Jordan Spieth’s painful pursuit of perfection, green jackets, and learning from failure.

The Masters Tournament is almost too perfect. The golf course itself is pristine and picturesque – every vista a postcard. The golfers are skilled, the spectators robotically well behaved, the commentators obsequious in their adulation of the players, the course, the “tradition”. Even the caddies are required to dress in the same white overalls, seemingly to blend in and not distract from the scenery and spectacle. The winner is presented with a jacket, the colour of which one would select for no other purpose. The result of all this is a bizarre collision of the sporting world with the Stepford Wives, all set in Fantasyland.

Despite all this artifice and contrivance, frail humanity emerges from time to time, and it certainly did earlier this month at this year’s tournament.

Jordan-SpiethOne year ago, Jordan Spieth, a 21 year old previously unheralded professional golfer, won the tournament in rather spectacular fashion. In doing so, he displayed a degree of skill and poise that one normally associates with much more “mature” professionals. He immediately vaulted to the top of the golfing world, that world rather desperately in search of a new hero following the precipitous demise of one Mr. Woods (another story). Mr. Spieth took up the mantle with aplomb, continuing to win several tournaments over the following year, always with a reserved dignity and deference for “the game”, winning the admiration of true aficionados.

JordanSpieth2All this came crashing down about half way through the final round of this year’s tournament. At that point Mr. Spieth had been leading since the start and was a full five strokes ahead of the field. Commentators had begun the coronation, speaking in hushed, admiring tones of his youth and speculating on how many records he would break during the career before him. The fans were poised for a repeat winner. All was right in the golfing world.

And then, the improbable, the unexpected, the inexplicable…happened. Mr. Spieth began golfing like a Sunday duffer. Balls were struck in errant directions, poor swings, bad decisions, two balls in the water. In less than an hour, the five stroke lead turned into a two stroke deficit. He looked, for the first time in his young career, visibly shaken, even bewildered. The perfection Spieth3he’d achieved and come to expect based on all his prior experience seemed to abandon him. He tried valiantly to recover, but to no avail. He ended tied for second place, losing to a previously little known golfer from Britain named Danny Willet, whose manner and demeanour upon winning seemed more akin to an English Premier League soccer game, a point not lost on either the commentators nor rather staid tournament officials.

To make matters worse for Mr. Spieth, he was required to engage in the traditional ceremony that calls for the previous champion to present the green jacket to the new winner. His expression at that time really said it all.
So what will become of Mr. Spieth? Retired golfers and previous champions, when asked to comment, spoke catastrophically of the depth of trauma speculating that “he may never recover psychologically”.

Spieth4From time to time, sporting events present revealing and poignant insights into the human condition. Those insights are not provided by times of great accomplishment and perfect application of practiced skills, but rather by times like these, when all of us can identify with the person and derive insights for ourselves. Golf provides a particularly apt metaphor because the object of the game is perfection, as defined rather clearly for every hole played. We all recognize that perfection is an unobtainable aspiration, but the trap for the very proficient, like Mr. Spieth, is that they live tantalizingly close to that goal and have made it their life’s work, so that times of failure are magnified in importance and, of course, very public.

The relevance to students and practitioners of medicine is obvious. We strive for perfection and mistakes, although rare, can be both consequential and visible.

Mr. Spieth, the golfer, has come second in a tournament that was his to win, but remains one of the most proficient practitioners of his craft in the world, and retains the potential to have a long, lucrative, perhaps uniquely successful career. But the test he now faces has nothing to do with golf skill. It has everything to do with Mr. Spieth, the man, and his ability to engage the same frailties and inevitable adversities we all face in our much more mundane lives.

Folks with great potential (talent, skill, natural gifts) are relatively common in our world. Such natural aptitude that crumbles in the face of adversity is of little reliable use to anyone. And adversity, unfortunately, is inevitable for us all. It’s inevitable in the sporting world, the business world, and certainly in the study and practice of medicine.

Moreover, the ability to not only endure but to actually learn from and improve as a result of those negative experiences is a defining attribute of those few who become truly great practitioners of their chosen professions.

The term that’s become most commonly associated with this trait, is resilience, and sports clubs, businesses, the military and medical training programs, are all looking for it.

So what is resilience? Basically, it is what allows us to overcome adversity. Much is being written on the topic, but in application to Mr. Spieth’s challenge, and the challenge faced by medical folks regularly in the course of their work, it might come down to five key issues.

Commitment. Adversity tests the true depth of commitment to our chosen occupation. How much do we really wish to pursue the life we find ourselves living? For the uncommitted, adversity provides excuses and convenient exit strategies. For the truly committed, it galvanizes resolve, allows us to push through those difficult experiences, and even promotes learning from them.

Confidence. Adversity experiences challenge self-confidence. Furthermore, they provide something of an acid test as to whether the confidence that takes us to work each day is founded on a truly held, internally validated faith in our own abilities, or is an illusion buttressed by fragile external validations.

Perspective. The ability to see a single issue for what it is. One failure, no matter how dramatic and visible, should not outweigh or excessively distract from otherwise consistent success. This lesson is obviously harder for the young.

The support of people we trust. Whether friends, family or mentors, we all need people we trust to have our best interests at heart, and who possess the judgment and objectivity to help us find our way through these experiences. They are precious and indispensible.

Time. Recovery takes time. Time to renew commitment, to restore confidence, to gain perspective. The greater the trauma, the more time required. We are skilled at deferring, but ultimately cannot and should not avoid coming to grips with negative experiences at some point. “Pay me now, or pay me later”.

Having said all this, I’m not worried about Mr. Spieth. It seems, at least to the casual observer, that he has the first two attributes well in hand. His family and friends, I’m sure, will provide the perspective, and time is on his side. He is, and will continue to be, a highly successful golfer. This experience will likely make him an even greater golfer, and even more admired for having overcome it. By undergoing his adversity experience in such a public and dramatic fashion, he provides us all a gift of insight that we can apply in our imperfect lives and careers, perhaps something far beyond golf and the pursuit of green jackets.

 

 

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

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Artificial Intelligence? Artificial Doctors?

This past month, a software program designed to play an ancient game called Go defeated Lee Sedol, a South Korean gentleman who is an 18 time world champion, widely acknowledged to be the leading human player of the game.

Screen Shot 2016-04-04 at 2.48.28 PMThe event didn’t attract much attention, probably because it was seen as a predictable, perhaps inevitable development. After all, computers have been capable of beating Chess Grand Masters for many years now.

However, if we pause for a moment and examine this a little more closely, we may find a deeper, more profound significance.

Screen Shot 2016-04-04 at 2.48.36 PMGo is a seemingly very simple game, hugely popular in the Far East. It’s played on a 19×19 grid of horizontal and vertical lines. Two players are provided with a bowl of either white or black stones. They take turns placing their stones on the points where the lines intersect. The object is to use your stones to claim territory on the board. Stones surrounded by enemy stones are considered “captured” and are removed from the board. The player with most stones on the board and territory wins. Play continues until somebody concedes.

The apparent simplicity of the game is actually quite deceptive. In chess, played on an 8×8 board with fairly restrictive rules as to how players can be moved, it’s been calculated that there are about 1047 different possible games that could play out. Although that’s a huge number, it is finite and therefore could be “solved” once computers developed sufficient processing power. Such programs are able to analyze any configuration of pieces and select options that will maximize likelihood of success based on an analysis of all possible outcomes.

The size of a Go board, and the simplicity of the rules mean that there are an enormous number of configurations and game possibilities. In fact, that number has been estimated to be 10170 (http://senseis.xmp.net/?NumberOfPossibleGoGames). That’s a number difficult to even conceive. To get some sense of its magnitude, let’s consider the following comparisons:

  • Postulated time that has elapsed since the “Big Bang” (beginning of the universe) = 13.8 billion years = 4.335 x 1017
  • Diameter of the observable universe = 93 billion light years = 8.8 x 1026
  • Estimated number of atoms in the observable universe (according to Universe Today http://www.universetoday.com/36302/atoms-in-the-universe/): 1080.

