Navigating multiple paths to service-learning projects

Anyone with their ear to the medical education ground in the past year will know that service learning is a very, very hot topic. Ever since the Committee on Accreditation of Canadian Medical Schools (CACMS) endorsed service-learning as an important (but optional) element of the education of future physicians, medical schools across the country have sought to incorporate this as a feature of their curriculum. However, service-learning, by its very nature, can leave students feeling uncomfortable: it’s structured but open-ended.

Consulting with community members to set goals and design projects is not always as straight forward as mastering the objectives of a standard medical course. Unlike other curricular and co-curricular activities, service-learning projects often start with pretty broad objectives. Add in consultation with multiple community stakeholders and the projects themselves can seem quite nebulous at the start.

We’ve written about service-learning on the blog before (here and here) as we’ve continued to develop our approach to encouraging and supporting our students in engaging in service-learning. Service-learning projects are one way our medical students (and pre-medical students, in the case of QuARMS) enhance their understanding of working with community members, explore intrinsic physician roles, and contribute in a very real way to our medical school’s social accountability to our communities.

On a national level, the Canadian Alliance for Community Service Learning (CACSL) provides support and networking opportunities for students, educators and communities engaged in these endeavors. At their recent biennial conference held in Calgary, multiple presenters addressed students’ issues with the ambiguity of service-learning projects compared to other learning activities.

When students have the autonomy to define what is happening with a project in cooperation with an organization, they can feel a little lost, one presenter, Chelsea Willness, an assistant professor at the Edwards School of Business at University of Saskatchewan, noted.

“Students are very uncomfortable with the ambiguity: ‘What do you mean, I don’t know what I’m going to be doing?’”

They want templates and checklists because that’s familiar, she added.

It’s clear that while many students are excited about the opportunity to engage with community partners, they both need and want support. Equally important is providing them with reassurances that  each project will have its own path – which includes some levels of uncertainty.

Here’s the Queen’s UGME operational definition of service-learning (as there are multiple interpretations of this term):

“Service-learning is a structured learning experience that combines community service with preparation and reflection. Medical students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided, the connection between their service and their academic coursework, and their roles as citizens and professionals.”

One key word in that definition is structured. Providing as much structure as possible can help ease students’ discomfort with some of the ambiguous nature of service-learning. To that end, the Teaching, Learning, and Integration Committee (TLIC) has been assigned oversight of service-learning for undergraduate medical students and has implemented three possible avenues students may use to have a service-learning project recorded on their MSPR.

To launch this, a one-hour session on service-learning was added to the first-year Professional Foundations course earlier this year. This learning event included information on why we’re deliberately supporting extra-curricular and co-curricular service-learning activities as well as information on potential service-learning avenues. As part of this session, members of the Class of 2019 were polled to see what types of service-learning projects they might be interested in and how these might fit in the three paths.three_roads

Here are the three paths to a recognized service learning project:

  • Participate in an existing student-led volunteer initiative and complete the additional tasks necessary to extend this to a service-learning project
  • Complete an individual service-learning project, which meets the requirements (including consultation and reflection)
  • Take part in a service-learning pilot project brokered by the TLIC

Dr. Lindsay Davidson (Director of the TLIC) and I have met with representatives from several established student groups whose existing activities were quite close to our service-learning definition and threshold to map out ways their participants could extend their volunteer service into a service-learning project (this is always optional). Typically, this meant documenting some form of consultation and implementing some form of reflection on learning. These groups include SwimAbility (formerly Making Waves) and Jr. Medics. Other groups can be added to this list (email me: theresa.suart@queensu.ca to set up a meeting about this if your group might fit).

The two initial pilot projects are with Loving Spoonful (an organization with the goal of enhancing access to healthy food) and the Social Planning Council (with a focus on social housing in the Kingston area). These will be longer-term projects with sequential groups of students completing phases of a larger, continuing project.  (The first participants have already been identified through the PF class poll. Recruitment of UGME students will be through the TLIC, not through the agencies).

For each of the three paths, students must submit evidence of meeting the threshold for each aspect, using forms provided by the TLIC. These will be made widely available in September using a MEdTech community page. Here are the requirements for any project to be recognized:

  • The project must serve the needs of a group in the wider community (i.e., not medical school-focused)
  • Complete some form of consultation with community participants and/or stakeholders (this will look different depending on the type of project and service)
  • Complete between 15-20 hours of service (with no more than 20% devoted to training)
  • Completed a required reflection on learning

In the future, as more students engage in formal service-learning projects, students’ reflections on their learning may be presented at a service-learning showcase, similar to the Undergraduate Research Showcase that is held each year.

While having three different routes to recognized projects may seem to add to the ambiguity of “what does a service-learning project look like”, providing multiple avenues for recognition was important.

“Our students have many different interests and we wanted to leverage that by providing multiple avenues for service-learning projects to be completed and recognized by the school,” Dr. Davidson said.

