We Are Not Amused
Let’s be clear, I am no royalist. I find the concept of a hereditary monarchy unjustifiable, care nothing about who is where in the “line of succession” and find the media attention paid to every public appearance and utterance of members of royal family as they struggle with the “anguish” and “burdens” of their unearned privilege to be silly at best and offensive at worst.
But I like the Queen. In fact, I like her a lot. And it’s not just because she looks like my mother, although that doesn’t hurt. It’s not simply because she’s “the Queen”. It’s because she has been, in the admittedly perverse context of the life and times in which she has found herself, a rare and remarkable example of commitment to service who has, through her words and actions, attempted to understand the real needs of the people she is meant to serve, intervene as best she could, and consistently given expression to the very best aspects of the national character. In all this she provides an example for us all as we engage our stations in life particularly, I hasten to point out, those of us in the health professions.
She has been forced to do so as the epicentre of continuing storms of controversy caused not by her, but by the shenanigans of the innumerable members of her extended family and in-laws. Her words, over the near 70 years of her reign, have provided solace and support in times of need. She has provided what, by all accounts, has been very sensible and citizen-focused counsel to no fewer than 14 British Prime Ministers, (beginning with Winston Churchill!). She has refused to submit to demands for “reforms” that would compromise the standards she has set for herself and for the position she holds. She has persevered. At the age of 95 and reputably quite wealthy, she certainly doesn’t need the work and, I imagine, could do without the aggravation. Who among us would not have retired to our estates and Corgis decades ago?
She has, in the vernacular of our day, been “one class act” in the evolving soap opera that has become the modern monarchy, the future of which now appears to hinge on her great-grandchildren– two toddlers and an infant whose duties to date have not yet extended beyond being adorable (a duty in which, I must admit, they have excelled).
And she’s smart! This past week we had a great example of regal grace and wit. Informed that she’d been elected, by a magazine and editorial team that should know better, to receive an “Oldie of the Year” Award, she crafted the following response:
“Her Majesty believes you are as old as you feel and, as such the Queen does not believe she meets the relevant criteria to be able to accept and hopes you find a more worthy recipient.
With Her Majesty’s warmest best wishes.”
A measured, dignified slap-down for the ages. Take that, you ageist boors!
Among all the unearned privilege our modern world seems to be tolerating, it’s both refreshing and encouraging to find someone who not only appreciates their station but attempts to the best of their ability to rise to the responsibility that it provides, staying true to their values.
You go, girl!
Sorry. You go, Your Majesty.
Summing things up: wrapping up case-based learning sessions effectively
We often spend a lot of time planning our learning events, especially our case-based small group learning (SGL) sessions. We tailor our sessional learning objectives to the course objectives that have been assigned, selected solid preparatory materials, build great cases and craft meaningful questions for groups to work through.
This makes sense, as the small group learning (SGL) format used in Queen’s UGME program is modeled on Larry Michaelsen’s team-based learning (TBL) instructional strategy that uses the majority of in-class time for decision-based application assignments done in teams.
One comment we often read on course evaluation forms and hear directly from students, however, is that sometimes they walk away from an SGL session and still aren’t sure what’s important.
Much of the focus in the literature on TBL is on the doing – setting things up, building great cases, asking good questions to foster active learning. There’s not as much written about how to finish well.
Wrapping up your SGL session should be as much a planned part of your teaching as preparing the cases themselves. If you build the time into your teaching plan, you won’t feel like you’re shouting to learners’ backs as they exit the classroom, or cut off as the next instructor arrives. Nor will you find yourself promising to post the “answers” to the cases on Elentra. Sometimes it’s not the answers that are important, but the steps students take to get there.
Wallace, Walker, Braseby and Sweet remind us that the flipped classroom we use for SGL (preparation before class, application in class) is one “where students adopt the role of cognitive apprentice to practice thinking like an expert within the field by applying their knowledge and skills to increasingly challenging problems.” One such challenge is figuring out what the key take-away points are from an SGL session. With this in mind, it’s a good idea to plan your session summary, but then have students take the lead since “the expert’s presence is crucial to intervene at the appropriate times, to resolve misconceptions, or to lead the apprentices through the confusion when they get stuck.”
So, have your own summary slide ready – related to your session objectives – but keep it in reserve. In keeping with the active-learning focus of SGL, save the last 10 minutes or os of class to have the groups generate the key take-away points, share them, and fill in any gaps from your own list.