So, suffice to say, 10170 is a pretty big number. In fact, it’s more of a concept than a number. Essentially, it’s infinity.

It’s difficult to understand what makes expert players succeed in a game so endlessly variable but, according to experts like Mr. Lee, it seems to be as much about creativity, spontaneous insights that emerge within a game, and much understanding of the tendencies of an opponent – all things we have considered to be uniquely human attributes.

What all this means is that the computer-based approach to the game must extend far beyond simply providing sufficient processing power to filter through possible outcomes. The computer has to develop what the programmers refer to as “intuition” developed through what they call (wait for this) “deep learning”.

Deep learning? From a computer?! Difficult for mere humans like myself to even grasp but it seems that, given enough processing power and enough historical game outcomes to review, the computer is able to analyze trends and resulting outcomes, eventually sorting through the “clutter” of countless individual human game experiences to develop principles, optimal approaches and even heuristic “rules of thumb”. In other words, it isn’t simply analyzing, it’s thinking.

Shortly after I’d read about Mr. Lee’s encounter with AlphaGo, I happened to overhear an interview on NPR between a rather enthusiastic computer programmer and somewhat bemused reporter. The programmer was making the case that the United States would be better off with an artificial intelligence President. In fact, he was making the case that this was inevitable within the next 15-20 years. Building on the success of AI approaches to complex games, he was making the case that a computer would be able to analyze all relevant facts, public opinions and historical events in coming to the most reasonable conclusion about any issue that might arise, and would do so without the various human frailties and inevitable personal/political influences that plague “human” political leaders. The interviewer, who seemed to initially approach the whole encounter in a humorous was, by the end, conceding that the AI “person” could at least serve as an impartial advisor to the human decision maker – for now.

All this raises some rather disturbing implications for the medical profession. Clearly, it’s not much of an extension to imagine artificial intelligence of this type finding its way to the development of “Artificial Doctors”. The ability to instantaneously consider all possible evidence, reference all prior outcomes and even “factor in” patient preferences without the nagging issues of personal distraction, fatigue or subconscious biases that plague mere humans seems hugely attractive, particularly when considering the emerging applications of robotic surgery and procedures. One can only imagine how governments and other funders who are struggling with the economic issues related to physician payment, might droll at the prospect of replacing physicians, or what they do, in this way.

This all begs the question, what will be the real value of physicians two or three decades into the future? Generations of physicians, to date, have earned their keep through their knowledge and technical expertise. As those commodities become available in alternative (and decidedly non-human) ways, what’s left? What “value” will mere human doctors provide? What implications does this have for the education we should be providing? I offer a few thoughts on this issue.

  • It all starts with communication. Patients will always come as unique and diverse individuals with varying illness experiences. The ability to interpret their experiences in a way that will allow for the diagnostic and then treatment process to begin will always be rooted in a personal and human relationship.
  • We will need more, not less basic science. A strong understanding in the underlying physiological and pathological processes that underlie disease and clinical presentations will continue to allow physicians to not only understand their patient problems, but also find creative and unique approaches to unusual or atypical presentations.
  • Patients will always value the human interaction. Any study looking at what they value from their physicians prominently includes compassion and the personal interaction that they receive.
  • Patients will need someone to advocate for them. Our health care system is complex, and this is likely to increase in the future. Patients will desire, and need, someone to help them navigate their illness experience. Our educational system should help medical students understand and learn how to utilize “the system” for the benefit of their patients.

Finally, it may all come down to a single word. “Care” is one of those interesting words that serves as both a noun and a verb. As such, it probably allows us a means to best describe the difference between artificial and human intelligence. Computer-based AI will, without question, be able to provide excellent, arguably superior, clinical decisions. However, they will never be capable of truly caring.

Vive la différence.

 

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

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Why students do (or do not) attend lectures

Imagine it’s just before 8:30 on a Monday morning in the School of Medicine Building. The class is assembling for the first session of the day – a lecture to be delivered by a clinical faculty member who teaches perhaps 4-5 times each academic year. The session has been prepared based on objectives assigned by the Course Director. This material, they’re assured, is consistent with the course plan and important to the overall learning plan for the class. As the 8:30 mark approaches and then passes, a sense of unease comes upon the room as it becomes clear that only about half the seats will be occupied. The lecturer, conscious of time, needs to get underway and does so, but is unsettled both by the poor attendance and apparent distraction of those students present, all of whom appear more attentive to their individual screens than to the dialogue. The students in attendance pick up on this unease and reflect it in their feedback about the session. The faculty member is left somewhat discouraged and perhaps embittered that their efforts appear to have been spurned by students, who they might perceive as poorly motivated and unappreciative. In short, everybody loses.

This is, fortunately, not a common occurrence in our school, but is an issue that comes to attention periodically, often early in the winter term when learning fatigue and the weather seem to combine to reduce student enthusiasm. When it does occur, it can be quite damaging and threatens to compromise the excellent student-faculty interaction that is otherwise a strength and characteristic of our school.

What’s really going on? It’s a topic, I think, worth some thought and exploration.

Even a quick literature survey (see below) makes it clear we are not alone with respect to this issue, and there’s no shortage of perspectives on causes and solutions.

The lecture has a long and venerable place in the history of medical education. Great physicians of the past such as Harvey and Osler are remembered as much for their lectures and oratory as for their scientific discoveries. Indeed, medical schools and universities continue to recognize excellence through named lectureships.

The classical lecture is unadorned with slides, videos or instantaneous audience feedback. It is, simply, an encounter between a learned, skilled orator and eager, attentive learners. An accomplished lecturer is informative, inspirational, provocative and thought provoking, and is somehow able to weave all these elements into a compelling narrative, capturing the attention of listeners at a very personal level, leaving them satisfied and enriched for the experience. Listeners at such sessions are wholly engaged, with no personal or electronic distractions. The attempt to “multi-task” is irrelevant, and in fact, detrimental to the experience.

Modern approaches to medical education quite rightfully emphasize the importance of active, small group and case-based approaches. At our 2007 accreditation review, our school was strongly criticized for being too “lecture heavy”. At that time, 80-90% of our teaching content was delivered in lecture format. The curricular review group tasked with revising our curriculum in the wake of that review decided (I think wisely) not to abandon the lecture format entirely, but to establish a balance with small group and case-based teaching, which it felt bring great and complimentary value to our students. Our School of Medicine Building was, in fact, designed with the clear intention of providing venues where both lecture and small group format teaching could be provided, even within the same session. Transition was difficult but has resulted in our current curriculum providing about 40-50% of teaching content in lecture format.

Lecture Classroom

To get a clearer idea of this issue at our school, I surveyed the second year class, posing three simple, open-ended questions:

  1. What do you find most valuable about lectures?
  2. Why do you attend lectures?
  3. Why do you not attend lectures?

I deliberately avoided providing pre-stated options and instead asked for narrative responses. Sixty students provided about 200 separate commentaries. Eleni Katsoulas, our Assessment Consultant, and I then carried out an analysis of the responses. The major themes that emerged are as follows:

What do you find most valuable about lectures?

Graph: What do you find most valuable about lectures?

It appears that what students find most valuable about lectures (37% of responses) is that attendance provides some educational value above and beyond what they can get from their own review of the available information. Almost as many (35%) expressed this somewhat differently, in terms of “clarification” of the information, which we interpreted as providing greater understanding about specific points or differentiation of more clinically relevant information rather than deeper understanding. About 20% identified the direct interaction with faculty and ability to ask questions as the most valuable feature. Smaller numbers identified the interaction with their own classmates (6%) as the most valuable feature, and a few (2%) noted the ability to bring real patients into the sessions.

Why do you attend lectures?

Graph: Why do you attend lectures?

The most common responses, by far, were comments related to the concept that attendance at lectures enhanced and deepened learning of the material (64%). About 16% attend lectures as a means of keeping track of the curriculum and not falling behind. Thirteen percent attend for purely social reasons, to interact with classmates. A few (3%) attend only when particular assessments or specific learning events are planned. Another 3% indicate they attend only because they’ve paid tuition to do so and essentially wish to “get their money’s worth”.

