The stories we tell…
I’ve been thinking a lot about stories lately.
It’s partly because of an independent study I’m completing at the Queen’s Faculty of Education on narrative inquiry. It’s partly because I’m increasingly conscious of several aging family members whose stories I want to record—and of other members whose stories have been lost. It’s partly because I’ve watched some excellent biographical documentaries on Netflix recently. It’s also partly because I just love good stories.
As an educator, I embrace stories and that’s easy to do since we’re surrounded by stories: The stories we tell. The stories we hear. The stories we learn—and learn from.
We all have stories we’ve seem to have known forever that we know we will share and pass along. This is because stories are personal, usually relatable, and “knowable”—it’s a way to memorize without strict rote memory.
We tell stories to impart lessons, to entertain, to remember. And sometimes all three.
Like the story I tell of leaving a political science essay to the last minute when I was in my second year at the University of King’s College. The one I stayed up until 3 a.m. writing, then got up at 5 a.m. to type it (on my electric typewriter, no personal computers in those days). It was on the Cuban Missile Crisis. Except in my sleep-deprived state, I didn’t type it that way. Instead, I wrote of the Cuban Missal Crisis.
And my professor circled “missal” every single time it appeared through the paper. (Which was a lot). I respected this man profoundly and his was my favourite course. I was mortified when he returned the papers and I saw all the circles (every single time). Still, he gifted me with a B+ (which was rare for him), so the content, if not the spelling, was fairly sound.
Why do I tell this story? (1) It’s kind of funny. (What would a Cuban missal crisis look like? Too many prayer books? Too few? Typos within them?) (2) It cautions against procrastination. (Which is why I shared it with my daughter when she started university and use it to remind myself, constantly). And (3) it advocates good proofreading – which we should all do, all the time. Plus, it’s relatable to many who have “pulled an all-nighter” who nod and smile through the telling (or reading) of this anecdote.
Medicine, and medical education, relies heavily on stories. Every medical encounter I’ve had as a patient has started with my story – what brought me there. Taking patient histories is one of the first clinical skills our students undertake.
What are case studies if not stories? Some are bare bones, some rich and colourful in detail. Like patients. Like people. We can’t see (or read) all, but we can see (read) enough. Stories are entrées into another person’s life, their point of view, the path they are on.
What goes into a good story? There’s characters, and place, and time, and plot – something has to happen. And woven into this, deliberately or incidentally, is meaning.
Stories can be loud “A-HA!” moments, or a gentle unfolding. They can be meandering streams-of-consciousness (perhaps a bit like this blog post), or a clear, linear narrative. Or something in between.
The best stories are conversations. What are the stories you tell? What stories will be told about you? As a student, as a teacher, as a person?
Do you have a story you want to tell related to medical education? Drop me a line at email@example.com – it may fit here in our Guest Blogger posts.
What stories do you want to tell?
Patients are key to our students’ learning
Students have been part of my health care journey long before I became an educational developer at Queen’s School of Medicine.
When my daughter was born in 1995 in Fredericton, NB, I had not one but two nursing students from the University of New Brunswick assigned to me. For each of them, I was their first ever patient. I was also their only assigned patient. As a first-time mom, this was both gratifying (they pretty much catered to my every need from running baths to making me snacks) and faintly terrifying (like when they, under their preceptor’s watchful eye, demonstrated to me how to give my newborn a sponge bath) and slightly uncomfortable (post-partum abdominal palpations aren’t fun at the best of times, let alone by a learner who isn’t quite sure what they’re looking for).
My mantra at the time was: “They have to learn somewhere – why not with me?”
And it’s true – there’s only so much to be learned in a classroom, a mock clinic, or simulation lab. Ultimately, our medical students consolidate all that learning during their two-year clerkship period where they engage with real patients, in real hospitals and real clinics, supervised by staff and resident physicians.
In my role as an educational developer, this is a part of their education that I don’t typically see first-hand. I’m generally classroom-based in the coaching I provide to faculty, and it’s hard to be an unobtrusive fly-on-the-wall observer of patient encounters when you aren’t a member of the healthcare team.