Here’s a suggested format:
- Prompt the groups to generate their own study list: “Now that we’ve worked through these three cases, what are the four key take away points you have about this type of presentation?”
- Give the groups 3-4 minutes to generate their own lists
- Have two groups share with each other
- To debrief the large group, do a round up of four or five groups each adding one item to a study list.
- Share your own list – and how it relates to the points the student raised. This is a time to fill in any gaps and clarify what level of application you’ll be using on assessments.
- If you’d like, preview an exam question (real or mock): “After these cases, and considering these take-away points, I expect that you could answer an exam question like this one.” This can make the level of application you’re expecting very concrete.
Why take the time to wrap up a session this way? Students often ask (in various ways) what the point is of a session. With clear objectives and good cases, they should also develop the skills to draw those connections themselves. This takes scaffolding from the instructor. As Maryellen Weimer, PhD, writes in Faculty Focus, “Weaning students from their dependence on teachers is a developmental process. Rather than making them do it all on their own, teachers can do some of the work, provide part of the answer, or start with one example and ask them for others. The balance of who’s doing the work gradually shifts, and that gives students a chance to figure out what the teacher is doing and why.”
If you would like assistance preparing any part of your SGL teaching, please get in touch. You can reach me at email@example.com
 Wallace, M. L., Walker, J. D., Braseby, A. M., & Sweet, M. S. (2014). “Now, what happens during class?” Using team-based learning to optimize the role of expertise within the flipped classroom. Journal on Excellence in College Teaching, 25(3&4), 253-273.
Kingston and its Students: A Tempestuous but Enduring Symbiosis
With tongue firmly in cheek, a friend recently remarked that “Town-Gown” relations seem somewhat strained in our community these days. A remarkable example of impish understatement if one was ever uttered. Indeed, the usual energy and sense of renewal that accompanies the return of students each September has been muted if not completely submerged under layers of pandemic-related anxiety and efforts intended to mitigate them. The juxtaposition of such efforts with images of unrestrained street parties, fenced off beach areas and rising local COVID case counts has been, for many, rather jarring and unsettling.
Amid all this, I recently received a letter from a local physician that cut through that gloom like a glimmer of sunshine on a stormy day. Dr. Stephen Yates, a longstanding Family Physician in our community, wrote to Dr. Philpott and myself about his experiences working in vaccination clinics alongside volunteer medical students. In Dr. Yates own words (provided in part and abridged with his permission):
I am writing to you both after a very busy 6 months working as the Clinical Lead at several community covid19 Mass Immunization Clinics that have run from March to August this year. Those MIC’s put Kingston on the “Vaccine Map” of Canada as one the very highest vaccine rates in a Canadian community.
We could not have accomplished this extremely successful vaccine roll out without volunteers and the Queen’s Medical School Students stepped up to the plate and helped us out. When the medical school academic year ended numerous 1st and 2nd year students, with a few 3rd and 4th year, and even a few students entering the school this year, came forward to donate their time.
To try and name all the students who took part will leave many students out by mistake but suffice it to say…all the students were an absolute delight to get to know and to work with.
Whether organizing student volunteers, helping with vaccine draws, functioning as principal vaccinators, organizing recipient stand by lists for extra vaccines, calling literally hundreds of recipients in for shots, reviewing side effects or even managing vaccine hesitancy, your students were exemplary and were key to helping this community get through the pandemic.
The community of Kingston owes a great debt of gratitude to your medical students!
Very best regards,
Dr Stephen Yates, MD, CCFP, FCFP
Kingston and its student population. A raucous, tempestuous, never-fully-resolved, but also never-boring relationship. A marriage, it would seem, doomed to constant struggle, never to achieve either complete happiness or peaceful separation. To the cynical or those hopelessly frustrated by all this, the idiom “can’t live with them, can’t live without them” might seem appropriately applied, by either party. But, like any relationship experiencing difficulty, causes are deep, complex and worthy of some thoughtful reflection. Like many, I encountered our city initially as a student, have embraced it as adopted home, raised a family here, have seen numerous family members attend as students, and now live both sides of the “Town-Gown” dichotomy. And so, some observations, respectfully offered.
Firstly, it must be said, Kingston would not be Kingston without its students. This is not simply an economic or political reality. The student population brings energy, purpose and, on a regular cycle, youthful renewal to one of the oldest communities in our country. The city of Kingston, for many generations of students, has provided a supportive environment and wonderful example of community life. It has been an incubator of citizens who learn what it means to be part of and to care for their “home”. Its productivity or place in Canadian society will never be measured in terms of manufactured goods or agricultural productivity. Its true “product” are the young people whose lives are, in ways great and small, shaped by their lived experience among us.