Why do you not attend lectures?

Graph: Why do you not attend lectures?

The most common reason (44%) students cite for not attending lectures is a belief that the sessions bring not value beyond what they can derive through their own review of the material. Another 29% miss for a variety of reasons that could be termed “personal”, which includes anything from preferring to sleep in, to events or activities that they find difficult to schedule outside lectures times. An additional 20% miss lectures in order to attend other activities they feel are more important to their learning, such as observerships. Three percent note that they have found they simply don’t learn in a lecture format, and another 3% indicate they choose not to attend when they fail to see the “relevance” of the material presented.

Additional comments included several expressions of disappointment on the part of students regarding low attendance, and a desire for video recording of lectures.

So, what are we to make of all this? A couple of key points would seem to emerge from both our results and the literature, perhaps self-evident, but relevant to this issue and probably worth articulating.

The students of today have very different learning needs than those of a generation (or two) ago. Fundamentally, they don’t need to attend lectures to gain pure knowledge or factual information, as did the students of Harvey and Osler or, for that matter, as did many of our current senior faculty. That information is readily available to them. Effective teachers understand this and, in addition to factual information, provide personal insights and novel perspectives borne of their own experience and ideas that enhance and complement the student’s personal learning experience. This “higher level” learning that students speak of can take many forms. It may involve explanation of key and complex concepts, guidance to key sources of reliable information, learning how to “translate” factual information into clinical decision-making, or simply the “real life” picture of how experienced clinicians manage the conditions they’re attempting to learn and understand. Fundamentally, they don’t need us (faculty) to deliver information they can easily and more efficiently obtain in other ways. They’re looking for something more.

The lecture is a very human, and therefore “social” event. This is what gives the lecture its power and potential to be a highly effective learning opportunity, providing something above and beyond what can be attained from any recorded material or electronic format. But this is only true if the format is appropriately utilized. From the perspective of faculty, this brings considerable responsibility, and probably some significant stress. They are the centre of attention. The lecture basically excels or fails on their “performance”. Moreover, their “real time” presence at the event requires them to be personally invested in the event, and allows them to interact with the listeners, sense their receptivity to the material, vary their approach, and respond to individual questions. What they provide, in essence, is something very personal, and much more valuable than simple recitation of facts and information.

Students, for their part, also contribute to the success of the lecture by not simply showing up, but by truly attending and participating actively. They must recognize that they get maximal value (the “higher level learning”) by being actively engaged and listening carefully not simply for the factual information, but for added insights the faculty member is able to provide.

In a greater sense, we might regard all this in the context of the Information-Knowledge-Wisdom paradigm. Information consists of all the factual content and points of understanding that are essential to the practice of medicine. The essentials of anatomy, physiologic processes, pathologic conditions and clinical examination would be examples relevant to the study of medicine. Knowledge can be defined as the accumulation of key information, in a manner that allows it to be used for a specific purpose. Learning how to manage a patient presenting with a particular clinical condition requires such accumulated and integrated knowledge. Wisdom is the ability to make correct judgments and decisions. In medicine, it can be considered the ability to decide whether established approaches are appropriate in a particular patient, or how to approach a specific patient when diagnosis is elusive or established approaches are not available. Wisdom derives from a combination of personal attributes, much accumulated knowledge/expertise, and acquired experience. Albert Einstein once said, “wisdom is not a product of schooling but of the lifelong attempt to acquire it.”

The educational process can be thought of as progressions through those three stages of learning as illustrated below:

Illustration of the educational process

In medical education, they clearly overlap, but the first two years of medical school can be considered as largely devoted to developing the information component, with some development of knowledge-based approaches to clinical illness. Clerkship and residency further develop and refine the knowledge component and, hopefully, begin the process of developing wisdom. The development of wisdom, of course, never ends, and never reaches perfection. In fact the three components are perhaps better illustrated in this way:

Better illustration of the educational process

Getting back to the lecture issue, its true place can be considered as providing a means to impart the knowledge and wisdom components of medical practice to the novice learner. That may be its greatest power, and greatest purpose.

The lecture, I would conclude, has evolved and must continue to evolve with the needs of our learners, but has a unique and valuable role in medical education. It is important that both students and faculty understand and actively engage its purpose if it’s full educational potential is to be realized.

A final, summarizing message to our students on this topic might be to remind them of a well-established adage:

“Knowledge speaks, but wisdom listens”

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

Many thanks to Eleni Katsoulis, UGME Assessment Consultant, for her valuable assistance in the compilation of information for this article.

Further reading suggestions:

  • Charlton BG. Lectures are an effective teaching method because they exploit human evolved “human nature’ to improve learning. Medical Hypotheses 2006; 67:1261.
  • Dolnicar S. What makes students attend lectures? The shift towards pragmatism in undergraduate lecture attendance. Conference proceedings of the Australian and New Zealand Marketing Academy. 2004. (http://ro.uow.edu.au/commpapers/81)
  • Massingham P, Herrington T. Does attendance matter? An examination of student attitudes, participation, performance and attendance. Journal of Univeristy Teaching and Learning Practice 2006; 3: 82.
  • Harvard Initiative for Learning and Teaching. 2014. Lecture attendance research: Methods and preliminary findings. http://hilt.harvard.edu/files/hilt/files/attendancestudy.pdf

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CARMS Match Day: 2016

What our students are experiencing, and how to help them get through it

For medical students in Canada, there are three days in the course of their career that stand out above all others: the day they receive their letter of acceptance to medical school; convocation (when they officially become graduate physicians); and Match Day. The most emotionally charged by far, is Match Day. For those of you not familiar, Match Day is when all fourth year students learn which postgraduate program they will be entering. The match is the final step in a long process of contemplation, exploration and application. The match and the day itself are full of drama, with all results being released simultaneously at noon.

This year, Match Day is March 2. By approximately 12:00:05 that day, all students will know their fate. As you can imagine, there will be much anxiety leading up to the release. For most (hopefully all), the day will be one of relief and celebration. For a very few (and hopefully none), there may be disappointment and confusion. Many schools release their fourth year clinical clerks from clinical duties on Match Day. At Queen’s we have taken the position that our students take on professional obligations during their training and their personal celebrations should not supervene those obligations. Having said that, I’d like to remind any faculty supervising our fourth year students on March 2nd of the following:

  1. Anticipate that your student will be distracted that morning
  2. Please ensure your student is able to review their results at noon.
  3. Check on your student. If he or she is disappointed, please be advised that the student counselors and myself are standing by that day to help any student deal with their situation and develop a plan.
  4. Be advised that the students will almost certainly be holding some type of celebratory event that evening. Although your students are not excused for personal purposes, I would ask that you give them every reasonable consideration.

Fortunately, we have an excellent Student Affairs team, headed by Renee Fitzpatrick, who are available and very willing to answer any questions you may have and respond to concerns regarding our students. They can be accessed through Jacqueline Findlay at jacqueline.findlay@queensu.ca, or 613-533-2542. The faculty counselors can also be contacted directly at the following:

FitzpatrickDr. Renee Fitzpatrick, MD, MRC Psych, FRCPC
Wellness Advisor

 

 

 

 


 

KellyHowseDr. Kelly Howse, BSc (Hon), MD, CCFP
Career Advisor
kelly.howse@dfm.queensu.ca

 

 

 

 


 

SusanHaleyDr. Susan Haley, MD, FRCPC
Career Advisor
haleys@kgh.kari.net

 

 

 

 


 

LakoffDr. Joshua Lakoff, MD, FRCPC
Career Advisor
lakoffj@kgh.kari.net

 

 

 

 


Thanks for your consideration, and please feel free to get in touch with myself or any of the Student Affairs Team if you have any questions or concerns about Match Day or beyond.

