CARMS Match Day 2015: 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. By approximately 12:00:05 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 4th 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 Victoria Atchison at learnerwellness@queensu.ca, Jacqueline Schutt at schuttj@queensu.ca, or 613-533-2542. The faculty counselors can also be contacted directly at the following:

Screen Shot 2014-02-24 at 9.30.45 AM Screen Shot 2013-05-24 at 3.55.07 PM Screen Shot 2014-02-24 at 9.34.46 AM
Kelly Howse
Careers Counselor
kelly.howse@dfm.queensu.ca
Jennifer Carpenter
Student Counselor and Wellness Advisor
carpentj@queensu.ca
John Smythe
Student Counselor and Wellness Advisor
smythej@kgh.kari.net

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

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

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In Defense of the Lecture

Medical Grand Rounds are a longstanding (dare I say, traditional) feature of the academic medical centre.  In fact, their durability and continuing appeal might be considered somewhat perplexing in an age of increasing, almost frantic, busy-ness, and easy access to medical information and prepared presentations ready for review at our convenience.  Here at Queen’s, they have become rejuvenated and are now a highlight of the academic week with the support of Dr. Archer and guidance of Dr. Mala Joneja.

The format is very simple: a formal lecture, followed by commentary and discussion from the audience.  That audience tends to be quite eclectic, including medical students, residents, nurses, hospital administrators, and attending physicians ranging from junior staff to senior clinicians, some very much expert in the topic under discussion.  The discussion following provides opportunity for those attending to add depth and perspective to the topic.  Because it’s a gathering of thoughtful clinicians who lack for neither opinions nor willingness to express them, the dialogue following can be rich, far-reaching and highly entertaining.  The challenge of the presenter is therefore considerable.  With minimal technical “tricks”, relying largely on the content and style of their presentation, they must not simply inform but provide texture, context and deeper meaning to the topics under discussion.

Three recent, excellent Grand Rounds on contrasting topics delivered by individuals of different backgrounds and practice profiles provide insights about the “art and science” of the well- crafted and well-delivered lecture.

blog53-1Dr. Zachary Liederman, a senior Internal Medicine resident, presented the topic of Myelodysplastic Syndrome. He described very nicely the current state of knowledge and clinical approach, and did not shy away from describing the complexities facing the treating physician when counseling a patient who has a condition that is causing minimal if any symptoms, and carries uncertain risk for progression. In the discussion that followed, senior departmental members questioned the obligation of treating physicians to disclose to every patient all information about conditions that are identified, but not the cause of symptoms, and of uncertain clinical significance.

 

aljinDr. Al Jin is a Neurologist with a impressive research background and clinical training in stroke.  He is actively involved in “leading edge” approaches to diagnosis and management of this condition,  sharing with the audience his insights about these emerging innovations, balancing thoughtfully the established and speculative, referencing the underlying scientific principles with practical clinical experience.  As an acknowledged and respected expert in this field, he combined high levels of personal credibility with an engaging, respectful and balanced presentation.  There was truly something for everyone, from the novice learner to seasoned clinician who treats stroke patients regularly.

 

david-hollandDr. David Holland is a well-established and highly-respected Nephrologist and educator.  He presented a superb lecture on the topic of Disruptive Innovation in Patient Centred Care.  He drew upon his clinical experience with chronic kidney disease and dialysis, but extended far beyond, providing insights drawn from industry and various models of change and innovation.  Presenting with considerable panache and directness, he provided concepts and insights novel to most in the audience, and did so in a highly engaging and thought provoking discussion.

Three very different topics.

Three individuals of very different backgrounds.

Three approaches.

All were highly effective in engaging their audience and presenting them with novel, fresh insights about topics in which many in attendance may have felt reasonably informed beforehand.  In short, they all made a room full of people sit back, listen, and think again about something important to them.

How did they manage it?  What makes any lecture effective?  I would suggest there are a few common denominators.

·      The content has relevance to the audience.  It is something that is, for whatever reason, important to them in their occupation, private lives or, better yet, both.

·      The content goes beyond simple transfer of knowledge.  It extends facts and figures to a thoughtful discussion of the application, implications or meaning of the basic information.

·      The presentation differentiates that which is factual and proven from that which is speculative, hypothetical or aspirational.  In doing so, the presenter draws the audience into the discussion, allowing them to develop their own conclusions and thus extend thought and provoke further discussion

·      The presenter is credible.  This arises not simply from their background and qualifications, but from the way in which they interpret and present the information.  The effective presenter, in fact, earns the trust of the audience by manner in which they present.

·      The presenter is passionate about the topic under discussion.  The audience must perceive that, at some level, the presenter cares about the subject on a personal level, to an extent that assures integrity about conclusions that are drawn.

·      The presenter respects the audience.  They truly wish to inform and advance understanding of the topic under discussion.

·      The material is presented in a “user-friendly” and entertaining manner.  This is not showmanship or a simple sprinkling of humorous anecdotes.  It involves a skillful use of familiar concepts, analogies and parallel discussion lines to weave a narrative that informs while telling a story.  It also requires a sense of the needs and preferences of the audience.

Despite a longstanding and venerable place in the history of medical education, the lecture format has come under considerable criticism, and is somewhat at odds with modern educational theory.  It has been rightfully pointed out we no longer need lectures for simple knowledge transfer, since students have available to them a myriad of other information sources.  It is also true that the lecture format can be a very passive experience for the learner, and may not engage them in the “active learning” process which is essential to deep and retained understanding of any topic.  Medical schools, including Queen’s, have all engaged a variety of active, small group learning techniques.  Many have abandoned the lecture format entirely.

The three examples and characteristics described above illustrate that the lecture format, appropriately structured and delivered, can be an integral part of a medical education curriculum, going far beyond passive information transfer, challenging students to extend their basic knowledge to the implications and application of the factual, thus deepening their understanding and providing a model for thoughtful reflection that should model processes they take into their professional lives.

At Queen’s, we have given considerable thought to the place of lectures and various learning techniques in our curriculum.  A number of key decisions were made about 7 years ago when we engaged curricular renewal:

1.     We would engage a variety of learning methods, including team based learning, case based presentations, facilitated small group learning, and lectures.  In short, we would strive for a balanced blend of teaching methods.  In addition to taking advantage of the benefits of all approaches, this allows us to model all methodologies for our students, who need to learn to teach themselves, a component of the scholar competency (the “medium is the message” approach).

2.     We would use lectures not to provide basic information, but to allow experienced faculty to extend that information into discussions of significance, professional implications and clinical applications of knowledge.

3.     We would structure into our courses sufficient resources, time and guidance for students to acquire basic information in a variety of formats, including on-line material, learning modules, reference material and reliable information sources that we would recommend.  We would, to use the educational terminology, engage Directed independent learning.

4.     We would dedicate significant components of our curriculum to helping students identify and recognize reliable information.  In fact, much of the Scholar competency and most of our Critical Appraisal, Research and Learning (CARL) course (developed and guided by Dr. Heather Murray) is devoted to this goal.

