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.

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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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The Educational Value of Diversity

In October of 1931, a 16-year-old college student joined a group of friends for a night of carousing and entertainment at the Driskill Hotel, in Austin Texas. He had no idea what to expect of the entertainment, the focus of the evening being on the “carousing” component. Rather unexpectedly, he is deeply moved by the performance, and particularly by the featured musician. Many years later, that student writes about that experience in his memoirs:

“He played mostly with his eyes closed. Letting flow from that inner space of music things that had never existed. He was the first genius I’d ever seen.”

diversity1The “genius” he was referring to was Louis Armstrong, who was himself only 31 at the time, at the beginning of a career that would eventually identify him as one of the greatest virtuosi and innovators in the history of American music.

The young man was Charles Lund Black, who would go on to become a Professor of Law at Yale and expert in American constitutional law and contribute importantly to a number of cases involving key civil rights issues.

Professor Black would later say the following about his experience that evening:

diversity2“It is impossible to overstate the significance of a sixteen year old Southern boy’s seeing genius, for the first time, in a black. We literally never saw a black man, then, in any but a servant’s capacity…Blacks, the saying went, were ‘alright in their place’, but what was the place of such a man, and of the people from which he sprung?” http://www.nytimes.com/2001/05/08/nyregion/charles-l-black-jr-85-constitutional-law-expert-who-wrote-on-impeachment-dies.html

In Black’s eulogy, a former student would say of him, “He was my hero…He had the moral courage to go against his race, his class, his social circle.”

In Medical Education, the concept of Diversity has become entrenched in our collective vision as expressed in both the Future of Medical Education in Canada recommendations and in accreditation standards. The rationale for such initiatives has been largely perceived to be the need to ensure equity of opportunity, and a need for medical schools to respect and reflect the gender, cultural, religious influences of the societies they serve. Laudable and worthy justifications, to be sure. However, Mr. Black’s encounter with Mr. Armstrong hints at deeper, even greater benefits. Does diversity within a learning environment, or as a deliberate component of a curriculum, have educational value? Does it shape thought and attitudes? Does it make students better practitioners of whatever career they undertake? Does it make them better citizens?

These questions have had particular relevance and attention in the United States for the past several decades, where they have been the focus of legal as well as pedagogical attention. Affirmative Action initiatives and subsequent legal challenges have required both jurists and educators to engage this question critically and analytically.

In 1978, Chief Justice Lewis Powell wrote the following opinion regarding the case Regents of the University of California vs. Bakke. He argued “the atmosphere of speculation, experiment and creation – so essential to the quality of higher education – is widely believed to be promoted by a diverse student body…It is not too much to say that the nation’s future depends upon leaders trained through wide exposure to the ideas and mores of students as diverse as this Nation of many peoples.”

Chief Justice Powell’s decision, however, did not settle the issue. Challenges have continued and the wisdom of mandated diversity initiatives has been repeatedly questioned. This is largely due to the lack of a theoretical framework or evidential basis demonstrating value. Since then, considerable work has either emerged or been resurrected to provide such evidence, which is summarized in an excellent paper by Gurin and colleagues (Harvard Educational Review 2002; 72: 330).

From the theoretical perspective, the work of a number of sociologists and psychologists is particularly relevant, and fascinating to review. In attempting to describe their work, I freely admit to venturing far beyond my expertise and apologize in advance to those much more knowledgeable.

Erik Erikson, as far back at the early 1950s, postulated that late adolescence and early adulthood were critical times in the development of personal and social identity. He theorized that such identity develops most effectively when people at that stage of life are provided what he called a “psychosocial moratorium”, by which he meant a time and situation during which they could feel free to “sample” and experiment with various social roles for themselves before taking on a more fixed and permanent role, i.e., before they “committed” to a profession, personal philosophy, or relationship. Colleges and universities are critical to providing this environment for most young people, certainly in North America. But how can they promote this critical social development? In the words of Gurin and colleagues:

“Higher education is especially influential when its social milieu is different from students’ home and community background and when it is diverse and complex enough to encourage intellectual experimentation and recognition of varied future possibilities.”

In other words, 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.