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

 

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The Framing Effect, Donald Trump and the meaning of truly Informed Consent

Imagine you’re responsible for planning a public health response to a virulent disease that is expected to kill 600 people. You have to choose between two management programs:

  • If Program A is adopted, 200 people will be saved.
  • If Program B is adopted, there is a one-third probability that all 600 people will be saved, and a two-thirds probability that no one will be saved.

Once you’ve made your choice, consider the same scenario, but with the following options:

  • If Program C is adopted, 400 people will die.
  • If Program D is adopted, there is a one-third probability that nobody will die, and a two-thirds probability that 600 people will die.

This test was developed by psychologists Amos Tversky and Daniel Kahneman and was published in Science in 1981. It’s also described in Kahneman’s remarkable 2011 book Thinking: Fast and Slow. Kahneman won the 2002 Nobel Prize for economics, Tversky having passed away in 1996 (apparently Nobel Prizes are never awarded posthumously).

Thinking Fast... Slow
Thinking Fast… Slow

It’s a test of willingness to accept risks, and part of their larger body of work on decision making behaviour. The pairs of options each require the participant to choose between accepting a sure thing (options A and C), or taking a risk (options B and D). Options A and C are factually identical (200 people live and 400 die in each), but differ in that they are expressed in either positive (A) or negative (C) terms. If our risk taking behaviour is consistent, choices should be the same for the two pairs. However, given the options outlined above, a significant majority of respondents (72%) chose Program A over B for the first selection, but then rejected the sure thing, favouring Program D (78%) over C in the second selection.

The differences relate to how the options are expressed, or “framed”. In the first pair, the choices are designed to focus on saving people. In the second, the focus is on how many people will die. When the intention is to save lives, it appears we are risk averse. When the situation is seen to be bleak and inevitably fatal, we are much more willing to engage risk. Put another way, when given choices that result in fundamentally identical outcomes, most people will avoid risk when they perceive potential gain, but are willing to engage risk when confronted with potential losses. “Framing” of our choices is therefore hugely influential.

Kahneman and Tversky describe this as the “psychophysics of value” and describe two ways of thinking. “System 1” thinking is automatic, involuntary and intuitive. It’s also easy, requiring very little effort – “lazy” thinking, one might say. “System 2” thinking is computational, requiring attention, time and effort. We have to actively decide to undertake System 2 thinking. They are the “fast” and “slow” options referred to in the title of Kahneman’s book. The thought experiment described above is System 1 thinking very much in action. World economies, stock markets, politics, advertising and consumerism are all very much about how System 1 thinking can be promoted and manipulated. Hence, the Nobel Prize.

Donald TrumpWe don’t have to go far these days to find an example of this principle in action. Donald Trump’s bombastic rhetoric in the American presidential primaries seems, at least in part, an attempt to “frame” the dialogue in negative terms (American weakness, vulnerability and multiple perceived foreign threats). By doing so, he develops a sense of fear for the future that he hopes will encourage the electorate to engage a risky, non-conventional alternative (i.e. him). Since Mr. Trump has basically no experience in elected office, foreign affairs or any of the expected concerns of a potential president, he needs to steer people away from System 2 thinking. He’s been doing a remarkably, frighteningly, effective job to date.

If you think physicians are above such influences, apparently you’d be mistaken. Tversky and his colleagues carried out a study at the Harvard Medical School wherein physicians were given information about the expected outcomes for surgical versus radiotherapy approaches to lung cancer (McNeil et al. New England Journal of Medicine 1982; 306:1259-62). The five-year survival rates favoured surgery, but with greater short term risk. Half the physicians participating were provided information that focused on survival (one month survival rate 90%), whereas the others were given mortality rates (10% mortality in the first month). Guess what? Eighty-four percent of the Harvard physicians favoured surgery given the first description, compared with only 50% when given the second description. System 1 thinking dominates when we focus on bad outcomes.

So how is all this relevant to medical students and practicing physicians? There are clear implications for our understanding of the concept of informed consent. In Ontario, this comes under the Health Care Consent Act of 1996, which reads, in part:

Consent is not valid unless it is informed. A physician must provide a patient with information about the nature of the treatment, its expected benefits, its material risks and side effects, alternative courses of action and the likely consequences of not having the treatment.

The following clause describes the terms “information” as follows:

The information provided to a patient must be information that a reasonable person in the same circumstances would require in order to make a decision about the treatment.

All, seemingly, very reasonable. However, given what we now understand about the power of framing in making critical choices, it appears making a choice is about much more than the factual content of information provided. The manner in which options are provided and the way in which outcomes are presented will be very influential in determining the response. Imagine an elderly patient with coronary and mitral valve disease who is highly symptomatic and considering surgery for both symptom relief and prolonged hospital free survival. Consider the following three presentations, all of which are factually true:

  1. “There’s a 90% chance that you’ll survive and be home within two weeks.”
  2. “The surgery carries a 10% risk of dying either in the operating room or within two weeks after.”
  3. “There’s no chance you’ll be alive within two years without surgery.”

Do you think there’s a difference in how patients and their families will respond to those three statements?

Do you think the person delivering those options has capacity to manipulate the decision?

Is this a problem?

I think we’d all agree that the answer to the first two questions I’ve posed is unquestionably “yes”. The third is obviously controversial.

Legislation is important and necessary to ensure protection of the public, but it will always be limited in its ability to penetrate the individual relationship between physician and patient. Its role is to balance the need to ensure rights that protect the vulnerable, while not handcuffing or interfering with the delivery of individual care. One can only respect the intention and great challenge of lawmakers who struggle to achieve that balance.

Physicians will therefore always bear a high responsibility in counseling about medical decisions. While it’s true that the patient and chosen advisors always have the “final say”, it’s both disingenuous and irresponsible for physicians to suggest that informed consent begins and ends with the provision of factual information. There’s no escaping the high responsibility that goes with advising. There’s no short cut. Truly informed consent can only be provided by someone who truly understands the patient’s full history, personal situation, wishes and ability to process information. Moreover, it can only be provided by someone who not only understands all that, but also has the patient’s best interest as their primary goal. In our increasingly busy, hospital and service-centred approach to acute care, all this is becoming more difficult to provide.

Are there solutions? Increasing involvement of primary care physicians or non-physician providers, advanced directives and enhanced access to all medical records will all help. At the heart of the matter, however, must be a recognition that the process of deciding to undertake a particular treatment or procedure is at least as important as its actual provision, and should be recognized as such.

Physicians can’t, and shouldn’t avoid being influential in patient decision-making. Is that a problem? Not if that influence is rooted in a truly caring relationship, informed by a deep understanding of the patient’s full situation, wishes and aspirations.

 

 

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

 

Posted on

The Framing Effect, Donald Trump and the meaning of truly Informed Consent

Imagine you’re responsible for planning a public health response to a virulent disease that is expected to kill 600 people. You have to choose between two management programs:

  • If Program A is adopted, 200 people will be saved.
  • If Program B is adopted, there is a one-third probability that all 600 people will be saved, and a two-thirds probability that no one will be saved.

Once you’ve made your choice, consider the same scenario, but with the following options:

  • If Program C is adopted, 400 people will die.
  • If Program D is adopted, there is a one-third probability that nobody will die, and a two-thirds probability that 600 people will die.

This test was developed by psychologists Amos Tversky and Daniel Kahneman and was published in Science in 1981. It’s also described in Kahneman’s remarkable 2011 book Thinking: Fast and Slow. Kahneman won the 2002 Nobel Prize for economics, Tversky having passed away in 1996 (apparently Nobel Prizes are never awarded posthumously).

Thinking Fast... Slow
Thinking Fast… Slow

It’s a test of willingness to accept risks, and part of their larger body of work on decision making behaviour. The pairs of options each require the participant to choose between accepting a sure thing (options A and C), or taking a risk (options B and D). Options A and C are factually identical (200 people live and 400 die in each), but differ in that they are expressed in either positive (A) or negative (C) terms. If our risk taking behaviour is consistent, choices should be the same for the two pairs. However, given the options outlined above, a significant majority of respondents (72%) chose Program A over B for the first selection, but then rejected the sure thing, favouring Program D (78%) over C in the second selection.