5.     We would promote faculty development opportunities for teaching faculty and recognize outstanding lectureship.

In short, we wanted fewer but better and more meaningful lectures, delivered to students already prepared with basic information and able to both discern credible information and make valid clinical decisions.  To accomplish this, we required a committed, engaged and well-supported faculty, clarification among our students about the learning goals, and teaching spaces that allowed all this to happen.

lectureOur School of Medicine Building, opened in September of 2011, was purpose built with these objectives in mind.  The large group rooms were designed to allow for both lecture and small group teaching, and easily allow a teacher to transition between the two methods, so students can move easily between attending to a single lecturer and small group discussions on the issue under discussion.

smallgroupThe building also includes 30 small group rooms for both formal and informal learning.

Has it worked?  Lectures continue to be featured in every course we offer but are now part of a teaching mix that includes all the other small group based methods we promote.  The graph provided depicts the current percentages, a significant change over the past few years and a tribute to our faculty.

Do our students value lectures?  Each year, the Aesculapian Society presents a “Lectureship Award” for the teacher in each course who they felt provided the most effective sessions.  These are awarded after each course and are very highly valued by faculty.

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The Canadian Graduation Survey, completed by all medical students at the completion of their final year, including 102 (99%) of our 2014 class, asks them to rate the overall quality of their medical education.  Seventy-two percent of our graduates rate their experience as “excellent”, comparing to a national average of 29.6%.

Percentage Responding
Screen Shot 2015-02-17 at 10.44.27 AMSo it seems we’re doing something right, and that the lecture has a secure future in undergraduate education, thanks in no small part to the example and contributions of excellent lecturers like Drs. Holland, Jin and Liederman.

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

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A Physicians life, well lived – Dr. Bruce L. Cronk

We all need role models. These are people who guide us through our lives by helping us understand the type of people we aspire to become. They may do so by providing wisdom or advice, but mostly they guide by the example of the lives they live. They are precious to us, and particularly so for those aspiring to a career in medicine. A physician’s life is a complex interplay of roles, values and encounters with the human condition in all its variations. To fulfill and balance these roles, and to derive joy and personal satisfaction while doing so, is indeed a great gift. Those among us who do it well are worthy of our admiration and should serve as models for our learners.

Dr. Bruce Cronk, who passed away recently, was certainly one of those people. Although I only had occasion to meet him personally a couple of times, I had opportunity to consult with him in the management of patients, and heard him speak on a number of occasions. His quiet competence, dignified civility, compassion for his patients and ability to connect on a personal level with people of all types were apparent to all who had opportunity to encounter him. Reading the various tributes that have come forward since his passing reaffirms these impressions and paints the picture of a person who was deeply committed to his various communities – his home town, his profession, his university, his faith, his country, indeed the world community. I can think of no better role model for the students and learners at Queen’s, and respectfully provide for them in particular the following tribute with the permission of Dr. Cronk’s family. It is the lived expression of every attribute and “competency” we profess.

 

bruce-cronk
1. Image Credit: The Intelligencer, Dr. Bruce Cronk 1923-2015

 

CRONK, Dr. Lawson Bruce – M.D.C.M., F.R.C.P.C., F.A.C.P, F.A.C.C
March 7, 1923 – January 24, 2015
It is with great sadness that the family of Dr. Lawson Bruce Cronk announces his passing on January 24, 2015 at Belleville, Ontario in his 92nd year. He was predeceased by his dearly beloved parents Dr. George Sampson Cronk and Lillian (Guthrie), and his sister Harriet Simmons.
Bruce was born and raised in Belleville, Ontario. He attended Queen’s University, graduating in Medicine, Class of ’47. Bruce served in the RCAMC in WW II and the RCN(R). From 1947 – 1949 he conducted, on behalf of the Defence Research Board, research in the Eastern Arctic as a member, then leader, of the Queen’s University Arctic Expeditions. While undertaking postgraduate training at the Ottawa Civic Hospital he met his cherished life partner Sylvia Elizabeth Byrnes, and they married in 1949. Bruce continued his medical training, first at Kingston General Hospital, and then at Johns Hopkins Hospital and University, Baltimore, Maryland. He returned to Belleville in 1951 to practice internal medicine, in collaboration with his surgeon father.
Bruce was a Fellow of the Royal College of Physicians of Canada, a Fellow of the American College of Physicians and a Fellow of the American College of Cardiology. During his practicing career he was Chief of Medicine and president of the medical staff of Belleville General Hospital on recurring occasions, and a consultant to the Picton, Trenton, Campbellford, and Cobourg hospitals, as well as the CFB Trenton base hospital. He was Chairman of the Section of Internal Medicine of the Ontario Medical Association in 1965, and from 1980 to 1985 represented District 6 of the Council of the College of Physicians and Surgeons of Ontario. He was a member of the Regional Advisory Committee and Committee of Fellowship Affairs, of the Royal College of Physicians and Surgeons of Canada. He was a life member of the Ontario Medical Association and a Senior Member of the Canadian Medical Association.
Bruce viewed medicine as a ‘calling,’ and firmly believed it could be delivered on no lesser terms. A cornerstone of this philosophy was his tremendous dedication to education and its institutions generally, and medicine in particular. His remarkable support and affection for Queen’s University spanned his adult life. He was permanent president of the Class of Meds ’47, graduating with the Gold medal in Surgery; the W.W. Near and Susan Near Prize for the second highest standing throughout his medical degree program, and the Hanna Washborn Colson Prize for Proficiency in Clinical Diagnosis in Medicine, Surgery and Obstetrics. He was president of the Queen’s Aesculapian Society (the undergraduate body of the faculty of Medicine), and a member of the Queen’s Alma Matter executive. He was recipient of the Queen’s Tricolour Society Award and played three seasons with the Golden Gaels football team. He was a member of the Faculty of Medicine as a clinical assistant, then lecturer, then Assistant Professor, from 1953 until his retirement in 1988. He was a life member of the Queen’s Grant Hall Society and a member of the Council of Queen’s University. In 2013 Queen’s established the Dr. Bruce Cronk Distinguished Lecture Series in his honour. This endowed annual event is designed to host eminent scholars involved with all areas of medicine.
Closer to home Bruce served on Loyalist College Board of Governors 1975-1979, and in 1993 was awarded Loyalist College’s highest honour, a Diploma in Applied Arts and Technology. He also served as a member of the Board of Governors of Belleville’s Albert College.
Bruce’s community service extended far beyond the schools with walls. From 1965 to present date Bruce and Sylvia sponsored, through Plan International, young children from countries which spanned the globe. As a long-time member of the Quinte Interfaith Refugee Sponsorship Committee, he was instrumental in bringing and establishing families from Rwanda, Ethiopia, Laos, and Kosovo in the Quinte area. He was a Director of Hospice Quinte and of the Museum of Health Care at Kingston; a Trustee of Bridge Street United Church; and a President of the Quinte Branch of the Canadian Red Cross. He served in Community policing; the Canadian Food Grains Bank; and in 1997-98 as President of the Christian Medical Foundation of Canada. On conclusion of his hospital and office practice in 1988, Bruce spent the ensuing 10 years volunteering his medical skills for 5 to 6 months a year in United Church Health Services hospitals located in Newfoundland and in indigenous communities on the north-west coast of British Columbia. Of this decade Bruce said “it was a wonderful time with wonderful people.”
Bruce made a difference, and it was recognized. In 1978 he was awarded the Queen Elizabeth II Silver Jubilee Medal and in 1987 the Humanitarian Award of the RCAF Association. He received the Sir William Osler Award of the Christian Medical Foundation (International) in 1990, the prestigious Alumni Achievement Award of Queen’s University in 1992, and although not a Rotarian, a Paul Harris Fellowship from the Foundation of Rotary International in 1994. In 1996 he was recognized by the Royal College of Physicians and Surgeons “for outstanding service to his community” and in 2004 was nominated by the Canadian Blood Service and received the ‘Volunteer 50+ Award’ by the Province of Ontario, for 63 years of volunteer service in blood donor clinics and 181 official blood donations. In 2009 he was one of eleven residents of Ontario to receive the Ontario Medal for Good Citizenship. The citation accompanying this award spoke to his role as a member of a team that pioneered cardiovascular and pulmonary surgery in the Belleville-Kingston area. Bruce was awarded the Queen Elizabeth II Diamond Jubilee Medal in 2012.
Bruce’s hobbies ranged from history, to music, to woodworking, to a number of sports – including bicycling, kayaking, windsurfing, skiing and wilderness canoeing. He paddled the Nahanni, Mountain, Natla, Keele, Hood and Mackenzie rivers in the Northwest Territories, and the Dumoine and other rivers in Quebec and Ontario. In recent years he did confess to being content to paddle flat water.
Bruce will be dearly missed by his loving wife Sylvia; devoted children Anne and her husband Bob Freeland, Robert and his wife Patti (Aspinall), and Michael Sam; eight grandchildren and three great grandchildren.
The Cronk family wishes to thank all of Bruce’s many close friends and colleagues who have been an intrinsic part of the marvelous life he has led and enjoyed.
A Celebration of Life ceremony will be held at Bridge Street United Church, Belleville on Saturday, March 7th, 2015 at 2:00p.m. with Rev. David Mundy officiating.
It was his wish that any donations in his memory be made to Bridge St. United Church, Belleville, Doctors Without Borders, or the charity of your choice.

