Justin Trudeau, “knowing when you might not know” and metacognition in medical education

Pierre-Trudeau

I will admit to being one of those people who went into the last election believing Justin Trudeau was “just not ready”. Too young. Too cocky. Too good looking. Just too perfect. Too dissimilar, I believed, from his famous father who I greatly admired and supported in the past. In fact, over forty years ago, I was quite an ardent supported of Pierre Trudeau. My brother and I were Young Liberals who campaigned actively for his election, and even had the opportunity to meet him briefly at a party event. He was young, intellectual, worldly, unabashedly unconventional, and professed a fresh vision of an open and inclusive “Just Society” that was, frankly, inspirational to idealistic (and probably naive) young people who were eager for change after the long line of staid and decidedly uninspiring conservative leaders who preceded him.

I was explaining all this to one of my sons a couple of weeks before the election when he asked, rather innocently, how was Justin so different from his father? What’s different now than then? Well, I began to explain wisely (and rather defensively), the world’s a vastly different place, much has changed…blah, blah, blah. No doubt true, but as I considered all this further I came to realize that what’s really changed, what really underlies my doubts about young Justin, is me. My own attitudes and perspectives have changed rather profoundly, altering both my comfort with status quo and willingness to embrace uncertainty. All this also brought to mind a piece of advice I came across in a leadership article recently:

“You need to know what you know, what you don’t know, and when you might not know”

All this speaks to the concept of Metacognition. This term, easily dismissed by the righteously self-assured as edu-babble, refers to “cognition beyond cognition” or, more simply put, “thinking about thinking”. The essential concept is that helping students develop self-awareness about their own learning strengths and weaknesses will make them better learners, both now and through their careers. Brings to mind the adage “give a man a fish, you feed him today – teach him to fish, he feeds himself”.

Contemporary interest in metacognition is credited to developmental psychologist John Flavell who published a number of articles in the 1970s which have triggered considerable educational theory. The concept and practice, however, is ancient and is perhaps best exemplified by Socrates who famously challenged his students with probing questions, forcing them to examine and question their own thinking process rather than simply their ability to relate factual information. Many believe that the single quality that differentiates the accomplished and comfortable learner from those who struggle, is the ability to understand how they learn and their ability to take charge of that process.

This is highly relevant to the teaching and learning of Medicine. Effective Physician teachers intuitively and instinctively foster metacognition whenever they challenge their students to explain their thinking or “approach” rather than simply produce a fact or single response to a problem. The emphasis on reflection and portfolio development in medical school are attempts to foster this awareness in our novice learners. Accomplished, highly regarded diagnosticians and scientists are not simply sources of accumulated knowledge. They are expert problem solvers who are able to focus their thinking and creativity on fresh challenges. In fact, they thrive on such challenges and are bored by repetitive application of “conventional” wisdom.

In addition to recognizing and refining our own learning processes, metacognition forces us to confront the fact that we may harbour unintentional cognitive bias. Even a casual search of the term uncovers numerous examples of such latent biases that sound disturbingly relevant to medical decision-making, and probably affected my election decision dilemma. Consider the following:

Anchoring is the tendency to rely too heavily on one trait or piece of information when making decisions. Consider our reliance on demographics, specific risk factors, clinical findings or diagnostic test results that we favour or are more adept at interpreting.

Availability cascade refers to the tendency to rely on events more “available” in our memory, which can be influenced by how emotionally charged they may be. This seems relevant to a physicians tendency to be strongly influenced by recent, adverse outcomes.

Choice-supportive bias is the all-too-human tendency to remember one’s choices as better than they actually were. Enough said.

Confirmation bias is the tendency to search for or interpret information in a way that confirms one’s preconceptions. In medical terms, favouring data that supports our hypothesis and discounting information that doesn’t.

Conservatism is resisting new evidence. The Semmelweis Reflex has come to be associated with rejection of new ideas simply because they’re new. It’s named for Ignaz Simmelweis, an Austrian physician who, in 1846, postulated and observed that maternal and infant mortality was much higher on wards where the physicians moved between autopsies and wards without washing their hands. Semmelweis met with great resistance from his colleagues. In doing so, those colleagues were demonstrating the Status quo bias, which is the tendency to want things to stay the same, to the extent that it prevents appreciation of new ideas or approaches.

Framing effect refers to our tendency to draw different conclusions from the same information, depending on how that information is presented. Any of us who have learned how to deliver critical feedback in conjunction with positive commentary knows what this is about. A related term is selective perception, the tendency for expectations to influence perception – we see what we wish to see.

Negativity effect is the tendency to unevenly evaluate the behaviour of a person one dislikes. This leads us to attribute their positive behaviours to the environment and their negative behaviours to the person’s inherent nature. Our political leaders, most recently Mr. Harper, are undoubtedly victims of this phenomenon.

Optimism bias is the tendency to be overly optimistic with respect to outcomes that we see as favourable or intrinsically pleasing. No doubt Mr. Trudeau benefited from this during the recent election. In the medical context, this might influence how we express interview questions, hoping to develop a picture of favourable outcome to therapies we’ve provided.

Reactance is the urge to do the opposite of what someone wants you to do because you perceive constraint to your freedom of choice, or sense of control. This speaks to less noble aspects of our nature, and is linked to reactive devaluation in which we devalue proposals or suggestions only because they originate from someone we do not value or view as an adversary.

All these concepts relate to limitations fundamental to our human nature and are relevant whether we’re doing the weekly grocery shopping, voting in elections, or making medical decisions. It also seems clear that nothing about the concept of Metacognition is new, in either Medicine or in everyday human affairs. Recognizing it as a valid learning process, and acknowledging the various ways in which our own engagement of new ideas and decision making can be unintentionally influenced is, I believe, of considerable value.

Trudeau-blog2By the way, I’m still not sure about young Justin, but I voted Liberal.

 

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

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Transitions

The past few months have seen a number of changes within the undergraduate program as people transition from and into key roles.