For most students, their time in Kingston is their first experience living, to some extent at least, on their own. They are going through a very challenging phase of life during which most struggle with understanding and developing their own interests, strengths, values, and purpose in life. For most of them, the time they spend in Kingston will be the most transformational of their lives.
That transformation doesn’t occur entirely or even mostly in the classrooms of Queen’s, RMC or St. Lawrence College. It also happens in the streets, shops, restaurants, waterfront, trails, lakes, and rivers of our community. It happens through interactions with their fellow students and faculty they encounter to be sure, but also within the community in which they must function, independent of the influences and supports of home. Those encounters, as we’ve observed recently, can be ill-advised and troublesome. Judgement may be lacking, consequences may not be understood or ignored, actions may be impulsively taken, untempered by experience. This is not to say that actions should be free of consequences. In fact, it would be a disservice not to maintain standards based on the best interests of the greater community. But those responses should be directed at the actions not the individuals, motivated by a desire to correct not condemn, and tempered with the understanding that most of us will have no difficulty recalling similar lapses of judgement if challenged to cast the first stone.
Symbiosis is a biologic term that might have relevance here. It implies a mutually beneficial relationship between different people or groups. Hummingbirds, for example, have a symbiotic relationship with wildflowers. The birds are feeding on nectar provided by the flowers and gaining nourishment. Without that occasional noisy intervention, the flowers would not cross-pollinate and and would not flourish so beautifully.
It’s also helpful to be reminded that the vast majority of students integrate well and even contribute positively to our community. For a group of eager medical students, that contribution occurred recently in an immunization clinic.
Thank you, Dr. Yates, for the reminder. When it comes to students and Kingston, it’s not “them” and “us”. They are us.
What are those learning event types, anyway?
Tucked on the right-hand side of every Learning Event Page on Elentra are notations about the date & time and location of the class, followed by the length of the session and then the “Breakdown” of how the time will be spent. In other words: the learning event type.
After the last 18 months of learning event types being broadly divided into “Zoom” and “not-Zoom”, it’s worth having a look at what these notations (really) mean as we get back to more face-to-face on-campus teaching.
We use 18 learning event types* in the Queen’s UGME program. The identification of a learning event type indicates the type of teaching and learning experience to be expected at that session.
Broadly speaking, our learning event types can be divided into two categories: Content Delivery and Content Application.
For content delivery, students are presented with core knowledge and/or skills with specific direction and/or commentary from an expert teacher. Content delivery learning events include:
Independent Learning (DIL) — these are
independent learning sessions which are assigned curricular time. Typically,
students are expected to spend up to double the assigned time to complete the
tasks – i.e. some of the work may occur in “homework time”. DIL’s have a
specific structure and must include:
- Specific learning objectives
- A resource or set of resources chosen by the teacher
- Teacher guidance indicating the task or particular focus that is required of students. This may be a formal assignment, informal worksheet or study guide.
- The session must link to a subsequent content application session.
- Formative testing in the form of MCQ or reflective questions are an optional component of DILs
While students have nicknamed these “do it later”, it’s important that learners complete the assigned material prior to the related in-class sessions in order to be ready for what comes next. DILs aren’t an alternative delivery of material covered elsewhere, but essential curricular delivery.
- Lecture – Whole class session which is largely teacher-directed. We encourage the use of case illustrations during lectures, however these alone do not fulfil the criteria for content application or active learning.
- Demonstration – Session where a skill or technique is demonstrated to students.
For content application (sometimes described as “active learning”), students work in teams or individually to use and clarify previously-acquired knowledge, usually while working through case-based problems. These learning event types include:
- Small group learning (SGL): Students work in teams to solve case-base problems which are revealed progressively. Simultaneous reporting and facilitated inter-team discussion is a key component of this learning strategy which is modeled on Team-Based Learning. SGL cases may be preceded by in class readiness assessment testing (RAT) done individually and then as a team. This serves to debrief the preparation and provide for individual accountability for preparation.
- Facilitated small group learning (FSGL): Students work in teams and with a faculty tutor to solve case-base problems which are revealed progressively. While there is structure to FSGL cases, students are encouraged to seek out and share knowledge based on individual research.
