Doctor Crisis?

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)
Associate Dean,
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.

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Welcoming Queen’s Meds 2020

September brings a crisp freshness in the morning air and, with it, anticipation for the beginning of a new academic year. In the university environment, it also brings renewal and the excitement that goes with welcoming a new group of students to our schools. This week we welcome members of Meds 2020, the 162nd class to enter the study of Medicine at Queen’s since the school opened its doors in 1854.

Photography by Lars Hagberg
Photography by Lars Hagberg

A few facts about our new colleagues:

They were selected from a pool of 4518 highly qualified students who submitted applications last fall.

Their average age is 24 with a range of 19 to 36 years.  Women comprise sixty-two percent of the class, the largest proportion in the history of our school.

They hail from no fewer than 41 communities across Canada, including; Ajax(2), Aurora(1), Brampton(4), Calgary(4), Dawson Creek(1), Edmonton(3), Etobicoke(1), Guelph(1), Halifax(2), Hamilton(3), Kanata(1), Kingston(3), Kitchener(1), Lakeshore(1), London(2), Maple(1), Markham(2), Mississauga(5), North Vancouver(1), Oakville(1), Ottawa(5), Owen Sound(1), Pickering(1), Richmond Hill(6), San Francisco(1), Sault Ste. Marie(1), Scarborough(1), Shakespeare(1), South Farmington(1), St. John’s(1), Stoney Creek(1), Surrey(3), Thornhill(2), Thunder Bay(1), Toronto(26), Vancouver(2), Victoria(1), Waterloo(1), Whitby(1), Winnipeg(1), Woodbridge(1)

Seventy-eight of our new students have completed an Undergraduate degree, and thirty-two have postgraduate degrees, including ten PhDs.  The average cumulative grade point average achieved by these students in their pre-medical studies was 3.69.  The universities they have attended and degree programs are listed in the tables below:

Universities of Undergraduate Studies

Carleton University 2
Cornell University 1
Dalhousie University 2
Harvard 1
MacEwan University 1
McGill University 3
McMaster University 14
Memorial University 1
Mount Allison 1
Queen’s University 19
Ryerson 1
University of Alberta 3
University of British Columbia 5
University of Calgary 2
University of Guelph 3
University of Ottawa 1
University of Toronto 20
University of Waterloo 5
University of Windsor 1
Vanderbilt University 1
Western University 12
York University 1

Undergraduate Degree Majors

Anatomy 1
Biochemistry 3
Biochemistry and Molecular Biology 1
Biology 13
Biomedical Computing 1
Biomedical Science 3
Cell & Molecular Biology 3
Computer Science 1
Ecological Determinants of Health 1
Economics 2
Electric and Biomedical Engineering 1
Gender Studies 3
Genetics 1
Health Sciences 7
Human Development 1
Immunology 2
Integrated Science 1
Kinesiology 5
Life Sciences 18
Mathematics 1
Medical Science 3
Medicine, Health and Society 1
Microbiology and Immunology 1
Music 1
Myth and Literature 1
Neuroscience 3
Occupational and Public Health 1
Pathology 1
Pharmacology 3
Pharmacy 1
Philosophy 1
Physics 2
Physiology 5
Psychology 7

Universities of Masters Studies

Dalhousie University 1
London School of Hygiene and Tropical Medicine 1
McGill University 1
McMaster University 2
Memorial University 1
Ottawa University 3
University of British Columbia 1
University of Calgary 3
University of Toronto 16
University of Waterloo 2
York University 1

Master’s Programs

Biological Science 1
Cell and System Biology 1
Cell Biology 1
Clinical Engineering 1
Computer Science 1
Epidemiology 2
Health Policy 2
Health Studies & Gerontology 1
Immunology 1
Kinesiology 3
Medical Genetics 1
Medical Science 5
Neuroscience 4
Pharmacology 2
Physiology 5
Physiology and Biophysics 1

University of PhD Study

McGill University 1
Ottawa University 1
University of British Columbia 1
University of Calgary 2
University of Toronto 5

PhD Programs

Biological Science 1
Computer Science 1
Health Policy 1
Immunology 1
Medical Genetics 1
Medical Science 1
Neuroscience 3
Physiology 1

 

An eclectic and academically very qualified group, to be sure.  Last week, they undertook a variety of orientation activities organized by both faculty and their upper year colleagues.

On their first day, they were called upon to demonstrate commitment to their studies, their profession and their future patients.  They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers.  At that first session, they were welcomed by Dean Reznick who challenged them to be restless in the pursuit of their goals and the betterment of our society. Mr. Jonathan Krett, Asesculapian Society President, welcomed them on behalf of their upper year colleagues, and Dr. Rene Allard provided them an introduction to fundamental concepts of medical professionalism.

Over the course of the week, they met curricular leaders who will particularly involved in their first year, including Dr. Michelle Gibson (Year 1 Director) and Dr. Cherie Jones (Clinical Skills Director). They were also introduced to Dr. Renee Fitzpatrick (Director of Student Affairs) and our excellent learner support team, including Drs. Martin Ten Hove, Jason Franklin, Kelly Howse, Susan Haley, Josh Lakoff and Craig Goldie, who oriented them to the Learner Wellness, Career Counseling and Academic Support services that will be provided throughout their years with us. They met members of our superb administrative and educational support teams led by Jacqueline Findlay, Jennifer Saunders, Sheila Pinchin, Amanda Consack, Kate Slagle, and first year Curricular Coordinator Corinne Bochsma.

Dr. Jaclyn Duffin led them in the annual Hippocratic Oath ceremony. Dr. Susan Moffatt organized and coordinated the very popular and much appreciated “Pearls of Wisdom” session, where fourth year students nominate and introduce faculty members who have been particularly impactful in their education, and invite them to pass on a few words of advice to the new students. This year, Drs. Bob Connelly, Jaclyn Duffin, Jay Engel, Melinda Fleming, Jason Franklin, David Holland, Steve Mann, Laura Milne, Heather Murray, Ashley Waddington, David Walker and were selected for this honour.