I’d like to particularly acknowledge the contributions of Jennifer Carpenter, John Smythe, Peter O’Neill, Richard Thomas and Melinda Fleming.

Jennifer CarpenterJennifer has been providing incredibly valuable personal support to students for many years, often as the only counselor for the entire school. Over that time, she has made herself available for any personal crisis, literally around the clock. Her work, by its nature, often goes completely unnoticed by all except the student she supports. I know, with certainty, that there are a number of physicians currently practicing and providing valuable care to their communities who simply wouldn’t be doing so if not for Jennifer’s intervention and support. Her dedication and effort really paved the way for the comprehensive student wellness programs we now provide.

John SmytheJohn Smythe has been a highly effective student advocate and promoter of student wellness. In addition to providing personal counseling, he has developed and provided a number of sessions and courses for both students and faculty in Mindfulness and personal wellness that have been much appreciated and highly valuable.

I outlined Peter O’Neill’s contributions in a previous article. I mentioned then how his pioneering efforts in career counseling provided an excellent base for Kelly Howse to build upon. This week, Kelly completed a pan-Canadian consensus effort that she led and which describes standards for the provision of career counseling for MD programs. Peter’s approaches and innovations certainly informed that process.

Richard Thomas has guided our Obstetrics and Gynecology Clerkship for several years. He further refined an already excellent clinical rotation, guiding it through a phase of expansion both in terms of content and regional scope. In addition, Richard was a valuable contributor to our Clerkship Committee and provided personal support to a number of students requiring specific support and accommodations.

Melinda Fleming took up the Directorship of our Peri-operative Medicine Clerkship Rotation with enthusiasm and creativity. This is a particularly challenging course that combines three student experiences- Anaesthesiology, Emergency Medicine and Sub-specialty Surgery. It therefore presents rather unique administrative as well as educational challenges. Learners will continue to benefit from Melinda’s dedication to clinical education in her new assignment.

We’re very fortunate to welcome a number of faculty members who have stepped forward to fill these and other positions.

Jason FranklinJason Franklin received his MD from Queen’s University and went on to complete the Otolaryngology program at the University of Western Ontario. He then completed a two-year fellowship in Head and Neck Surgical Oncology and Reconstructive Surgery at the University of Toronto. He returned to Queen’s in 2013 and has been actively engaged in our teaching program as well as providing valuable mentoring to students. Jason will be building on those interests as he takes on the role of Wellness Advisor.

 

Martin ten HoveMartin ten Hove will also be joining the Student Affairs team as a Wellness Advisor. Martin received his MD from Queen’s University in 1989 and then completed his postgraduate training in neuro-ophthalmology as a McLaughlin Fellow at the University of Miami in 1995. He returned to Queen’s as an Assistant Professor in the Department of Ophthalmology. He was promoted to Associate Professor and awarded tenure in 2001. Dr. ten Hove currently serves as Head of Ophthalmology at Queen’s University, Hotel Dieu Hospital and Kingston General Hospital. He is an active researcher in the neural mechanisms underlying visual attention and has served on the Examination Committee of the Royal College of Physicians and Surgeons of Canada, on the Royal College Specialty Committee for Ophthalmology, and on the editorial boards for the Canadian Journal of Ophthalmology and the Journal of Neuro-ophthalmology. He has worked with ORBIS, the CNIB and the University of West Indies to bring tertiary level ophthalmology to remote locations to help fulfill their educational and clinical needs, and served as the Department’s Postgraduate Program Director from the time of his appointment until 2000.

Joshua LakoffJoshua Lakoff will be working with Kelly Howse as a Career Counselor. Josh joined the Department of Medicine in January 2015 as Assistant Professor in the Division of Endocrinology and Metabolism.  His academic focus is medical education with clinical interests in thyroid cancer, diabetes and pituitary disease. He completed medical school at the University of Toronto. His Internal Medicine and subspecialty training in Endocrinology were completed at Dalhousie University in Halifax.

Craig GoldieCraig Goldie will be working with Susan MacDonald in the Academic Advisor portfolio. He is a Palliative Care physician and an Assistant Professor at Queen’s.  He obtained his undergraduate medicine degree at Queen’s before completing his family medicine and palliative fellowship in Vancouver through the University of British Columbia. Prior to medical school his first degree was in computer engineering. Dr. Goldie is the coordinator for undergraduate medical teaching in palliative care and is involved in the Student Assessment Committee. His area of interests include medical education, use of technology in medical practice, education, and medical quality improvement, and student mentorship.

Gregory DaviesGregory Davies will be replacing Richard Thomas as Director of the Obstetrics and Gynecology Clinical Clerkship. Greg is a Professor and Chair of the Division of Maternal-Fetal Medicine. He has cross-appointments to the Department of Diagnostic Imaging and the School of Kinesiology, and is Director of The Fetal Assessment Unit at the Kingston General Hospital. He received his medical degree from McMaster University after a BA Hons. at Queen’s University. He did his residency in Obstetrics and Gynecology at Queen’s University and his Maternal-Fetal Medicine sub-specialty training at Duke University. Dr. Davies returned as full-time GFT at Queen’s University in 1996. His clinical practice focuses on high-risk pregnancy management, and the detection and management of fetal anomalies. Dr. Davies is an active clinical researcher whose areas of interest include preterm birth prediction, management issues in labour and delivery, aneuploidy screening protocols, and exercise and obesity in pregnancy. Dr. Davies is an awarded teacher and has taught presentation skills internationally to residents and faculty alike on subjects such as effective large group learning, small group dynamics and teaching at the bedside.

Nishardi Waidyaratne WijeratneNishardi Waidyaratne-Wijeratne will become co-director of the pre-clerkship Psychiatry course. Nisha is an Assistant Professor in the Department of Psychiatry. She works as a Consultation-Liaison Psychiatrist at KGH and Hotel Dieu Hospital. She completed her Psychiatry residency training at Queen’s in June 2015 and is a three-time recipient of the UGME Resident Teaching Award. Her academic interests include Psychopharmacology and Innovations in Medical Education.

