Teachers and Learners “Spring” Forward for Each Other
By Jonathan Krett, Aesculapian Society President, Meds’18
Recently I attended the Canadian Federation of Medical Students Spring General Meeting in Montreal, QC. Sitting around a table with medical student society presidents from across the country discussing a variety of issues really drove home that at Queen’s School of Medicine, we students have it pretty good.
One of our strengths is certainly the huge part that learners play in driving the student experience. The peer-peer support at our medical school is a true standout and I believe it fosters a strong sense of community. Another one of our notable strengths is without a doubt, the engagement and responsiveness of the faculty that come into the classroom to teach us each day.
Twice a year, the Aesculapian Society (AS) Council hosts general assemblies in which we have an opportunity to recognize both faculty and student contributions to our life as learners at the Queen’s School of Medicine.
It’s on these rare occasions where I have the opportunity to reflect on, and be proud of, the above-and-beyond efforts of a handful of very special people. I wanted to take this chance to celebrate peers and faculty who fuel the very essence of our wonderful community at Queen’s.
Without further adieu…
First-year President and AS President-Elect, Gray Moonen presented two AS lectureship awards on behalf of the Class of 2019.
Dr. Filip Gilic (Family Medicine), applied his direct and practical teaching style, helping to render common presentations in Family Practice accessible to medical students in their very first term of school.
Dr. David Lee (Hematology), engaged students in the classroom with a life-sized red blood cell piñata to demonstrate hemolysis. His careful and thoughtful approach to lecturing went a long way towards enabling material to percolate into the heads of his students.
Second-year President, Monica Mullin, presented four AS lectureship awards on behalf of the Class of 2018.
Dr. David Holland (Renal Course), won over students with his simplified framework for approaching renal disease. Leaving us with the wise words, “Teach Once, Learn Twice,” Dr. Holland thanked his students for the lessons they have taught him along the way.
Dr. Robyn Houlden (Endocrinology Course), was recognized for her organized course framework and emphasis on key concepts for practice in endocrinology. Her sense of humour in the classroom brought a certain levity to otherwise intimidating, complex material.
Dr. Alex Menard (Radiology), made several appearances before the second-year class and de-mystified diagnostic imaging using an interactive teaching method. He left us with pragmatic approaches to common clinical scenarios.
Finally, Dr. Heather Murray (Extended CARL, 2nd-year Course Director), was applauded for her extensive contributions to the well designed second-year curriculum. This year she incorporated a brand new initiative called “Case of the Month.” This series runs longitudinally through second-year, helping students to consolidate approaches to several core clinical presentations and get comfortable with applying our non-medical expert physician competencies.
In addition, non-academic awards were distributed to non-graduating students. (Note that students in fourth year receive their awards at graduation, and will not be specifically mentioned here.)
Wei Sim, AS VP Internal Affairs, presented the A. A. Travill Award to Graham Skelhorne-Gross. Graham was congratulated for his immense work and sacrifice on behalf of the entire student body at Queen’s in his role as our VP External. He spent countless weekends out of town representing us on provincial committees, such as the Ontario Medical Students Association (OMSA).
The AS Awards of Merit were presented to several students who excelled in their efforts to promote student life and learning in a variety of areas.
Adam Mosa (Meds’18), was applauded for his work as Queen’s Medical Review Co-Editor-in-Chief and as one of the Class of 2018’s Clerkship Curricular Representatives.
Peter Wang (Meds’18), was heavily involved in enhancing extra-curricular learning for his peers (SSTEP, Emergency Medicine Interest Group), along with his work in the community teaching first-aid to youths with Junior Medics.
Henry Ajzenberg (Meds’18), provided a great deal of leadership on the advocacy scene this year. He co-chaired the successful Health Policy Interest Group (HPIG) and acted as Chief Outreach Officer for the Ontario Political Advocacy Committee (OPAC).
Wei Sim (Meds’18), also received an award for heading up the popular acapella group, Hippochromatic Notes, and his many behind-the-scenes efforts on student council.
When all was said and done, I had to stop and think once again, at Queen’s we have things pretty good.
Please don’t hesitate to contact me at firstname.lastname@example.org with any questions or comments.
A list of past faculty winners can be found here.
Celebrating Student LEADership
This week, I’ve invited one of our soon-to- be-graduating students, Elizabeth Clement (Meds 2016), to report on the LEAD (LEadership Enhancement and Development) program, an initiative she and a group of her colleagues have conceived and completed over the past year. When Liz, Alia Busuttil and Graydon Simmons first came to me with this idea, I must admit to thinking it was overly ambitious, particularly given they were just beginning their clerkship. Once again, I underestimated the commitment and tenacity of our students when they are pursuing a deeply held and worthy cause. I attended the presentations of the Service Learning projects that Liz describes below, and was greatly impressed at the ingenuity and commitment to community service that went into them. Inspiring, indeed. The LEAD program is being passed along to other students, who will work with myself and other faculty to ensure this great work continues.
I’m often asked what keeps our Queen’s faculty so engaged and energized about medical education. For a glimpse into the explanation, read on.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
Mind the Gap by Elizabeth Clement
There’s always a natural tension between student and teacher. While there is a clear common goal, which in medicine is that of graduating a competent doctor, it is easily muddied by the varied opinions on how to achieve such a goal. Students have many competing interests – that extracurricular activity, research project, or family commitment. Faculty, too, are juggling their many hats – hospital service, clinics days, conferences and their home life. Over time, many, if not all, show up to the classroom with slightly less enthusiasm, and as teaching begins to deviate further from one’s preconceived notion, it’s easy to see how that unity of working toward a shared goal begins to erode.
If you’ve ever been on the subway in London, England, I find this reminiscent of the vaguely haunting mind the gap. As the train pulls up to the platform, the two bodies never perfectly line up, leaving a small space between the two: a gap. The overhead voice reminds you to mind the gap: don’t fall in. Because of the nature of the subway’s short stops, you’re either on one side of the gap or the other. You’re either on the train or off the train. You’re either a student or a teacher. Mind the gap.
