Real life lessons in Interprofessional Practice
The term “ivory tower” apparently has its origin in the Song of Solomon (7:4) where the writer describes the beauty of his beloved with a list of poetic terms, including “your neck is like a tower of ivory”. The image found its way into descriptions of venerable figures, as depicted in “Hunt of the Unicorn Annunciation” (circa 1500). For obscure reasons, the term has, over the centuries, come to be used to refer to “a world or atmosphere where intellectuals engage in pursuits that are disconnected from the practical concerns of everyday life” (Wikipedia).
University faculty are often accused of such intellectual self-indulgence. They can seem disconnected from the “real world” issues and challenges faced by practitioners of their respective disciplines. Physicians engaged in both care delivery and medical education might think themselves somewhat protected from the “ivory tower” mentality. I have certainly been of that opinion; at least until a recent “real life” experience has caused me to question that assumption as it relates to how we educate our learners with respect to interprofessional practice.
The development of educational processes that teach and promote Interprofessional Care and Practice has proven to be one of the biggest challenges faced by our school and faculty. The largest obstacles, in my view, have been two-fold. The first is purely pragmatic. It is very difficult to bring together the complex and very full curricula of multiple educational programs. Finding “space” in the packed schedules of our learners that coincide with compatible points in their separate learning continuums is a considerable logistic challenge, and will always be limited. The second issue is more philosophical. To be successful, any educational initiative must be directed toward clearly understood and mutually accepted objectives. Both teachers and learners must have a common understanding of the desired outcome. Simply put, they need to share a vision of the “final product”. Although we, and most schools, have developed articulate vision statements, I believe we lack a practical and commonly accepted understanding of that “final product” of Interprofessional Education programs. Our “ivory tower”, in this instance, has perhaps become a little too high to see what’s needed on the ground.
This brings me to my recent “real life” revelation. My parents are now 91 and 86 years of age. My father has increasing health issues that require regular supervision and assistance. They have lived in the same small community all their 60+ years of marriage, and wish to remain in the home that they built for their retirement. My siblings and I, as well as all involved in their care, agree this is the best option for them and, frankly, the desired option for all seniors wherever practical. Achieving this is becoming increasingly complex. They are blessed to have an absolutely incredible Family Physician with whom I communicate regularly. On a recent visit to my parents, we agreed to meet while I was there to update on a few issues. He took the opportunity to ask some other individuals involved in my parents care to join us. So, on a weekday morning, in my parents’ living room in that small community, a Family Physician, visiting Home Care nurse and Personal Support Worker met with myself and one of my sisters with both my parents in attendance. We were in telephone contact that morning with the Home Care supervisor, Respiratory Technician, Heart Failure Nurse Specialist, as well as the local Pharmacist who packages my father’s medications and is very familiar with recent changes. The complexity and extent of care required to support my parents was not a surprise to me. What I’ve had trouble imagining is how it could all possibly be coordinated in the home.
That morning, as I watched this process work so effectively, it became apparent that the single most essential key to success was that the contributions of each person were consistently centred on the welfare of their common patient. People knew the technical aspects of their jobs, to be sure, but their focus never deviated from the patient.
The second key to success was in the listening. Each individual was receptive to and respectful of the input of the other contributors, recognizing that the input of each was independently important to the central goal. Interestingly, the input of the PSW was perhaps the most relevant and led the discussion, because that person was closest to and most familiar with the impact of everyone’s work on my parents themselves. The Family Physician initiated the conversations, provided medical input a couple of times and, at the end, ensured everyone (including my parents themselves), had had the opportunity to get all their concerns and issues discussed. There was no jockeying for dominance. There was an openness and acceptance of each role that allowed everyone to make suggestions without fear of compromising their status. There was, in short, a sense of trust and mutual respect that allowed full and effective collaborative effort.
Although this particular experience crystallized this issue in a personal way for me, I realize that these highly effective interprofessional interactions play out in our wards, clinics, offices, emergency departments and operating rooms every day. They are becoming part and parcel of effective health care delivery, and provide a prime example of how our university based teaching programs must emulate and promote exemplary practice.
So what makes this work in the “real world”, and what lessons can we, ensconced in our Ivory Tower, take back to our educational programs that strive to teach and model optimal IP practice? Based on our real world exemplars, I would suggest five principles that may provide useful points of departure to examine any IP teaching program:
- The purpose of IP practice must be to optimize patient care. This is accomplished through common understanding and coordinated effort. Our educational programs and those who lead them must share that single goal and reinforce it in their teaching programs. IP must not be used to promote “political” causes.
- The various providers involved understand and accept that they cannot provide optimal care in isolation. That is simply no longer a realistic goal, a reality that a visit to the home of my parents or any patients living with chronic issues will quickly make apparent. Our educational programs must not simply state, but allow our learners to experience this reality.
- Health care providers must understand each other’s role in care delivery. In practice, this is learned by practical experience. Our educational processes must find ways to ensure providers learn these roles. For this purpose, experiential learning in active practice is much more effective than theoretical exercises.
- There must be mutual respect. This must be built on an understanding of the value of all contributions, and is best modeled through the behavior and attitudes of faculty. The converse, of course, is that negative attitudes expressed through “hidden curriculum” behaviours can be highly damaging.
- Active practice opportunities are essential. The awareness of roles, value, and mutual respect are best built through shared and successful practice opportunities where learners will find that their combined efforts bring added value. Their combined and cooperative effort, in essence, will be of greater value to their patients than the sum of individual and isolated efforts.
Our university based “ivory tower” can certainly provide a protected environment, isolated from the realities of clinical practice, and perhaps thus distracted by theoretical rather than practical concerns. However, it can also provide a perspective from which we can appreciate the value of practices that are tested and successful in the “real life” arena, and motivated solely by the best interests of the patients we serve. Many schools, including ours, have made great strides in IP education. As we continue to strive to improve, we’d be well advised to pay close attention to the lived experience and successes occurring every day, so close to us all.
