above, the concept of endowed trust has been, and continues to be, central to the provision of competent, safe care in our clinical teaching centres. In fact, it’s becoming increasingly complex in settings where the interaction between supervising physicians and trainees is more sporadic and truncated (as illustrated above), and where the sheer volume of cases requires efficient decision making. The concept of admitting patients to hospital for “observation” has become a thing of the past.
Moreover, as we move toward the concepts of Entrustable Professional Activities and Competency Based Assessment, our medical schools will be grappling with the challenge of developing methods by which these “entrustment decisions” can be made objectively within our increasingly busy and hectic workplaces.
This was the topic of a recent webinar provided by the Office of Faculty Development and featuring Dr. Olle ten Cate, widely regarded as the originator and major proponent of EPAs in medical education. Among the many insights he provided was a consideration of the key elements that should inform an entrustment decision. It begins with simple ability, which consists largely of knowledge and technical skills. Ability is relatively easy to observe and assess in brief encounters. It’s also fairly straightforward to simulate encounters so they can be practiced or tested, as with OSCEs. However, entrustment also involves a number of key elements that are much more complex and difficult to objectively assess, including integrity (truthfulness, honesty), reliability (consistency) and humility (awareness of limitations). These latter attributes defy objective quantification, can’t be reliably assessed in a single encounter, and are very difficult to simulate for practice or examination purposes. They require longitudinal observation, in a variety of clinical situations, carried out by appropriately oriented and consistent observers. They require, in fact, a continuing relationship between teacher and learner.
And so, to borrow a phrase from Hamlet, “there’s the rub”. Those continuing relationships, so essential to the development of trust, are notoriously difficult to establish in our current clinical clerkships and residency training programs, where teachers and learners collide almost randomly, de-linked by separate and independent schedules. What’s more, when they do come together, the number of learners, clinical volumes and primacy to expedite patient care makes it even more difficult to establish effective relationships. Paradoxically, the long abandoned apprenticeships and long, service-based clinical placements were, in some ways, much more suited to establishing the continuing workplace relationships that allowed this longitudinal, more holistic approach to assessment and entrustment decisions.
And so, what to do? We certainly can’t and shouldn’t attempt to turn back the clock. But can we learn from prior experience to develop a clinical workplace that better promotes more effective teacher-learner coordination, and therefore more valid entrustment decisions? Obviously there are no easy fixes, but a few observations are offered that may have some relevance:
Maximizing continuing contact between teacher-preceptors and learners is key. Coordination of assignments and call schedules is logistically challenging and would require coordination of multiple, currently siloed administrations, but would be well worth the effort, and should perhaps be seen as a priority and strategic direction for undergraduate and postgraduate programs. Integrated, community- based programs provide an environment much more conducive to establishing effective entrustment decisions. In this regard, Family Medicine programs are leading the way and may provide valuable guidance. Social programs and team building exercises involving trainees and faculty members, once a common component of training programs, may play a prominent role in building effective working relationships. We are, quite simply, more likely to trust people we know personally. Finally, it might well be time to reconsider the role of attending physician, and the assumption that the same individual can simultaneously manage a busy clinical service and provide effective educational supervision.
Clarity with respect to the scope of entrustment for each individual learner will facilitate decisions. In other words, teachers and learners need to be “on the same page” with regard to expectations. Dr. ten Cate refers to a “zone of proximal development” as the difference between what the learner has already mastered and the next level of proficiency. It’s important for both parties to not only understand the task for which entrustment is provided, but the level of proficiency or degree of resolution with respect to that task. This, of course, gets back to the issue of relationship and need for a greater level of understanding between trustor and trustee. It involves better communication regarding individual learner needs, and more targeted faculty development.
Transmission of learner information between programs is essential. We need to come to grips with our collective paranoia about “forward feeding” and develop effective means to get relevant and useful information about individual learner needs, goals and teaching requirements to the right people. Both learners and faculty must appreciate that the goal is to enhance the educational experience, not prejudice decisions. In this regard, the soon to be released Learner Handover Project initiated through the Future of Medical Education in Canada initiative and chaired by Dr. Leslie Nickell will provide a valuable contribution.