The differences relate to how the options are expressed, or “framed”. In the first pair, the choices are designed to focus on saving people. In the second, the focus is on how many people will die. When the intention is to save lives, it appears we are risk averse. When the situation is seen to be bleak and inevitably fatal, we are much more willing to engage risk. Put another way, when given choices that result in fundamentally identical outcomes, most people will avoid risk when they perceive potential gain, but are willing to engage risk when confronted with potential losses. “Framing” of our choices is therefore hugely influential.

Kahneman and Tversky describe this as the “psychophysics of value” and describe two ways of thinking. “System 1” thinking is automatic, involuntary and intuitive. It’s also easy, requiring very little effort – “lazy” thinking, one might say. “System 2” thinking is computational, requiring attention, time and effort. We have to actively decide to undertake System 2 thinking. They are the “fast” and “slow” options referred to in the title of Kahneman’s book. The thought experiment described above is System 1 thinking very much in action. World economies, stock markets, politics, advertising and consumerism are all very much about how System 1 thinking can be promoted and manipulated. Hence, the Nobel Prize.

Donald TrumpWe don’t have to go far these days to find an example of this principle in action. Donald Trump’s bombastic rhetoric in the American presidential primaries seems, at least in part, an attempt to “frame” the dialogue in negative terms (American weakness, vulnerability and multiple perceived foreign threats). By doing so, he develops a sense of fear for the future that he hopes will encourage the electorate to engage a risky, non-conventional alternative (i.e. him). Since Mr. Trump has basically no experience in elected office, foreign affairs or any of the expected concerns of a potential president, he needs to steer people away from System 2 thinking. He’s been doing a remarkably, frighteningly, effective job to date.

If you think physicians are above such influences, apparently you’d be mistaken. Tversky and his colleagues carried out a study at the Harvard Medical School wherein physicians were given information about the expected outcomes for surgical versus radiotherapy approaches to lung cancer (McNeil et al. New England Journal of Medicine 1982; 306:1259-62). The five-year survival rates favoured surgery, but with greater short term risk. Half the physicians participating were provided information that focused on survival (one month survival rate 90%), whereas the others were given mortality rates (10% mortality in the first month). Guess what? Eighty-four percent of the Harvard physicians favoured surgery given the first description, compared with only 50% when given the second description. System 1 thinking dominates when we focus on bad outcomes.

So how is all this relevant to medical students and practicing physicians? There are clear implications for our understanding of the concept of informed consent. In Ontario, this comes under the Health Care Consent Act of 1996, which reads, in part:

Consent is not valid unless it is informed. A physician must provide a patient with information about the nature of the treatment, its expected benefits, its material risks and side effects, alternative courses of action and the likely consequences of not having the treatment.

The following clause describes the terms “information” as follows:

The information provided to a patient must be information that a reasonable person in the same circumstances would require in order to make a decision about the treatment.

All, seemingly, very reasonable. However, given what we now understand about the power of framing in making critical choices, it appears making a choice is about much more than the factual content of information provided. The manner in which options are provided and the way in which outcomes are presented will be very influential in determining the response. Imagine an elderly patient with coronary and mitral valve disease who is highly symptomatic and considering surgery for both symptom relief and prolonged hospital free survival. Consider the following three presentations, all of which are factually true:

  1. “There’s a 90% chance that you’ll survive and be home within two weeks.”
  2. “The surgery carries a 10% risk of dying either in the operating room or within two weeks after.”
  3. “There’s no chance you’ll be alive within two years without surgery.”

Do you think there’s a difference in how patients and their families will respond to those three statements?

Do you think the person delivering those options has capacity to manipulate the decision?

Is this a problem?

I think we’d all agree that the answer to the first two questions I’ve posed is unquestionably “yes”. The third is obviously controversial.

Legislation is important and necessary to ensure protection of the public, but it will always be limited in its ability to penetrate the individual relationship between physician and patient. Its role is to balance the need to ensure rights that protect the vulnerable, while not handcuffing or interfering with the delivery of individual care. One can only respect the intention and great challenge of lawmakers who struggle to achieve that balance.

Physicians will therefore always bear a high responsibility in counseling about medical decisions. While it’s true that the patient and chosen advisors always have the “final say”, it’s both disingenuous and irresponsible for physicians to suggest that informed consent begins and ends with the provision of factual information. There’s no escaping the high responsibility that goes with advising. There’s no short cut. Truly informed consent can only be provided by someone who truly understands the patient’s full history, personal situation, wishes and ability to process information. Moreover, it can only be provided by someone who not only understands all that, but also has the patient’s best interest as their primary goal. In our increasingly busy, hospital and service-centred approach to acute care, all this is becoming more difficult to provide.

Are there solutions? Increasing involvement of primary care physicians or non-physician providers, advanced directives and enhanced access to all medical records will all help. At the heart of the matter, however, must be a recognition that the process of deciding to undertake a particular treatment or procedure is at least as important as its actual provision, and should be recognized as such.

Physicians can’t, and shouldn’t avoid being influential in patient decision-making. Is that a problem? Not if that influence is rooted in a truly caring relationship, informed by a deep understanding of the patient’s full situation, wishes and aspirations.

 

 

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

 

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Is “Apprenticeship” Dead? The case for clinical service in medical education

An “apprentice” is someone who works for a fully qualified individual for the purpose of learning a trade. Although the term has taken on a somewhat negative connotation of semi-indentured servitude, the word itself, interestingly, shares entomologic roots with French verb apprendre (to learn), and the Latin apprehendere (to “grasp” or understand). It would seem then that apprenticeships are intended to be primarily educational endeavors.

Apprenticeships served admirably as the original model of medical education. Eager and bright young people who wished to become doctors would enter the service of an established practitioner, in the same way that aspiring masons or carpenters would engage training from masters of those trades. The apprenticeship provided, in addition to instruction in fundamental knowledge and skills, on-the-job, supervised practice training. Presumably, the level of responsibility and independence of the learner increased progressively over the period of training but, in fact, the contractual arrangements, terms of service and educational program were entirely at the whim of the “master” without consistent standards or regulation. At the end of the agreed-to term of service, the learner would receive the endorsement of the teacher and, after submitting to whatever regulatory process might exist, enter independent practice.

Our Clinical Clerkships and Residency programs are modern day vestiges of the apprenticeship model, the major points of departure being the organizational (school-based) rather than individual focus, and considerably expanded, highly defined and rigorously regulated educational expectations. However, the delicate interlacing of the two fundamental components-education and supervised clinical practice-remains the core, defining characteristic. As those two elements combine (as illustrated in the diagram below),three domains of activity are defined.

3domainsofactivityThe purely educational activities consist of scheduled rounds, conferences, academic days, assessments and various other structured events. Learners are either expected or required to attend. Together, these events provide an established “protected” learning curriculum. These events are deliberately, completely separated from clinical service in order to ensure opportunities exist for the requisite learning.

There are also activities where clinical service and education overlap and occur simultaneously. These consist of clinical activities where learners and teaching faculty work together in the delivery of care, such as clinics, operating rooms, procedural suites and emergency departments. In these settings, the learner is directly supervised, is involved in care delivery to the extent their training and acquired skills allows, and receives instruction ‘on the fly’. The “curriculum” is defined not by a pre-determined schedule, but by the issues presented by the patients receiving care.

This leaves a third component of clinical service that can be considered either indirectly supervised, or independently provided. This consists of activities appropriate to the learner’s qualification and can be considered the “scope of practice” at that point in his or her training. Examples vary considerably, but could consist of ordering basic investigations, prescribing, charting, minor procedures, and patient assessments. As learners progress in training, their “scope of practice” escalates accordingly. This more distinctly service role is recognized officially in the residents’ hospital or practice privileges, provision of payment for service, and development of professional organizations such as PARO which recognize residents as service providers and work to protect that role.