Sociologist Theodore Newcomb carried out a series of studies and long-term follow-ups of Bennington College students between 1943 and 1991. (Newcombe et al 1967. Persistence and change: Bennington College and its students after 25 years. New York: John Wiley and Sons), (Alwin et al 1991. Political attitudes over the life span. Madison: University of Wisconsin Press). To medical folks, this is the sociologic equivalent of the Framingham studies. He and his colleagues found that political and social attitudes were most likely to change and remain so in students who had encountered novel concepts and attitudes, largely through peer influences, while attending college, thus supporting Erikson’s theory and demonstrating long term durability of the early life experience.

In the Gurin paper, the authors draw on the work of Jean Piaget and Diane Ruble in extending the concept of disequilibrium, to the early learning experience. In Gurin’s words:

“Transitions are significant because they present new situations about which individuals know little and in which they will experience uncertainty. The early phase of transition, what Ruble calls construction, is especially important, since people have to seek information in order to make sense of the new situation. Under these conditions individuals are likely to undergo cognitive growth unless they are able to retreat to a familiar world.”

In simple terms (that even a cardiologist would understand) the greater the difference between the students prior life experience and the learning environment in which they find themselves, the greater potential for new thought, new concepts and personal growth.

The Michigan Student Survey (MSS) and Cooperative Institutional Research Program (CIRP) are longitudinal studies examining, among other things, how diverse education processes influence attitudes and career success. The MSS is a single site study involving 1,582 students. The CIRP is a national cooperative involving 11,383 students from 184 American institutions. Both involved racially and culturally diverse populations of students assessed on the basis of their pre-university and university cultural environments i.e. their “diversity experience”. For detailed description of results, I would refer the reader to Gurin et al. Harvard Educational Review 2002;72:330. The key findings relevant to those considering diversity initiatives in university programs:

  • There was a positive relationship between diversity experiences and educational outcomes
  • The influence of a diverse educational environment was consistent across schools and cultural groups
  • “interactional” diversity was more influential than “classroom diversity”

But are these effects also relevant to medical education, where one might suppose that students are older and further along developmentally, and perhaps pre-selected for cultural diversity and preparedness?

  • In 2003, Whitla and colleagues (Academic Medicine 78:460) reported on a study involving medical students at Harvard Medical School and the University of California, San Francisco. Students surveyed reported that contact with diverse peers enhanced their educational experience and supported ongoing affirmative action initiatives.
  • A graduation questionnaire administered by the Association of American Medical Colleges to 20,112 graduates from 118 medical schools (Saha et al, JAMA 2008; 300: 1135), demonstrated that, for white students, attendance at a school with high proportions of peers from underrepresented minorities was associated with greater confidence in caring for minority patients and positive attitudes regarding equity issues. These associations were not found for non-white students.
  • Niu and colleagues (Academic Medicine 2012; 87: 1530) surveyed 460 Harvard medical students and found that those who reported spending more than 75% of their study time with students from diverse backgrounds or having participated in diversity related extracurricular activities felt more prepared to care for diverse patients.

And so, it seems Mr. Black’s experience in 1931 was not simply an isolated event, but indicative of the potential for great things to emerge when open minds are exposed to new situations, new social constructs, new paradigms. The value of Diversity in education is about much more than a need to exhibit “fairness” and some notion of social justice, but rather an active educational intervention capable of expanding the vision, imagination and therefore potential of students.

So, what does all this psychosocial theory and American experience say to those of us engaged in medical education in Canada in 2014? We might feel, with some justified smugness, that we are not faced with the same social divides and engrained class issues as our southern neighbours. We might also take solace in the knowledge that our schools are uniformly committed to the concepts of equity, fairness and diversity in the workplace, and have rather rigorous policies in place intended to ensure the issue of structural diversity. However, we might also see this as an opportunity to enhance our approaches to medical education, where the ability to effectively engage people of diverse backgrounds and with diverse needs would seem particularly relevant. Finally, many in 2014 Canada might define Diversity as more of a socioeconomic as opposed to racial/ethnic issue, given the well-documented struggles of our First Nations and immigrant populations. With all this in mind, I pose a few perhaps unsettling questions for consideration:

  • Do our students engage in medical school in the type of passive and active learning environment that theories and studies suggest could truly influences their development as physicians?
  • Do our policies, which focus largely on identifying numbers and proportions of various groups in our school relative to the general population, truly promote the development of that effective learning environment, or simply attempt to demonstrate token compliance with regulations?
  • Our students, raised in and drawn from a Canadian culture that promotes equity and fairness, are good and instinctively fair people, unfailingly tolerant of diverse individuals and eager to contribute, but do they develop a deep understanding of the issues of those less-advantaged, and are we, as the stewards of their education, doing all we can to develop a learning environment that will promote that understanding?