As a patient (and parent of a patient, and partner of a patient), however, I’ve had several opportunities to see our clinical clerks in action first hand.
I’ve watched a senior clerk valiantly (and ultimately successfully) conduct a physical exam on my pleasant-but-non-cooperative then-nine-year-old son.
I saw another clerk—working on a rotation with anesthesia—get a reluctant laugh out of my grumpy (from fasting) and nervous (because, well, surgery) husband during the pre-op airway examination and checklist.
Most recently, one of our clerks independently led off an appointment I had at my family physician’s office. I’ve hit a milestone birthday (full disclosure: 50) that can trigger a number of screening tests and things. The clerk was well-prepared, asked me good questions, and had good information. It was clear to me that they had at least scanned my file before coming into the room and had done their homework on the types of screening tests that might be relevant to me.
Along the way, I’ve also seen some of the various ways the clinical clerkship preceptors supervise and monitor our students’ learning.
For the clerk who examined my son: after a consultation outside the exam room, the clerk and physician came in together for the rest of the appointment. There was a Q&A amongst all of us which included gentle coaching and good feedback for the clerk.
Prior to my husband’s surgery, after the clerk’s exam, the anesthesiologist followed up with their own exam and pointed out a couple of things to the clerk – who then had another look down my husband’s throat which they and the physician then discussed.
For my encounter, I know my clinic has video monitoring (as there are signs posted in the examination rooms) and the clerk themselves noted they were going out to consult with the physician.
These are all different ways that clinic-based teaching and learning takes place. And that’s due in large part to patients who willingly engage in these encounters. As part of the UGME team, I feel a certain obligation and responsibility for their education and training. Most other patients don’t have this same motivation and it’s their generosity that makes this learning possible.
Through not only their classroom based studies, but especially their clinical skills training over two years, their simulation lab work, and our First Patient Project, our students are ready to engage with patients and be part of the healthcare team in their clerkship years. A sincere thank you to patients in Kingston and at our regional sites who engage with them as they learn.
Lectures aren’t inherently bad
In a pedagogical quest for active learning, we’ve somehow cast lectures in the role of arch-villain.
I’ve had conversations with faculty about their teaching which have started out with: “I know lectures are bad, but…”
This is definitely the case of a pendulum swinging too far. While research definitely supports active learning as the optimal way for students to retain learning – applying new knowledge either to simulated or real scenarios – the initial learning has to come from somewhere, and lectures are one of these sources.
Because of our focus on improving small group learning/TBL sessions in our curriculum, I can seem to be anti-lecture. The truth is, I’m actually a closet lecture aficionado. I own DVDs and CDs from The Teaching Company’s “Great Courses” series and love CBC’s Ideas. And the proliferation of podcasts has fed my love of lectures even more, as podcasts are nothing if not fabulous lectures. And TED Talks, who hasn’t lost a few minutes to those? Really, the world loves a good lecture.
Lectures absolutely have a place in universities in general and in medical education specifically. While we can’t – and don’t want to – return to a curriculum with 100% (or near to it) lectures, we can keep great lectures in our menu of methodologies to provide students with optimal learning experiences.
If you’re planning a lecture, or looking to improve an existing one, here are some things to consider:
Why do you want to do a lecture?
It’s ok if it’s just your first instinct, but think beyond that. Is this the best way to convey your content? How will providing this content in a lecture format enhance students’ learning?
Are you comfortable with the mechanics?
Lecturing is a skill which improves with practice. There are certainly standard “do’s” and don’ts”. For example, Don’t read your own slides; don’t keep your nose down in notes. And the classic: Don’t be boring. If you aren’t comfortable, do you have a plan to improve?
How can you keep things fresh and interesting for an hour or more?
Research on attention habits tell us that after 20 minutes of sustained listening, it’s hard to stay focused. With this in mind, how can you pace you lecture to break things up? Consider things like polls (with our PollEverywhere account), short think-pair-share activities, or other creative ideas. At least one instructor I know shows short topic-related videos and has the class stand up to watch them to get everyone out of their standard sitting positions.