On Friday, the practical aspects of curriculum, expectations of conduct and promotions were explained by Drs. Michelle Gibson and Richard Van Wylick. They were welcomed to our Anatomy Learning Centre and facilities by Drs. Steve Pang, Les MacKenzie, and facility manager Rick Hunt, and participated in the annual memorial service with a moving dedication by University Chaplin Kate Johnson.

Their Meds 2019 upper year colleagues welcomed them with a number of formal and not-so-formal events. These include orientations to Queen’s and Kingston, introductions to the mentorship program, and a variety of evening social events which, judging by appearances the next morning, were much enjoyed.

For all these arrangements, flawlessly coordinated, I’m very grateful to Rebecca Jozsa, our Admissions Officer, and second year Vice-President Diana Cuckovic.

I invite you to join me in welcoming these new members of our school and medical community.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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Malcolm’s Italian Adventure, and the art of teaching through storytelling.

When I first met Malcolm Williams, he was trying valiantly to teach me how to examine the back of a child’s throat without getting bitten or having the patient throw up on my white shirt and tie. He was only partially successful. Over the years, I’ve gotten to know Malcolm well, in various contexts. Such continuing and evolving relationships are one of the real blessings of training, practicing and living in a relatively small medical community. blog91Malcolm is now an Emeritus Professor and former Head of Otolaryngology. He’s also an accomplished musician, traveller and observer of humanity. Moreover, and more relevant to this article, he is a master storyteller. In fact, he’s what you might call a raconteur. Blessed with a resonant baritone voice, impeccable delivery, and personal connections with most of the citizenry of Kingston, he truly spins a great yarn, and can do so anywhere, anytime.

Recently, he told me about an encounter he and his wife Denny (also an accomplished musician) had experienced during a trip to Italy. He mentioned he had written about it, and I asked if he’d agree to me sharing it on this blog. He graciously agreed. And so, in the words of the master…

Every string player knows (or should know) of Cremona, Italy. After all, that is where Antonio Stradivari hung out his shingle in the late 17th century, when Canada was only in its infancy. My wife Denny and I moved to Kingston (now in a somewhat more developed country!) in 1969, without ever having visited Italy. Two years later, the International Congress of Otolaryngology was being held in Venice, so we went.

Venice was extraordinary that June. The sun shone every day, the water sparkled, and there weren’t too many tourists. St. Mark’s Square was filled with music from a dozen café orchestras playing in the open air, just far enough apart to avoid cacophony, and the shops were full of wonderful leather, glass and fashionable garments, which we thought were unfortunately too expensive at several million lire each. We had actually returned home before it dawned on us that the lira was worth so little (at several hundred to the dollar) that we could have purchased that lovely pair of red high-heeled shoes after all!

After the meeting ended, I asked our very obliging hotel concierge to arrange a self-drive car for us. The conversation went something like this:

Concierge: “Where to, Signore?”

Me: “Cremona.”

Concierge: “But, Signore, there is nothing in Cremona!” (This, with much waving of hands and other negative body language.)

Me: “Look, my wife and I are players of stringed instruments, and we are determined to make a pilgrimage.”

Concierge: (with heavy sigh) “Signore, you will be wasting your time, but I see you are quite determined, so please let me advise you on your journey. I will have a very comfortable automobile waiting for you after breakfast. You will drive it to Verona, where you will have coffee at the Amphiteatro, which is very beautiful and historic, so you will enjoy it a lot. After coffee, you will drive along the Autostrada to the Village of Sirmione, on Lago di Garda. The village is inside the walls of an old castle, and there is a beautiful hotel with a terrace bar, which overlooks the lake, where you will sit and have an aperitif before lunch. And you will enjoy it. You will ask to see the luncheon menu, you will decide it is too expensive and go down instead to the Trattoria Verdi in the village, which is owned by my sister. You will have a delicious lunch, which you will enjoy very much. And, after that – if you still want to go to Cremona, go!” (And on your own heads be it!)

We are still glad that Giovanni planned our day so well. We did everything he suggested, including eating a wonderful lunch (trout from the lake and a simple salad, with local white wine) at Trattoria Verdi. We did go on to Cremona, to find only a miserable display of two violins in glass cases in the silent, cavernous Town Hall, where we were the only visitors. The fiddles were nice enough – a Nicolo Amati and an ordinary Stradivarius (if there is such a thing), but there was no display of tools, wood, drawings etc. The attendant spoke little English, and did not even know where Stradivari had lived.

The following morning, we were warmly greeted by Giovanni, who asked about the trip. I said “We enjoyed the day as you said we would – but there is nothing in Cremona!” With a smile and a shrug, he sighed: “Ah, Signore!” as he took my generous tip.

He was not to know that the tradition of violin-making would be revived later in Cremona, including a well-respected school and a very impressive museum! This was brought to light in an interesting documentary on TVO as recently as January 2013, which I would urge readers to look at, whilst noting that the presenter’s style is a little brash and superficial for my taste! I wish we could go back and see it all in the flesh, though.

Venice itself was not a total loss in instrumental terms, however. Half-way up the stairs inside the tower of St Mark’s Basilica is a glass-covered niche in the wall containing the most extraordinary double-bass I have ever seen. It was made for the virtuoso Dragonetti in the early 1700s by Gasparo Da Salo, and is one of only two or three in existence. The ROM in Toronto owns a similar one, and I have seen it, although it is no longer on display there. I have only recently become aware that as Denny and I sat on that hotel terrace in Sirmione, we were looking directly up Lake Garda to Salo, where Gasparo was born.