- Simulation: Session where students participate in a simulated procedure or clinical encounter.
- Patient or Panel Presentation (PPP): Session where students interact with guest patients and/or health care providers who share their experience. Builds on prior learning and often includes interactive Q+A component.
- Laboratory: Hands-on or simulated exercises in which learners collect or use data to test and/or verify hypotheses or to address questions about principles and/or phenomena, such as Anatomy Labs.
The other learning event types we use don’t fit as neatly into the content delivery/content application algorithm. These include:
- Clerkship seminar – instruction provided to a learner or small group of learners by direct interaction with an instructor. Depending on design, clerkship seminars may be either content delivery or content application.
- Self-Directed Learning (SDL) is scheduled time set aside for students to take the initiative for their own learning. A minimum of eight hours per week (pro-rated in short weeks) is designated SDL time. (This is referred to as “Independent Learning” or “IL Time” in the UGME Policy Governing Curricular Time).
- Peer Teaching is learner-to-learner instruction for the mutual learning experience of both “teacher” and “learner” which includes active learning components. This includes sessions that require students to work together in small groups without a teaching, such as Being a Medical Student (BAMS) sessions, the Community Based Project and some Critical Enquiry sessions.
- Career Counseling sessions, which provide guidance, direction and support; these may be in groups or one-on-one.
Two other notations you’ll see are “Other-curricular” and “Other—non-curricular”. Other—curricular is used for sessions that are directly linked to a course but that are not included in calculations of instructional methods. This includes things like examinations, post-exam reviews, and orientation sessions. Other—non-curricular are sessions of an administrative nature that are not directly linked to a particular course and are outside of curricular time, for example, class town hall meetings and optional events or conferences.
Incorporating a variety of learning event types in each course is important to ensure a balance of knowledge acquisition and application. Course plans are set by course directors with their year director, in consultation with the course teachers and with support from the UG Education Team.
*In 2015, Queen’s UGME adopted the MedBiquitous learning event naming conventions to ease sharing of data amongst institutions. For this reason, some learning event type categories may be different from ones used here prior to 2015, or ones used at other, non-medical schools or medical schools which have not adopted these conventions.
Together again, in person and with gusto
The last in-person, full-class teaching session in the Queen’s School of Medicine took place over 18 months ago. Seems much longer. Since then, as is known to all reading this article, we’ve been providing our curriculum with a combination of virtual and appropriately regulated small group teaching events. These arrangements, contrived and cumbersome as they may appear, have allowed programming to continue and student learning to progress.
Just last week, we received very welcome news from the province and university that restrictions could be reduced to allow full class, in person sessions to proceed as of September 7th. Unfortunately, this didn’t arrive in time for our Orientation Week which was scheduled to begin August 30th. We had therefore planned and received approval from the university for a modified program which would be compliant with current requirements. The week kicked off with a welcoming event for all first, second and third year students (our fourth years being on clinical rotations and unable to attend) held in the main gymnasium of the ARC (Athletics and Recreation Centre). Our fully vaccinated, screened, disease-free, and masked students were welcomed back to the school year and to a “more normal” learning environment by faculty and student leadership. The significance and poignancy of assembling after such a long period of relative isolation cannot be overstated. To add to the celebration, music was provided by “Old Docs New Tricks” (ODNT), a group of SOM faculty physicians who not only entertained the crowd but demonstrated how busy practicing physicians can maintain personal interests while achieving great things in their professional lives.
Below is a small album of photos from the event, all by Lars Hagberg, go-to photographer extraordinaire and friend of the School of Medicine.
ODNT performing for the crowd
Many thanks to our Student Affairs group, capably led by Dr. Renee Fitzpatrick and supported by Erin Meyer and Hayley Morgenstern, who worked tirelessly and with great adaptability to make these arrangements.
We all recognize that the pandemic is far from resolved. We remain guided by continuing public health requirements. We recognize that further adaptations will likely be required in the weeks and months to come. We remain committed to providing the best possible educational experience for our students and learning environment for all involved.
But, for now, we’re just grateful to be in our classrooms and in person. We’re back!
Looking for a Few Good People
We’re incredibly fortunate at Queen’s to be blessed with a faculty that engages educational leadership with enthusiasm, creativity and dedication. When new positions emerge, or when people who have been key contributors come to the end of their terms, the program faces both challenges and opportunities. The challenge is obviously to fill the position and assist the incumbent. The opportunity, of course, is that it allows another faculty member to engage a new challenge, to influence medical education and advance their careers in new ways.