The concept of entrustment means we will occasionally (hopefully rarely) be required to say someone is not yet ready to take on a particular task, or advance within a program. We must be willing to engage these situations objectively and constructively. The development of key abilities essential to any discipline requires time, practice and immersion in the appropriate training environment. However, the attributes of integrity, reliability and humility can (and should) be identified early in the educational process. This provides an appropriate “division of labour” between undergraduate and postgraduate programs. Undergraduate programs, in addition to focusing on the development of appropriate foundational knowledge and skills, should ensure they are admitting and graduating individuals with the appropriate personal attributes to engage any field of medical practice. Postgraduate programs should be able to assume the individuals entering their programs are worthy of entrustment, and can concentrate on the development of discipline specific expertise.
Stephen R. Covey, the late educator and author of “The Seven Habits of Highly Effective People” describes trust as “the glue of life…the most essential ingredient in effective communication…the foundational principle that holds all relationships”. In the end, trust is about people, effective working relationships and open communication. Our challenge is to find ways to ensure this uniquely human, essential ingredient can develop and flourish despite the challenges of our increasingly complex and stressed clinical learning environments.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Recognizing our Course Directors
“The People Who Make Organizations Go – or Stop” was the intriguing title of an article that appeared in the Harvard Business Review in 2002, authored by management experts Rob Cross and Laurence Prusak. In it, they describe the key people and largely informal networks that are necessary to the functioning of any organization, regardless of its purpose or product. They make the point that the success or failure of organizations can usually be attributed to the effectiveness of a group of key people they refer to as “central connectors”. In their own words:
“In most cases, the central connectors are not the formally designated go-to people in the unit. For instance, the information flow… at a large technology consulting company we worked with depended almost entirely on five midlevel managers. They would, for instance, give their colleagues background information about key clients or offer ideas on new technologies that could be employed in a given project. These managers handled most technical questions themselves, and when they couldn’t, they guided their colleagues to someone else in the informal network—regardless of functional area—who had the relevant expertise. Each of these central connectors spent an hour or more every day helping the other 108 people in the group. But while their colleagues readily acknowledged the connectors’ importance, their efforts were not recognized, let alone rewarded, by the company. “
In a medical school, these critical central connectors are called Course Directors. They are the folks with the practical knowledge, functional relationships and, importantly, “street cred” required to translate the high level educational goals of our program into the multiple packets (courses) of education that, in aggregate, will come together to produce the fully formed graduate, ready for residency and great things beyond. Their job is basically to take a subset of the overall program objectives that are assigned to them by the Curriculum Committee, and develop the multiple components of teaching and assessment designed to ensure our students achieve the objectives. In doing so, they must engage and coordinate the efforts of their professional colleagues, other members of the educational community, educational specialists and our administrative support staff. By effectively orchestrating all these efforts, guided by the “score” provided by the curricular framework, they develop an effective and coordinated educational experience for our students. They are truly “connectors” as described by Cross and Prusak. They are absolutely indispensible to the success of the program.
Last week, we recognized the contributions of four of our Course Directors who are moving on from those roles, three of whom are retiring. Fittingly, students, representing those who had benefited so greatly from the efforts and dedication of these remarkable people, provided the tributes. In their words:
Elisabeth Merner, Meds 2019, speaking on behalf of Dr. Jennifer MacKenzie:
It’s a pleasure to thank Dr. Mackenzie for all of her work as the inaugural Co-Director of the QuARMS program on behalf of the QuARMS students.
Most people have heard of the QuARMS program, but very few people understand the QuARMS vision as well as you do, Dr. Mackenzie. From the very beginning of the program, you helped to deepen students’ understanding of the role of the physician, the qualities of a leader in the medical community, and the values and ethics that are to be upheld in medicine.