Can we do better? Can’t help but think so.

My next article will focus on initiatives currently in place and being undertaken here at Queen’s to enhance the student experience through Diversity initiatives. As always, your input is welcome.

Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.

 

 

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Introducing Queen’s Meds 2018

With the all-too-soon end of summer comes the beginning of a new academic year. This week we welcome members of Meds 2018, the 160th class to enter the study of Medicine at Queen’s since our school opened its doors in 1854.

meds2018

A few facts about these new members of our learning community:

They were selected from our largest ever applicant pool – 4366 highly qualified students submitted applications last fall.

Their average age is 24 with a range of 20 to 31 years.  For the first time in several years, there are slightly more men (55) than women (45) in the class.

They hail from no fewer than 38 communities across Canada, including; Ajax, Belle River, Belleville, Brampton (2), Brooklin, Burlington, Caledon, Calgary(4), Dundas, Edmonton, Fall River, Guelph, Halifax, Harrowsmith, Holland Landing, Kanata (3), Kingston (5), Langely (2), London (3), Markham (4), Midland, Mississauga (8), North Bay, North York (2), Oakville, Ottawa (10), Peachland, Peterborough, Sherwood Park, St Marys , Thornhill (5), Toronto (21), Vancouver, Waterloo (2), West Vancouver (2), Whitby (2), Whitehorse, Winnipeg

Ninety-one of our new students have completed an Undergraduate degree, and twenty-seven have postgraduate degrees, including nine PhDs.  The average cumulative grade point average achieved by these students in their pre-medical studies was 3.76.  Their undergraduate universities and degree programs are listed in the tables below:

UGStudies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UGDegree

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UMastersStudies

MastersPrograms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PhDStudy

 

 

 

 

 

 

PhDPrograms

 

 

 

 

 

 

 

 

 

 

An eclectic and academically very qualified group, to be sure.  Last week they undertook a variety of orientation activities organized by both faculty and their upper year colleagues.

On their first day at Queen’s, they were welcomed to the study of Medicine by myself and Dean Richard Reznick. Over the course of the week, they met curricular leaders who will be 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. Jennifer Carpenter, John Smythe, Kelly Howse, Peter O’Neill 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 Schutt, Jennifer Saunders and Sheila Pinchin, and first year Curricular Coordinator Brittany Lovelock.

Dr. Jaclyn Duffin led them in the annual Hippocratic Oath ceremony, and coordinated the very popular and much appreciated “Pearls of Wisdom” session, where fourth year students nominate and introduce faculty members who have been particularly impactful in their education, and invite them to pass on a few words of advice to the new students. This year, Drs. Bob Connelly, Jay Engel, Michelle Gibson, Mala Joneja, Michael Leveridge, Susan Moffatt, Michael Sylvester, David Taylor, Ruth Wilson and former Dean David Walker were selected for this honour.

On Friday, they were welcomed to our Anatomy Learning Centre and facilities by Drs. Steve Pang, Conrad Reifel, Ron Easteal and facility manager Rick Hunt, and participated in the annual memorial service with a moving dedication by University Chaplin Kate Johnson.

Their Meds 2017 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 Cluett and Arian Ghassemian.

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

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Traffic under the Tuscan sun

Perhaps nowhere on earth do the ancient and modern come into such stark juxtaposition as on the narrow streets of a small Tuscan town. Pedestrians, pets, strollers, bicycles, walkers, wheelchairs, motorcycles, private cars, tuscan2taxis, trucks, buses, ambulances and horses all share these cobbled laneways, apparently with equal access. There are no lane dividers (there being only one lane), no bicycle paths, no sidewalks. The only rule, unwritten of course, is that if something larger or faster is approaching, best get out of the way. Adding to the apparent confusion, most people are smoking, texting and talking (actually yelling) on cellphones, some all at the same time. tuscan1Keep in mind that most of these folks are Italian, a people not known for either patience or stoicism. And yet, it all seems to work. Everybody moves along, no fuss, surprisingly little agitation.