In my first year at Queen’s, I remember being floored by the openness and candidness of our faculty. Town halls and curricular feedback and personal email exchanges. Even more surprising was that changes were made within courses reflecting this feedback. Often this would happen in real time; courses would morph not after, but as we advanced through them.
It was not surprising to me, therefore, that when a dialogue began about students’ interest in leadership training, the idea of a student-run leadership course received faculty support. The first of many conversations about this project happened more than two years ago, and was the seed for the Leadership Enhancement and Development (LEAD) course. Now, at the conclusion of its first iteration, 12 preclerkship students have wowed us.
In the first of those two years, members of the Class of 2016 (Graydon Simmons, Alia Busuttil and myself) worked together to create a curriculum structure: one part seminar, one part self-reflection, and one part project. In the second year, the team grew as three members of the Class of 2017 (Rajini Retnasothie, Laura Bosco and Lauren Kielstra) joined us to help plan, administer and facilitate the course. Then, in November of this past year, 12 preclerkship students joined the course and we met for the first time as a large group. Amidst explanation of the structure of the course, we were clear about one thing: you will get out what you put in, and what you put in is completely up to you.
During the course, we heard from Queen’s School of Business’ Borden Professor of Leadership Julian Barling, who taught us about motivating with responsibility, and the importance of showing gratitude. We heard from our very own Dr. Sanfilippo about the pillars of leadership; optimism is imperative. We broke into groups of three to discuss our thoughts and reflections while working through the CMA’s “Leadership begins with self-awareness” modules. Meanwhile, outside of the course, students were independently working on “service learning projects,” which required community consultation, strategic design and a significant time commitment. The final seminar, held in mid-April, was a platform for the students taking the course to give short presentations on their service learning projects.
This was inspiring:
- Reza Tabanfar’s Telemedicine to Improve Access-to-Care and Treatment of Ear Disease in Remote Ontario Communities: We hope to use digital otoscopy and existing telemedicine infrastructure to leverage ENT’s expertise in diagnosing ear disease, facilitating much quicker review and prioritization of patients presenting with ear complaints in remote Ontario communities.
- Zain Siddiqui’s Jumu’ah Prayer Service at the Kingston General Hospital (KGH): The project’s aim is to have Jumu’ah, the weekly Islamic congregational prayer, in the KGH chapel so that that KGH staff and visitors can attend.
- Sejal Doshi and Elisabeth Merner’s Street Soccer Kingston: This project is an opportunity to build routine and social supports for Kingston’s homeless/transition housing community all while promoting the importance of physical health.
- Mahvash Shere’s Global Health Simulations – Queen’s Chapter: This project will allow students to engage in hands-on negotiation and problem-solving, by putting them in the middle of a humanitarian crisis and asking them to engage with different stakeholders attempting to resolve the crisis. Post-simulation debriefs will give students the opportunity to reflect on the complexity of problem-solving and power dynamics in these situations.
- Stephanie Pipe’s Revamping Altitude’s Mentee Recruitment Process: This project involves implementing new recruitment strategies, such as more advertisement of the program at the high school level and working with other groups and resources on Queen’s campus, to better reach our target population and hopefully increase the representation of our target population in the program.
- Katherine Rabicki’s Women and HIV/AIDS Situational Analysis: We are collecting data on the experiences of women living with, or at heightened risk of contracting, HIV/AIDS, with the goal of adapting Kingston’s community-based services to better suit the self-identified needs of this population.
- Connor Well’s Inspiring Future Medical Students Through High School Community Outreach: this project will determine the feasibility of encouraging high school students, especially from underrepresented backgrounds, to consider medicine as a career through knowledge translation of the medical school application process at high school career fairs.
- Akshay Rajaram’s Quality Improvement Practical Experience Program (QIPEP): QIPEP offers Queen’s students a chance to develop quality improvement and patient safety through participation in real quality improvement and patient safety initiatives that impact patient care.
As I walked around the room hearing students talk about Jumu’ah, global health simulations, and street soccer, (I’m a little embarrassed to admit it, but) I was getting euphoric. Maybe it was these students’ optimism or show of hard work. Maybe it was their passionate pursuits in the absence of obligation. At the end of the day, I think it was quite simply that I was learning about topics that, without these students, I would know nothing about. THEY were teaching and I was learning; not the original design of our course!
I had not occurred to me until then that perhaps faculty who teach are motivated because they, too, want to learn. When we consider life-long learning as a part of our professional responsibility, most of us consider that to mean staying up-to-date with medical practice changes, but there’s a lot more to be learned that can impact the practice of medicine. When faculty solicit student feedback, it’s in an effort to connect with students and better appreciate how learning is changing. Perhaps like a student’s satisfaction when performing well on an exam or rotation, faculty find satisfaction when making improvements to curricula; both demonstrate knowledge gain. And beyond this, I wonder if there is a deeper satisfaction borne from the notion that better learners will make better teachers.
In any case, a cyclic theme emerges: those who are committed to teaching are those who are committed to learning.
At Queen’s, it is clear that the doors are open to peer-teaching; the anatomy and Being a Medical Student professionalism curricula are two of many examples. But I think we can do more. Students are a resource; our diverse walks of life foster perspectives that can help reinvigorate content and delivery – this has particular relevance with the non-medical expert competencies.
Under no circumstance am I trying to suggest that Queen’s does not involve its students; in fact, I know the opposite to be the truth. Instead, I’m suggesting that a deeper involvement may serve both faculty and student in a novel way – by helping us appreciate the complexities of one another’s roles. Not only would the end product have curricular value, but the process would help us all to collectively mind the gap.
3 Key Teaching and Learning Principles: Revisiting RIA in UGME
This weekend, I was digging around in my hard drive, and pulling files, as I’m working with Dr. Lindsay Davidson on the concept of integrated threads in our curriculum. (Stay tuned for a future blog.) All of a sudden, out popped a document called “3 key teaching principles,” which Dr. Elaine Van Melle and I worked on in 2008. It eventually became part of the Teaching and Learning Policy for UGME.