For some, it would be daunting to teach these topics to a group of teenagers, but you were more than ready for the challenge. Your passion for education and innovation has been clear to all of us. We appreciate the fact that you attended every single three hour Wednesday session for the first two years of the QuARMS program. Honestly, with young adults of your own, we would have understood if you claimed that you had administrative duties to perform and missed out on one or two of the sessions – but you were there, leading by example.
We also recognize your role in designing the QuARMS curriculum, which is unlike any other program in Canada. Through service-learning projects, you helped students to understand the importance of social accountability within the medical profession. You also led a transformation in how students think about volunteer work. Your vision and your values have shaped the QuARMS program. Thanks to you, service-learning projects have now become a much more important part of our medical school here at Queen’s.
On behalf of four generations of QuARMS students, we want to thank you, Dr. Mackenzie, for your tireless dedication to the development of the QuARMS program and to shaping our lives, both as future professionals and as mature students.”
Jeff Mah, Meds 2019, speaking on behalf of Dr. Conrad Reifel,
Let me start off by saying, anatomy is one of the most overwhelming topics in medicine. From head to toe, there is a seemingly endless number of muscles, bones, nerves, blood vessels and organs that each serve a specific purpose and thus need to be learned. Needless to say, without a good teacher, this subject can be very difficult to master.
At Queen’s, we have been extremely fortunate to have had Dr. Conrad Reifel as an anatomy instructor for the last 43 years. Over his time here, Dr. Reifel has guided thousands of medical students through the vast, unfamiliar world of gross anatomy and has done so with patience and commitment. What I always appreciated about Dr. Reifel was his ability to take an area of the body that is incredibly complex and systematically break it down so that by the time he finished talking, it seemed quite manageable.
Dr. Reifel also has a fantastic ability to keep a class engaged even when teaching a somewhat dry topic with his unique sense of humour and vast repertoire of personal anecdotes. I’ll never forget Dr. Reifel, standing at the front of the class with his arms outstretched using his own body to demonstrate the anatomy of the uterus. While the memory of that lecture does conjure up some odd images, I’ve never had trouble visualizing the uterine anatomy since then.
Dr. Reifel, on behalf of the medical students of Queen’s University, past and present, thank you for the decades of excellent instruction. Please know that you are respected and loved by the students you have taught and have positively impacted the lives of so many. You will be truly missed and we wish you all the best in your retirement.
Calvin Santiago, Meds 2018, speaking on behalf of Dr. Lewis Tomalty
Dr Tomalty has been teaching in the Mechanisms of Disease course since 2010 and took over as Course Director in 2012. In this role, Dr. Tomalty worked tirelessly to make improvements to the course. He attended all the MoD lectures and met weekly with the class curricular reps. He set up consultations with students and faculty, organized a strategic planning curricular retreat and established a framework to link together a diverse range of subjects including pathology, immunology, microbiology and infectious disease.
In addition to his role as Course Director for the Mechanisms of Disease Course, Dr. Tomalty also previously served as Vice Dean of Medical Education for the Faculty of Health Sciences and is the current Chair of the Course and Faculty Review Committee. As well, Dr. Tomalty is heavily involved in global health initiatives and provides his consultation services on infection control in Mongolia.
On a more personal note, and speaking on behalf of the many students who have had the privilege of knowing him over the years, I have found him to be an absolute pleasure to work with. Even in his last year as the Course Director, he still met with the curricular reps on a weekly basis to discuss ways to fine-tune an already well-received course. I know from their stories that they looked forward to these meetings with Dr. Tomalty, calling it their weekly “T-Time”. To quote another student, he is the “bestest, most efficient chair of a meeting ever.” I look to him as an exemplary role model of a leader and educator and as an inspiration for stylishly funky socks.
Dr. Tomalty, thank you so much for your leadership as Course Director and I wish you all the best in your future endeavours.