To the North American sense of order and compulsion for efficiency, all this seems bewildering. How is this allowed in a presumably civilized country? How do these people tolerate such apparent chaos and, one must ask, why do we in Canada seem to have so much angst about what we perceive as “traffic”, given more space, wider streets, fewer people, and sensible rules that are generally adhered to. How do we account for this? Is there something to learn here?

To all this, I offer some theories, developed after making the strategic decisiontuscan3 to stoptuscan4 moving and instead spend more time sitting in one of the many sidewalk cafes and watch the flow of humanity over plenty of espresso, dolci and vino rosso.

Firstly, there’s a sense of permanence and continuity in such places that provides perspective. When you find yourself casually leaning against a column or archway that dates back two millennia, you gain a sense of yourself in time and history that is rather humbling, promotes acceptance and disavows one of the responsibility to improve upon every imperfection. The urge to “bring order” becomes a decidedly new world notion.

tuscan5There’s also a profound respect for what is established and has withstood the test of time. One would no more paint a traffic line on these ancient streets than one would paint trousers on Michelangelo’s David. tuscan6There is a certain humanity and humility in the acceptance of chaos in order to preserve the history.

And, of course, there’s that famous Italian temperament. Italians, it must be said, have no love of rules and regulations. In fact, they fundamentally reject direction. However, they are an instinctively generous people who will generally do the right thing, as long as it isn’t required of them. Moreover, they seem to almost admire a creative flouting of the rules. Any understanding of how Silvio Berlusconi was able to gain and hold power for so long in the famously fickle Italian political structure must really begin with an acceptance of this quintessentially Italian characteristic.

tuscan7Finally, perhaps the best lesson of all, I found I learned much more when I stopped trying to dodge collisions and instead found a comfortable vantage point to observe and ponder. Surely, a lesson to take home and apply to the steady stream of challenges and unexpected obstacles that continually come our way. And the vino rosso certainly didn’t hurt.tuscan8

 

 

 

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

 

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The Virtue of Resilience

Should Medical Schools be looking for it?
Should Medical Schools be teaching it?

What do professional sports teams, executive search firms and medical school admissions committees have in common? (This is not a trick question). Answer: they are searching for young people with the quality of resilience.

This particular quality may go by many names, both formal and colloquial: grit, perseverance, determination, truculence, tenacity, gutsiness. These are all terms for the quality perhaps best defined as “the ability to function in the face of adversity”. What professional hockey managers, headhunters and admissions committees have come to learn through bitter experience are three great truths common to their respective worlds:

resilence

Resilience, quite simply, is essential if the talented are to achieve success.

This is nothing new in the world or in human history:

Resilience is what has allowed communities and even peoples to survive and rebuild despite incredible suffering and losses.

Resilience is what got the British through the bombardments of the Second World War.

Resilience is what motivated so many of our ancestors to seek greater opportunities in this country.

Resilience is what our patients demonstrate as they endure their illnesses.

Resilience is what allows physicians to deal with stress, long hours, inability to “cure” every patient, and to function in a world that often fails to recognize or even acknowledge their efforts.

The lack of resilience has been cited as a major cause of “burn out” in students, residents and qualified physicians. So how can we characterize resilience in learners and practitioners of Medicine?

  • In a 2013 article, Zwack and Schweitzer (Academic Medicine 2013; 88:382) pose the intriguing question “If Every Fifth Physician is Affected by Burnout, What About the Other Four?” They conducted 200 interviews with physicians of various ages, disciplines and level of training who, upon assessment, were found to exhibit high levels of personal accomplishment and low levels of characteristics associated with “burnout” (emotional exhaustion, depersonalization). The analysis identified a number of factors these high functioning physicians shared, including gratification from the doctor-patient relationship and satisfaction from medical successes. These also exhibited what the authors called “resilience practices”, including leisure time activities intended to reduce stress, cultivation of contact with colleagues, good relations with family and friends, proactive engagement with the limits of skills and treatment errors, personal reflection, spiritual practices, and ritualized “time-out” periods in their schedules. They also identified a number of “useful attitudes”, including acceptance and realism, self-awareness and reflexivity, active engagement with limitations, recognizing when change is necessary, and appreciation of positive experiences.
  • Sarles and colleagues surveyed 141 general surgery residents and found that measures of “grit” were predictive of later psychological well-being (Am J Surgery 2014; 207(2): 251).
  • In their editorial to the Zwack paper, Epstein and Krasner (Academic Medicine 2013; 88: 301) point out that physicians are at particularly high risk, and therefore even more vulnerable. “All too often, busy clinicians ignore the early warning signs of stress – fatigue, irritability, and feeling outside their comfort zone – in the hope that the situation will self-correct or that their baseline adaptive skills will carry them forward”.
  • Angela Lee Duckworth, a PhD Psychologist at the University of Pennsylvania, has been studying the relationship between “grit” (defined as “the tendency to sustain passion and perseverance for long term goals”) and individual success. In “The Grit Effect: Predicting Retention in the Military, the Workplace, School and Marriage” (Eskries, Winkler, Shulman, Beal, Duckworth, Frontiers in Psychology 2014; 5: 36), she and her colleagues found that “grit predicted retention over and beyond established context-specific predictors of retention (eg. Intelligence, physical aptitude, Big Five personality traits, job tenure)…Grittier soldiers were more likely to complete an Army Special Operations Forces selection course, grittier sales employees were more likely to keep their jobs, grittier students were more likely to graduate from high school, and grittier men were more likely to stay married.”