“Reluctant Congratulations” to Dr. Ted Ashbury on his retirement
We would like to extend reluctant congratulations to Dr. Ted Ashbury on his retirement, and acknowledge his contributions to our Undergraduate Medical Program.
Here are remarks from Dr. Sanfilippo on the occasion of Dr. Ashbury’s retirement party:
Ted Ashbury has been as important as any individual to our curricular renewal over the past 7 years. He was conscripted, somewhat deviously, to an Advisory Group that was formed in 2007 to completely review and overhaul the MD program. In that process, Ted became the voice and strong proponent of Professionalism within the curriculum. He chaired a working group consisting of dedicated faculty and students that developed effective and innovative teaching methods. He participated actively in that teaching, and became the “face” of professionalism by speaking to the first year class annually on the first day of their medical school orientation. Whether in the pre-clerkship or clinical rotations, Ted’s sincerity and the passion of his commitment to the advancement of professionalism, and to medical education in general, has always been at least as powerful as his words. The students immediately identify him as the “real deal”, as someone who “walks the walk”. Quite simply, they listen and try to emulate his example. He has had an incredibly powerful and positive influence on a generation of Queen’s medical graduates.
In addition to being the voice of professionalism, Ted has been the voice of reason. I have been incredibly grateful for his thoughtful and always tactful commentary at meetings, and for his continuing support and advice over the years. The only thing that really gets me about Ted is this unfathomable notion that he needs to retire, but here’s hoping he comes to his senses at some point soon. In any case, I fully intend to call from time to time for advice, whether he’s on a porch or in a boat, and welcome unsolicited commentary at any time.
I’d like to add a personal note as well. I joined the Advisory Committee when Ted did and I was a rookie medical educational developer. He was a constant source of support, of inspiration, and of knowledge as we all negotiated our foray into competency-based education and the development of a curriculum framework. Throughout the next 7 years (!), collegial, collaborative, articulate, learned and wise, he taught and worked as he practised, and the students and I and many faculty and staff are much the better for it. It’s my fervent hope that Ted will soon tire of the peace of retirement, and yearn for the excitement and pressure of life in UG, and return to us. In the meantime, Ted, I can see you on that dock, relaxed in the sunshine, eyes looking ahead to the future! Congratulations!
Can students achieve excellence without stress or competition?
Striving for a Culture of Competency
A few days ago walking through the hospital I ran into a very excited third year medical student who was anxious to tell me about a recent clinical experience. Apparently she’d admitted a patient with a complex array of medical problems and, after considering the differential diagnosis, ordered a test that confirmed the presence of fairly rare condition that led to a very effective therapeutic approach. The patient was much improved and our student, for the first time in her experience, felt that she had personally made a significant contribution to a patient’s care. Importantly, she wasn’t telling me this to boast or claim personal credit. She was simply very excited in the moment and wanted to share.
Our student experienced what could be referred to as the “magic moment”. This is a term for that point in a physician’s development when they realize, for the first time, that they have acquired the ability to positively influence a patient’s life. For some it comes in the form of a procedure well carried out, for others it’s a diagnostic success, for some the realization that they’ve brought resolution or comfort to a personal crisis in a patient’s life. Whatever the form, the central element is the realization that their long and arduous learning process has borne fruit, and finally, rather unexpectedly, makes sense. Their learning has transformed from an abstract, theoretical exercise to a pragmatic and practical application of knowledge and skills. The “competency-based” construction of our curriculum suddenly seems sensible and, importantly, much less threatening. I’ve also noted that when our students come to this point, the “stress” of medical school changes in a favourable way. They realize that if they allow their learning to truly focus on their competency- based learning objectives, the rest will basically take care of itself. With this realization comes confidence. They come to regard exams as necessary inconveniences rather than fearsome high stakes threats. They no longer require their teachers to validate their learning. They have become, dare I say it, competent life-long learners.
Many medical schools have, over the past several years, adopted a competency-based framework to structure their curricula and assessment processes. Here at Queen’s, we adopted this as the basis of our curricular reform which began 6 years ago. It has provided a logical and comprehensive framework around which to establish objectives, courses, learning events, and all their associated assessment tools. Unfortunately, I think we have to recognize that we have not yet adopted a competency culture. Our students continue to have difficulty evolving from the consciousness that short-term knowledge assimilation and examination marks are the sole components of success. Many continue to see medical school as a series of “hoops” through which they must pass, discarding now “unnecessary” information at each step in order to move on to the next challenge. Experiences intended to build “softer” skills, such as reflective exercises and portfolio assignments, are often given short shrift, or at least secondary effort, because their relevance may be less apparent and “they’re hard to fail”. To a novice mountain climber, the ability to effectively and efficiently tie knots seems a tedious and pedantic exercise, until one is perched on a ledge and relying on that skill to negotiate a climb.
This difficulty is, in many ways, completely understandable and we, as medical school faculty, are partially to blame.
- Our admission processes are heavily reliant on academic success as a criterion. Our students are therefore pre-selected and “hard-wired” to excel in relative terms (relative to other students), rather than against pre-determined competency goals.
- We continue to use very traditional assessment processes to evaluate success. While it’s true that our major purpose in setting assessments is to inform rather than select or stratify, our students can’t help but have a very fundamental and visceral response to the examination experience. If you breed thoroughbreds to race, it seems, they will run when the gate opens.
- We continue to award academic “standing” through a multitude of awards that our schools have administered for generations, the very purpose of which is becoming increasingly irrelevant in our current curricular structures, and may be unintentionally promoting many behaviours we now recognize as counter to our competency goals.
- Perhaps most troubling of all, shortly after admission to medical school, we thrust our students into another increasingly competitive process to select and engage postgraduate training positions.