Kate Rath-Wilson, Meds 2019, speaking on behalf of Dr. Chris Ward
Dr. Chris Ward was one of the inaugural course directors for our new curriculum when it was introduced in 2009, and was responsible for developing and consistently aiming to improve the Normal Human Function course in Term 1. He has coordinated multiple faculty members, built a strong curriculum for the course, been part of the initiative to bring in Drs Moffatt and Parker to apply physiology to cases (which has added immeasurably to our learning), and helped to build introductory physiology modules for students struggling with physiology. This led him to be asked to join many, many, many UGME committees, including (but not limited to) the Curriculum Committee, The Teaching, Learning and Innovation Committee, and the Student Assessment Committee – currently, Dr. Gibson believes this to be a record for any one course director. He was instrumental in preparing our brief for the CACMS/LCME accreditation, reviewing all the sections that pertained to foundational science and its impact across the curriculum. Dr. Ward is known at Curriculum Committee for being the person to move that the meeting be adjourned! It started with only a few times, but now we look to him for this and he’s become everyone’s favourite motion-maker!
As a medical student, I have not had much of a chance to get to know Dr. Ward personally. His name will always be associated with hypovolemic shock for me – which some may deem as unfortunate but I think is one of the highest honours a teacher can be granted. He elucidated complex cardiac physics with clarity and patience, and acted as a model to the other professors in his course. He expertly managed a complex course, juggling the schedules of many faculty members and even more stressed out A-type students.
Dr. Ward has worked tirelessly behind the scenes to build our medical curriculum from the bottom up. This is a position that often lacks glory and recognition. We owe Dr. Ward a lifetime’s worth of thanks. The positive impact he has had as director of the Normal Human Function course on his colleagues and his students is immeasurable, and we thank him today for his contributions to the foundational medical knowledge of hundreds of medical students and wish him all the best for his future work.
Let me add my thanks and personal appreciation to those of our students. I’d also like to acknowledge the ongoing efforts of all our Course Directors, who carry out their roles so effectively and provide those key “central connections” so essential to our program.
All photographs by Lars Hagberg
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Apparently we have a Doctor crisis. Certainly that’s the impression one would gain from articles, columns and letters commenting on the recent impasse between the government and doctors of Ontario. It’s also the impression that many medical students have been left with after the decisive defeat this summer of the draft Physician Service Agreement developed and endorsed by the Ministry of Health and Ontario Medical Association.
The OMA not only represents all Ontario physicians, but also includes in its voting membership all students enrolled at Ontario’s six medical schools. Those students, who were very much involved and rigorously lobbied by both sides in this debate, have now returned to their studies considerably more uncertain about how physicians and government interact, about how physicians function within the health delivery system, and about their personal futures as physicians in this province. I think it’s also fair to say they’re a little dismayed by the tactics and rhetoric on display through the lead up to the vote. Simply put, they seem a little shell-shocked about what they’ve seen and heard. They’re asking “what happened?”
In medical school, we try to teach students to always look beyond the surface and to identify root causes in understanding any patient illness and developing treatment decisions. A cough, we teach, can be easily suppressed, but failure to consider sinister underlying causes such as obstructive masses can be a disservice to the affected patient.
It’s certainly easy and perhaps tempting to characterize the dispute as a labour issue about fair compensation for service provided. However, the roots of this dispute are much deeper and it’s becoming clear that failure to understand and engage those underlying issues will both compromise resolution and render any settlement incomplete and therefore only a transient respite. With that in mind, I offer a few considerations:
Issue 1: The Blank Cheque
As Canadian citizens, we have high expectations with respect to the provision of health care. We (and let’s remember that doctors are consumers of health care as well as providers) have come to expect health care that is comprehensive and available whenever, wherever we require it. In fact, such an expectation has become an unassailable right of citizenship, as deeply rooted in the Canadian persona as hockey and maple syrup.
It’s been in place in various forms for several decades, but came to full fruition with the passing of the Canada Health Act in 1984, which states in its preamble the primary objective: “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”
And who can, or would, argue with the “rightness” of universal health care? We take care of our people, from birth to grave. We share resources for the benefit of all. We will permit no one to suffer for want of personal resources. Truly, these are worthy and appropriate goals of any “just society”.