We have no Italian instruments now, although for years my wife played a 19th-century violin made in Genoa by Eugenio Praga. We do have a well-thumbed copy of the book “Italian Violin Makers” by Jalovec, and also the fascinating “The Violin Hunter” by William Silverman, and we treasure them. My 1849 English bass, which I played in the Kingston Symphony Orchestra for a long time, was sold when I left the orchestra, as it needed to be used professionally. However, I soon realized that I still wanted an instrument of my own to play in The Community Strings, and bought one on eBay! This had been brought through the Iron Curtain in disguise, its varnish covered over with black sticky house paint and its strings tattered and frayed, to avoid confiscation at the border, finishing up in Mississauga, Ontario. Three years and a lot of work later, it has been restored to its former glory, and I am not ashamed to take it out of its bag any more. It sounds good, too.

The Venice connection was reborn recently as well. I was asked if I would lend my bass for a “show” at the Grand Theatre. The last time I did anything like this was to lend my big bass travelling trunk to the theatre as a prop for a murder mystery play, in which it would conceal a dead body. This time, the instrument itself was needed by the very good Venetian group, Interpreti Veneziani. I was happy to see it used, and to find that it sounded very good in hands more expert than mine. Music is alive and well in Venice, Kingston, and, I know, now also in Cremona! Long may it last.

Malcolm has always reminded me of the essential role of storytelling as an educational tool. From kindergarten to medical school, much of what (and how) we learn is delivered as accounts of real life or imagined experiences, expressed in ways that stimulate the imagination, provide vivid imagery, and therefore not only entertain, but embed key messages in our memory to be recollected, re-considered and extended to future situations and circumstances. In the words of the Youth, Educators and Storytellers Alliance of the National Storytelling Network: ”Storytelling is an art, a tool, a device, a gateway to the past and a portal to the future that supports the present. Our true voices come alive when we share stories.”

In medical education, how much of our early and ongoing learning relates to accounts of clinical experiences, formally and not-so-formally passed between teacher and learner, and between colleagues? Our best teachers and mentors are not simply reservoirs of facts and figures – they’re able to contextualize into familiar and memorable accounts, weaving what we need to learn into engaging and memorable narratives that engage and persist in our memory.

Malcolm is one of those people. He reminds us that whether the message is about respecting local culture, maintaining our artistic passions, or assessing pharyngeal pathology, the delivery can be as important as the content, and certainly as enduring.

 

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

 

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“Have you even read the United States constitution”

This past week’s Democratic National Convention provided many dramatic moments and stirring oratory from prominent national figures. For me, the most poignant and powerful presentation came not from a famous personality or polished public speaker, but from Mr. Khizir Khan.

 

Mr. Khan is not a politician and far from a famous national figure. Born in Pakistan, he immigrated to Boston in 1980 and obtained a Masters degree from Harvard. He is currently a legal consultant living in Charlottesville Virginia. His son, Captain Humayun Khan, is one of 14 HumuyanKhanAmerican Muslims who have died in military service since the September 11 terrorist attacks. Captain Khan died in a car bombing incident in Iraq in 2004, apparently sacrificing himself to save the lives of his comrades. For his service, he received both the Bronze Star and Purple Heart and was buried with full military honours in Arlington National Cemetery.

 

Addressing the convention with his wife standing quietly at his side, Mr. Khan managed, in a few minutes of powerful, simple narrative, to capture both the great promise and great threat to the American system of government.

 

He challenged Donald Trump directly. “Have you even read the United States constitution?” he said, looking directly into the camera and defiantly waving a copy of the document. It was a truly astounding Khizr-Khan-DNCmoment: a Pakistani-born, Muslim immigrant calling out an established, mainstream and powerful figure on the basis of their presumably shared societal values. Amazingly, he topped it with an even more powerful statement a few minutes later, when he said, with the conviction and veracity that can only come from a bereaved parent: “You have sacrificed nothing”.

 

With those four words, he reminded everyone listening that the strength of American civilization has come from the promise provided by the principles and rights articulated in their constitution, and the willingness of its citizens to defend them. Over the centuries, that promise has attracted people from all parts of the world and of all ethnic backgrounds who sought to escape persecution and oppression of various forms and, critically, were willing to not simply work hard, but to sacrifice personally for the preservation of those principles. With those words, he didn’t simply establish the right of so-called minority groups to be part of that society, he actually elevated them above those who have been part of American society longer, but who do not fully understand or truly embrace the founding principles. Full membership requires commitment and sacrifice. Mr. Khan passionately made the point that, like many, he’s paid his dues, but not all have.

 

In the midst of the rancor and extremist demagoguery that has characterized this recent election campaign, it’s tempting to disparage the American system of government and lose hope for its future. It’s worth recalling what actually happened in colonial America in the late eighteenth century, leading up to the constitutional congress, Declaration of Independence and, eventually, American Revolution.

 

Essentially, thirteen British colonies who had, since their initial establishment, become culturally disparate, economically diverse and fiercely independent decided it was in their mutual best interests to elect and send delegates to a series of conferences to discuss means by which they might establish more effective political relationships with Great Britain, at that time the greatest military power in the world. The colonies and delegates varied greatly in their goals and perspectives. Some saw it necessary to achieve complete independence, at whatever cost. Some were committed pacifists (even on religious grounds) who considered themselves British subjects and advocated for continued rule under the King and parliament, but with more refined political and economic ties. To be even discussing these matters was treasonous, and the delegates were taking considerable personal risk, to say nothing of being away from family and home for months at a time.