We’re never going to completely eliminate the ambiguous nature of service-learning projects, but we’re working to put structures in place that can meet a variety of students’ interests and community needs.


With thanks to Dr. Davidson for her contributions to writing this post.

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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)
Associate Dean,
Undergraduate Medical Education

 

Mind the Gap by Elizabeth Clement

elizabeth-clementThere’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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.

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CCME 2016: We came, we saw, we presented!

It’s been a busy four days at the Canadian Conference on Medical Education in Montreal – five or six days for those involved in business meetings and pre-conference workshops that started on Thursday.

In addition to attending sessions, plenaries and business meetings, Queen’s contributors were lead authors, co-authors, supervisors, and collaborators with colleagues from other universities. We presented posters, led workshops, and gave oral presentations.

All told, close to 80 members of the Faculty of Health Sciences – faculty, administrative staff, and students – contributed to producing 36 workshops, oral presentations and posters. While not all of these people were in Montreal, Queen’s was well represented in the conference rooms.

We invited those participants to share information on their presentations as well as any thoughts they had about the conference itself. (Keep in mind that it’s been a jam-packed weekend and we weren’t able to track everybody down.) Here’s a sampling of what went on:

Alyssa Lip and Shannon Chun (MEDS 2017) gave an oral presentation on the progress of the Wellness Month Challenge which was developed by the Queen’s Mental Health and Wellness Committee. “This year, this challenge has expanded to 12 medical schools across Canada and reached 1085 medical students,” Alyssa noted. “In addition, we found a significant increase in resiliency in students surveyed before and after participation in the initiative.”

Laura Bosco and Jane Koylianskii (MEDS 2017) presented on the “Impact of Financial Management Module on Undergraduate Medical Students’ Financial Preparedness.”

“We created a novel web-based financial management educational module with the aim to educate medical students on the expenses of medical school, as well as the various sources of available funding, and outline the necessary steps to achieve the most financial support throughout undergraduate medical education,” Laura explained. “Our primary objective aimed to compare medical students’ financial stress prior to and following the completion of this financial management educational module. This issue is important because medical students often make residency and career decisions that are influenced by their accumulated financial debt, and we feel that the process of career selection and development should revolve around students’ interests, not financial barriers.”

Brandon Maser (MEDS 2016) presented a poster on the CFMS-FMEQ National Health and Wellbeing Survey. “The Canadian Federation of Medical Students and the Fédération médicale étudiante du Québec have worked together developing and implementing a national survey on medical student health and wellbeing at all 17 Canadian medical schools,” he said. “With approximately 40% national response, we now have a wealth of data on medical student health, and will be working with faculties and medical societies in order to elucidate risk and protective factors for medical student health, and to create recommendations for the improvement of supports and resources.”

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Bob Connelly (standing, left) and his co-presenter Ross Fisher, present to a full house on presentation skills.

Louisa Ho and Michelle D’Alessandro (MEDS 2017) presented on the Class of 2017’s Reads for Paeds project. “Reads for Paeds is a Queen’s medical student-led initiative that seeks to develop engaging, illustrated, and age-appropriate books for children with specific medical conditions,” Louisa explained. “Our study shows that participation in a student-developed and student-led service-learning project like Reads for Paeds can enhance students’ understanding and application of CanMEDS roles, thus benefitting their overall development as medical trainees.”

Jimin Lee (MEDS 2017) was one of several students who prepared the poster presention on Jr. Medics. “We evaluated the Jr. Medics program at Queen’s medical school as a service learning project,” she said. “We found that while engaging with the community by teaching basic first aid skills to local elementary school students, medical students developed competence in the CanMEDS roles as a communicator and professional. Our findings support the development of service learning opportunities for medical students with explicit learning values for students and quantifiable outcome in the community.”

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Jennifer MacKenzie presents on the initial outcomes of the QuARMS evaluation.

Justin Wang (MEDS 2017) shared information on “SSTEPing into Clerkship”: A Technical Skills Elective Program for Second Year Medical Students, which was prepared with coauthors Tyson Savage, Peter (Thin) Vo, Dr. Andrea Winthrop, and Dr. Steve Mann“The Surgical Skills and Technology Elective Program is a 5-day summer elective program designed for second year medical students to teach and reinforce both basic and advanced technical skills ranging from suturing to chest tube insertion,” he said. “Anxiety as well as a lack of both knowledge and confidence in the performance of technical skills has been found to inhibit medical student involvement in real clinical settings. Our research found that anxiety was significantly decreased, confidence and knowledge were significantly increased, and objective technical skills were significantly improved immediately after program completion as well as 3-months later, demonstrating retention of these effects. These results support the use of a week-long surgical skills program prior to the start of clerkship for second year medical students.”

Alessia Gallipoli (MEDS 2017) presented her poster on an “”Investigation of the Cost of the CaRMS Process for Students”, completed with Dr Acker. “It looks at the average costs that graduating medical students can expect to pay in regards to different aspects of the residency application and interview process,” she said. “The results of this study may help students make informed decisions throughout the CaRMS process, to balance career ambitions with smart financial planning. It can also inform initiatives to support students both financially and with career planning throughout their training.”