What’s your follow-up plan?
If you think of lectures as content delivery, what’s your plan for students to be able to apply this new knowledge? Does your lecture lead into an application session in your own course or in another one? If you’re not the instructor for the follow-up session, be sure to coordinate with the person who is.
As with all your teaching endeavours, you’re not on your own. Get in touch – I’m here to help!
Now what? Making the most of a conference, now that you’re home
Many of us from Queen’s UG – faculty, staff and students – are just returning to campus after a few days in Halifax, NS for the annual Canadian Conference on Medical Education (CCME).
CCME brings together those involved in all aspects of medical education from across Canada and beyond for workshops, meetings, plenaries, research orals and posters, and general sharing of innovations and challenges.
Like most jam-packed conferences, the information overload can be overwhelming. Here are five ways to make the most of your conference experience, once you’re back home:
That Bag O’Stuff: If you didn’t do this prior to packing to come home, take two minutes to sort the “stuff” acquired at the exhibitors’ hall, at the poster presentations, and handouts from workshops. Are you really interested in that program/service/product/innovation or did you add it to your bag from habit? I sort my conference bag while standing over the recycle bin and keep only things I’m going to follow-up on. Put what remains aside for tip #2.
Get out your Post-Its! For everything that’s left from your paper purge, put a note on it RIGHT NOW. In two weeks you’ll forget exactly why you picked that up – especially if you thought it might be of interest for a colleague. Write yourself those notes!
Sort 2: Electronic edition: Did you use your smart phone to take pictures of posters or of presenter’s slides that spoke to you? Move them to a labelled folder NOW and offload to your computer to ensure they don’t get lost amongst your upcoming summer shots. Label things a la electronic stickies (see #2)
Follow-through: Did you collect emails from anyone you met along the way? Did you make tentative plans to get together, pursue a project, or generally stay in touch? Send off that quick networking email now, before those potentially productive contacts are lost in the busy of day-to-day responsibilities.
Plan ahead: Mark your calendar now for next year’s CCME in Niagara Falls April 16-19, 2019. (Abstracts open later this month!)
The special challenges of researching teaching and learning
[Italics indicates a hyperlink]
We’re passionate about teaching and learning and equally passionate about evidence-based medicine. So, it follows that we’re also interested in evidence-based teaching methods. That translates into interest in Scholarship of Teaching and Learning (SoTL) at the School of Medicine.
This means we have teachers interested in conducting research studies about their teaching and in finding better ways to help students learn. This is a particularly challenging type of research that raises unique issues about power, confidentiality, captive populations, and the burden on participants.
The Queen’s General Research Ethics Board (GREB) issued a four-page guideline document on Scholarship of Teaching and Learning (SoTL) in June 2017.
As much of the research conducted by those involved in the UGME program focuses on SoTL – and the HSREB is aligned with the Queen’s GREB – these Guidelines are relevant to research considerations for both faculty, staff, and student-led projects.
The Guidelines document draws attention to studies with direct student involvement, as well as self-studies, which both have implications for student privacy, including during the research dissemination process.
For studies with direct student involvement, other considerations that are highlighted include:
The power-over relationships between instructors/researchers and students can impact the students’ decision to participate in the research. This differential can be managed by keeping the instructors/researchers at arm’s length from the students by person or time [with suggestions provided]
This term can be applied when participants are dependent on an ‘authority figure’ (e.g., instructor/researcher) who can infringe on their freedom to make decisions. [Guideline include ways to mitigate this risk.]
The main purpose of formal education is for students to gain knowledge, not to be participants in research. If students are repeatedly asked to participate in research studies, their educational pursuits may be compromised. It may be of value for instructors/researchers to consider what other types of research are being conducted with students to diminish the impact of participant burden. Also, instructors/researchers should try to design studies that help enrich the students’ educational experiences instead of distracting from those experiences.
Students may have concerns about whether or not their instructors/researchers know if they took part in the research. Students may feel their decision not to participate in the research could impact their academic trajectory. [Includes suggestions for how to mitigate this risk].