 

The accounts of those proceedings provide fascinating and instructive studies of what is possible when strong, diverse personalities are united by an abiding desire to promote the common good of their families and peoples. The delegates were certainly committed, courageous, strong-willed and intelligent, critical thinkers. They were articulate communicators, shrewd, sensitive to deception and not easily duped. Many of them were well versed in political theory, philosophy and world history. What ultimately allowed them to be successful and to establish common and effective agreements were two key attributes: they shared an abiding respect for each other, and out of that respect came a willingness to listen, truly listen, to each other’s perspective.

 

And what success they achieved! Although it can be argued that they have never been fully realized, who can argue that the principles set forward in the Declaration of Independence and implemented in the American Constitution are as great an articulation of what an independent and righteous people might achieve as anything that’s been written.

 

The second paragraph of the Declaration sets out the justification and vision:

 

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

 

It continues to set out their intention in clear and unambiguous terms:

 

“We, therefore, the Representatives of the united States of America, in General Congress, Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name, and by Authority of the good People of these Colonies, solemnly publish and declare, That these United Colonies are, and of Right ought to be Free and Independent States; that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do.

 

It ends with a rather sublime statement wherein they each personally commit to the principles they have declared and, critically, to each other:

 

And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.”

 

In signing the document on July 4 1776 in Philadelphia, those 56 delegates, still British citizens at the time, were fundamentally committing treason, punishable by death. It’s worth noting that, at the time, there was no government, no army and no clear means to do any of things described. This was no arms-length commitment. They were taking unimaginable personal risks. The Constitution, which restates the principles and outlines the form of government that would hopefully achieve these lofty goals, wasn’t signed into law until Sept. 17 1787, and not ratified until June 21 1788, almost 12 years after the signing of the Declaration, and after those delegates and many of their countrymen had endured the sacrifices of the Revolutionary War.

 

The contrast between what those courageous delegates achieved so many years ago stands in rather stark contrast to the fear-mongering and petty dialogue that is currently on display. It also providesH_Khan_Arlington inspiring insights for any government, organization or group struggling to find effective solutions despite opposing perspectives and backgrounds. In the end, we advance not by capitulation, but by thoughtful, informed and respectful compromise. Compromise, in turn, requires an element of sacrifice. As Mr. Khan so effectively reminds us, we earn our place in a free society through sacrifices, both great and small.

 

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

 

 

For those interested in some very readable accounts of the people and proceedings of those constitutional conferences:

 

John Adams by David McCullough. Simon and Schuster, 2001.

Founding Brothers by Joseph P. Ellis. Vintage Books, 2000.

Benjamin Franklin: An American Life by Walter Isaacson. Simon and Schuster, 2003.

Thomas Jefferson: The Art of Power by Jon Meacham. Random House, 2012.

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Where have all the people gone?

Anyone who has grocery shopped at a large supermarket recently will notice that you’re now confronted with a decision at check-out time. You can line up as usual to have a clerk check and bag your items, or you can opt to go to the do-it-yourself kiosk, where you have the privilege of scanning and packing your items yourself. I’ve been tempted to canvass folks who choose the clerkless option. I suspect some feel it’s faster (by my observation, that’s dubious at best). Some may be obsessive-compulsive enough to want to handle and pack their own things in some preferred manner. I suspect some may simply wish to avoid the need to interact with another person, however briefly.

grocery-store

Whatever the reason, it seems likely that the option we’re currently being provided is not going to continue, but rather is a transition process preparing us for a time when grocery chains will no longer hire actual human beings for the purpose. When that happens, your friendly check-out person will join the growing list of community roles that are no more, or exist in a much more limited capacity:

people

In fact, it’s now entirely possible to leave your home in the morning and carry out all your domestic and business chores without ever having to be troubled with the need to interact with an actual human being. Moreover, we don’t require another person’s help to accomplish many of the functions of day-to-day life. In essence, we’re paradoxically becoming more isolated in the midst of increasingly crowded and busy urban environments.

Recently, we’ve witnessed a further blurring of the boundary between our personal space and the wider world. The introduction of Pokemon-Go basically makes the wider world a personal playground. In the words of the manufacturers, “Travel between the real world and the virtual world of Pokémon with Pokémon GO for iPhone and Android devices. With Pokémon GO, you’ll discover Pokémon in a whole new world—your own!”

So, what are we to think of all this increasing detachment from the people with whom we coexist, sharing our communities and services? Is it a problem, or simply evolution towards a greater, technologically driven efficiency? Is there a price to be paid for our virtual isolation from the growing number of people around us?

At the risk of sounding like a sentimental reactionary, I’ll admit that a few concerns come to mind.

Firstly, on a purely pragmatic level, these jobs provided income and, for those who engaged them as full time occupations, a sense of identity and purpose within our communities. They, in turn, were able to support their families and local economies. Jobs, all jobs, are likely our best social investment. A loss of jobs, even unglamorous jobs, should concern us.

They also provided part-time employment opportunities for young people, valuable experiences in self-sufficiency and human relations that informed and supported future careers. Interacting with various folks in the course of our routine day promotes “people skills”. One learns how to “read” people, sense concerns, respond appropriately.

Moreover, the need to interact and communicate on a regular basis with other folks of diverse ages and backgrounds, I believe, promotes tolerance, civility and fundamental sensitivity to the challenges faced by others in our midst. How much do children learn by simply observing how their parents interact with all the folks they encounter in daily life? How much is lost if that never occurs?

I believe we’re seeing some consequences in our medical schools.

One of the most stressful moments for medical students is their first encounter with a patient. At our school, this takes place in first term Clinical Skills. Very early on, students are taught and expected to introduce themselves to a patient, obtain some basic information, and begin the encounter that will eventually allow them to obtain a complete and accurate clinical history. It all starts with simply introducing oneself and beginning a basic conversation, which, one might think, would come quite naturally to bright and gifted young people. Amazingly, many students find this quite difficult and even unnatural. In fact, students vary considerably in their comfort and aptitude for the patient encounter, and this has very little to do with their academic qualifications. It does, however, have much to do with their prior experience engaging people on a personal level, particularly those of diverse ages or backgrounds. That ability is (or should be) learned through real life everyday experiences, at home, in their communities, in their workplace. In our competency-based world of medical education, it’s easy to forget that the most essential physician competency is the affinity for effective and comfortable exchanges with people of all types. That particular skill is first developed, not in medical school, but in our homes and communities.