The environment, intentionally or not, is highly competitive. Is this productive? Does it drive desirable qualities? Does it result in better (more competent) physicians? Many would argue that competition for personal success is inevitable, drives learning and selects for qualities that will serve our students well in their careers and personal life. The counter argument is that it drives the wrong (short term) approach to learning and requires students to make strategic decisions regarding their learning that are unaligned with the needs of their future patients. The inconsistency between internal competition and the “collaborator” and interprofessional competencies we strive to achieve is obvious, as is the potential to disrupt peer-to-peer education that we recognize is so valuable. Many schools, including our own, have taken baby steps to address this issue by moving to “pass-fail” assessments, but even this has been met with considerable internal controversy.
So, what’s to be done? Can we do better? I would respectfully offer a few suggestions for consideration and discussion.
1. Frank discussion early in medical school. We need to engage the issue early on, clarifying for our student the reality that their learning objectives have fundamentally changed. Essentially, their objective needs to shift from personal achievement to the needs of their future patients.
2. The concept of “relevance” is best learned through patient contact. More contacts, in more “real life” venues, earlier in the medical school experience will be key. Observerships, the First Patient Program and Week in the Country are great examples, but need to be contextualized in a way that allow the student to recognize the importance of competency acquisition.
3. More clarity regarding our learning objectives. I think we have to acknowledge that the competency domains as defined by our professional colleges are insufficient unless buttressed by concrete applications. Being a good Manager, for example, means very little. However, when broken down into more practical applications, students not only see the purpose, but can navigate the learning much more efficiently. For example:
- Managing personal time
- Managing a medical practice
- Managing diagnostic testing for your patient
- Managing your finances
This now become more than knot-tying for the sake of knot-tying. Fortunately, there is considerable activity currently underway that will help. The Royal College is in the process of revising and refreshing the CanMEDS framework. A joint AAMC/AFMC committee is in the process of developing a set of competencies required of the medical student about to enter residency training, and documents such as “The Scottish Doctor” represent thoughtful and comprehensive attempts to catalogue practical physician competencies.
4. Testimonies from near peers and role models. The experiences of senior colleagues who have recently and successfully navigated the challenges our students are facing can provide powerful motivation and validation. It can also provide critical perspective to reduce unnecessary stress.
5. Assessment review. There has been movement in recent years toward competency-based assessments, such as Objective Structured Clinical Examinations (OSCEs), both by the Medical Council of Canada and most medical schools. However, these are very difficult to design, complicated to administer and very resource intensive. We need to develop more practical approaches that will allow our students to demonstrate their achievement of the various competencies in an open, objective way.
6. Reconsideration of our awards. Recognizing excellence and personal achievement is undeniably of value, but do our awards recognize the qualities and achievements we strive to develop?
7. Rethink and refine the process of transition to postgraduate training. This has been identified as a concern by the Future of Medical Education in Canada initiative of the Association of Faculties of Medicine of Canada (AFMC), and is under active discussion at this time. Models for more graduated transition are being considered, and will come under increasing discussion in coming months and years.
In summary, some degree of competitive tension will likely always be present within our medical training processes, and some degree of stress is not only inevitable, but may have a useful role in preparing students for the pressures of clinical practice. However, are we doing our best to use both intentionally and intelligently? Can we ensure they all experience their “magic moment” early in their training? I think we could do better. What do you think?
Student Medical Health Talks: “Let’s Talk Mental Health” on March 27
The student lecture entitled, “Let’s Talk Mental Health” is to take place Thursday, March 27th, 2014 from 6:00PM – 7:00PM in Lecture Hall 132A (main floor) in the School of Medicine Building (15 Arch St. in Kingston). Dr. Kevin Varley from the Department of Psychiatry will be there for the Q and A period.
This event is open to the public. All are welcome; simply RSVP to email@example.com.
First Annual Med/Law Games
This report comes from Ellen Miles,Women’s Athletic Stick.
On February 7th, 2014 the faculties of Medicine and Law came together on a Friday afternoon for the first annual Med-Law Games. The first of its kind here at Queen’s, Med-Law Games was designed by a committee of students from both faculties to foster inter-professional competition while raising funds for local charities.
The event was hosted by our two emcee’s Craig Lynch (Meds, 2017) and Naheed Yaqubian (Law, 2016) who entertained the crowd while the two faculties competed in 4 sports over the course of the afternoon. Friends watched from the sidelines, with baked goods and raffle tickets in hand.
It was an exciting day for QMED onlookers, starting out with a strong showing from the Meds Volleyball team made up of Daniel You (2016), Mike Baxter (2016), Trevor Morey (2017), Nick Latham (2017), Michael Yang (2016), Jocelyn Boyley (2017), Jillian Cottreau (2017), Cassy Graham (2016), Allie Engelhardt (2016) and Lydia Farnell (2017). Things took a turn however, with the Faculty of Law coming out on top in dodge-ball. The day continued to favour the law students, with strong performance in both soccer and basketball, ultimately winning the tournament.
Though our egos were bruised, QMeds should take pride in our fundraising efforts headed up by Alana Fleet (2017), where we managed to raise over $3300 which will be donated to the Cancer Centre of Southeastern Ontario. Special thanks to all the volunteers who helped bring this event together, the athletes for putting on a good show, and everyone who came out to support their friends.
See you all next year!
– Ellen Miles (Women’s althetic stick), Kevin Morash (Men’s althetics stick), Alana Fleet (VP External Jr.)
CARMS Match Day: What our students are experiencing, and how to help them get through it
For medical students in Canada, there are three days in the course of their career that stand out above all others: the day they receive their letter of acceptance to medical school; convocation (when they officially become graduate physicians); and Match Day. The most emotionally charged by far, is Match Day. For those of you not familiar, Match Day is when all fourth year students learn which postgraduate program they will be entering. The match is the final step in a long process of contemplation, exploration and application. The match and the day itself are full of drama, with all results being released simultaneously at noon. By approximately 12:00:05 all students will know their fate. As you can imagine, there will be much anxiety leading up to the release. For most (hopefully all), the day will be one of relief and celebration. For a very few (and hopefully none), there may be disappointment and confusion. Many schools release their fourth year clinical clerks from clinical duties on Match Day. At Queen’s we have taken the position that our students take on professional obligations during their training and their personal celebrations should not supervene those obligations. Having said that, I’d like to remind any faculty supervising our fourth year students on March 5th of the following:
- Anticipate that your student will be distracted that morning
- Please ensure your student is able to review their results at noon.