Vidur ShyamVidur Shyam has taken on the Directorship of Peri-operative Medcine. He is an Assistant professor in the Department of Anaesthesiology. Vidur has been on staff at KGH as an anesthesiologist since 2006. He completed his training in West Germany and received his FRCPC in 2009. He has have been teaching undergraduate clinical skills and FSGL for several years. He is also director of regional anesthesia and his special interests are regional anesthesia and acute pain management.

In his 1910 review of our school, Abraham Flexner quite reasonably questioned whether a small school surrounded by larger centres could survive. The fact that we have not only survived but excelled, is a testimony to our dedicated and talented clinical/teaching faculty. The willingness of so many busy and accomplished folks to step forward to fill these key roles confirms that dedication to education and to our students is alive and well.

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

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It’s time to re-invent the Clinical Clerkship

FlexnerThe need to provide supervised learning within the clinical setting has always been regarded as essential to the development of future physicians. Indeed, early versions of medical education consisted entirely of what could only be termed apprenticeships under the direction of a fully- qualified physician who was engaged by the student as the tutor, mentor and assessor. It was largely as a result of Abraham Flexner’s (pictured) transformational 1911 review of medical education in North America that medical schools were required to provide formal instruction in the basic and medical sciences. However, Flexner continued to emphasize the critical role of learning with the clinical setting. This became consolidated into the discrete role that came to be known as the Clinical Clerkship.

group72Being a “Clerk” was to have a job or role within a hospital’s complex system of service delivery. The role consisted of “clerking” patients (carrying out admission histories and physicals), following the progress of patients through their hospital stay, arranging and following up on investigations, and coordinating discharge and post hospitalization follow-up. In addition, Clerks had unofficial but widely accepted service delivery roles of their own within hospitals, including phlebotomy, administering intravenous medications, performing simple procedures such as Foley catheter insertion, cast removal, simple suturing and recording electrocardiograms. Appropriately supervised and monitored, this role provided opportunities to engage patient care in all its complexity in a transitional fashion, leading eventually to more independent practice after graduation. The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today. Importantly, the role of the Clerk varied very little between services, specialties and differing patient populations, the goal being to develop strong foundational skills in patient assessment and management, which were felt to be consistent and “learnable” within any patient care context.

In short, being a Clinical Clerk was a job. Clerks had a widely understood and (dare we say) useful role within the hospital. As a Clinical Clerk, a medical student felt part of the service delivery because they were making a tangible contribution. They therefore felt, and were, valued.

Many factors have combined to, gradually and without deliberate intention, dramatically alter the role:

  1. The service components came to be recognized as excessive and non-educational, to the point of diminishing true educational opportunities. Accreditation standards confirm and reinforce this perspective.
  2. Our hospitals have become much more focused on efficient, focused, therapeutic management of patients with complex and critical diseases. Diagnostic processes, so important to the Clerkship learning experience, have largely shifted to the outpatient setting.
  3. Career selection and the CaRMS application process have become a major focus for our students, making multiple, shorter service assignments preferable to the longer, continuing assignments that allowed the Clerk to develop a clear role within service teams.
  4. Hospitals are much more regulated environments that require clear definitions of roles and scope of practice for all providing care.

Although these issues are all valid, one must now ask what price we’ve paid for this evolution. A few questions come quickly to mind, and are being asked by our students, faculty and hospital personnel on a daily basis :

  • What aspects of patient charting are Clerks expected to provide?
  • To what extent are Clerks empowered to write patient orders?
  • What diagnostic tests are Clerks empowered to order?
  • Is a Clerk permitted to submit a consultation request or requisition for an invasive investigation?
  • What medications can a Clerk prescribe, if any?
  • What procedures are Clerks expected to provide?
  • Can a Clerk obtain informed consent for procedures? If so, what procedures?
  • To what extent should a Clerk be expected to provide care for a patient in an emergency (arrest) situation?
  • In all these issues, what degree of supervision is required, and by whom?

Clearly, the application of all these aspects of service provision will vary between clinical assignments, but their fundamental nature (or, to use hospital terminology “scope of practice”) should be consistent throughout. It should not be necessary to re-define the Clerk role for every rotation.

Our Hospital Liaison Committee, capably chaired by Christopher Gillies with representation from all teaching hospitals, faculty, administration and students, has recently been considering solutions to the Learning Environment concerns described in previous articles (meds.queensu.ca/blog/undergraduate/?p=2026). They recognized that many of these concerns may have their roots in this lack of clarity regarding the Clerk role and have therefore advocated a redefinition of the role. To this end, our Clerkship Committee (Chaired by Andrea Winthrop and consisting of all Clerkship Course Directors) met this past week to re-define the role or “job” of the Clinical Clerk, recognizing our current educational requirements and current reality of the hospital based learning environment. They have already made excellent progress in addressing the various issues listed above.

To short, our senior medical students (Clinical Clerks) are able to make valuable contributions to patient care in the hospital environment. It is in doing so that they truly grow as physicians. That can only happen with a clearly articulated and widely accepted role description, appropriate to the modern hospital environment, developed jointly by medical education and hospital leadership.

 

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

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Accreditation Success Stories…and lessons going forward.

Medical school accreditation has been described, with some justification, as the colonoscopy of medical education. The parallels are rather striking:

  • Both require a long and distinctly uncomfortable period of preparation.
  • Both require a public exposure of personal features most would prefer to keep modestly hidden.
  • Both can get messy.
  • Both carry high potential for embarrassment.
  • In both cases, the procedure itself can be tortuous and painful.
  • And finally, for the asymptomatic and fundamentally healthy, their value is highly debatable.

Also like colonoscopy, one emerges from a successful examination with a sense of great relief. That relief, in part, is simply related to having completed the process. Doing so with a successful report of findings adds immeasurably to that sense of relief.

At Queen’s, we are fortunate to have recently emerged from our own collective internal examination with that great relief, having achieved a full eight year approval, with no further invasive procedures required until 2023.