It would be silly to expect that technology will not continue to advance and that the now redundant occupations described above will make some sort of magical resurgence. However, we should recognize that something has been lost and not replaced. These roles were not just jobs or functions. They were actual people, with faces, personalities, roles in our communities for which they became known and identified. They contributed something far beyond the tasks they performed. They contributed to our learning, our sense of community, and our comfort with personal interactions. In their absence, we must find ways to identify and develop those skills in our students who are products of a rapidly changing social structure.

 

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

 

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Best wishes to our 2016 Grads – beginning residency, and continuing a long tradition.

1884 - Graduating ClassThe image below is taken from one of the many graduation photographs hanging on the walls of the School of Medicine Building. The young men in the photo are members of the 1884 graduating class. On the surface, one may be struck by the obvious differences to our current world, in terms of gender and ethnic diversity, medical knowledge, and the needs of the society they were about to enter as physicians. But I’m more struck by the similarities. Although their careers and lives have long since ended, those young faces frozen in the photograph seem eager, confident in their training, and perhaps a little nervous, about what challenges the future will bring, and how they will contribute to it. In all those regards, they are not at all unlike our current students.

This week, our most recent graduates begin the next phase of their medical careers. They also seemed eager and a little nervous when they started their medical education here at Queen’s in September of 2012, as may be apparent in the photograph taken that first day.

classof2016
That eager nervousness has probably not disappeared completely, but is hopefully supplemented by the same confidence in their abilities and desire to contribute that characterized so many of their predecessors. As they do, they’ve spread across this great country. Their areas of specialization and locations are summarized below. specialization

I’m particularly pleased to welcome back those who will be pursuing postgraduate education here at Queen’s.

Dr. Carl Chauvin, former Aesculapian Society President, will be starting the Anaesthiology program.

Drs. Kelly Fernandes, Matthew Legassic, Hollis Roth, Calvin Chan and Betty Chiu are entering Family Medicine.

Drs. Alex Astell, Roxana Chis, Josh Durbin, Ioulia Pronina and Kamran Shaikh are beginning their careers in Internal Medicine.

Drs. Alida Pokoradi, Stefania Spano and Ainsley Alexander have joined the Obstetrics and Gynecology, Orthopedic Surgery, and Psychiatry programs, respectively.

All of our graduates, I’m confident, will enhance and contribute to the programs they enter, and they do so with the best wishes of their undergraduate teaching faculty.

graduates2016Their graduation photograph has joined those of all their predecessors on the walls of our School of Medicine Building. These photographs remind those of us who serve as stewards of our medical education heritage that we have an entrusted responsibility to produce graduates who are not just academically successful, but who bring real value to the profession and society. That mission hasn’t fundamentally changed over the years, but requires very different approaches than it did in the past. Our purpose remains to attract eager, dedicated, capable young people to the profession, and to prepare them intellectually and personally for a career of service, promoting and providing for the health of our society and fellow citizens.

That’s what we’ve done. That’s what we do.

 

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

 

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Island Inspiration

island-inspiration1Inspiration comes in various forms and at unexpected times.  For me, it came recently and quite unexpectedly during a brief getaway in Prince Edward Island with three great friends.  Although the trip was structured largely around golf (or a reasonable facsimile thereof), we took the opportunity one evening to attend a concert, the first in an annual series that’s known as the Indian River Festival.  The festival is something of an inspiration itself.  It began in 1996, initially to aid in the upkeep of St. Mary’s Church, a truly lovely example of Atlantic ecclesiastical architecture.  When the local diocese decommissioned the church, it was purchased by the festival association. They collaborated with former parishioners, the Friends of St. Mary’s, to restore and preserve the building, now a historical site.  The result is a truly special venue for the staging of local talent that preserves the dignity and spiritual quality of the building.  island-inspiration2In fact, it’s that “spiritual” quality that seemed to link the building, its history and the dedication of the local community in the performance we attended.

island-inspiration3The highlighted performers were a group called The Once. I will freely admit (likely to the bemused consternation of my children) that I was not previously familiar with them.  The group consists of three Newfoundland-born musicians who, in their own words, are “bridging Celtic-inspired traditional music and contemporary, original songs that spring from their friendship and shared experiences at home and on the road”.  Those original songs are poems that capture the experience and struggles of small communities and the people who live or grew up in them. They’re about people who have never lost those ties, and strive to preserve the memories and the culture.  Geraldine Hollett, the lead singer, combines an engaging vocal quality that some might call “haunting”, with a remarkable ability to make the lyrics of their songs come alive and reach every listener.  There is a truly authentic quality to her singing. She’s not just mouthing words; she seems to be conveying deep, personal meaning. Phil Churchill and Andrew Dale provide accompaniment and vocal harmonies that combine almost seamlessly.  It becomes very clear that the centre of the performance, the message, the intention, is in the song itself and something far beyond their individual parts within it.  Fundamentally, they’re beyond simply trying to impress us with their considerable musical skills – it was about the stories contained in those lyrics.  And powerful, poignant stories they are:
From “Town Where You Lived”, dedicated to the songwriters’ fathers:

I am drained cause it’s rained and it’s rained
For the last 20 days it won’t give
Up an inch no not one little ray from the son
On the face of the town where you lived

It’s been years I’ve got hundreds more fears
And tried not to as much as I’ve tried
Giving way to the flood of my tears in the mud
On the ground of the town where you died