- Check on your student. If he or she is disappointed, please be advised that the student counselors and myself are standing by that day to help any student deal with their situation and develop a plan.
- Be advised that the students will almost certainly be holding some type of celebratory event that evening. Although your students are not excused for personal purposes, I would ask that you give them every reasonable consideration.
Fortunately, we have an excellent Student Affairs team, headed by Renee Fitzpatrick, who are available and very willing to answer any questions you may have and respond to concerns regarding our students. They can be accessed through Erin Meyer at firstname.lastname@example.org, or directly at the following:
Student Counselor and Wellness Advisor
Student Counselor and Wellness Advisor
Thanks for your consideration, and please feel free to get in touch with myself or any of the Student Affairs Team if you have any questions or concerns about Match Day or beyond.
Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean, Undergraduate Medical Education
Medical students offer Queen’s Medical Health Talks for the community
Nothando Swan, one of our first year medical students is heading up a new initiative, Community Health Talks, which begin Feb. 20 at 6:00 p.m. in room 132 of the School of Medicine Building. She writes:
Our medical students at Queen’s University are privileged to study in a state-of-the-art facility taught by experts in the medical field. But what of those who are equally interested in health education but are not medical students?
Queen’s Medicine Health Talks is a new student initiative that invites the public to the School of Medicine Building to engage in lectures on a number of clinically relevant topics. Through a service-learning model, medical students will present lectures with the aim of welcoming and integrating Kingstonians in medical learning. The presentations will be followed by question and answer sessions led by community physicians.
In honour of National Heart Month, the first talk on February 20th is entitled Let’s Talk Heart Health, featuring Dr. Sanfilippo, cardiologist and Associate Dean of the School of Medicine.
The event will run on February 20, 2014, from 6:00-7:00PM in the School of Medicine Building, room 132.
Subsequent talks will be held on March 27th and April 17th. The events are for the public and all are welcome.
If you would like to attend, or would like more information about this event, please email email@example.com
It (still) Takes a Village
How we do what we do.
One of the greatest challenges we face in the accreditation process is convincing the outside world that we’re actually doing what we claim to be doing. Accrediting councils and review teams, themselves made up of medical school Deans and Associate Deans, are well aware of the needs and challenges involved in recruiting committed and capable faculty leaders. They recognize that our needs in this regard are no less than that of much larger schools, and have trouble reconciling that reality with the number of core academic faculty.
With that in mind, it’s useful to periodically review our governance structure and recognize those who provide key leadership in all the various domains required of a fully functioning medical school.
I last did this about a year ago. At that time, I provided an article on this site describing the various positions and people who are so integral to the growth and ongoing quality of our MD program. The past year has brought changes to our MD Program leadership structure, both in terms of its organization and faculty assignments. In fact we’ve carried a rather extensive review of our governance structures and key responsibilities, recently reviewed and approved by School of Medicine Council. It seems an appropriate time to review both and update all our faculty and students.
In terms of overall organization, we have developed a number of key leadership positions, termed Directorships. Each of these carry responsibility for a discrete component essential to the overall mission of the program. The general responsibilities are described below.
In many cases, Directorships have evolved from positions that existed previously, but in different forms. Many were previously described simply as committee chairs. It’s become clear over the years that the scope of responsibility and need for ongoing oversight has gone far beyond simply chairing a monthly meeting. The Director designation is a more appropriate recognition of the effort, expertise and scope of responsibility required. So, with that introduction, we’ll review these positions.
Director, Undergraduate Admissions
The complexity of our admissions process has increased dramatically over the past several years. In addition to the 4300-plus applications to our MD Program, the Admissions Committee now has additional responsibility for admissions to our MD-PhD, QuARMS and International programs. Each brings its unique challenges, and continuing scrutiny to ensure they reflect appropriate values and fairness to all applicants. Hugh MacDonald has chaired our Admissions Committee for several years through these transitions, and I’m most grateful that he will be continuing in the Directorship role.
The oversight and guidance of our accreditation related efforts is a continuous responsibility, that will be escalating as we move toward our full survey in March of 2015. In addition to guiding our local processes, that individual serves as our representative at national and international accreditation committees. John Drover has been capably filling that role for the past 3 years and will be continuing to do so.
Director, Student Assessment
Michelle Gibson has recently assumed this role, previously carried out capably by Sue Chamberlain. This Director is responsible for establishing policies, processes and oversight of all assessment activities within our program. Having recently completed her Masters in Education, Michelle brings considerable expertise and practical experience to this role.
Director, Teaching, Learning and Innovation
Perhaps the biggest change (and challenge) undertaken by our faculty over the past few years has been the introduction of new and innovative teaching methodologies. Our Director of Teaching, Learning and Innovation (and committee) are responsible for developing policy, processes and oversight that will guide the introduction and delivery of teaching methods. We have also charged that group with developing methods to assist faculty in realizing scholarship opportunities as they provide their teaching. Lindsay Davidson will bring a wealth of knowledge, experience and innovative energy to that position.
Director, Course and Faculty Review
Over the past few years, we have developed a comprehensive process for continuing review of all our curricular courses. We are in the process of expanding that process to provide more targeted and relevant feedback to all teaching faculty. Andrea Winthrop has been integral to this process and will be continuing as Director.
Director, Student Affairs
One of the key changes involved in this governance renewal has been to develop a position that would provide oversight and coordination to our Student Wellness/Counseling, Career Counseling and Academic Counseling portfolios. I’m very pleased that Renee Fitzpatrick has taken on this challenge and is already developing proposals to augment our Learner Wellness program.