To extend the illustration above, the spheres progressively diverge until, at the end of training, they separate completely as the learner assumes independent practice and, with it, complete responsibility for both their clinical and educational activities. The latter is, in fact, an expression of professional identity.prof-practice

The balance between these two domains and three spheres of activity within medical training has been, and remains, contentious and a point of competitive tension. The need to vigorously protect the educational components of residency training has been very appropriately promoted through the development and protection of core curriculum within training programs and mandated by accreditation standards. The need to put limits on the clinical role has also been recognized and effectively enforced through accreditation and professional organizations that advocate for their members by, historically, promoting protection of purely educational endeavours above purely clinical service activities. The move to more competency-based models of residency education brings many potential advantages, but by formalizing and emphasizing educational processes, may further sideline the clinical service role.

It could certainly be argued that we’ve passed a tipping point where our emphasis on protection of educational activities has diminished the value of clinical service and portrayed to our learner the impression that avoidance is somehow virtuous. This would be appropriate if clinical service had no educational value and was simply a distraction from “pure” learning experiences. But is this the case? Is there an educational price to be paid for reduced clinical service experiences during training? Is it reasonable to consider residency as a “job” in and of itself with expectations of service independent of direct educational context? Expressing the issue another way: is there, in fact, educational value in the provision of clinical service? Some compelling arguments can be made:

The practice of medicine is much greater than the sum of the educational components. It is a complex interplay of scientific knowledge, specific technical skills, and an ability to understand and relate to the individual human situations in all their variety and complexity. There is something about engaging these situations individually that is far beyond what can be attained in any classroom or even directly supervised situation. The ability to do so in a nonetheless safe setting, with understood limits and readily available help is the core educational value of clinical service delivery.

Personal growth and development of professional identity. People in any human endeavour learn by engaging personal challenges and confronting adversity. This is certainly true of developing physicians. In medical school, it begins with the first time a student has a one-on-one encounter with a patient. It progresses steadily through training, but whether it is performing a minor procedure, an assessment in clinic or attending to a distressed patient with an urgent problem, these are all opportunities to grow as providers in a protected and supervised setting where optimal patient care is not only assured, but likely enhanced. This provides training physicians the opportunity to not only learn clinical medicine, but also about their own individual strengths and weaknesses in a way that can’t be reproduced in any artificial educational setting. That self-awareness is essential to professional development and critical to career decisions. Strong personal preferences or deficiencies should be identified and addressed during training, not after graduation to independent practice.

Our patients are our best teachers. Great physicians learn from every patient encounter, no matter how apparently straightforward or routine. This is the basis of lifelong learning. If the practice of valuing and learning from every patient encounter is not engaged and refined progressively during training, will it be developed in independent practice?

Valuing clinical service as a privilege, not a chore. The core mission of Medicine, and of physicians, is the provision of clinical service to our patients. To them, there is no “scut work”. If we don’t value clinical service as an educational community, what message are we sending to our learners? Are they graduating to a career of uninspiring and boring chores? In an educational sense, the development of clinical competence and increasing independence should be recognized, highly valued and accompanied by increasing status and prestige.

Pragmatically, there already exists a contractual definition of residency as a “job” with compensation and obligations. Rather than live in denial of this reality, we might be better advised to engage the balance between those obligations and educational development in a thoughtful way ensuring the optimal expression and value of both aspects.

Finally, we must recognize that this is no longer a theoretical discussion or abstract educational concept. Clinical care is becoming more, not less, demanding within our schools, outpatient clinical settings and academic teaching hospitals. Education and clinical service delivery are on a collision course that can only be averted by recognizing that these two aspects of medical education are individually necessary and mutually interdependent. Both must be preserved. We must recognize this essential duality, particularly as we go about developing newer models for both undergraduate and postgraduate education.

 

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

 

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The Troublesome Ethics of Entrepreneurship in Medical School Admissions

Medical school applications are becoming big business, and a rather troubling expression of supply and demand economics.

The “demand” side consists of the many thousands of young people in North America engaged in the highly competitive process of applying to the limited number of seats available at publicly subsidized Canadian and American schools. Rebecca Jozsa, our intrepid Admissions Officer and I recently explored the “supply” side by carrying out a simple Google search of options available to the assist the aspiring medical school applicant.

For MCAT preparation, we found no fewer than 22 available courses (probably an underestimate). The “MCAT Ultimate LiveOnline 123-hour” experience is offered multiple times per year for $2,199US. For those who prefer more intense and more personal preparations, the “MCAT Summer Immersion” experience can be had for $9,499US, not counting, of course transportation and accommodation. The “Most Comprehensive Prep Course in Canada” runs over 10 weeks, costs $2,195, comes with testimonials from satisfied customers and features both instruction by successful students and “unlimited free repeat policy”. There are many other choices, a veritable smorgasbord of choices.

One can also opt for more comprehensive guidance through the entire application process. One group provides the following offering: “With our flagship service, we offer unparalleled quality that will make your application to medical school stand out”. In addition to “MCAT prep”, clients can opt for any or all of “Online Diagnostic”, “Comprehensive Application Planning”, “Application Review”, “CASPer prep”, “Interview Crash Course”, “Interview Preparation”, and “MMI prep”. Costs, understandably, vary based on individual preference and perceived need, but appear to range from a few hundred dollars for individual components to more comprehensive packages such as the Platinum bundle which goes for $3500US. It’s hard to get all the details as to what’s available without engaging one of the friendly “consultants” for a “personalized needs analysis” (which we declined) but the sky appears to be the limit in terms of costs. Some arrangements even come with money-back guarantees!

It’s clear from the advertising that many of these programs employ, or are even operated by, medical students or recent grads. Who, after all, would be in a better position to provide the “inside information” so essential to success?

So, is all this a problem?

On the one hand, all this is perfectly legal free enterprise. It’s addressing a perceived need, clients are fully informed and fully competent, no one is forced to engage these processes unwillingly. It could be argued that these programs allow very worthy and genuinely motivated young people to pursue their dreams and overcome many of the unintentional barriers that we all would acknowledge are inherent in the admissions system. One could argue that medical schools themselves have given rise to these business opportunities by making the MCAT such an integral component of the admission process, while at the same time dropping basic science prerequisites.

On the other hand, one must also acknowledge a number of potential concerns:

  • The widespread availability of these services may force students to participate to simply not be disadvantaged relative to other applicants. It’s no understatement to say that candidates feel desperate for any advantage in the process. That desperation, it could be argued, is being exploited.
  • This intensive preparation and rehearsing for the various application processes may result in candidates portraying themselves in an unrealistic fashion, thus subverting a process fundamentally intended to ensure applicants are appropriately suited to a career in medicine. Such “mismatches” can be disservice to all, including the applicant themselves.
  • These services are obviously expensive, adding a further socioeconomic barrier to medical education, a problem widely acknowledged in both Canada and the United States.
  • The involvement of medical students, as paid consultants or instructors is troubling. Their recent experience with the details of application processes, including the structured interviews (for which most schools require them to sign a non-disclosure agreement) makes them attractive for this role, but also sets up an ethical dilemma: Can they undertake to help applicants navigate their interviews without sharing information or insights they have acquired as a result of their own experience? Even if specifics are not explicitly divulged, it’s hard to imagine that their recent intimate involvement in the process won’t find its way into their “counseling”.

All this provides lessons and demands reflection on a number of levels.

For the aspiring applicant, perhaps a word of caution. The principle of “caveat emptor” (let the buyer beware) very much applies. There is no accreditation or credentialing process for these offerings. Applicants may not be getting valid advice. I’ve heard anecdotally from students who have been advised to avoid expressing any personal opinions and instead memorize and regurgitate the prepared responses to anticipated questions. Admission committees and interviewers, searching for sincerity and deep commitment to a career in medicine, are astute assessors and have become very attuned to the “coached” candidate. They will become even more vigilant. The sincerity and true commitment they’re looking for tends to stand out, and is very difficult to artificially manufacture.