From “We Are All Running”
We are all running
We are all running the same race
We are all going
We are all going to the same place

From Sonny’s Dream, by the late Ron Hynes:

Sonny, don’t go away, I’m here all alone
Daddy’s a sailor, he never comes home
And the nights are so long and the silence goes on
I’m feelin’ so tired, not all that strong
Sonny, don’t go away

They were joined that evening by an ensemble called The Atlantic String Machine, a group of talented musicians who performed Bach’s second Brandenburg concerto, as well as their own compositions and arrangements of contemporary popular music.  They were dressed somewhat formally and, on the surface, one might reasonably wonder how they would combine with the folksy Newfoundlanders.  Well, that wasn’t a problem.  They complemented the trio beautifully, adding power and texture to the songs without in any way detracting from their essential messages.  The fact that the two groups had only one practice together highlighted the incredible skill of all these musicians, mastery of their instruments and dedication to their professions.

As I watched all this in the company of three close friends and working colleagues who I admire greatly, I couldn’t help but think of the parallels between these dedicated musicians and those who accomplish great things in Medicine.  Dedication to craft, mastery of skills, empathy with those in our communities and desire to reach out to promote their welfare, are the exclusive domains of no particular profession.  In the end, great musicians, great doctors, great citizens, care deeply for their communities and give of themselves, going beyond the mere application of skills and knowledge.

Those qualities, fortunately, abound all around us, but are often muted by the pace of our hectic daily lives and continual, frenetic barrage of seemingly random information. Sometimes it takes an evening on an island in the right company to be reminded of what really matters. Fortunately, you know it when you hear it.

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

 

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Canada’s Medical Schools collaboratively engaging the issue of Student Wellness.

For this week’s article, I’ve asked Renee Fitzpatrick, Director of Student Affairs, to write to us about a topic of critical importance. Indeed, the issue of student wellness and risk should be a major concern of both individuals and institutions engage in the education and development of young people. As she points out, our efforts in this regard need to be ongoing, and she introduces a recent initiative taken up jointly by the Canadian Undergraduate Deans and Student Affairs leaders to consolidate and strengthen our approach to this problem.

___________________________________________________

FitzpatrickIn April 2016, Laura Taylor, a third year medical student at UBC, died just days before her 34th birthday. Her parents, devastated by the loss of their kind, loving, brilliant, athletic daughter shared that the bipolar disorder that she had struggled with for more than half of her life, became too much. She had worked tirelessly to reduce the stigma of mental illness.

Her photograph shows a girl with a full smile, the kind that would inspire confidence in any patient, a smile that is referred to repeatedly in her book of condolence, a hockey helmet, reflecting her passion for hockey and a stethoscope, the signature of the medical profession.

The tributes speak to her energy, her athletic ability, her generosity in volunteering, her openness about her mental illness, her academic brilliance, her wit, her courage  and her humility.

Any medical school in the country would have been proud to have Laura as a student, and UBC was particularly proud of her. She had all the attributes that we have identified as important to sustain a career in medicine. She also had a serious mental illness, one that she had prior to medical school, which she actively tried to manage.

Just days before Laura’s death, at this year’s CCME, the Canadian Federation of Medical Students, presented results of a mental health survey of medical students across Canada, results that challenged us to take action. The report described increased rates of anxiety, depression, suicidal ideation and burnout, compared to the general population, replicating results from other countries.  The Undergraduate Deans committed to a review of suicide risk factors in medical students in an attempt to understand what factors are associated with the conversion of suicidal ideation, a sign of distress to suicide.

Over the last few decades there has been increasing emphasis on the need to identify and treat mental illness in medical students, residents and physicians. Accreditation requirements include a need to demonstrate that there is access to help for mental health issues. However, there is still stigma about seeking help, with concerns ranging from impact on license to fear of judgment. The ACGME Council of Review Committee Residents made suggestions to identify ways to improve resident wellness and resiliency following the death by suicide of 2 resident physicians in New York in August 2014. These were. (1) increasing awareness of the risk of depression during training and destigmatizing it; (2) building systems to confidentially identify and treat depression in trainees; (3) establishing a more formal system of peer and faculty mentoring; (4) promoting a supportive culture during training; and (5) fostering efforts to learn more about resident wellness.

We had made some strides in the last few years to increase wellness initiatives, promote resilience and reduce burnout. The CFMS survey indicates that we have no reason to be complacent. It is crucial to identify the risk factors that convert ideation to suicide. We must reflect on the degree of perfectionism that we require to achieve one of the coveted spots in our medical schools. We must ask how students survive our scrutiny as we demand competent collaborators, communicators, managers, experts, leaders and advocates. Is the perfection that we demand reasonable? Is the environment conducive to negotiating the developmental tasks of early adulthood in addition to training as physicians?

I do not suggest for one moment that we reduce our standards or dilute the fact that medicine is demanding and that we need to be able to tolerate uncertainty, failures, distress and pain. I believe that this is achievable in an environment that promotes and facilitates the growth of healthy physicians. The leadership and support of the Undergraduate Deans is crucial in enhancing the health and resilience of the next generation of physicians, who have taken a courageous step in identifying the issues.

Our Undergraduate Deans have made a commitment that deserves all of our support and challenges us also to become healthy physicians.

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Finding hope amid the chaos: The baffling, reassuring, authentic appeal of Bernie Sanders

The ongoing and rather turbulent journey that is the American presidential election provides many opportunities to despair for the future of democratic institutions. However, a lone beacon for optimism arising from the whole spectacle may be the completely unanticipated appeal of one Mr. Bernie Sanders.