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Michelle D’Alessandro and Louisa Ho presenting on Reads for Paeds.

Jason Kwok (MEDS 2017) presented on a novel method of teaching direct ophthalmoscopy to medical students in the current medical curriculum, where there is decreasing emphasis and time dedicated to ophthalmology. “Our  learning method, which consists of a peer competition using an online optic nerve matching program that we created here at Queen’s University, effectively increases the self-directed practice, skill, and learning of direct ophthalmoscopy in medical students,” he said. “This learning exercise has been implemented in the first year Queen’s medical curriculum for the past two years with great success.”

Vincent Wu (MEDS 2018) noted, “The CCME serves as an avenue for us to present the accomplishments of the First Patient Program, as well as some of the unintended student learning themes. This research helps to further refine student learning within the undergraduate medical curriculum, in order to better understand healthcare delivery from the patient’s perspective.”

Adam Mosa (MEDS 2018) presented his research on using patient feedback for communication skills assessment in clerkship in a project entitled Sampling Patient Experience to Assess Communication: A Systematic Literature Review of Patient Feedback in Undergraduate Medical Education. “This project highlighted a paucity of studies on how to use patient feedback, which is an untapped source of learner-specific assessment of this fundamental CanMEDS competency,” Adam said.  “CCME 2016 was a great place to meet like-minded educators. In particular, my suggestion for an “unconference” was chosen, and I spent time discussing the future of patient feedback with a diverse group of enthusiastic participants.”

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Andrew Dos-Santos, Lynel Jackson, Laura McDiarmid, and Eleni Katsoulas at the Dean’s Reception.

Amy Acker (Pediatrics) presented a workshop with two other pediatric program directors (Moyez Ladhani and Hilary Writer from McMaster and Ottawa) to help give concrete suggestions for teaching and assessing some of the challenging non-medical expert competencies. “We came up with the idea and thought it was a session we would have liked to have attended when we started as PDs,” she explained. “We took participants through a blueprinting exercise to identify what they need to teach, resources they will need to teach and how to assess, in case-based format… hopefully everyone learned something!”

Catherine Donnelly (School of Rehabilitation Therapy) was the PI on the Compassionate Collaborative Care project, which was funded by AME “The Phoenix Project”. “The aim of the project is to support the development of compassionate care,” she said. “The output of the project was an online module intended for use by health care students, clinicians, educators and administrators.  The module consists of 6 chapters that can be used independently or collectively.  The modules have been pilot tested and evaluated with students and health care providers.   The modules are open access and can be found here.

Karen Smith (Associate Dean, Continuing Professional Development), shared information on her team’s work: “I am here with my CPD and FD colleagues. We presented at the CPD Dean’s Business meeting on how to meet CACME accreditation standards. We will be sharing some of our scholarly work with posters and a workshop exploring aspects of what makes self-directed learning effective and what CanMEDS competencies are addressed in SDL and the impact of note-taking style on memory retention and reflection,” she said. “In addition to seeking the excellent feedback from our peers to advance our own work, we are learning from our peers. Networking and building relationships with others across Canada is key to our ongoing success‎.”

Sita Bhella (Department of Medicine) presented a usability study on an online module she designed and created with colleagues in Toronto aimed at improving the knowledge and comfort of general internal medicine residents in managing sickle cell disease on the wards and in outpatient settings. “Presenting at CCME introduced me to new ideas and research methodologies and I hope to continue to present my work there in the future,” she said in an email. “It was an honour to present my work at CCME and to interact and engage with colleagues across the country on research in medical education.”

Kelly Howse (Family Medicine) presented both a poster and workshop. The poster explored issues of Family Medicine Resident Wellness: Current Status and Barriers to Seeking Help.

“Residency training can be a very stressful time and may precipitate or exacerbate both physical and mental health issues. Residents, however, often avoid seeking help for their own personal health concerns,” she said. “The purpose of this study was to assess the current status of resident wellness in our Queen’s family medicine program, with particular attention to identifying barriers to seeking help.”

The Seminar she presented focused on Supporting Medical Students with Career Decisions: National Recommendations for Medical Student Career Advising. “Specialty decision-making and preparation for residency matching are significant sources of stress for medical students. Through the FMEC PG Implementation Project, Queen’s led the development of national recommendations regarding the guiding principles and essential elements of Medical Student Career Advising,” she said. “This workshop helped disseminate these recommendations nationally and will help guide the exploration of relevant career advising resources.”