All well and good, but can anything be done for the resilience-deficient? One might imagine that resilience is an inherent quality determined by one’s genetic makeup and therefore beyond learning or development. Apparently not.

  • Sood and colleagues tested the utility of a resiliency training intervention consisting of single 90 minute one-on-one interactions among their colleagues in the Department of Medicine at the Mayo Clinic (J Gen Intern Med 2011; 26: 858) and found significant improvements in a number of measured wellness parameters, including resiliency, perceived stress, anxiety and overall quality of life.
  • Gail Wagnild is both a Registered Nurse and PhD psychologist who has been promoting the concept that although we can’t avoid adversity in our lives, we can choose how to respond to such events in a way that promotes personal resilience. In “Discovering Your Resilience Core”, she describes five essential characteristics of resilience (purpose, perseverance, self-reliance, equanimity, and existential aloneness) and how each can be identified and strengthened.

So it appears the answer to the two questions I posed are “yes”, and that resilience is not only something that can be recognized, but also developed. Given its importance to career success, it would seem advisable for medical schools to both recognize it as an attractive (maybe essential) applicant quality that should be actively searched out, and also promote it’s further development in our students.

Admissions committees will have long debates about which personal qualities are the most relevant to career success. I vote for resilience.

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Out of adversity, gifts of learning.

In the course of my career, I’ve unfortunately had many occasions to deliver “bad news” to patients and their families. This usually involves making them aware that treatments are either not working or no curative options are available, and that the end is imminent. In these moments, reactions are personal, individual and usually unpredictable. No matter how much one rationally anticipates the end of life, the actual reality can never be fully prepared for. The responses are raw, without pretense or veneer. As physicians delivering such news, we’re never truly prepared, and never feel adequate to the task.

I particularly recall an occasion when I participated in delivering “bad news” to a patient I’d been following for many years through several cardiac crises and surgeries. Together with two of my colleagues also involved in his care, and a number of involved students and residents, we informed him, his wife and teen-aged sons that, despite the fact that he was only in his mid 50’s, there were no options any longer available to treat his severely damaged heart and that he had only a short time to live.

There is no truly good way to deliver “bad news” to a patient. There are, however, a number of very bad ways to go about it. My experience and readings would suggest a number of key considerations:

  • Clarity is a virtue. The use of euphemisms or expressions of uncertainty about the outcome just increase anxiety. If we’re not sure, we shouldn’t be having the conversation.
  • Patients appreciate hearing bad news from someone they know and have come to trust. We should try to have such people involved, even though current patterns of practice make this difficult.
  • Patients don’t usually need or desire detailed medical descriptions of why treatments have failed, but once they realize the outcome is certain, will have very practical questions about what will happen. How long? How will it happen? Will there be pain?
  • Patients are often more aware of the realities than we anticipate. They are, after all, experiencing the success or failure of treatments. What we’re telling them is often much less of a surprise and we’re really confirming their impressions.
  • Patients need to know they will not be abandoned. We need to express the ongoing plan for management.

I was anticipating all this when we spoke to my patient.  I was ready for anger, disappointment, denial and all the other responses we’re taught to anticipate and I’ve seen before. I was not, however, prepared for his reaction. Sadness, to be sure, but his first response was to thank us. He shook our hands. Incredibly, his only question was whether any of his organs would be suitable for donation.