Director, Student Progress, Promotion and Remediation
This complex and critical portfolio requires a combination of astute administrative skill and sensitivity to the needs many needs of students who struggle with various challenges. Richard VanWylick has been chairing our P&P Committee with great skill for several years, and will be taking on this Directorship, which better recognizes the expertise and effort required.
In addition to these largely administrative roles, a number of Directorships are required to provide programmatic leadership;
Director, Year 1
The first year of our program introduces our students to a wide variety of material including Basic Science, introductory clinical medicine, Clinical and Communication Skills, Professional Competencies and Facilitated Small Group Learning. It is also a time of considerable personal and professional growth for our students, during which they evolve their learning and interpersonal skills. Michelle Gibson has been guiding Year 1 through our curricular transition process and, I’m pleased to say, will be continuing in this role.
Director, Year 2
In second year, our students undertake more intensive learning within clinical medicine. They are expected to not simply learn facts about various conditions, but to integrate that knowledge into cogent approaches to patient problems. To do so, they undertake more small group approaches, more challenging FSGL cases, advanced Clinical and Communication Skills program, and integrated Professional Competencies. Heather Murray, who has been active in the development of Scholarship in the curriculum, and its integration into Clinical Presentation courses, is very well suited to this role, and will be taking over from Lindsay Davidson who has been guiding Year 2 through our transition.
Director, Clinical and Communication Skills
This program, which runs through the first two years of our curriculum, is key to the development of our students as physicians. It has benefitted over the years from the leadership of Sue Moffatt and Henry Averns. The role requires a high level organizational and educational expertise. I’m very pleased that Cherie Jones took on this role last year and has already brought considerable innovation to the both educational and assessment components. Cherie would wish me to mention that components of the program are ably coordinated by a team of dedicated Course Directors, including Basia Farnell, Hoshi Abdollah, Laura Milne and Lindsey Patterson.
Director, Clerkship Curriculum
One of the major benefits of our curricular reform was to expand the clinical clerkship in a manner that would allow for the provision of three blocks within the clerkship dedicated to formal education on a variety of advanced clinical and professional topics. Susan Moffatt has developed and coordinated the curriculum for those blocks, with capable assistance from Armita Rahmani and Chris Parker. Sue’s dedication and extensive educational knowledge are evident in the quality of those blocks.
Director, Clerkship Rotations
Our clerkship consists largely of a series of clinical placements in the major clinical disciplines. Although largely in Kingston, clerkship rotation options have been expanded dramatically over the past several years, to both expand our teaching capacity, and provide students experience in various contexts and systems. These include our Integrated Community Clerkships (in Perth, Picton, Brockville and Prescott), as well as rotations in Belleville, Oshawa, Markham and even Brisbane, Australia. In addition, our students undertake about 18 weeks of Electives during the clerkship, intended to allow for career exploration and self-directed learning. The coordination of these all these options requires a high level of organizational skill, sensitivity to student needs and attention to detail. Andrea Winthrop has been very effectively coordinating and expanding this program since her return to Queen’s a few years ago.
Co-Director, QuARMS Program
Jennifer MacKenzie has developed and directed a de novo pre-medical curriculum for our QuARMS program which is highly creative, delivering competency based learning in a variety of creative teaching formats. This program, and Jennifer’s continued oversight, will be key to the success of this exciting new initiative.
Chair, Professional Competencies Committee
Ruth Wilson has generously taken on the considerable challenge of chairing our Professional Foundations Committee and coordinating the efforts of our Competency Leads. Her steady leadership has guided and promoted the development and integration of those essential components of our curriculum.
In addition to these positions, our program relies on the contributions of about 40 Course Directors, Competency Leads and Discipline Coordinators. These key people are listed in our MD Program Directory, which can be accessed here.
So how does all this fit together? Most Directors work with committees that are charged with the various areas of responsibility, as well as the accreditation standards that relate. Our MD Program Executive Committee brings together all the committees and Directors to provide integrated program governance. The graph below illustrates these relationships and reporting structures.
In developing these positions, committees and organizational relationships, the underlying principle has been that “form follow function”. Each one, with it’s associated responsibilities and inter-relationships, arises from a need based on the mission of our school – to prepare our students for success in postgraduate training and in their ongoing careers as highly successful and effective physicians. In doing so, we’re guided by our need to meet and exceed all medical school accreditation standards.
Achieving this, as well as all the other varied tasks required to operate our medical school requires tremendous dedication and commitment on the part of our faculty, which has never been lacking. Three examples:
- A need arose last Fall for people to chair our Accreditation Self-Study Sub-committees. Those who came forward to provide fill these valuable roles are among the busiest people in our school: Leslie Flynn (Vice-Dean, Education), Iain Young (Vice-Dean, Academic Affairs), Stephen Archer (Head, Department of Medicine), Michael Adams (Head, Biomedical and Molecular Sciences), and Karen Smith (Associate Dean, Continuing Professional Development).
- This term we are offering a re-vamped Term 4 Clinical Skills curriculum that provides full patient encounters with groups of two students observed and tutored by a two faculty members. This has been creatively developed by Course Directors Hoshiar Abdollah and Laura Milne, and involves no less than 50 faculty members, 37 of whom are members of the Department of Medicine. We have had full support of the Departments and their leadership in this initiative.
- Our Admissions committee and administrative support personnel process increasing number of applications each year, and have developed increasingly complex methodologies to review those applications. The committee itself, document reviews, MMIs and panel interviews require the active participation of about 160 faculty members, who give of their free time to assist in ensuring all applications are reviewed thoughtfully and fairly. They work side by side with members of our first and second year classes, almost all of whom contribute to the process in various ways.
What’s the motivation of all these people: building a better school – their school – in which they are valued members, and in which they take pride.
A village indeed, and an impressive expression of our collective dedication to the education of our students.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Singing the praises of our unsung heroes: Curricular Leaders in UGME
In our world of big names, curiously, our true heroes tend to be anonymous. In this life of illusion and quasi-illusion, the person of solid virtues who can be admired for something more substantial than his well-knownness often proves to be the unsung hero: the teacher, the nurse, the mother, the honest cop, the hard worker at lonely, underpaid, unglamorous, unpublicized jobs.