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We may have indulged in a few tasty desserts…

In addition to presenting their own work, School of Medicine faculty served as mentors for the many student presentations. Lindsay Davidson (Director, Teaching, Learning & Innovation Committee) shared “This year, I’m proudly watching some of our second year students present the poster that we collaborated on, Pre-clerkship interprofessional observerships: evaluation of a pilot project. It has been a pleasure to watch the students come up with the idea, which grew out of their own experiences as participants in a new inter-professional shadowing initiative for first year students, develop the project and reach conclusions that are helping to shape our teaching here at Queen’s. In addition to providing students with experience in conducting educational research, the partnership of students and faculty on such projects is a strength of our UGME program.”

So that’s a bit of what we’ve been up to in Montreal. Oh, and the food was great, too!


With thanks to everyone who was able to make time to send me some information, and apologies to all I’ve left out, especially given that I sent my email request on Friday when many were already in Montreal or enroute. Feel free to send me information I can add as an update (the beauty of blog over print.)

 

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Five great reasons to attend medical education conferences

This weekend many involved in undergraduate medical education at Queen’s are heading to Montreal for the annual Canadian Conference on Medical Education (CCME). From faculty, to students, to administrative staff, we’re attending as presenters, workshop facilitators, and in several other roles.

As described on its website, CCME is the largest annual gathering of medical educators in Canada. Attendees include Canadian and international medical educators, students, other health educators, health education researchers, administrators, licensing and credentialing organizations and governments. The goal is to “share their experiences in medical education across the learning continuum (from undergraduate to postgraduate to continuing professional development).”

This year’s conference in Montreal from April 16-19 is hosted by the University of Sherbrooke (other partners are the Association of Faculties of Medicine of Canada (AFMC), the Canadian Association for Medical Education (CAME), The College of Family Physicians of Canada (CFPC), The Medical Council of Canada (MCC), and The Royal College of Physicians and Surgeons of Canada (RCPSC).)

With the theme is Accountability: From Self to Society, the program includes workshops, posters, oral presentations and plenary sessions designed “to highlight developments in medical education and to promote academic medicine by establishing an annual forum for medical educators and their many partners to meet and exchange ideas.”ccme theme

Here are five good reasons we take the time from busy spring schedules to take part in this conference:

  1. To present innovations in medical education at Queen’s: We’re doing some great things here at Queen’s and it’s great to share these successes. From early-adoption of the flipped classroom to our First Patient Program, to our Accelerated Route to Medical School – CCME gives a forum to celebrate what we’re doing well.

  2. To learn from colleagues from other Canadian and international medical schools. While we share our innovations, it’s equally beneficial to learn from our colleagues at other schools. We don’t always have to reinvent the wheel.

  3. To wrestle with common issues and gain comfort from being in the same boat. There’s a synergy in working together to sort out challenging issues in medical education.

  4. To network with colleagues from across the country and around the world – this is closely related to both #2 and #3 – networking may not be about a specific challenge at a specific time, it’s making connections with like-minded individuals involved in similar circumstances.

  5. And the food. OK, so this might not be a “good” reason to commit to attend a conference, but it’s certainly a fun part of it. Combining #4’s networking with colleagues with exploring local cuisine is an added bonus.

If you can’t attend this year, consider it for next time. Also, explore conference options closer to home. Our own Queen’s Faculty of Health Sciences Celebration of Teaching, Learning and Scholarship is coming up on June 15.

 

 

 

 

 

 

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Improving existing MCQs

By Theresa Suart & Eleni Katsoulas

Writing and editing test questions is an ongoing challenge for most instructors. Creating solid multiple choice questions (MCQs) that adequately address learning objectives can be a time-consuming endeavor.

Sometimes you may have existing questions that are pretty good, but not quite where you need them to be. Similar to a house reno versus new construction, sometimes it might be worth investing the time improve what you already have. How do you know which questions need attention and how can you rework them?

Previous exams are analyzed to determine which questions work well and which don’t. This can provide some guidance about questions that can be improved.

To select questions for an MCQ renovation, you can start with checking out the statistics from last year’s exams (available from your curricular coordinator or from Eleni).

Two statistics are useful indicators for selecting individual questions for tweaking, rewriting or other fixes: Item Difficulty and Discrimination Index.

Item difficulty is a check on if questions are too easy or too hard. This statistic measures the proportion of exam takers who answered the question correctly.

Discrimination index differentiates among text takers with high and low levels of knowledge based on their overall performance on the exam. (Did people who scored well on the exam get it right? Did people who scored poorly get it right?)

These two statistics are closely intertwined: If questions are too easy or too hard (see item difficulty), they won’t provide much discrimination amongst examinees.

If questions from previous years’ tests were deemed too easy or too hard, or had a low discrimination index, they’re ripe for a rewrite. Once you have a handful of questions to rewrite, where do you start? Recall that every MCQ has three parts and any of these could be changed:Exam

  • The stem (the set-up for the question)
  • The lead-in (the question or start of the sentence to be finished with the answer)
  • The options (correct answer and three plausible but incorrect distractors*)

The statistics can inform what changes could be necessary to improve the questions. For one-on-one help with this, feel free to contact Eleni, however, here are some general suggestions:

Ways to change the stem:

  • Can you change the clinical scenario in the stem to change the question but use the same distractors? (e.g. – a stem for a question that asks students what the most likely diagnosis is based on a patient presenting with confusion with the correct answer being dementia, can be then re-written to change the diagnosis to delirium)
  • Ensure the stem includes all information needed to answer the question.
  • Is there irrelevant information that needs to be removed?