[Excerpts from pages 2-3 of the Guideline]
If you’re interested in creating a study related to your teaching in the UGME program, feel free to get in touch with the Education Team to talk through some of these challenges. We’re here to help.
Five things attending a gaming expo reinforced about medical education
It’s March Break in much of Ontario – including for UGME students and faculty at Queen’s School of Medicine – so I found myself at “EGLX” in Toronto with my 13-year-old son. Billed as “Canada’s Largest Video Game Expo” the three-day extravaganza included virtual reality, cosplay, exhibitors, panels, artists, a giant Nerf battle, and various and sundry gaming competitions. Given that the height of my gaming career was “VICman” (a Pac-Man knock-off by Commodore back in the early 1980s) and playing a mean game of Tetris (so, translation: Worst. Gamer. Ever.), this is perhaps one of the last places anyone would expect to find me. However: moms do stuff. (Dads do, too. My husband valiantly went to TWO days of it). In this and other unfamiliar territory, medical education is rarely far from my mind. Here are five things the expo reinforced about Med Ed:
Be open to new experiences
This one works for both teachers and students. Whether it’s tackling a new subject or trying out a different teaching or assessment method, it can pay off to be brave and just dive right in. While I’m not a gaming convert, EGLX gave me a new view to some of my son’s interests and showed the breadth of the industry. When we do the same thing over and over again, we can get trapped in our own “bubble” of experiences and not realize what else is out there. There’s value in new perspectives.
Learning works in multiple directions
I’m used to being in the role of educator – both as a parent and at work, where I’m mostly behind the scenes in the planning stages. It’s important to remember that learning isn’t mono-directional. At the expo, I was the rookie, and my kid the mentor. (And my husband, the trade-show veteran, was the navigator). In medical education, learning comes from our faculty, our students, allied health professionals, our patients and their families.
Technology is cool
What starts as games can turn into tools and vice versa. Some of the virtual reality stuff at the expo was pretty cool (fly like Superman, anyone?) and, for parents, the cycle-to-power-the-game stuff never gets old. (Just when am I going to be able to buy one?). Likewise in the classroom and clinics – what’s the next good thing to enhance learning?
One whole segment of the expo featured projects by students at Sheridan College. While this, of course, served to promote the programs at the college, it also gave students well-deserved recognition for hundreds (thousands) of hours of work, problem-solving, and creativity. Sometimes the accomplishments of our students and faculty become routine to us – we need to take time to showcase and celebrate the great things we’re doing.
If something doesn’t work the first time, try something else.
My son wanted to meet some of the YouTube gaming celebrities. (Yeah, I learned this is a thing). Our first day there, we were waiting in a very long line that was moving about one person every five or six minutes. I counted those ahead of us, did some math and figured we’d be there for about 2.5 hours before we hit the front of the line. We ditched the line and went to an awesome ribs place for supper instead. The next day, my son and husband went to one of the YouTube gamer panels, left strategically early, and landed second in line. Likewise in Med Ed, sometimes we introduce innovations and don’t get them quite right. We need to step back, figure out what went wrong, and go at it a different way.
Next week: Five things about medical education reinforced by the multiple shoe stores at the Vaughan Mills Mall. (Just kidding…. Maybe).
Five ways being a Geneticist helped me improve my teaching skills
By Andrea Guerin, Year 2 Director and Clinical Geneticist
When growing up, the career choices offered are often dichotomous, do you want to be a lawyer or a firefighter, nurse or entrepreneur, doctor or teacher? In reality, most jobs are a blend of a few different skills. In medicine, doctors can be scientists, can run a business, and for most of us, being a teacher is a large part of our job. At first blush, being a Geneticist and a teacher doesn’t seem to have much in common, but my training in Medical Genetics has significantly influenced my role in education. Here are five examples I’d like to share:
Geneticists are wordsmiths. Language is very highly selected, “cause” not “reason”, “typical” not “normal” and “chance” not “risk”. The language I use with my patients is specific and inclusive, positive and hopefully, precise. Words are important, to convey meaning without an agenda, to educate without prejudice. I use the same thought in the classroom. I am mindful of the implicit biases that can be drawn from words. Words are powerful and their power needs to be recognized and headed.