To our current medical students who are searching for that model of the ideal physician, I would suggest you need look no further. Want to be a great physician and a great citizen? Be like Dr. Cronk.

 

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

1. Image Credit: The Intelligencer  http://www.intelligencer.ca/2015/01/25/dr-bruce-cronk-1923-2015

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A Fragile Trust – Reflections on the Dalhousie Controversy

A patient reports to a hospital outpatient procedure unit early one morning for an electively planned, medically necessary surgical procedure.

They divulge personal and sensitive information to a clerk.

They disrobe at the request of a registered nurse.

They allow a phlebotomist to start an intravenous line in their arm.

They allow a resident physician to carry out a physical examination, review test results and reassure them that they are fit to undertake the procedure.

They allow an anesthesiologist to administer medications that will render them insensible, unconscious and unable to breath without assistance.

They allow a surgeon to carry out an invasive procedure that may result in some degree of disfigurement and carries risk of injury or death.

When they awaken, they allow another nurse and a respiratory technician to carry out examinations and measurements, and accept their assurances that they are safe to return home that evening.

Other than the surgeon, they are meeting all these people for the first time.

How does this happen? What allows a person to suspend the usual inhibitions and natural cautions of everyday life to depend so completely on perfect strangers, and for so much?

It happens, I would suggest, because they are able to trust.

That trust is rooted in an assurance that the selection processes, training and regulatory frameworks that govern the activities of these various providers are all robust and vigilantly monitored.  Although our patients can understand and accept that all these providers are people like themselves, subject to human frailty and error, they must believe that, in the context of the services they are providing, those providing care will be highly competent, attentive and focused.  They will be, for that encounter, perfect.

By extension, they must believe that the institutions that train such individuals are focused not only on the acquisition of knowledge and development of technical skills, but also on the identification and development of high levels of integrity, responsibility and concern that ensure that those skills will be applied in the best interests of their patients.

That trust is no mere abstraction or theoretical construct.  It is, in fact, a key component in ensuring patients are willing and able to seek help when needed, and allows them to comply with necessary treatment.  It is a key factor in ensuring effectiveness of the care provided.  It is a core and essential attribute of every health care professional.

Over the past few weeks, the widely-publicized and much-discussed events arising from the Dalhousie Faculty of Dentistry have demonstrated the fragility of that trust.  Without attempting to judge the merits of the charges or question the approach taken by the school officials, it is clear that even the perception of such serious breaches has shaken the confidence of the public in the ability of our schools to ensure our graduates are worthy of those high levels of trust.  Witness the numerous postings from individuals expressing reluctance to seek help from any dental school graduate, requests from regulatory bodies to examine the records of every graduate and withdrawal of financial support from previously loyal school supporters.  Rightly or wrongly, the perceived breach of trust has extended beyond the alleged perpetrators, and threatens to affect a wide array of people and institutions.  To borrow a military term, the “collateral damage” is huge.

These events also bring into sharp focus key issues that professional schools have struggled with for many years.  Because graduates of programs such as Medicine, Nursing, Dentistry and Education will engage positions of public trust and, in fact, are engaging such roles even during their training, they struggle with two key issues:

1. To what extent does the need to preserve the public trust and ensure the safety of people they engage during their training “trump” personal rights, due process and assumption of innocence until proven guilty?  To be more specific, if a student is suspected of a major offense, or even involved peripherally in such activities, can they be allowed to continue in their training or expect anonymity until resolution?

2. To what extent does a university degree confer assurance of public trust?  Our professional schools are largely housed in universities and colleges, institutions that recognize through their degrees and diplomas intellectual mastery of a particular discipline, but not necessarily practice readiness nor assurances of exemplary personal conduct.  Does a student who has demonstrated understanding of content but whose behavior has been deficient merit that degree? Since the final determination of practice readiness resides with the various regulatory agencies, should incidents and issues arising during the educational program be made available to those agencies?  In short, where does the institution’s social accountability over-ride the natural tendency to support their students?

In medical schools, the increasing engagement of competency-based objectives and curricula, although initially somewhat reluctantly engaged, has served to embed social responsibility in the consciousness of both learners and faculty.  It becomes clear to all that medical school is as much about personal and professional development as acquisition of knowledge and skills, and has provided a framework to identify and address behavioural lapses.

If any good is to arise from the “ill wind” of the recent controversy, perhaps it is to engage a wider conversation on these two vital issues and to engage public input on issues that, after all, have the potential to affect them directly.  The public’s trust must be earned, and once earned must be vigorously preserved.

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

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Solstice

Solstice

I find myself writing these words on the day of the winter solstice. The days that have been getting progressively shorter and darker stop doing so, and now begin to slowly lengthen and become brighter. The derivation of the word “solstice” is itself interesting, stemming from the latin sol (sun) and sistere (to stand still). It’s therefore a time when all nature stops, pauses, and changes direction.

Over the years, the solstice has had considerable and variable significance, ranging from providing scientific insights about our position in the universe, to rituals, community events and social practices. In the end, however, it is a predictable, natural event that touches us all, regardless of our cultural, racial or religious background.