Ways to change the lead-in:

  • Decide if the questions is to test recall, comprehension, or application.
  • Recall questions should be used sparingly for mid-terms and finals (but are the focus for RATs)
  • Verbs for comprehension questions include: predict, estimate, explain, indicate, distinguish. How can these be used with an MCQ? For example: “Select the best estimate of…” or “Identify the best explanation…”
  • You can use the same stem, but change the lead in (and then, of course, the answers) – so if you had a stem where you described a particular rash and asked students to arrive at the correct diagnosis, you can keep the stem, but change the lead-in to be about management (and then re-write your answers/distractors).

Ways to change one or more distractors:

  • Avoid grammatical cues such as a/an or singular/plural differences
  • Check that the answer and the distractors are homogeneous to each other: all should be diagnoses, tests or treatments, not a mix.
  • Make the distractors a similar length to the correct answer
  • Ensure the distractors are reasonably plausible, not wildly outrageous responses
  • Skip “none of the above” and “all of the above” as distractors

As you dig into question rewriting, remember the Education Team is available to assist. Feel free to get in touch.

Watch for MCQ Writing 2.0 later this spring.


* Yes, there could be more than three distractors, but not at Queen’s UGME. The Student Assessment Committee (SAC) policy limits MCQs to four options.

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QMed students cooking up wellness strategies

 by Meghan Bhatia, AS Wellness Officer

and Monica Mullin, Nutritional Wellness Lead

What is wellness? This is a question that proves far more complex than it would appear to be. Although on the surface it may seem easy to define, wellness is an interesting topic to discuss because it can be very personal and take different roles in students’ lives. Buzzwords often surround the wellness curriculum, things like work-life balance, healthy eating, ‘Get Your 150’ and mental or emotional well-being. These categories do indeed contribute to wellness, but with 400 different students and multiple faculty, one size does not fit all.

The idea of taking ownership of one’s own wellness was what piloted Wellness Month at Queen’s University. We may all know the areas of personal wellness, but this month added structure and challenge to these categories, in a hope that people would get new ideas, form habits and lifelong learning would result naturally.

The #keepsmewell challenge was piloted at Queen’s Medicine last year and this year was taken nationally through the CFMS, and run across the country concurrently. At Queen’s we had 160 QMed students participate (including clerks) as well as 18 faculty/staff and 16 QuARMS students.Salad

What was the #keepsmewell challenge? It was a positive habits challenge that had four themed weeks: nutrition week, mental health week, physical week and social academic balance week. Students would receive points for completing tasks on the spreadsheet and were often asked to promote these activities on social media with #keepsmewell.

It was always interesting seeing students stay active and well through their photos with all of the creative paths they took. In particular, the amazing cooking photos from last year were the inspiration behind the QMed cookbook. We decided to compile what students did throughout the challenge so they would have a reference for the rest of the year, of ideas and inspirations; QMED COOKS is available in ibooks or pdf and is free for anyone. It is available here and has been shared nationally and provincially. One of our contributions to the book was adding in nutrition facts and tips that we learnt in school, through resources, or the dietician talk during nutrition week to keep it fun and educational!

Our wellness curriculum is wide and quite diverse, but it is really only a part of QMed students’ wellness. The interest in this month and the positive feedback we have received from this book really does show that students are invested in their own wellness. We both hope that this is just a launching pad for even more nutritional integration into the curriculum, and that many wellness months will continue on, as wellness is difficult to teach, but so essential to learn.

 

 

 

 

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3 Key Teaching and Learning Principles: Revisiting RIA in UGME

filing cabinet
Sheila digging around in her filing cabinet

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 . . .

RELEVANT

“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?

Why relevance?

  • 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, calendar consider this checklist for relevance in your teaching:

  1. Do I use case studies both of my own, and as activities to let students apply learning to “real life”? relevant 1Do I use lots of examples to clarify concepts?
  2. Have I reviewed the MCC’s for my learning event and made sure that my teaching is aligned to them?
  3. Have I got 2-3 clear statements of learning objectives at the level the learners per 1 hour learning event?
  4. Can I state a key idea or “core message” for this one hour of teaching
  5. 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)

INTEGRATED

“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?

Why integrate?

  • 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 integrate 4of 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, calendar try this checklist for integrated learning:

  1. Have I vetted the level of learning in my teaching with other faculty, my course director and/or an Educational Developer?
  2. 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.)integrated 2
  3. 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?
  4. Do I know where my material fits in with in Clinical Skills, FSGL, and other parts of this course as well as others?
  5. 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)

ACTIVE

“ 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.  active 5
  • Students learn well by doing, and participating in “real-world” experiences.