Reflecting now on a process that really started after our last review in 2007, it’s possible (and probably healthy in a preventive sense) to set aside for a moment the struggles and various deficiencies that required attention, and focus rather on the positives that have emerged. A few come particularly to mind and merit attention because they bear important messages we should carry into the future.

Firstly, our success was based on our ability to mount a common effort. Without question, the very real threats to our school imposed by the 2007 review galvanized our efforts and collective will in a way that made possible the changes that we needed to make.

Our Deans (both Drs. Walker and Reznick), engaged accreditation efforts with resolve and unconditional support. Our university leadership (particularly Principal Woolf whose first duty in his new role was to publicly defend a medical school he had just inherited), have been staunch supporters of the accreditation effort. Our Department Heads, to a person, have been nothing but supportive of the school. Our curricular leadership, undergraduate office, medical education team, medical technology unit, hospital partners and, critically, our students, all came together to meet the various challenges, and did so with methodical efficiency, driven by a shared desire to support (dare I say, defend) our school. One sees such common, focused effort only rarely, and usually only when necessitated by great and imminent peril. It is nonetheless rather inspiring to consider what our common efforts achieved and speculate on what might be possible if we could continue to work collaboratively without the need for external motivation.

Secondly, one must acknowledge that many significant and enduring changes emerged from these efforts. A robust and effective new curriculum, effective assessment methodologies, creative and updated approaches to teaching, a revised and much more effective governance structure, a refurbished framework of policies and procedures, our highly impressive and sought after MedTech curricular management system, and even our new School of Medicine Building itself were all, at least in part, motivated or accelerated in their development by our accreditation efforts.

The process brought welcome attention to a number of areas of strength within our school, often overlooked as we focus attention on problem areas. Refreshingly, and unexpectedly, the recent report made reference to our teaching, which it identified as an area of strength. To quote from our report:

As reported by students in the ISA [Independent Student Analysis] and by the survey team, the program benefits from many capable and dedicated teachers. For example, in the MEDS 125 [Blood and Coagulation] course, with 99% of students commenting on the course, no negative comments were made within the 9 pages of comments, and the survey report suggests that the Course Director and the faculty involved in this course are to be congratulated…. Another course that received similar accolades was MEDS 127 [Musculoskeletal], where the team reported: “Dr. L Davidson who continually monitors and enhances the course. This is a “poster child course” and Dr. Davidson deserves significant recognition for the evolution of this highly innovative and interactive course.”

In fact, we are truly blessed with many dedicated and talented teachers, knowledgeable and committed faculty leaders in all key portfolios, committed and hard working undergraduate administrative and educational support teams, and a receptive and engaged student body.

In the final analysis, the most enduring lesson we should take away from our eight-year struggle with the accreditation process must be that we never again require a “crisis” to spur us to collective action in order to ensure we are providing the very best educational experience for our students. Complacency is poison. The continual, collective pursuit of quality improvement and courageous innovation must be our continuing goals. These are the lessons of the day.

 

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

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The Museum of Health Care: Documenting our Inspirational History

Inspiration is one of those things we all intuitively understand, but defies clear definition. The best I’ve come across is “stimulation or arousal of the mind to special or unusual activity or creativity”. Sounds a little too clinical. Perhaps better capturing the spirit of inspiration are a couple of quotes from fairly famous folks who have more than a passing familiarity with the topic:

“You never have to change anything you got up in the middle of the night to write.”

– Saul Bellow

“I never made one of my discoveries through the process of rational thinking”

– Albert Einstein

What seems clear is that Inspiration drives creative discovery and innovation in all fields of human endeavor, from the arts to fundamental science. It comes upon us unexpectedly, almost like a gift from above, but we need to be prepared to receive it, open to possibilities, open to novel ideas, willing to challenge convention.

I was “inspired” to consider “inspiration” recently when asked to provide some remarks at a showcase highlighting the role of the Museum of Health Care in our community.

MuseumAs one looks over the various displays and artifacts in its impressive collection, it’s easy to feel a little smug and even amused by the quaintness and crudeness of some of the devices and approaches that are no longer in use. In reality, each new retractor, forceps, sterilization technique or monitoring device represents an occurrence of inspiration and creative innovation. Behind each display lurks a physician or scientist who had an idea and, by virtue of their unique contribution, advanced the standard of care for the patients of their day. They also contributed to a line of continuing innovation that reaches us today. They remind us that we have no monopoly on creativity, industry, or dedication to the care of our patients. Certainly no monopoly on inspiration.

inspiration2The showcase provided an opportunity for our students and faculty to not only view and experience the richness of our heritage but also reflect on our place in it. Dr. Susan Lamb, our interim Hannah Chair in History of Medicine provided a fascinating perspective on the impact of Laennec and his contribution to the development of the stethoscope.

It’s particularly reassuring that the inspiration for this showcase came from one of the youngest among us. Chantalle Valliquette, one of our QuARMS students, shown here with Dr. Jennifer McKenzie (QuARMS Co-Director) and inspiration3Theresa Suart (Educational Developer), developed and promoted this idea as part of her community outreach project, together with the support and capable assistance of Museum of Health Care staff Maxime Chouinard, Jenny Stepa, Ashley Mendes, Deanna Way, Kathy Karkut and Diana Gore.

Knowing that such dedicated folks are safeguarding and promoting our heritage is, well, inspiring.