However, by codifying these principles, our governments have issued what is basically a blank cheque, without limits in time or scope. The challenge, of course, is that much has changed with respect to what is encompassed by the concept of “universal” health care, and the draw on that blank cheque is growing beyond available resources. Not only is the population getting larger and older, but highly-effective (and highly resource intensive) therapies have emerged and are continuing to emerge for the treatment of conditions that previously had no options other than palliation. To name a couple from the field of cardiology, transcutaneous approaches to critical valve conditions have opened therapeutic options for patients who would otherwise be too ill or weak to tolerate standard surgical approaches. Implantable defibrillators reduce risk of catastrophic cardiac arrhythmias in patients with severely damaged hearts. These approaches are well tested and effective, improving quality and length of life in certain patients. However, they come at considerable cost, both in terms of hospital resources, training of personnel, and the devices themselves, which can run tens of thousands of dollars each.
In addition, the pharmaceutical industry has developed a variety of medicinal treatments for chronic debilitating conditions such as arthritis and chronic inflammatory conditions, powerful antibiotics for drug resistant organisms, and chemotherapeutic agents effective for otherwise terminal cancers.
As a result of all this, the commitment so nobly envisioned by our political leaders several decades ago to provide basic health coverage to all, has grown beyond what anyone could have imagined at that time. The “blank cheque” has become due, and our elected officials struggle to honour the commitment of their predecessors.
Issue 2: The Mandate of our Elected Governments.
Governments struggle to maintain the promise of universal care while attending to their other societal obligations (education, infrastructure, security, to name a few), and all while under pressure to maintain financial solvency and a vigorous economy. In fact, our governments are elected and maintained in office substantially on their ability to deliver on the universal health care promise. One can only admire the dedication of individuals willing to take on such positions of public responsibility and scrutiny. They certainly devote considerable resources to health care. In fact, Canadian governments collectively spend more on health care than most other western countries.
To make matters worse, the system is crying out for even more investment. Hospitals, their single greatest expense item, have already been cut to the bone and are now over-extended with much evidence of strain, and rightfully petition for expanded support. Home care services, so valuable to both patients in need and to hospitals in need of acute care beds, are inadequate to the demand and require drastic expansion. There is a growing pressure on government to support pharmaceuticals for all citizens, a position recently championed by the Canadian Medical Association.
There are limited, acceptable sources of new funding. There have been scattered attempts to limit their scope of responsibility to “medically necessary” therapies, but consider the public response when new, expensive but untested therapies emerge and provide hope for previously untreatable conditions, or when an Ontario citizen must seek out therapy out of province or at great personal expense. Surcharges for services were abandoned many years ago, and it’s difficult to imagine a government surviving any attempt to re-introduce them. There may well be opportunities for savings within the administration of the system and provision of redundant services that could and should be explored, but that potential certainly hasn’t been clarified, at least publicly through the current debate.
In the midst of all these demands and their “blank cheque” mandate, government turns to physician payments for financial relief. These payments, in Ontario, apparently constitute about 20% of health care expenditures (second after hospitals) and seem to provide a politically acceptable target. The unavoidable, and very unfortunate, implication in this approach is that physicians are, at least in part, a cause of the financial problem.
Issue 3: The Doctors
Much has changed about doctors since the concept of universal health care was introduced so many years ago. In the past, doctors were a much more homogeneous group. A doctor’s job and role within the community, was to care for a group of patients who engaged them. They provided continuing, comprehensive and lifelong care to those patients. They were also independent business people who were paid by their patients for the services they provided. With the advent of socialized medicine, the payment shifted from the patient to a third party (i.e. government), but doctors remained responsible for their own expenses and income, and payment continued to be on the basis of services provided. In Ontario, Bill 94, passed in 1986 despite much opposition, effectively eliminated any physician billing outside the accepted list of publicly funded services. That fee schedule, initially consisting of direct patient encounters and assessments, has been drastically expanded over the years as new diagnostic and therapeutic procedures have been introduced. Those components, usually limited to highly- specialized groups, have become the most lucrative fees and greatest overall expenses. The fee schedule now very much favours specialized procedural work over direct or continuing patient contact.