 

Here’s the 2016 checklist calendarfor active learning:

  1. How will I change the students’ ways of thinking, feeling or doing with this learning event
  2. 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?
  3. 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?active3.jpg
  4. 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?
  5. Do I pause at key points and “change up” what is happening in the room?
  6. Have I integrated student activity in the learning event, or partnered with an expanded clinical skills or clinical skills learning event?
  7. 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.

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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:

  1. Anticipate that your student will be distracted that morning
  2. Please ensure your student is able to review their results at noon.
  3. 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.
  4. 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 jacqueline.findlay@queensu.ca, or 613-533-2542. The faculty counselors can also be contacted directly at the following:

FitzpatrickDr. Renee Fitzpatrick, MD, MRC Psych, FRCPC
Wellness Advisor

 

 

 

 


 

KellyHowseDr. Kelly Howse, BSc (Hon), MD, CCFP
Career Advisor
kelly.howse@dfm.queensu.ca

 

 

 

 


 

SusanHaleyDr. Susan Haley, MD, FRCPC
Career Advisor
haleys@kgh.kari.net

 

 

 

 


 

LakoffDr. Joshua Lakoff, MD, FRCPC
Career Advisor
lakoffj@kgh.kari.net

 

 

 

 


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

 

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The Framing Effect, Donald Trump and the meaning of truly Informed Consent

Imagine you’re responsible for planning a public health response to a virulent disease that is expected to kill 600 people. You have to choose between two management programs:

  • If Program A is adopted, 200 people will be saved.
  • If Program B is adopted, there is a one-third probability that all 600 people will be saved, and a two-thirds probability that no one will be saved.

Once you’ve made your choice, consider the same scenario, but with the following options:

  • If Program C is adopted, 400 people will die.
  • If Program D is adopted, there is a one-third probability that nobody will die, and a two-thirds probability that 600 people will die.

This test was developed by psychologists Amos Tversky and Daniel Kahneman and was published in Science in 1981. It’s also described in Kahneman’s remarkable 2011 book Thinking: Fast and Slow. Kahneman won the 2002 Nobel Prize for economics, Tversky having passed away in 1996 (apparently Nobel Prizes are never awarded posthumously).

Thinking Fast... Slow
Thinking Fast… Slow

It’s a test of willingness to accept risks, and part of their larger body of work on decision making behaviour. The pairs of options each require the participant to choose between accepting a sure thing (options A and C), or taking a risk (options B and D). Options A and C are factually identical (200 people live and 400 die in each), but differ in that they are expressed in either positive (A) or negative (C) terms. If our risk taking behaviour is consistent, choices should be the same for the two pairs. However, given the options outlined above, a significant majority of respondents (72%) chose Program A over B for the first selection, but then rejected the sure thing, favouring Program D (78%) over C in the second selection.

The differences relate to how the options are expressed, or “framed”. In the first pair, the choices are designed to focus on saving people. In the second, the focus is on how many people will die. When the intention is to save lives, it appears we are risk averse. When the situation is seen to be bleak and inevitably fatal, we are much more willing to engage risk. Put another way, when given choices that result in fundamentally identical outcomes, most people will avoid risk when they perceive potential gain, but are willing to engage risk when confronted with potential losses. “Framing” of our choices is therefore hugely influential.

Kahneman and Tversky describe this as the “psychophysics of value” and describe two ways of thinking. “System 1” thinking is automatic, involuntary and intuitive. It’s also easy, requiring very little effort – “lazy” thinking, one might say. “System 2” thinking is computational, requiring attention, time and effort. We have to actively decide to undertake System 2 thinking. They are the “fast” and “slow” options referred to in the title of Kahneman’s book. The thought experiment described above is System 1 thinking very much in action. World economies, stock markets, politics, advertising and consumerism are all very much about how System 1 thinking can be promoted and manipulated. Hence, the Nobel Prize.

Donald TrumpWe don’t have to go far these days to find an example of this principle in action. Donald Trump’s bombastic rhetoric in the American presidential primaries seems, at least in part, an attempt to “frame” the dialogue in negative terms (American weakness, vulnerability and multiple perceived foreign threats). By doing so, he develops a sense of fear for the future that he hopes will encourage the electorate to engage a risky, non-conventional alternative (i.e. him). Since Mr. Trump has basically no experience in elected office, foreign affairs or any of the expected concerns of a potential president, he needs to steer people away from System 2 thinking. He’s been doing a remarkably, frighteningly, effective job to date.

If you think physicians are above such influences, apparently you’d be mistaken. Tversky and his colleagues carried out a study at the Harvard Medical School wherein physicians were given information about the expected outcomes for surgical versus radiotherapy approaches to lung cancer (McNeil et al. New England Journal of Medicine 1982; 306:1259-62). The five-year survival rates favoured surgery, but with greater short term risk. Half the physicians participating were provided information that focused on survival (one month survival rate 90%), whereas the others were given mortality rates (10% mortality in the first month). Guess what? Eighty-four percent of the Harvard physicians favoured surgery given the first description, compared with only 50% when given the second description. System 1 thinking dominates when we focus on bad outcomes.

