Category: Associate Dean
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.
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.
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
|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|
Undergraduate Degree Majors
|Biochemistry and Molecular Biology||1|
|Cell & Molecular Biology||3|
|Ecological Determinants of Health||1|
|Electric and Biomedical Engineering||1|
|Medicine, Health and Society||1|
|Microbiology and Immunology||1|
|Myth and Literature||1|
|Occupational and Public Health||1|
Universities of Masters Studies
|London School of Hygiene and Tropical Medicine||1|
|University of British Columbia||1|
|University of Calgary||3|
|University of Toronto||16|
|University of Waterloo||2|
|Cell and System Biology||1|
|Health Studies & Gerontology||1|
|Physiology and Biophysics||1|
University of PhD Study
|University of British Columbia||1|
|University of Calgary||2|
|University of Toronto||5|
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)
Undergraduate Medical Education
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. Malcolm 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?”
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)
Undergraduate Medical Education
“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 American 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 moment: 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 provides 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)
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.
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.
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:
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)
Undergraduate Medical Education