It seems we’re also united this time of year by a need to stop, rest, reflect and be with those who are closest to us. As the days grow shorter, and as the solstice provides indisputable evidence of our fragility in the universe, it seems that natural biorhythms urge us to slow down, cleave to what we perceive to be unshakably reliable, and restore our spiritual energy for challenges ahead.

It’s in that spirit that I wish our faculty and students a restful, safe and restorative break from the routine of busy lives, and very best wishes, as we will again come together to engage the year ahead.

 

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

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Why, What and How We Teach at Queen’s Medicine.v3

UGMEframeworkFor a teenage boy growing up in a small town, the local auto mechanic can become a best friend and key to social success. I had great admiration for one in particular who would let me watch and explain what he was doing as he went about trying to resuscitate whatever antiquated pile of spare parts I was currently passing off as my “drive”. He always seemed to be able to find a way to repair whatever part was ailing, or adapt yet another spare part to replace whatever previously adapted spare part was no longer operational. But sometimes, even he would throw in the proverbial towel. “There are times”, he would say, wiping grease from his hands, “when you just need to jack up the horn and drive under a new car”.

Many times, when grappling with really difficult and highly complex problems, we are tempted to just “blow it up and start all over again”. The concept of going back to first principles and taking a new and fresh approach that sets aside all of the partial “patch work” fixes and “spare parts” that have been put in place over the years can be hugely tempting, particularly when it’s obvious that those noble and well-intentioned attempts are now resulting in a system that is unnecessarily complex and no longer addresses the initial intent.

But we don’t often get those opportunities, particularly when dealing with established and multifaceted systems like, for example, medical schools. Former United States President Calvin Coolidge is credited with remarking that “changing a college curriculum is like moving a graveyard – you never know how many friends the dead have until you try to move them.” We tend to resist change and cling to the familiar, particularly when those changes may be seen as threatening or offensive to folks who have developed or embraced them with every good intention.

All that notwithstanding, a rather courageous (and perhaps naïve) group set out to do just that at our medical school 7 years ago. There were multiple motivations. Many faculty were expressing frustration and a sense that we could do much better. Students were quite vocal in their view that the curriculum seemed out of keeping with their needs. The catalyst was provided by a recently received accreditation review that made it abundantly clear that multiple and key facets of our program required review and that no partial repair was going to address those concerns.

And so, an intrepid group was assembled and set out on what turned out to be a year long journey to “jack up the horn and drive under a new car”. The group consisted of three clinical faculty members who were established and respected medical educators and had great familiarity with our current curriculum and its history (Lindsay Davidson, Michelle Gibson, Sue Moffatt); two specialists in medical education theory and practice (Sheila Pinchin, Elaine VanMelle); a much respected clinician and teacher with longstanding interest in the development of Professionalism and the so called “non-medical expert” competencies (Ted Ashbury); a Pathologist/Immunologist who had led our basic science group in developing and delivering what was called “Phase 1” of the curriculum (Sherry Taylor); and a freshly minted and recently recruited Master of Education who was passionate about the role of generalism and the representation of Family Medicine within our curriculum and medical school (Michael Sylvester).

Despite their differences, the group gelled remarkably well. They were united by many things but, I believe, first and foremost by a shared commitment to provide the best possible educational experience for our students, summed up rather nicely in the following statement of intent:

Our graduates will have exemplary foundations in medical competencies that will prepare them for success in qualifying examinations and in post-graduate training programs and for fulfilling careers serving their patients and their communities.

A number of key decisions followed…

  • We would base our curriculum on competencies as expressed by the CanMEDS framework and Family Medicine principles of practice.
  • We would use the AAMC Scientific Basis of Medical Practice as a framework for our basic science teaching
  • We would use the Medical Council of Canada Clinical Presentations as a basis for teaching the Medical Expert components of our curriculum
  • We needed a course-based structure in order to assign competencies and clinical presentations in a logical, integrated and progressive fashion
  • We would introduce more small group teaching to complement our lecture-based approach
  • We would ensure students had opportunity to monitor their own learning process by introducing formative assessments into every course
  • We would identify and retain aspects of our curriculum that were very successful, such as our Clinical Skills program
  • We would provide more patient-centred experiences early in the curriculum in order for the students to engage their “physician” role early and to recognize the relevance of their early learning
  • We would provide more opportunities for structured learning in later years by expanding our Clerkship to two years in order to develop three periods of “Core Curriculum” where the students would come back to school to learn complex issues or those that are best introduced after they’ve engaged clinical medicine.

What emerged was dubbed the “Foundations Curriculum” which had to be introduced over four years in order to ensure every class enrolled during those years received a full, albeit somewhat different, curricular experience.

The description of that new curriculum was articulated in a document entitled “Curricular Goals and Competency-Based Objectives” that was widely discussed, passed by our Curriculum Committee and endorsed by all faculty at School of Medicine Council. Because the undergraduate office happened to have a large supply of red printing paper that was used to produce a cover, the document became known as the “Red Book”.

That document has now been revised twice, based on experience with its implementation and considerable feedback from students, teaching faculty and curricular leaders. That third version, approved recently by our Curriculum Committee, has been packaged very attractively by Sheila Pinchin and her colleagues, and is being released this week. It will be made widely available in both electronic and print formats, and should serve as an articulation of the “why, how and what” we teach, and unifying focus for all the following:

  1. Student Learning – this document outlines what we expect our students to know, to do and to be, by the time they graduate
  2. Curricular Design – our course structure, sequencing and content will all be guided by this document. Each course will be assigned some subset of the Program Objectives and MCC presentations outlined.
  3. Teaching Events – each one of the 3,000 or so individual teaching sessions we provide over the four year curriculum will be structured with the goal of relating to one or more of the Curricular Objectives.
  4. Assessments – a comprehensive “blueprinting” process developed and monitored by our Student Assessment Committee will ensure that all summative assessments relate to a subset of the objectives assigned to the course or competency to which they relate.

In sotaummary, the “Red Book” provides a basis to ensure that the key educational triad is maintained, interrelating the three pillars of any educational program – Objectives, Teaching and Assessment. It also serves to keep all of those engaged in our educational enterprise “on the same page”.

I’m very grateful to all of our educators, students, faculty and administrative staff whose dedication and commitment make our curriculum, and our school, so special – spare parts and all.

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Medical Student Debt:

Is it a problem, or just a shrewd investment?

By the end of his or her medical education, the average Canadian graduate will owe $71,721. That amount, which has increased by about 7.3% over the past 5 years, may seem either huge or trivial depending on your perspective and stage of life. Interpretation might be enhanced with a few more details:

  • 17.5% manage to get through medical school with no debt at all, a figure that has not changed over the past 5 years.
  • on the other extreme, 6.2% report debts of over $200,000, which has increased from 4.1% in 2010
  • 28.3% report already having debt before even entering medical school (26.4% in 2010), with an average premedical indebtedness of $7,465 or, perhaps more telling, an average of $27,094 for those who report any debt (comparing to $6,506 and $25,968 respectively for 2010).
  • 32.5% report having accumulated “non-educational debt” during medical school (eg. credit cards, car loans, mortages) averaging $23,976 (comparing with $31,455 in 2010)
  • 28% feel that the amount of financial assistance available to them fails to meet their needs (compared to 31.5% in 2010)
  • 3.7% report “no need for financial assistance” (unchanged over the past 5 years)

All this comes from the Canadian Medical School Graduation Survey, which is conducted as part of the Academy of American Medical Colleges Graduation survey and was completed (voluntarily) by 2,048 graduating students in 2014 including (I’m pleased to report) 99% of our graduating class at Queen’s.