So how is all this relevant to medical students and practicing physicians? There are clear implications for our understanding of the concept of informed consent. In Ontario, this comes under the Health Care Consent Act of 1996, which reads, in part:

Consent is not valid unless it is informed. A physician must provide a patient with information about the nature of the treatment, its expected benefits, its material risks and side effects, alternative courses of action and the likely consequences of not having the treatment.

The following clause describes the terms “information” as follows:

The information provided to a patient must be information that a reasonable person in the same circumstances would require in order to make a decision about the treatment.

All, seemingly, very reasonable. However, given what we now understand about the power of framing in making critical choices, it appears making a choice is about much more than the factual content of information provided. The manner in which options are provided and the way in which outcomes are presented will be very influential in determining the response. Imagine an elderly patient with coronary and mitral valve disease who is highly symptomatic and considering surgery for both symptom relief and prolonged hospital free survival. Consider the following three presentations, all of which are factually true:

  1. “There’s a 90% chance that you’ll survive and be home within two weeks.”
  2. “The surgery carries a 10% risk of dying either in the operating room or within two weeks after.”
  3. “There’s no chance you’ll be alive within two years without surgery.”

Do you think there’s a difference in how patients and their families will respond to those three statements?

Do you think the person delivering those options has capacity to manipulate the decision?

Is this a problem?

I think we’d all agree that the answer to the first two questions I’ve posed is unquestionably “yes”. The third is obviously controversial.

Legislation is important and necessary to ensure protection of the public, but it will always be limited in its ability to penetrate the individual relationship between physician and patient. Its role is to balance the need to ensure rights that protect the vulnerable, while not handcuffing or interfering with the delivery of individual care. One can only respect the intention and great challenge of lawmakers who struggle to achieve that balance.

Physicians will therefore always bear a high responsibility in counseling about medical decisions. While it’s true that the patient and chosen advisors always have the “final say”, it’s both disingenuous and irresponsible for physicians to suggest that informed consent begins and ends with the provision of factual information. There’s no escaping the high responsibility that goes with advising. There’s no short cut. Truly informed consent can only be provided by someone who truly understands the patient’s full history, personal situation, wishes and ability to process information. Moreover, it can only be provided by someone who not only understands all that, but also has the patient’s best interest as their primary goal. In our increasingly busy, hospital and service-centred approach to acute care, all this is becoming more difficult to provide.

Are there solutions? Increasing involvement of primary care physicians or non-physician providers, advanced directives and enhanced access to all medical records will all help. At the heart of the matter, however, must be a recognition that the process of deciding to undertake a particular treatment or procedure is at least as important as its actual provision, and should be recognized as such.

Physicians can’t, and shouldn’t avoid being influential in patient decision-making. Is that a problem? Not if that influence is rooted in a truly caring relationship, informed by a deep understanding of the patient’s full situation, wishes and aspirations.

 

 

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

 

Posted on

The Framing Effect, Donald Trump and the meaning of truly Informed Consent

Imagine you’re responsible for planning a public health response to a virulent disease that is expected to kill 600 people. You have to choose between two management programs:

  • If Program A is adopted, 200 people will be saved.
  • If Program B is adopted, there is a one-third probability that all 600 people will be saved, and a two-thirds probability that no one will be saved.

Once you’ve made your choice, consider the same scenario, but with the following options:

  • If Program C is adopted, 400 people will die.
  • If Program D is adopted, there is a one-third probability that nobody will die, and a two-thirds probability that 600 people will die.

This test was developed by psychologists Amos Tversky and Daniel Kahneman and was published in Science in 1981. It’s also described in Kahneman’s remarkable 2011 book Thinking: Fast and Slow. Kahneman won the 2002 Nobel Prize for economics, Tversky having passed away in 1996 (apparently Nobel Prizes are never awarded posthumously).

Thinking Fast... Slow
Thinking Fast… Slow

It’s a test of willingness to accept risks, and part of their larger body of work on decision making behaviour. The pairs of options each require the participant to choose between accepting a sure thing (options A and C), or taking a risk (options B and D). Options A and C are factually identical (200 people live and 400 die in each), but differ in that they are expressed in either positive (A) or negative (C) terms. If our risk taking behaviour is consistent, choices should be the same for the two pairs. However, given the options outlined above, a significant majority of respondents (72%) chose Program A over B for the first selection, but then rejected the sure thing, favouring Program D (78%) over C in the second selection.

The differences relate to how the options are expressed, or “framed”. In the first pair, the choices are designed to focus on saving people. In the second, the focus is on how many people will die. When the intention is to save lives, it appears we are risk averse. When the situation is seen to be bleak and inevitably fatal, we are much more willing to engage risk. Put another way, when given choices that result in fundamentally identical outcomes, most people will avoid risk when they perceive potential gain, but are willing to engage risk when confronted with potential losses. “Framing” of our choices is therefore hugely influential.