–Daniel J. Boorstin, US historian
I’d like to devote this blog article to talking about the props of our curriculum and program: our Curricular Leaders.
And I’d like to feature some resources, especially the new Course Directors’ Community as a place for those leaders to find some support (https://meds.queensu.ca/central/community/coursedirectors)
A few weeks ago, on January 10, our Course Directors, Competency Leads, Year Directors and other curricular leaders took part in our semi-annual Curricular Leaders’ Retreat. We had an action packed day, with workshops that actually included work time, with 10 different options throughout the day from which people could choose as well as 2 plenary sessions and a Be Tech Savvy, Teach Savvy finale. The topics were: Narrative Feedback for Clerks, Ideas for SGL, Blueprinting your Course, Building a Quality Exam, Poll Everywhere, Remediation, Evaluating Complexity of Cases, Graded Team Assignments, Teaching Diagnostic Reasoning in Pre-Clerkship, and Presentations on Med Ed research colloquia. We had lots of food, lots of breaks for discussion, and (I hope) lots of fun! The slides, handouts and everything else from the day are posted on MEdTech in the Faculty Resources Community at https://meds.queensu.ca/central/community/facultyresources:retreats/january_10_2014
Dr. Sanfilippo kicked things off with a report that included some very telling videos: Lucy and Ethel at the Chocolate Factory (http:/http:/www.youtube.com/watch?v=8NPzLBSBzPI), Spinning Plates while balancing on a ball (and jumping rope), http://www.youtube.com/watch?v=R3J-2UEPpPM and of course the iconic scene where the crew tries to turn the Titanic from the iceberg: “Why isn’t it turning?!”. http://www.youtube.com/watch?v=78W-J3tpL6s
The theme, of course, is the challenge of the role of the Curricular Leader—the art of coping with faster and faster deadlines, the skill of balancing and juggling clinical work, research and academic work, the delicate tension of steering a team and a curriculum and moving in time to avoid program icebergs.
This is the role of the unsung hero—the ordinary individual who finds the strength to persevere and triumph in the face of obstacles that may seem overwhelming.
It’s important to know that our curriculum runs as well as it does because of our 37 Course Directors, 6 Competency Leads, 10 Directors, 5 additional Committee Chairs, 3 Integrated Clerkship Site Leads, 8 Regional Clerkship Discipline Reads and 3 Learner Advocates in Regional Education. And an Associate Dean extraordinaire, too!
Our Course Directors have a new role description. In addition to carrying out the specific roles of clerkship or preclerkship Course Directors, there are these 10 general roles:
- Provide orientation to and mentoring of new faculty members, ensuring cohesion of all course teaching/assessment.
- Ensure that the assigned course objectives are taught within the course.
- Review sessional content and ensure that there is appropriate integration among the learning events within the course and with other courses as applicable.
- Ensure that teaching methods are varied and appropriate to the course objectives in accordance with the Teaching Methodology Policy (CC-10)
- Ensure that assessment strategies are in accordance with the Student Assessment Committee Policy (SA-05) and the Student Assessment Practices and Procedures.
- Oversee the course, provide content for the course’s Web site and review the Web site, ensuring that the information on it is correct.
- Complete the course review process with the Course and Faculty Review Committee.
- Engage in professional development.
- Identify faculty development needs in the course through the CFRC course directors’ survey and to the Educational Development Team and Year Director.
- Identify information and resources relevant to courses.
The full UG Course Directors’ Role Description can be found on our new Course Directors’ Community at https://meds.queensu.ca/central/community/coursedirectors:course_director_role_description
It’s one thing to state the roles in a document; it’s another to enact them. At the last retreat, curricular leaders had asked for some time to network, and to give each other tips about being a Course Director or Competency Lead. We were able to build this into the retreat, and half an hour later, we have some results to show you.
Here are the Tips and Traps curricular leaders shared with each other at our recent retreat.
- Develop objectives for themes, such as oncology, throughout curriculum, as it spans from 1st to 4th year
- Use MEdTech: Curriculum Search Function and other functions will let you see what is covered in other courses, which allows building on previously taught material and avoidance of unnecessary overlap
- Use keywords or tags to ensure all material gets picked up in a MEdTech search
- Ask for help – you will get it! Communicate. The Education Team (Sheila Pinchin, Eleni Katsoulas, Theresa Suart and Alice Rush-Rhodes) will come to sessions, help you plan, search for links, etc. Your Program Assistants and Curricular Coordinators will also help in many ways.
- Your course should have defined goals, objectives, curricular content and you should an overall picture of your course and related curricular components
- Remember your courses/clerkship rotations are not designed for becoming a specialist in that discipline; breadth and depth need to be appropriate
- Deal with student issues personally and quickly (professionalism & ethics)
- Balance between micromanaging and some flexibility
- Assessment Tips: Write exams before course starts and tweak as needed; Blueprint immediately after course is completed
- Use team work to design (or redesign) the curriculum—to have objectives assigned to your course, to link to other parts of the curriculum, to integrate competencies, interprofessionalism, etc within your course
The Integrated Clerkships contributed these specific ideas, but they’re actually useful for all courses:
- Be guided by expressed student needs
- Students enjoy exposure to other disciplines
- Find great teachers and keep them enthusiastic
- Expose students to real professional dilemmas (but don’t overwhelm them), e.g. ethical issues re EOL conversation
- Expose students to ethical interaction w/ industry (relate to C Courses)
- Micromanaging; rigidity, square pegs and round holes
- Communication—try hard to communicate with other course directors, with Ed Team, with faculty in your course, with students, with MEdTech, with Curricular Coordinators…
- Not being able to see the big picture, i.e. what is concurrent, before & after in the curriculum
- Time management for prep and delivery is more extensive than originally thought
- If the work is unrealistic, it is unrealistic. Tell someone you cannot make the deadline. There may have been an error.