 

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

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Tony’s Top Ten Tips for Success and Happiness in the Clinical Clerkship

This week, the class of Meds 2017 begins their Clinical Clerkship. This is a highly significant milestone in their medical education, representing not only the half-way point, but also a transition from a program dominated by knowledge and skills acquisition carried out in classrooms and simulation settings, to “real life” learning in a variety of clinical placements and elective experiences. Last Friday, this occasion was marked by a White Coat Ceremony, conducted by Drs. Armita Rahmani and Sue Moffatt, and featuring personal presentations and “pearls” from Drs. Heather Murray, Andrea Winthrop and Dean Reznick.

meds2017

Top Ten lists have become ubiquitous, including those providing unsolicited advice for medical students. In fact, a quick Google search revealed no fewer than 76,200 such compilations, ranging from the authoritarian to the humourous. Undeterred, I offer my own list, all based on more than a few years of experience and observation as to what works and what sometimes goes wrong. So, here goes, in no particular order…

  1. Show up, and show up on time. It all starts with dependability. Even the most brilliant among us are useless if absent or unreliable. On the other hand, there will always be a welcome for the honest, steady contributor. If you are late, apologize, and do not show up with the coffee or snack that you picked up on the way.
  1. Repeat after me: “I don’t know. Self-awareness is right up there with dependability. There will be things you don’t know. There will be things nobody knows. You will not get into trouble or lessen your reputation by admitting to a lack of knowledge or experience with a particular clinical situation or procedure. After all, you’re a medical student, you’re not supposed to know everything! You do need to know what you don’t know. You will have major problems if you compromise a patient’s care through your unwillingness to admit limitations.
  1. Make it your business to learn about things you didn’t know first time. In fact, become an expert in that issue and look for opportunities to apply your new knowledge. When you do, you’ll find it intoxicating, and will search out even more knowledge. Careers have been built on less. Regard every patient and fresh problem you encounter as your curriculum. Keep track. You’ll be amazed at what you’ll be learning, and how fast.
  1. Remember that no decision that’s made honestly and in the patient’s best interest can be wrong. Anything we recommend for our patients, even the simplest decision, test or therapeutic intervention must meet one of three (and only three) criteria – it must relieve symptoms, improve functional capacity or increase life expectancy. There is no other justification for any intervention. You can’t be wrong for trying honestly to achieve one of those goals.
  1. And yet, things can go wrong... Even the best and most obvious decision may not go the way we intend or hope for. When things do go wrong and patients suffer adverse outcomes, it must be openly acknowledged and understood to ensure everyone (including you) learns from that outcome and becomes a better provider. As a medical student, you will not be the responsible party, but are nonetheless in a position to learn. Don’t be afraid to engage such situations, and don’t hesitate to discuss your feelings and reactions with more experienced people.
  1. Ask questions. Not to impress or stand out, but because you really want to know, and are concerned about the impact on your patient. Ask respectfully, but don’t be afraid to challenge decisions. Good clinicians don’t mind being asked to explain what they’re doing. Really, they don’t.
  1. Get along. With everybody, not just those you think are important. Do this all the time. Everyone you encounter knows more about the practical aspects of health care delivery than you do. They all have something valuable to pass along if you’re attentive and receptive. I’m going to use a key word here: Humility. People can sense it and respond positively to it. The opposite is arrogance, which people can also sense but respond to quite differently.
  1. Eat, sleep, laugh. You’ll be busy, but not so busy that you won’t have opportunity to look after your own well-being. Use your down time wisely. Plan meals and recreation. Surround yourself with people who know you well and have the capacity to make you laugh. They will become increasingly precious to you. Talk to them.
  1. Be open to possibilities. If you think you’ve decided on career choice, don’t be shocked (or worse yet, disappointed) if something unexpected emerges. If you feel strongly conflicted, there’s probably a good reason. Talk it out with someone and remember it’s never really too late to change. If you can’t decide because everything seems great, that’s a good thing, but you might also need to talk it out. We’re available.
  1. And finally… look after each other. You know each other very well, and will know when someone is having difficulties, likely before they know it themselves. Don’t be afraid to reach out, or to seek advice or help. Our Student Affairs staff, headed by Dr. Fitzpatrick, Janet Roloson and myself are all available to you or your colleague. Remember QMed Help, the red button available on MedTech.

 

So there you have my list. Happy to receive revisions, additions or comments from readers. Final word to our students – enjoy. Clerkship is a great time to grow and learn.

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

 

 

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Summer School for Surgical Skills:

More student directed learning

About a month ago, we published the first installment in a series of articles we’ll be providing over this academic year featuring student directed learning that’s occurring in our school. We heard at that time of Alyssa Louis’ exploration of aerospace medicine. This week, I’ve asked Meds ’16 student Riaz Karmali to report on behalf of a group who have worked together and collaborated with faculty to develop a special learning experience in practical surgical skills. Riaz adds some personal perspectives based on his own experience with a medical student fellowship at the MD Anderson Cancer Centre.


Stepping from Idea to Reality: My Experience with the Surgical Skills and Technology Elective Program (SSTEP)

Only a handful of medical schools in North America have structured surgical bootcamps available to pre-clerkship medical students. Two summers ago, the Surgical Skills and Technology Elective Program (SSTEP) was piloted at Queen’s for second year students. This 2-week simulation-based program is designed to build technical skill and prepare students for the operating room. Participants practice suturing, vascular anastomoses, bone fixation, local skin flap design, and nasogastric and chest tube placement amongst other procedures in the surgical skills laboratory. The inaugural program had 22 participants and ran again this summer with increased faculty support and expanded simulation workshops.