Physicians have recognized for many years that our patients are our best teachers. For the most part, this relates to what they teach us about medical matters. What’s less apparent is that they also have the capacity to teach us so much about the human condition and the human spirit, at its worst and at its very best. We have the privilege of sharing life-altering experiences and witnessing not only the suffering, but also how people are able to summon incredible reservoirs of strength and generosity of spirit in times of apparent hopelessness. It’s simply inspiring. That day, in a few moments, that patient, with a few gestures and comments, provided invaluable gifts of learning, not only for myself and my colleagues, but also for the nurses, residents and students in attendance. Perhaps most importantly, he provided an inspiring example for his young family. Out of his adversity, those gifts of learning will affect other patients and other lives.

By the way, I’ve since signed my organ donor card.

 

 

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

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Thank you Dr. McLean

The following note was sent by one of our fourth year students to her community preceptor at the end of her Integrated Community Clerkship. Both parties have graciously agreed to allow me to share it with you.

Dear Dr. McLean

Thanks for:

  1. Teaching me Medicine
  2. Trusting me with your patients
  3. Introducing me to Perth
  4. Letting me be wrong
  5. Helping me get to the right answer
  6. Asking my opinion
  7. Demonstrating to me how to make patients feel heard
  8. Having office hours that work for patients (the 7am start makes so much sense)
  9. Encouraging me to be curious about patients’ personal histories
  10. Stashing Fudgeo’s
  11. Asking me hard questions
  12. Not making me feel silly when I didn’t know the answer
  13. But expecting that I know it next time
  14. Being patient as I learn procedural skills
  15. Filling out the paperwork while I finish the fun jobs
  16. Showing me that people are the most interesting part of medical practice
  17. Helping the office get through an entire Costco bag of Swiss chocolate…in a week.
  18. Demonstrating the type of discipline you keep teaching me to foster
  19. Taking me to the family medicine update conference
  20. Letting me draft on the bike and in the office!
  21. Building me up in front of patients
  22. Laughing with me at the occasional absurdities of family practice
  23. Teaching me to look
  24. To always look
  25. Introducing me to DQ milkshakes
  26. Telling me something isn’t right with a simple glance during procedures
  27. And feedbacking a quiet “better” once I corrected
  28. Magically knowing when I was prepared enough for you to disappear behind the curtain
  29. Giving me generations of social history in one or two sentences
  30. Helping me process hard-to-process patients
  31. Teaching me to dictate after every patient
  32. Showing me that the chart can be your friend…
  33. …it lets you go on holiday
  34. …and remind you of things you forget
  35. Patching up the first-year medical student
  36. Saying “I don’t know” with patients
  37. Saying “I don’t know” to me
  38. Showing me that we have a responsibility to advocate aggressively but politely for our patients
  39. Not using much technology but having an awesome EMR
  40. Teaching me to look for the why
  41. Reminding me why I do not want to be a rhythmologist
  42. Post-clinic Buster Bars
  43. Teaching me to punt when appropriate, better too soon than too late
  44. Stressing the importance of good documentation
  45. Making me remember the type of doctor I wanted to be as a kid
  46. Walking down to radiology.
  47. Talking to me about my future
  48. And making me think twice about what it might hold
  49. Deliberately debriefing the patient who coded
  50. Reminding me that I cannot solve all of a patient’s problems but can stand by her as she chooses to make her life better, or not
  51. Organizing similar experiences for so many other medical students
  52. So proudly showing me Lanark Lodge
  53. Teaching me an approach to explain the “needs further testing” imaging results with patients
  54. Challenging me to make a real difference for patients, not just correct their serum sodium concentration
  55. Auto-bolusing the syncopal wedding guest
  56. Taking off early one afternoon to go biking
  57. Reminding me to read around patients
  58. Teaching me that if to make a clinical decision you need more information, then go get that information
  59. To help me in my first “teaching role” during community week
  60. Letting me check all the well babies
  61. Including me in the joys and sorrows of rural family practice
  62. Helping me to find even more fulfillment in Medicine
  63. And…inspiring me to dream big while rooting my future in discipline, curiosity, wonder, humility and purpose.