At the same time, tuition rates appear to be on the rise (http://studymagazine.com/2011/11/01/tuition-canadas-medical-schools-rises/), currently averaging about $11,000 annually, but with considerable variability between schools, ranging from as low as about $4,000 to highs of over $25,000, according to the Canadian Medical Education Statistics published by the Association of Faculties of Medicine of Canada (http://www.afmc.ca/pdf/CMES2014-Complete-Optimized.pdf).

So, what does all this mean? Is this a problem that we and other medical schools need to engage, or are we observing what is, from a strictly financial perspective, an investment by shrewd and well- informed young people in an education that will lead to a secure, well-paying future in which they should be able to quickly dissipate even the higher levels of indebtedness?

On the “what’s the fuss” side of this argument are those who point out that medical students, once enrolled, have easy access to large loans from banks and other institutions who are confident in their success and financial prospects. They would note that almost all medical students graduate to lucrative careers (unlike most other university graduates), and that even a resident physician’s income, sensibly managed, provides the means after graduation to pay down those loans. They would further point out that there is very little post-graduation default on debts. Finally, they might make the point that these students are, in fact, adults who make conscious and highly informed career and financial decisions, and that medical schools are either their parents nor socially responsible for those decisions.

Those on the “we have a problem” side of this issue might make the following points:

  • Although manageable after medical school and a minor issue in retrospect, the perception of increasing debt during medical school is a major stressor for students during an admittedly demanding period of their training, and may therefore distract from their education
  • The high debt load may influence career decisions, prompting students to consider specialties with shorter duration of training and greater perceived long-term economic benefits.
  • High debt load may discourage students from taking up research, educational or other academic training opportunities, either in parallel with or after their core training.
  • The high costs and accumulated debt may discourage many young people from socioeconomically challenged backgrounds from even considering careers in medicine, thus establishing a further barrier to the social diversity that all medical schools and the medical education community are endeavouring to establish. To quote the AFMC’s Future of Medical Education In Canada: A Collective Vision for Medical Education in Canada:

Achieving this diversity means attracting an applicant base that is more representative of the Canadian population. This will involve, for example, addressing perceived and real barriers to medical education, such as the high debt loads of medical graduates.”

The last point is particularly vexing. It’s easy to imagine that, for a family of limited financial means and with incomplete knowledge of the financial realities, the prospect of over $20,000 in annual tuition and possibly hundreds of thousands in accumulated debt may be sufficient to quash any dreams of medical education very early in life. (see previous blog article http://meds.queensu.ca/blog/undergraduate/?p=1165&preview=true&preview_id=1165&preview_nonce=e904b6e40f&post_format=standard).

In addition, there are considerable financial hurdles a student must face to simply apply to medical school, including three to four years of pre-medical undergraduate medical education, MCAT examinations (including preparation and travel) and quite likely a sense that income-generating jobs should be sacrificed in order to pursue studies or activities deemed more “attractive” to medical school admissions officers. Although considerable financial assistance and loans are available to students once accepted to medical school, there is no similar level of assistance to those in the application process where it would arguably be of greater benefit.

daviesAt Queen’s, we are concerned about the rising profile of student indebtedness and it’s impact on both current and prospective students. To further examine this issue, we have established an Advisory Panel on Medical Student Debt, chaired by Dr. Greg Davies and supported by Brian Rutz, UG Financial Officer. The panel is populated by several current students from all years, recent graduates in residency training, not-so-recent graduates now in the early years of independent practice, and several members of faculty and the university community with interest in this issue. That group has already begun its work by undertaking a review of the Canadian medical school environment through the Graduation survey, and current literature. It is focusing on several topics:

  1. The sources of debt
  2. The impact of debt on individual students
  3. Counseling and information sources available to students as they engage financial planning
  4. Financial aid availability and access
  5. How support might be provided to young people considering careers in Medicine

Their findings and recommendations, once available, will be brought forward for wide discussion and implementation. I’m sure Greg and his committee would appreciate hearing from readers about any and all of these issues. I know I would.

 

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

 

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A Call for Clarity

Beyond competencies – What should every Canadian medical graduate be able to do?

Consider this: When you find yourself a passenger on an aircraft coming in for a tricky landing on a stormy night, would you be more comforted by the knowledge that your pilot is an expert in aeronautics and aircraft design, or that he/she has demonstrated the ability to successfully land similar aircraft, in similar conditions, many times previously?

I think most folks would hope, and reasonably expect, that somebody at pilot school is ensuring that their graduates are able to land airplanes safely before pinning those wings on his or her chest.

Let’s switch to a medical equivalent. If you or your loved one is brought to an emergency department with severe abdominal pain, you should certainly expect that the physician providing care has all of the attitudes and personal qualities that have been articulated by our professional bodies and engaged by our medical schools. But, at that moment, I suspect that what you’re looking for is someone who can deal efficiently and effectively with the vessel, viscus or infectious process that’s causing the grief. There are, after all, priorities, and there are things that we expect doctors, and only doctors, to do.

Undergraduate medical education programs have become increasingly competency-based. A “competency”, in the educational sense, can be defined as an attribute, knowledge or skill that an individual learns and eventually possesses. Being an effective communicator, professional, scholar are examples of such competencies that all would agree should be part of any physician’s toolbox. In such frameworks, being a “Medical Expert” (knowing about clinical conditions and how to manage them) is another independently described competency. Many organizations have developed very well thought out and comprehensive descriptions of the competency set they feel describes the ideal, fully formed and practice-ready physician. For example:

  • The College of Family Medicine describes a “Triple C” curriculum–comprehensive care, continuity of care, centred on Family Medicine. The CFM has also provided an examination of CanMEDS from a Family Medicine perspective, interpreting the seven roles as 63 more tailored competencies, many of which are further described with bulleted sub-competencies. http://www.cfpc.ca/uploadedFiles/Education/CanMEDS-FMU_Feb2010_Final_Formatted.pdf
  • South of the border, our American colleagues at the Association of American Medical Colleges (AAMC) has recently released a vision which articulates 8 “Domains” informed by 58 “competencies”, which are roughly equivalent to the CanMEDS “enabling competencies”.
  • The Medical Council of Canada, the body responsible for developing the examinations that qualify medical school graduates to practice, has largely embraced the CanMEDS framework in describing objectives for their examinations. It describes the “Medical Expert” in terms of “clinical presentations”, which are patient issues that graduates are expected to handle effectively. http://apps.mcc.ca/Objectives_Online/objectives.pl?loc=home&lang=english

In this increasingly cluttered landscape, our seventeen Canadian medical schools are independently working to produce graduates ready to engage residency programs. (Read this “on the way to, but not yet quite there” with respect to full qualification). To do so, they develop frameworks based on competencies, usually leaning heavily on CanMEDS. As they go about this, they face a number of challenges:

  • These competency frameworks were developed with the intention of describing attributes and skills of practicing physicians, not novice learners. They therefore require upstream translation, which can lead to inconsistent interpretation.
  • Competencies are notoriously difficult to objectively and fairly assess. (How would you design a final examination for the “professionalism” competency?).
  • The evaluative standard used to measure success of medical school graduates is established by the Medical Council of Canada and is based primarily on clinical presentations (ie. do-ing, not be-ing). Purely competency-based curricula are therefore at risk of being out of step with the testing their graduates will be expected to undertake.
  • Dedicating increasing curricular time and attention to teaching and assessment of individual competencies threatens to further stress already packed curricula and displace core teaching of the basic and clinical sciences.