- Relative & accidental invisibility of good programming (Eg. History of medicine, often ignored in accreditation)
- Some patient-based issues get accidentally ghetto-ized, eg. (1) women in repro only (2) palliative care for oncology cancer only
The Integrated Clerkships have these concerns:
- Work on faculty appointment which can be somewhat obstructive for some community MD’s willing to teach
- Work on overextending expectations of a community, esp. with student wellness
- Being overly-exposed to a particular [ethical] agenda
- Ensure the sessions are aligned with Curricular Objectives
- Ensure interdisciplinary objects are understood and taught
Now that this list has been compiled, it will go to our Associate Dean. There are some solutions already present through MEdTech, the Curricular Coordinators, the UG Educational Team, the Office of Learner Wellness, Bracken Library of Health Sciences, the Curriculum and Program Committees which are some of the resources that curricular leaders (and all faculty) can access. We are also ably supported by the Office of Regional Education, the Office of Faculty Development, the Office of Interprofessional Education, and the Office of Health Sciences Education.
One resource is the new community for Course Directors built by the UG Educational Team. It’s at https://meds.queensu.ca/central/community/coursedirectors
It contains information we’ve gleaned from interviewing Course and Year Directors, from experience, and from consulting medical education literature.
One section we compiled with the help of Dr. Sue Moffatt contains the Course Director Checklists organized into Before, During and After the Course: https://meds.queensu.ca/central/community/coursedirectors:course_director_checklist
You may also find the Assessment Planning section helpful (tho’ there is still more to come) https://meds.queensu.ca/central/community/coursedirectors:assessment_planning
There’s a lot more: from Course Planning to Student Roles, to the Curriculum structure and the Committee and Leadership structure. Why not dive in and look around?
Our Curricular Leaders support the program through their hard and varied work. They work diligently at aligning the triumvirate of learning objectives, teaching strategies and assessment. They often teach a great deal in their courses, and are responsible ultimately for the assessment of the students’ progress. They have huge communication responsibilities with Year Directors, Curricular Coordinators, in committees, and with their faculty members and students. They are curriculum builders and adapters. They, along with the faculty who teach in our program, are heroes in the work they do…
Typically, the hero of the fairy tale achieves a domestic, microcosmic triumph, and the hero of myth a world-historical, macrocosm triumph. Whereas the former–the youngest or despised child who becomes the master of extraordinary powers–prevails over his personal oppressors, the latter brings back from his adventure the means for the regeneration of his society as a whole.
–Joseph Campbell The Hero with a Thousand Faces
The Challenge of Career Selection
When are Medical Students ready to decide?
Medical students begin their studies believing they have decided upon and achieved their career path, and can now devote their energies and attention to advancing that goal. They soon learn that even greater and more complex decisions lay ahead. The process of career selection has become a major cause of concern and stress for both medical students and curricular leaders at our Canadian medical schools. Students must, by the end of medical school, select from among over 30 postgraduate training program options, which will further differentiate into over 70 approved medical specialty certifications. Are students ready? A recent, informal survey was carried out among the first and second year classes at our medical school. Students were asked to state their agreement with one of three statements:
- I have a single, clear career interest.
- I have narrowed my focus to between 2 and 5 options
- I have no idea
So it would appear only a minority of our students have established a choice by these early years, although it’s unclear how durable these choices will prove to be. It also seems that some further clarity emerges even by second year, but the majority of students remain uncertain. Studies from the British medical educational system would suggest that about a quarter of doctors change their career choice after qualification (Goldacre MJ, Lambert TW, Medical Education 2000:34:700-707). A review of Canadian graduates reports that 83% of graduates felt somewhat or very well prepared to make career decisions, but that leaves a full 17% who described themselves as “not at all sure” by graduation (Columbia B. Can Med Assoc J 1997;156:1248)
To illustrate how much the medical landscape has evolved, it might be useful to consider a “Tale of Three Classes”.
This photograph provided by Queen’s Archives illustrates one of our earliest graduating classes, circa 1870. Students of that era received a common 3-4 years of instruction and clinical training, after which they were fully qualified practitioners. Their scope of practice throughout their careers was virtually identical, determined only by the needs of the communities they served.
Let’s move forward about a hundred years. The second photo was taken at the 25th reunion of my class, Meds ‘81. My classmates and I also undertook a common four year curriculum. With one further year of training, in virtually any “internship”, we were all deemed fully qualified as “General Practitioners”. About half the class remained in General Practice, eventually becoming qualified by the College of Family Physicians when that body and its qualifying examinations came into being. The remainder went on to additional training in one of the limited number of specialty programs and certification examinations offered by the Royal College of Physicians and Surgeons. Importantly, I doubt any of my contemporaries regretted their general training, and even those eventually engaging very specialized disciplines would say that their clinical proficiency and effectiveness was enhanced by that background.
Contrast all this to the graduates of Meds 2009. About a quarter of these students undertook training in Family Medicine. Many will, by now, have completed the minimum two year training program and will have begun practice, having passed qualifying examinations and achieved full certification through the College of Family Physicians. The remainder are still in training, having undertaken further training through the CFP or entered a variety of Royal College programs, all with their own entry requirements, training program and qualification examinations. Although their undergraduate experience would have differed in many ways from that of their predecessors, it was based on a structurally similar four year model, common to all students regardless of career direction.
The routes to practice are, in fact, becoming increasingly tortuous, complex and longer. In order to better understand this, I’ve consulted with my colleagues in our postrgraduate education office. Jordan Sinnett, PG Program Manager, provided me with the accompanying table that outlines the various paths to the current available postgraduate programs. The reasoning by which some programs are direct entry from undergrad whereas others diverge after core training, and the length of time of various programs is all rather opaque, but appears to reside with the individual program committees.