 

Mr. Sanders, the 75-year-old Brooklyn born son of Polish-Jewish immigrants and current junior senator from the tiny, off-the-beaten-track state ofSandersPic1 Vermont, doesn’t look, sound or behave like someone who should be contending for the presidency in 21st century America. His political biography sounds like an extended version of Frank Capra’s “Mr. Smith Goes to Washington”. A former carpenter, filmmaker, writer and populist mayor (Burlington, Vermont) gets elected to congress as a self-professed socialist with no affiliation to major political parties (until 2015 when he finally became a Democrat). He opposes tax cuts, campaign funding, infringement of privacy and foreign wars. He promotes social welfare programs, environmental and LGBT issues, parental leave and universal healthcare. He filibusters on points of political principle. Since declaring his candidacy for the presidency, his views have not deviated. His speaking style is unpolished, his campaign rudimentary compared to the well funded approaches of his opponents, and his policies, although appealing in their idealism, seem overly simplistic and perhaps naïve approaches to rather profound social and economic issues.

 

He is, in many ways, a poster child for the Baby Boomer generation. That’s the huge segment of BoomerPostersociety born in the post World War II years who are now largely in their 60s and 70s. These folks, who were rebellious, idealistic, free living, pot smoking “hippies” in their youth, largely moved away from those socialistic ideals as they grew older and become hard working supporters of “the system” and are now the conforming leaders of our private and public institutions. Except, of course, for Mr. Sanders. It seems he’s never moved away from the liberal, leftist ideals and unapologetic honesty of his youth. All of this is causing fits for his fellow Baby Boomer opponent Ms. Clinton, whose political experience, strong corporate support and polished dialogue almost become liabilities in contrast.

 

The most remarkable aspect of Mr. Sander’s success is his base of support. It’s not, as one might expect, his fellow unrepentant Baby Boomers. His main support is, surprisingly, coming from young people. In particular from those much maligned Millennials. In fact, he far outpolls Ms. Clinton in the 18-29 year old demographic, in marked contrast to his performance in all others. (http://www.statista.com/statistics/521935/michigan-democratic-primary-2016-exit-polls-votes-by-age/).

Sanders Data3

Exit polls of the 2016 Michigan Democratic primary in the United States on March 8, 2016, share of votes by age

 

MillennialPic

The Millennials, you’ll recall, are that generational group born between 1982 and 2004. Their major cultural influences have been massive advances in technology and economic uncertainty. They have been regarded as privileged, entitled and narcissistic. Their enthusiastic support of Mr. Sanders is truly one of the most intriguing themes in this bewildering election campaign.

What’s the explanation?

In my view, it comes down to a single word, that word being Authenticity. For this purpose, authenticity can be defined as “the degree to which one is true to one’s own personality, spirit, or character, despite external pressures”. Authenticity is about being truthful, genuine and credible. It’s very difficult to fake over the long term, and the millennial generation appears to be particularly adept at seeking it out. They also value it greatly, and for good reason. Authenticity is rooted in truthfulness, and SandersPic2engenders trust. We may not always agree with authentic people, but we believe what they say and feel we can rely on them to act on their professed beliefs. Mr. Sanders, I think we all would agree, is nothing if not unfailingly authentic.

 

 

There are lessons here for those of us involved in education, which is largely about gaining the trust and confidence of these bright, young and eager millennials. The authenticity that works so well for Mr. Sanders can be thought of as comprising three key elements:

  1. Credibility, or fundamental believability. Also referred to as “street cred”. This arises from a combination of reputation, behaviour and qualifications. Not sufficient in itself, but a necessary starting point.
  2. Genuineness, which is honest dedication or devotion to what we profess to teach or believe. Again, hard to fake if not sincere.
  3. Validity. This refers to the “real goods”. It’s not enough to appear credible or sincere. An effective teacher must prove their effectiveness by achieving real learning for their students. Fundamentally, if they’re not learning, you’re not teaching.

 

Mr. Sanders will likely not become President, but his valiant campaign, dogged adherence to his principles and unexpected resonance with young people provide lessons for us all on how to bridge generational gaps, and a hopeful tone to an otherwise demoralizing electoral process.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

 

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Celebrating Student LEADership

This week, I’ve invited one of our soon-to- be-graduating students, Elizabeth Clement (Meds 2016), to report on the LEAD (LEadership Enhancement and Development) program, an initiative she and a group of her colleagues have conceived and completed over the past year. When Liz, Alia Busuttil and Graydon Simmons first came to me with this idea, I must admit to thinking it was overly ambitious, particularly given they were just beginning their clerkship. Once again, I underestimated the commitment and tenacity of our students when they are pursuing a deeply held and worthy cause. I attended the presentations of the Service Learning projects that Liz describes below, and was greatly impressed at the ingenuity and commitment to community service that went into them. Inspiring, indeed. The LEAD program is being passed along to other students, who will work with myself and other faculty to ensure this great work continues.

I’m often asked what keeps our Queen’s faculty so engaged and energized about medical education. For a glimpse into the explanation, read on.

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

 

Mind the Gap by Elizabeth Clement

elizabeth-clementThere’s always a natural tension between student and teacher. While there is a clear common goal, which in medicine is that of graduating a competent doctor, it is easily muddied by the varied opinions on how to achieve such a goal. Students have many competing interests – that extracurricular activity, research project, or family commitment. Faculty, too, are juggling their many hats – hospital service, clinics days, conferences and their home life. Over time, many, if not all, show up to the classroom with slightly less enthusiasm, and as teaching begins to deviate further from one’s preconceived notion, it’s easy to see how that unity of working toward a shared goal begins to erode.

If you’ve ever been on the subway in London, England, I find this reminiscent of the vaguely haunting mind the gap. As the train pulls up to the platform, the two bodies never perfectly line up, leaving a small space between the two: a gap. The overhead voice reminds you to mind the gap: don’t fall in. Because of the nature of the subway’s short stops, you’re either on one side of the gap or the other. You’re either on the train or off the train. You’re either a student or a teacher. Mind the gap.