I took a look and it’s one of those ageless documents that I think we can still learn a lot from and perhaps refresh in the light of 2016. Do any of you recall “RIA“? Come take a journey back and forward with me around the 3 Key Principles of Relevance, Integration and Active learning.
All learning experiences should be . . .
“to have significant and demonstrable bearing on the needs of the learner.”
A student says, Why should I care about this?
A teacher says, Why is this important for a student to know?
- Creating relevance fosters interest, motivation and engagement. It is a key step in facilitating retention and transfer of information.
How can I make teaching/learning relevant?
- Illustrate clinical applicability in the primary management of patients
- Ask these key questions about foundational concepts: “What does every physician need to know about this concept?” and “What does a learner entering my sub-specialty need to know?”
- Link the material to the Medical Council of Canada’s (MCC) objectives as the MCC objectives document forms the basis for the licensing exam.
- Begin with a clear statement of essential learning objectives reasonable for the time allotted.
- Explicitly state the relationship between the learning experience and the assessment process
Back to 2016, consider this checklist for relevance in your teaching:
- Do I use case studies both of my own, and as activities to let students apply learning to “real life”? Do I use lots of examples to clarify concepts?
- Have I reviewed the MCC’s for my learning event and made sure that my teaching is aligned to them?
- Have I got 2-3 clear statements of learning objectives at the level the learners per 1 hour learning event?
- Can I state a key idea or “core message” for this one hour of teaching
- Do I describe why this is important for students to know?
Learning is enhanced when it is relevant, particularly to the solution and understanding of real-life problems and practice. (Kaufman and Mann, 2007)
“to be connected and interrelated”
A student says, Where does this fit?
A teacher says, How can I connect this with other teaching and learning?
- Connecting to the knowledge of the learner facilitates retention & transfer of information from one context to another
- You’re not the only person in the curriculum teaching about this topic.
How do I integrate?
- Ensure learning is appropriate to the level of the learner and relates to the learner’s previous experiences.
- Structure information in a way that demonstrates the relationship between key ideas.
- Link to other sessions to allow for progressive reinforcement of fundamental concepts.
- Connect with other teachers to minimize unnecessary redundancy.
- Create horizontal integration by explicitly connecting to sessions that have come before and those that will follow a particular learning experience.
- Create vertical integration by linking to other types of learning experiences that may be going on at the same time e.g. problem-based learning, clinical skills, basic science teaching, etc.)
Back in 2016, try this checklist for integrated learning:
- Have I vetted the level of learning in my teaching with other faculty, my course director and/or an Educational Developer?
- Have I checked where else in the curriculum the topics of this learning event are taught? (Tip: Year Director and Educational Developers can help. So can MEdTech: Curriculum: Curriculum Search. TLIC is working on Integrated Threads.)
- Is my learning event “integrated” and well-organized in itself with sub-topics, links back to the introduction and a summary? Do I provide an outline and refer back to it during the learning event to orient the students?
- Do I know where my material fits in with in Clinical Skills, FSGL, and other parts of this course as well as others?
- If I’m teaching in C2, or a clerkship seminar, does this topic build on and become more complex than the foundational concepts taught in years 1 or 2 and C1? (Have I looked back at those? Looked forward to C3? Thought about how this applies in clinical clerkship rotations?)
In the hands of the most effective instructors, [this] then becomes a way to clarify and simplify complex material while engaging important and challenging questions…(Bain, 2004)
“ Students engage with and take responsibility for learning”
A student says, How will I learn this?
A teacher says, How will I engage the students?
Why use active learning?
- Facilitates retention and transfer through the construction of new ideas and/or ways of thinking.
- Learning is a process that results in some modification, relatively permanent, of the learner’s way of thinking, feeling or doing.
- Requires the active construction of new ideas or ways of thinking on the part of the learner.
How do I use active learning strategies?
- Students are encouraged to take responsibility to achieve new levels of understanding and/or skill development
- Create learning environments that foster rich interactions among students, between the instructor and students, and between the student and the learning materials.
- Students learn well by doing, and participating in “real-world” experiences.
Here’s the 2016 checklist for active learning:
- How will I change the students’ ways of thinking, feeling or doing with this learning event
- As a way to engage, have I tried using video clips? Illustrations? Demonstrations? Real (live) patients? A poll to take the “temperature” of the class? My own experiences in the clinic or workplace?
- How can I get the students to “construct” new ideas? Have I tried asking probing questions in key places in the learning event, or providing a worksheet or algorithm for the session? Have I tried to present an intriguing question, problem or case study and use different points in my lecture to solve the problem? Can I use “real world” artifacts to engage the students?
- How can I get the students interacting with each other, or with me and other faculty or residents in the room? Have I tried partner work, or small group work? Have I thought about Group RATs? Have I tried, Think, Pair, Share?
- Do I pause at key points and “change up” what is happening in the room?
- Have I integrated student activity in the learning event, or partnered with an expanded clinical skills or clinical skills learning event?
- Do I give the students a chance to demonstrate what they are learning?
Learning is not a spectator sport. Students… must talk about what they are learning , write about it, relate it to past experiences, apply it to their daily lives.” (Chickering and Gamson, 1987)
I hope you’re finding the results of my filing cabinet diving helpful. Do the checklists make sense now in 2016? Is there anything here you can use? Please check in and let me know. Or contact one of us in Educational Development at UGME.
CARMS Match Day: 2016
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.
This year, Match Day is March 2. By approximately 12:00:05 that day, 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 2nd 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 Jacqueline Findlay at email@example.com, or 613-533-2542. The faculty counselors can also be contacted directly at the following:
Dr. Renee Fitzpatrick, MD, MRC Psych, FRCPC
Dr. Kelly Howse, BSc (Hon), MD, CCFP
Dr. Susan Haley, MD, FRCPC
Dr. Joshua Lakoff, MD, FRCPC
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
Smashing Stereotypes Using YouTube™ in Teaching – a Geriatric Medicine Perspective
By Michelle Gibson
Why Use Videos in Geriatric Medicine Teaching?