A number of such positions become available at the end of each academic year. I will describe some of these below and invite any interested faculty members to forward any inquiries or expressions of interest to myself or Dr. Michelle Gibson.
Chair, Student Assessment Committee
The Student Assessment Committee has a key role within an undergraduate medical program. It’s basically responsible for the oversight of all assessment practices in UGME, including setting policy & procedures. Peter McPherson has been very capably filling this role for the past few years. The Chair of SAC also works closely with course directors and other curricular leaders on the implementation of exams and other assessments. This includes reviewing the design and content, and assisting in the post-exam analysis process, supported by our Assessment and Evaluation Consultant (Eleni Katsoulas). They also work with our assessment team, headed by Amanda Consack. In addition, the chair of SAC sits on Curriculum Committee and has a key voice within that key group. SAC meetings take place quarterly, with additional duties for the chair throughout the year in terms of the day-to-day oversight of our assessment systems. Expertise and interest in assessment practices is required for this position, as well as the willingness to work with our very capable administrative team, our assessment consultant and numerous faculty colleagues who serve as Course Directors.
We are looking for three Competency Leads. These individuals are responsible for oversight of relevant learning objectives, by way of working with course directors and other curricular leaders to enhance the teaching and assessment of these roles in our curriculum. Competency leads often work together as there are natural links between many different of these roles.
The Communicator lead will review how we teach and assess communication objectives across our curriculum, to ensure our students are excellent communicators in many different settings. This includes looking at communication in different contexts such as with patients, families, health care professionals, colleagues, and the community.
This role has been held and developed by Heather Murray since it was developed as part of our curricular renewal several years ago. Heather has developed a robust and innovative set of curricular offerings that meet our program objectives that relate to critical appraisal, research methodology and life-long learning. The Scholar lead will review how we teach and assess all these components. This role also addresses students’ skills for self-assessment and ensures they have the skills to implement a plan to address their own personal learning needs throughout their careers. The scholar lead will also oversee and direct the annual Research Showcase.
The alliteratively named Leader Lead will review how we teach and assess different objectives designed to help our students develop their skills as leaders. This includes developing skills that will lead to effective management of the care of their patients, their practice, and themselves in the context of the Canadian health care system, community, and society in which they practice. This includes an understanding of the principles of patient safety, stewardship, and quality improvement systems. The competency also includes working with our well-established Student Affairs group in providing students with opportunities for career exploration to inform their career choice, and development of personal insight and behaviours that will promote wellness and self-management, leading them to healthy life-long and rewarding careers.
Clerkship OSCE lead
This faculty member would work with our established OSCE support team and clerkship course directors to design and implement an OSCE for clinical clerks, once a year. This is a new position, ideal for a faculty member interested in student assessment who would like to be more involved in UGME. The date of the clerkship OSCE for the 2021/2022 academic year will be in February 2022.
Course & Faculty Review Committee members
Three committee members are needed for this committee that reviews course evaluations to make recommendations to the curriculum committee. These positions are open to any faculty members who have familiarity with UGME. This committee meets quarterly, with additional need for electronic review between meetings.
All these positions will receive credit within our Workforce accountability system. For information or further discussion regarding any of these positions, please contact me directly at firstname.lastname@example.org or Michelle Gibson, Assistant Dean Curriculum at email@example.com.
They’re Going to be OK. A Thank-you to Our First Patients and Remarkable First Year Class
These days, more than ever, bits of good news are truly welcome. Like rays of sunshine breaking through the clouds on a gloomy day, they remind us that things are still basically right with the world and brighter days are ahead.
I had one of those experiences last week attending a wrap-up session for our First Patient Program. The FPP is a rather unique curricular offering at Queen’s supervised by Dr. Brenda Whitney and superbly organized by Ms. Kathy Bowes, an RN who has been working in various capacities in the undergraduate program for many years.
Patients are recruited from the Kingston community who have chronic medical problems requiring regular encounters with physicians and other health care providers. These patients generously agree to allow two of our first-year students to meet with them and their families, to get to know them personally and to follow them through the year. At the end of each year, a reception is held to thank them. Following are some pictures from the 2019 event.
The students are expected to learn about the illness experience through the eyes of the patient. They check in regularly and accompany patients to their various medical encounters. They are expected to gain insights not only about the specific condition afflicting the patient, but the impact of that condition on them and their family members, and of the practical challenges involved in the process of receiving care. For most of our first-year students, it is their first personal experience with chronic illness and its impact.