Despite the complexity of modern pedagogical theory, expectations of multiple “shareholders” and increasing demands of accrediting agencies, the essence of medical education remains constant since the pre-Flexner apprenticeship days. Fundamentally, the overriding objective of any program hoping to graduate competent physicians is to identify motivated, receptive learners, and put them into contact with capable, inspiring physicians in a setting that allows the interchange to flourish. That’s basically what any medical school struggles to accomplish. And when those three elements come together….well, the effect is just magical and wonderful to behold.

Motivated learners aren’t hard to come by. As we’re all aware, there are many more highly motivated young people pursuing medical education than positions available. The considerable challenge, as we’ve discussed in previous blogs, is identifying those with the right motivations.

Medical School Admissions: Striving for fairness despite “ill designed” tools http://meds.queensu.ca/blog/undergraduate/?p=363

Medical School Admissions: Unintended Consequences http://meds.queensu.ca/blog/undergraduate/?p=407

Effective educational settings are essential and include appropriately structured and resourced classrooms, clinical learning centres, simulation laboratories, libraries and a continually evolving variety of learning facilities. However, medical education must necessarily extend to clinical settings where students can engage “real” patients in “real” venues. Our Integrated Community Clerkships, which have been in operation in Perth, Picton, Brockville and Prescott for the past four years, are true immersion experiences for our students. They spend 18 weeks living in those communities, working with local physicians, seeing patients in offices, emergency departments, hospital wards, nursing facilities, their homes, or wherever the circumstances require. In addition to learning a great deal about a variety of clinical problems, they become part of those communities and learn about how physicians manage their professional and personal lives. Importantly, they develop a more complete sense of themselves as independent physicians. These rotations have proven remarkably successful, as measured by student satisfaction and academic success. Although many educational leaders and affiliated community faculty have contributed to this success, the two most responsible have been Richard VanWylick, who took on and still provides administrative leadership for the program, and Ross McLean, who not only participates so effectively in the teaching, but has provided steadfast and highly effective support for the program through his role as leader of the Eastern Ontario Regional Medical Education Program (ERMEP).

Which brings us to the most important and valuable of our three key ingredients: the capable, inspiring physician-teachers. At Queen’s, we’re blessed with many such people, none more dedicated or effective than Dr. McLean. Although he’d never describe himself as an “educator”, he is an instinctive teacher with an abiding drive to pass on his 40+ years of experience and wisdom to the next generation of learners (I can assure you he’s not in this for the monetary awards). The qualities of responsible advocacy, sensitivity, professional commitment and diligence that make him such an effective physician, translate naturally to his role as a teacher. His dedication to the profession and to his community are legendary and have been recognized by his having been presented with the Glenn Sawyer Award honouring “a distinguished career of service” in 2011.  I understand there is a lively debate in Perth as to how many physicians will be required to replace him when he retires. Estimates range from three to five.

Eve Purdy’s letter captures more effectively than any treatise on educational theory or compendium of accreditation standards, the elements of an effective learner-teacher interaction. I can’t really add to it, except to join her in saying…Thank you Dr. McLean.

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One Day in Clinic…

Sarah (fictitious name to protect the innocent) is a second year medical student attending my Cardiology clinic for an “observership”. Like her peers, Sarah had an outstanding academic career prior to entering medical school, as well as a variety of personal experiences that demonstrated an interest in the human condition and commitment to public service. Since entering medical school, she has continued to excel academically, easily passing all her courses. She participates in a number of extracurricular activities, is well liked by her classmates and well regarded by faculty.

She is now exploring career interests, which is what brings her to my clinic. Sarah requested this observership because she feels she may be well suited to Internal Medicine, and Cardiology in particular, and would like to explore that interest in greater depth.

As we chat before clinic, she tells me that she hopes to both increase her knowledge and learn more about the practice of Cardiology. It’s obvious that she’s prepared herself for the clinic by reviewing course content from the previous term, and arrives in her crisp white clinical jacket with stethoscope in hand.

My approach with second year students in clinic is to introduce them to a few selected patients and give them about 30 minutes alone to take a history of the presenting issue and carry out a directed physical examination, including vital signs and cardiovascular and respiratory components. The student then presents their findings to me in a separate room, and we then see the patient together.

Sarah sees three patients.