I teach first year medical students about the awesome world of geriatric medicine. I am a family medicine-Care of the Elderly trained doctor who loves her work, and although I am dutifully teaching about all the sacred geriatric syndromes (falls, confusion, frailty, etc.), my main motivation is to help (very) young medical students start to see why I fundamentally love my patients – because they are truly wonderful human beings.
Many students, most of whom are under 25, have little or no experience with seniors, particularly in health care settings, and some have unfortunately had negative experiences. Regardless of their experience, they, like all of us, are often bombarded by negative portrayals of older adults in the media.
To make matters worse, I am (ahem) “competing” with the following courses:
Pediatrics (cute babies and kids – unfair advantage), Genetics (the future of medicine according to everyone, with cool, high-tech tricks), and Musculoskeletal (broken bones! surgery! trauma!). I know my patients can take any of these competing patient populations in terms of general coolness, but my students don’t always realize this.
I have often invited my patients to come to class to discuss their experiences in the interdisciplinary outpatient program in which I am based, but due to their general frailty, this often doesn’t work out, and even when it does, there are many logistics barriers that must be overcome (such as a lack of accessible parking, but I digress).
My solution? I use carefully selected YouTube videos in class. I show these videos mostly at the beginning of class, so it also takes care of the (super-rare … or not) incidents of students arriving late for an 8:30 a.m. class, and missing my carefully constructed, brilliant opening teaching gambit.
Below, I have included a selection of the videos I use, including some information about how I found them, and why I use them.
This is one of the first videos I used, and it remains a fan favourite. Dancing Nana is 88 years young, and her grand-daughter takes her out for lunch every week. On this week, her grand-daughter played one of her grand-mother’s favourite songs, and you can see what happens next.
This video also illustrates one of the challenges of YouTube videos. The original video has had the audio blocked due to a copyright complaint. So far, as of today (February 2016), the music is intact here.
Why do I love it? Because Dancing Nana is real. She’s just like many of my patients. She has a great outfit, complete with her personal alarm system in place, and she puts her purse down to dance down the stairs. She is aging (she’s 88!) and but she loves life, and her granddaughter takes her out to lunch every week. It’s perfect.
It’s also a good length to show in class – 2.5 minutes long. How did I find Dancing Nana? I searched “old person dancing” on YouTube back in 2013. Complex search strategy, n’est-ce-pas?
I show this video before I teach about prescribing exercise to the elderly. I can’t think of a better introduction.
Pearls of Wisdom
This is a video I can use before any of my teaching sessions.
This is a lovely little video full of humour and poignancy. Older adults in a care home in the UK provide “Pearls of Wisdom” – which reflect lifetimes of experience.
This video makes me smile, and (sometimes) can make me tear up. The folks are eloquent, witty, and have obviously thought about what they are going to say – and each Pearl reflects their individual personality, which then shines through. The stars of the video really demonstrate the great spirits contained in older bodies, which are often frail. It really helps us appreciate the person and not the disease, age, or condition. I choose it because it demonstrates that one’s humanity does not depart upon admission to a care home.
Hal Lasko: Painting with technology
Hal Lasko is an amazing 97 year old man, who was losing his vision, and his grandson introduced him to a software program that allowed him to continue to “paint”. The video is in fact produced by a huge company (you’ll see if you watch the movie) but it’s really all about the amazing art that Hal can make using technology.
I think this video truly “smashes stereotypes”. Hal’s cognition appears very much intact, at the age of 97. He has embraced technology, and he makes art that most of us could never hope to make. He has a passion, and he pursues it, despite his disability.
How did I find Hal? I was searching for another video, since taken down, about “Old man painting”, and Hal popped up.
I do address explicitly in class that I have no financial affiliation with the company in question, nor have I ever used the product. I wish it wasn’t a commercial, but it is, so I just discuss it explicitly. I have decided not to use other videos that were produced by pharmaceutical companies, as I am not comfortable with the implied endorsement.
Mark Ronson ft. Bruno Mars – Uptown Funk “Oldtown Cover” ft. Alex Boye’, & The Dancing Grannies
Some videos are just plain fun, and need to be shown.
This one was posted by a friend of mine on Facebook (sometimes these videos just fall in my lap), but also by a number of first year students after I started to show the videos in the geriatrics unit. It’s a great resource. It’s impossible for students to ignore at the beginning of class and it works better than coffee to wake up in the morning. It’s got great seniors being, well, funky. It’s very clever.
I often point out that many of the seniors are “too young” for me, in terms of the patient population I see, but it’s important to me to show healthy aging at all ages.
As Alex Boyé says in the notes on YouTube:
“All the grandmas and Grandpas in this video did their own stunts 🙂
They range in age from 65-92! Between them, they have raised 500 children, 1,200 grandchildren, and 250 great grandchildren!!!”
(And not, I do not show videos to make me seem cool. That ship sailed eons ago. I don’t even pretend to try anymore. You get what you see- quirky, middle-aged, me.)
100 Year Old Drivers (I saved the best for last)
This is my all-time favourite teaching video. It’s actually much too long to show in class in its entirety, but it is so well done, that showing 3-5 minutes worth hooks many of my students. I give you, the BBC’s 100 Year Old Drivers. I encourage you to watch the first 5 minutes, but I should probably warn you not to do this unless you’re ready to devote 46 minutes to frequent, uncontrollable bursts of laughter.
This was another accidental find. I was searching YouTube for videos of centenarians and found this gem. Harry, Ken, Basil, and friends are spectacular. They’re amazing examples of healthy aging, with perfectly intact senses of humour. I dare you not to laugh WITH these amazing folks. Basil is my especial favourite – with his exercise program, his patents, and his tennis. (Intrigued yet?)
This video is actually a perfect teaching video for those of you who might have to teach about determining medical fitness to drive. If you do, you’re likely like me, and you dread it. Or rather, I used to dread it, until I found this video.