This year, the pandemic posed considerable logistic challenges. Dr. Whitney and Ms. Bowes were remarkably creative and adaptable in adjusting the program to allow the students to gain valuable experiences despite the limitations.
This past week a virtual wrap-up of the program was held, involving both students and their “first patients”. The highlight of the program, for me, was hearing from the students themselves about insights they had gained and taken away from their encounters. Here are a few samples, taken from the slide presentation prepared for the session.
What’s particularly remarkable is that all this was gleaned by a group of students whose introduction to the study and profession of medicine has been, to say the least, unconventional. Indeed, the pandemic and its myriad of imposed restrictions have drastically altered the educational experience for all our students. Although everyone involved has done everything possible to make the best of it, our students have not had opportunity to assemble as a class, work together or engage patient encounters as planned. They have accepted all this, by and large, with understanding and patience.
The first year class has been particularly affected because they’ve not yet had the opportunity to fully meet as a class or personally encounter many faculty members. Those of us responsible for their learning experience have had some apprehension and a few sleepless nights about the adequacy of what was being provided. Certainly, the course content and necessary knowledge was being imparted and learned. Assessments were satisfactorily completed. Skills that could be demonstrated and practiced were being mastered. But were they learning about what it is to engage patients? Were they learning to regard their patients as individuals with lives, hopes and families, to understand their suffering, to search for ways to help? Were they learning how necessary all this is to providing effective care?
Last week’s session made me realize that much has already been learned, including real-life lessons that could never have been imparted in a classroom or by reading scholarly works. They’ve learned that only by engaging real people with real problems can the full scope and value of medical care be truly realized. They’ve learned that our patients can be our best teachers.
And I learned that this group of students, despite all the accommodations that have been made to our curriculum, are going to be OK. They get it. They are on their way to becoming fine doctors.
Silent Victims of the Pandemic
“Jean died last night.”
That was my first email message of the morning. It came from Jean’s daughter. Jean (not her real name) had been in hospital being treated for heart failure. She didn’t want to be in hospital, to be sure. It took her daughter, her family physician and I to convince her that she could no longer manage on her own, up most of the night sitting in her chair panting for breath, the skin of her swollen legs beginning to break down.
Although I wasn’t her attending cardiologist during this admission, I had treated her for many years and dropped by to visit with her the day before. Propped up in her high backed hospital chair with her feet elevated, she almost reluctantly admitted she was feeling a bit better. Her legs were clearly less edematous. But she didn’t think she was going to go home this time and that, she said, was OK. She had made her wishes clear to all. Her “comfort care” status was well documented.
Although in her late 80’s, Jean retained a perceptive intelligence and disdain for convention. Anything she didn’t approve of was quickly dismissed as “nonsense”. The word that immediately comes to mind to describe her is “feisty”.
She’d immigrated to Canada with her husband and infant daughter shortly after the second world war. They worked various jobs eventually opening and operating a successful small business . When her husband passed away, she operated the business, eventually turning it over to her daughter.
Jean had rheumatic fever in her youth which left her with valvular heart disease. In the early part of the twentieth century, rheumatic mitral stenosis was a major cause of morbidity and mortality in young women, resulting not only in heart failure but also stroke due to cardiac thrombi precipitated by the onset of atrial fibrillation, often during pregnancy. Many years ago, when she began to develop symptoms, Jean underwent a closed mitral commissurotomy. This was one of the first surgical approaches available. The surgeon would attempt to break the fusion of the mitral leaflets caused by the rheumatic inflammatory process, either with dilators or a finger passed across the valve.
This approach, which sounds rather crude to us today, was very effective in relieving symptoms and is the same basic approach used today with catheter based balloon valvuloplasty.
She did well for many years after the commissurotomy and even had a baby despite conventional medical wisdom at the time advising against pregnancy. Her mitral stenosis gradually progressed, and she went on to have a valve replacement with a mechanical prosthesis about 25 years ago. Over the years, she evolved varied and expected cardiac manifestations including atrial fibrillation, progressive aortic valve disease, coronary disease and, most recently, right-sided heart failure. She faced each challenge with grace and acceptance. As she said many times, she never expected to live to be an “old lady” and was grateful for whatever treatments were available to her. But, in recent years, she was quite clear that there would be no more interventions, catheterizations or surgeries. The goals of care were very clear: “I’ll take whatever pills you suggest, just keep me independent and out of hospital”.