Medicine is learning a new language. So is education. I’m not going to lie, I had never designed a small group session before coming to Queen’s and I certainly did not know what a Directed Independent Learning event was. When I came, I was disoriented, DILs, SGLs, RATs, GTAs. The terminology was overwhelming. But, like learning the language of medicine, I learnt the language of education too. We’ve added a few more in the past year in undergraduate medical education CBME, EPA, with only more to come.
Technology is forever changing, but good ideas stand the test of time
When I started my residency 10 years ago the understanding of genetic testing was very different. Many tests were not available. Testing was laborious, going from gene to gene, with months of anxious anticipation in between. Now, a decade later, I can order a test that looks at all the necessary genes of the body that have a purpose. Results can be available more quickly. Interpretation is more of a challenge, as we learn more, it becomes more evident the gaps in our knowledge and tying findings to patient symptoms can be a challenge. The concept of having parents and environment contributing to the health of the child is an old one, with influences from Ancient Greece to India. This testing is a reinvention of an old idea — we have only identified the individual factors (genes) that support what has been seen for thousands of years.
When I went to medical school, problem based learning was new. Powerpoint was a staple of lectures. There were almost no laptops. We would never have thought to work in groups while in the same classroom. That was an activity reserved for afternoon sessions, segregated into rooms under the watchful eye of a faculty facilitator. Marks were given from formal assessments, not team assignments or readiness assessment tests. That’s not to say assessments were not happening, they were just less formalized. It was a gut feeling. Did the clinical skills tutor think you were professional? Did the small group facilitator see that you participated? Now, assessments, both summative and formative are happening all the time. The actual process has become more concrete and transparent, but the idea has not changed.
It’s all developmental
Genetics is one of only a few specialties where the patient population spans from before cradle to grave. When I see a patient with a concern, I endeavour to find out when it started. An understanding of development, both physical and emotional, is key to my practice. You must walk, before you run.
Education is no different. The expectation must be adjusted to where the student is in their education journey. It’s okay to not know the differential in the first year, but in fourth year, students must be equipped with the knowledge and expertise to generate a differential and initiate management. Expectations need to match where the learner is, just like my patients.
No person is an island
Genetics is a team sport. In clinic, amongst clinician and researchers spanning the province, country or world, we work together to solve diagnostic mysteries and provide good patient care.
Education is the same. Teachers, admin support, education support, technical support and student support and feedback are essential to the teaching process. Behind every teacher, there is a team supporting them in their journey.
Comfortable with the uncomfortable concept of unknowns
After years of education, I will never be done learning. There is always more to learn, and no physician, despite years of practice and experience knows everything. When I counsel patients I always raise the possibility of an unknown. A confusing result, a question left unanswered. There is no crystal ball.
Education continues to surprise me, but I am open to the concept of something new, unknown. Can we produce excellent physicians using different teaching methods? Of course we can. Each of my colleagues had different curricula, different forms of instruction. There is more than one way to teach — the “best way” is still unknown.
On a gumdrop cake fail and multiple points of assessment
What can a failed gumdrop cake remind us about assessment?
I’m a pretty good baker and love to indulge myself when there’s time, like last month’s holiday season. For me, baking is partly about eating (of course!) but also about tradition, hospitality, and comfort.
Just before Christmas, I set out to make a gumdrop cake. It was an unmitigated disaster. When I turned it out of the pan, it collapsed. (See embarrassing photo at right).
Based on that single point of baking, a casual observer could determine that I’m a lousy baker. In fact, I should be barred from the kitchen and given directions to the closest bakery for all subsequent treats. This wouldn’t be a fair representation of my skills, just a snapshot of a single – bad! – evening.
It’s the same for our system of assessment in the UG program: no single assessment determines a student’s progress. We use multiple points of assessment, both in preclerkship classes and through clerkship rotations, to ensure we have an accurate portrait of a student’s performance over time. Admittedly, some assessments are higher stakes than others, but no single assessment will determine a student’s fate in the program.