Now, I love teaching about driving. I use clips from this video to illustrate many features of aging and how they may (or may not!) affect driving safety. In addition, it leads to a great discussion about differences in regulations in different countries.
In this case, I embed the YouTube link into my slides (insert hyperlink works well), and I note when to start and stop the video right on the slide, and I post the link to the full video for my students.
I’ve received very positive feedback from students about my use of videos. It’s great to see students smiling as they watch these great folk, all of whom remind me of my own patients. Instead of seeing one patient in class, they see many over the course of my unit.
(For those who wonder, I do use lots of clinical videos in teaching- they are great for demonstrating movement disorders, gait analysis, etc, and they’re great resources for students. )
All the videos are of “regular” seniors- not famous folk, by design. I will only show videos where seniors are treated like adults, with respect. (This means there are many news interviews I won’t use, sadly, because they often have a patronizing “yes dear” tone to them that I can’t stand.)
Although some of the videos are more professionally produced than others, so long as the sound is clear, and the image is reasonably clear, I will consider using them. I try to match something to my teaching session, but even if I can’t, I still start with a video.
I have elected not to show videos that are negative in tone or portrayal of seniors, and I’m explicit with my students about this. They will see enough of ageist attitudes, and people treating seniors like children/problems/not worthy of care over and over and over again in their health care training, sadly. I aim to challenge stereotypes, have my students question their assumptions, and, ultimately, to have them think of their first year geriatrics unit with a smile.
In fact, every year, students themselves send me videos to use in class – which I view as a major victory in my efforts to engage students with the awesomeness of my patients!
Contact Information – Feel free to ask questions
Keeping things fresh: Routine doesn’t have to be boring
It’s February, and despite the recent Family Day holiday, we’re still stuck in the depths of winter. Things are just a little harder to get excited about when it’s bleak, cold and snowy. Add in the task of teaching something that’s become routine, and the doldrums can be nearly certain to set in.
It can be a challenge for experts to teach introductory content. This can be further exacerbated by the cycle of teaching: each year brings another round of the same—or very similar—material. When the old adage of reminding yourself that while this is the hundredth time you’ve taught this, it’s the first time for these learners just isn’t enough, how can you get excited about teaching for the 101st time?
Here are five suggestions to ramp up your enthusiasm:
- Back to basics: What do you want your learners to know or be able to do when you’re done? Sometimes when teaching becomes routine, we’ve actually lost focus on the goal. Make a quick list of your key take-away points. If you’re not sure, take some time to reflect and make revisions to your teaching plan.
- Get some feedback: Add in some formative assessment either partway through your learning event, or partway through your sessions if you are teaching multiple times. This gives you—and them—feedback partway through to make sure things are clear. Formative assessment can be individual or team-based and doesn’t necessarily have marks attached. It can be as simple as an online poll to gauge understanding of a key concept.
- Refresh the page: Since the underlying concepts haven’t changed, it’s easy to slip into a rut of repeating yourself. Even if it’s new to this group of learners, you’ll be more engaged if you freshen your cases, or revise the background materials you assign. Is there something in the news that’s timely and on-point?
- Toss in technology: It may strike you as gimmicky, but using technology can freshen “old” material. Consider incorporating PollEverywhere’s polling (which you can use for #2 above) or incorporating a short video for discussion.
- Ask for input: Bounce ideas around with colleagues, brainstorm with others teaching in your course. Ask your course director for feedback. If you’re the course director, that conversation can work both ways: ask for input from your team.
Keeping things fresh for yourself can help your learners. Your excitement and enthusiasm contributes to a climate of learning. If you’re looking for more ways to shake things up but you’d like some customized advice, get in touch with the Education Team. We’re here to help.
7th Annual QHIP Speaker Series underway
The 7th Annual Queen’s Health Interprofessionals (QHIP) Speaker Series launched last week, but there’s still time for students to register for the remaining workshops.
Each workshop takes place on Mondays from 6:30 – 8 p.m in Room 132 at the Medical Building. The series is free, but you need to register to attend. (Here’s the form: http://goo.gl/forms/xgH2k2ao2U). Those who attend at least four workshops are eligible to receive and Interprofessional Education Certificate.
While some of these topics are covered in uni-professional classrooms, this is an opportunity to address these complex issues as an interprofessional group of students.
For more information on QHIP, check out their page on Facebook: https://www.facebook.com/QHIPSociety/
Is “Apprenticeship” Dead? The case for clinical service in medical education
An “apprentice” is someone who works for a fully qualified individual for the purpose of learning a trade. Although the term has taken on a somewhat negative connotation of semi-indentured servitude, the word itself, interestingly, shares entomologic roots with French verb apprendre (to learn), and the Latin apprehendere (to “grasp” or understand). It would seem then that apprenticeships are intended to be primarily educational endeavors.
Apprenticeships served admirably as the original model of medical education. Eager and bright young people who wished to become doctors would enter the service of an established practitioner, in the same way that aspiring masons or carpenters would engage training from masters of those trades. The apprenticeship provided, in addition to instruction in fundamental knowledge and skills, on-the-job, supervised practice training. Presumably, the level of responsibility and independence of the learner increased progressively over the period of training but, in fact, the contractual arrangements, terms of service and educational program were entirely at the whim of the “master” without consistent standards or regulation. At the end of the agreed-to term of service, the learner would receive the endorsement of the teacher and, after submitting to whatever regulatory process might exist, enter independent practice.
Our Clinical Clerkships and Residency programs are modern day vestiges of the apprenticeship model, the major points of departure being the organizational (school-based) rather than individual focus, and considerably expanded, highly defined and rigorously regulated educational expectations. However, the delicate interlacing of the two fundamental components-education and supervised clinical practice-remains the core, defining characteristic. As those two elements combine (as illustrated in the diagram below),three domains of activity are defined.
The purely educational activities consist of scheduled rounds, conferences, academic days, assessments and various other structured events. Learners are either expected or required to attend. Together, these events provide an established “protected” learning curriculum. These events are deliberately, completely separated from clinical service in order to ensure opportunities exist for the requisite learning.