And independent she was. In her own home until moving into a rather posh retirement complex a few years ago. I attended a reception in her honour organized by her daughter and friends for her 85th birthday. She was the epitome of charm, holding court like a duchess at a ball.
Her daughter’s message was accompanied by a request to call. She let me know how very important it was that she was able to visit with her mother the evening before she passed away. Given the pandemic restrictions, what they both feared most about the hospitalization was the separation from each other. This, no doubt, was the main reason they delayed so long in asking for help. However, the medical and nursing staff went out of their way to make arrangements for them to see each other. She asked me to express how important this was to them and to pass along their gratitude, which was one of the motivations for this article. What may have seemed to be a small act of kindness was highly meaningful.
The other objective of this article is to highlight the impact this pandemic is having on management of chronic disease and end-of-life care. Jean’s reluctance to come to hospital despite a clear need for help is typical of many patients suffering from cardiac and other chronic diseases.
A recent article examining emergency room visits for acute heart failure found a 43.5% reduction in 2020 compared to the previous year, and a 39.3% reduction in hospital admissions (Frankfurter et al. Can J Cardiol 2020;36:1680).
The authors conclude with this important observation:
“The precipitous decline observed in ADHF (acute decompensated heart failure)-related ED visits and hospitalizations raises the timely question of how these patients are managing beyond the acute-care setting and reinforces the need for broad public education on the continued availability and safety of emergency services throughout the COVID-19 pandemic.”
This issue is not limited to heart failure patients. In fact, while preparing this article, I was contacted by another patient with known multi-vessel coronary artery disease and previous myocardial injury who was awaiting much needed surgical intervention. He’d been experiencing chest pain for two hours and was calling to ask whether it was “safe” to go to the emergency department. He’s now being admitted awaiting surgery while being treated for his unstable ischemic syndrome.
In an examination of patients with coronary artery disease presentations, Natarajan et al (Canadian Journal of Cardiology Open 2020: 678e683) reported both lower rates of myocardial infarction and delays to coronary angiography in 2020 compared with the previous year.
Clearly, the coronavirus has not reduced the prevalence of either heart failure or coronary disease. It has, however, imposed barriers to access. Although we do not yet have precise information as to the nature of these barriers, it’s apparent that each step along the path from initial symptom assessment to final treatment is made more difficult by necessary pandemic precautions, and that patients, advised strongly to isolate, are understandably more fearful about venturing into emergency departments and diagnostic facilities.
And so, the accounts of these two patients have much to teach us.
It’s important to remember that, even during a terrible pandemic, most of the patients we’re treating do not have COVID-19. Most of them are suffering from the same medical and surgical conditions they’ve always had, and these diseases don’t wait for the pandemic to pass. However, the pandemic does impose barriers to their ability and/or willingness to access care. As the medical and public health communities message the public about the need to adhere to all the preventive measures, it’s important also emphasize the importance of continuing to manage all health concerns and work to diminish access barriers wherever possible.
As always, our patients are our greatest teachers. Jean taught me and the countless learners she was always pleased to engage along the way much about the natural history, features and available treatments for rheumatic heart disease. That’s a legacy that will benefit many future patients. For that, she deserves our gratitude, and the kindness shown her during her final admission seems well earned.
I will miss her.
Lessons in Diversity and Inclusion: The Legacy of Joey Moss
Joey Moss, by all accounts, achieved his dream job. He was an avid hockey fan who became locker room attendant for the Edmonton Oilers. The Oilers, it must be understood, are not just any hockey team. They were Mr. Moss’s favourite team and personal passion. During the 1980s, they were phenomenally successful, winning no fewer than five championships.
As a locker room attendant, he will have had a variety of tasks, including organizing equipment, looking after needs of players during games and generally bringing some order to the chaos that ensues when 20 or so young athletes are engaged in a fast-paced, high-pressure sport.
Mr. Moss, who was born with Down Syndrome, passed away last week. It appears, based on numerous testimonials that have come forward since his death, that his influence extended well beyond his designated tasks. His unrelenting good humour, infectious enthusiasm and continual encouragement of the players brought value far beyond his assigned duties. Wayne Gretzky, a star member of those teams, summed it up nicely when, upon hearing of Mr. Moss’s passing said simply “He made our lives better”.