And there’s an even more fundamental problem. Any profession, indeed any occupation, is best understood in terms of the services provided. We understand lawyers, for example, as people who defend us in court, ensure our legal documents are in order etc, not as expert communicators, translators of legislation, advocates for social justice, or any of what I am sure are many important competencies that enable lawyers to be lawyers.

The competencies, whether considered individually or in aggregate, fall short in providing a clear and universally understood image of the “complete” medical school graduate.

Doctors, I think anyone would agree, are people trained to care for other people in the context of clinical illness.

If we extend that understanding a little further, we could pragmatically define the mission of undergraduate medical education to produce graduates capable of assessing, diagnosing, stabilizing and initiating both preventive and therapeutic management for the patients they will serve. If we accept that definition, then it would appear we have a “gap” between our mission and our competency frameworks.

Out of all this, the concept of “Entrustable Professional Acts” (EPAs) is beginning to emerge. This concept, attributed to and well articulated by by Dr. Olle ten Cate (ten Cate,2013: Nuts and Bolts of Entrustable Professional Activities. Journal of Graduate Medical Education: March 2013, Vol. 5, No. 1, pp. 157-158).

and has recently been promoted by the AAMC who have developed an approach that is being trialed at ten US medical schools. https://members.aamc.org/eweb/upload/Core%20EPA%20Curriculum%20Dev%20Guide.pdf

EPAs can be regarded as the specific set of skill and knowledge- based responsibilities that graduates can be expected to achieve. Competencies become the component attributes, knowledge and skills students must achieve in order to adequately carry out the EPAs.

Examples of EPAs would include the following:

  • the ability to carry out an efficient and effective history and physical examination
  • developing a useful differential diagnosis for patients presenting with common clinical problems
  • the recognition of critically ill patients, and how to stabilize their condition
  • accurate documentation of clinical encounters
  • the ability to obtain informed consent for medical procedures

The performance of EPAs must be informed by and incorporate appropriate competencies, such as communication, scholarship, professionalism and collaboration with other providers. EPAs cluster competencies into meaningful activities that can be observed in the workplace and therefore much more amenable to assessment.

Each competency may relate to multiple EPAs. The scholar competency, for example, would be critical to the ability to diagnose, develop management plans, and provide informed consent.

A set of EPAs in aggregate, provide an intuitively appealing and holistic impression of physician expectations that can be consistently understood by students, UG teaching faculty, postgraduate training programs, medical regulatory agencies and the public. As such, they provide a point of common understanding that may provide clarity as to developmental milestones, including the UG-PG interface (ie. Post-graduate programs can more easily understand and provide input as to the expectations at entry).

The AAMC document describes 13 EPAs and how they relate to their competency framework. The “Scottish Doctor” is another EPA-based framework. Beyond the particular items these two groups have identified, I think their value is in the demonstration that a clear, performance-based, objectively assessable and intuitively understandable articulation of the Canadian medical graduate is within our reach.

The Canadian undergraduate medical education community, at recent meetings, has been engaging these issues with increasing interest and commitment. The vision that’s emerging is for a pan-Canadian definition of the medical school graduate, based on EPAs, and informed by the excellent work carried out by organizations such as the Royal College, CFP and MCC. Such a consensus would benefit our medical schools, students, faculty, postgraduate program leaders and, importantly, the Canadian public.

I, for one, am looking forward those discussions.

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

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The Greatest Generation: Our Greatest Teachers

There is, perhaps, no more common or expected site on a warm, late summer afternoon than that of a man mowing his lawn. When I came upon just such a scene during a solitary walk not too long ago, I nonetheless found it distinctive for two reasons. Firstly, the gentleman mowing the lawn was elderly. In fact, very elderly. A conservative estimate would be well past 80, closer to 90. He was also a small, thin man who seemed to weigh not much more than the lawnmower he was pushing, and had a prominent kyphosis that necessitated him raising his head in order to see forward, making the task all that much harder.

The second remarkable thing was that he was not simply mowing his own lawn, but as pushed the machine back and forth, it was apparent that he was also mowing the lawn of his neighbor.

While I was passing by, two random encounters occurred in rapid succession. The neighbor whose lawn he was mowing drove into the driveway, returning home. A lady emerged from the car, perhaps in her late 30’s or early 40’s, and after extracting a baby from a car seat hurriedly thanked and waved to the gentleman who acknowledged with a smile and dismissive wave of the hand, as if to say “think nothing of it”. She quickly disappeared into the house with her baby and packages, leaving him to the lawn.

At the same time, a young boy, perhaps 14 or 15, was walking past on the sidewalk, headphones on, deeply engrossed in whatever was playing on his device. As he passed, he actually slowed down for a moment, took off the headphones and glanced back at the scene of the lawn mowing, shaking his head briefly, and then turned back resuming his walk and his musical solitude.

I have no idea what he was thinking, or what caused him to pause, but whether it was reflection or simply irritation from the noise of the mower, that elderly gentleman somehow, unknowingly and however briefly, shook that young man from his self-imposed isolation.

It occurred to me that in that very brief scene we’d been afforded a glimpse into the characteristics of three generations, or four if you count mine.

Authors William Strauss and Neil Howe have popularized the concept of Generational Theory in their enormously popular, if controversial, 1991 book “Generations”. Fundamentally, they advance the notion that groups of people born into the same culture at about the same time are subjected to common sociologic influences and global events that serve to shape that group in a characteristic manner. In their original book and a number of follow-up works, they trace history as a series of such generational periods.

In Strauss and Howe terminology, the young man passing on the street is a Millennial (Millennials Rising: The Next Generation, 2000), born 1982-2004. The neighbour lady is a Generation X-er (1961-1981), and I am a Baby Boomer (1943-1960).

greatest2The elderly gentleman, the central focus of my brief summer encounter, is a member of what Strauss and Howe dubbed the G.I. Generation (1901-1924), but has come to be more commonly referred to as “the Greatest Generation”, a term attributed to Tom Brokaw who used it as the title of his excellent 1998 book. In his 1960 inaugural address, President John Kennedy was speaking of this remarkable group when he spoke of a generation that was “born in this century, tempered by war, disciplined by a hard and bitter peace, proud of our ancient heritage…”

These folks were born between the First World War (1914-1918) and the late 1920s. The dominant influence during their childhood was the great economic depression of the late 1920s and 1930s. Just as the depression was lifting, and as they were reaching late adolescence and early childhood, they were drawn into the global cataclysm that was the Second World War. Whether or not they were direct combatants in that struggle, the life of everyone living at that time, male or female, was affected and influenced by those events. greatest3The early and formative years of that generation was therefore characterized by struggle, joint effort against great social threats, encounters with great personal and public loss, and shared suffering. For those 12 or so million men who returned to Canada and the United States after the war, and for the families they rejoined, there was also the sense of success brought about by common effort, and a confidence in and loyalty for the society they’d struggled so hard to support. For those survivors of European countries who’d been part of the same struggle, many turned to Canada and United States as places where they could, through their own effort, earn a place for themselves and their progeny in that “great society”.