SSTEP

How did SSTEP, an entirely student-led initiative, transform from a progressive educational idea into a sustainable program? The success of any early-stage venture, like a high-stakes horse race, is based on two players: the idea itself (the horse) and the team behind it (the rider). Jennifer Siu, Daniel You, and Stefania Spano were the “instigators.” As driven students, outside-of-the-box thinkers, and great team players, they developed a comprehensive proposal and pitched it to Queen’s faculty. Thankfully, they allowed me to come along for the ride. The goal was to prove that SSTEP was worth its $10,000 budget, faculty time commitments, and use of surgical training and laboratory resources.
The SSTEP curriculum has both a didactic and hands-on component integrated into each day. It was eventually tailored to align with clerkship learning objectives. The idea is to provide students with a non-threatening academic environment where they can practice with up-to-date surgical simulation technology. Students can also be able to explore their interest in surgery and surgical subspecialties. In addition, they can receive guidance from senior medical staff and take advantage of a low faculty to student ratio. The curriculum went through multiple iterations before faculty and administration approval.
But how do we know that SSTEP actually builds technical skills? The concept of hands-on instruction in a simulation-based laboratory accelerating the acquisition of technical skill is intuitive. I had experienced this as a first year medical student. I won a summer research fellowship to MD Anderson Cancer Center in Houston, Texas where my project required me to learn basic microsurgery techniques. In the laboratory, I started out with silicon tubes and progressed to arteries and veins in a live rat. However, I was disappointed that I could not quantify my improvement.
Practicing basic microsurgery techniques but unable to quantify improvement.
Practicing basic microsurgery techniques but unable to quantify improvement.
Naturally, we then decided that SSTEP participants should complete an Objective Structured Assessment of Technical Skill (OSATS) before and after the program. It was mandatory to complete a 12-minute basic suturing station in order to track skill acquisition. This research was particularly important given our cost-sensitive healthcare environment that is increasingly dominated by outcomes assessment.
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Participants completing an OSATS before and after SSTEP to track outcomes
Outside of technical skill, SSTEP also develops surgical knowledge, confidence, and career interest. With the guidance of our supervisor, Dr. Paul Belliveau, we created a written test (partly adapted from Principles of Surgery Royal College Exams) and exit survey to measure these outcomes directly. Our results were accepted to the Association of Surgical Education (ASE) and Canadian Conference on Medical Education (CCME). Jenn and Dan recently presented at the CCME. Hopefully, our experience with SSTEP can be a template for other medical schools interested in launching a pre-clerkship surgical boot camp. At Queen’s, we punch above our weight!
Outcomes of SSTEP:
→ The SSTEP written exam had a maximum test score possible of 73 and students scored significantly higher on the post-test compared to the pre-test (52.1 5.9 vs. 35.8 6.5 p =0.01)
→ Participants showed an increase in technical skill:

→  At the end of the program, 50% of participants said they considered a new surgical subspecialty while 72% of participants reconsidered elective choices

→ SSTEP was recommended to fellow pre-clerks by 100% of participants

→ Comparative and long-term analyses of SSTEP outcomes will continue with subsequent generations of the program
Looking forward, new “disruptive” ideas and technologies will continue to change the way medicine is taught and practiced. The mobile web, big data, robotics, and accelerated drug development are just a few domains where we have seen an unprecedented explosion of investment. Therefore, it is important that the next generation of physicians be dynamic thinkers that can anticipate future challenges and meet them with relevant experience. Any venture that improves the way we take care of a patient, treat disease, or deliver therapy is well worth the successes and failures that go along with it.
I would like to thank the leaders of SSTEP, Jenn, Dan, and Stefania, for bringing me onto their team. I would like to thank Dr. Belliveau for his support with the research study, Dr. Reznick, Dr. Rudan, and Dr. Sanfilippo for their dedication and wisdom, Ms. Kim Garrison for help with the surgical skills lab, Dr. Winthrop for curriculum development, Dr. Leslie Flynn and Bill Leacy for their financial expertise, all of the residents and faculty facilitators, and the amazing support staff who made SSTEP possible!
The inaugural SSTEP Class of 2014
The inaugural SSTEP Class of 2014

A vastly expanded number of practice options are now available to our students. At graduation, they are faced with a choice between no fewer than thirty direct entry postgraduate training programs. Providing opportunities to explore career options and to tailor their learning experience has therefore become a common and major objective of both students and medical schools. Working with our students, building on their imagination and initiative, is proving to be a winning strategy.

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

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Introducing Queen’s Meds 2019

In late August and early September each year, the university seems to reawaken as returning students repopulate the campus. Our medical school curriculum is one of the first to get underway and, this past week, we welcomed members of Meds 2019, the 161th class to enter the study of Medicine at Queen’s since the school opened its doors in 1854.

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A few facts about our new colleagues:

They were selected from the largest applicant pool in recent memory – 4669 highly qualified students submitted applications last fall.

Their average age is 23 with a range of 19 to 31 years, with almost equal numbers of men and women (51% women, to be exact).

They hail from no fewer than 46 communities across Canada, including; Ajax, Ancaster(2), Aurora, Bowen Island, Brampton, Brantford, Calgary(2), Cambridge, Campbellton, Coquitlam(2), Courtice, Elora, Gormley, Guelph-Eramosa, Halifax, Kanata(2), Kelowna(2), Kingston, Lasalle, London(2), Markham, Midland, Mississauga(6), Newmarket(2), North Vancouver, Okotoks, Orillia, Orleans, Ottawa(10), Pembroke, Pickering, Richmond Hill(7), Rosseau, Scarborough(5), St. Catharines, Thornhill (2), Thunder Bay, Toronto (19), Trenton, Vancouver, Vaughan, Victoria, Virgil, Waterdown, Windsor (2) and Winnipeg (2) .

Seventy-six of our new students have completed an Undergraduate degree, and twenty-seven have postgraduate degrees, including five PhDs.  The average cumulative grade point average achieved by these students in their pre-medical studies was 3.77.  Their undergraduate universities and degree programs are listed in the tables below:

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An eclectic and academically very qualified group, to be sure.

At their welcoming session they were called upon to demonstrate commitment to their studies, their profession and their patients.  They were assured that they will have a voice within our school and be treated with the same respect they are expected to provide each other, their faculty and all patients and volunteers they encounter through their medical school careers.  At that first session, they were welcomed by Mr. Jonathan Krett, Asesculapian President, and Dr. Rene Allard, who provided them an introduction to fundamental concepts of medical professionalism. Over the course of the week, they met curricular leaders who will particularly involved in their first year, including Dr. Michelle Gibson (Year 1 Director) and Dr. Cherie Jones (Clinical Skills Director). They were also introduced to Dr. Renee Fitzpatrick (Director of Student Affairs) and our excellent learner support team, including Drs. Kelly Howse, Susan Haley, and Susan MacDonald, who oriented them to the Learner Wellness, Career Counseling and Academic Support services that will be provided throughout their years with us. They met members of our superb administrative and educational support teams led by Jacqueline Findlay, Jennifer Saunders, Amanda Consack, Kate Slagle, and first year Curricular Coordinator Corinne Bochsma.