The flaws of the fee schedule are well described and have been acknowledged by all parties. It favours and promotes brief, procedurally based approaches to both diagnostics and therapeutics, and is internally divisive. Moreover, it effectively re-defines the role and expectations of practicing physicians, shifting the emphasis from continuing, comprehensive care, to sporadic, as-required interventions. All acknowledge it needs massive revision. Most recognize that nibbling at the edges by reducing specific fees is neither fair nor adequate, but even those “nibbles” evoke highly defensive responses, which surely mute willingness to engage more comprehensive approaches.
Following the expanding knowledge and growing need for specialized technical expertise, the medical profession itself has changed dramatically over the past several decades. Doctors have become highly specialized and many specialties, such as Cardiology have further divided into sub-specialties and even sub-sub-specialties. The training system is such that more technical specialization requires greater length of time, so doctors emerge from their training and engage practice often with considerable personal debt, and much older than other members of society beginning their careers.
The heterogeneity relates not only to specialty, but also practice type. Increasing numbers of physicians are moving away from the private, business/practice model and opting to work in health care groups or capitation (alternative funding) arrangements, which means that the results of PSA negotiations may have very different impacts on them. All this begs a very large and contentious question. Can a single negotiating organization continue to effectively represent the interests of so many disparate physicians? The emergence of so many splinter organizations in recent years, and the development of a coalition specifically to challenge the PSA at least challenges that notion.
Whatever their specialty or area of activity, doctors work long and irregular hours at considerable personal sacrifice, and have jobs that carry considerable levels of personal responsibility and public scrutiny. Although it would be naïve to imagine that the system is completely free of misconduct or abuse, the vast majority of doctors wish to apply the skills they’ve acquired at much effort and personal sacrifice to the service of patients who can benefit, are supportive of the principles of universal care noted above, and are content to work within the parameters of an established, fair compensation system. They would like that system to provide them reasonable compensation. They would like to be truly involved in its development. They would like to be acknowledged as part of the solution rather than the cause of the problems.
Summarizing: The Real Issues and Tough Questions.
My own view is that the reason so many physicians voted “no” in the recent ratification vote has less to do with the dollars involved, and much more with frustration over the inadequacy of the approach exhibited by both sides to the profound issues at stake. Accepting the proposed compromise without a commitment to real reform and a real role in that reform is facile and simply postpones the hard work we all know is required.
Squabbling over whether the global physician payment envelope should increase or decrease by a few percentage points will not address the real issues, and will only reset the clock until the next inevitable confrontation. Government and physicians must work together to discuss and seriously engage the underlying key issues, and the public must be actively involved in those conversations.
The issues are profound and fundamental to our national identity. What is the current day meaning of ”to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers”? It seems clear that fulfilling that commitment in our current funding model is not sustainable. Certainly efficiencies should be pursued and wastage eliminated, but the underlying commitment, the funding model, or possibly both, must change. Our choice is not whether they will change, our choice is how that change will occur.
Having our government, charged with public trust to ensure delivery of health care, at loggerheads with our doctors, so critical to the provision of that care, is both perverse and destructive. The relationship needs to improve, and the dialogue needs to elevate above superficial issues of compensation. To do so, both government and doctors must submit to an element of risk. In engaging the difficult but core issues, government risks public disapproval. Doctors risk their income and security. In essence, both parties must put something “on the line” if effective discussion is to be engaged. If both are truly focused primarily on the welfare of our patients and citizens, these should be risks both parties are willing to undertake.
We have a crisis, to be sure, but it’s not a doctor crisis – it’s a system crisis, and any solution that fails to recognize and engage all its dimensions will only provide a stop gap measure, deferring to the next “crisis”. As all patients and doctors are well aware, effective therapies often require short-term pain for long-term benefit. At some point, that pain must be engaged. If not now, then when?
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
To explore issues related to the recent physician/government impasses, the Aesculapian Society and Undergraduate Medical Program are jointly sponsoring a symposium on September 20th at 6:00 pm in the School of Medicine Building. A panel of speakers with various perspectives on this issue will be providing their insights, followed by a Question and Answer session. All students are invited to attend.