Anyone can have an “off” day – for any number of reasons. What’s important following poor performance, is to take stock of what happened, reflect on what may have contributed to the poor outcome, and make a plan for next time.
I was really upset. I’d made this many times. I was “good” at this. Had I somehow lost my baking mojo? Plus, I was embarrassed — as well as annoyed with myself for wasting all kinds of butter, sugar, eggs, flour and gumdrops!
My adult daughter gamely offered this advice: “Sometimes a new recipe takes a few times to get right.” Except it wasn’t a new recipe. I’ve made this gumdrop cake dozens of times for over two decades. What could possibly have gone wrong? I reread the recipe (photocopied from my mother’s handwritten book) and my scrawled notes in the margins. I’d used mini-gummy-bears in place of the “baking gums”. In trying to be cute and expedient (didn’t have to chop those up!), I’d sabotaged my own cake. I’d also forgotten to put the pan of water on the bottom rack, but I thought that was likely pretty minor.
For students after a poor assessment, that same reflection can help: did I study or practice enough? Was it efficient study/practice? Was I under the weather? Did I have enough sleep? These self-reflection questions will vary based on the type of assessment, but it boils down to this: What can I learn from this assessment experience and what can I do differently next time?
I waited over a week before I attempted the gumdrop cake again. In the meantime, I (successfully) made four kinds of cookies, a triple-ginger pound cake, and a slew of banana breads. Then, I bought the right kind of baking gumdrops and remembered to follow ALL the instructions, and it turned out just fine. In fact, I sent some to my parents in New Brunswick and my mother judged it “delicious”.
With thanks to Eleni Katsoulas, Assessment & Evaluation Consultant, for her continued counsel on assessment practices.
17th Health and Human Rights Conference held
By Aalok Shah (Meds 2020), HHRC Conference Co-Chair
Human Rights, a concept that has existed for millennia and documented in seminal political and religious documents such as the Magna Carta and the Vedas, got a more modern treatment in November 2017 at the Health & Human Rights Conference (HHRC). The HHRC is a proud tradition of Queen’s medicine students, who have organized this conference autonomously for the past 16 years. Since its inception in 2001, this conference has evolved in both
scope and reach, reflecting the push for interdisciplinary learning and collaboration in education. The 17th iteration of the conference reached out to professionals both within and outside of medicine to educate and engage delegates on its theme of “affirming the human right to health for the poor.” With generous donations from organizations such as the Ontario Medical Students Association (OMSA) and the Canadian Federation of Medical Students (CFMS), the 17th HHRC was the first student-run conference in Canada to welcome over 150 students from all over the nation to discuss human rights and health.
The conference itself was divided into two days.
The first day was more didactic in nature, featuring events aimed at educating delegates on traditional social assistance programs and the newer model of the basic income guarantee. Sheila Regehr, the chair of Basic Income Guarantee Canada, gave a keynote address explaining both the philosophical and practical reasons for incorporating a basic income model of social assistance, and its impact on health of the poorest populations in Canada. After this address, delegates witnessed a debate between economists, politicians, and professors on whether a basic income guarantee should replace traditional social assistance programs in Ontario. While parts of the debate were very technical and required knowledge of economics, many delegates reported learning a lot more about the issue with a better appreciation of the pros and cons of both sides.
The second day was more interactive, offering several workshops that engaged delegates in topics including indigenous health, global health, mental health, and art-based interventions in health promotion. Additionally, the “community initiatives fair” provided a great opportunity for delegates to interact and network with organizations in Kingston that are involved in local development work. Some students signed up to volunteer at such organizations during this time, and appreciated the chance to channel their motivation and energy from the conference into action right away. Finally, the second day also featured Dr. Samantha Green, who gave a keynote address on mental health, and offered practical tips for healthcare providers in engaging with patients who may be facing financial or emotional calamities.