This entrepreneurial phenomenon should also cause medical admissions committees to reflect on their processes. One has to question the validity of the MCAT as an assessment of scientific aptitude if an “immersion experience” is truly effective in influencing test results. Do we believe a background or interest in basic science is an important applicant characteristic? If so, do we feel successfully undertaking an MCAT prep course meets that criterion?

For medical students, entering a profession that is self-regulatory and rightfully expects high levels of personal integrity and accountability, opportunities to become involved in these programs pose perhaps their first personal ethical dilemma. Clearly, what makes them attractive to these agencies is not their personal counseling or teaching skills, but rather their status as successful medical school applicants, which brings considerable cachet and intimate knowledge which is of high value. They will find (as they will as practicing physicians) that their professional identity can’t be easily separated from their personal lives, and therefore puts them in an ethically ambiguous position.

In our society, it seems supply will always be found when demand exists and sufficient resources are made available. That this has extended to the medical school admission process should come as no surprise. However, it does raise some unintended, but nonetheless concerning consequences. As always, your views on this issue are most welcome.

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

 

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The Art and Science of Medicine – a critical but troubled marriage

“I always feel better after talking to the doctor.”

The first time I recall hearing this statement, it was many years ago, spoken by an elderly lady emerging from the inner office of our family physician. I also recall it leaving me me a little confused, and a little intrigued.

Dr. Mitchell practiced in Collingwood for many years and looked after any malady that might befall members of my family. I was waiting to get my biweekly “allergy shot” (another story). With Dr. Mitchell, you didn’t really have an appointment; you just showed up and read magazines until called. No one ever complained. There seemed to be acceptance that the order was based on some greater principle than “first come, first served”. As I was leafing through a New Yorker searching for the cartoons, I overheard the lady make that statement to her waiting husband as they got ready to leave. I wasn’t really eavesdropping; she seemed to intend the comment for everyone in the room. She’d been in there only a few minutes. She entered clearly worried and upset. She emerged looking considerably relieved and energized.

What, I wondered, had happened in there? Clearly, there had been no time for any treatment to have been administered, let alone take effect. All he could have done was talk to her. And yet, she was better. She was relieved. She was grateful. Whatever happened was effective and made a difference to her. Some talking! I was intrigued, and whatever process eventually led to my decision to consider a career in Medicine probably started, or was at least advanced, that day.

I’ve since heard variations of that statement many times. During medical school and residency I heard it applied by patients to many of the excellent physicians I had opportunity to train with over the years. I heard it applied to many of the highly skilled colleagues I’ve worked with. I consider it to be one of the simplest but also purest ways patients can acknowledge the effectiveness of their encounters with their physician. Simply put, they feel better afterward than they did before.

This ability is not the exclusive domain of physicians. People emerge everyday from their encounters with nurses, therapists, pharmacists with similar feelings of well being and renewed energy.

What’s going on?

To the skeptical, this could be dismissed as some sort of placebo effect, a psychological delusion or defense mechanism that those desperate for help construct for themselves in order to deal with their malady. After all, no concrete intervention has occurred. No pathophysiologic process has been medically or surgically influenced. It doesn’t really make logical sense.

On the other hand, it doesn’t always work, and we’re all aware that making the correct diagnoses and applying appropriate therapy can often be inexplicably ineffective. Patients tell us repeatedly how frustrated and abandoned they feel after encounters where they’re told “everything’s fine”, or “take this medication and you’ll be fine” but are unconvinced, and feel no better afterward. Moreover, sound recommendations may be completely ignored by patients, leaving their doctors baffled, or perhaps never even knowing and therefore content in the false knowledge of a job well done.

All this relates, of course, to the fundamental and critical duality of the physician role – what we’ve come to regard as the “art” and the “science” of Medicine. It’s been appreciated since ancient times that, in order to be effective, physicians must combine their knowledge of medical science with personal qualities and skills that provide and promote a human relationship, a personal link with their patients, and it’s in the context of that relationship (and only in that context) that scientific therapies are effectively applied.

The importance of these humanistic “healing arts” has been well described.

Hippocrates is credited with the aphorism “it is more important to know what sort of person has a disease than to know what sort of disease a person has.”

William Osler is famously quoted as proclaiming, “the good physician treats the disease, the great physician treats the patient who has the disease”.

Abraham Flexner, the non-physician educator who so profoundly transformed medical schools in the early 20th century is famous for championing the inclusion of fundamental science in medical education. He’s less well known for his views on what were termed the “empiric” aspects. The following is taken from his 1910 report:

“The practitioner deals with facts of two categories. Chemistry, physics, biology, enable him to apprehend one set; he needs a different…appreciative apparatus to deal with the other, more subtle elements. Specific preparation in this direction is more difficult; one must rely for the requisite insight and sympathy on a varied and enlarging cultural experience. Such enlargement of the physician’s horizon is otherwise important, for scientific process has greatly modified his ethical responsibility.”1

It’s interesting that 15 years later he tried to correct what he perceived to be an over-emphasis on his recommendations regarding science and technology. The following is taken from Medical Education: A Comparative Study (1925):

“In respect to the position I have thus far taken, a curious misapprehension not uncommonly arises. The careful scrutiny, reflection, and decision (which is the essence of the scientific method), the employment of every weapon by means of which the causation of disease may be ferreted out and health restored (which is the essence of the scientific procedure) – these are sometimes regarded as in conflict with the humanity which should characterize the physician in the presence of suffering. Assuredly, humanity and empiricism are not identical; with equal assurance, one may assert that humanity and science are not contradictory…It is equally important and equally possible for physicians of all types to be humane, and at the same time to employ the severest intellectual effort that they are severally capable of putting forth…The art of noble behaviour is thus not inconsistent with the practice of scientific method”2

The late Bernadine Healy, prominent American physician, academic leader and former head of the NIH, spoke eloquently on this subject and is perhaps more pragmatic: “the art of medicine transcends all else when an anxious individual confronting death or disability looks to the physician and asks, ‘What’s right for me?’” In an excellent article on the subject, she goes on to describe four key components: Mastery, Individuality, Humanity and Morality. Her description of Mastery seems particularly apt: “expertise, not just experience; wisdom more than knowledge; and a creative way of thinking, ever alert to the reality that sickness is not as obvious as it seems.”3

It would seem that the importance of maintaining the “art” as we engage the ever expanding “science” of medicine is critical and fundamental to effective practice. It is what elevates the profession beyond the simple application of remedies or technical interventions. It is, to be more pragmatic, what the public expects, and what it feels it is paying for. It is also what makes the teaching and learning of medicine so very challenging. Knowledge, these days, is easily within our grasp. Technical skill comes to the appropriately skilled with dedication and practice. The ability to understand patients as individuals, establish relationships of trust, and apply treatments with sage wisdom are all much more difficult to identify in applicants, to teach and to assess.

At this point in our history, it seems we’re at a critical juncture. Our dual roles appear to be heading in opposite trajectories. Medical science is in unprecedented ascendency. In virtually every discipline, new and highly effective therapies are available. Conditions previously untreatable are being cured or at least improved. People are living longer and better. All this is wonderful. At the same time, we have many indications that the “art”, the humanistic components of medicine, are under threat and in decline.

The threats are both multidimensional and unintentional.

Time pressure. I know no physician who doesn’t feel under over-extended and under pressure to do more in less time. The provision of “timely”, “efficient” and “cost effective” care has become the paramount objective. Although this may seem necessary and even noble, the result is that our clinics, emergency departments, hospital wards, procedural units, are all under intense pressure to deal with high volumes expeditiously. We fall back on corporate, business- based approaches to deal with these practical issues. It becomes easy to forget that those “high volumes” are individual people experiencing what they perceive to be a time of great personal crisis. They often do not feel the centre of care, but rather something more akin to components on an assembly line. It’s not all bad – necessary care is provided, conditions are treated and usually resolved. But patients too often emerge wondering what happened, and even who was treating them.

The harsh reality is that the medical/technical aspects of care are more easily and more efficiently applied devoid of the need for interpersonal interaction. In our multidisciplinary and team based approach, compassion can come to be regarded as a delegated act.