Shaped by these influences, the members of this generation are patriotic and self-reliant, taking on responsibility for earning through the efforts of one’s own greatest4labour, eschewing social assistance, but supportive of those truly in need. They did not feel the need to speak of their early war experiences or the suffering they’d encountered at that time, as touchingly described by James Bradley in “Flags of our Fathers”. They believed in family, were fiscally conservative, religious and led by example. They parented the Baby Boomers, and attempted, with variable success, to impart their values to that generation. Like the gentleman mowing his lawn of his neighbour, they are generous and address needs without being asked or thought of reward. They have a sense of duty to those who did not survive the struggles they have witnessed. In short, they endeavor to “do the right thing”.

Those still surviving are also our patients.

One of the great and unanticipated benefits of our First Patient Program at Queen’s has been to facilitate encounters between our young students and members of this special generation. In reading the reflections provided by our students, and learning of the relationships that have been formed, it’s clear that these patients have imparted invaluable insights far beyond any knowledge of their medical conditions. Here’s a sampling of “lessons learned” provided by our students:

Perhaps just as importantly for me, I found Mr. X to be an excellent mentor, who taught us that to be good physicians we must go beyond understanding a patient’s medical problems to appreciate the holistic patient experience, including social and family histories.

Being with this patient made me appreciate how much patients benefit from, and value the time that you take to educate them about their treatment and their medical condition. I will hold on to these experiences and remember how it felt for our patient on the opposite side of the healthcare system. I think that some of the experiences that I’ve had in the First Patient Program will help me shape into a more compassionate, patient, and understanding physician.

Who ever knew that old patients were so cool?

Don’t assume you know what an elderly person is capable of. Always ask

Set aside your stethoscope, and connect with your patient beyond his/her diagnosis

Talk with the patient, not at the patient. Even better, listen more than you talk, and both you and the patient will be better for it.

There are many changes associated with normal aging, but it is important to remember that these don’t necessarily represent pathology. Patients who are elderly can also be healthy, and it is essential for physicians to understand the numerous community resources that can help facilitate happy and healthy aging

A chronic illness is truly that. It is a consideration in every decision, of every day. Living with a lifelong disease requires day-to-day adjustment of plans and a lifetime with medicine by your side

Seniors can be Apple fans, too. Technology can play a huge role in helping people stay connected to the world and their loved ones, especially if they are frail and find it difficult to leave the house

I don’t know the name or personal history of the lawn-mowing gentleman I encountered that afternoon. I do know that he is part of a generation of remarkable people whose life experience was far beyond that of myself, my contemporaries, or that of our children. That afternoon, with a selfless, generous gesture and quiet example, he continues to give and to teach us what it is to care and contribute to our society.

These remarkable people who lived through two global wars are the parents and grandparents of my generation of “Baby Boomers”, who are now involved in the education and leadership of these emerging, highly talented and technologically sophisticated “Millennials”. When I was in elementary school, I recall that each Remembrance Day veterans would visit our classrooms, dressed in their dark blue jackets, berets and decked out with medals. They were soft spoken and sombre, never glorifying themselves or their war exploits, but rather trying to express their respect for their fallen colleagues. The word that kept creeping into their dialogue, and the word I still recall so many years later, was “sacrifice”. Those gentlemen were veterans of the First World War, and are no longer with us. Soon, our Second War veterans will also be gone. Let us listen and learn from them while we have the opportunity.

Lest we forget.

greatest5

 

 

 

 

 

 

 

Anthony J. Sanfilippo, MD
Associate Dean
Undergraduate Medical Education

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Engaging Diversity to “enlighten” Medical Education

The word “education” has etymological roots that are both interesting and revealing. It evidently derives from the Latin “educo”, roughly translated “I lead forth” or “I raise up”. “Educatio” is “a breeding; a bringing up; a rearing”.

The word “education” has been defined in various ways, but definition that I prefer is simpler and more consistent with the origin and intent of the process; “an enlightening experience”.

In a previous article (http://meds.queensu.ca/blog/undergraduate/?p=1569) we explored the role of diversity as a component of that “enlightening experience”. The main points:

  • the environment in which education is provided can be as powerful as the instruction itself.
  • early adulthood is a critical time in the development of social and personal identity. Erikson wrote of that time being a “psychosocial moratorium”, during which they feel free to “sample” and experiment with various social roles for themselves before taking on a more fixed and permanent role.
  • early diversity experiences are both impactful and enduring, as evidenced by Newcombe and colleagues work with the Bennington College cohort, and both the Michigan Student Survey and Cooperative Institutional Research Programs.

Perhaps most importantly, higher education diversity experiences are most influential when the social milieu differs from the students home and social background. In the words of Gurin, it needs to be “diverse and complex enough to encourage intellectual experimentation and recognition of varied future possibilities.” Simply put, the real power to influence goes far beyond lofty mission statements and curriculum, and arises largely from developing an environment where students are able to interact both passively and actively with individuals who are “different” and therefore force new thought and new perspectives during this critical developmental phase.

Building on the last point, it would seem that any attempt to improve the educational environment from a diversity perspective must begin with an understanding of the pre-university home and social backgrounds of our learners. What do we know of the background of students undertaking medical education in Canada?

An important study by Dhalla and colleagues (CMAJ 2002:166;1029) surveyed 1223 first year Canadian medical students and found that, compared to the general population, medical students were:

  • Less likely to be of Black (1.2% vs 2.5%) or Aboriginal (0.7% vs. 4.5%) heritage
  • Less likely to hail from rural areas (10.8% vs. 22.4%)
  • More likely to have parents with master’s or doctoral degrees (39.0% of fathers and 19.4% of mothers, compared to 6.6% and 3.0% respectively)
  • More likely to have parents who were professionals or high level managers (69.3% of fathers and 48.7% of mothers compared to 12.0% of Canadians), including 15.6% of medical students having physician parents.
  • Less likely to come from households with incomes under $40,000 annually (15.4% vs. 39.7%)
  • More likely to come from households with incomes over $150,000 (17.0% vs. 2.7%)

These findings have since been substantially confirmed by Steve Slade and and his colleagues, who compile the Canadian Post-MD Education Registry (http://www.caper.ca/~assets/documents/CAPER_Poster_AAMC_Physician_Workforce_Conference_May-2012.pdf.), and more recently by Young and colleagues who surveyed 1,552 Canadian medical students (Academic Medicine 2012, 87; 1501), concluding that they are “overrepresentative of higher-income groups and underrepresentative of populations of Aboriginal, black or Filipino ethnicities in Canada.”