Overall, the conference was successful in renewing a discussion about intrinsic rights of humans to health, and how to best achieve equity in an era of equality. This conference would not have been possible without the hard work of the executive committee of 13 people featured below and generous sponsors including the Aesculapian Society, the Dean’s Fund, OMSA, CFMS, Queen’s Innovation Centre, Principal’s Office, Society of Graduate Studies, School of Kinesiology, Global Development Studies, Queen’s Human Rights Office, and the Office of the Vice-Provost.
“To boldly go where no (Doctor) has gone before”
Those as nerdy as I will recognize the title of this article as paraphrased from the introduction to the original Star Trek television series. That program, set in a technologically advanced future, was about a long journey of discovery. Perhaps the most peculiar aspect of that journey is that it had no particular destination. The voyagers were simply wandering aimlessly, hoping to run into something interesting. Consequently, they often found themselves woefully unprepared for the challenges they faced – an excellent means to provide dramatic tension to a fictional story, but a dubious strategy for real life.
A medical school curriculum is basically a journey. For our students, it’s a journey that will take them into an unknown future. Like any real journey (and in contrast to the intrepid Star Trek crew), establishing a destination is the first, critical step. A long journey may consist of many stages and stops along the way that demand our immediate attention, but those stages are only meaningful if they move the traveler toward some ultimate goal. That goal, of course, is to become effective, fulfilled providers of medical care to members of our society.
The students currently in medical school will be practicing into the mid 21st century. If we’re to provide them an education that will best prepare them to make meaningful contributions, we need to give some thought what that world will look like, and what it will require of them as physicians and professional leaders.
This was the topic of a presentation and subsequent discussion at our semi-annual Curricular Retreat this past week. In preparing some remarks to begin that discussion, I attempted to draw on changes that have occurred in the course of my career and use those observations to extrapolate into the future. I came up with five that I think are particularly relevant. This is, by no means, a complete list, but perhaps sets the tone and the challenge.
In no particular order:
- The role of physicians as purveyors of medical knowledge.
Knowledge is the fundamental fuel of medical practice, and the commodity that gives legitimacy to those providing care. A generation ago, medical knowledge was elusive. It had to be searched out, a process that was paper based and time consuming. Physicians were the primary source and conveyors of medical knowledge. People who wished to become physicians went to medical schools largely to seek out the knowledge and skills that were embodied in the practicing physicians who taught there.
That has all changed. Medical knowledge is now available, almost instantly, who anyone who wishes to find it. Physicians are no longer the primary source of that knowledge. They no longer hold any monopoly on knowledge.
- The expanding applications of Artificial Intelligence and robotic technology.
We were all impressed when Watson defeated chess masters and Jeopardy champions. In my field of cardiology, I think many dismissed automated interpretations of electrocardiograms as simple algorithm-driven time savers that would always require physician verification. The same is happening with respect to interpretation of diagnostic imaging such as chest x-rays and CT scans.
But AI is moving far beyond these applications that are based simply on prodigious memory storage and processing capacity. Applications are becoming much more sophisticated and are developing the ability to learn and adapt to dynamic situations. Diagnostic algorithms are available that will provide reasonable differential diagnoses for patient presentations, and computer interfaces are under development that are frighteningly life like in their ability to interpret individual patient speech and even facial expressions.
Robotic applications in the operating rooms and procedure suites hold the promise of increasing technical expertise and consistency while reducing infection rates. They also allow for interventions in locations where the human hands are simply incapable of performing.
Extrapolating forward, it’s not at all hard to imagine a world where most diagnostic imaging and many therapeutic interventions will require much less, or perhaps no human intervention.
- Our fundamental understanding of human disease.
For generations, physicians have understood and characterized disease states based on what they could observe clinically. “Consumption”, “Whooping Cough” and “Scarlet Fever” are examples of conditions described solely on symptoms and visual inspection. As the ability to image patients and do laboratory analyses improved, patients with Consumption were found to have pulmonary damage caused by Tuberculosis, Whooping Cough became Pertussis and Scarlet Fever became associated with streptococcus infection.
I have lectured students for over 20 years on the classification, diagnosis and management of cardiomyopathies based on morphologic distinctions (Dilated, Hypertrophic, Restrictive) established by clinical examination and imaging appearances. My teaching is now changing, based on new classification schemes based not on morphology, but on the genetic mutations that result in abnormal development of cardiac muscle cells and channels.