It’s important, in considering all this change, to recognize that the major driver is the increase in medical knowledge, available technologies and vast expansion of valuable service the profession is able to provide to our patients. Our society requires (and demands) physicians who have the highly specialized knowledge and training that’s required to diagnose and manage our ever-expanding array of conditions and provide technologically complex treatments. This is obviously all good. However, as training needs have increased, we have simply added more time and qualifications to those previously available rather than to consider new educational paradigms. At this point, a few questions must be posed:
- Is this a problem? Stated another way, are there unintended consequences of this evolutionary change that should be addressed?
- What, if anything, is being done?
- How will all this affect our learners, and can they be expected to engage career selection in a different way?
1. Increasing focus of attention and stress for medical students. The expansion of career options and requirement to choose from so many postgraduate training tracks is becoming an increasing focus (some would say obsession) of our students during medical school. Observerships, interest groups, electives and even summer voluntary placements are all seen, and used, as opportunities to explore career options and advance one’s suitability for the increasingly competitive application process. Although all of value, these pursuits compete with ever increasing educational demands expected of our students.
2. Unhealthy competition among students. Many postgraduate programs are over- subscribed relative to available training positions. This results in a competitive environment at the very time medical schools are working hard to “undo” the pre-medical focus on superficial academic success and advance principles of patient-centred learning, collaboration and cooperation among colleagues.
3. Subversion of medical education. Medical school curricula are increasingly directed toward career exploration, to the extent that both core content and Electives (18 to 20 weeks at most schools) are essentially devoted to this purpose. Career exploration is, in essence, subverting the educational priority.
4. Increased time required to achieve practice readiness. With the expansion of postgraduate programs and numerous emerging competency tracks, the duration of training is getting progressively longer. Becoming a qualified interventional cardiologist, for example, requires 15 years from university entry (4 year undergraduate degree + 4 years of medical school + 3 years General Internal Medicine + 3 years Cardiology + at least 1 year Interventional fellowship). Given that much of that time is spent in educational pursuits not directly relevant to the eventual practice requirements, the need for such a long training period is, at the very least, debatable, and given the increasing resource limitations of our health care system, will come under increasing scrutiny.
What’s happening that will affect all this?
The Future of Medical Education Postgraduate recommendations included the following:
To implement this recommendation, the Association of Faculties of Medicine of Canada has established three committees with mandates to explore methods to refine processes within undergraduate programs, the transition from undergraduate to postgraduate education, and the transition to practice. Those groups have been encouraged to think beyond current models. Those revisions may involve more “streaming” or specialty-specific teaching during medical school, a more gradual transition from foundational to specialty-specific learning, and effective career counseling processes.
However (and this is a big “however”), any such change in the three or four-year common curriculum paradigm will necessarily require our students to make even earlier career choice decisions. Is this a reasonable expectation? The information I provided above would suggest they certainly are far from optimally prepared at this time. So, what would be required to allow our students to make valid, durable career decisions earlier in their training?
The following would seem at least a reasonable place to start:
Clear and easily accessible information about the various career choices available to them. Students need to understand the scope of specialty options and the essential differences, not only in clinical content, but also credible information about the “life” that goes with each. They’re particularly interested in issues such as call expectations, mobility, and the availability of opportunities to integrate academic interests with their clinical obligations.
An understanding of their own preferences and aptitudes. Students require direction and help in thoughtfully and honestly considering a number of personal issues relevant to career selection, such as:
- Their willingness to engage patients with undifferentiated presentations
- Their comfort with critically ill patients
- Their comfort with continuing care versus issue-specific consultancy
- Their comfort with surgery and procedural work
- Their comfort with certain patient populations, such as children, the elderly, the terminally ill
- Their comfort with various practice settings, such as hospital wards, emergency rooms, ICUs, clinics, and offices
- The degree of flexibility with respect to practice settings and mobility they wish to have
Although it can be very difficult for students, a full and candid consideration of issues such as these will allow them to reduce their reasonable options to a more manageable number.
Knowledge about availability of training and career opportunities. Students have expressed very clearly their desire to know about long-term career availability. Both shared experiences and recent studies (Frechette D et al, http://www.para-ab.ca/upload/files/docs/employment/RoyalCollege_EmploymentSummary_2013.pdf) have suggested that many highly-qualified graduates of postgraduate programs have difficulty finding practice opportunities in certain specialties. Students wish to have such information. In this regard, they are allied with our provincial governments who seek to ensure our production of various medical specialists matches societal needs. Unfortunately, accurate information is very hard to come by, particularly for students whose entry into the workforce is several years in the future.
An understanding of the application process. Students need to understand the process by which they will apply and compete for postgraduate positions. This requires clarity and transparency about both the matching and selection processes. The former is carried out by the Canadian Residency Matching Service (CARMS), and is open, transparent and effectively provided. The latter, which is in the hands of each specific postgraduate program, is considerably less transparent and subject to considerable rumour and “urban myth” among students.
Is there hope on the horizon?
All this requires a fresh, early and much more comprehensive approach to career exploration and counseling than medical schools have provided to date. This week, those directing career counseling curricula and services at the six Ontario medical schools are assembling at the request of the Council of Ontario Faculty of Medicine Undergraduate committee to compare approaches, discuss challenges, and begin to develop more cooperative and effective approaches for our students.
The AFMC and ministry are jointly interested in providing more reliable definition of societal needs for all our specialties. Such information will certainly be informative for our students.
The FMEC sub-committees mentioned above have, as a component of their collective mandate, consideration of improved student counseling and application processes.
These initiatives provide some optimism that students will be better prepared for their career decisions, and for the systematic changes likely to develop within our medical education programs in the coming years. All these discussions and initiatives will be more effective if informed by those involved in (and effected by) the processes under discussion. It’s in that spirit that this article is provided and your feedback is welcome.
Many thanks to Jordan Sinett (Postgraduate Program Manager), Sarah Wickett (Health Informatics Librarian, Bracken Library), Jonathan Cluett (Meds 17 Class President), Sean Henderson (Meds 16 Class President), Jennifer Siu (Meds 16) and, as always, Lynel Jackson, for their assistance in the compilation of information for this article.