The first is a 79 year old gentleman who underwent aortic valve replacement and coronary bypass grafting about 6 weeks previously having been followed with gradually increasing symptoms over the previous year. He is a retired construction worker of Portuguese background who speaks no English, but is accompanied by his wife (who also speaks no English) and their devoted daughter who translates for them both. In fact, the daughter doesn’t translate so much as respond directly to questions on behalf of both parents. Although he’s doing well, they have a number of questions and concerns. Sarah has difficulty because she feels she needs to pay attention to three anxious people simultaneously, and isn’t sure the responses she’s getting from the daughter are valid. In discussion afterward, she has missed a number of key issues, and feels somewhat frustrated by the encounter.

Sarah’s second patient is a 60 year old adult who has been followed for over 10 years because of Hypertrophic Cardiomyopathy. The patient is developmentally handicapped and, although very pleasant and cooperative, responds to every enquiry in the same polite manner, affirming how well she feels without elaboration or apparent depth of thought. This is in distinction to the results of the recent echocardiogram that indicate the condition is getting progressively more severe, to an extent that treatment would usually be indicated. The case worker who accompanies our patient and knows her well, tells us that she’s “slowing down”, but never complains of any of the symptoms about which we have enquired. Sarah is aware of a number of treatment options that are known to improve symptoms and prognosis in this condition, but isn’t sure how they should be applied given her patient’s apparent lack of symptoms and inability to understand the indications and possible side effects reliably enough to participate in the decision.

The third patient is a 21 year old native woman who lives in lives near Moose Factory and works in the local hospital. She is referred by her Family Physician because she’s experienced two syncopal episodes within the past month. Sarah takes a complete history, and uncovers a number of issues that might suggest a cause, including a history of drug and alcohol abuse, and a family history of sudden cardiac death at young ages. We discuss a plan for investigations, as well as the need to inform the patient that her driver’s license must be suspended until we’ve resolved the problem. The patient is angry and upset, and doesn’t know how she’ll be able to carry out further investigations, since she was expecting to return home on the first flight early the next morning.

After clinic, Sarah and I take some time to “debrief”. She’s clearly a bit shaken by these encounters. We agree that her level of knowledge about the medical conditions she’s encountered (aortic stenosis, coronary artery disease, syncope, cardiomyopathy) is excellent, entirely in line with her level of training. However, she felt very limited in her ability to obtain a complete history and to apply accepted management strategies to these patients. In addition, she found the experience of encountering a person close to her own age with so many issues complicating her care particularly troubling on a personal level.

We were able to identify the various physician competencies that were required to effectively manage these patients. Sarah found, somewhat to her surprise, that the Medical Expert components, which she’d always assumed were the most important in her learning were, in fact, not much of a problem for her. It became obvious as we reviewed the cases that the Portuguese family and disabled adult challenged her communicator skills. The young lady with so many social issues required advocacy and highlighted her professional role to enforce public policy. Deciding what managements were applicable to the cardiomyopathy patient required an exercise of the scholar role, and coordinating all these aspects of care was a manager challenge, as was dealing with her personal responses to the young woman’s social situation. Some of the recommendations we made required collaboration with community physicians, therapists, pharmacists and other health providers. Even more importantly Sarah was able to see that providing comprehensive patient care requires these roles to be integrated rather seamlessly. They simply don’t segregate conveniently for us, as early medical education would suggest.

It also became apparent that these aspects of the learning experience had little to do with the cardiology-specific content but are relevant to any discipline. The “career exploration” element that Sarah was initially seeking certainly took place, but in a much broader and likely more effective way than she had imagined.

So, in summary, what did Sarah gain from her clinic experience:

  1. A deeper understanding of the pathophysiology, clinical presentation, physical examination and fundamental management of four specific medical conditions.
  2. An appreciation of the importance, complexity and subtlety of communication as a key physician skill.
  3. The relevance of all physician roles, and how they come together in every patient encounter as integrated, “intrinsic” competencies.
  4. Considerable self-awareness regarding her own level of professional development, personal strengths and preferences.
  5. Something about how different medical specialties differ, and how her particular strengths and preferences might fit those choices.

For my part, I was again impressed with the value of providing patient-centred opportunities that allow our students to experience the real life application of the knowledge and skills they are acquiring. Beginning early in their medical education, these experiences provide a framework and relevance that invigorates their learning process, and informs their career choices. Guiding our students through these formative experiences, and watching the immediate impact they can have, is also one of the most powerful and satisfying roles for any clinician-educator.

 

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

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