There are also activities where clinical service and education overlap and occur simultaneously. These consist of clinical activities where learners and teaching faculty work together in the delivery of care, such as clinics, operating rooms, procedural suites and emergency departments. In these settings, the learner is directly supervised, is involved in care delivery to the extent their training and acquired skills allows, and receives instruction ‘on the fly’. The “curriculum” is defined not by a pre-determined schedule, but by the issues presented by the patients receiving care.
This leaves a third component of clinical service that can be considered either indirectly supervised, or independently provided. This consists of activities appropriate to the learner’s qualification and can be considered the “scope of practice” at that point in his or her training. Examples vary considerably, but could consist of ordering basic investigations, prescribing, charting, minor procedures, and patient assessments. As learners progress in training, their “scope of practice” escalates accordingly. This more distinctly service role is recognized officially in the residents’ hospital or practice privileges, provision of payment for service, and development of professional organizations such as PARO which recognize residents as service providers and work to protect that role.
To extend the illustration above, the spheres progressively diverge until, at the end of training, they separate completely as the learner assumes independent practice and, with it, complete responsibility for both their clinical and educational activities. The latter is, in fact, an expression of professional identity.
The balance between these two domains and three spheres of activity within medical training has been, and remains, contentious and a point of competitive tension. The need to vigorously protect the educational components of residency training has been very appropriately promoted through the development and protection of core curriculum within training programs and mandated by accreditation standards. The need to put limits on the clinical role has also been recognized and effectively enforced through accreditation and professional organizations that advocate for their members by, historically, promoting protection of purely educational endeavours above purely clinical service activities. The move to more competency-based models of residency education brings many potential advantages, but by formalizing and emphasizing educational processes, may further sideline the clinical service role.
It could certainly be argued that we’ve passed a tipping point where our emphasis on protection of educational activities has diminished the value of clinical service and portrayed to our learner the impression that avoidance is somehow virtuous. This would be appropriate if clinical service had no educational value and was simply a distraction from “pure” learning experiences. But is this the case? Is there an educational price to be paid for reduced clinical service experiences during training? Is it reasonable to consider residency as a “job” in and of itself with expectations of service independent of direct educational context? Expressing the issue another way: is there, in fact, educational value in the provision of clinical service? Some compelling arguments can be made:
The practice of medicine is much greater than the sum of the educational components. It is a complex interplay of scientific knowledge, specific technical skills, and an ability to understand and relate to the individual human situations in all their variety and complexity. There is something about engaging these situations individually that is far beyond what can be attained in any classroom or even directly supervised situation. The ability to do so in a nonetheless safe setting, with understood limits and readily available help is the core educational value of clinical service delivery.
Personal growth and development of professional identity. People in any human endeavour learn by engaging personal challenges and confronting adversity. This is certainly true of developing physicians. In medical school, it begins with the first time a student has a one-on-one encounter with a patient. It progresses steadily through training, but whether it is performing a minor procedure, an assessment in clinic or attending to a distressed patient with an urgent problem, these are all opportunities to grow as providers in a protected and supervised setting where optimal patient care is not only assured, but likely enhanced. This provides training physicians the opportunity to not only learn clinical medicine, but also about their own individual strengths and weaknesses in a way that can’t be reproduced in any artificial educational setting. That self-awareness is essential to professional development and critical to career decisions. Strong personal preferences or deficiencies should be identified and addressed during training, not after graduation to independent practice.
Our patients are our best teachers. Great physicians learn from every patient encounter, no matter how apparently straightforward or routine. This is the basis of lifelong learning. If the practice of valuing and learning from every patient encounter is not engaged and refined progressively during training, will it be developed in independent practice?
Valuing clinical service as a privilege, not a chore. The core mission of Medicine, and of physicians, is the provision of clinical service to our patients. To them, there is no “scut work”. If we don’t value clinical service as an educational community, what message are we sending to our learners? Are they graduating to a career of uninspiring and boring chores? In an educational sense, the development of clinical competence and increasing independence should be recognized, highly valued and accompanied by increasing status and prestige.
Pragmatically, there already exists a contractual definition of residency as a “job” with compensation and obligations. Rather than live in denial of this reality, we might be better advised to engage the balance between those obligations and educational development in a thoughtful way ensuring the optimal expression and value of both aspects.
Finally, we must recognize that this is no longer a theoretical discussion or abstract educational concept. Clinical care is becoming more, not less, demanding within our schools, outpatient clinical settings and academic teaching hospitals. Education and clinical service delivery are on a collision course that can only be averted by recognizing that these two aspects of medical education are individually necessary and mutually interdependent. Both must be preserved. We must recognize this essential duality, particularly as we go about developing newer models for both undergraduate and postgraduate education.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education
“When the patient fainted, her eyes rolled around the room”: How to make medical charting clear and accurate.
Recently Dr. Maurice Bernstein from The Keck School of Medicine, at University of Southern California, wrote into the listserve DR ED with this intriguing question:
I find many first and second year medical students present their patient write-ups for their instructor’s review with errors both typographical but also errors in presentation that makes statements seriously ambiguous. I tell my students to read what they have written and then re-read again as an individual who knows nothing about the patient. In addition, I have presented them with a list of “comic” but presumably also realistic medical charting errors.
Is there something more I can do to teach the students to be more attentive particularly later when what they write for the record has greater clinical significance for the patient than a first or second year student?
MEDICAL CHARTING ERRORS
- By the time he was admitted, his rapid heart had stopped, and he was feeling better.
- Patient has chest pain if she lies on her left side for over a year.
- On the second day the knee was better and on the third day it had completely disappeared.
- She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.
- The patient has been depressed ever since she began seeing me in 1986.
- Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.
- The patient is tearful and crying constantly. She also appears to be depressed.
- Discharge status: Alive but without permission.
- The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.
- Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.
- The patient refused an autopsy.
- The patient has no past history of suicides.
- The patient expired on the floor uneventfully.
- Patient has left his white blood cells at another hospital.