Mr. Gretzky was, in fact, instrumental in bringing Mr. Moss to the attention of the hockey club. The two met when Gretzky became acquainted with Moss’s sister. Gretzky, at that time, was in the ascendancy of a career that was to eventually define him arguably (and these things are always arguable) as the greatest hockey player of all time. He arranged the introduction, but it was Mr. Moss’s work ethic, dedication and attitude that made him such a fixture and success with the team.
How did all this come about? What motivates a rising star and celebrity to go the trouble to advocate for someone they’ve just met? Gretzky is not known to be a comfortable public figure nor a vocal advocate for social change. At that time, he was a young man adapting to celebrity in a large city. He’d been born and raised Brantford, a town in southwestern Ontario best known (pre-Gretzky) as the birthplace of the telephone. His father Walter worked for Bell Canada and, together with wife Phyllis, taught their five children lessons of life and hockey in their busy home and on the ice rinks installed annually on their lawn. Those lessons, one might imagine, involved how to relate to the people in one’s community and a responsibility to help those in need when the opportunity presented itself. In advocating for Mr. Moss, it appears Gretzky was perceiving and responding to such an opportunity. What he did was not about publicity or self-promotion. It was something personal, a selfless act of kindness.
The struggle for inclusion and acceptance of diversity will not be won solely by legislation, public campaigns or vitriolic dialogue. It will be won through individual encounters that challenge assumptions and dispel fears. Mr. Gretzky and Mr. Moss did not set out to convince a team of young athletes, a business organization, a city or a nation that a person who looked different and was considered disabled could make a valuable contribution. And yet, that’s what they did, all beginning with a chance encounter and simple act of kindness. Indeed, making lives better.
Medical Student Research Showcase moves online
By Drs. Andrea Winthrop & Melanie Walker
This year the School of Medicine is proud to invite you to the 9th annual Medical Student Research Showcase on Friday October 30th, 2020. The event this year will be held virtually.
This event celebrates the research achievements of our undergraduate medical students, with both posters and an oral plenary session featuring research performed by students while they have been enrolled in medical school. All students who received summer studentship research funding through the School of Medicine in 2020 will be presenting their work, as well as many other research initiatives. This year we have 80 poster submissions and students will be presenting their posters virtually from 10:30-11:30 a.m. The links to the 2020 Medical Student Research Showcase Abstract Book, posters and the virtual room for each presenter is on our Medical Student Research Showcase Community in Elentra at the following link https://elentra.healthsci.queensu.ca/community/researchshowcase:2020_poster_submissions. (You need to log in to Elentra to access this link).
The oral plenary features the top research projects selected by a panel of faculty judges, and will run virtually from 11:30 a.m. – 12:30 p.m. The Zoom link is available on the Elentra community page (above link).
This year’s faculty judges included:
- Dr. Sheela Abraham
- Dr. Andrew Bickle
- Dr. Anne Ellis
- Dr. Laura Gaudet
- Dr. Sudeep Gill
- Dr. Mark Harrison
- Dr. Robyn Houlden
- Dr. Diane Lougheed
- Dr. Alexandre Menard
- Dr. Shaila Merchant
- Dr. Sonja Molin
- Dr. Lois Mulligan
- Dr. Chris Nicol
- Dr. Stephen Pang
- Dr. Emidio Tarulli
- Dr. Timothy Phillips
- Dr. Michael Rauh
- Dr. Sonal Varma
- Dr. Maria Velez
- Dr. Nishardi Wijeratne
We are very grateful to these faculty members for evaluating our oral plenary applicants this year.
The three students who have been selected for the oral plenary session, and the titles of their research presentations and faculty supervisor names are listed below. Each of these three students will receive The Albert Clark Award for Medical Student Research Excellence.
Ricky Hu – “An artificial intelligence-based time-dependent model to predict prognosis of patients with colorectal liver metastases” Hu, R.; Chen, I.; Beaulieu, K.; Zhang, Y.; Reyngold, M.; Simpson, A.*
Nathan Katz -“A Novel Way of Teaching Gross Anatomy to Medical Students: Instructor-guided ‘Fly-by’ of Digital 3D Anatomical Structures” Katz, N.K.; Kolomitro, K.; MacKenzie, L.W.; Zevin, B.*
Michelle Lutsch – ““Local” Anesthesia: A history of malignant hyperthermia in southwestern Ontario” Lutsch, M; Healey, J*
Please set aside some time to attend the Medical Student Research Showcase on October 30th. The students will appreciate your interest and support, and you will be amazed at what they have been able to achieve.