In my first year at Queen’s, I remember being floored by the openness and candidness of our faculty. Town halls and curricular feedback and personal email exchanges. Even more surprising was that changes were made within courses reflecting this feedback. Often this would happen in real time; courses would morph not after, but as we advanced through them.

It was not surprising to me, therefore, that when a dialogue began about students’ interest in leadership training, the idea of a student-run leadership course received faculty support. The first of many conversations about this project happened more than two years ago, and was the seed for the Leadership Enhancement and Development (LEAD) course. Now, at the conclusion of its first iteration, 12 preclerkship students have wowed us.

In the first of those two years, members of the Class of 2016 (Graydon Simmons, Alia Busuttil and myself) worked together to create a curriculum structure: one part seminar, one part self-reflection, and one part project. In the second year, the team grew as three members of the Class of 2017 (Rajini Retnasothie, Laura Bosco and Lauren Kielstra) joined us to help plan, administer and facilitate the course. Then, in November of this past year, 12 preclerkship students joined the course and we met for the first time as a large group. Amidst explanation of the structure of the course, we were clear about one thing: you will get out what you put in, and what you put in is completely up to you.

During the course, we heard from Queen’s School of Business’ Borden Professor of Leadership Julian Barling, who taught us about motivating with responsibility, and the importance of showing gratitude. We heard from our very own Dr. Sanfilippo about the pillars of leadership; optimism is imperative. We broke into groups of three to discuss our thoughts and reflections while working through the CMA’s “Leadership begins with self-awareness” modules. Meanwhile, outside of the course, students were independently working on “service learning projects,” which required community consultation, strategic design and a significant time commitment. The final seminar, held in mid-April, was a platform for the students taking the course to give short presentations on their service learning projects.

This was inspiring:

  1. Reza Tabanfar’s Telemedicine to Improve Access-to-Care and Treatment of Ear Disease in Remote Ontario Communities: We hope to use digital otoscopy and existing telemedicine infrastructure to leverage ENT’s expertise in diagnosing ear disease, facilitating much quicker review and prioritization of patients presenting with ear complaints in remote Ontario communities.
  2. Zain Siddiqui’s Jumu’ah Prayer Service at the Kingston General Hospital (KGH): The project’s aim is to have Jumu’ah, the weekly Islamic congregational prayer, in the KGH chapel so that that KGH staff and visitors can attend.
  3. Sejal Doshi and Elisabeth Merner’s Street Soccer Kingston: This project is an opportunity to build routine and social supports for Kingston’s homeless/transition housing community all while promoting the importance of physical health.
  4. Mahvash Shere’s Global Health Simulations – Queen’s Chapter: This project will allow students to engage in hands-on negotiation and problem-solving, by putting them in the middle of a humanitarian crisis and asking them to engage with different stakeholders attempting to resolve the crisis. Post-simulation debriefs will give students the opportunity to reflect on the complexity of problem-solving and power dynamics in these situations.
  5. Stephanie Pipe’s Revamping Altitude’s Mentee Recruitment Process: This project involves implementing new recruitment strategies, such as more advertisement of the program at the high school level and working with other groups and resources on Queen’s campus, to better reach our target population and hopefully increase the representation of our target population in the program.
  6. Katherine Rabicki’s Women and HIV/AIDS Situational Analysis: We are collecting data on the experiences of women living with, or at heightened risk of contracting, HIV/AIDS, with the goal of adapting Kingston’s community-based services to better suit the self-identified needs of this population.
  7. Connor Well’s Inspiring Future Medical Students Through High School Community Outreach: this project will determine the feasibility of encouraging high school students, especially from underrepresented backgrounds, to consider medicine as a career through knowledge translation of the medical school application process at high school career fairs.
  8. Akshay Rajaram’s Quality Improvement Practical Experience Program (QIPEP): QIPEP offers Queen’s students a chance to develop quality improvement and patient safety through participation in real quality improvement and patient safety initiatives that impact patient care.

As I walked around the room hearing students talk about Jumu’ah, global health simulations, and street soccer, (I’m a little embarrassed to admit it, but) I was getting euphoric. Maybe it was these students’ optimism or show of hard work. Maybe it was their passionate pursuits in the absence of obligation. At the end of the day, I think it was quite simply that I was learning about topics that, without these students, I would know nothing about.  THEY were teaching and I was learning; not the original design of our course!

I had not occurred to me until then that perhaps faculty who teach are motivated because they, too, want to learn. When we consider life-long learning as a part of our professional responsibility, most of us consider that to mean staying up-to-date with medical practice changes, but there’s a lot more to be learned that can impact the practice of medicine. When faculty solicit student feedback, it’s in an effort to connect with students and better appreciate how learning is changing. Perhaps like a student’s satisfaction when performing well on an exam or rotation, faculty find satisfaction when making improvements to curricula; both demonstrate knowledge gain. And beyond this, I wonder if there is a deeper satisfaction borne from the notion that better learners will make better teachers.

In any case, a cyclic theme emerges: those who are committed to teaching are those who are committed to learning.

At Queen’s, it is clear that the doors are open to peer-teaching; the anatomy and Being a Medical Student professionalism curricula are two of many examples. But I think we can do more. Students are a resource; our diverse walks of life foster perspectives that can help reinvigorate content and delivery – this has particular relevance with the non-medical expert competencies.

Under no circumstance am I trying to suggest that Queen’s does not involve its students; in fact, I know the opposite to be the truth. Instead, I’m suggesting that a deeper involvement may serve both faculty and student in a novel way – by helping us appreciate the complexities of one another’s roles. Not only would the end product have curricular value, but the process would help us all to collectively mind the gap.

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