Our students have also weighed in on this issue. The Canadian Federation of Medical Students has published a position paper entitled “Diversity in Medicine in Canada: Building a Representative and Responsive Medical Community.” http://www.cfms.org/attachments/article/163/diversity_in_medicine_-_updated_2010__cait_c_.pdf. To quote their document:

“As medical students in a country that embraces diversity, we believe that our medical system should be representative of and responsive to the diversity within our communities. Unfortunately, the medical school admissions process has traditionally favoured students from high-income, urban dwelling, majority groups, thereby limiting the diversity of medical students across Canada and further marginalizing underrepresented patients and communities…An increased emphasis on diversity in medicine would help ensure that medical students and physicians are in tune with the needs of the communities that they strive to serve and represent.”

And so it appears that if we’re to develop this “enlightening” environment within Canadian medical schools, we’d be well served by facilitating entry of socioeconomically less advantaged population, and particularly member of our Aboriginal populations.

But how? An examination of the literature and our own local experiences seems in order.

Lessons from Other Programs

Recognizing that any attempt to encourage and support historically disadvantaged groups must begin very early in the educational process, the “cascading mentorship” model has been advocated by many. In their recent article Afghani and colleagues (Academic Medicine 2013; 88: 1232) describe a model they have developed at the University of California “in which high school students are coached by premed undergraduate students, who are in turn mentored by medical students, who are mentored by faculty.” The program expanded over a short period of time and both undergraduates and medical students reported very high ratings in self-confidence, motivation for a career in academic medicine, understanding different cultures, leadership ability, teaching ability and commitment to serve the underserved.

In “How leaky is the Health Career Pipeline?” (Academic Medicine 2009; 84: 797), Alexander and colleagues sought to explore how students from underrepresented minority (URM) groups performed in “gateway courses” (general chemistry, organic chemistry, general biology, introductory physics and calculus) required for application to California medical schools. They found that URM students received significantly lower grades in these courses, even after adjusting for prior academic performance (ie. poorer background in those subject areas). However, despite this greater academic adversity, URM students were at least as likely as white students to complete all the gateway courses and become eligible for application. They conclude that “interventions at the college level to support URM student performance in gateway courses are particularly important for increasing the diversity of medical and dental schools”.

In 2001, the Medical University at South Carolina embarked on an ambitious and aggressive strategic planning program to increase the diversity of their student population and faculty (Academic Medicine 2012; 87: 1548). At the admissions level, they provided “added value” to an application for certain characteristics intended to diversify the pool of qualified applicants. These included advanced community service, cultural experiences attending to the needs of underserved and underrepresented populations, sustained work experience, artistic/athletic achievements, overcoming adversity, and rural or inner-city backgrounds. In addition, individual Departments were called on to develop specific diversity plans, and financially supported to do so. Other initiatives included the development of pipeline programs and strategic partnerships with more than 40 colleges and universities to develop interest in the health professions among URM individuals. This comprehensive, multi-dimensional and leader-driven approach has proven highly successful in increasing the diversity of both student body and faculty over a 10 year follow-up.

Since 1973, the Sophie Davis School of Biomedical Education has been operating an innovative program within the City University of New York (Roman SA, Academic Medicine 2004;79:1175). They offer an innovative 5 year combined BS/MD program to promising high school graduates who express a definite interest in a medical career. Successful graduates of this program are guaranteed advanced transfer into the final two clinical years at one of five cooperating medical schools in New York State. The mission of the program “to expand access to medical careers to among talented inner-city youths and youths who have experienced educational disadvantages despite demonstrated evidence of high levels of academic achievements”. The program has been remarkably successful in providing access to socioeconomically disadvantaged students (27% of their students coming from families with incomes below federal poverty levels, and 70% eligible for state sponsored tuition support), underrepresented minorities (only about 15% of their students identified as “white”) while maintaining academic success (90% pass rate in USMLE Step1) and producing graduates who provide service in underserviced and underprivileged areas.

Current programs at Queen’s

Closer to home, Queen’s has had an Aboriginal Admissions Process since 1998. Under the process, applicants who self-identify and who meet reduced cut offs for GPA and MCAT scores have file reviews conducted by a team that includes members of the Aboriginal community. Interviews with selected candidates also involve members of the Aboriginal community. Since the program’s inception, data have been kept on the number of self-identified applicants, the number of offers and the number of acceptances.

MedExplore is a student-led program created in 2012. It provides opportunities for skill development, networking, and career exposure to students from disadvantaged groups that are under-represented in health care professions, so that they can make informed educational and career decisions. Queen’s medical students run workshops and serve as mentors to high school students from a variety of backgrounds, including

Altitude Healthcare Mentoring is a student-led initiative that has been operating at Queen’s since 2011. It provides mentoring and programming to first-year students from disadvantaged groups, including Aboriginal students and students of low socioeconomic means.

Queen’s University Accelerated Route to Medical School (QuARMS) has the potential to address the many barriers inherent in the medical school admissions process. Writing MCAT tests, submitting applications and attending interviews all involve significant cost. As well, low-income students may not be able to afford to take a summer off from working to prepare for the MCAT or to participate in volunteering and extracurricular activities that less financially constrained students employ to enhance their applications. QuARMS is available to students in all schools, from all parts of the country. Full travel bursaries are provided for students who demonstrate financial need. A student from an underrepresented group who applies through QuARMS therefore has the opportunity to access medical education on a more equal footing with higher-income candidates, avoiding many of the barriers that might otherwise deter them from applying to medicine.

Going Forward

In my previous article on this topic, I closed by posing the not-so-rhetorical question “Can we do better?” The home-grown initiatives noted above are certainly praise worthy steps in the right direction, but I think all would agree that they would benefit from more visibility and more structured, consistent support. Moreover, they would seem to fall short of the deep, institutional commitment typified by the programs like those described at South Carolina and the Sophie Davis School. For all these reasons, a number of initiatives are being brought forward within the School of Medicine to better define and bolster our approach to advancing Diversity.

  1. A Diversity Statement has been developed and approved by the MD Program Executive Committee that will be brought to the School of Medicine Academic Council for approval this week that statement reaffirms the university commitment to underrepresented groups and focuses the School of Medicine on two target populations, the Aboriginal peoples of Canada, and the socioeconomically disadvantaged.
  1. A Diversity Advisory Panel, consisting of interested students and faculty is being struck to develop and support initiatives to advance Diversity within our school, including those student led projects already underway. Dr. Leslie Flynn has agreed to take on the chairmanship of this panel, and no fewer than 9 student volunteers have already stepped forward to participate, and that group has its first meeting scheduled for later this month.
  1. A Diversity Fund has been developed that will be available to the panel for support of projects or initiatives it recommends.
  1. Dean Reznick has given high priority to the recruitment of a faculty Diversity Lead to coordinate our approaches.
  1. I will be asking our Admissions Committee to consider means by which they could more directly support our Diversity goals through modification of our current MD Program and QuARMS admission processes.

As always, your views on these and any other initiatives you’d like to bring forward are most welcome.

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

Many thanks to Sarah Wickett and Sandra Halliday, Health Informatics Librarians, Bracken Library, for their valuable assistance in the compilation of information for this article.

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