Dr. Jaclyn Duffin led them in the annual Hippocratic Oath ceremony. Dr. Susan Moffatt organized and coordinated the very popular and much appreciated “Pearls of Wisdom” session, where fourth year students nominate and introduce faculty members who have been particularly impactful in their education, and invite them to pass on a few words of advice to the new students. This year, Drs. Erin Beattie, Jaclyn Duffin, Jay Engel, Renee Fitzpatrick, Jason Franklin, Michelle Gibson, Mala Joneja, Steve Mann, Alex Menard, Terry O’Brien, John Smythe, David Taylor and were selected for this honour.

They met and were greeted by Dean Richard Reznick who welcomed them and challenged them to be “restless” in their pursuit of personal goals and advancement of the profession.

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

Their Meds 2018 upper year colleagues welcomed them with a number of formal and not-so-formal events. These include orientations to Queen’s and Kingston, introductions to the mentorship program, and a variety of evening social events which, judging by appearances the next morning, were much enjoyed.

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

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

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The Making of a Closer

Roberto Osuna is a closer.

The term “closer”, in this case, refers to a person who has a critical, very specialized, and highly visible position of responsibility on a baseball team. These folks are called upon to come into the game at the most critical juncture, when the outcome is very much in doubt, and are entrusted with ensuring that all the hard work accomplished by their teammates in establishing a lead is completed by striking out the last few opposition batters. As the closer goes about his task, he stands alone, the focus of attention. His teammates, managers, the opposing team, forty or so thousand people in the stadium and millions of people viewing, are transfixed in attention to every move. If successful, there is great jubilation, and he emerges as a hero, at least for today. If he fails, it is with great public exposure and he bears the burden of responsibility for the loss.

OsunaMr. Osuna has an uncanny way of engaging this role with cool and detached resolve. He is very successful, performing at the highest level, on a professional baseball team, in the midst of a highly scrutinized playoff race.

Did I mention that he’s 20 years old?

 

All this begs the question: what allows anyone to engage and excel in such a role, much less someone so young? An obvious answer is that Mr. Osuna is blessed with the ability to throw baseballs with prodigious velocity and accuracy. While certainly true, this fails to capture the entirety, or even the essence, of what’s required. There are many professional pitchers whose skills match those of Mr. Osuna and yet are ineffective in the closer role. How many of us, if magically endowed with the ability to throw the 97 mph fastball, would be able to do so effectively in the highly stressful setting Mr. Osuna faces on a regular basis? The physical skills, it would seem, are essential but not sufficient. There’s something about the attitude and personal qualities of the individual that enable him to translate these innate skills to success in his chosen occupation.

Recent attention in the press to Mr. Osuna’s dramatic emergence sheds some light (references below). Growing up in a poor coastal city in northern Mexico, quitting school at age 12 to work harvesting crops to support his family, practicing and playing baseball in the evenings, competing in leagues far away from home against men much older than himself in Mexico, Japan and the United States, overcoming language issues and, just last year, undergoing and rehabilitating from major elbow surgery, are all evidence that he has packed much life experience into his 20 years. He himself attributes his success to his family support and deep religious faith. He displays self-awareness and perspective well beyond his years: “I don’t think I deserve anything. But I try to do the best I can, get ready each day and be ready inside the stadium and outside too. I know where I came from and where I want to go.”

LaTroy Hawkins, a veteran relief pitcher who has seen his own share of adversity and began his career before Mr. Osuna was born, provides these insights regarding his new teammate: “I’ve always said, guys who are from rough areas, they’re comfortable being uncomfortable…Pitching in the big leagues is nothing compared to living where I did. Trying to live and survive in the inner city…that’s stress.”

In “Aequanimitas”, William Osler’s 1889 valedictory address at the University of Pennsylvania, he describes “imperturbability” as an essential attribute of the successful physician, and defines it as “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril”….“it has the nature of a divine gift, a blessing to the possessor, a comfort to all who come in contact with him.” He goes on, however, to describe how a “mental equivalent to this bodily endowment”, which he terms equanimity, can be characterized and cultivated by the student physician.

This week, a hundred of Mr. Osuna’s contemporaries began the study of Medicine at our school. They’ve been selected partially because they’ve demonstrated that they possess the academic equivalent of the 97 mph fastball. As with Mr. Osuna, their career success will be determined by much more, by an array of personal qualities also considered in the application process, Osler’s “imperturbability” among them. Their medical education will be as much about developing equanimity and those “mental equivalents to the bodily endowments”, as about acquiring factual knowledge and skills – a truth as relevant in our time as in Osler’s.

 

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

 

Thanks to Meds ’16 student and former Aesculapian Society President Carl Chauvin who shared with me some key insights that contributed to this article.

http://www.theglobeandmail.com/sports/baseball/blue-jays-rookie-reliever-roberto-osuna-thriving-on-the-games-biggest-stage/article26041351/

http://www.thestar.com/sports/blue_jays_baseball_blog/2015/08/blue-jays-bullpen-latroy-hawkins-says-roberto-osuna-has-it-factor-.html

http://www.thestar.com/sports/bluejays/2015/08/10/blue-jays-roberto-osuna-pitching-well-beyond-his-years.html

Sir William Osler 1849-1919. A Selection for Medical Students. Edited by Charles G. Roland. Hannah Institute for the History of Medicine. Toronto.

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“When you wish upon a star…” Alyssa’s Journey

When you wish upon a star
Makes no difference who you are
Anything your heart desires
Will come to you.

From: Pinocchio (1940), Walt Disney Pictures. Sung by: Cliff Edwards

The idea of allowing students to determine and design their own educational experiences may seem counter-intuitive to many, including students themselves. It’s certainly not easy to implement. However, setting aside the initial reaction and obvious practical issues, what eventually emerges is the realization that this is an approach with potential to bring out the best in the motivated student, extend the educational experience far beyond the traditional paradigms, and model the sort of life-long learning we’re hoping to ingrain in all our students.