This is not only highly appropriate, but promises to bring genetically based therapeutics that promise to alter the natural history of these conditions in ways currently not available. It also represents an entirely new science, involving genomics and an understanding of sub-cellular processes that practitioners of the future will need to understand and develop comfort with if they’re to provide optimal care.
- Standardized approaches to disease management.
Physician order sheets used to be blank and on paper. They have not only become electronically integrated into patient management systems of various designs, but have also become prepopulated with standard orders for many, even most, clinical conditions. Often, all that’s required are patient specific data such as body size and renal function, and a physician’s signature (real or virtual) at the bottom of the page.
This is good in the sense that it promotes consistent and evidence based approaches to these conditions, and reduces transcription errors. However, it can also diminish the educational experience of medical students, and may not fully account for the needs of patients with multiple medical problems or individual characteristics that require an individualized approach.
- Expanding role of non-physicians in health care delivery.
The widespread availability of medical knowledge in general and guideline based management strategies specifically has allowed for other health care providers, such as nurse practitioners, pharmacists and physician assistants, to participate more fully many situations. Another example from my field would be the expanding role of nurse practitioners in heart failure clinics. NPs are fully capable of managing the introduction and maintenance of standard therapies in this population of patients who often require close and continuing surveillance. They do so very effectively, and their participation has been shown to improve patient functional status and reduce hospital admissions.
And so, what to do…
It’s important to state from the outset that this is all good. These five changes will make health care more effective and efficient. Like any development they have potential pitfalls, but, appropriately managed, they will bring significant advantages to our patients. It’s also important to recognize that they are not going away. Technologic progress does not wait for us, or any group, to be ready.
And so, we must engage some very difficult and disturbing questions, summarized in this slide I presented at our recent retreat:
Obviously, there are no definitive answers, but I provide a few thoughts that emerged from recent discussions.
- Students no longer need to undertake medical education in order to locate knowledge – they are quite capable of doing that on their own. They do, however, require guidance as to what will be relevant to their careers, and an ability to interpret and evaluate the merits of the tsunami of information that will come their way.
- AI has the potential to dramatically improve the delivery of care, but can be highly threatening, partly because applications can develop out of context and without clear applications. Physicians of the future need to be more than consumers of AI, they need to involved in the development of applications, the purpose of which should always be to advance care. To do so, they will need fundamental education that develops familiarity with the technology and its potential.
- Medical education has always been rooted in science, but the nature of that science is changing rapidly. Fundamental knowledge about normal human structure and function will always be required, but will need to extend beyond the superficially observable to penetrate the genetic and subcellular levels of normal and abnormal human function.
- As Physicians are needed less and less to interpret test results or manage standard, well-defined clinical issues, their role will extend to ensuring patients enter the care system appropriately, and managing situations where the complexity or multiplicity of issues goes beyond standard management. This will require them to be even more acute assessors of patients at the primary presentation, develop high levels of sensitivity to patient outcomes that deviate from optimal, and have a depth of understanding of the scientific underpinnings of disease and system management that will allow them to step in and provide “customized” management when required. Indeed, “personalized medicine” may become the primary focus of the physician of the future.
All this, and no doubt much more, will require a vastly different approach to medical education, one that we need to begin to consider today. The future is closing in very rapidly. I’ll end with a quote regarding the future role of physicians from someone who was always technologically ahead of his time and not shy about expressing disruptive views:
“The doctor of the future will give no medicine, but will instruct his patient in care of the human frame, in diet, and in the cause and prevention of disease.”
Thomas Alva Edison (1847-1931)
Edison may have been somewhat overly optimistic about the “give no medicine” prediction, but was certainly perceptive in predicting fundamental change in approach. Over the next few months, we’re going to engage a series of dialogues about the doctor, and medical school, of the future, beginning with our recent retreat and this article. Please feel free to participate with your thoughts as we “boldly go” about charting a course into the next few decades of medical practice and education.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education