The primacy of therapeutics over diagnostics. The practice of medicine has gradually and unceremoniously shifted over the past several decades from a largely diagnostic to therapeutic endeavor. This is a function of the greatly expanding therapeutic options, medical, interventional and surgical, now available for many conditions previously not treatable. In addition, many diagnostic tests and procedures are now available that can establish a diagnosis with a minimum of historical information. This is all obviously good, to the benefit of our patients and society at large. However, a consequence of this change is that the communication skills, personal contact and relationships required ferreting out a useful history and differential diagnosis is a less prominent, less essential physician skill, particularly in procedurally heavy specialties. Conditions previously diagnosed by historical and physical examination features alone are now established (even defined) on the basis of laboratory or imaging studies. This may have advantages in terms of time required and objectivity, but the “art” of establishing a diagnosis through insightful questioning and insight (still essential in all but completely straightforward situations) is gradually being eroded and, with it, the necessary human interaction.

Specialization. The dramatic expansion of knowledge and therapeutic options has required physicians to specialize in specific applications of medical service. Medical school graduates in Canada currently select between about 30 entry disciplines, many of which branch further resulting in well over a hundred very different practice options. This, again, is a function of our success and provides advanced, effective service to patients. However, a consequence of this specialization is that, for many physicians, their engagement of patients is exclusively in the context of a very specific, often predetermined, service. The need to establish that interpersonal connection may not be seen as necessary or welcome and, amazingly, may even be seen to be inappropriate to the encounter. This has important consequences. Patients are at risk of being deprived of individual consideration during these encounters. Perhaps more profoundly, the practice of medicine is finding a home for individuals who are unable, or unwilling, to engage the humanistic aspects. In essence, what was previously requisite is becoming optional.

Our award system. In terms of both prestige and monetary compensation, we clearly value situational, specialized technical or procedural expertise over primary patient contact and continuing care. We may value the art and science equally from a theoretical perspective, but our practical choice is very clear. Our learners and young physicians, both astute and aware, are faced with unbalanced choices.

Medical school admissions and curricula. Despite decisions and efforts to make medical education more broadly available to individuals with backgrounds and interests in the broader human experience, it remains largely the domain of those with scientific backgrounds. In fact, pre-medical courses in the humanities are seen as disadvantageous to potential admission since they generally provide much lower marks than science or math courses. Medical school curricula themselves are very much, and understandably, directed to knowledge and skill acquisition, and increasingly to career exploration. The “arts” are simply being squeezed.

These issues, although rather daunting, are nonetheless individually approachable and our profession lacks neither the imagination nor capacity to approach them. However, this brings us to the most significant issue of all. Do we see this as a problem? Is the gradual erosion of humanism within the practice of medicine a threat we must marshal our efforts to reverse, or do we see it as a natural evolutionary change, a natural consequence of how medicine and health care in general must adapt to a vastly expanding base of interest and the resource constraints we’re all only too familiar with? Are those who raise these concerns simply pining nostalgically for a bygone era?

In posing this question, I recognize that my contemporaries and I are not the ones who must provide the answer and necessary commitment to change. It is, in fact, our students and young colleagues who will face this choice and determine the direction of our profession. They will need to consider what’s left without the humanistic “art” of medicine, how it will be regarded by their patients, and how it will be valued by society. The choice is perhaps best summarized by Thomas Lewis, a former medical school Dean and frequent essayist and writer, who wrote:

“The uniquely subtle, personal relationship has roots that go back into the beginnings of medicine’s history and need preserving. To do it right has never been easy; it takes the best of doctors, the best of friends. Once lost, even for as short a time as one generation, it may be too difficult a task to bring it back again. If I were a medical student or intern, just getting ready to begin, I would be more worried about this aspect of my future than anything else. I would be apprehensive that my real job, caring for sick people, might soon be taken away, leaving me with the quite different occupation of looking after machines. I would be figuring out ways to keep this from happening.”4

So, does your patient feel better after seeing you?

 

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

  1. Medical Education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Abraham Flexner. Arno Press &The New York Times. New York. 1910. Page 26.
  2. Medical Education: A Comparative Study. Abraham Flexner. The MacMillan Company. New York. 1925. Page9-10:
  3. http://www.cbsnews.com/news/medicine-the-art/
  4. The Youngest Science: Notes of a Medicine Watcher. Thomas Lewis. Alfred P. Sloan Foundation Series.1983.

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“Visions of sugar plums” and that which endures

Clement Clarke Moore (1779–1863) accomplished much during his lifetime.clement

He was a Professor of Oriental and Greek Literature at the General Theological Seminary in New York City.
His philanthropy led to the development of the section of New York City known at Chelsea.
For many years, he served as a Board member for the New York Institution for the Blind.He produced the two-volume A Compendious Lexicon of the Hebrew Language (1809).
He translated from the French of A Complete Treatise on Merinos and Other Sheep (1811).
He authored a number of treatises and political pamphlets, the most well known being an 1804 attack on then president Thomas Jefferson, somewhat ponderously entitled “Observations Upon Certain passages on Mr. Jefferson’s Notes on Virginia Which Appear to Have a Tendency to Subvert Religion and Establish a False Philosophy”.
He wrote the historical biography George Castriot, Surnamed Scanderbeg, King of Albania (1850), which was apparently highly acclaimed at the time.
Throughout his life he also wrote poetry, which was published in the Portfolio and other periodicals of the day.

blog75-1Despite all this scholarship and civic leadership, the work for which Mr. Moore had the greatest societal impact, is most famously acclaimed, and remembered to this day, is a simple poem he wrote on Christmas Eve 1822 for the entertainment of his own children entitled “A Visit from Saint Nicholas”. In it, he describes Saint Nicholas as “a right jolly old elf”, who arrives on Christmas Eve in an airborne sleigh propelled by eight fancifully-named flying reindeer and enters homes leaving toys for the children. We, of course, have come to know that poem as “The Night Before Christmas”, and recognize that it gave rise to a rather prodigious, endearing and enduring cultural (and commercial) mythology.

blog75-2He never intended for the poem to be published. In fact, it’s said that he was embarrassed that his much more scholarly works were overshadowed by what he considered a trivial work written to calm his overly excited children on Christmas Eve. Over the years, there has been controversy regarding its true authorship, since he didn’t acknowledge it until years after its initial publication. Nonetheless, it has not only survived the passage of time, but has flourished and essentially shaped the Christmas experience of generations of children, not to mention many other literary works, plays, songs and motion pictures.

The story of Mr. Moore and his most enduring work provide interesting lessons and insights. It speaks to the fundamental human appetite for whimsy, willing suspension of reality, and our craving for optimism – the belief in human generosity, and that good things will come to us ‘just because’. Let’s acknowledge that the concept of a kindly, giving, fatherly Santa Claus hasn’t endured simply as a childhood fantasy. After all, children haven’t been purchasing or reading “The Night Before Christmas” themselves over the years. It has endured because those children grow into parents who retain some element or aspiration for that spirit, and wish to pass it along as a gift to their children.

The other lesson from Mr. Moore’s life story, of course, is that we don’t get to choose our legacy. History is replete with examples of people who are remembered not for what they intended or for what they believed they were building through their lives, but for their own personal attributes and how those attributes affected those around them and those who followed. The passage of time provides a harsh and impartial judgment of the worth of what we do. Empires and civilizations rise and crumble. The names and stories of those who led them fade into obscurity “as dry leaves before the wild hurricane fly”, but the human spirit, with all its foibles and idiosyncrasies endures and, with it, the memory of those who express it in various forms. Admiration for those creative, artistic people endures and grows over the years.

I close my last blog of 2015 with a reproduction of the initial, anonymous publication of Mr. Moore’s most enduring work as it appeared originally in the Troy Sentinel in 1823. A little hard to read, but I suspect you can fill in the words.

sentinel

Happy Christmas, indeed.

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

 

Thanks to Lynel Jackson for her always valuable assistance with the illustrations.

 

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