“Self-directed learning, in its broadest meaning, describes a process in which individuals take the initiative with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying resources for learning, choosing and implementing learning strategies and evaluating learning outcomes.”  (from: Knowles, M. S. 1975. Self-directed learning: A guide for learners and teachers, Prentice Hall, Englewood Cliffs, New Jersey).

For those who require further convincing, I’ve asked Alyssa Louis, one of our Meds ’16 students to provide a guest blog this week. With the help and cooperation of Clerkship Director Andrea Winthrop and assistance of Clerkship Coordinator Jane Gordon, Alyssa arranged to undertake a rather unique elective experience during her Clerkship, pursuing an interest (perhaps “dream” or “obsession” would be better descriptors) she’s had for some time. As you’ll see as you read on, that pursuit has been very valuable and promises to pay huge dividends as her very promising career unfolds. And so, in Alyssa’s words…

Everyone I’ve worked with, spoken to or passed quickly in a hallway in the past 6 months has heard, at least on a few occasions, about my upcoming aerospace medicine elective. I was over the moon with excitement and probably made a few too many bad puns. However, before I launch into my personal experiences, I should explain that Aerospace Medicine is a sector within occupational health and preventative medicine that aims to preserve the health, safety and performance of individuals involved in air and space travel. Specialists, also known as “flight surgeons” must also be experts in delivering care in extreme environments, as many analog training missions occur at deep sea, high altitudes, remote deserts and polar locations.
This past July I participated in the Principles of Aviation and Space Medicine short course offered by the University of Texas Medical Branch (UTMB) as affiliated with the National Aeronautics and Space Administration (NASA.) The course, which is offered to final year medical students, residents and practicing physicians is run by UTMB faculty, many of whom have held the impressive titles of NASA flight surgeon or are acting medical directors for commercial space companies such as Virgin Galactic and Space Adventures.
In order to understand the unique health considerations for astronauts, we learned the basic physics and physiology of launching into space. Given that our millions of years of evolution selected human traits for life in earth’s gravitational field, it is truly remarkable that humans are able to adapt to life in space. Some of the many physiologic stressors include high G-force exposures of launch and landing, exposures to microgravity, galactic and solar radiation, circadian disruptions, noise exposure, carbon dioxide exposure, stress and isolation.
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Twice flown astronaut and physician Dr. Michael Barratt gave us an overview of the physiologic adaptation and maladaptation to spaceflight, including the important responses of the neurovestibular system, caudal fluid redistribution, blunting of autonomic responses, and of course the concerning loss of bone density and muscle mass. In order to counteract this loss, astronauts aboard the international space station train for approximately 2 hours every day. The challenge of creating weight-bearing exercise in a weightless environment is achieved with bungee straps and vacuum cylinders, which make for a surprisingly high fidelity training experience. Though I had worked up a fair appetite, I was not able to sample the “just-add-water” nutritionist-designed and astronaut approved freeze-dried shrimp cocktail or steak in a pouch.
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We received the historical perspective on aerospace medicine in a lecture by Dr. Charles Berry, a NASA flight surgeon during the Apollo and Gemini missions. At the tender but not subdued age of 92, Dr. Berry certainly did not withhold his objections to his Hollywood portrayal in Apollo 13. I got to sit in Dr. Berry’s old desk at mission control, the very same room where the moon landings were directed.
blog65-img3Back on earth, Aerospace Medicine also encompasses health maintenance and medical flight certification of airplane pilots. There is a truly complex relationship between pilot health and safety, and as we learned first hand in the full motion flight simulator, even perfectly healthy medical students can have vestibular mediated spatial disorientation leading to fatal crashes. We also learned the physiologic effects of airplane decompression, and its impact on time of useful consciousness through an altitude chamber run to 7620 metres (25,000 feet.) I thought fleetingly of Dr. Moffat’s respiratory physiology lessons as we reached atmospheric pressure of 276mmHg and my O2 saturation plummeted to 63%.
Now that I’m back home at Queen’s, I am looking forward to continuing to share my experiences with the rest of our community. I was extremely pleased to learn from a fellow tricolour, Queen’s emergency medicine graduate Dr. Christian Otto who is currently acting as a United Space Research Association principal investigator for the ocular health project with NASA. I will remain deeply grateful for the opportunity to blend my passions for medicine and physiology at environmental extremes. Of course, none of this would have been possible without support from Dr. Winthrop, Dr. Hollins, Jane Gordon and the UTMB faculty. Thanks Queen’s!
Did you know that…
  • Aboard the ISS, the sun rises every 90 minutes. And you thought your on-call room was a bad place to get a decent night sleep! In fact, one of the major challenges being addressed right now is circadian rhythm modulation for crew health.
  • CPR is very challenging in space because classic compressions would essentially push the operator across the room rather than pump the patient’s heart. The current literature suggests that the most efficient delivery is in the handstand position with feet braced against the ceiling.
  • Above 19.2km (63,000 feet) above sea level, the boiling point for water is approximately 37 degrees Celsius. One individual who survived exposure to this pressure described the feeling of saliva boiling off his tongue. Full pressure suits are required for survival above this altitude.
  • Astronauts train for their space walks in a massive swimming pool called the neutral buoyancy lab. There are mockups of the ISS underwater for astronauts to practice repairs.
  • Aboard the international space station, the main source of potable water is recycled urine. This water is used for drinking and rehydrating freeze-dried meals.blog65-img4
  • The current price tag to visit space as a commercial spaceflight participant is approximately $20 million dollars. This would not be covered on the average line of credit. The first Canadian to do so was Guy Laliberte, co-founder of Cirque du Soleil.

Medical school should be a place where students not only learn the “knowledge, skills and attitudes required of a physician”, but are also inspired to grow individually, gain self-awareness, pursue their own goals and develop their particular talents and interests in a way that will allow them to make unique, unanticipated contributions to society and to the profession. Alyssa’s story is a great example of what can happen when we work together with our students to go “outside the box” and make the extra effort to make the difficult and unconventional possible. When they “wish upon a star”… we’ll find a way.

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

 

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