Kahneman and Tversky describe this as the “psychophysics of value” and describe two ways of thinking. “System 1” thinking is automatic, involuntary and intuitive. It’s also easy, requiring very little effort – “lazy” thinking, one might say. “System 2” thinking is computational, requiring attention, time and effort. We have to actively decide to undertake System 2 thinking. They are the “fast” and “slow” options referred to in the title of Kahneman’s book. The thought experiment described above is System 1 thinking very much in action. World economies, stock markets, politics, advertising and consumerism are all very much about how System 1 thinking can be promoted and manipulated. Hence, the Nobel Prize.

Donald TrumpWe don’t have to go far these days to find an example of this principle in action. Donald Trump’s bombastic rhetoric in the American presidential primaries seems, at least in part, an attempt to “frame” the dialogue in negative terms (American weakness, vulnerability and multiple perceived foreign threats). By doing so, he develops a sense of fear for the future that he hopes will encourage the electorate to engage a risky, non-conventional alternative (i.e. him). Since Mr. Trump has basically no experience in elected office, foreign affairs or any of the expected concerns of a potential president, he needs to steer people away from System 2 thinking. He’s been doing a remarkably, frighteningly, effective job to date.

If you think physicians are above such influences, apparently you’d be mistaken. Tversky and his colleagues carried out a study at the Harvard Medical School wherein physicians were given information about the expected outcomes for surgical versus radiotherapy approaches to lung cancer (McNeil et al. New England Journal of Medicine 1982; 306:1259-62). The five-year survival rates favoured surgery, but with greater short term risk. Half the physicians participating were provided information that focused on survival (one month survival rate 90%), whereas the others were given mortality rates (10% mortality in the first month). Guess what? Eighty-four percent of the Harvard physicians favoured surgery given the first description, compared with only 50% when given the second description. System 1 thinking dominates when we focus on bad outcomes.

So how is all this relevant to medical students and practicing physicians? There are clear implications for our understanding of the concept of informed consent. In Ontario, this comes under the Health Care Consent Act of 1996, which reads, in part:

Consent is not valid unless it is informed. A physician must provide a patient with information about the nature of the treatment, its expected benefits, its material risks and side effects, alternative courses of action and the likely consequences of not having the treatment.

The following clause describes the terms “information” as follows:

The information provided to a patient must be information that a reasonable person in the same circumstances would require in order to make a decision about the treatment.

All, seemingly, very reasonable. However, given what we now understand about the power of framing in making critical choices, it appears making a choice is about much more than the factual content of information provided. The manner in which options are provided and the way in which outcomes are presented will be very influential in determining the response. Imagine an elderly patient with coronary and mitral valve disease who is highly symptomatic and considering surgery for both symptom relief and prolonged hospital free survival. Consider the following three presentations, all of which are factually true:

  1. “There’s a 90% chance that you’ll survive and be home within two weeks.”
  2. “The surgery carries a 10% risk of dying either in the operating room or within two weeks after.”
  3. “There’s no chance you’ll be alive within two years without surgery.”

Do you think there’s a difference in how patients and their families will respond to those three statements?

Do you think the person delivering those options has capacity to manipulate the decision?

Is this a problem?

I think we’d all agree that the answer to the first two questions I’ve posed is unquestionably “yes”. The third is obviously controversial.

Legislation is important and necessary to ensure protection of the public, but it will always be limited in its ability to penetrate the individual relationship between physician and patient. Its role is to balance the need to ensure rights that protect the vulnerable, while not handcuffing or interfering with the delivery of individual care. One can only respect the intention and great challenge of lawmakers who struggle to achieve that balance.

Physicians will therefore always bear a high responsibility in counseling about medical decisions. While it’s true that the patient and chosen advisors always have the “final say”, it’s both disingenuous and irresponsible for physicians to suggest that informed consent begins and ends with the provision of factual information. There’s no escaping the high responsibility that goes with advising. There’s no short cut. Truly informed consent can only be provided by someone who truly understands the patient’s full history, personal situation, wishes and ability to process information. Moreover, it can only be provided by someone who not only understands all that, but also has the patient’s best interest as their primary goal. In our increasingly busy, hospital and service-centred approach to acute care, all this is becoming more difficult to provide.

Are there solutions? Increasing involvement of primary care physicians or non-physician providers, advanced directives and enhanced access to all medical records will all help. At the heart of the matter, however, must be a recognition that the process of deciding to undertake a particular treatment or procedure is at least as important as its actual provision, and should be recognized as such.

Physicians can’t, and shouldn’t avoid being influential in patient decision-making. Is that a problem? Not if that influence is rooted in a truly caring relationship, informed by a deep understanding of the patient’s full situation, wishes and aspirations.

 

 

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

 

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