Island Inspiration

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

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

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

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

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

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

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

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

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

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

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

 

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

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

___________________________________________________

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

 

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

Sanders Data3

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

 

MillennialPic

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

What’s the explanation?

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

 

 

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

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

 

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

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

 

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Celebrating Student LEADership

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

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

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

 

Mind the Gap by Elizabeth Clement

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

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

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

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

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

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

This was inspiring:

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

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

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

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

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

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

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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

Posted on

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

 

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

 

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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