- The patient’s past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.
- She slipped on the ice and apparently her legs went in separate directions in early January.
- The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.
- The patient had waffles for breakfast and anorexia for lunch.
- Between you and me, we ought to be able to get this lady pregnant.
- The patient was in his usual state of good health until his airplane ran out of gas and crashed.
- She is numb from her toes down.
- While in the ER, she was examined, X-rated and sent home.
- The skin was moist and dry.
- Occasional, constant, infrequent headaches.
- Coming from New York, this man has no children.
- Patient was alert and unresponsive.
- When she fainted, her eyes rolled around the room.
After I finished giggling, I started to think…this is a problem with an educational and literacy component. What does educational pedagogy teach us to assist with this issue?
So here are a few ideas from my experience as an educator —these could be potential teaching strategies. BTW, don’t do all of these…:) 1-3 should make some impact.
- Work with this list: Give students the charting errors list above—it will be a good teaching moment for them and help them see how awful some of their errors could be. You could ask them in partners (to share the fun) to correct the errors as best they can, reading between the lines, or to create a set of questions that would help clarify some of them. In other words, put them in the role of the teacher.
- Think of busy times: Ask students to list the times they may be most busy in a clinical setting. This list should be posted for them to remind them that these are the times they need to slow down and focus most, ironically, on their writing.
- Writing and recall for purpose:
a. Ask students to generate a list of purposes for charting; writing for purpose is a strong strategy for improving writing. I’m hopeful some of the purposes will be: pay respect to the patient’s illness and the patient (patient-centred care), safe care for handover and for others reading the chart, legal documents for liability, etc.
b. Then, ask students to keep these in mind as they chart. Mindful exercises could include using a symbol to associate with each purpose—drawing it, literally, or drawing it clearly in their minds, using a key word to help them recall, or if they tend to associate sounds, or colours with concepts, they could do that.
Ask students pause for exactly 3 seconds prior to charting to collect their mind, to steady their writing and to recall these purposes. Actually 3 seconds is like taking a deep breath.
NOTE: thinking about the target audience, as in “Who potentially is going to read this?” can also achieve a impact.
- Simulated chart exercise: Give students a simulated case and a chart exercise and a very stringent time limit. Ask them to work in pairs and edit each other’s notes after the exercise. OR, use “Pass It On” strategy, where students affix a nickname, or number to their work (to preserve anonymity and dignity :)) and pass the chart along to the left, so that at least 4 people get to weigh in on it with feedback. NOTE: this is also a good exercise in how to give feedback—warn them against being sarcastic, or harsh—their time will come! Ask students to practice good feedback techniques: being specific, offering suggestions, avoiding judgements of the person, focusing on the writing, etc.
- Read the chart entry aloud. Ask students to practice this. This takes approximately 6 seconds at most (depending on the chart). Reading a piece of writing aloud is another recommended editing strategy practiced by writers.
- Be careful with the use of abbreviations and acronyms which are not commonly used or can be ambiguous in interpretation. For their patient write ups, except for absolutely classic clinical acronyms such as C for “centigrade” or BP for “blood pressure”, the words should be written out such as “myocardial infarction” and NOT “MI” since MI could also represent “mitral insufficiency”. You could teach students that if any obscure acronym is to be used later on in the text, in its first use, the full expression should be written then followed in parentheses with the acronym noted. Unfortunately, also, many acronyms or abbreviations in medical use are not written in a standardized manner between one institution and another and this can also lead to errors if not recognized. Bottom line: avoid or be really careful. (Thanks to Dr. Maurice Bernstein for this tip.)
- Avoid General statements: I got this feedback to a student from a nursing blog article by Katie Morales called 17 Tips to Improve Your Nursing Documentation.
Teacher: For example, you wrote “Dr. Smith called.” Did you mean: you called and are waiting for a return phone call; physician called nurse; or nurse called and spoke to physician?” A better option is “MD
paged, assessment findings discussed, and no additional orders at this time.”
Similar to strategy 1, I would give the students general statements where they can figure out what’s going on, similar to Ms. Morales’ example. I’d work through one or two on the screen with the students first.
- Checklist of common charting errors: Making a checklist of these for students is helpful and having it handy when they are charting is also helpful (make it pocket-sized). Checklists are a helpful literacy tool—no reason they shouldn’t work with charting literacy: Here are errors from a good module RN.com has: Professional Documentation: Safe Effective Legal. (Students could make it into an alpha list or an acronym list). Most of these would be applicable for physicians as well as nurses. (You might want to make them positive: e.g. “Record Pertinent Health or Drug Information.”)
Common charting mistakes to avoid include the following:
- Failing to record pertinent health or drug information
- Failing to record nursing actions
- Failing to record that medications have been given
- Recording in the wrong patient’s medical record
- Failing to document a discontinued medication
- Failing to record drug reactions or changes in the patient’s condition
- Transcribing orders improperly or transcribing improper orders
- Writing illegible or incomplete records
from: Nurses Service Organization, 2008, pp. 4 – 5
From a medical standpoint: Take a look at: Top 10 documentation error pitfalls: from Wisconsin Medical Society: 2008.
- Teach with examples. Show students excellent examples of charting to give them the necessary language for their work. Give them criteria that facilitate effective charting. Look back at the RN.com for some great criteria! As well CMA (Canadian Medical Association) has a good module called Medical Records Management with 31 (!) criteria for effective charting.
NOTE: I’ve never met anyone who can keep to a 31 point checklist, but the criteria cited are all really important, so…perhaps students can check off the ones they think they do well already, and star the ones they need to work on. A sampling of their work in clerkship (observation and feedback—still necessary) will demonstrate their self-assessment skills as well as how well they record.
10. For senior clerks and residents: The nursing module, RN.com: Professional Documentation: Safe Effective Legal, has a list of situations that are classified as high stakes documentation. This would be critical information for senior clerks and residents. (You’ll see that I’m citing nursing education here a lot: Nurse Researchers and Nurse Educators do excellent work on health and education.)
In Ratnapalan et al, Charting Errors in a Teaching Hospital, these suggestions for residency are included:
- Many training programs recognize that residents in their first month may have charting errors and have put in place orientation programs, increased supervision from senior residents and staff, and a more thorough review of the notes that are written by new residents.
- The ED at the Hospital for Sick Children is the only dedicated pediatric emergency department in the city of Toronto, and 380 to 400 trainees rotate through the department annually. Currently, there are orientation packages, orientation sessions, and a Web-based orientation available for trainees to teach accurate charting of emergency records.
- The orientation package is a large binder with complete instructions on goals and expectations, codes of conduct, medical record keeping, handling of specimens, procedures, and academic activities.
Glad to get feedback on these strategies, and add to the list! What do you suggest?
The Troublesome Ethics of Entrepreneurship in Medical School Admissions
Medical school applications are becoming big business, and a rather troubling expression of supply and demand economics.
The “demand” side consists of the many thousands of young people in North America engaged in the highly competitive process of applying to the limited number of seats available at publicly subsidized Canadian and American schools. Rebecca Jozsa, our intrepid Admissions Officer and I recently explored the “supply” side by carrying out a simple Google search of options available to the assist the aspiring medical school applicant.
For MCAT preparation, we found no fewer than 22 available courses (probably an underestimate). The “MCAT Ultimate LiveOnline 123-hour” experience is offered multiple times per year for $2,199US. For those who prefer more intense and more personal preparations, the “MCAT Summer Immersion” experience can be had for $9,499US, not counting, of course transportation and accommodation. The “Most Comprehensive Prep Course in Canada” runs over 10 weeks, costs $2,195, comes with testimonials from satisfied customers and features both instruction by successful students and “unlimited free repeat policy”. There are many other choices, a veritable smorgasbord of choices.
One can also opt for more comprehensive guidance through the entire application process. One group provides the following offering: “With our flagship service, we offer unparalleled quality that will make your application to medical school stand out”. In addition to “MCAT prep”, clients can opt for any or all of “Online Diagnostic”, “Comprehensive Application Planning”, “Application Review”, “CASPer prep”, “Interview Crash Course”, “Interview Preparation”, and “MMI prep”. Costs, understandably, vary based on individual preference and perceived need, but appear to range from a few hundred dollars for individual components to more comprehensive packages such as the Platinum bundle which goes for $3500US. It’s hard to get all the details as to what’s available without engaging one of the friendly “consultants” for a “personalized needs analysis” (which we declined) but the sky appears to be the limit in terms of costs. Some arrangements even come with money-back guarantees!
It’s clear from the advertising that many of these programs employ, or are even operated by, medical students or recent grads. Who, after all, would be in a better position to provide the “inside information” so essential to success?
So, is all this a problem?
On the one hand, all this is perfectly legal free enterprise. It’s addressing a perceived need, clients are fully informed and fully competent, no one is forced to engage these processes unwillingly. It could be argued that these programs allow very worthy and genuinely motivated young people to pursue their dreams and overcome many of the unintentional barriers that we all would acknowledge are inherent in the admissions system. One could argue that medical schools themselves have given rise to these business opportunities by making the MCAT such an integral component of the admission process, while at the same time dropping basic science prerequisites.
On the other hand, one must also acknowledge a number of potential concerns:
- The widespread availability of these services may force students to participate to simply not be disadvantaged relative to other applicants. It’s no understatement to say that candidates feel desperate for any advantage in the process. That desperation, it could be argued, is being exploited.
- This intensive preparation and rehearsing for the various application processes may result in candidates portraying themselves in an unrealistic fashion, thus subverting a process fundamentally intended to ensure applicants are appropriately suited to a career in medicine. Such “mismatches” can be disservice to all, including the applicant themselves.
- These services are obviously expensive, adding a further socioeconomic barrier to medical education, a problem widely acknowledged in both Canada and the United States.
- The involvement of medical students, as paid consultants or instructors is troubling. Their recent experience with the details of application processes, including the structured interviews (for which most schools require them to sign a non-disclosure agreement) makes them attractive for this role, but also sets up an ethical dilemma: Can they undertake to help applicants navigate their interviews without sharing information or insights they have acquired as a result of their own experience? Even if specifics are not explicitly divulged, it’s hard to imagine that their recent intimate involvement in the process won’t find its way into their “counseling”.
All this provides lessons and demands reflection on a number of levels.
For the aspiring applicant, perhaps a word of caution. The principle of “caveat emptor” (let the buyer beware) very much applies. There is no accreditation or credentialing process for these offerings. Applicants may not be getting valid advice. I’ve heard anecdotally from students who have been advised to avoid expressing any personal opinions and instead memorize and regurgitate the prepared responses to anticipated questions. Admission committees and interviewers, searching for sincerity and deep commitment to a career in medicine, are astute assessors and have become very attuned to the “coached” candidate. They will become even more vigilant. The sincerity and true commitment they’re looking for tends to stand out, and is very difficult to artificially manufacture.
This entrepreneurial phenomenon should also cause medical admissions committees to reflect on their processes. One has to question the validity of the MCAT as an assessment of scientific aptitude if an “immersion experience” is truly effective in influencing test results. Do we believe a background or interest in basic science is an important applicant characteristic? If so, do we feel successfully undertaking an MCAT prep course meets that criterion?
For medical students, entering a profession that is self-regulatory and rightfully expects high levels of personal integrity and accountability, opportunities to become involved in these programs pose perhaps their first personal ethical dilemma. Clearly, what makes them attractive to these agencies is not their personal counseling or teaching skills, but rather their status as successful medical school applicants, which brings considerable cachet and intimate knowledge which is of high value. They will find (as they will as practicing physicians) that their professional identity can’t be easily separated from their personal lives, and therefore puts them in an ethically ambiguous position.
In our society, it seems supply will always be found when demand exists and sufficient resources are made available. That this has extended to the medical school admission process should come as no surprise. However, it does raise some unintended, but nonetheless concerning consequences. As always, your views on this issue are most welcome.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education